Evaluation of the WHO IMCI
Guidelines in Haiti
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PRESENTED BY
DR. HARRY HAZELWOOD,MD
WORLD HEALTH ORGANIZATION/
GENEVA FOUNDATION FOR MEDICAL
EDUCATION
GENEVA,SWITZERLAND
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AIMS AND OBJECTIVES
To improve the overall assessment-skills of
skilled healthcare workers in order for them to better ASSESS, CLASSIFY,
and IDENTIFY the at-risk child in need of treatment
and referral
To increase the training and education
of lay-workers and peer-counselors to be able to ASSESS,
CLASSIFY, and IDENTIFY the particular signs of the “at-risk” child in
need of treatment and referral
To empower healthcare workers through IMCI training to
be able to ASSESS, CLASSIFY,and IDENTIFY anything unusual
about the general health of the child,and to recognize whether what
is unusual is nothng to worry about (IMCI green),can be successfully hometreated with a “follow-up” plan to evaluate the child (IMCI yellow),or whether an
immediate “urgent” referral is needed (IMCI red or pink)
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SPECIFIC COMPONENTS OF THE IMCI STRATEGY
The Child with a Cough
The Child with Diarrhea
The Child with Fever due to Malaria
The Child with Fever due to Measles
The Child with an Ear Problem
The Child with Malnutrition and Anemia
The Immunization status of the Child
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Advantages/Disadvantages of each IMCI component
In the IMCI strategic plan, the child is observed first
for any of the “general danger signs” of:
1) convulsions
2) vomiting everything up
3) not able to breastfeed or to drink well
4) Lethargy
If any general danger sign is observed, code is Red; referral is “urgent” and
“immediate”
Identify the child for the possibility of having
pneumonia:
To Classify Pneumonia as Severe or depends on the Age of Child:
fast-breathing (greater than 50 breaths/minute
if the child is age 2 months-12 months),or
(greater than 40 breaths/minute if the child is between 12 months -5 years )
If the child also has chest-retractions (indrawn-chest) then, put the child on
an antibiotic for 5-days (eg, co-trimoxazole)
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Advantages of the IMCI strategic plan applied to the Child
with a Cough component are:
IT IS AN EASY METHOD TO TEACH A HEALTHCARE WORKER (HCW)
TO COUNT THE NUMBER OF BREATHS PER MINUTE (TACHYPNEA)
OR TO OBSERVE CHEST-INDRAWING AS A DIAGNOSTIC CRITERIA
FOR PNEUMONIA
 Disadvantages of the IMCI strategic plan are that there is a potentially-high “False Negative
“possibility (ie, problems in design and construction with “Sensitivity”):
 The child classified by the IMCI strategic plan as not having pneumonia could have pneumonia
 The child who is misclassified and does have Pneumonia
could develop severe disease from lack of treatment which may have been able to make a difference
Some types of pneumonia are NOT characterized by tachypnea (eg, Mycoplasma pneumonia,
or Tuberculosis, and the IMCI classification makes no mention of, or provision for, this possibility
Another potential disadvantage is that the Health Care Worker (HCW) may not have a watch
to be able to count the number of breaths per minute; also, Fast-breathing could be due to Malaria !
Another possible Disadvantage could be that the IMCI does NOT have ANY “general danger
signs” for infants less than 2 months, or for children greater than 5-years of age;
For infants less than 2 months, Bacterial infection and Diarrhea have to be used instead
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THE CHILD WITH DIARRHEA
Management of the child with Diarrhea involves
the assessment of the child for Severe Dehydration
(IMCI code red for “urgent” immediate referral);
Moderate Dehydration with ORS given at home, (IMCI code yellow);
Continue Breastfeeding frequently throughout the day (IMCI green);
Assessment
Teaching the Healthcare worker to look at the
stool for the presence of blood; if no blood is seen, no Shigella;
then, assess the child for the presence of “sunken-eyes”,
“irritability” or “restlessness” or the “child’s inability to
breastfeed, bottle-feed, to drink from a cup, or to eat solids well.
The Healthcare worker is taught that a “lethargic” child
who is not drinking or eating well is the case-definition for “dehydrated”
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The Child with Diarrhea (continued)
 The Healthcare worker is taught that the child
with sunken eyes, who is irritable, with a pinch-test slow
to return to normal has “moderate dehydration”
The Healthcare worker is instructed to give fluids and foods at home
if the dehydration is not severe
and to have follow-up in 5-days if there is no improvement
The Healthcare worker is instructed that any diarrhea lasting more than
14 days is classified “Persistent Diarrhea”
The Healthcare worker is instructed that any sign of blood in the
stool is considered “dysentery” and the child then needs antibiotic
treatment for Shigella
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Advantages of the IMCI approach to managing Diarrhea are:
 The Healthcare worker has a reference guide to the severity and
duration of diarrhea
 Diarrhea greater than 14 days is “Persistent Diarrhea”
 Blood in the stool is considered to be “dysentery”
 The Healthcare worker is given a severity-index to
“Mild-Moderate-Severe“ Dehydration, and is taught to
administer fluids to correct fluid-imbalances, and to
encourage the mother to continue breastfeeding frequently
throughout the day and night to provide a source of fluids
to correct the dehydration in the child
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Disadvantages to the IMCI approach to the Management of
the Child with Diarrhea include:
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There is no mention about the color of the urine
Normal urine will appear pale-to-clear in color
The urine of a dehydrated child will be dark in color
A child who is severely-dehydrated is often too weak to
cry,so is often mistakenly considered to be a “good baby”
who never cries or makes a fussy noise
A lethargic child does not have to necessarily be dehydrated
Lethargy may be due to other conditions such as
Meningitis, or severe Anaemia from Malaria
This is not accounted for under the IMCI guidelines
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The Child with a Fever due to Malaria or Measles:
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The Healthcare worker is instructed to assess the malaria risk for areas to which malaria is known to be
endemic, or non-endemic.
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The Healthcare worker is taught to keep a record of whether or not the fever lasts for greater than 7 days
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To distinguish between fever due to malaria, or fever due to Measles virus, the mother or caregiver is shown how to look
for mouth ulcers,Koplik spots,pus draining from the eye, corneal claudication as signs pathognomonic of Measles
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The Healthcare worker is taught to treat fever (temp. Greater than 38.5 degrees) by administering paracetamol if there
is no evidence of pneumonia (or Fast-breathing)
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If pneumonia ( tachypnea, or fast-breathing), assess for Malaria , if in a endemic malaria location.
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If in a malarious area, treat for high-risk malaria possibility by giving anti-malarial drugs
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If in a low–risk malarious area, treat with co-trimoxazole for 5 days
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Malaria can be ruled-out by the absence of fever and/or absence of alternating hot-sweats and cold chills
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Healthcare worker is taught to Assess for Measles by looking for Koplik spots and mouth ulcers
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Health care worker is taught to treat mouth ulcers with gentian violet; treat eye-infection with eye-ointment
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If Measles,Healthcare worker is taught to give large amounts of Vitamin A and to follow-up with patient in 2 days
ADVANTAGE of TREATMENT OF CHILD WITH FEVER:
Fever lasting greater than 7 days is urgent; is easy to r/o malaria by absence of fever , or by Fever in a non-endemic
area for malaria
DISADVANTAGE: No mention of the importance to continue Breastfeeding during a fever;
Breast milk is major source of Vitamin A and anti-pyretic cytokines and immune factors
DISADVANTAGE: Diarrhea could be another important cause of fever that is not mentioned in the IMCI protocol
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The Child With Ear Pain
 Teach the Healthcare worker to look for discharge draining from the ear
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for less than 14 days (Acute OM) or for more than 14 days (Chronic OM); if
greater than 14 days, consider ear pain Urgent and refer
If ear pain is less than 14 days, Teach the HCW to treat and send home
with a “follow-up” plan in 5 days
Teach the Healthcare worker to administer antibiotics for 5 days (Acute
OM) and to Dry the ear with wick (Chronic OM)
Advantages: Simple easy-to-follow regimen which can treat and Cure most
child ear problems
Disadvantage: No mention is made of the importance in holding the child
while feeding to prevent milk-drainage into the eustachian tube & ear canal
which can introduce lactose as a nutrition source for bacterial growth in the
ear; breastfeeding protects the child from external ear-rotation & limits
milk-drainage to the middle-ear thus reducing the likelihood of Acute
Otitis Media
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The child with Malnutrition and Anemia
Instruct the Healthcare worker to look for
signs of visible, severe wasting; if severe wasting is seen, consider IMCI code red, and refer immediately
Instruct the Healthcare worker to look at the palms of
the hands for evidence of severity of pallor; if severe pallor (anemia), Give Vitamin A and Refer
Instruct the Healthcare worker to examine both feet for
signs of Edema and fluid retention (ascites due to malnutrition and Kwashiorkor)
If less-severe signs of pallor are found, instruct the Healthcare worker to give iron to the child and
follow an “at-home” protocol with iron and then bring the child back for a “follow-up” visit
If the child has pallor and is also in an area which is endemic for Malaria,
then instruct the Healthcare worker to give “anti-malarial” medications to the child
Instruct the Healthcare worker to assess the child for malnutrition by the weight/age
indicator system
Advantages: The color of the palmar creases of the hands is an excellent indicator of anemia because
it shows delayed capillary-filling time very clearly in Pallor which reflects the lack of oxyhemoglobin
Disadvantage: Pallor of the nail beds from delayed capillary-refilling is a much more reliable method
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Assessment of feeding problems: Counseling the Mother
 Assess the age of the child to determine if he/she is greater than 4months old, or less than 4-months old
 If the child is greater than 4-months old, determine if the mother is
still breastfeeding exclusively, or is now beginning to do
complementary feedings (with bottle-milk and weaning foods)
 If the mother is using a bottle, the health worker may recommend that
the mother substitute a cup for the bottle, and show the mother how to
feed the child from a cup
 If mother is doing both breast-and-bottle feeding, determine which
method she is using most-0ften; encourage breastfeeding
 Help the mother to increase her breast milk supply by giving more
frequent feedings throughout the day and night
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Assessment of feeding problems: Counsel the
Mother
 Is the baby’s chin touching the breast?
 Is the baby’s mouth wide open (like a fish-mouth)?
 Is the baby’s lower-lip turned outward?
 Is more of the areola visible above than below the mouth?
 A ll of the above signs should be present if the “latch” onto
the breast (or, the “attachment” is good)
 Does the infant take slow deep (audible) sucks?
 Does the infant have any white patches (thrush) in the mouth?
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Assessment of Feeding Problems: Counseling the Mother
If the mother is having problems breastfeeding a younger child (2
months or less than 2 months),
 The Healthcare worker should instruct the mother that the child
should be assessed for visual cues that he/she is hungry and is ready to
take the mother’s breast
 (Non-verbal )Visual Cues of readiness should be observed:
the baby may be trying to suck his/her fingers or
trying to put the toes into his/her mouth
the baby is displaying “mouthing behavior” indicating
he/she is ready to feed
verbal cues (eg, “crying”) are often “late-signs” of hunger that has
turned to unmanageable distress and frustration and screaming
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Counseling the Mother
mother
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The healthcare worker should instruct the
to breastfeed as much as possible during the day and at
night, gradually reducing other milk and/or weaning foods
The mother should be taught how to assess the child that breastfeeding is going
well:
Look for 6 -8 wet-diapers per 24-hours; if less than 6 wet-diapers x2 days, refer
Look for 1-3 formed stools per 24-hours (or, q.48hrs)
Examine the breasts before a feed: they should be “firm and full”
Examine the breasts after a feeding should be “softer “and easier for “latch”
Examine the baby’s fontanelle, and “skin pinch-test” for dehydration signs
Examine the color of the urine: non-concentrated urine should be clear-to-pale
in color; concentrated urine may be darker and a sign of dehydration
Dehydration may often present as a “good baby” who is too weak to ever cry
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Assessment of the Immunization status of the child
Instruct the Healthcare worker to assess the child for any vaccinations that may
have been given already or to administer the vaccine herself/himself
addcording to the recommended schedule of (BCG at birth, OPV at birth, DPT
at 6 wk, 10 wk, and 14 wk)
Instruct the Healthcare worker to assess the child for any vaccine-preventable
diseases (VPD) where the child needs to be given a vaccine booster for
previous vaccine injections, or a new vaccine at a later age (eg,MMR at 9 mo)
Advantages: vaccines create an antibody -titer to protect against common
childhood diseases
Disadvantages: Instruct the Healthcare worker NOT to give BCG to a child
with HIV/AIDS
Instruct the Healthcare worker NOT to give the 2nd or 3rd DPT
within 3 days of a convulsion or seizure following the last DPT