Integrated Management of Neonatal &

Childhood Illnesses (IMNCI)

IMNCI Algorithm
IMNCI?

WHO/UNICEF have developed a new

approach to tackling the major diseases of
early childhood called the Integrated
Management of Childhood Illnesses (IMCI)

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Developments related to child health
1978: EPI
1984: UIP
1985: Oral Rehydration Therapy
1990: UIP and ORT universalized,ARI as a pilot in 26 districts
1992: CSSM
1997: RCH-1
2005: NRHM and RCH II
2009: NSSK
2011: JSSK
2013: NRHM and NUHM divided as sub-missions of NHM

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Why IMNCI
• Reduce infant and child mortality rates
• Improving child health & survival
• IMR reduced from 114 (1980) to 53 (2008 SRS
bulletin)
• Decline not uniform across states
• 8 states including Rajasthan are below
national average
• Malnutrition and low birth weight (LBW) are
contributors to the about 50% deaths

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IMNCI: Status
India Rajasthan
Number of districts
where IMNCI is 156 33
implemented

Total Numbers of
People trained on 124636 16672
IMNCI(30th Nov. ‘09)

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IMNCI Beneficiaries

• Care of Newborns and Young Infants

(infants under 2 months)

• Care of Infants (2 months to 5 years)

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Care of Newborns and Young Infants
(infants under 2 months)
• Keeping the child warm
• Initiation of breastfeeding
• Counseling for exclusive breastfeeding
• Cord, skin and eye care
• Recognition of illness in newborn and
management and/or referral
• Immunization
• Home visits in the postnatal period

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Care of Infants (2 months to 5 years)

• Management of diarrhoea, ARI malaria, measles,

acute ear infection, malnutrition and anemia
• Recognition of illness and risk
• Prevention and management of Iron and Vitamin
A deficiency
• Counseling on feeding for all children below 2
years
• Counseling on feeding for malnourished
• Immunization

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IMNCI Components and
Intervention areas

Improve health Improve Improve family

worker skills health & community
systems practices
Case management District & Block Appropriate Care
standards & planning and seeking
guidelines management
Training of facility- Availability of Nutrition
based public health IMNCI drugs
care providers

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IMNCI Components and
Intervention areas
Improve health Improve health Improve family
worker skills systems & community
practices
IMNCI roles for Quality Home case
private providers improvement management &
and supervision adherence to
at health recommended
facilities – public treatment
& private

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IMNCI Components and
Intervention areas
Improve health Improve health Improve family
worker skills systems & community
practices
Maintenance of Referral Community
competence pathways & services planning
among trained services & monitoring
health
Health
Information
System

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Components of IMNCI

Training
Effective implementation
• Improvements to the health system
• Improvement of Family and Community
Practices
Collaboration/coordination with other
Departments

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Components of IMNCI
Training

IMNCI is a skill based training in both

facility and community settings
Broadly, two categories of training are
included
• for medical officers
• for front-line functionaries including ANM’s and
AWW’s

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Components of IMNCI
Effective implementation
 Improvements to the health system
• Ensuring availability of the essential
drugs
• Improve referral
• Referral mechanism
• Functioning referral centers
• Ensuring availability of health workers /
providers at all levels
• Ensuring supervision and monitoring
through follow up visits
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Components of IMNCI
Effective implementation
Improvement of Family and Community
Practices
Counseling of families and creating
awareness which includes:
• Promoting healthy behaviors
• IEC campaigns
• Counseling of care givers and families
• During home visits identify sickness and focused
BCC

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Components of IMNCI

Collaboration/coordination with other

Departments

• Involvement of ANM and AWWs

• Involvement of grass-root
functionaries of other sectors
• Active involvement of PRI, SHGs and
women’s groups

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F-IMNCI

From November 2009 IMNCI has

been re -baptized as F-IMNCI, (F -
Facility) with added component of:
• Asphyxia Management and
• Care of Sick new born at facility level,
besides all other components included
under IMNCI

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Institutional Arrangements

• State Level

• District Level

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State level Institutional
Arrangements
• Appoint Nodal Officer
• Set up a co-ordination Group
• Arrange logistics
• Create pool of State level trainers
• Selection of priority districts
• Review progress
• Identify the State Nodal institute for
training
• Improvement in family and community
practices
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District level Institutional
Arrangements
• Appoint District Coordinator
• Set up an IMNCI Coordination Group
• Train District Trainers.
• Develop a detailed plan for
implementation
• Ensure timely supplies & logistics,
supervision and follow-up
• IEC activities

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Training in IMNCI
Focus on Skill Development

Hands-on training

• Visits to hospitals
• Field visits and visits to the homes of sick
children

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Training in IMNCI

Training at two levels

• In-service training for the existing staff

• Pre-Service Training

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Type of Personnel to be Durat Package Place of
Training trained ion to be Training
used
Clinical Medical Officer 8 Physician Medical
skills and Pediatrician days Package college
training /District
Hospital
Health workers 8 Health District
ANMs, LHVs, days Workers Hospital
Mukhya sevika Package
CDPO’s and
AWWs
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Type of Personnel to Durati Package Place of
Training be trained on to be Training
used
Supervis Medical 2days Superviso Medical
ory Skills Officers, ry Skills college /
Training Pediatricians, package District
CDPO’s LHVs Hospital
and
Mukhiya
Sevikas)

SIHFW: an ISO:9001 certified institution 25

Training of Trainers
• All pediatricians in the district

• Selected medical officers from CHCs

and block PHCs

• Selected staff nurses and LHVs and

CDPO’s and Mukhiya Sevikas from
ICDS

SIHFW: an ISO:9001 certified institution 26

Number to be trained
• Average size District -1800 health staff
will need to be trained

• Number of the staff of other departments

should be included in consultation with
concerned district officers

• Staff belonging to PHC areas may be

taken up fully before moving to another
PHC area

SIHFW: an ISO:9001 certified institution 27

Training Institutions

• State Level

• District Level

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State Level Training Institutions

• Identify a Regional Training Centre

• The Departments of Pediatrics and Preventive

& Social Medicine in each college

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District Level Training Institutions

• District hospital for training of medical

officers

• CHCs/operational FRUs etc for training

of health workers

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Follow-up Training (FUT)

The Follow-up Training is designed to

improve supportive supervision for 2
days which may either be clubbed with
Clinical skills training or conducted
within 6-8 weeks of the initial Clinical
skills training.

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Pre-Service Training

• Training of undergraduate students

and interns

• ANM, AWW, and Staff Nurses’

training schools need to include
IMNCI in their training schedules

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Funding arrangements
National Level training: by the GoI
State Level training: State project funding -
NRHM/RCH-II-PIPs
District Level training: State project funding
-NRHM/RCH-II-PIPs
a. At District Training Cell (in the
District
Hospital)
b. At other Training Centres within the
District (Maximum two in identified
CHCs/PHCs)
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Funding arrangements

• Translation, printing and supply of

training material

• Field-level Monitoring Support,

Follow up and Coordination

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Limitations of IMNCI

• Outpatient Facility Based

• Community activities not given

adequate focus

• Training centre of attention

• Vertical initiatives in Non IMNCI districts

sorely lacking

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ARIs| MANAGEMENT

HISTORY TAKING(8):what are the questions to be asked?

1.Age of the child?

2.How long is the cough present?
3.Is the child able to drink (if between 2m and 5yrs) OR
has he young infant stopped feeding well (< 2m)?
4.Has there been any prior illness?
5.Does the child have fever?
6.Is the child extremely drowsy or difficult to wake?
7.Did the child have convulsions, irregular breathing or short
periods of turning blue?
8.Is there any H/o prior treatment?
ARIs| MANAGEMENT

 PHYSICAL EXAMINATION(8):

1. Count the number of breaths in ONE minute.

For a young infant,count it twice

2. Look for chest indrawing

3.Look and listen for stridor

4.Look and listen for wheeze

5.Is the child abnormally sleepy or difficult to wake?

ARIs| MANAGEMENT

 PHYSICAL EXAMINATION:

6.Feel for fever or low body temperature

7.Check for severe malnutrition. VQ.Why?

8.Check for cyanosis

ARIs| MANAGEMENT

 PHYSICAL EXAMINATION:

DANGER SIGNS: pointers to VERY SEVERE DISEASE

ARIs| MANAGEMENT

 PHYSICAL EXAMINATION: DANGER SIGNS

1.Not able to drink

2.Convulsions
3.Abnormally sleepy or difficult to awake
4.Stridor in a clam child
5.Severe malnutrition
ARIs| MANAGEMENT
NO chest indrawing
No fast breathing
CLASSIFY as
< 60 bpm if child 0-2m
NO PNEUMONIA
<50 bpm if child 2m-12m
< 40 bpm if child 12m-5 yrs

Assess and treat ear problem and sore throat,if present

Assess and treat other problems

Advise mother to give home care

Treat fever and wheezing if present
ARIs| MANAGEMENT
NO chest indrawing
fast breathing
CLASSIFY as
>60 bpm if child 0-2m
PNEUMONIA
>50 bpm if child 2m-12m
>40 bpm if child 12m-5 yrs

Give an antibiotic (Cotrimoxazole pediatric tablet/syrup)

Advise mother to give home care
Treat fever and wheezing if present

Reassess after 2 days

ARIs| MANAGEMENT
•chest indrawing
CLASSIFY as
•fast breathing
• >60 bpm if child 0-2 m SEVERE
>50 bpm if child 2m-12m PNEUMONIA
>40 bpm if child 12m-5 yrs
Other signs
Nasal flaring Grunting
Cyanosis

Give the 1st dose of an antibiotic (Benzyl penicillin,Ampicillin or

Chloramphenicol )

Refer urgently
Treat fever and wheezing if present
ARIs| MANAGEMENT
•chest indrawing
CLASSIFY as
•fast breathing
VERY SEVERE PNEUMONIA
•>60 bpm if child 0-2 m
>50 bpm if child 2m-12m
>40 bpm if child 12m-5 yrs
DANGER SIGNS

Refer URGENTLY to hospital

Give first dose of an abtibiotic
Treat fever,if present
Treat Wheezing,if present
If cerebral malaria is possible,give an antimalarial
ARIs| MANAGEMENT
During reassessment after 2
days

BETTER SAME WORSE

Finish 5-day course Change Antibiotic Refer urgently

or refer
Of Antibiotics
ARIs| MANAGEMENT
During reassessment after 2
days

SAME

Change Antibiotic
or refer
ARIs| MANAGEMENT
Changes in Antibiotic Schedule

1.If getting Ampicillin, change to Chloramphenicol

2.If getting Chloramphenicol, change to either:

Cloxacillin 25 mg/kg/dose IM 6 hourly

Gentamicin 2.5 mg/kg/dose IM 6 hourly
ARIs| MANAGEMENT|Antibiotic
Dosages
1.COTRIMOXAZOLE
AGE WEIGHT TABLET SYRUP
GROUP GROUP
DOSE DOSE IN DOSE DOSE IN
PLAIN ENGLISH PLAIN ENGLISH

0-2 m 3-5 kg 240 mg 1 tab BD 2.5 mL BD ½ tsf BD

2m-1yr 6-9 kg 480 mg 2 tabs BD 5 mL BD 1 tsf BD

1-5 yrs 10-19 kg 720 mg 3 tabs BD 7.5 mL BD 1½ tsf BD

ARIs| MANAGEMENT|Antibiotic
Dosages
1.COTRIMOXAZOLE:Notes about Cotrimoxazole therapy

 Not recommended in age< 2m,premature & neonatal

jaundice
 Strength of pediatric tablet=1/5th Adult strength
CONSTITUENT ADULT PEDIATRIC

Trimethoprim 100 mg 20 mg

Cotrimoxazole 500 mg 100 mg

 Strength of Pediatric Syrup= Each spoon(5mL)= 2 tablets

ARIs| MANAGEMENT|Antibiotic
Dosages
ANTIBIOTIC USAGE IN SEVERE PNEUMONIA

Initial assessment

ANTIBIOTIC DOSE ROUTE

Benzyl Penicillin 50,000 IU per kg/dose x 2 days IM

Ampicillin 50 mg/kg/dose x 2 days IM

Chloramphenicol 25mg/kg/dose x 2 days IM

ARIs| MANAGEMENT|Antibiotic
Dosages
ANTIBIOTIC USAGE IN SEVERE PNEUMONIA

If condition improves, then for the next 3 days, give…

ANTIBIOTIC DOSE ROUTE

Procaine Penicillin 50,000 IU per kg/dose IM

ONCE x 3 days
Ampicillin 50 mg/kg/dose 6 hourly x 3 days oral

Chloramphenicol 25mg/kg/dose 6 hourly x 3days oral

ARIs| MANAGEMENT|Antibiotic
Dosages
ANTIBIOTIC USAGE IN SEVERE PNEUMONIA

If there is NO IMPROVEMENT after 48 hrs,CHANGE to:

INITIAL ANTIBIOTIC CHANGE TO…

Ampicillin Chloramphenicol

Chloramphenicol Cloxacillin

Gentamicin
 ASSESS for MEASLES
Any danger sign
OR SEVERE
Pus from eyes COMPLICATED
Clouding of cornea MEASLES
Deep & Extensive
Mouth Ulcers

Give ONE dose of Vit A

Give TETRACYCLINE ointment for eyes if pus
Refer urgently to hospital
 ASSESS for MEASLES
Typical rash
Clouding of cornea MEASLES WITH EYE
Mouth Ulcers, but OR MOUTH
not Deep & Extensive COMPLICATIONS

Give ONE dose of Vit A

Give TETRACYCLINE ointment for eyes if pus
Refer urgently to hospital
 ASSESS for MEASLES
Typical rash
Clouding of cornea NO MEASLES
Mouth Ulcers, but
not Deep & Extensive

Give ONE dose of Vit A

Give TETRACYCLINE ointment for eyes if pus
Refer urgently to hospital