MARLYN M.

GEOPANO, RN,MAN
IMCI is an integrated IMCI
approach to child health that
focuses on the well-being of
the whole child.

IMCI aims to reduce death,

illness and disability and to
promote improved growth
and development among
children under five years of
age.
 IMCI
• A strategy that does not
intended to give curative care
but to address aspects of:
 Nutrition
 Immunization
 Important elements of disease
prevention and health
promotion
 Initiated in 1992
 Conducted in Sarangani and
Zamboanga del Sur
 Inequities of Child Health
• 1990 ( UNICEF and WHO) respond to
challenges, developing a strategy called IMCI
• 1990 reported cases of death among children
are:
• Pneumonia
• Diarrhea
• Malaria
• Measles
• Neonatal causes ( malnutrition)
 Inequities of Child Health
• DHEPCSI ( Department of Health Essential
Package of Child Survival Interventions)
addressses these situation by:
• Skilled attendant (pregnancy, childbirth and
immediate postpartum
• Care for newborn
• breastfeeding
 Inequities of Child Health
• DHEPCSI ( Department of Health Essential
Package of Child Survival Interventions)
addressses these situation by:
• Immunization (children and mothers)
• Micronutrient supplementation
• Use of insecticide treated bed nets (malaria)
• IMCI
 Objectives of IMCI
1. Reduce death
2. Decrease frequency and severity of
illness and disability, and
3. Contribute to improved growth and
development
 Components of IMCI
1. Improving case management skills of health
workers
 Case management and standards
 Training of facility based health providers
 Maintenance of competence among trained
health care workers
 Components of IMCI
2. Improve the health systems to deliver IMCI
- District planning and management
- Availability of IMCI drugs
- Organization of work at health facilities
- Quality improvement and supervision at
health facilities
 Components of IMCI
2. Improve the health systems to deliver IMCI
- Referral pathways and services
- IMCI and health sector reforms
 Components of IMCI
3. Improve family and
community health practice
 Care seeking, nutrition
 Home case management
 Adherence to recommend
treatment
 Community involvement in
health planning and
monitoring
Rationale for an integrated approach
in the management of sick children
• Majority of these deaths are caused by
5 preventable and treatable conditions
namely: pneumonia, diarrhea, malaria,
measles and malnutrition. Three (3) out of four
(4) episodes of childhood illness are caused by
these five conditions
• Most children have more than one illness
at one time. This overlap means that a single
diagnosis may not be possible or appropriate.
 Who are the children covered by the
IMCI protocol?
• Sick children birth up to 2 months (Sick Young
Infant)
• Sick children 2 months up to 5 years old (Sick
child)
 Principles of IMCI
 All sick children must be routinely assess for
major symptoms
a. 2 months – 5 years
b. 1 week to 2 months
 Strategies/Principles of IMCI

All sick children aged 2 months up to 5

years are examined for GENERAL DANGER
signs
and all Sick Young Infants Birth up to 2
months are examined for VERY SEVERE
DISEASE AND LOCAL BACTERIAL INFECTION.
These signs indicate immediate referral or
admission to hospital
>The children and infants are then assessed for
main symptoms.
• For sick children, the main symptoms include:
cough or difficulty breathing, diarrhea, fever and
ear infection.
• For sick young infants, local bacterial infection,
diarrhea and jaundice. All sick children are
routinely assessed for nutritional, immunization
and deworming status and for other problems
Only a limited number of clinical signs are
used based on evidence of their sensitivity
and specificity to detect disease. These signs
were selected considering the conditions of
realities in the first level facility
A combination of individual signs leads to
a child’s classification within one or more
symptom groups rather than a diagnosis.
Classification are color coded
IMCI guidelines address most but not all of
the major reasons a sick child is brought to the
clinic.
IMCI management procedures use limited
number of essential drugs and encourage
active participation of caretakers in the
treatment of children
Counseling of caretakers on home care,
correct feeding and giving of fluids, and when
to return to clinic is an essential component of
IMCI
 Strategies
• Integrated case management of sick children
• Nutrition
• Immunization
• Other disease prevention
• Prevention injuries
• Psychosocial support stimulation
 BASIS FOR CLASSIFYING THE CHILD’S
ILLNESS
• The child’s illness is classified based on
a color-coded triage system:
• PINK- indicates urgent hospital referral or
admission
• YELLOW- indicates initiation of specific
Outpatient Treatment
• GREEN – indicates supportive home care
 Case Management Process
Assessment
• Danger signs
• Main symptoms
• Nutritional Status
• Other problems
 Case Management Process
Classification
• Pink row- needs urgent referral
• Yellow row – OPD Basis
• Green Row- Home treatment or
management
 Check for Danger Signs
1. Convulsions
2. Abnormal sleepy or difficult to awaken
3. Inability to drink or breastfeed

Assess Main Symptoms

•Cough/ difficulty breathing
•Diarrhea
•Fever
•Ear Problems
 Assess Nutrition and Immunization Status and
Potential Feeding Problems

Check for other problems

Classify conditions and Identify treatment actions

According to the color – coding treatment
 Urgent Treatment at Home
Referral OPD Management

•Pre- referral •Treat local •Home

Treatment infections Treatment
•Advise •Give oral •Feeding and
parents drugs Fluids
•Refer child •Advise and •When to
teach return
caretakers immediately
•Follow up
 Urgent Treatment at Home
Referral OPD Management

Referral Facility
ETAT (
Emergency
triage and
Treatment)
Diagnosis
Treatment
Monitoring and
Follow up
 Steps of the IMCI Case management
Process
• The following is the flow of the IMCI process. At the
out-patient health facility, the health worker should
routinely do basic demographic data collection, vital
signs taking, and asking the mother about the child's
problems. Determine whether this is an initial or a
follow-up visit. The health worker then proceeds with
the IMCI process by checking for general danger signs,
assessing the main symptoms and other processes
indicated in the chart below.
• Take note that for the pink box, referral facility
includes district, provincial and tertiary hospitals. Once
admitted, the hospital protocol is used in the
management of the sick child.
 Assess and Classify the SICK
CHILD Aged 2 Months Up to 5
Years
Chart describes how to assess and classify the
sick children so that signs of the above
conditions are not overlooked
A child who has one or more of the main
symptoms could have a serious problem
ASK THE MOTHER WHAT THE CHILDs
PROBLEMS ARE

When you see the mother and the sick child:

• Greet the mother appropriately
• Use good communication and reassure the mother that her
child will receive good care
- Listen carefully to what the mother tells you
- Use words that the mother understands
- Give the mother time to answer the questions
- Ask additional questions when the mother is not sure about her
answer
 Check for DANGER SIGNS

Check ALL sick children for general

danger signs
• The child is not able to drink or
breastfeed
• Vomits everything
• Child has convulsions
• Child is abnormally sleepy or difficult to
awaken
A child with ANY of the danger signs has a serious
problem and needs URGENT referral to the hospital

Ask: Is the child able to drink or breastfeed?

 Signs: he/she is too weak to drink and is not able to
suck or swallow when offered a drink
 If not sure of mother’s answer, ask her to offer a
child a drink– check the response
 Bfeeding child have difficulty sucking when their
nose is blocked, clear it first
Ask: Does the child vomit everything?
Sign: if a child is not able to hold anything down

Ask: Has the child has convulsions?

- Use other terms, “fits”, “spasms” or “jerky
movements” that the mother understands
LOOK: See if the child is abnormally sleepy or
difficult to awaken
 Abnormally sleepy child- drowsy and does not show
interest in what is happening around him/her
 Does not look at his/her mother or watch your face
when you talk
 May stare blankly and does not notice what is going
on around
 Does not respond when touched, shaken or spoken to
 COUGH OR DIFFICULT
BREATHING
Assess Cough or Difficult Breathing
(Pneumonia)
2 Clinical Signs:
• Fast Breathing
• Chest Indrawing
Child with cough or difficult breathing is assessed for
 How long the child has had cough or difficult
breathing
 Fast breathing
 Chest indrawing
 Stridor in a calm child
• Fast Breathing
 Count breaths/ minute (child must be calm if asleep
do not wake him/her up)
 2 months – 12 months: FB is 50 or more cpm
 12 months – 5 years : FB is 40 or more cpm
LOOK for CHEST INDRAWING
• Lift the child’s shirt
• Lower chest wall(lower ribs) goes IN when child
breathes IN
• If not present: ask mother to change child’s position
so the child is LYING FLAT
If still you do not see it: NO CHEST indrawing
LOOK and LISTEN for stridor
Stridor- harsh noise when the child breathes in
- Caused by swollen larynx, trachea, epiglottis whicj
interferes with air entering the lungs
- Life threatening when swelling causes the child’s
airway to be blocked
- Put your ear near the child’s mouth and see if it is
present as the child breathes in (listen when child is
calm) while looking at the abdomen (Hoarse sound
during inspiration
Wheezing – sound heard when child breathes out
 Classify or Difficult Breathing
Classify - to make a decision about the severity
of illness
- Not exact diagnoses
- Categories that are used to determine the
appropriate action or treatment
Case:
Dan is 6 months old. He weighs 5.5 kg. His
temperature is 38 C. His mother says he has been
coughing for two days now. His mother says that he is not
able to breastfeed. He has not vomited during his illness.
He has not had convulsions. Dan is not abnormally sleepy
or dificult to awaken.
His mother says he has been coughing for two days.
The health worker counts 58 bpm. He does not see any
chest indrawing nor hear stridor.
Record Dan’s signs on the recording form
Using CLASSIFICATION box, how would you
classifiy his illness
 Assess Diarrhea
 Assessed for
How long the child has had diarrhea
Blood in the stool to determine if the child has
dysentery
Signs of dehydration
Answer: No – do not assess further for signs r/t
diarrhea
 Assess Diarrhea
Answer: YES– consider a case of DYSENTERY
Look and FEEL for the ff signs of dehydration:
 Abnormally sleepy or difficult to awaken
 Restless and irritable
 Sunken eyes
 Offer the child water
 Assess Diarrhea
 Offer the child water
Not able to drink –not able to take fluid in his
mouth and swallow it
Drinking poorly – weak and cannot drink with
help
- Swallows only when
Fluid is put on
mouth
 Assess Diarrhea
 Offer the child water
Drinking eagerly –THIRSTY – the child wants
to drink and could be reaching out for the cup or
spoon when you offer water
 Assess Diarrhea
Pinch skin of the abdomen
- Does it go back : very slowly (longer than 2 seconds)
- Put the child on his back with arms at his sides. Locate
area halfway between umbilicus and the side of the
abdomen. Using your thumb and index finger in line up
and down the child’s body and not across, firmly pick
up all the layers of the skin and the tissue under it.
Pinch it for one second and then release it. Look to see
if the pinched skin goes back
Classify Dehydration
Classify Dehydration
 2 or more signs in PINK : SEVERE
DEHYDRATION
 If none is seen on pink row, go down to yellow row
 If 2 or more signs in YELLOW : SOME
DEHYDRATION
 If none is seen on yellow row go down to GREEN:
NO DEHYDRATION
 If one sign is present in PINK and one in Yellow
classify him on YELLOW: SOME DEHYDRATION
Classify PERSISTENT DIARRHEA
 Diarrhea is 14 days or more, which has no signs of
dehydration
 Severe persistent diarrhea for 14 days or more and
also has some severe dehydration
Classify DYSENTERY
 A child with diarrhea and blood in the stool is
classified as having dysentery
Note: A child with diarrhea may have one or more
classifications for diarrhea
Case: Dawn is 14 months old. She weighs 12 kg. Her
temperature is 37.5C. Her mother says she has had
diarrhea for 3 weeks. Dawn does not have any general
danger signs and she does not have cough or difficult
breathing. The mother says she does not have blood in
her stool. The health worker notes that Dawn is irritable
throughout the visit. Her eyes are not sunken. She
drinks eagerly when offered water. Her skin pinch goes
back immediately

Record Dawn’s signs on the form

 FEVER
Assess and Classify FEVER
A child with fever may have malaria,measles or other
severe diseases. Or a child with fever may have simple
cough or cold or other viral infections.
Malaria
> is a serious and sometimes fatal disease caused by a parasite
that infects a type of mosquito which feeds on humans. Once an
infected mosquito bites a human, the parasites multiply in the
host’s liver before infecting and destroying their red blood cells.
People who get malaria are usually very sick with symptoms such
as high fevers, shaking chills, and flu-like illness.

It is transmitted to humans through the bite of the Anopheles

mosquito.
 Category A Provinces ( no significant improvement)
o Apayao, Kalinga, Ifugao, Mt. Province, Isabela, Cagayan,
Quirino, Zambales, Palawan, Mindoro Occidental, Quezon,
Zamboanga del Sur, Bukidnon, Misamis Oriental, Davao
Oriental, Davao del Sur, Davao del Norte, Compostela
Valley, Saranggani, Agusan del Sur, Agusan del Norte,
Surigao del Sur, Tawi-tawi, Sulu, Basilan
· · ·
Category B Provinces ( has improvement)
o Abra, Ilocos Norte, Pangasinan, Nueva Vizcaya, Tarlac, Nueva
Ecija, Bulacan, Bataan, Aurora, Laguna, Rizal, Romblon,
Mindoro Oriental, Camarines Norte, Camarines Sur,
Zamboanga del Norte, South Cotabato, North Cotabato, Sultan
Kudarat, Lanao del Sur, Lanao del Norte, Maguindanao, Surigao
del Norte
Category C Provinces (significant reduction)
o Benguet, Ilocos Sur, La Union, Batanes, Pampanga, Batangas,
Cavite, Marinduque, Masbate, Albay, Sorsogon, Aklan, Negros
Occidental, Negros Oriental, Eastern Samar, Western Samar,
Misamis Occidental, Surigao del Norte

Category D Provinces
o Provinces that are already malaria-free (no more
indigenous cases for at least 3 years)
o Some are potentially malarious due to the presence of the
vector
o Cebu, Bohol, Catanduanes, Aklan, Capiz, Guimaras,
Siquijor, Biliran, Iloilo, Leyte Norte, Leyte Sur, Northern Samar,
Camiguin
A child who lives in these areas or who has visited and stayed
overnight in the past 4 weeks or who has had blood transfusion
for the past 6 months.
If you do not have information always assume that
children under 5 years old who have fever are at
risk for malaria
MEASLES
 Measles is a childhood infection caused by a virus.
 Signs and symptoms of measles include cough,
runny nose, inflamed eyes, sore throat, fever and a
red, blotchy skin rash.
 called rubeola,
MEASLES
Complications:
 Diarrhea
 Pneumonia
 Mouth ulcers
 Ear infection
 Severe eye infection ( lead to corneal ulceration and
blindness)
 Encephalitis (inflammation of the brain)
DENGUE HEMORRHAGIC FEVER
 a mosquito born disease caused by the dengue virus
 Symptoms typically begin three to fourteen days
after infection
 include a high fever, headache,
vomiting, muscle and joint pains, and a
characteristic skin rash
A child has the main symptom of fever if
 The child has a history of fever
 The child feels hot
 The child has an axillary temperature of 37.5 or
above
If the child has fever, determine
 How long he had it
 History of measles
 Stiff neck could be a sign of meningitis or
encephalitis
 Runny nose- common colds
 Signs of measles: rash, cough, runny nose red eyes
 If child has measles within last 3 months assess for
measles complications –mouth ulcers, pus draining
from the eyes(conjunctivitis) and clouding of the
cornea (Vit A deficiency)
Then for all children with fever
 Decide dengue fever risk
 If with risk assess signs of dengue:
>nosebleeding, gums, vomitus, stools
 petechiae in skin,
 cold clammy extremities,
 slow capillary refill ( more than 3 seconds)
 Persistent abdominal pain
 Persistent vomiting
If all above symptoms are negative and child is 6
months and older with fever in dengue risk area
perform tourniquet test
• Torniquet Test
1. Take child’s blood pressure
2. Inflate the cuff halfway between systolic and
diastolic pressures for 5 minutes (add systolic and
diastolic pressures and divide two)
3. Release pressure and draw one inch size square
below cuff. Count the number of petechiae inside
the square. If there are 20 or more the test is
positive
 Classify FEVER

Malaria – there is a risk has

fever, no runny nose, no
measles has + blood smear
Note: The child with fever and general danger sign of stiff neck will have been classified
already as having VERY SEVERE FEBRILE DISEASE
Case:
Simon is 10 months old. He weighs 8.2 kg. His temp is
37.5 C. His mother says he has a rash and cough. The
health worker does not see any general danger sign.
Simon is able to drink, has not vomited, does not have
convulsions and is not abnormally sleepy or difficult to
awaken. His mother says he has been coughing for five
days and his respiration is counted at 43 per minute. No
chest indrawing is seen and no retraction is heard.
Simon does not have diarrhea.
Next, the health worker asks Simon’s fever. There is
malaria risk. Simon has felt hot for 2 days. He does not
have a stiff neck. The health worker notices runny nose.
The health center has no facility for blood smear.
Simon is noted to have rashes covering his whole
body and his eyes are red. No mouth ulcer is seen and
although his eyes are red. There is no pus draining f
rom it and his corneas are clear. They live in Tondo
where there are reported cases of dengue. He has no
sign though of bleeding, black vomitus or stool or
abdominal pain

Fill up the recording form