The Integrated Case Management Process The IMCI process can be used by doctors, nurses and other health

care professionals who see sick infants and children aged 1 week to 5 years. It is a case management process for a first-level facility such as clinic, health center, or the outpatient department of a hospital. Three Components of the IMCI 1. Upgrading the case management and counselling skills of health care providers 2. Strengthening the health system for effective management of childhood illness. 3. Improving family and community practices related to child health and nutrition The complete IMCI case management process involves the following elements: ASSESS a child by checking first for danger signs, asking questions about common conditions, examining the child and checking nutrition and immunization status. Assessment includes checking the child for other problems CLASIFY a childs illness using color-coded triage system. Because many children have more than one condition, each illness is classified according to whether it requires: Urgent pre-referral treatment and referral (PINK), or Specific medical treatment and advice (YELLOW), or Simple advice on home management (GREEN) After classifying all conditions, IDENTIFY specific treatments for the child. If the child requires urgent referral, give essential treatment before the patient is transferred. If the child needs treatment at home, develop an integrated treatment plan for the child and give the first dose of drugs in the clinic. If a child should be immunized, give immunization. Provide practical TREATMENT instructions, including teaching the caretaker how to give oral drugs, how to feed and give fluids during illness, and how to treat local infections at home. Ask the caretaker to return for follow-up on a specific date, and teach her how to recognize signs that indicate that the child should return immediately to the health facility.

Assess feeding, including BF practices. COUNSEL to solve any feeding problems found. Then, counsel the mother about her own health. When a child is brought back to the clinic as requested, GIVE FOLLOW-UP CARE and, if necessary, reassess the child for new problems.

The Principles of Integrated Care

The IMCI guidelines are based on the following principles:

All sick must be examined for GENERAL DANGER SIGNS, which indicate the need for immediate referral or admission to the hospital. 1. All sick children must be routinely assessed for major symptoms. For children aged 2 months to 5 years: cough, difficulty of breathing, diarrhea, fever, ear problem. For children aged 1 week to 2 months: bacterial infection and diarrhea. 2. Only a limited number of carefully-selected clinical signs are used, based on evidence of their sensitivity and specificity to detect disease. These signs were selected considering the conditions and realities of first-level health facilities. 3. A combination of individual signs leads to a childs classification/s rather than diagnosis. The classifications are color-coded. 4. The IMCI guidelines address most, but not all, of the major reasons a sick child is brought to the clinic. 5. IMCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of children. 6. An essential component of the IMCI guidelines is the counselling of caretakers about home management, including counselling about feeding, fluids, and when to return to a health facility.

ASSESS

ASK THE MOTHER WHAT THE CHILDS PROBLEM ARE

When you see the mother and the sick child: Greet the mother appropriately Use good communication and reaasure 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 GENERAL DANGER SIGNS

Check ALL sick children for general danger signs The child is not able to drink or breastfeed The child vomits everything The child has convulsions The 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? A child has this sign if he/she is too weak to drink and is not able to suck or swallow when offered a drink. If you are not sure about the mothers answer, ask her to offer the child a drink. Look to see the childs response.

 Breastfeeding children may have difficulty sucking when their nose is blocked, clear it first. ASK: does the child everything? A child who is not able to hold anything down at all has the sign vomits everything. ASK: has the child had convulsions? Use other terms for convulsions like fits, spasms, or jerky movements, which the mother understands. LOOK: see if the child is abnormally sleepy or difficult to awaken. An abnormally sleepy child is drowsy and does not show interest in what is happening around him/her. He/she does not look at his/her mother or watch your face when you talk. He/she may stare blankly and does not notice what is going on around him/her. He/she does not respond when she/he is touched, shaken, or spoken to.

THEN ASK ABOUT THE MAIN SYMPTOMS:

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

I.

ASSSESS COUGH OR DIFFICULT BREATHING. A child with cough or difficult breathing may have pneumonia or another severe respiratory infection. The health worker can identify almost all cases of pneumonia by checking for these two clinical signs: FAST BREATHING AND CHEST INDRAWING. A 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.

In determining fast breathing, COUNT the breaths in one minute. Remember that the child must be calm so if the child is sleeping, do not wake the child up. The cuttoff for fast breathing depends on the childs age. 2 months-12 months (11 months and 29 days): 50 or more breaths per minute 12 months-5 years (4 years, 11 months and 29 days): 40 or more breaths per minute

LOOK for chest indrawing. Lift the childs shirt to do this. Chest indrawing is when the lower chest wall (lower ribs) goes IN when the cild breathes IN. If you are not sure if this is present, ask the mother to change the childs position so he/she is LYING FLAT. If you still do not see the lower chest wall go INas the child breathes IN, there is NO chest indrawing. For chest indrawing to be present, it must be clearly visible and present ALL THE TIME. If seen only during feeding or crying, there is NO CHEST INDRAWNG. Intercostal indrawing is NOT chest indrawing.

LOOK and LISTEN for stridor. Stridor is a harsh noise when the child breathes in. This could be caused by a swollen larynx, trachea, or epiglottis, which interferes with air entering the lungs. It could be life-threatening when swelling causes the childs airway to be blocked. To listen for stridor, put your ear near the childs mouth and see if it is present as the child breathes in. Be sure to listen for stridor only when the child is calm. If the sound is heard when the child breathes out, this is wheezing and NOT stridor

II.

CLASSIFY COUGH OR DIFFICULT BREATHING. CLASSIFY means to make a decision about the severity of illness. They are not exact disease diagnoses. Instead, they are categories that are used to determine the appropriate action or treatment.

 PINK/RED-NEEDS URGENT ATTENTION AND REFERRAL OR ADMISSION FOR IN-PATIENT CARE-SEVERE CLASSIFICATION YELLOW-APPROPRIATE TREATMENT GREEN-HOME MANAGEMENT

SIGNS Any General danger sign; or Chest indrawing; or Stridor in calm child Fast breathing No signs of pneumonia or very severe disease

CLASSIFY AS SEVERE PNEUMONIA OR VERY SEVERE DISEASE

TREATMENT

PNEUMONIA NO PNEUMONIA; COUGH, OR COLD