Integrated Management of Neonatal & Childhood Illness

1. Integrated Management of Neonatal & Childhood Illness (IMNCI)

2. Child Health-Approach in RCH-II • The IMNCI approach is the centrepiece of newborn and child health strategy in RCH II.

3. UNDER-FIVE MORTALITY RANKINGS

4. Recent trends in Neonatal and Infant Mortality Rate Neonatal Mortality Rate shows stagnation; need to act IMR high in Bihar, Chhattisgarh, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and Assam

6. 2020 1990 55% 52% 5% 7% 18% 9% 19% 11% 12% 11% Distribution of deaths of children less than 5 Years, by cause, the world, 1990 and projected for 2020 The 5 main killers of children: ARI, diarrhoea, measles, malaria and malnutrition Perinatal conditions Other communicable diseases Non-communicable diseases Injuries

7. Possible cause or associated condition Pneumonia Severe anaemia malaria P. falciparum Cerebral malaria Meningitis Severe dehydration Very severe pneumonia Pneumonia Diarrhoea Ear infection Pneumonia Meningitis Sepsis For many sick children a single diagnosis may not be apparent or appropriate Presenting complaint Cough and/or fast breathing Lethargy or unconsciousness Measles rash "Very sick" young infant

8. WHO/ UNICEF -Integrated Approach • 3 out of 4 children who seek health care are suffering from at least one of the five conditions • Some children are often suffering from more than one condition, making a single diagnosis impossible • Such children need complete assessment and combined therapy for successful treatment. Integrated Management of Childhood Illness (IMCI) - Focuses on the child and not on the illness Integrated Management of Childhood Illness (IMCI) is a cost-effective approach

10. Share of under-five mortality in India 40% Infant deaths within 7 days of birth Neonatal deaths 50% Infant deaths 76% Infant deaths between 7 days of birth and within 28 days 10% Infant deaths between 28 days and within one year of birth 26% Child deaths between one year and within five years of birth 24% Source : SRS 2007

11. IMCI to IMNCI-INDIAMajor Adaptations The entire 0-5 year period covered including the first week of life 50% of training time for management of young infants (0-2 months) The order of training reversed; now begins with management of young infants Reduced training duration (8 days), separate training materials for physicians & health workers Management now consistent with current policies of the MOHFW, DWCD and NVBDCP

12. IMNCI as a key strategy for improving child health Other disease Management Nutrition Immunization Prevention & of sick newborn & children Promotion of growth and development Integrated Management of Neonatal & Childhood Illness

13. What Needs to be Done in IMNCI  Improving the case management skills of health workers • Improving the health system for effective management of childhood illness • Improving family and community practices

14. Case Management Process Two groups: (A) Young infants : From birth up to 2 months of age. (B) Older children : From 2 months up to 5 years of age.

15. What does IMNCI Offer • IMNCI guidelines address most but not all of the major reasons a sick infant and child is brought to a clinic • Only a limited number of signs based on evidence are used to detect a disease • A combination of individual signs leads to action oriented colour coded classification(s) • IMNCI management includes a limited number of drugs and encourages active participation of caretakers • Counselling of caretakers is an essential component

16. Core interventions to improve child survival • Combating pneumonia/sepsis • Combating diarrhoea • Nurturing newborns (and their mothers) • Infant feeding • Immunization • Combating malaria IMNCI

17. “IMNCI”approach Focused Assessment Classification Treatment Counsel & Follow-up Identify treatment Treat Counsel Caretakers Follow-up Danger signs Main Symptoms Nutritional status immunisation status other problems Need to Refer Specific treatment Home management Standard Clinical Guidelines “Golden” paediatric standard Complete examination all signs and systems Preliminary Diagnosis Laboratory examination Differential Diagnosis Final Diagnosis Treatment strategy Treatment procedures Advise to caretakers Follow- up • Essential Investigations

18. Case Management Process • Assess the Child. • Classify the Illness. • Identify Treatment. • Treat the Child. • Counsel the Mother • Give Follow-Up Care.

19. Assess the Child Tools for assessment: • Ask, • Look, • Listen, and • Feel.

20. Classify The Illness • “Classify the illness” means making a decision on the severity of the illness according to the child’s major symptoms. • Classifications are not diagnoses. • They are categories that are used to determine treatment.

21. CLASSIFICATION

22. IDENTIFY TREATMENT • This is further direction to management • If a child needs urgent referral (hospitalization), give pre-referral treatment • If a child needs treatment at home, explain mother how to do it home • If a child needs immunization, give it

23. TREAT THE CHILD • This explains complete treatment to be given at clinic and at home • This includes teaching the mother (or caretaker) how to give oral drugs, how to feed and give fluid during illness, and how to treat local infection at home • Return for follow up • When to return immediately

24. COUNSEL THE MOTHER • Assess and Counsel the mother to solve any feeding problem found • Counsel on home care • Counsel on when to return immediately • Counsel the mother about her own health

25. Classify ALL YOUNG INFANTS

26. Classification- Pneumonia

27. VIDEOS & PHOTO BOOK Good attachment to Breast lower lip is curled outward baby’s mouth is wide open chin touches the breast lower portion of the areola is not visible

28. VIDEOS & PHOTO BOOK Poor attachment to Breast

29. VIDEOS & PHOTO BOOK Breastfeeding- Correct Positioning

30. Is this baby well positioned ?

31. VIDEOS & PHOTO BOOKSKIN PINCH- DEHYDRATION ASSESSMENT

32. VIDEOS & PHOTO BOOKMORE THAN 10 SKIN PUSTULES

34. VIDEO • GRUNTING- Short expiratory sound, signifies infant having difficulty in breathing- Severe illness • 2 Grunting.wmv

35. VIDEO SIGNS OF SEVERE PNEUMONIA • CHEST INDRAWING- Lower chest wall goes in during inspiration • STRIDOR- Harsh sound when child breathes in • 2 Severe Respiratory Distress_Large.wmv

36. VIDEO • VISIBLE SEVERE WASTING- severe wasting of the shoulders, arms buttocks and legs with ribs easily seen- MARASMUS • 11Severe malnutrition_Large.wmv

37. REMEMBER- SEVERE CLASSIFICATIONS Sick Young Infant age up to 2 months Sick Child age 2 months up to 5 years Severe Pneumonia Or Very Severe Disease Severe Dehydration with another severe classification Severe Persistent Diarrhea Very Severe Febrile Disease Severe Complicated Measles Mastoiditis Severe Malnutrition Severe Anemia • Possible serious bacterial infection • Severe Jaundice • Severe Dehydration • Severe Persistent Diarrhea • Severe Dysentery • Not able to feed- Possible serious bacterial infection OR Severe Malnutrition ACTION- PRE- REFERRAL TREATMENT & URGENT REFERRAL

38. Hospital is the best place for treating a very sick infant/child But if Referral is not possible, IMNCI Guidelines can save a life !

39. TAKE HOME MESSAGE IMNCI--Colour coded case management strategy • PINK CLASSIFICATION: Child needs inpatient care, Provide Pre-referral treatment and Refer Urgently • YELLOW CLASSIFICATION: Child needs specific treatment, provide it at home (e.g. antibiotics, anti-malarial, ORT) • GREEN CLASSIFICATION: Child needs no medicine, advise home care

40. CONCLUSION • The IMNCI Strategy focuses on the diseases of the childhood that cause the greatest global burden. • An integrated approach is needed because the overlap in the signs and symptoms of the major diseases is common.

41. Conclusion(continued) • It is important to treat the child as a whole, not simply the most apparent disease. • The IMNCI approach ensures a complete assessment of a sick child, provision of treatment and counseling the mother to improve health practices at home and to promote health seeking behavior.

42. THANK YOU