Definition
IMCI is an integrated approach to child health that focuses on the well-being of the whole child.
IMCI strategy is the main intervention proposed to achieve a significant reduction in the number of
deaths from communicable diseases in children under five
Goal
By 2010, to reduce the infant and under five mortality rate at least one third, in pursuit of the goal
of reducing it by two thirds by 2015.
Aim
To reduce death, illness and disability, and to promote improved growth and development among
children under 5 years of age.
IMCI includes both preventive and curative elements that are implemented by families and
communities as well as by health facilities.
IMCI Objectives
To reduce significantly global mortality and morbidity associated with the major causes of disease in
children
To contribute to the healthy growth & development of children
IMCI Components of Strategy
Improving case management skills of health workers
§ Improving the health systems to deliver IMCI
Improving family and community practices
**For many sick children a single diagnosis may not be apparent or appropriate
Presenting complaint:
Cough and/or fast breathing
Lethargy/Unconsciousness
Measles rash
“Very sick” young infant
Possible course/ associated condition:
Pneumonia, Severe anemia, P. falciparum malaria
Cerebral malaria, meningitis, severe dehydration
Pneumonia, Diarrhea, Ear infection
Pneumonia, Meningitis, Sepsis
Five Disease Focus of IMCI:
Acute Respiratory Infection
Diarrhea
Fever
Malaria
Measles
Dengue Fever
Ear Infection
Malnutrition
The IMCI Case Management Process
Assess and classify
Identify appropriate treatment
Treat/refer
1
Counsel
Follow-up
The Integrated Case Management Process
Check for General Danger Signs:
A general danger sign is present if:
The child is not able to drink or breastfeed
The child vomits everything
The child has had convulsions
The child is lethargic or unconscious
Assess Main Symptoms
Cough/DOB
Diarrhea
Fever
Ear problems
Assess and Classify Cough of Difficulty of Breathing
Respiratory infections can occur in any part of the respiratory tract such as the nose, throat, larynx,
trachea, air passages or lungs.
Assess and classify PNEUMONIA
Cough or difficult breathing
An infection of the lungs
Both bacteria and viruses can cause pneumonia
Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized
infection).
** 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.
Remember:
** If the child is 2 months up to 12 months the child has fast breathing if you count 50
breaths per minute or more
** If the child is 12 months up to 5 years the child has fast breathing if you count 40 breaths
per minute or more.
Color Coding
PINK YELLOW GREEN
(URGENT REFERRAL) (Treatment at outpatient (Home management)
health facility)
OUTPATIENT HEALTH OUTPATIENT HEALTH HOME
FACILITY FACILITY Caretaker is counseled on:
Pre-referral Treat local infection Home treatment/s
treatments Give oral drugs Feeding and fluids
Advise parents Advise and teach When to return immediately
Refer child caretaker Follow-up
Follow-up
REFERRAL FACILITY SEVERE PNEUMONIA OR Give first dose of an appropriate
2
Emergency VERY SEVERE DISEASE antibiotic
Triage and Give Vitamin A
Treatment Treat the child to prevent low blood
( ETAT) sugar
Diagnosis, Refer urgently to the hospital
Treatment Give paracetamol for fever > 38.5oC
Monitoring,
follow-up
Any general PNEUMONIA Give an appropriate antibiotic for 5
danger sign or days
Chest indrawing Soothe the throat and relieve cough
or with a safe remedy
Stridor in calm Advise mother when to return
child immediately
Follow up in 2 days
Give Paracetamol for fever > 38.5oC
Fast breathing NO PNEUMONIA : COUGH OR If coughing more than more than 30
COLD days, refer for assessment
Soothe the throat and relieve the cough
with a safe remedy
Advise mother when to return
immediately
Follow up in 5 days if not improving
No signs of
pneumonia or
very severe
disease
Assess and classify DIARRHEA
A child with diarrhea is assessed for:
How long the child has had diarrhea
Blood in the stool to determine if the child has dysentery
Signs of dehydration.
Classify DYSENTERY
Child with diarrhea and blood in the stool
Two of the following signs? SEVERE If child has no other severe
Abnormally sleepy or DEHYDRATION classification:
difficult to awaken Give fluid for severe
Sunken eyes dehydration ( Plan C ) OR
Not able to drink or If child has another severe
drinking poorly classification :
Skin pinch goes back Refer URGENTLY to hospital
very slowly with mother giving frequent
sips of ORS on the way
Advise the mother to continue
breastfeeding
If child is 2 years or older and there
is cholera in your area, give
antibiotic for cholera
Two of the following signs : SOME Give fluid and food for some dehydration
Restless, irritable DEHYDRATION ( Plan B )
Sunken eyes If child also has a severe classification :
Drinks eagerly, thirsty Refer URGENTLY to hospital with
Skin pinch goes back mother giving frequent sips of
slowly ORS on the way
Advise mother when to return
immediately
Follow up in 5 days if not improving
Not enough signs to NO DEHYDRATION Home Care
classify as some or Give fluid and food to treat diarrhea at
severe dehydration home ( Plan A )
Advise mother when to return
immediately
Follow up in 5 days if not improving
Dehydration present SEVERE Treat dehydration before referral unless
PERSISTENT the child has another severe
DIARRHEA classification
3
Give Vitamin a
Refer to hospital
No dehydration PERSISTENT Advise the mother on feeding a child
DIARRHEA who has persistent diarrhea
Give Vitamin A
Follow up in 5 days
Blood in the stool DYSENTERY Treat for 5 days with an oral antibiotic
recommended for Shigella in your area
Follow up in 2 days
Give also referral treatment
Does the child have fever?
**Decide:
Malaria Risk
No Malaria Risk
Measles
Dengue
Malaria Risk
Any general VERY SEVERE Give first dose of quinine ( under
danger sign or FEBRILE medical supervision or if a hospital is
Stiff neck DISEASE / not accessible within 4hrs )
MALARIA Give first dose of an appropriate
antibiotic
Treat the child to prevent low blood
sugar
Give one dose of paracetamol in health
center for high fever (38.5oC) or above
Send a blood smear with the patient
Refer URGENTLY to hospital
Blood smear ( + ) MALARIA Treat the child with an oral antimalarial
If blood smear not Give one dose of paracetamol in health
done: center for high fever (38.5oC) or above
NO runny nose, Advise mother when to return immediately
and Follow up in 2 days if fever persists
NO measles, and If fever is present everyday for more than 7
NO other causes days, refer for assessment
of fever
Blood smear ( – ), FEVER : MALARIA Give one dose of paracetamol in health
or UNLIKELY center for high fever (38.5oC) or above
Runny nose, or Advise mother when to return immediately
Measles, or Other Follow up in 2 days if fever persists
causes of fever If fever is present everyday for more than 7
days, refer for assessment
Any general danger VERY SEVERE Give first dose of an
sign or FEBRILE DISEASE appropriate antibiotic
Stiff neck Treat the child to prevent low
blood sugar
Give one dose of paracetamol
in health center for high fever
(38.5oC) or above
Refer URGENTLY to hospital
No signs of very severe FEVER : NO MALARIA Give one dose of paracetamol in
febrile disease health center for high fever
(38.5oC) or above
Advise mother when to return
immediately
Follow up in 2 days if fever
persists
If fever is present everyday for
more than 7 days, refer for
assessment
No Malaria Risk
Measles
4
Clouding of cornea SEVERE COMPLICATED Give Vitamin A
or MEASLES Give first dose of an
Deep or extensive appropriate antibiotic
mouth ulcers If clouding of the cornea
or pus draining from the
eye, apply tetracycline
eye ointment
Refer URGENTLY to
hospital
Pus draining from MEASLES WITH EYE OR MOUTH Give Vitamin A
the eye or COMPLICATIONS If pus draining from the eye,
Mouth ulcers apply tetracycline eye
ointment
If mouth ulcers, teach the
mother to treat with gentian
violet
Measles now or
MEASLES Give Vitamin A
within the last 3
months
Dengue Fever
Bleeding from nose SEVERE DENGUE If skin petechiae or Tourniquet
or gums or HEMORRHAGIC FEVER test,are the only positive signs
Bleeding in stools give ORS
or vomitus or If any other signs are positive,
Black stools or give fluids rapidly as in Plan C
vomitus or Treat the child to prevent low
Skin petechiae or blood sugar
Cold clammy DO NOT GIVE ASPIRIN
extremities or Refer all children Urgently to
Capillary refill hospital
more than 3
seconds or
Abdominal pain or
Vomiting
Tourniquet test
(+)
No signs of severe FEVER: DENGUE DO NOT GIVE ASPIRIN
dengue HEMORRHAGIC UNLIKELY Give one dose of paracetamol in health
hemorrhagic fever center for high fever (38.5oC) or above
Follow up in 2 days if fever persists or
child shows signs of bleeding
Advise mother when to return
immediately
Does the child have an ear problem?
Tender swelling behind the ear MASTOIDITIS Give first dose of
appropriate
antibiotic
Give paracetamol for
pain
Refer URGENTLY
Pus seen draining from the ear and ACUTE EAR Give antibiotic for 5
discharge is reported for less than 14 INFECTION days
days or Give paracetamol for
Ear pain pain
Dry the ear by wicking
Follow up in 5 days
Pus seen draining from the ear and CHRONIC EAR Dry the ear by wicking
discharge is reported for less than 14 INFECTION Follow up in 5 days
days
No ear pain and no pus seen draining NO EAR INFECTION No additional treatment
from the ear
Check for Malnutrition and Anemia
Give an Appropriate Antibiotic:
A. For Pneumonia, Acute ear infection or Very Severe disease
COTRIMOXAZOLE AMOXYCILLIN
BID FOR 5 DAYS BID FOR 5 DAYS
5
Age or Weight
Adult Syrup Tablet Syrup
tablet
2 months up to 12 months ( 4 1/2 5 ml 1/2 5 ml
– < 9 kg )
12 months up to 5 years ( 10 – 1 7.5 ml 1 10 ml
19kg )
B. For Dysentery
COTRIMOXAZOLE AMOXYCILLIN
BID FOR 5 DAYS BID FOR 5 DAYS
AGE OR WEIGHT TABLET SYRUP SYRUP 250MG/5ML
2 – 4 months ½ 5 ml 1.25 ml ( ¼ tsp )
( 4 – < 6kg )
4 – 12 months ½ 5 ml 2.5 ml ( ½ tsp )
( 6 – < 10 kg )
1 – 5 years old 1 7.5 ml ( 1 tsp )
( 10 – 19 kg )
C. For Cholera
TETRACYCLINE COTRIMOXAZOLE
QID FOR 3 DAYS BID FOR 3 DAYS
AGE OR WEIGHT Capsule 250mg Tablet Syrup
2 – 4 months ( 4 – < 6kg ) ¼ 1/2 5ml
4 – 12 months ( 6 – < 10 kg ) ½ 1/2 5 ml
1 – 5 years old ( 10 – 19 kg) 1 1 7.5ml
Give an Oral Antimalarial
Primaquine Primaquine Sulfadoxine +
CHOLOROQUINE Give single Give daily Pyrimethamine
Give for 3 days dose in for 14 days Give single dose
health for P. Vivax
center for P.
Falciparum
AGE TABLET ( 150MG ) TABLET TABLET TABLET
( 15MG) ( 15MG) ( 15MG)
DAY1 DAY2 DAY3
2months – ½ ½ ½ ¼
5months
5 months – ½ ½ ½ 1/2
12 months
12months – 1 1 ½ ½ ¼ ¾
3 years old
3 years old – 1½ 1½ 1 3/4 1/2 1
5 years old
GIVE VITAMIN A
AGE VITAMIN A CAPSULES 200,000 IU
6 months – 12 months 1/2
12 months – 5 years old 1
GIVE IRON
AGE or WEIGHT Iron/Folate Tablet Iron Syrup
FeSo4 200mg + 250mcg FeSo4 150 mg/5ml
Folate (60mg elemental iron) (6mg elemental iron per
ml )
2months-4months 2.5 ml
(4 – <6kg )
4months – 12months 4 ml
(6 – <10kg )
12months – 3 years (10 – 1/2 5 ml
<14kg)
3years – 5 years ( 14 – 19kg ) 1/2 7.5 ml
GIVE PARACETAMOL FOR HIGH FEVER (38.5oC OR MORE) OR EAR PAIN
AGE OR WEIGHT TABLET ( 500MG ) SYRUP ( 120MG /
5ML )
6
2 months – 3 years ( 4 – <14kg ) ¼ 5 ml
3 years up to 5 years (14 – 19 kg ) 1/2 10 ml
GIVE MEBENDAZOLE
Give 500mg Mebendazole as a single dose in health center if :
hookworm / whipworm are a problem in children in your area, and
the child is 2 years of age or older, and
the child has not had a dose in the previous 6 months
Reference:
Ms Ma. Adelaida Morong, Far Eastern University- Institute of Nursing
In-House Nursing Review
