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Review

A review of Integrated
Management of Childhood
Illness (IMCI) Kerry T, MBChB, MFamMed, DipMid COG(SA)
uMgungundlovu Health District, KwaZulu-Natal.

Keywords: IMCI, case management, sick children, pneumonia, diarrhoea, fever,


malnutrition, anemia, HIV/AIDS, sick young infant, feeding assessment.

Correspondence: Dr. Kerry T, District Medical Manager, uMgungundlovu Health District, KwaZulu-Natal.
PO Box 21741, Mayors Walk, Pietermaritzburg, 3208, Tel:033 3426675, Fax:033 3943235, e-mail: kerry@futurenet.co.za

(SA Fam Pract 2005;47(8): 32-38)

Introduction children are commonly referred documents: Firstly, a short textbook


The Integrated Management of with a classification of “Severe called IMCI: A Handbook for Medical
Childhood Illness (IMCI) strategy is Pneumonia or Ver y Severe Practitioners.4 The second is a desk
the primary child-care approach of Disease”. What does this mean? reference, used by all nurses and
choice for South Africa.1,2 IMCI training How should the doctor manage doctors practicing IMCI, called the
was introduced into South Africa in this child? Chart Booklet.5 These were developed
1996 by WHO and UNICEF. Since then • Secondly, this review introduces by WHO and adapted to the South
8695 health workers have been trained some of the basic IMCI skills. An African setting. The Chart Booklet
in IMCI – mainly primary health care understanding of these skills could contains all the information needed to
nurse practitioners, but also primary be helpful for doctors working with conduct a comprehensive primary
care doctors and paediatricians. The sick children in general practice, child-care consultation and is available
basic 11-day course comprises clinics, community health centres on the website . The key information
classroom activities, assessing or in an outpatient setting. However, in the Chart Booklet has been
children both in an outpatient setting to become a skilled IMCI summarized into Table I of this review.
and paediatric ward.3 A compact 4- practitioner, it is essential for a Table I is designed as an easy
day course has been developed for doctor to attend an IMCI course. reference on the wall of the
doctors and is being taught in some consultation room. The rest of this
medical schools. IMCI has been very The IMCI approach review revolves around the information
well received by nurse practitioner IMCI focuses on illnesses that cause in Table I.
and doctor alike in empowering them the majority of deaths in children As can be seen in Table I, the IMCI
to make easy, evidence-based under-6 years, many of which are practitioner asks pertinent questions,
decisions in the management of sick preventable or readily treatable using examines the child and will then
children at first contact level. However simple interventions: These are assess these signs. Depending on the
many doctors continue to work with pneumonia, diarrhoea, meningitis, signs present, one or often more
children without knowledge of IMCI. malaria, malnutrition, anemia and HIV/ classifications are made. Classification
Thus, the purpose of this review is AIDS. This is called a “child survival” is similar to a diagnosis but is context-
two-fold: approach. Other important aspects of specific: For example, in a primary
• Firstly, many doctors working in child health are also addressed such care setting, a classification of
hospitals receive referrals from as ear infections, the sick young infant Suspected Meningitis is made in a
clinic-based IMCI nurse practi- (under 2 months), breast-feeding and feverish child with neck stiffness. Only
tioners. Doctors need to be feeding assessment. when this child is referred to hospital
informed what an IMCI classi- Doctors attending a 4-day IMCI where a lumbar puncture can be
fication means. For example, c o u r s e w o r k f ro m t w o m a i n performed and the cerebro-spinal fluid

32 SA Fam Pract 2005;47(8)


Review

examined under the microscope can the calm child breathes in (Figure 1).
a diagnosis be made. The classi-
Figure 1: Chest Indrawing
fications are graded into levels of
seriousness and are colour-coded. A
severe classification, coloured red,
requires urgent treatment and referral
to hospital. The less serious
classification, coloured yellow, requires
some treatment at home such as
amoxycillin for Pneumonia. The least
severe classification, coloured green,
requires supportive treatment at home.

Assessing children between 2 If the child has none of these signs,


months and 5 years but has fast breathing, then the
The IMCI practitioner performs the classification is Pneumonia. The cut-
consultation in a systematic manner, off rates for breathing rate decrease
checking the important systems in the with age and are written in Table I for
same order as in Table I. Start by the older child and the sick young
checking for the 4 General Danger infant. The breathing should be
Signs (GDS). These are: A child who counted for a full minute in a calm
is unable to drink or breastfeed; a child child. The breathing rate has been
who vomits everything taken by mouth; shown to be much more reliable in
convulsions in this illness; a child who diagnosing pneumonia than listening
is lethargic or even unconscious. If with a stethoscope.6 A child with none
one or more of these signs are present, of the severe signs and a normal
the child is likely to be seriously ill and breathing rate is classified as Cough
require hospital care. or Cold. Using these simple signs, it
The practitioner then asks for all 4 is easy to decide which child needs
of the main symptoms, even if the referral to hospital, an oral antibiotic
caregiver does not mention them. or supportive care at home. Treatment
These are: cough or difficult breathing, is listed in the right hand column. Full
diarrhoea, fever and ear problem. The dosages for all medicines used can
relevant symptoms and signs are listed be found in the Chart Booklet. The
in the left hand column of Table I. presence of a wheeze is also
Cough is one of the most common considered together with cough.
presenting complaints among sick Diarrhoea is also a common
children. The practitioner needs to be childhood illness. The first step is to
able to efficiently identify which decide on the degree of dehydration:
children do not just have coryza, but 4 signs are assessed: general
may have pneumonia. When making condition (restless/ irritable or lethargic/
a classification, always start with the unconscious), sunken eyes, skin pinch
severe, red row: Then very sick (slow or very slow if the skin returns
children will not be missed – IMCI is to normal only after 2 seconds) and
like a safety net catching the very sick response to a cup of Oral Rehydration
children. A child with cough or difficult Solution (ORS) (drinking eagerly or
breathing together with a GDS, chest unable to drink). As can be seen in
indrawing or stridor would be assigned Table I, at least 2 signs need to be
to the severe, red classification, called present to classify the child as either
Severe Pneumonia or Very Severe Diarrhoea with Severe Dehydration or
Disease. Chest indrawing is an inward Diarrhoea with Some Dehydration.
movement of the lower chest wall when Plan C is used to treat Severe

SA Fam Pract 2005;47(8) 33


Review

Table I: Summary of IMCI Case Management


Summary of IMCI Case Management
CHECK FOR GENERAL DANGER • Is the child able to drink or breastfeed? • Convulsions in this illness?
1 SIGNS: ASK • Does the child vomit everything? • Is the child lethargic or unconscious?

CHILD 2 MONTHS TO 5 YEARS: ASSESS CLASSIFY TREATMENT

DOES THE CHILD HAVE COUGH • Any General Danger Sign • Give ceftriaxone IMI (80mg/kg)
OR DIFFICULT BREATHING? OR and if child < 6 mths also give co-
• For how long? • Chest Indrawing trimoxazole
• Count the breaths in one minute OR SEVERE PNEUMONA OR • Give O2 and check blood sugar
• Look for chest indrawing • Stridor in a calm child VERY SEVERE DISEASE • If stridor, nebulize with adrenalin
• Look and listen for stridor or • Keep child warm and refer
2 wheeze

URGENTLY to hospital
Give amoxycillin for 5 days
• Fast breathing PNEUMONIA • Consider symptomatic HIV
• Follow up in 2 days
• Soothe the throat and relieve the
Age Fast breathing • No signs of pneumonia or very cough
2 - 12 mths = 50 or > breaths/min severe disease COUGH OR COLD • If coughing for more than 21 days
1 – 5 yrs = 40 or > breaths/min consider TB or asthma
• Follow-up 5 days if not better

DOES THE CHILD HAVE Two of the following signs: • Start Fluids for Plan C
DIARRHOEA? • Lethargic or unconscious DIARRHOEA WITH • Refer URGENTLY to hospital
• For how long? • Sunken eyes SEVERE DEHYDRATION • Give frequent sips of ORS on the
• If >14 days, has child lost weight? • Not able to drink or drinking way, continue breastfeeding
• Is there blood in the stool? poorly • Keep the child warm
• What Rx is the mother giving? • Skin pinch goes back very
• Look at child’s general condition slowly (>2 secs)
• Look for sunken eyes. Two of the following signs: • Give fluids: Plan B
• Offer the child fluids. • Restless or irritable DIARRHOEA WITH SOME • Continue breastfeeding or feeding
• Pinch the skin of the abdomen • Sunken eyes DEHYDRATION • Follow up in 2 days if not improving
• Child drinks eagerly and is thirsty
• Skin pinch goes back slowly
CLASSIFY FOR DEHYDRATION • Not enough signs to classify NO VISIBLE • Give fluid and food to Rx diarrhoea
3 (All children with diarrhoea) as severe or some dehydration DEHYDRATION

at home: Plan A
Follow up in 5 days if not improving

• Child has signs of dehydration • Rx for dehydration if present


• Child has history of weight SEVERE PERSISTENT • Refer URGENTLY to hospital
CLASSIFY FOR PERSISTENT loss DIARRHOEA • Give Vit A unless given in last month
DIARRHOEA • Give frequent sips of ORS on the way
(If diarrhoea for 14 or more days) • Counsel the mother about feeding
• No dehydration PERSISTENT DIARRHOEA • Give Vit A unless given in last month
• No history of weight loss • Consider symptomatic HIV infection
• Follow up in 5 days

• Child has signs of dehydration • Rx for dehydration if present


• Child less than 12 months of SEVERE DYSENTERY • Refer URGENTLY to hospital
age • Give frequent sips of ORS on the way

CLASSIFY FOR DYSENTERY • Blood in stool DYSENTERY • Nalidixic acid for 5 days
(If diarrhoea with blood) • Follow up in 2 days

DOES THE CHILD HAVE A FEVER? • Any General Danger Sign • Give ceftriaxone IMI (80mg/kg)
OR SUSPECTED • Check blood sugar
• For how long? • Stiff neck OR MENINGITIS • Rx the fever
• Examine for stiff neck • Bulging fontanelle • Refer URGENTLY to hospital
• Examine for bulging fontanelle • No General Danger Signs and.. • Rx the cause of the fever
• Look for other causes of fever • No stiff neck or bulging FEVER, OTHER CAUSE • Rx the fever
fontanelle • Follow up in 2 days if fever persists

• Any General Danger Sign • If child > 12 months, give first dose
OR SUSPECTED SEVERE of co-artemether
• Stiff neck MALARIA • Give ceftriaxone IMI
4 •
OR
Bulging fontanelle


Refer URGENTLY to hospital
If child <12 months refer URGENTLY
(Malaria rapid test or positive to hospital for malaria Rx
IF EXPOSED TO MALARIA, ALSO or negative or not done)
CLASSIFY FOR MALARIA • Rapid malaria test positive MALARIA • If child >12 months, give co-
artemether at clinic and then for 3
• Do a rapid malaria test if available days at home
• Rx fever
• Follow up in 2 days if the fever
persists
• Rapid malaria test not done POSSIBLE MALARIA • Refer for malaria testing
• Rx fever
• Rapid malaria test negative FEVER, OTHER CAUSE • Rx the fever and the cause
• Follow up in 2 days if fever persists

34 SA Fam Pract 2005;47(8)


Review

ASSESS CLASSIFY TREATMENT

• Tender swelling behind the MASTOIDITIS • Give ceftriaxone IMI and refer
ear URGENTLY to hospital
• Rx amoxycillin for 5 days
DOES THE CHILD HAVE AN EAR • Ear pain ACUTE EAR INFECTION • If ear discharge teach mother dry
PROBLEM? OR wicking and consider symptomatic
• Red tympanic membrane HIV
5 •

Ear pain?
Is there ear discharge? If yes for •
OR
Pus draining from the ear < CHRONIC EAR INFECTION
• Analgesia and follow up in 5 days
if pain or discharge persists
how long? 14 days • Teach mother dry wicking
• Pus draining from the ear > • Consider symptomatic HIV
14 days • Follow up in 14 days
• No ear pain and no pus • No Rx
draining NO EAR INFECTION

• Very low weight (<60% exp’d) • Vit A unless given in the last month
OR SEVERE MALNUTRITION • Refer URGENTLY to hospital
CHECK FOR MALNUTRITION AND • Visible severe wasting • Check blood sugar and keep warm
ANAEMIA OR
• Oedema of both feet
• Has the child lost weight? • Low weight • Consider Vit A and mebendazole
• Plot the weight on the RTHC OR • Check and treat for oral thrush
• Look for visible severe wasting • Poor weight gain NOT GROWING WELL • Consider symptomatic HIV, TB
• Feel for oedema of both feet OR contact
6 • Mother reports weight loss •

Assess feeding and counsel
Follow up in 14 days
• Not low weight and.. • Check feeding
• Good weight gain GROWING WELL • Consider Vit A and mebendazole

• Look for palmar pallor • Severe palmar pallor OR SEVERE ANAEMIA • Refer URGENTLY to hospital
• Check hemoglobin level • Hb < 6 g/dl • Keep the child warm
• Some palmar pallor OR • Rx with iron and counsel about
• Hb < 10 g/dl ANAEMIA feeding
• Follow up in14 days
• No pallor and Hb > 10 g/dl NO ANAEMIA • No additional Rx

• Any pneumonia now • Offer HIV testing for mother and


• Ear discharge now or in the past? SUSPECTED child if status unknown
• Low weight for age SYMPTOMATIC HIV • Start co-trimoxazole prophylaxis
ASSESS FOR SYMPTOMATIC HIV • Poor weight gain or weight loss? (3 or > positive findings) • Counsel the mother

7 INFECTION: •

Persistent diarrhoea in last 3 mths?
Enlarged lymph nodes in 2 or
• Follow up for counselling about
results
• 3 OR MORE POSITIVE more of the following 3 sites:
FINDINGS OF THESE 8 Neck, axilla or groin SYMPTOMATIC HIV • Counsel mother about her health
SYMPTOMS AND SIGNS • Oral thrush UNLIKELY and precautions against HIV
• Parotid gland enlargement (< 3 positive findings) infection

INFANT: 1 WEEK - 2 MONTHS


One of the following signs:
• Fast breathing 60 or > breaths/min. (Repeat if fast) • Give IMI ceftriaxone (80mg/kg)
CHECK FOR • Severe chest indrawing (deep and easy to see) • Give O2
POSSIBLE • Nasal flaring or grunting POSSIBLE SERIOUS • Give rectal diazepam if convulsing
BACTERIAL • Convulsions BACTERIAL INFECTION • Check and Rx low blood sugar
INFECTION • Bulging fontanelle • Refer URGENTLY to hospital
• Umbilical redness extending to skin, and or draining pus • Continue breastfeeding
1 • Fever (> 37.5°C) or low body temperature (<35.5°C)
• Many or severe skin pustules (> 5 pustules)
• Keep the child warm

• Lethargic, unconscious or less than normal movements


• Apnea attacks
• Not taking feeds or taking feeds poorly
• Jaundice worsening or still present after 2 weeks
• Red umbilicus LOCAL BACTERIAL • Give erythromycin for 7 days
• Skin pustules INFECTION • For eye infection give ceftriaxone IMI
• Pus draining from the eye • Advise mother on care of the infection
None of the above signs: NO BACTERIAL INFECTION • Relevant health counselling

• Not able to feed • Give IMI ceftriaxone (80mg/kg)


CHECK FOR FEEDING PROBLEM • Infant not able to attach to breast NOT ABLE TO FEED • Check blood sugar and keep warm
OR LOW WEIGHT IN BREASTFED • Not suckling at all • Refer URGENTLY to hospital
BABIES: • Infant not well attached to • Advise on breastfeeding esp.
breast correct positioning and attachment
• Infant not suckling effectively • Breastfeed > 8x in 24 hrs and at
FEEDING PROBLEM OR NOT
2 •

Less than 8 breastfeeds in 24 hrs
Infant receiving other foods
GROWING WELL

night
Breastfeed more, reducing other
• Low weight for age or poor wt. foods
gain • Follow up weight gain
• Oral thrush • Nystatin drops
• Using a feeding bottle
• Not low weight and feeding well NO FEEDING PROBLEM • Relevant health counselling

SA Fam Pract 2005;47(8) 35


Review

Dehydration: Until the child can be Figure 2: Ear wicking is a reliable indicator of anaemia.
referred to hospital, Ringers Lactate Compare the child’s palm to that of
20ml/kg is given IV in the first 30 the mother’s. Just a trace of pinkness
minutes and then 20ml/kg/hour IV for around the outside of the palm
the next 5 hours. Plan B is used for indicates Anaemia. However if the
Some Dehydration: ORS 20ml/kg/hour palm is completely pale, classify as
is given per os for 4 hours in the first Severe Anaemia and check the
contact health facility. The child is then hemoglobin level.
reassessed and sent home if better. HIV infection has become very
Plan A is used for the child with No common. As seen in Table I, Eight
Visible Dehydration: For the child Malnutrition and anemia should signs have been identified as best
under 2 years, give 50-100ml ORS be checked in all children. The proper determining the presence of HIV
after each loose stool; For the child use of the Road to Health Chart infection 7. The presence of 3 or more
older than 2 years, give 100-200ml (RTHC) is essential. The first step is of these signs makes the classification
after each loose stool. If diarrhoea is to write the birth month in the first Suspected Symptomatic HIV and the
present for 14 days or more, assess column of the RTHC. The weight for child should be formally tested. PCP
for Persistent Diarrhoea. If there is the current month is then plotted on the prophylaxis with cotrimoxazole should
diarrhoea with blood, then assess for dotted line for that month (Figure 3). be considered especially before the
Dysentery. age of 1 year.
Figure 3: RTHC
Fever is ver y common in
childhood illness but can indicate Assessing infants between 1
serious illnesses especially if week and 2 months
prolonged. Meningitis should always Sick infants presenting in this age
be excluded by feeling for a bulging group should all be carefully checked
fontanelle and testing for neck for Possible Serious or Local Bacterial
stiffness. If one or both signs or a Infection: Because sick young infants
General Danger Sign are present, the die quicker than older children, the
classification becomes Suspected IMCI approach for this age group is
Meningitis. Children with a febrile rigorous: The breathing rate of all
convulsion may present like this, and infants should be counted – the cut-
meningitis should be excluded. Urgent off rate being 60 breaths per minute.
treatment should be instituted with IM Look for severe chest indrawing: Mild
ceftriaxone and the child referred to indrawing is normal in a young infant
hospital for lumbar puncture. because the chest wall is soft. Fever
In a malaria area such as northern or low body temperature are significant
KwaZulu-Natal, malaria should always at this age are indicators of a serious
be considered in a child with fever. illness as is the non-specific sign of
Severe signs in the red row make the not taking feeds. As can be seen from
classification Suspected Severe Signs of visible severe wasting Table I, any 1 of the signs present from
Malaria and the child should be (marasmus) are loss of muscle and the red row makes the classification
referred to hospital. Other subcutaneous tissue. The child’s arms to be Possible Serious Bacterial
classifications depend on the result and legs are thin with ribs and spine Infection. These infants should be
of the malaria rapid test as can be prominent. The buttocks become flatter treated and referred urgently to
seen in Table I. and the skin hangs in folds, giving the hospital. An infant classified as Local
Ear infections, although not life appearance of “baggy pants”. Bacterial Infection is treated
threatening, may cause deafness and Oedema of the dorsa of the feet may appropriately at home.
learning problems. With a chronic ear indicate kwashiorkor. If wasting,
infection, dry wicking with thick paper oedema or very low weight-for-age Feeding Assessment
towel is an effective means of drying are present, the classification is Severe The IMCI practitioner assesses feeding
the discharge. (Figure 2) Follow up is Malnutrition. The classification Not problems in all children under-2 years
very important to ensure healing and Growing Well indicates a more minor or who are low weight-for-age. More
proper function of the ear. nutritional problem. Pallor of the palm complete information on assessing

36 SA Fam Pract 2005;47(8)


Review

the older child’s feeding can be found The 4 signs of good attachment are: (012-3120199) can supply information
in the Chart Booklet. In the young Infant’s mouth wide open; chin on doctor courses being conducted
infant, a feeding or low weight problem touching the breast; lower lip turned throughout the country.
should be checked as per Table I. The outward; more areola visible above
severe classification is Not Able to than below the infants mouth while Acknowledgements
Feed. However many more infants are feeding. Oral thrush or the concurrent Thanks to Prof. W Loening, Dr. C
classified as Feeding Problem or Not use of a feeding bottle also indicates Horwood and Dr. G Morris for
Growing Well. Infants should be Feeding Problem. constructive comments.
breastfed at least 8 times in 24 hours.
Attachment refers to how well the infant In summary References
1. SA National Dept. of Health. The primary health
s u c k l e s o n t h e b re a s t – a l l The IMCI approach ensures that a care package for South Africa: A set of norms
breastfeeding mothers should be c o m p re h e n s i v e a n d a c c u r a t e and standards: National Dept. of Health, Sept
2001.
checked and counselled for assessment is made of a sick child 2. Zar H, Hussey G, Mhlanga E, Loening W, de
Klerk E. Integrated Management of Childhood
attachment. using simple yet reliable clinical signs Illnesses – A new approach to old diseases
(Editorial). SAMJ 1998; 88(12): 1565-1566.
at the first contact level. Also doctors, 3. KwaZulu-Natal Dept. of Health. IMCI modules,
Figure 3: Breastfeeding especially those working in the public adapted by South Africa from WHO and
UNICEF Modules of 1995: KZN Dept. of Health,
sector need to understand the IMCI Sept 2002.
4. Loening W, Horwood C. A doctors IMCI
approach that is used in primary health handbook. KZN Dept. of Health, Nov 2004.
care throughout South Africa: They 5. KwaZulu-Natal Dept. of Health. KZN IMCI
guidelines, adapted by South Africa from WHO
will be better able to receive referrals and UNICEF Guidelines of 1995: KZN Dept. of
Health, Sept 2002.
and send the child back for care and 6. World Health Organization. Technical basis for
the WHO recommendations of pneumonia in
follow up into the primary health care children at first-level health facilities: WHO
system. All doctors who manage sick 1995.
7. Horwood C, Liebeschuetz S, Blauuw D, Cassol
children should consider updating S, Qazi S. Diagnosis of paediatric HIV infection
in a primary health care setting with a clinical
their skills to include IMCI. The National algorithm. Bulletin of the World Health
Child and Youth Health Directorate Organization 2003; 81: 856-864.

UNIVERSITY OF LIMPOPO Additional reguirements for International Students(Foreign


(MEDUNSA CAMPUS) Graduates)
a) SAQA evaluaton of academic qualifications must accommpany
the application for admission: SAQB Postnet Suit 248, P/B X05,
Waterkloof 0145 (Telephone 012 431 500, Fax 012 4315039)
b) Details regarding the requirements for obtaining a study permit
may be obtained from the South African Embassy or South African
High Commissioner in the country of origin

Contact Sessions:
Trainees/registrars will be expected to attend contact session at
Medunsa and in the provincial groups throughout the years. The
programme covers the following modules:
The consultation; Human development (including whole person
MASTERS DEGREE IN FAMILY MEDICINE medicine); The Faamily; Ethics including screening; Research Methods;
M Med (Family Medicine) Applied Social Science in Medicine; Learning: Portfolio development;
Practice management & organisation of health services; Evidence
The Department of Family Medicine & Primary Health Care, Univesity Based Medicine; Clinical reasoning & Therapeutics; Prevention and
of Limpopo (Medunsa Campus) invites applications from doctors who health promotion; Quality improvement; Principles & Foundations of
wish to enroll for its M Med (Family Medicine) program in the year Family Medicine.
2005, and on completion register as Family Physicians with HPCSA.
The program spans a minimum of four years with regular contact Applications close 30th November 2005
sessions five times per year at the department and in provincial groups
and with local facilitators. Application forms and further information are obtainable from: HOD,
Department of Family Medicine & Primary Health Care, PO Box
Requirements: 222, Medunsa 0204
1. Possession of MBChB degree plus completed community service Tel: (012) 521 4314/4528
year or equivalent qualification for at least two years for foreign Fax: (012) 521 4172
graduates e-mail: ansie@mail.ngo.za
2. Clinical work should be done in Primary Health Care settings or
district hospitals with a strong association with PHC patients. “A world-class African University which responds to education,
3. Registration as a medical practitioner with the Health Professions research and community development needs through partnerships
Council of South Africa or with the regulatory body of the country and knowledge generation – continuing the tradition of
in which the doctor is practising. empowerment”

38 SA Fam Pract 2005;47(8)