INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) Steps in the IMCI Case Management Process: 1.Assess and Classify 2.

Identify Treatment 3. Treat 4.Counsel the Mother 5. Follow-Up A. Assess and Classify Sick Children 2 months up to 5 Years 1. Determine which age group the child belongs: 1 week up to 2 months 2 months up to 5 years 2. Record the child’s data : Name, Age in months, Weight in kg., temperature, etc. 3. Ask the mother what the child’s problems are. 4. Determine if this is an initial or follow – up visit: Initial visit – 1st visit for this episode of an illness or problem Follow-up visit- the child has been seen a few days ago for the same illness -if the child’s condition improved, still the same or is getting better 4. Check for general danger signs: a.not able to drink or breastfeed •too weak to drink and is not able to suck or swallow when offered a drink or Breast-feed •if not sure: ask mother to offer child a drink of clean water or breast milk •A child may have difficulty sucking when his nose is blocked. If the nose is blocked, clean it. b. vomits everything •a child is not able to hold anything down at all •if in doubt, offer the child water c.convulsions (during this illness) •arms and legs stiffen because muscles are contracting •the child may lose consciousness or not be able to respond to spoken directions or handling, even if eyes are open •“fits” or “spasms” or “jerky movements” Note: Shiver is not convulsion. There is no loss of consciousness. d.abnormally sleepy or difficult to awaken •drowsy and does not show interest in what is happening around him •stare blankly and appear no to notice what is going on around him •does not respond when touched, shaken or spoken to Note: 1. If the child is asleep and has cough or difficult breathing, count the number of breaths first before you try to wake the child. 2. If there is any general danger sign, complete the assessment and any pre-referral treatment immediately so referral is not delayed. 5. Assess and classify cough or difficult breathing •2 Common Causes of Pneumonia 1.Stretococcus pnemoniae 2.Hemophilus influenzae •2 Causes of Death 1.hypoxia – too little oxygen 2.sepsis – generalized infection •Health workers can identify almost all causes of pneumonia by checking for 2 clinical signs: 1. fast breathing – body’s response to stiff lungs and hypoxia 2. chest indrawing Assess cough or difficult breathing: Does the child have cough or difficult breathing? “fast” or “noisy” or “interrupted”?

Stridor – harsh noise made when the child breaths IN happens when there is swelling of the larynx. crying or angry ∗ Ask the mother to lift the child’s shirt. whooping cough or another problem •fast breathing a.no feeding.child must be quiet and calm 2. •Offer the child fluid : . look back to see if you think the child has cough or difficult breathing. repeat the count. asthma. trachea. Assess and classify diarrhea diarrhea – loose or watery stool -defined as 3 or more loose or watery stools in a 24 – hour period Assess: •how long? •blood in stool •signs of dehydration If YES. •how long? chronic cough – more than 30 days . asses for: •dehydration •persistent diarrhea – 14 days or more •Dysentery Asses for dehydration: •Abnormally sleepy or difficult to awaken •Restless and irritable: (all the time) •Sunken eyes: If not sure.cut-off for fast breathing: if the child is: fast breathing is: 2 months up to 12 months 50 breaths/ minute or more 12 months up to 5 years 40 breaths/ minute or more ∗Determine if the child is breathing IN or breathing OUT •chest indrawing – the lower chest wall goes IN when the child breaths IN NORMAL: the whole chest wall and abdomen move OUT when the child breaths IN Best position: lying down Conditions : clearly visible Note: intercostals indrawing or intercostals retractions and subcostal indrawing are not chest indrawing. b. If you are notsure about the number of breaths you counted.harsh noise while breathing OUT.count the breaths in one minute 1.may be sign of tuberculosis. ask the mother if the child’s eyes look unusual. not stridor CLASSIFY COUGH OR DIFFICULT BREATHING 6.* If the answer is NO. •Look or listen for stridor. or epiglottis ∗Put your ear near the child’s mouth and look at the movement of the abdomen to determine if child is breathing IN or OUT wet noise blocked nose wheezing .

does not itch. not tender. -Cold and clammy extremities -If with cold and clammy extremities. check for . If the child has measles now or within the last 3 months.Not able to drink .5 C or above Decide malaria risk: -child lives in malarious area or -has been in a malaria risk area in the past 4 weeks. Look or feel for stiff neck: -look to see if the child moves and bends his neck easily as he looks around or -draw the child’s attention to his toes or -gently support his back and bend the head forward toward hid chest.Measles rash: begins behind the ears and on the neck. Look for runny nose ( not history of runny nose) Look for signs of Measles: generalized rash and any one of the following: cough. runny nose.:DEHYDRATION PERSISTENT DIARRHEA DYSENTERY 7. and to the rest of the body. thirsty –reaches out for the cup or spoon when you offer water. look like small dark red spots or patches in the skin. does not have vesicles or pustules. or red eyes. CLASSIFY DIARRHEA FOR . not raised. Drinking eagerly. spreads to the face. Assess Fever: A child has the main symptom fever if: -the child has history of fever – no fever now but had fever within 72 hours or -the child feels hot or -the childhas an axillary temperature of 37.Look and feel for signs of bleeding and shock: -bleeding from the nose and gums -skin petechiae – small hemorrhages in the skin.. assess for: -mouth ulcers – painful open sore on the inside of the mouth and lips or tongue -pus draining from the eye -clouding of the cornea – hazy area in the cornea Assess for Dengue Hemorrhagic Fever all children two months of age or older. • Pinch the skin of the abdomen: Goes back very slowly – longer than 2 seconds Goes back slowly – the skin stays up for even a brief time after release.if he is not able to take fluid in his mouth and swallow it Drinking poorly – if the child is weak and cannot drink without help. if you stretch the skin they do not lose their color.

Count the number of breaths in one minute.Severe chest indrawing is very deep and easy to see. Look for palmar pallor – a sign of anemia Some palmar pallor – the skin on the child’s palm is pale Severe palmar pallor – the palm is very pale or so pale that it looks white Look and feel for edema of both feet – the child may have kwashiorkor. 6.Look for nasal flaring – widening of the nostrils when the young infant breaths in. CLASSIFY FEVER 8. short sounds when breathing out.slow capillary refill ( longer than 3 seconds -Perform the tourniquet test if: there are no signs in the ASK or LOOK and FEEL. and the fever is present for more than 3 days. . a form of severe malnutrition.Look and listen for grunting – soft.Ear pain -Ear discharge . 1.Fast breathing is 60 breaths per minute or more. Check the child’s Vitamin A status.Mild chest indrawing is normal in a young infant or young child. where the bones of the head have not formed completely. 12. Assess Ear Problem Assess the child for : . Present less than 2 weeks – Acute ear infection Present 2 weeks or more – Chronic Ear Infection -Tender swelling behind the ear CLASSIFY EAR PROBLEM 9..Ask if the child had convulsion at any time after birth. 11.‘Look and feel for bulging fontanelle. 2. has no fat.Fontanelle is the soft spot on the top of the young infant’s head. Assess other Problems. 5. a form of severe malnutrition. 3. B.Management of the Sick Young Infant Age 1 Week Up to 2 Months 1. Checkthe child’s immunization status. CLASSIFY NUTRITIONAL STATUS 10. the child is 6 months or older. 4.A child has this sign if he is thin. Check for malnutrition and anemia: Look for visible severe wasting – a child with visible severe wasting has marasmus.Look for severe chest indrawing. Determine weight for age: Very low weight for age – child’s weight is below the bottom curve of a weight for age chart. and looks like skin and bones. Assess the sick young infant Check the young infant for possible bacterial infection.

rectal temperature 38 Cor more).5 C or more.Hypothermia ( axillary temperature below 35.Look for skin pustules – red spots or blisters which contain pus.7.Thrush looks like milk cuds on the inside of the cheek. 9. Is it “Abnormally sleepy or difficult to awaken” or “Restless and irritable”? -Look for sunken eyes.Measure temperature or feel for fever or low body temperature.Try to wipe it off.Fever (axillary temperature 37. Not suckling effectively – he is taking only rapid. LOOK at the young infant’s movement. . Milk curds will be removed but thrush will remain. 10. Suckling effectively – the infant suckles with slow.You may see indrawing of the cheeks. A severe pustule is large of has redness extending beyond the pustule.You do not see or hear swallowing. You may see or hear the infant swallowing. LOOK: See if the child is abnormally sleepy or difficult to awaken. Look for ulcers or white patches in the mouth (thrush). -Pinch the skin of the abdomen. Does it go back very slowly? Or slowly? CLASSIFY DIARRHEA Check for feeding problem or low weight. or thick white coating of the tongue. with infant’s nose opposite her nipples -with infant’s body close to her body -supporting infant’s whole body. Not suckling at all – not able to suck breastmilk into his mouth and swallow.5 C. 4 Signs of Good Positioning. 11. Assess Breastfeeding. shallow sucks. not just neck and shoulders 4 Sign of Good Attachment: -Chin touching breast -Mouth wide open -Lower lip turned outward -More areola visible above than below the mouth. rectal temperature below 36 C). -with infant’s head and body straight -facing her breast.Look at the umbilicus – is it red or draining pus? 8. deep sucks and sometimes pauses. Are they less that normal? CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION Assess Diarrhea -For how long? -Is there blood in the stool? -Look at the young infant’s general condition.

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