Republic of the Philippines

City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

College of Allied Health Studies

Detailed Learning Module(Case-Based Learning Module)

Program: Graduate in Midwifery

Course Code: MDW 204(Seminar in Midwifery)

Title: Introduction of Integrated Management of Childhood Illness(IMCI)

Module No. 1

I. Introduction: IMCI stands for "Integrated Management of Childhood Illness". You will learn more about IMCI
later in this training course and studying the succeeding module. During the training, you will learn how to
manage sick children and how to address all the child's problems and needs together, in an integrated way.
You will also learn how to provide essential care to all newborn children, to ensure their quick and safe
adaptation to the new environment.

The IMCI will help you learn how to manage major childhood problems using the IMCI clinical management
guidelines. With this module, you will be able to read new information, see videos and photos, and do some
useful exercises. It will also let you test your progress, as you learn about IMCI.

Remember that everything you learn about IMCI through the succeeding module must be supported by
clinical practice in real clinical settings. You will need to practise in clinical settings in order to learn how to
apply your new skills in management of sick young infants and children. Your clinical instructor will help you
with this clinical practice. In each training unit and each module, you will find a list of the clinical skills you
should have in order to correctly apply what you have learned in that unit.

Additional information on major causes of childhood illness and death, and on the IMCI strategy
o Reading the first three chapters of this introduction is part of your IMCI training. The fourth
chapter, containing additional information, is optional. This chapter contains a selection of
documents and publications giving general information on IMCI implementation, as well as
on major diseases and conditions affecting child health.

II. Learning Objectives: After studying the module, the student should be able to:
1. Know the key information on the IMCI strategy, its rationale, guiding principles and objectives.
2. Outline the components of the IMCI strategy.
3. Determine the IMCI clinical guidelines, and how those guidelines can help to be effective in managing
the sick children and young infants who come to your clinic.
4. Differentiate the form of IMCI case management charts from the IMCI chart booklet or on IMCI wall
charts.
5. Know the ways of establishing good communication and correctly ask the child’s mother or other
caregiver after completing the clinical practice relevant in this module.
6. Understand on how to use and fill the IMCI front side form and the other side/reverse side of the form.
7. Learn how to interact with the child's mother or other caregiver who brings the child at the health
institution during clinical practice sessions.

III. Topics and Key Concepts

TOPIC 1:
Your training or the succeeding module has three components:
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

1. INTRODUCTION
2. CARE OF SICK YOUNG INFANT AGED UP TO 2 MONTHS
3. CARE OF SICK CHILD AGED 2 MONTHS TO 5 YEARS.

This INTRODUCTION component will help you to understand the IMCI strategy and the IMCI clinical guidelines.
It comprises the following chapters:
 What is IMCI?
o This chapter provides key information on the IMCI strategy, as well as its rationale, guiding
principles and objectives. It also gives an overview of the components of the IMCI strategy.
 The IMCI case management process
o Here you will learn about the IMCI clinical guidelines, and how those guidelines can help to
be effective in managing the sick children and young infants who come to your clinic.
 IMCI case management charts and case recording forms
o For practical purposes, all key elements of the IMCI clinical guidelines are presented in the
form of IMCI case management charts, in the IMCI chart booklet or on IMCI wall charts.
This chapter explains how to use these charts in your daily work.

What is IMCI?
 Integrated Management of Childhood Illness (IMCI) is a strategy for reducing the mortality and
morbidity associated with the major causes of childhood illness.

 WHO and UNICEF started to develop the IMCI strategy in 1992, and today more than 100 countries
worldwide have adopted it. The implementation of the IMCI strategy produces impressive results,
both in the decrease of childhood mortality and in improving the quality of life of young children all
over the world.

RATIONALE FOR AN INTEGRATED APPROACH

 Every year almost 10 million children die before they reach their fifth birthday. A majority of these
deaths caused by just five preventable and treatable conditions:
1. pneumonia
2. diarrhea
3. malaria
4. measles
5. malnutrition
 Often, those deaths are caused by a combination of the above conditions. Many of childhood deaths
could be avoided if those children received appropriate and timely care. In addition, three out of four
episodes of childhood illness are caused by these five conditions.

 In the 1990s, major progress was made to reduce childhood mortality and morbidity through
universal childhood immunization, control of diarrheal diseases and acute respiratory infections,
nutrition programmes (including the promotion of breastfeeding) and through implementation of
other primary health care activities. In 1995, the WHO Department of Child and Adolescent Health
and Development (CAH), in collaboration with eleven other WHO programmes and UNICEF, finalized
the development of the Integrated Management of Childhood Illness (IMCI) strategy. The global
implementation of the IMCI strategy applied the lessons learned from these vertical programmes to
strategies that promote coordination and, where appropriate, greater integration of activities, in
order to improve the prevention and management of childhood illness.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

45 % of global under-five deaths are associated with nutrition-related factors

 The extent of childhood morbidity and mortality in low-income and middle-income countries caused
by the above-mentioned five conditions is not in itself the only rationale for an integrated approach
to the management of childhood illness. Every day, millions of parents seek health care for sick
children, taking them to hospitals, health centers, pharmacists, community health-care providers and
traditional healers, and most of these sick children present with signs and symptoms related to more
than one disease.

 This overlap means that often a single diagnosis may not be possible or appropriate, and treatment
may be complicated by the need to combine therapy for several conditions. An integrated approach
to managing sick children is, therefore, indicated. There is a real need for a health care provider to go
beyond single diseases and address the overall health of a child. Use of IMCI strategy, which takes
into account the variety of factors that put children at serious risk, ensures the combined treatment
of the major childhood illnesses, while emphasizing prevention of disease through immunization and
improved nutrition.

IMCI OBJECTIVES, COMPONENTS AND INTERVENTIONS

 The IMCI strategy combines the improved management of childhood illness with aspects of nutrition,
immunization and other important factors influencing child health, including maternal health.

 The key objectives of the IMCI strategy are to:

1. reduce death and the frequency and severity of illness and disability
2. contribute to improved growth and development.

 The IMCI strategy seeks to reduce childhood mortality and morbidity by adopting a broad and cross-
cutting approach with the following three components:

1. improving the case management skills of health workers through the provision of clinical
guidelines on the integrated management of childhood illness, adapted to the local context,
and training to promote their use;
2. Improving the health system by:
o ensuring the availability of essential drugs and other supplies
o improving the organization of work at the health facility level
o improving monitoring and supervision;
3. improving family and community practice through the education of mothers, fathers, other
caregivers and members of the community, with a focus on health-seeking behaviour,
compliance, care at home and overall health promotion.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

Each component includes a set of specific interventions, with emphasis on their practical
implementation.

Improve health worker skills
o Case management
standards & guidelines
o Training of facility-based
public health care
providers
o IMCI roles for private
providers. Maintenance
of competence among
trained health workers
Improve health system Improve family &
community practices
o District planning and o Appropriate
management careseeking
o Availability of IMCI drugs o Nutrition
o Quality improvement o Home case
and supervision at management &
health facilities adherence to
o Referral pathways and recommended
services treatment
o Health information o Community
system involvement in health
services planning &
monitoring

INTEGRATED CASE MANAGEMENT AS THE CORE IMCI INTERVENTION

 The core IMCI intervention is integrated case management of the most important causes of
childhood death and illness, such as acute respiratory infections, diarrhea, measles, malaria,
malnutrition, neonatal infections and a few others. The strategy includes a range of other preventive
and curative interventions, which aim to improve practice both in health facilities and at home

Interventions included in the IMCI guidelines for first-level health workers (Philippine version)
Curative interventions Preventive interventions
Effective case management of the following o Breastfeeding support
conditions: o Immunization
o acute respiratory infections, including o Nutrition counselling
pneumonia o Periodic deworming
o anemia o Vitamin A supplementation
o diarrhea (dehydration, persistent diarrhea, o Iron supplementation
dysentery) o Zinc supplementation
o ear infection o Micronutrient powder supplementation
o HIV/AIDS o Oral health
o local bacterial infections
o meningitis, sepsis
o malaria
o measles
o dengue hemorrhagic fever
o malnutrition
o neonatal jaundice
o wheeze

 The WHO/UNICEF case management guidelines are a generic version. Although they are widely
applicable, they need to be adapted in a specific country to:
1. cover the most serious childhood illnesses seen at first level-health facilities, that first level-
health workers must be able to treat;
2. be consistent with national treatment guidelines and other policies;
3. be appropriate for the local conditions that affect the care of children in the health facility and
at home.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

IMCI BENEFITS
The IMCI strategy:
o addresses major child health problems – The strategy systematically addresses the most important
causes of childhood death and illness.

o responds to demand – Every day millions of parents take their sick children to hospitals and health
centres, pharmacists and community health care providers. Three out of four of these children are
suffering from at least one of the five conditions that are the focus of IMCI.

o promotes prevention as well as cure – In addition to its focus on treatment, IMCI also provides the
opportunity for, and emphasizes, important preventive interventions such as immunization and
improved infant and child nutrition, including breastfeeding.

o Is cost-effective – the World Bank ranked IMCI among the ten most cost-effective interventions in
low- and middle-income countries.

o promotes cost saving – Inappropriate management of childhood illness wastes scarce resources.
Although increased investment will be needed initially for training and reorganization, the IMCI
strategy will result in cost savings.

o improves equity - Nearly all children in the developed world have ready access to simple and
affordable preventive and curative care, which protects them from death as a result of acute
respiratory infections, diarrhoea, measles, malaria and malnutrition. Millions of children in the
developing world, however, do not have access to this same life-saving care. The IMCI strategy
addresses this inequity in global health care.

PRINCIPLES OF THE INTEGRATED CLINICAL CASE MANAGEMENT GUIDELINES

 The IMCI clinical guidelines are based on the following principles

o All sick children aged up to five years of age are examined for general danger signs and all
young infants are examined for signs of very severe disease. These signs indicate the need for
immediate referral or admission to hospital.

o The children and infants are then assessed for main symptoms. For older children the main
symptoms include cough or difficulty breathing, diarrhea, fever, and ear infection. For young
infants, the main symptoms include local bacterial infection, diarrhea, and jaundice. In addition,
all sick children are routinely assessed for nutritional and immunization status, and other
potential problems.

o Only a limited number of clinical signs are used, selected on the basis of their sensitivity and
specificity to detect disease.

o A combination of individual signs leads to a child's classification within one or more symptom
groups rather than a diagnosis. The classification of illness is based on a color-coded triage
system: "pink" indicates urgent hospital referral or admission, "yellow" indicates initiation of
specific outpatient treatment, and "green" indicates supportive home care.

o IMCI management procedures use a limited number of essential drugs and encourage active
participation of caregivers in the treatment of children.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

o An essential component of IMCI is the counselling of caregivers regarding home care,

appropriate feeding and fluids, and when to return to the clinic - immediately or for follow-up.

TOPIC 2: IMCI case management process

STEPS IN INTEGRATED CASE MANAGEMENT

The IMCI integrated case management process consists of a number of steps that should be taken by
a health-care provider to ensure effective case management.

STEP 1. ASSESS
 When a child or young infant is brought to a clinic, a health-care provider uses good communication
skills to ask the mother about the child's problems and makes an assessment of the child's condition.
The health worker checks first for general danger signs, which would indicate any life-threatening
condition. In young infant the health worker checks for signs of very severe disease and local bacterial
infection. Then the health worker asks specific questions about the most common conditions affecting
a child's health. If the answers are positive, he or she examines the child appropriately. An essential
part of the assessment is checking the child's nutrition and immunization status. The assessment
includes checking the child for other health problems.

STEP 2. CLASSIFY
 Based on the results of the assessment a health-care provider classifies a child's illnesses using a
specially developed color-coded triage system. Because many children have more than one condition,
each condition is classified according to whether it requires:
Urgent pre-referral treatment and referral, or
Specific medical treatment and advice or
Simple advice on home management
STEP 3. IDENTIFY TREATMENT
 After classifying all the conditions present, a health-care provider identifies specific treatments for the
sick child or the sick young infant.

o If a child requires urgent referral (pink classification), essential treatment to be given before
referral is identified.
o If a child needs specific treatment (yellow classification), a treatment plan is developed, and the
drugs to be administered at the clinic are identified. The content of the advice to be given to the
mother is decided on.
o If no serious conditions have been found (green classification), the mother should be correctly
advised on the appropriate actions to be taken for care of the child at home.

STEP 4. TREAT

 After identifying appropriate treatment, a health-care provider carries out the necessary procedures
relevant to the child's conditions. The health worker:
o gives pre-referral treatment for sick children being referred;
o gives the first dose of relevant drugs to the children who are in need of specific treatment,
and teaches the mother how to give oral drugs, how to feed and give fluids during illness,
and how to treat local infections at home;
o provides advice on the home management of sick children at home;
o if needed, asks the mother or other caregiver to return with the child for follow-up on a
specific date.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

STEP 5. COUNSEL
 If the follow-up care is indicated the health-care provider teaches the mother when to return to the
clinic, the health worker also teaches the mother how to recognize signs indicating that the child
should be brought back to the clinic immediately.
 When indicated, a health-care provider assesses feeding, including breastfeeding practice, and
provides counselling to solve any feeding problems found. This also includes counselling the mother
about her own health.

STEP 6. FOLLOW-UP
 Some children need to be seen more than once for a current episode of illness. The IMCI case
management process helps to identify those children who require additional follow-up visits. When
such children are brought back to the clinic, a health-care provider gives appropriate follow-up care,
as indicated in IMCI guidelines, and if necessary, reassess the child for any new problems.

CASE MANAGEMENT CHARTS

 To facilitate the use of the IMCI case management process in practice all the case management steps
described above have been presented in a series of IMCI charts. These charts show the sequence of
steps and provide information for performing them. WHO has assembled this series of charts into the
IMCI chart booklet. When providing care to sick children you should use the IMCI chart booklet to
help you apply the IMCI case management guidelines.

 Most health facilities have a procedure for registering children and identifying whether they have
come because they are sick, or for some other reason, such as for a well-child visit or an
immunization, or for care of an injury. When a child is brought to you, you need to know the age of
the child in order to select the appropriate IMCI charts and begin the assessment process. Because
clinical signs which can be found in sick young infants and older children are somewhat different and
because case management procedures also differ between these age groups, the IMCI chart booklet
is divided into two main parts:

SICK CHILD AGED 2 MONTHS TO 5 YEARS. This part contains all the necessary
guidelines, information and instructions on how to provide care to sick children
aged 2 months to 5 years brought to the attention of a health-care provider.
SICK YOUNG INFANT AGED UP TO 2 MONTHS. This part includes case management
clinical guidelines for the care of a young infant aged up to 2 months

o Each of these parts contains IMCI charts corresponding to the main steps of the IMCI case
management process.

o Steps 1, 2 and 3: ASSESS, CLASSIFY AND IDENTIFY TREATMENT chart helps you to assess
and classify the child's condition, and identify treatments.

The ASSESS column on the left side of the chart describes

how to take a history and do a physical examination.

The CLASSIFY column of the ASSESS AND CLASSIFY chart

lists clinical signs of illness and their classifications.
"Classify" means to make a decision about the severity of
the illness. For each of the child's main symptoms, you will
select a category, ("classification"), that corresponds to the
severity of the child's illness.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

 Step 4: TREAT chart shows how to do the treatment steps identified in the ASSESS AND CLASSIFY
chart. TREAT means giving treatment in the clinic, prescribing drugs or other treatments to be given at
home, and also teaching the mother of other caregiver how to carry out the treatments.

 Step 5: COUNSEL THE MOTHER chart gives recommendations on feeding, fluids and when to return.
For many sick children, you will assess feeding and counsel the mother about any feeding problems
found. For all sick children who are going home, you will advise the child's mother of other caregiver
about feeding, fluids and when to return for further care. You will also advise the mother about her
own health.

o Step 6: GIVE FOLLOW-UP CARE chart describes the steps for conducting different types of follow-up
visits depending on the classification the child had during the initial visit. At a follow-up visit, you can
see whether the child is improving on the treatment that was prescribed, or whether some additional
interventions are needed.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

CASE RECORDING FORMS

The case recording forms are designed to help you to systematically record information about child or young
infant condition. You will be using these forms during your IMCI training. If you will find these forms useful,
you may also use them in your own clinical work.

How to fill the

IMCI form

MAJOR CAUSES OF DEATH IN CHILDREN UNDER 5 YEARS OF AGE

 Despite the substantial reduction in the number of deaths observed in recent decades, around 10.6
million children die every year before reaching their fifth birthday. Almost all of these deaths occur in
low-income and middle-income countries.

 Most deaths among children under five years are still attributable to just a handful of conditions and
are avoidable through existing interventions.

 Just a very few conditions account for 70% to over 90% of all these deaths. These are: lower
respiratory infections, mostly pneumonia; diarrhea; malaria; measles: HIV/AIDS, and neonatal
conditions, mainly pre-term birth, birth asphyxia, and infections.

 Malnutrition increases the risk of dying from these diseases. Over half of all child deaths occur in
children who are underweight.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

 The relative importance of the various causes of death has changed, with the decline in mortality from
diarrhea and many of the vaccine-preventable diseases. The relative contribution of HIV/AIDS to the
total mortality of children under 5 years of age, especially in sub-Saharan Africa, has been increasing
steadily. In 1990 it accounted for around 2% of mortality in the African region among children under 5
years of age, but in 2003 the figure had reached about 6.5%.

 Summarizing data across regions and countries masks substantial differences in the distribution of
causes of deaths.

 Approximately 90% of all malaria and HIV/AIDS deaths in children, more than 50% of measles deaths
and about 40% of pneumonia and diarrhea deaths are in the African region.
In contrast, deaths from injuries and non-communicable diseases other than congenital anomalies
account for 20-30% of deaths among children under 5 years of age in the region of Americas, and in
the European and Western Pacific regions.

TOPIC 3: Use good communication skills

o Listen carefully to what the mother tells you. This will show her that you are taking her
concerns seriously.
o Use words the mother understands. If she does not understand the questions you ask her,
she cannot give the information you need to assess and classify the child correctly.
o Give the mother time to answer the questions. For example, she may need time to decide if
the sign you asked about is present.
o Ask additional questions when the mother is not sure about her answer. When you ask about
a main symptom or related sign, the mother may not be sure if it is present. Ask her
additional questions to help her give clearer answers.

Fill in a case recording form

o You should always write down key information about the child on a recording form. You will
find this form useful in clinical practice to remind you about the case.
o Locate the case recording form in your chart booklet.
o Example of how to fill in a case recording form
Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 °C. The health worker
asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6
days, and she is having trouble breathing." This is the initial visit for this illness.

Steps in assessing a child 2 months up to 5 years old:

1. Ask what is the child’s problem
2. Check for general danger signs
3. Check for the main symptoms:
a. Does the child have diarrhea
b. Does the child fever
c. Does the child have an ear problem
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

4. Check for Acute Malnutrition

5. Check for Anemia
6. Check the child’s Immunization Status, Vitamin A, Deworming Status and Oral Health
7. Assess Other Problem

IV. Teaching and Learning Materials and Resources

o Reference book
o Have your copy of the chart booklet IMCI manual and chart(soft and hard copy)
o IMCI forms(2 to 5 years old and sick child up to 2 months)
o -Midwifery Skills Procedure Checklist
o -white paper and pen/computer
o -Download to your cellphone the IMCI chart

References:
WHO Global Health Observatory(http://www.who.int/who/child health/en/index.html)

Prepared by:
Maria Sandra C. Rivera, RM MCHS

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