Integrated Management of Childhood Illness I MC I Teachers Guide

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Integrated Management of Childhood Illness (IMCI) Teacher's Guide
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Government of the People’s Republic of Bangladesh
IMCI
TEACHER’S GUIDE - 2019
IMCI TEACHER’S GUIDE

1
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
(IMCI)
Government of the People’s Republic of Bangladesh

2019
2
Lesson plan for teaching
Pre- service IMCI
3
Advisory Board
Prof Mohammod Shahidullah, Chair-NTWC, President BPA & BMDC
Professor. Md. Abdul Mannan, Professor of Neonatology, BSMMU
Prof. Dr. Nazmun Nahar, Professor of Paediatrics, BIRDEM
Prof. Dr. Abid Hossain Mollah, Professor of Pediatrics, BIRDEM
Dr.Md. Shamsul Haque, Line Director, MNCAH, DGHS
Dr. Shams El Arifeen, Senior Director & Senior Scientist, Maternal and Child Health Division,
icddr,b
Technical Contribution
WHO
UNICEF
Save the Children
icddr,b
Dr Md. Emdadul Haque, Deputy Director, ME&HMD, DGHS
Dr. Md Abdul Wadud, DPM, Monitoring and Data Quality, NNHP & IMCI, DGHS
Dr. Sabina Ashrafee Lipi, DPM, Training and Child Injury, NNHP & IMCI, DGHS
Dr. Md. Jahurul Islam, DPM, Newborn Health, NNHP & IMCI, DGHS
Dr ANM Ehtesham Kabir, Focal Point, NNHP Cell, NNHP & IMCI, MNCAH, DGHS
Dr. Mahbuba Khan, NPO-Making Pregnancy Safer and Healthy Aging, WHO
Dr. Samina Sharmin, Health Specialist, UNICEF
Dr. Sabbir Ahmed, Advisor, Pneumonia Centinel Commitment (PCC) Project, Save the
Children
Dr. Ziaul Ahsan, Project Manager, EHD Project, Ipas, Bangladesh
Dr. Jobayer Chisti, Senior Scientist, icddr,b
Dr. Ahmed Ehsanur Rahman, Associate scientist, icddr,b
Dr. Sabrina Jabeen, Research Investigator, icddr,b
Dr. Goutom Banik, Research Investigator, icddr,b
Dr. Md. Rezaul Hasan, Deputy Project Coordinator, icddr,b
Reviewed by
Dr. Md. Shariful Islam, Assistant Director and Program Manager, NNHP & IMCI, DGHS
Dr. Sabina Ashrafee Lipi, DPM, Training and Child Injury, NNHP & IMCI, DGHS
4
Dr. Md. Jahurul Islam, DPM, Newborn Health, NNHP & IMCI, DGHS
Dr ANM Ehtesham Kabir, Focal Point, NNHP Cell, NNHP & IMCI, MNCAH, DGHS
Dr. Ahmed Ehsanur Rahman, Associate scientist, MCHD, icddr,b
Dr. Sabrina Jabeen, Research Investigator, MCHD, icddr,b
Dr. Anika Tasneem Chowdhury, Project Research Physician, MCHD, icddr,b
Supported by
Nazir Ahmed Talukder, Field Research Manager, MCHD, icddr,b
A.F.M.Azim Uddin, Field Research Officer, MCHD, icddr,b
Sultan Md. Ershadur Rahman, Field Research Officer, MCHD, icddr,b
Md. Hafizur Rahman, Field Research Assistant, MCHD, icddr,b
Financial Support by
USAID
NIHR Global Health Research Unit on Respiratory Health (RESPIRE) based at the University
of Edinburgh
Printed by
Director General of Health Service, Ministry of Health & Family Planning
5
Integrated Management of Childhood Illness was prepared by the World Health
Organization (WHO) and UNICEF.
The Bangladesh adapted version is prepared by National Newborn Technical Working
Committee and IMCI, Directorate General of Health Services, Ministry of Health and
Family Welfare, Bangladesh with support from WHO-Bangladesh, UNICEF-Bangladesh,
Save the Children-Bangladesh, Bangladesh Paediatric Association and icddr,b.
6
Contents
CHAPTER-I .................................................................................................................................. 8
Introduction: ................................................................................................................................ 8
Instructional materials needed .................................................................................................... 8
Lesson Plan ................................................................................................................................. 9
CHAPTER-II............................................................................................................................... 14
Effective Teaching .................................................................................................................... 14
CHAPTER lll ............................................................................................................................... 20
Schedule of the IMCI Teaching for Students (Day 1 – Day 12) .............................................. 20
CHAPTER lV .............................................................................................................................. 66
Assessment of the student ......................................................................................................... 66
7
CHAPTER-I
Introduction:
Bangladesh is implementing IMCI as the main strategy for child survival. Per service IMCI
teaching of under graduates presents an opportunity of sustaining the IMCI implementation in the
country. It helps health professional to work for the welfare of the country by using public health
approach.
The IMCI teaching will be conducted over 2 weeks of clinical pediatric posting of students in 3rd
years. It will require 12 sessions of 3 hours each. The schedule of teaching is for guidance only
and can be adapted at institutional level. If time is less students can be instructed to read at home
and discussions are done in the session.
This book has been prepared to assist the teachers in teaching IMCI to undergraduate student. The
book describes the teaching schedule, materials needed and assessment of students.
Instructional materials needed

Materials Number
Teacher’s Guide 1 for each Teacher
Student’s hand book 1 for each teacher and 1 for each student
Video tape 1 set
IMCI Chart booklet 1 for each teacher and 1 for each student
IMCI Register 10 register pages per student
A) 0 to 2 months 10 registers per student
b) 2 to 59 months
8
Lesson Plan
DAY- 1
Morning Time Evening Time
• Introduction to Pediatrics (With 20 min. • Reading on Introduction of 1 hour
all faculties of Pediatrics dept.) 15 min. General danger sign, cough or
• Introduction of IMCI difficult breathing
• Introduction of IMCI student’s 15 min.
hand book 15 min.
• Introduction of IMCI chart 15 min. • Practice on relevant cases

booklet 10 min.
• Introduction to IMCI registers 45 min.
• Reading on introduction of
General danger sign, cough or
difficult breathing (page 23-32)
DAY- 2
 Video exercise on general 45 min.  Reading on Introduction of 1 hour
danger sign, cough & difficult 15 min. General danger sign, cough or
breathing difficult breathing
 Case demonstration 30 min.
 Clinical practice by the students 30 min.
(up to cough & difficult  Practice on relevant cases
breathing)
 Reading on diarrhea (page 39-
43)
9
DAY- 3
 Video exercise on diarrhea & 45 min.  Reading on fever 1 hour
dehydration 15 min.
 Case demonstration on diarrhea
 Clinical practice by the students 30 min.  Practice on relevant cases
(up to diarrhea) 30 min.
 Reading on fever (page 49-54)
DAY- 4
 Video exercise on fever 45 min.  Reading on ear problem & 1 hour
 Case demonstration on fever 15 min. checking nutrition statues;
 Clinical practice by the students malnutrition & anemia
(up to fever) 30 min.
 Reading on ear problem &
checking nutritional status; 30 min.  Practice on relevant cases up to
malnutrition & anemia (page- fever
61-78)
DAY- 5
 Video on ear problem, 45 min.  Reading on immunization 1 hour
malnutrition & anemia 15 min. status, assessing the child’s
 Demonstration of WHO growth feeding up to other problems
chart 30 min.
 Case demonstration on
malnutrition 30 min.  Practice on relevant cases up
to fever
10
 Reading on immunization
status, assessing the child’s
feeding up to other problems
(Page 81-88).
DAY- 6
 Clinical practice on full 45 min.  Reading on identify treatment 1 hour
assessment by the student 15 min. & treat the child
 Drill on fast breathing
 Reading Identify treatment & 30 min.
treat the child (Page 88-106).
DAY- 7
 Reading on counseling & 45 min.  Reading on Counseling and 1 hour
follow-up (Page 107-110) follow-up
 Introduction of IMCI registers
 Clinical practice on full 15 min.  Practice on relevant cases
assessment by the students
including IMCI registers 1 hour.
11
DAY- 8
 Role play on treat child, 40 min.  Reading on sick young infant 1 hour
demonstration & practice by
students
 Reading on sick young infant 60 min.
(Page 111-133)
 Introduction of IMCI register 20 min.
for 2 to 59 months
DAY- 9
 Video on sick young infant & 60 min.  Practice on Full assessment by 1 hour
feeding assessment (Positioning the student
& attachment)
 Case demonstration on sick 30 min.
young infant
 Clinic practice by the students 30 hour.
on sick young infant (if
possible)
12
DAY- 10
 Demonstration on feeding 30 min.  Review & feed back 1 hour
assessment (Positioning &
attachment)
on feeding assessment
(Positioning & attachment) in the 10 min.
postnatal ward
 Drill on weigh for height and 40 min.
weight for length
 Review & feed back
DAY- 11
 Assessment by OSCE + MCQ + 1 hour  Reading on infant & young child 1 hour
SAQ feeding and early childhood
development (Page 188 - 198)
 Reading on Eye problem
DAY- 12
 Feedback with all faculty 1 hour 1 hour
members
13
CHAPTER-II
Effective Teaching
A. Techniques for motivating students
 Encourage Interaction
 Keep Students Involved in Discussions
 Keep the session focused and lively
 Present information conversationally rather than read it
 Speak clearly, Vary the pitch and speed of your voice
 Use example from your own experience and ask students for examples from their
experience
B. Manage any problems

Some students may talk too much. Some suggestion on how to handle overly talkative students are
given below:
 Do not call this person first after asking a question
 After a student has gone on for some time say “You have had an opportunity to express
your views. Let’s hear what some of the other students have to say on this point. Then
rephrase the question and invite other students to respond or call on sometime else
immediately by saying “Shomona” you had your hand up a few minutes ago
 When the student pauses, break in quickly and ask hear from another member of the group
or ask a question to the group, such as “What do the rest of you think about this point?”
 Record the student’s main idea on the flipchart. As he continues to ask about the idea, point
to it on the flipchart and say, “Thank you, we have already covered your suggestion. Then
ask the group for another idea
 Do not ask the talkative student any more questions. If all the pervious questions were
directed to the group, ask for an answer from an individual specifically or from a specific
sub-group. (For example, ask “Does anyone have an idea?)
Try to identify students who have difficulty in understanding or speaking course language. Speak
slowly and distinctly so you can be more easily understood and encourage the student in his efforts
to communicate.
14
C. Reinforce student’s efforts:
As a Teacher, you will have your own style of interacting with students. However, a few techniques
for reinforcing student’s efforts include:
 Avoiding use of facial expression or comments that cloud cause students to feel
embarrassed
 Sitting or bending down to be on the same level as the student when talking to him
 Answering questions through fully, rather than hurriedly
 Encouraging students to speak to you by allowing them time
 Appearing interested, saying That’s a good question/suggestion
 Reinforce students Who:
o Try hard
o Ask for an explanation of a confusing point
o Participate in group discussions
o Help other students (with distracting them by talking at length about irrelevant matters)
D. When students are working:

 Look available, interested and ready to help
 Watch the students as they work and offer individual help if you see a student looking
troubled, staring into space not writing answers or not turning pages. These are clues that
the student may need help
 Encourage students to ask you questions whenever they would like some help
 If important issues or questions arise when you are talking with an individual, make a note
of them to discuss later with the entire group
 If a question arises which you feel you cannot answer adequately obtain assistance as soon
as possible from another teacher or the course director
E. When leading a group discussion:

 Plan to conduct the group discussion at a time when you are that all students will have
completed the preceding work. Wait to announce this until most students are ready, so that
others will not hurry
15
 Before beginning the discussion refer to the appropriate section in this guide to remind
yourself of the purpose of the discussion and major points to make
 Always begin the group discussion by telling the students the purpose of the discussion
 Often there is no single correct answer that needs to be agreed on in a discussion. Just be
sure the conclusions of the group are reasonable and that all students understand how the
conclusion were reached
 Try to get most of the group members involved in the discussion. Record key ideas on a
flipchart as they are offered. Keep your participation to a minimum but ask questions to
keep the discussion active and on track
 Always summarize or ask a student to summarize what was discussed in the exercise
 Reinforce the students for their good work by (for example):
o Praising them for the list they complied
o Commenting on their understanding
o Commenting on their creative or useful suggestions
o Praising them for their ability to work together as a group.
F. When co-coordinating a role play:

 Before the role play, refer to the appropriate notes in this guide to remind yourself of the
purpose of the role play, roles to be assigned, background information and major points to
make in the group discussion after wards
 As students come to you for instructions before the role play:
o Assign roles. At first select individuals who are outgoing rather than shy perhaps by
asking for volunteers. If necessary, a teacher may be a model for the group by acting
in an early role play
o Give role play students any materials for example a baby doll, drugs
o Give role play students any background information needed (There is usually same
information for the “mother” which can be photocopied or clipped from this guide.)
o Suggest that during role play students speak loudly
o Allow preparation time for role play students
16
o When everyone is ready, arrange seating/placement of individuals involved. Have the
“mother” and “healthcare provider” stand apart from the rest of the group, where
everyone can see them
 Interrupt if the players are having tremendous difficulty or have strayed from the purpose
of the play
 When the role play is finished, thank the players. Ensure that feedback offered by the rest
of the group is supportive. First discuss things done well. Then discuss things that could be
improved
 Try to get all group members involved in discussion after the role play. In many cases,
there are questions given in the hand book to help structure the discussion
 Ask students to summarize what they learned from the role play
G. During clinical practice sessions:

Clinical Practice Objectives:
Clinical practice is an essential part of the Integrated Management of Childhood Illness teaching.
This provides practice in using case management skills so that students can perform them
proficiently. Students learn about the skills by reading information in the hand book or observing
demonstrations by teachers or on videotape. They then use the information by doing case studies.
Finally, and most importantly in clinical practice students practice using their skills with real sick
children and young infants.
General Objectives: During clinical practice sessions students will:
See examples of sings of illness in real children.
See demonstrations of how to manage sick children and young infants according to the case
management charts.
Practice assessing, classifying and treating sick children and young infants and counseling
mothers about food, fluids and when to return.
Receive feedback about how well they have performed the skill and guidance about how to
strengthen particular skills.
Gain experience and confidence in using the skills.
17
Outpatient Sessions
Outpatient Sessions take place in outpatient clinics. Each small group of students travels to an
outpatient clinic and is supervised by their teachers. The focus of the outpatient session is to
provide practice of the case management process with sick children and young infants.
In outpatient sessions, students will:
- See sick children and young infants who have been brought to the clinic by their mothers
- Practice assessing and classifying sick children and young infants according to the ASSESS
& CLASSIFY session
- Practice identifying the child’s treatment by using the “Identify Treatment” children on the
ASSESS & CLASSIFY charts
- Practice treating sick children and young infants according to the TREAT THE YOUNG
INFANT AND COUNSEL THE MOTHER charts
- Practices counseling communication skills when assessing, treating and counseling
mothers of sick children and young infants
- Practice using good communications skills when assessing, treating and counseling
mothers of sick children and young infants
Inpatient Sessions
Inpatient sessions take place on an inpatient ward. The focus of the inpatient sessions is to practice
assessing and classifying clinical signs especially sings of illness. During inpatient sessions
students will:
- See as many examples as possible of signs of severe classifications from the ASSESS &
CLASSIFY section, including signs not frequently seen
- Practice assessing and classifying sick children and young infants according to the ASSESS
& CLASSIFY section focusing especially on the assessment of general danger sings, other
signs of severe illness and signs which are particularly difficult to assess (for example chest
indrawing and skin pinch.)
- Practice treating dehydration according to plans B and described on the TREAT THE
CHILD section
- Practice helping mothers to correct position and attachment
18
Students practice the case management steps as part of case management process. The clinical
practice skills are presented in the order they are being learned in the hand book. In each clinical
session students use the skills they learned up to and including that day’s session. This allows
students to gain experience and confidence in performing skills introduced in earlier sessions.
To make sure that students receive as much guidance as possible in mastering the clinical skills
the teacher gives particular attention and feedback to the new skill being practiced that day. If any
student has difficulty with a particular skill the teacher continues working with the student on that
skill in subsequent session until the student can perform the skill with confidence.
Role of Teacher during Clinical Sessions

The role of the Teacher during outpatient sessions is to:
1. Do all necessary preparations for carrying out the clinical sessions
2. Explain the session objectives and make sure the students know what to do during each
outpatient session
3. Demonstrate the case management skills as expected from the students
4. Observe the student’s progress throughout the outpatient sessions and provide
feedback and guidance as needed
5. Be available to answer questions during the outpatient sessions
6. Lead discussions to summarize and monitor the student’s performance
19
CHAPTER lll
Schedule of the IMCI Teaching for Students (Day 1 – Day 12)
DAY- 1
• Introduction to Pediatrics 20 min. • Reading on Introduction of 1 hour
(With all faculties of Pediatrics 15 min. General danger sign, cough or
dept.) difficult breathing
• Introduction of IMCI 15 min.
• Introduction of IMCI student’s 15 min.
hand book 15 min.
• Introduction of IMCI Wall 10 min. • Practice on relevant cases

chart 45 min.
• Introduction to IMCI registers

• Reading on introduction of
General danger sign, cough or
difficult breathing (page 23-32)
Introduction to pediatrics
• Introduce all faculties of the department of pediatrics
• Explain the objectives of the department
• Define Pediatrics
• Who is a Child? (Highlight different age groups)
• Discuss common diseases in pediatrics
• Some basic epidemiological data of children e.g. NMR, IMR, under 5 mortality etc. can be
discussed
• Discuss rules and regulations of clinical classes
20
Introduction of IMCI (Students handbook page 11-22)
• Discuss IMCI strategy
• The objectives of the IMCI strategy
• The principles of integrated care
• The IMCI case management process
• Materials needed for IMCI teaching as well as case management
• Distribution of Handbook to all Students
Introduction of the Students’ Hand book
Material needed: Students Hand Book
To conduct the demonstration:

Introduce the hand book by explaining why this book is for. It is also necessary to mention briefly
each part for the book and its purpose. For example: This hand book on IMCI is a module for
teaching pre-service IMCI. IT focuses an approach to the sick child in an integrated manner to
reduce mortality and morbidity of under five children (0 day – up to 5 years). The student Hand
Book adapt uniform presentation while dealing with an overview of the integrated case
management process, assessment and classification of sick child, identification of treatment
priorities, appropriate treatment, counseling of mother or caregiver and follow-up care. It also put
emphasis on assessment of growth, nutrition and immunization status. It provides with knowledge,
skill and attitude to empower students to be a safe and competent doctor. So that they will be able
to take appropriate decision to treat the sick child and to improve their health.
Introduction of IMCI Wall Charts

Review following points:
A. The case management process is described on 5 charts: (point to or walk to each of the
charts on the wall as you say its title.)
Management of the sick child age 2 months up to 5 years is summarized on the following
charts:
21
• Assess & Classify The Sick Child Age 2 Months Up To 5 Years
• Treat The Child
• Counsel The Mother & Follow Up
Following 2 charts are used for sick young infants age up to 2 months.
• Assess And Classify The Sick Young Infant
• Treat The Sick Young Infant And Counsel The Mother
B. To Use the charts, you first decide which age group the child is in
- Age up to 2 months
- Age 2 months up to 5 years
• If the child is 2 months up to 5 years, select the chart Assess And Classify of The Sick Child
Age 2 Months Up To 5 Years
“Up to 5 Years” means the child has not yet had his fifth birthday.
(Be sure that students understand “up to” means up to but not including that age.)
• If the child is NOT yet 2 months of age, the child is considered a young infant
Use the charts ASSESS CLASSIFY THE SICK YOUNG INFANT and TREAT THE SICK
YOUNG INFANT
• A combination of individual sign leads to a child’s classification(S) rather than a diagnosis.

Classification(S) indicates the severity of condition(S). The call for specific actions based on
whether the child-
(a) Should be urgently referred to higher level of care (Pink)
(b) Requires specific treatments (such as antibiotics or anti-malarial treatment) (Yellow), or
(c) May be safely managed at home (Green)
Why not use this process for children age 5 years or more?
The case management process is designed for children less than 5 years of age. Although much of
the advice on treatment of pneumonia, diarrhea, malaria, measles and malnutrition is applicable to
older children, the assessment and classification of older children would differ. For example, the
22
cut-off rates for determining fast breathing would be different, because normal breathing rate are
slower in older children. Chest in drawing is not a reliable sign of pneumonia as children get older
and the bones of the chest become firmer. Older children can talk and so are able to report
additional symptom which are not in these charts.
In addition, certain treatment recommendations or advice to the mother on feeding would differ
for children over 5 years of age. The feeding advice for older children may differ and they may
have different feeding problems.
To summarize: Much of the treatment advice may be helpful for a child age 5 years or more.
However, because of differences in the clinical signs of older and younger children who have these
illnesses, this assessment and classification process using these clinical signs is not recommended
for older children.
Introduction of the IMCI registers
Materials needed: Blank IMCI registers for –

1. IMCI Register (0 to 2 months)
2. IMCI Register (2 to 59 months)
To conduct the demonstration:

When all the students are ready, introduce the IMCI registers for the two age groups, one for the
0 to 2 months old sick young infants and another for the 2 months to 59 months old sick children
by briefly mentioning each part of the registers and their purpose. Use enlarged IMCI registers, to
help student see each part as you refer to it. For example:
“This is a IMCI Register for 2 to 59 months’ children. Its purpose is to help you register
information collected about the children’s signs and symptom when you do exercise in the hand
book and when you see children during clinical practice sessions.
The registers have 6 columns which are used to register the children’s identification, findings of
physical examination, assessment, classification and treatment.
23
Look at the first column of the registers. (Point to each space as you say) there are spaces for
writing:
• The infant’s name, age, sex, mother’s name, father’s name, address and mobile number
• The mother’s answer about the infant’s history of past problems and drug history
• Whether this is an initial visit or follow-up visit
Arrangement of the IMCI registers:

The register is divided into 6 columns: (point to each column as you mention it)
• One is for “Assess” and the other is for “Classify”. These two columns relate to the Assess
and Classify columns on the ASSESS & CLASSIFY section of wall chart
• Point to the relevant columns on the wall chart and then on the IMCI register to show their
correspondence
• Look at the assess column on the wall chart. It shows the assessment step for assessing the
children’s signs and symptoms. Here is the Assess column on the IMCI register where you
register any signs and symptoms that you find are present
• There is also a section for recording information about the infant’s immunization status
• Here is the “Classify” column on the chart, and here is the classify column on the register.
You record the children’s classifications in this column
• When you use the IMCI Register with sick infants during clinical sessions, you record
information by:
o Ticking any sign that is present, like this (Tick () a sign on the enlarged IMCI
Register). If the infant does not have the sign, you do not need to tick anything.
o Writing specific information in spaces such as the one for recording the number of
breathes per minute (point to where this number is written).
o Ticking the classification.
As you work through this hand book, you will only see the part of the form for the symptoms and
signs you have learned.
At the end of the demonstration, ask if there are any questions.
24
DAY- 2
 Video exercise on general 45 min.  Reading on Introduction of 1 hour
danger sign, cough & difficult 15 min. General danger sign, cough or
breathing difficult breathing
 Case demonstration 30 min.
(up to cough & difficult  Practice on relevant cases
breathing)
 Reading on diarrhea (page- 39-
43)
Video exercise “Check for general danger signs” and “Does the child have cough or difficult
breathing?”
To conduct this video exercise:
1. Introduce students to the procedure for video exercises in this course. Explain that during
video exercises they will:
• See video demonstrations and exercises
• Do exercises and record their answers in the IMCI register for 2 months to 5 years
• Check their own answers to exercises and case studies with those on the video
2. Tell students that in the first part of the video for Exercise A they will see examples of
general danger signs. They will see:
• A child who is not able to drink or breastfeed
• A child who vomits everything.
• A mother who is being asked about her child’s convulsions, and
• A child who is lethargic or unconscious.
Then students will do an exercise to practice deciding if the general danger sign “lethargic or
unconscious” is present in each child.
3. Start the video. if they are not writing answers, encourage them to do so. if they seem to be
having difficulty, replay the exercise. Ensure that all students are able to watch the
video
25
At the end of the exercise, stop the video. Ask if any student had problems identifying the
sign “lethargic or unconscious”. Replay the video if any exercise item or demonstration
that you think students should see again. Emphasize points such as:
• Notice that a child who is lethargic may have his eyes open but is not alert or paying
attention to what is happening around him
• Some normal young children sleep very soundly and need considerable shaking or
a loud noise to wake them. When they are awake, however, they are alert
Answers to Exercise A
1. For each of the children shown, answer the question:
Is the child lethargic or unconscious?

YES NO
Child 1 ✓
Child 2 ✓
Child 3 ✓
Child 4 ✓
Conduct Video Exercise – ‘Child with Cough or Difficult Breathing’

Tell the students that they will now:
• See a demonstration of how to count the number of a child’s breaths in one minute
• Practice counting the number of breaths a child takes in one minute and decide if fast
breathing is present
• See examples of looking for chest in drawing and, fast breathing
• Do a case study and practice assessing and classifying a sick child up through cough or
difficult breathing
Start the video and show the demonstration, exercises and case study for cough or difficult
breathing. If any student has difficulty seeing the child’s breaths or counting them correctly, play
the video again to the particular case and repeat the example. Show the student where to look for
and count the breaths again.
26
Chest In drawing
Note: Chest in drawing may be a difficult sign for students to identify the first time. It may take
several trials for the student to feel comfortable with this sign and they can gain more proficiency
during clinical sessions.
• If any student has difficulty in identifying chest in drawing, repeat an example for the
video. Talk through with the student where to look for chest in drawing pointing to where
the chest wall goes in when the child breathing in. Assure students that they will be able to
see the chest in drawing during assessment of sick child in clinical practice sessions
• Some student may need help determining when the child is breathing IN. Show an example
from the video. Point to where on the child’s chest the student should be looking. Each
time the child breaths in, say “IN” to help the student see clearly where to look and what
to look for
• It may be helpful to pause the video and ask a student to point to the place where he would
look for chest in drawing. This will help you to check if students are looking at the
appropriate place for identifying chest in drawing. Repeat the exercises on the video until
you feel confident that the students understand where to look for chest in drawing and can
identify the sign in each child shown in this exercise
27
For each of the children shown in the video, answer the question: Exercise C
Does the child have fast
breathing?
Age Breaths per YES NO
minute
Mano 4 years 65 ✓
Wambai 6 months 66 ✓
For each of the children Does the child have chest in drawing?
shown in the video, YES NO
answer the question:
Mary ✓
Jenna ✓
Ho ✓
Anna ✓
Lo ✓
Does the child have stridor

YES NO
Petty ✓
Helen ✓
Simbu ✓
Hassan ✓
28
29
Video Case Study
30
31
Clinical session
Assess & classify the sick child:
General Danger Signs – Cough or Difficult Breathing
To Prepare - Ask Student to bring their Hand Book
- Give 2 copies of IMCI Registers for 2 months to 5 years per student.
Objectives - Check for general danger signs.
- Assess and classify sick children for cough or difficult breathing
- Measure SpO2 level by pulse oximetry
- Practice using Register in outpatient setting
- Use good communication skills
Procedures - Choose children with cough or difficult breathing and any child with a
general sign
- Introduce clinic facility and staff, describe general procedures for
outpatient sessions
- Demonstrate how to check for general danger signs and how to assess
and classify child for cough or difficult breathing
- Demonstrate how to measure arterial saturation of oxygen
- Make small groups for the student and assign patients to each group
- Supervise closely first-time student counts child’s breaths, looks for
chest indrawing, listens for stridor and measure oxygen saturation with
pulse oximeter
- Observe each student as he works with a patient. If you cannot observe,
ask student to present case or look at student’s IMCI register for 2
months to 5 years
- Give feedback on skills practiced and guidance as needed. Return
patient to clinic staff with note for treatment or treat according to
arrangements
At the end of the - Lead discussion to summarize session
session - Tell students to keep their IMCI Registers for 2 months to 5 years to use
when they return to the classroom
32
DAY- 3
 Video exercise on diarrhea & 45 min.  Reading on fever 1 hour
dehydration 15 min.
 Case demonstration on diarrhea
 Clinical practice by the students 30 min.  Practice on relevant cases
(up to diarrhea) 30 min.
 Reading on fever (page- 49-54)
Video exercise and case study

“Does the child have diarrhea?”
1. Tell students that in this video exercise, they will:
• See examples of children with diarrhea who have the signs of dehydration
• Watch a demonstration on assessment of diarrhea and classification of dehydration
• Do the exercise to practice recognizing sunken eyes and slow or very slow skin pinch
2. Explain that the students should write answers to their books first later on they check their
answers with those provided on the video
3. At the end of each exercise, stop the video. If students are having trouble identifying a
particular sign, replay the video and show the exercise item again. Talk through the
exercise item and show the students where to look to recognize the sign
At the end of the video, conduct a short discuss. If students had any particular difficulty, provide
guidance as needed. Emphasize the points during the discussion such as:
• If you can see the tented skin even briefly after you release the skin, this is a slow skin
pinch (>2 sec.). A skin pinch which returns immediately is so quick that you cannot see the
tented skin at all after releasing it
• Repeat the skin pinch if you are not sure. Make sure you are doing it in the right position
• Sometimes children who are sick or tired and seem lethargic but they respond to touch or
voice. Josh is an example of this. They should not be considered lethargic. It can be hard
to tell this on the video because you only see a few minutes of the child. If you initially
think a child is lethargic but then he awakens and becomes alert later in the examination,
do not consider this child to have the general danger sign “Lethargic or unconscious”
33
Answers to Exercise E
Does the child have sunken eyes?
YES NO
Child 1 ✓
Child 2 ✓
Child 3 ✓
Child 4 ✓
Child 5 ✓
Child 6 ✓
Does the skin pinch go back?

Very slowly? Slowly? Immediately?
Child 1 ✓
Child 2 ✓
Child 3 ✓
Child 4 ✓
Child 5 ✓
34
35
Video Case Study
36
37
Clinical session
Assess & classify the sick Child: Diarrhea.
Top Prepare - Ask students to bring their hand book

- Give 2 copies of IMCI Registers for 2 months to 5 years per students
- Make sure the following are available are each room where students are
working: cup, spoon and ORS for offering fluid to assess dehydration
Objectives - Assess and classify sick children for Diarrhea
- Practice using IMCI Register for 2 months to 5 years in outpatient
setting
- Use good communication skills
Procedure - Choose children with Diarrhea
- Introduce clinic facility and staff, describe general procedures for
outpatient sessions. And show where supplies are located
- Demonstrate how to assess child for Diarrhea with the help of wall chart
- Clinical demonstration with a child who is dehydrated. Show how to
examine the skin pinch
- Make small groups of the students and assign patients to each group
- Supervise the students closely while assessing a child with Diarrhea to
be sure that the assessment is done correctly (especially skin pinch and
thirst)
- Observe each student as he works with a patient. If you cannot observe,
ask student to present case or look at the student’s IMCI Register for 2
months to 5 years
- If child with SOME DEHYDRATION or SEVERE DEHYDRATION
presents during sessions, demonstrate signs to all students of all groups
- Give feedback on skill practice as needed
- Return patient to clinic staff with note for treatment, or treat according
to arrangements
session:
38
- Tell students to keep their IMCI Registers for 2 months to 5 years to
use when they return to the classroom
DAY- 4
 Video exercise on fever 45 min.  Reading on ear problem & 1 hour
 Case demonstration on fever 15 min. checking nutrition statues;
 Clinical practice by the students malnutrition & anemia
(up to fever) 30 min.
 Reading on ear problem &
checking nutritional status; 30 min.  Practice on relevant cases up to
malnutrition & anemia (page- fever
61-78)
Video exercise
“Does the child have fever?
When all the students are ready, arrange from them to move to where the video exercise will be
shown. Make sure they bring their hand books.
To conduct the video exercise:

1. Tell students that during the video for Exercise they will see explain of how to assess a
child with fever for:
• Stiff neck
• Generalized rash of measles
They will also see how to assess children with measles for:
• Mouth ulcers
• Pus draining from the eye
• Clouding of the cornea
They will do an exercise to practice identifying whether stiff neck is present and do a case
study to practice assessing and classifying sick child with fever.
2. Ask if students have any question before you start the video. When there are no additional
questions, start the video
39
3. At the end of the video presentation, lead a short discussion, answer any questions that
students might have about identifying and classifying clinical signs in children with fever.
If they had any particular difficulty identifying signs during the case study, replay the video
and show especially clear examples that demonstrate the sign effectively for the student.
Important points to emphasize in this video are:

• The video shows examples rash at different stages; the early red rash and the older rash
which is peeling as you saw in Pus case
• Assessing for stiff neck varies depending on the state of the child. You may not need
to even touch the child. If the child is alert and calm. You may be able to attract his
attention and cause him to look down. If you need to try to move the child’s neck, you
saw in the video a position which supports the child while gently bending the neck, it
is hard to tell from a video whether the child’s neck is stiff. When you do this step with
a real child, you will feel the stiffness when you try to bend the neck. You also saw the
child cried from pain as the doctor tried to bend the neck.
For each of the children shown, answer the question:
Does the child have a stiff neck?

Yes No
Child 1 
Child 2 
Child 3 
Child 4 
40
41
42
Video Case Study
43
Practice Classifying sick children with fever
44
Classifying fever involves selecting the appropriate classification table. This is slightly different
from the system students have learned so far. Make sure that student use the correct classification
table when answering the case for this exercise.
Maternal needed:
• Enlargement of Blank IMCI Register for 2 months to 5 years
• Enlargement of Classification Table- Fever (High or low Malaria Risk and No Malaria
Risk or no Travel to Malaria Risk Area)
• Enlargement of Classification Table-Measles
• Patient with fever
To conduct the group discussion:

Review with students how to assess a child with fever. Review the assessment steps and how to
do them. Emphasize that you do the assessment steps below the broken line only if the child has
signs of measles within last 3 months.
• Review briefly with students the step “Decide malaria risk”, point out that to assess the
correct classification table for fever, students need to know the malaria risk
• Explain that students can tick () on the IMCI Register for 2 months to 5 years how they
decided to assess the child for fever. They can choose the appropriate phrase – by
history/feels hot/temperature 99.50 F (37.50 C) or above – that follows the question, “Does
the child have fever?”
Clinical session:
Assess and classify the sick child: Fever
To prepare - Ask students to bring Hand Book, Pencil, timing devices

- Give 2 IMCI Registers for 2 months to 5 years per student
Objectives - Assess and classify a sick child for fever
Procedures - Choose Children who have any sickness
- Demonstrate how to assess and classify a child with fever
- Make small groups of students and assign patients to each group
45
- Supervise students closely when they are assessing
- Observe each student as he works with a case. if you cannot observe, ask
student to present the case
- Give fatback on skill practice and guidance as needed
- Return patient with note to nurse to continue treatment
session - Remind students to keep their IMCI Registers for 2 months to 5 years
46
DAY- 5
 Video on ear problem, 45 min.  Reading on immunization 1 hour
malnutrition & anemia 15 min. status, assessing the child’s
 Demonstration of WHO growth feeding up to other problems
chart 30 min.
 Case demonstration on
malnutrition 30 min.  Practice on relevant cases up
 Reading on immunization to fever
status, assessing the child’s
feeding up to other problems
(Page 81-88).
Demonstration: growth chart:

To determine for age
Material needed: WHO growth chart weight
1. Weight for Height chart: Girls and Boys
2. Weight-for-length chart: Girls and Boys
Before giving demonstration on children with malnutrition. Introduce the growth chart by
explaining Z- score and the lines used in the growth chart in the student’s handbook.
These are WHO growth chart weight one is weight for Height chart for girls and boys and another
one is weight-for-length chart for girls and boys —for children from birth up to 5 years. These
growth charts are being used by pediatrician and health care provider for assessing the growth of
children around the world since 2006. It reflects a more accurate description of physiological
growth of children.
47
In the student’s hand book there are 6 charts:
a. Weight for age – Birth to 5 years (Girls)
b. Weight for age – Birth to 5 years (Boys)
c. Weight for length – Birth to 2 years (Girls)
d. Weight for length – Birth to 2 years (Boys)
e. Weight for height – 2 to 5 years (Girls)
f. Weight for height – 2 to 5 years (Boys)
Weight for age

Each chart has five lines, middle line is the mean. It is expressed as 0. (Z score will always have
mean = 0 in a normally distributed date). The lines above and below the middle line are the
deviations of any observed weight from the mean (Standard division = SD). Two lines above are
expressed as +2Z and +3Z scores respectively. If the child’s age is up to 2 months, weight falls
below the line expressed as -2Z score in supplied growth chart. He/she will be classified as low
weight for age (<-2SD).
Weight for length and Weight for height charts

Each chart has 6 lines, middle line is the mean. It is expressed as 0. (Z score will always have mean
= 0 in a normally distributed date). The lines above and below the middle line are the deviations
of any observed weight from the mean (Standard division = SD). Three lines above are expressed
as +1Z, +2Z and +3Z scores and below as -1Z, -2Z and -3Z respectively. If the child’s age is up to
2 years Weight for length chart is used and if the child’s age is 2 to 5years Weight for height chart
is used. -3Z score along with other medical complication/ not able to finish nutritional therapy/
breastfeeding problem denotes COMPLICATED SEVERE ACUTE MALNUTRITION where if
the child is able to finish the nutritional therapy it will be classified as UNCOMPLICATED
SEVERE ACUTE MALNUTRITION. If the Z-score falls between -3 to -2Z then the child has
MODERATE ACUTE MALNUTRITION.
N. B. Z-score is the measure of the distance in Standard deviation (SD) of a sample from the mean.
It not only just says whether a point is above or below the average but also how unusual the
measurement is.
48
How will you measure a child’s length?
Remember that length is used for children under 2 years, or those too weak to stand. One assistant
should hold the child’s head over the ears and with straight arms. The measurer holds one hand on
the child’s knees keeping the legs straight and the other on the foot-place to read the length. The
child should lie flat on the board.
How will you measure a child’s height?

Remember that height is used for children 2 years and older. The assistant should hold the child’s
knees to keep the legs straight with one hand, and the other hand on the shins to keep the heels
against the back and base of the board. The measurer should hold one hand the child’s chin and
the other on the head-piece to read the height. The child’s eyes should the in horizontal level and
the body flat against the board.
49
How do you calculate a child’s Z-score?
Once you have the child’s weight and height/length, you will calculate their Z-score. This is
basically a score comparing the weight-for-height/length of children across the world. Children
with low Z-scores have low weight-for-height/length. The Z-score does not require any math. You
will use an easy chart.
1. There are separate charts for height (2 to 5 years) and length (birth to 2 years)
2. Determine which chart to use based on the child’s sex
It is important to note that there are two separate charts for females and males.
They cannot be used interchangeably.
50
Process:
3. Mark the intersection of the child’s weight and height/ length
Next you will find the intersection of the weight and height/ length. The numbers for weight
(kg) run up the chart, and guiding lines run across the chart. The numbers for height/ length
(cm) are along the bottom of the chart, and the guiding lines run up the chart.
Let us review an example. Ben is 10.5 kg and 82 cm. See how we find the intersection:
4. Use the intersection point to find the z-score

Think about the Z-scores like zones between two lines. Look at the figure below. You
should be most worried about any weight-for-height/ length intersection points that fall:
▪ Between the -2Z and -3Z lines, like the circle below. This is a MODERATE ACUTE
MALNUTRITION
51
▪ Below the -3Z line, like the star below. This is SEVERE ACUTE MALNUTRITION
Clinical session
Assess and classify the sick child: Malnutrition and Anemia
To prepare - Ask the students to bring Hand Book, pencils & weight chart
- Bring 2 IMCI Registers for 2 months to 5 years per student
Objective - Determine weight of length (birth up to 2 years) / height (2 to 5 years)
Procedures - Choose children who have any sickness
- Demonstrate how to take height/ length of the child and plot the height/
length on weight chart
- Demonstrate how to assess and classify a child with malnutrition
- Make small group of students and assign patient to each group
- Supervise students closely when they are assessing.
- Observe each student as he/she works with a case. If you cannot
observe, ask student to present the case
- Give feedback on skills practiced and guidance as needed
- Return patient with note to clinic staff to continue the treatment
session: - Remind Students to keep their IMCI Registers for 2 months to 5 years
52
DAY- 6
 Clinical practice on full 45 min.  Reading on identify treatment 1 hour
assessment by the student 15 min. & treat the child
 Drill on fast breathing
 Reading Identify treatment & 30 min.
treat the child (Page 88-106).
Drill on fast breathing

To conduct the drill:
• There are no special materials required for this drill. However, before you begin, help
students review the cut-offs determining fast breathing. Ask one of the students to tell the
group the cut offs for fast breathing in a child age 2 months up to 11 months, ask another
to tell the group the cut off for fast breathing in a child 12 months up to 5 years
• Remind students about the procedures for doing drills and that this is not a test. They should
wait to be called on and should be prepared to answer as quickly as they can
• Start the drill by asking the first question, call on students one at a time. If a student cannot
give an answer or gives an incorrect answer, cheerfully go to the next student and ask if he
can answer the question
When the group is ready, start the drill by asking the first question below:
QUESTION ANSWER
Ask: What is first breathing in a child And number of breaths in a minute is:
who is:
4 Months old 50 breaths per minute or more
53
QUESTION ANSWER
Ask: Does the child have fast And number of breaths in a minute
breathing if the child is: is:
3 months old 58 Yes
2 years old 38 No
6 months old 48 No
12 months old 38 No
12 months old 42 Yes
3 years old 37 No
8 months old 54 Yes
4 months old 45 No
4 years old 43 Yes
7 months old 48 No
10 months old 38 No
11 months old 45 No
54
Clinical Session
Assess and classify the sick Child: Full assessment & classification
To Prepare - Ask students to bring Hand Book, pencils, timing devices
- Give 2 IMCI Registers for 2 months to 5 years per student
Objectives - Assess and classify a sick child
Procedures - Choose Children who have any sickness
- Demonstrate how to assess and classify a child
- Make small group of students and assign patients to each group
- Supervise students closely when they are assessing
- Observe each student as he/she works with a case. If you cannot
observe, ask student to present the case
- Give feedback on skills practice and guidance as needed
- Return Patient with note to clinic staff to continue treatment
session: - Remind Students to keep their IMCI Registers for 2 months to 5
years
55
DAY- 7
 Reading on counseling & 45 min.  Reading on Counseling and 1 hour
follow-up (Page 107-110) follow-up
 Introduction of IMCI registers
for 2 months to 5 years 15 min.  Practice on relevant cases
 Clinical practice on full
assessment by the students 1 hour.
including IMCI registers for 2
months to 5 years
Demonstration of how to use the IMCI Register

• Hold up a blank IMCI Register
• Give instructions as follows:
Column 1:
Registration No.:
Write down the consecutive serial number.
Date: Write down the date as day/month/year, when a sick child will come to your center
Name of the Child: Write down the name of the child clearly
Date of Birth: Write down the date of birth of the child. Fill up the correct information by following
immunization card or birth registration certificate.
Age: Write down the age of the child. Fill up the correct information by following immunization
card or birth registration certificate.
Sex: Provide the sex of the child. Put tick mark on boy or girl.
Visit: Mention about the visit of the child, Put tick () mark on appropriate box as per visit
Name of the mother: Write down name of the mother of the child in this portion
Name of the father: Write down name of the father of the child in this portion
Address: Write down the detail address of the sick child
Mobile No.: You must collect the mobile number of mother or father of service recipient child
56
Column 2 (Physical Examination):
You will examine the child physically and write down the detail information of that day
Weight (kg): Measure weight of the child and write it in kg
Length (inch): Measure the length of the child and write it in inch
Temperature (°F): Write the temperature in degree Fahrenheit after measuring
Breath (number per minute): Write down how many breathes the child breath within one minute
in this column
Measure the Oxygen Saturation (%) by Pulse Oximeter: Measure the Oxygen Saturation (%) by
Pulse Oximeter and write it down
Date of starting of signs: Write down the date of starting of any sign
Examine the palm: Examine the palm of hand
Eye examination: Examine eyes
Examination to determine other problems: Examine if there exist any other problems
Column 3 (signs of sick child aged 2-59 months):
You will examine the child’s physical condition and provide tick () in box ( ) for appropriate
sign and symptoms
Column 4 (Classification according to signs of sick child aged 2-59 months):
Provide tick () according to classification of sickness
Column 5 (Child management of 2-59 months): If referred
Provide treatment according to IMCI protocol in your service center. Put tick () in provided
treatment for sick child and mention dose where required
Column 6 (Child management of 2-59 months): If not referred
Provide treatment according to IMCI protocol in your service center. Put tick () in provided
treatment for sick child and mention dose where required
Other information related to nutrition:
Put tick () for appropriate boxes regarding other information related to nutrition
Counselling:
Counsel in your service center according to IMCI protocol and put tick () on provided counseling
section
Assess the immunization status:
(circle, if there is a need to provide immunization today)
57
Bring the child for next immunization:
Write down the date on which the child should bring for next immunization
Clinical session
Assess and classify a sick child and identify treatment
Feeding assessment and advice
To Prepare - Ask student to bring hand book and open the page on counsel the mother
- Arrange children less than 2years or those with MODERATE ACUTE
MALNUTRITION
Objectives - Assess and classify a sick child and identify the child’s treatment,
including feeding advice. Advice mother when to return
- Counsel mother about feeding
- Ask feeding questions
- Identify feeding problems
- Give advice on feeding problems
- Use good communication skills for counseling mothers
Procedures - Choose children who appear to be MODERATE ACUTE
MALNUTRITION
- Demonstrate how to assess feeding and counsel the mother about food,
fluid and when to return
- Make small groups of students and assign patient to each group
- Supervise students closely when they assess feeding and counsel the
mother about feeding for the first time
- Observe each student as s/he works with a case. If you cannot observe,
ask student to present the case
- Give feedback and guidance as needed
- Return patient with note to clinic staff to continue treatment
At the end of - Discuss feeding problems identified and the advice given
the session:
58
DAY- 8
 Role play on treat child, 40 min.  Reading on sick young infant 1 hour
demonstration & practice by
students
 Reading on sick young infant 60 min.
(Page 111-133)
 Introduction of IMCI register 20 min.
for 2 to 59 months
Role play:
Teaching a mother to give oral drugs at home using good communication skills
Purpose: To demonstrate good communication skills and show the steps of teaching a mother to
give oral drugs to a sick child.
Highlights of the case:
A physician has decided that a young infant named Gita has been classified as pneumonia
needs the antibiotic Amoxicillin (syrup will be used for this role play, however Amoxicillin is
also available in tablet and dispersible tablet form). The physician will teach Gita’s mother
how to give the drug to the infant. Gather the following supplies and put them on a table.
Materials needed:
• Doll
• Syrup Amoxicillin
• Pen and paper
• Cup and spoon (measuring 5 ml, supplied with medicine)
Students are advised to read general steps of giving oral drugs at home (student’s handbook page-
104-105)
59
Select two students for role play, one as mother and another as health worker. Selected students
are advised to read the role play script thoroughly form page 74-75 of this guide.
Demonstrate the role play by telling the selected students that you are going to tech a mother to
give an oral drug at home. Tell the other students to observe the role play and to look for:
• The steps to follow when giving oral drugs to the mother of a sick child, and
• Whether good communication skills are used while teaching the mother to give the drugs
at home
The step to follow when giving oral drugs to the mother of a sick child are:
• Giving information
• Showing the mother how to measure the does and give to the child
• Letting the mother practice
• Checking the mother’s understanding by asking good checking questions
• Praise the mother when she answers the checking questions correctly
After the role play lead a group discussion. Point out that all steps were followed in the role play
At the end emphasize following points:

• Determine the appropriate drugs and dosage for the child’s age or weight
• Tell the mother the reason for giving the drug to the child
• Demonstrate how to measure a dose
• Watch the mother practice measuring a dose by herself
• Ask the mother to give the first does to her child
• Explain carefully how to give the drug, then level and package the drug. If more than one
drug will be given, collect, count and package each drug separately
• Explain that all the tablets or syrup must be used to finish the course of treatment, even if
the child gets better
• Check the mother’s understanding before she leaves the clinic
60
DAY- 9
 Video on sick young infant & 60 min.  Practice on Full assessment by 1 hour
feeding assessment (Positioning the student
& attachment)
 Case demonstration on sick 30 min.
young infant
 Clinic practice by the students 30 hour.
on sick young infant (if
possible)
Clinical session
Assess and classify a Sick Young Infant
To Prepare Choose young infants with signs of VERY SEVERE DISEASES or
JAUNDICE as many of the clinical signs as possible. Also choose some
normal young infants and infants with infrequently seen signs
Objectives Assess and classify a young infant for VERY SEVERE DISEASE and
JAUNDICE
Record findings on the IMCI Register for age up to 2 months: Use the chart
to choose classifications and record them
Procedures Demonstrate signs of sickness on a sick young infant. Assign students to
young infants. Ask them to assess the young infant. Observe and assist as
needed. Conduct rounds. Have all Students assess as many of the signs present
as possible
Show any young infants with infrequently seen signs
At the end of Summarize the session with Students
the session:
Note: Look for young infants in the paediatric ward or in postnatal ward
61
DAY- 10
 Demonstration on feeding 30 min.  Review & feed back 1 hour
assessment (Positioning &
attachment)
on feeding assessment
(Positioning & attachment) in the 10 min.
postnatal ward
 Drill on weigh for height and 40 min.
weight for length
 Review & feed back
Video demonstration of how to teach correct positioning and attachment for breastfeeding
When all the students are ready, arrange for them to move to where the video will be shown. Make
sure they bring their hand books.
If it is possible in the room where the video is shown, display the enlargement of “Teach Correct
positioning and Attachment for Breastfeeding”.
To show the video demonstration:

• Tell students that they will watch a demonstration of helping a mother to improve
positioning and attachment for breast feeding
• Ask if students have any questions before you start the video. When there are no additional
• At the end of the video, lead a short discussion. Ask students to look at the box, “Teach
Correct Positioning and Attachment for Breasting”. Explain that the video showed exactly
these steps
• Then make the following points:
o Good positioning is important for good attachment. A baby who is well positioned can
take a good mouthful of breast
62
o Review the four steps of positioning
o When you explain to a mother how to position and attach her infant, let her do as much
as possible herself
o Then review the 4 steps to help the infant to attach
Check for signs of good attachment and effective suckling. It may take several attempts
before the mother and baby are able to achieve good attachment.
• If students are not clear about the steps, replay the video and show it again
Video demonstration of breastfeeding assessment

• If possible, in the room where the video is being shown, display the wall chart:
• Tell students that they will see demonstration of assessing feeding. In particular they will
see how to assess breastfeeding. Point to the wall chart and review the steps of assessing
breastfeeding. The video will show examples of the signs of good and poor attachment and
effective and ineffective sucking
• Ask if students have any questions before you start the video. When there are no additional
• At the end of the video lead a short discussion. If students are not clear about the assessment
of any signs, replay the video and show the relevant portions again
• Important points to emphasize in the discussion are:
o The four signs of good attachment
o An infant who is well attachment does not cause any pain or discomfort to the breast.
Good attachment allows the infant to suckle effectively
Signs of effective suckling are:

• The infant suckles with show deep sucks
• You may see or hear swallowing
An infant who is sucking effectively may pause sometimes and then start suckling again.
Remember that the mother should allow her baby to finish the feed and release the breast
himself. A baby who has been sucking effectively will be satisfied after a breastfeed
63
Drill: Determine weight for age for children Birth to 5 years (Boys)
Conduct this drill at any convenient time.
To conduct drill:
• Make sure each student is looking at the weight for age charts (student’s handbook page
68-69)
• Tell the students that you will state some age, sex and weights of children. You will then
call on individual students to answer whether the child is VERY LOW WEIGHT FOR
AGE. Ask students to wait to be called on and to be prepared to answer as quickly as they
can
• Start the drill by saying aloud the weight and age of the first child. Allow students time to
look at a weight for age chart and determine the answer. Then ask as student to give the
child’s weight for age status. Continue calling on different students, making sure each
understands how to use the weight for age chart correctly
Drill: Weight for age for young infants

Tell students that in this drill they will practice determining whether a young infant is low weight
for age. Ask them to take out their Hand Book and turn to the Weight for Age chart.
Ask the question in the left column. Students should answer in turn.
Questions Answers
Which curve do you look at to assess weight The line expressed as -2Z score/ -2SD
for age in a child age up to 2 months?
If a young infant’s weight is on the line No, below the curve is low weight. But on or
expressed as -2Z score the child is the low above the curve is not
weight for age
Does the weight for age chart show age in Weeks
weeks or months for young infants?
64
Drill: determining weight for age
Is the young infant Low weight for age if
The infant is: And weighs? Answer
3 weeks old (girl) 3 kg No
6 weeks old (boy) 4 kg No
7 weeks old (boy) 3 kg Yes
4 weeks old (girl) 2.5 kg Yes
5 weeks old (girl) 3.25 kg No
2 weeks old (girl) 2.5 kg Yes
6 weeks old (boy) 3.75 kg No
5 weeks old (boy) 2.9 kg Yes
DAY- 11
 Assessment by OSCE + MCQ + 1 hour  Reading on infant & young child 1 hour
SAQ feeding and early childhood
development (Page 188 - 198)
DAY- 12
 Feedback with all faculty 1 hour 1 hour
members
65
CHAPTER lV
Assessment of the student
Guidelines for student assessment

Introduction
The Integrated Management of Childhood Illness (IMCI) strategy has been incorporated into the
pre-service teaching of medical students in Bangladesh so that it would improve the skills of care
providers. It is important that Students should be able to demonstrate their competence in IMCI.
This also means that principles and concepts of IMCI need to be incorporated into student
assessment.
Why assess Students in IMCI?

The primary objective of assessment is to ensure that students have achieved a minimal level of
competence and to grade them. However, there are also other important reasons for assessing
Students. Assessment helps to:
• Motivate students by providing feedback on their progress
• Decide if students should progress to the next stage of study
• Ensure that important subjects are given priority in the curriculum
• Decide if the academic program has effectively met its objectives; and
• Offer evidence to regulate authorities that standards are being met
What should the students be assessed for?

The essential competencies (both knowledge, skills and attitude) that students should be assessed
for can be organized as follows:
1. Assess the child
2. Classify the child
3. Identify actions to be taken
4. Treat the child
5. Counsel the mother
66
Assessment of the students
Students are assessed twice, at the end of their placement to Pediatric ward for IMCI (formative)
and during final professional examination (summative).
Formative assessment
It is the regular monitoring of students during their period of study. Its primary aim is to improve
student learning by identifying the strengths and weakness of Students and provide feedback. It
also gives feedback to teachers on the effectiveness of their teaching.
Summative Assessment
It is conducted at the end of the course usually during final professional examination along with
entire Paediatrics curriculum.
Assessment Methods
Knowledge
For the assessment of knowledge in IMCI the following methods can be used:
• Multiple choice questions (MCQs)
(One or more correct answer, from 5 suggested answers)
• Short answer questions (SAQs)
(Questions requiring a short answer)
• Written case studies
A case is provided with variable patient data and several questions, e.g. MCQ, SAQ, are
prepared on data.
Skill and attitude

For the assessment of skills in IMCI the following methods can be used:
• Direct observation of student performance
The teacher observes the student performance during case management of a patient using
an IMCI Register
• Objective Structured Clinical Examination (OSCE)
67
Students rotate through a series of stations where they are observed by examiners while
undertaking clinically related tasks. Thus, all students are examined on the same set cases
by the same set of examiners.
Integrating IMCI evaluation with pediatric assessment

The main object of teaching pre-service IMCI is to integrate IMCI as part of the routine Paediatric
curriculum and assessment. In summative assessment, life formative knowledge in IMCI can be
evaluated MCQs & SAQ. Similarly, summative assessment of skills can be done during the final
professional examination where some part of the paediatric OSCE can be given as IMCI.
68
IMCI Knowledge Assessment
Samples of Multiple-Choice Questions (MCQs) and
Short Answer Questions (SAQs)
1. Multiple Choice Questions

Each item is followed by five possible responses. Write ‘T’ for true and ‘F’ for false statement.
1. The general danger sign in children from 2 months up to 5 years are:
a. Stridor
b. Chest in drawing
c. Not able to drink
d. Convulsion
e. Lethargy
2. The pulse oximeter measures:

a. Haemoglobin level in blood
b. Body temperature
c. Percentage of blood saturated with oxygen
d. Pulse rate
e. Cardiac output
3. Detection of measles is based on fever and generalized rash along with following signs:
a. Cough
b. Mouth ulcer
c. Red eyes
d. Runny nose
e. Eye discharge
4. Which children should be assessed for feeding:

a. All children brought to the clinic
b. All children less than 24 months
c. All children classified as anaemia
69
d. All children classified as very low weight
e. All children with diarrhea
5. Vitamin A is Given to:

a. All children with persistent diarrhea
b. All children with measles
c. All children with severe malnutrition
d. All children with very low birth weight
e. All children with malaria
Short Answer Questions

1. A 2 years old boy weighting 8 kg has been admitted with diarrhea. On assessment you have
found SEVERE DEHYDRATION.
a. What fluid will you give for correction of dehydration?
b. Calculate the amount of fluid to be given along with duration.
2. One and half year-old child has been brought to you with history of cough or difficult
bleeding.
a. How will you assess the child?
b. What advise will you provide to the mother if your classification is no pneumonia:
cough or cold
70
Organization of OSCE
Please note:
• All the faculty members should be well oriented about OSCE
• All teachers should sit together to decide the content and organization of OSCE
• Check-list for the station should be prepared in advance
• There should be a structured marking scheme
• Clear instruction for the student should be there
• Each student will have 5 minutes time at each station and student rotates on the ring of a
bell until the cycle is complete
• Keep a separate time keeper
• In procedure station, students’ performance is observed by an examiner with the help of a
check-list
• In the question station student write the answer on script and after completion drop it in a
box. At the end of the examination script will be assessed with standard check-list
71
Station 1
Fatima is 11 months old. She is assessed for feeding. Her mother says she breast feeds Fatima
as often as she wants. She gives her some thin dal with rice twice a day. She gives her half a
cup at each feed. Fill the Assessment form provided and in the Feeding Problems column write
down the problems identified.
Please keep this form with you till you have completed the next station. You will use this
information in the next station.
(Instruction for examiner: Place adequate number of copies of the ASSESSMENT FORM
ASSESSES CHILD’S FEEDING depicted below for each student to fill)
Assess Child's Feeding
Assess feeding if child is Less Than 2 Years Old, has MODERATE ACUTE
MALNUTRITION and ANAEMIA. Ask questions about the child's usual feeding and feeding
during this illness. Compare the mother's answers to the Feeding Recommendations for the
child's age.
ASK - How are you feeding your child?
• If the child is receiving any breast milk, ASK:

- How many times during the day?
- Do you also breastfeed during the night?
• Does the child take any other food or fluids?
- What food or fluids?
- How many times per day?
- What do you use to feed the child?
• If Moderate Acute Malnutrition, ASK:
- How large are servings?
- Does the child receive his own serving?
- Who feeds the child and how?
- What foods are available in the home?
• During this illness, has the child's feeding changed?
- If yes, how?
72
Station 2
Counselling station
This is Fatima’s mother. Use the information you have from Fatima’s feeding assessment in
the previous station to counsel Fatima’s mother for feeding.
(Instruction for examiner: You can use a dummy mother to sit here. The examiner observes the
counseling and ticks for each student as per format provided below. Please collect the assessment
form completed by the student at the previous station at this station once counseling is over.)
Assessment form: Use the columns to enter roll no. and tick where appropriate. Each correct
Performance scores 1 mark
Name:
Criteria (marks) Done Not done Remark
1. Praises mother (1)
2. Counsels about increasing frequency (1)
3. Counsels about consistency of weaning feeds (1)
4. Counsels about quantity of food (1)
5. Asks checking questions (1)
73
Station 3
This 4-year-old child from high or low risk malaria area is classified as MALARIA. He has a
temperature of 38°c. The peripheral blood smear is positive for P. Vivax.
Write the anti-malarial treatment

(Instruction for examiner: Place a copy of the chart booklet so that student can search out the
appropriate treatment and write it down.)
Flow of OSCE Station
Station 1 Station 2 Station 3
Station 8 Station 4
Station 7 Station 6 Station 5
74
Script for demonstration role play
Health Worker: Now I am going to teach you how to give this drug to Gita. This is syrup
Amoxicillin which is an antibiotic. She needs to take this drug to treat her
pneumonia. Are you the person who will give the drug to Gita?
Mother: Yes, I am.
Health Worker: Good. I will show you how much to give her. Since Gita is a baby of 9
months old, she needs to take two spoonsful (10 ml) at a time. (Show the
mother how to measure the dose)
Mother: Yes, I will try (Mother will try to show).
Health Worker: Good, you did it. Now, how much is one dose for Gita?
Mother: (Mother holds up the spoon supplied with medicine). This much twice.
Health Worker: That’s correct. Now you are going to give the syrup to Gita. Have you ever
given syrup to Gita before?
Mother: Yes, I have. Shall I do that now?
Health Worker: Now, with the spoon, try to put the medicine into Gita’s mouth (show the
mother).
Mother: I’ll try. (She spoons it into the baby’s mouth)
Health Worker: You are doing fine. See, she is swallowing it now. At home, you will give
in this way.
Mother: I will.
Health Worker: You need to give a dose to Gita two times each day, once in the morning.
Such as breakfast, and again at dinner. I am giving you enough syrup for 5
days. (Health Worker writes the instructions on a paper. He hands the paper
to the mother so that she can see the instructions).
Mother: Thank you.
Health Worker: I have written the instructions on the paper to remind you when to give the
medicine. Would you read me the instructions on the paper?
Mother: Yes, of course. (mother tries unsuccessfully to read the instructions on the
paper).
75
Health Worker: (Reads the instructions on the paper to the mother). Who can help you read
the paper?
Mother: My sister can read. She lives with us.
Health Worker: Good. I want to tell you another important thing- Continue giving Gita the
medicine until it is all gone. Even if she seems to be better, she needs to
take all the medicines to be sure that she will get well and stay well.
Mother: I can do that.
Health Worker: Good. And how much will you give to Gita each time?
Mother: I will give her two spoonsful.
Health Worker: Good. Can you tell me how many times each day will you give Gita a dose
of the medicine?
Mother: I will give the medicine at sunrise and sunset.
Health Worker: That’s correct. Twice each day. I want you to bring Gita back to see me in
3 days. So that I can be sure she is getting better.
Mother: When is that?
Health Worker: On ________ will you, or someone else in your family be able to bring Gita
back?
Mother: Yes, I can bring Gita back on _________
Health Worker: Good, I will expect you then.
Mother: (Gathering up her things and Gita and leaving) Thank you.
Health Worker: Good bye.
-------------------------------------End-----------------------------------
76
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Integrated Management of Childhood Illness (IMCI) Teacher's Guide

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IMCI TEACHER’S GUIDE

IMCI TEACHER’S GUIDE

Government of the People’s Republic of Bangladesh

Instructional materials needed

• Introduction of IMCI chart 15 min. • Practice on relevant cases

• Introduction to IMCI registers 45 min.

B. Manage any problems

D. When students are working:

E. When leading a group discussion:

F. When co-coordinating a role play:

G. During clinical practice sessions:

Role of Teacher during Clinical Sessions

• Introduction of IMCI Wall 10 min. • Practice on relevant cases

• Introduction to IMCI registers

Introduction of the Students’ Hand book

Material needed: Students Hand Book

To conduct the demonstration:

Introduction of IMCI Wall Charts

• A combination of individual sign leads to a child’s classification(S) rather than a diagnosis.

Introduction of the IMCI registers

Materials needed: Blank IMCI registers for –

To conduct the demonstration:

Arrangement of the IMCI registers:

Is the child lethargic or unconscious?

Conduct Video Exercise – ‘Child with Cough or Difficult Breathing’

Does the child have stridor

Video exercise and case study

2. For each of the children shown, answer the question:

Does the skin pinch go back?

Top Prepare - Ask students to bring their hand book

To conduct the video exercise:

Important points to emphasize in this video are:

For each of the children shown, answer the question:

Does the child have a stiff neck?

To conduct the group discussion:

To prepare - Ask students to bring Hand Book, Pencil, timing devices

Demonstration: growth chart:

Weight for age

Weight for length and Weight for height charts

How will you measure a child’s height?

4. Use the intersection point to find the z-score

Drill on fast breathing

Demonstration of how to use the IMCI Register

Highlights of the case:

At the end emphasize following points:

To show the video demonstration:

Video demonstration of breastfeeding assessment

Signs of effective suckling are:

Drill: Weight for age for young infants

Guidelines for student assessment

Why assess Students in IMCI?

What should the students be assessed for?

Skill and attitude

Integrating IMCI evaluation with pediatric assessment

1. Multiple Choice Questions

2. The pulse oximeter measures:

4. Which children should be assessed for feeding:

5. Vitamin A is Given to:

Short Answer Questions