SEMINAR ON

INTEGRATED MANAGEMENT OF NEONATE AND CHILDHOOD ILLNESS

INTRODUCTION
Common neonatal and childhood illness like acute respiratory infections,
diarrhea, malaria and malnutrition result in high mortality among children less
than 5years of age .National mortality contributes to over 64% of infants deaths
and most of these deaths occurs during the first week of life. Poor access of
health care and delay in referral further compound the problem.

In India, there are nearly 17 lakh child deaths each year, and
child mortality rates are one of the highest in the world. The Government of India
recognized the need to strengthen child-health activities in the country and
decided to launch IMCI. The entire age group of 0 to 59 months was included to
address the neonatal mortality challenge.

CONCEPT OF IMNCI
 The Integrated Management of Neonatal and Childhood Illness (IMNCI)
is the Indian
adaptation of the WHO-UNICEF generic Integrated Management of Childhood
Illness (IMCI) strategy and is the centerpiece of newborn and child health strategy
under
 Reproductive Child Health II and National Rural Health Mission.
The strategy provides an integrated approach for standard management of
major causes of childhood morbidity and mortality like Pneumonia, Diarrhea,
Malnutrition, Neonatal
 problems, Measles, Malaria in the out-patient settings. According to this
approach , sick children are assess, classify their illness , identify the
treatment and provided referral services, counseling services to
children’s care taker and follow up care. With the
 implementation of IMNCI strategy in the country, more and more
newborns and children are being referred to health facilities for
inpatient care.

Definition
Integrated Management of Childhood Illness of IMCI is a systematic approach
to
 children's health which focuses on the whole child. This means not only
focusing on curative
care but also on prevention of disease. The approach was developed by United
Nations
Children's Fund and the[ World Health Organization in 1992.]

 IMCI is an integrated approach to child health that focuses on the well-

being of the
whole child.

 IMCI strategy is the main intervention proposed to achieve a significant

reduction in the number of deaths from communicable diseases in
children under five."

WHO/UNICEF have developed a new approach to taking the major disease of

early childhood called integrated management of childhood illness. The
integrated approach ensure that all the relevant needs of child are looked at and
attended during the contact of the child with the health worker .The strategy has
been expanded in India to include all neonates and renamed as ‘Integrated
management of neonates and childhood illness.’

Objectives

 The major objectives of IMNCI strategy are to reduce mortality and the
frequency and
severity of illness and disability
 Contribute to improve growth and development during the first five
years of a child's
life.
 The guidelines represent an evidence-based, syndromic approach of
case
management that includes rational, effective, and affordable use of drugs and
diagnostic tools.
 The syndromic approach is used to determine the health problems of
the child,
severity of child's condition, and the actions taken.
  It also promotes the adjustment of interventions to the capacity of the
health system
and the active involvement of family members and the community in the
health care
process. IMNCI includes both preventive and curative interventions.

Many well-known prevention and treatment strategies have already proven

effective for saving young lives (evidence based ).

 Childhood vaccinations have successfully reduced deaths due to

measles.
 Oral rehydration therapy has contributed to a major reduction in
diarrhoea
deaths.
 Effective antibiotics have saved millions of children with pneumonia.
 Prompt treatment of malaria has allowed more children to recover and
lead
healthy lives.
 Even modest improvements in breastfeeding practices have reduced
childhood
deaths.
While each of these interventions has shown great success, accumulating
evidence suggests that a more integrated approach to managing sick children
is needed to achieve better outcomes. Child health programs need to move
beyond single diseases to addressing the overall health and well-being of the
child. Because many children present with overlapping signs and symptoms of
diseases, a single diagnosis can be difficult, and may not be feasible or
appropriate.
Care of Newborns and Young Infants (infants under 2
months)Under IMNCI
 Keeping the child warm.
 Initiation of breastfeeding immediately after birth and counseling
for exclusive
breastfeeding and non-use of pre lacteal feeds.
 Cord, skin and eye care.
 Recognition of illness in newborn and management and/or
referral).
  Immunization
 Home visits in the postnatal period."

Home visits are an integral part of this intervention. Home visits by health
workers
(ANMs, AWWs, ASHAs and link volunteers) help mothers and families to
understand and provide essential newborn care at home and detect and manage
newborns with special needs due to low birth weight or sickness.

Three home visits are to be provided to every newborn starting with first visit
on the day of birth (day 1) followed by visits on day 3 and day 7. For low birth
weight babies, 3 more visits (total of six visits) are to be undertaken before the
baby is one month of age. The details of these visits are given in the training
package

In addition the opportunity of home visit is to be used for the care of mothers
during the post-partum period. This will help mothers and families on how to
recognize and manage minor conditions and will ensure timely referral of severe
cases.

Care of Infants (2 months to 5 years) Under IMNCI

 Management of diarrhea, acute respiratory infections (pneumonia)

malaria, measles,
acute ear infection, malnutrition and anemia.
 Recognition of illness and at risk conditions and management/referral)
 Prevention and management of Iron and Vitamin A deficiency.
 Counseling on feeding for all children below 2 years
 Counseling on feeding for malnourished children between 2 to 5 years.
 Immunization

The strategy has the following three components:

HEALTH-worker component: Improvements in the case-management skills of
health staff through the provision of locally adapted guidelines
 Health-service component:- Improvements in the overall health system
required for effective management of neonatal and childhood illness.
  Community component: Improvements in family and community health
care practices.

COMPONENTS OF IMNCI
 Health worker Component
1)Focus on Skill Development-

IMNCI is a skill based training. The training is based on a

participatory approach combining classroom sessions with
hands-on clinical sessions in both facility and community
settings.
2)Training at two level-

Broadly, two categories of training are included, one for

medical officers and a second for
front-line functionaries including ANM’s and Anganwadi
Workers (AWW’s). Physician

"spend 6days in the hospital and 1day in the community, workers spend 3days in
hospital and
4 days in community settings.
 In-service training for the existing staff—The existing staff in the district
will have to
be provided in-service training in a passed manner. The objective of the training
effort
would be to ensure that all medical officers and health worker are trained in
IMNCI.
 Pre-service training – For including IMNCI in the pre-service teaching of
doctors ,
nurses , ANMs, LHVs and others. The state governments will need to issue
instructions in this regard.

3)Personnel to be trained
Health worker’s ANMs, LHVs ,AWWs, Pediatricians and nurses.
.
4) Trainers For The Training-
 For training of the district staff it would be essential to have adequate number of
trainers within the districts. The trainers at district level include all pediatricians in
the district, selected medical officers from the CHCs and block PHCs, selected staff
nurses and LHVs from ICDS. Total training time is 10 days ,8 days.(clinical skills
training)+ 2 for supportive supervision . All candidates should have good
communication skills. Districts with limited manpower might also consider
including to freelance facilitators.

5)Number be trained
 It is estimated that in a district of the average size about 1800 health staff
will need to be trained. The exact numbers will however have to be calculated for
each district will be taken up for implementation of IMNCI.

 Since the staff of other departments like ICDS etc is also to be trained,
their numbers should be carefully included in consultation with the concerned
district officers.

Training institutions-
State: Each state will need to train adequate number of trainers for training the
district level trainers. Therefore the state will have to identify a Regional Training
Centre Level. States may identify one or more medical colleges in the first year
depending on the number of
districts they wish to bring under IMNCI during year one. The staff of these
medical colleges will be trained at the Kalavati Saran Children Hospital, New Delhi
and Safdarjang Hospital New Delhi which have been designated as the National
level IMNCI Training Centers.
DISTRIC LEVEL:
The following issues need consideration before selecting the institutions for
training of
district staff.
1- As IMNCI training focuses on building skills by hands on training on cases, the
selected
institution for training should have sufficient load of inpatient newborns to
provide case
material for hands on training.
2-Health workers have to be given opportunity for practice on case in home
situations.Therefore at- least 4 visits have to be organized.
Classroom teaching is also an important of the training. Classroom training can be
done
where there are adequate number of classrooms with sitting capacity of 12-15
participant
each.
4- The facilitators should have sufficient clinical skills to demonstrate signs of
illness in sick
newborns.
5- The follow up training is designed to improve supportive supervision skills such
as
methods for skill, reinforcement, record review and assessment of facility
functioning.
While training is an important input for implementation of IMNCI, this is not the
only one.
Effective implementation of IMNCI in a district also involves the following
components.
 Improvements to the health system.
The essential elements include:
 Ensuring availability of the essential drugs with workers and at facilities
covered under IMNCI.
 Improve referral to identified referral facility.
 Referral mechanism to ensure that an identified sick infant or child can be
swiftly
transferred to a higher level of care when needed. Every health worker must be
aware
of where to refer a sick child and the staff at appropriate health facilities must be
in
position to identify and acknowledge the referral slips and give priority care to the
sick children.
 Functioning referral centers, especially where healthcare systems are weak,
referral institutions need to be reinforced or private/public partnerships
established
 Ensuring availability of health workers / providers at all levels
 Ensuring supervision and monitoring through follow up visits by trained
supervisors
as well as on-the-job supportive supervision
  Improvement of Family and Community Practices Counseling
of families and creating
awareness among communities on their role is an important component of
IMNCI. This
includes
 Promoting healthy behaviors such as breastfeeding, illness recognition, early
case
seeking etc.
 Counseling of care givers and families as part of management of the sick child
when
they are brought to the health worker/health facility.
 During Home Visits- Home Visits provide an opportunity for identification of
sickness and focused BCC for improving newborn and child care practices.
IMNCI is a Child Health Intervention to be implemented as part of NRHM/RCH-II.
Training for IMNCI will therefore be part of the overall training plan under RCH