Integrated Management of

Childhood Illness
 Causes of 10.5 million deaths among children <5
in developing countries, 1999
One in Pneumonia
every two 18%
child deaths
in
developing Malnutrition
countries Diarrhoea
54%
are due to 15%
just five
infectious
diseases Measles
8%
and
malnutrition HIV/AIDS Malaria
3% 7%
Source: EIP/WHO, 1999 data
 Distribution of deaths of children
<5 the world, 1990 and projected
for 2020
The 5 main killers of
children: 1990 2020
ARI, diarrhoea,
measles, malaria
and malnutrition

55% 52%
Perinatal
conditions

Other 5% 7%
communicable
9% 18%
diseases 19% 11%
12%
Non-communicable
11%
diseases

Injuries
Objectives of the Global Child
Health Programme

• To reduce significantly global mortality and

morbidity associated with the major causes of
disease in children

• To contribute to healthy growth and

development of children
 IMCI CASE MANAGEMENT
PROCESS
• Assess by checking for danger signs (or
possible bacterial infection in a young
infant) asking questions about common
conditions, examining the child, and
checking nutrition and immunization
status. Ask other health problems
• Classify using a color-coded triage
system
 IMCI CASE MANAGEMENT
PROCESS
• Identify specific treatments
• Provide practical treatment instructions
including teaching how to give oral drugs,
how to feed and give fluids and how to
treat local infections at home
• Counsel to solve any feeding problems
after assessing feeding
• Give follow-up care when a child is
brought back as requested
The Integrated Case Management Process
Outpatient Health Facility
•check for danger signs
•assess main symptoms
•assess nutrition and Immunization status
and potential feeding problems
•Check for other problems
•classify conditions and
• identify treatment actions

Outpatient Health Facility

Urgent referral
•pre-referral treatment Outpatient Health Home
•advise parents Facility
•refer child Caretaker is
Treatment counselled on:
•treat local infection •home treatment
•give oral drugs •feeding &fluids
Referral facility •advise and teach •when to return
•emergency triage & caretaker •immediately
treatment •follow up •follow-up
•Diagnosis & treatment
•monitoring & ff-up
 Overall Case Management
Process
Outpatient
1 - assessment
2 - classification and identification of treatment
3 - referral, treatment or counseling of the child’s
caretaker (depending on the classification identified
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of patient
progress
• Sick young infant
– 1 week up to 2 months

• Sick young children

– 2 months up to 5 years
 SELECTING THE APPROPRIATE CASE MANAGEMENT
CHARTS

FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to
the clinic

ASK THE CHILD’S AGE

IF the child is from 1 week up to 2 monthsIF the child is from 2 months up to 5

years

USE THE CHART: USE THE CHART:

ASSESS, CLASSIFY AND TREAT ASSESS AND CLASSIFY THE SICK CHILD
THE SICK YOUNG INFANT TREAT THE CHILD
COUNSEL THE MOTHER
 SUMMARY OF ASSESS AND CLASSIFY

Ask the mother or caretaker about the child’s problem.

If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up
visit for the problem, give follow-up care according to PART VII)

Check for general danger signs.

Ask the mother or caretaker about the four When a main symptom is present:
main symptoms: assess the child further for signs
related to
cough or difficult breathing, the main symptom, and
diarrhoea, classify the illness according to the
signs
fever, and œ ear problem which are present or absent.
Check for signs of malnutrition and anaemia and classify the child’s nutritional status

Check the child’s immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child

(PART V), and Counsel the Mother (PART VI)
Assessing the Sick Child

• lethargy or
unconsciousness
General • inability to drink or
Danger breastfeed

Signs • vomiting
• convulsions
Checking the Main Symptoms

- cough and difficult breathing

- diarrhea
- fever
- ear problem
Checking the Main Symptoms

1. Cough or difficult breathing

3 clinical signs
– Respiratory rate
– Lower chest wall indrawing
– Stridor
Checking the Main Symptoms
2. Diarrhea
• Dehydration
– General condition
– Sunken eyes
– Thirst
– Skin elasticity
• Persistent diarrhea
• Dysentery
Checking the Main Symptoms
3. Fever
• Stiff neck
• Risk of malaria and other endemic
infections, e.g. dengue hemorrhagic
fever
• Runny nose
• Measles
• Duration of fever (e.g. typhoid fever)
 Checking the Main Symptoms
4. Ear problems
• Tender swelling behind the ear
• Ear pain
• Ear discharge or pus (acute or
chronic)
 Checking Nutritional Status,
Feeding, Immunization Status
• Malnutrition
– visible severe wasting
– edema of both feet
– weight for age
• Anemia
– palmar pallor
• Feeding and breastfeeding
• Immunization status
 Assessing Other Problems
• Meningitis
• Sepsis
• Tuberculosis
• Conjunctivitis
• Others: also mother’s (caretaker’s) own
health
Session 4
Main Symptoms
- cough or difficult breathing
- diarrhea
- fever
- ear problems
Session 4-a

Cough or Difficult Breathing

 Parts of the Respiratory System

•Nasal
passages
•Windpipe
or trachea
•Lungs
Inside the alveolus
 Cough or Difficult Breathing
ASK: Does the child have cough or difficult breathing?

If NO If YES

IF YES, ASK: LOOK, LISTEN, FEEL: Child

•For how long? •Count the breaths in one minute must
•Look for chest indrawing be
•Look and listen for stridor calm

If the child is: Fast breathing is:

Ask about 2 mos – 12 mos. 50 breaths/min or more
next main 12 mos – 5 yrs 40 breaths/min or more
symptoms:
diarrhea,
fever, ear Classify child’s illness using the color-coded
problems classification table for cough or difficult breathing
Video of child with chest indrawing
Video of child with stridor
 Cough or Difficult Breathing
SIG N CLASSIF Y A S ID EN TIF Y
S danger
•Any general GiveTR EAdose
first TM ENT
of an
sign or SEVERE appropriate antibiotic
•Chest indrawing or PNEUMONIA OR Refer URGENTLY to hospital
•Stridor in a calm child VERY SEVERE
DISEASE
Give an appropriate oral
antibiotic for 5 days
Soothe the throat and relieve the
•Fast breathing PNEUMONIA cough with a safe remedy
Advise mother when to return
immediately
Follow-up in 2 days

If coughing > 30 days, refer for

assessment
No signs of NO PNEUMONIA: Soothe the throat and relieve the
COUGH OR COLD cough with a safe remedy
pneumonia
Advise mother when to return
or very severe immediately
disease Follow-up in 5 days if not improving
 Treatment
Soothe the Throat, Relieve the Cough
with a Safe Remedy
•Safe remedies to recommend:
Breastmilk for exclusively
breastfed
infant; tamarind, calamansi,
ginger

•Harmful remedies to discourage:

Codeine cough syrup
Other cough syrups
Oral and nasal decongestants
 Treatment for Pneumonia or
Very Severe Disease
Age or Cotrimoxazole Amoxycillin
Weight Give 2 times daily Give 3 times daily
for 5 days for 5 days
Adult Syrup Tablet Syrup
tab. 40 mg
80mg TMP 250 mg 125
TMP 200 mg mg/ 5 ml
400 mg SMX
SMX

2 -12 mos 1/2 5.0 ml. 1/2 5.0 ml

12mos-5yrs 1 7.5 ml 1 10 ml.

 Vitamin A Supplementation
for Severe Pneumonia or Very Severe
Disease
Age Vitamin A Capsule

100,000 I U 200,000 I U

6 to 12 mos. 1 capsule ½ capsule

12 mos-5 yrs 2 capsules 1 capsule

Session 4-b

DIARRHEA
Anatomy of the Gastrointestinal
System
 Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs,
ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHOEA?

If NO If YES

Does the child have diarrhoea?

IF YES, ASK: LOOK, LISTEN, FEEL:
For how long? Look at the child’s general condition.
Is the child:
Is there blood in the
stool Lethargic or unconscious?
Restless or irritable?

Look for sunken eyes.

Classify
DIARRHOEA
Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

Pinch the skin of the abdomen.

Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhoea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and
anaemia, immunization status and for other problems.