Integrated Management of Childhood Illnesses (IMCI) Dr. Pushpa Raj Sharma DCH, DTCH, FCPS Professor of Child Health Institute of Medicine, Kathmandu, Nepal

Burden of the Paediatric Disease in Nepal  40,000 deaths are pneumonia related.  30, 000 deaths are diarrhea related  40, 000 deaths are nutrition related  50% deaths are related with neonatal problems.

Burden of these diseases are due to:  Unskilled health worker  Bad family health practices  Unequipped health facility  Unavailability of health resources

Problems in different age groups:  Neonatal period: resuscitation problems, infections, metabolic.  Under five: infections, nutritional.  Preadolescent: developmental, worms, skin.  Adolescent: psychological, sexual habits, drugs.

Common causes of morbidity and mortality  Morbidity  Acute respiratory infections.  Diarrhea  Fever  Ear infections  Malnutrition  Local skin infections  Oral thrush  Mortality  Pneumonia  Severe dehydration  Meningitis/encephalitis  Cerebral malaria  Kwashiorkor/marasmus  Sepsis  Hypothermia  Hypoglycemia

Previous programmes  Training of health workers  Vertical programmes  Child problems were seen as a separate issues  Very little counseling training  Little emphasis on clinical practice

What is needed?  National goal for reducing the morbidity and mortality.  Holistic approach.  Improving family practices.  Equipping the health facility.  Upgrading the health workers skills.  Emphasis on counseling.

How to do it?  Targeting the problem.  All the components in one part.  Optimal use of resources.  Evidence based.  Feasible.  Acceptable by community.

Sensitivity and specificity 100%Sensitivity Specificity Clinical signs Investigations Sensitivity: positive with disease Specificity: negative without disease

The answer  Integrated  Management of  Childhood  Illnesses  IMCI

How it helps?  Identifies a child who needs urgent referral.  Gives evidenced based clinical signs for the diagnosis of common problems.  Provides guidelines for the appropriate treatment.  Educates the parent.  Upgrades the health care facility.  Follow-ups the child.

Conditions that it covers  Respiratory: pneumonia, cough/cold.  Diarrhea: acute watery, dysentery, persistent.  Fever: malaria, measles, meningitis, encephalitis.  Ear problems: mastoditis, acute and chronic infections.  Nutritional: kwashiorkor/marasmus, anemia

Conditions that it covers  Nutritional: feeding problems, breast feeding, counseling.  Neonatal sepsis.  Local infections.  Hypoglycemia, hypothermia.  Oral thrush  Immunization.  Vit. A supplementation  Deworming.

What it contains? 2 months up to 5 years  Simple clinical signs of severe disease.  Simple clinical signs to diagnose pneumonia.  Simple clinical signs to identify three clinical types of diarrhea.  Simple clinical signs to identify malaria.  Simple clinical signs to identify ear infections.  Simple clinical signs to identify malnutrition.

What it contains? Young infant.  Simple clinical signs to identify for referral.  Simple clinical signs to treat at health facility.  Simple signs to identify good breast feeding.

What it contains? General  Simple guidelines for nutrition.  Simple guidelines for treatment of severe diseases, pneumonia, diarrhoea, dysentery,fever,malaria, ear infections, local infections, anaemia, malnutrition.  Guidelines for counseling.  Home care messages, safe practices.  Immunization, vit A, deworming information.

What are the evidences?  Trained health worker identified target disease better than doctors.  Over prescriptions were reduced.  Parents were more satisfied.  Cost effective.  Mortality and morbidity reduced.  Health facility better equipped.

Some examples  Simple questions and simple observations to find out the problem: severe disease.  Does child vomits every thing?  Is the child able to drink?  History of convulsions?  Is the child lethargic or unconscious?

Four main symptoms: 2 months up to 5 years  Does the child has cough or difficulty breathing?  Does the child has diarrhea?  Does the child has fever?  Does the child has ear problem?

Assess every child for: 2 months up to 5 years  Malnutrition:  Weight for age  Oedema  anaemia  Immunization  Vitamin A supplementation  Deworming

If the answer is yes:  For how long?  Associated symptoms?  Classify the illness  Identify treatment  Treat the child

My child has cough for 2 days: (example)  Observe for general danger signs.  If present refer the child with first dose of antibiotics.  Count the respiratory rate: 60/50/40.  Fast breathing indicates pneumonia.  Look for indrawing.  If present indicates severe pneumonia and needs referral.  Look and listen for stridor in a calm child.  If present indicates severe disease and referral is needed.

Classify the disease (example)  Age 9 months: no general danger signs, no chest indrawing, no stridor, no fast breathing.  No pneumonia (cough and cold).  Age 12 months: chest indrawing.  Severe pneumonia.  Age 4 months: fast breathing only.  Pneumonia.  Age 6 months: presence of general danger sign.  A child with very severe disease.

Identify treatment (example)  No pneumonia:  Safe home remedies/ paracetamol/ when to return? Counsel.  Pneumonia:  Antibiotic/paracetamol/safe home remedies/when to return? Counsel.  Severe pneumonia/very severe disease:  First dose of antibiotic/ referral note/ counsel.

Treat the child  Essential drugs.  Safe home care.  Duration of treatment.  When to return.  Change of treatment.  Counsel the parent.  Other problems.

Other Options in IMCI  Neonatal problems of first week  Developmental pediatrics  Perinatal problems  Injury  ……….

IMCI : model for other problems in pediatric diseases  Entry questions.  Threading questions.  Evidenced based specific clinical signs.  Treatment.  Follow-up.  Referral.  Counsel.

History of IMCI in Nepal  1995: IMCI Activities started. District identified, Saptari.  1996: Orientation meeting, nutrition survey, necessary adaptations to generic materials.  1997: Nepali translation, TOT courses.  1998: Follow-up visits, review meeting, pre- service training.  Expansion: at present 13 district.

Thank you. Any questions? Any clarifications? Any suggestions for this presentation?