However, this reduction has not been evenly distributed throughout the world. Every year more than 10 million children die in developing countries before they reach their fifth birthday Fig. The most common causes of infant and child mortality in developing countries including India are perinatal conditions, acute respiratory infections, diarrhoea, malaria, measles and malnutrition. These are also the commonest causes of morbidity in young children. Mortality rate in the second month of life is also higher than at later ages. Any health program that aims at reducing IMR needs to address mortality in the first two months of life, particularly in the first week of life.
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However, this reduction has not been evenly distributed throughout the world. Every year more than 10 million children die in developing countries before they reach their fifth birthday Fig. The most common causes of infant and child mortality in developing countries including India are perinatal conditions, acute respiratory infections, diarrhoea, malaria, measles and malnutrition.
These are also the commonest causes of morbidity in young children. Mortality rate in the second month of life is also higher than at later ages. Any health program that aims at reducing IMR needs to address mortality in the first two months of life, particularly in the first week of life.
Projections based on the analysis The Global Burden of Disease indicate that common childhood illnesses will continue to be major contributors to child deaths through the year unless significantly greater efforts are made to control them.
This assumption makes a strong case for introducing new strategies to significantly reduce child mortality and improve child health and development. Rationale for an Evidence-based Syndromic Approach to Case Management Many well-known prevention and treatment strategies like UIP, Oral Rehydration and appropriate antibiotic therapy for pneumonia have already proven effective for saving young 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 programmes 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.
This is especially true for first-level health facilities where examinations involve few instruments, little or no laboratory tests, and no X-ray. Although the major reason for developing the IMCI strategy stemmed from the needs of curative care, the strategy also addresses aspects of nutrition, immunization, and other important elements of disease prevention and health promotion.
The objectives of the strategy are to reduce death and the frequency and severity of illness and disability, and to contribute to improved growth and development. The IMNCI clinical guidelines target children less than 5 years old the age group that bears the highest burden of deaths from common childhood diseases.
The guidelines take an evidence-based, syndromic approach to case management that supports the rational, effective and affordable use of drugs and diagnostic tools. Evidence-based medicine stresses the importance of evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning for medical decision-making.
In situations where laboratory support and clinical resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients. Careful and systematic assessment of common symptoms and well-selected clinical signs provides sufficient information to guide rational and effective actions.
An evidence-based syndromic approach can be used to determine the: Health problem s the child may have; Severity of the childs condition; Actions that can be taken to care for the child e.
In addition, IMNCI promotes: Adjustment of interventions to the capacity and functions of the health system; and Active involvement of family members and the community in the health care process. Parents, if correctly informed and counselled, can play an important role in improving the health status of their children by following the advice given by a health care provider, by applying appropriate feeding practices and by bringing sick children to a health facility as soon as symptoms arise.
Components of the Integrated Approach The IMNCI strategy includes both preventive and curative interventions that aim to improve practices in health facilities, the health system and at home. At the core of the strategy is integrated case management of the most common childhood problems with a focus on the most common causes of death. The strategy includes three main components: Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on Integrated Management of Neonatal and Childhood illness and activities to promote their use; Improvements in the overall health system required for effective management of childhood illness; Improvements in family and community health care practices.
The Principles of Integrated Care The IMNCI guidelines are based on the following principles: All sick young infants age up to 2 months must be examined for signs of possible serious bacterial infection and all children 2 months to 5 years must be examined for general danger signs which indicate the need for immediate referral or admission to a hospital.
All sick children must be routinely assessed for major symptoms for young infants up to 2 months: diarrhoea; and for children age 2 months up to 5 years: cough or difficult breathing, diarrhoea, fever and ear problem. They must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems. Only a limited number of carefully selected clinical signs are used, based on evidence of their sensitivity and specificity to detect disease.
These signs were selected considering the conditions and realities of first-level health facilities. A combination of individual signs leads to a childs classification s rather than a diagnosis. Classification s indicate the severity of condition s. They call for specific actions based on whether the young infant or the child a should be urgently referred to another level of care, b requires specific treatments such as antibiotics or antimalarial treatment , or c may be safely managed at home.
The classifications are colour coded: pink suggests hospital referral or admission, yellow indicates initiation of treatment, and green calls for home treatment. The IMNCI guidelines address most, but not all, of the major reasons a sick child is brought to a clinic. A child returning with chronic problems or less common illnesses may require special care. The guidelines do not describe the care at birth and the management of trauma or other acute emergencies due to accidents or injuries.
IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of children. An essential component of the IMNCI guidelines is the counselling of caretakers about home care, including counselling about feeding, fluids and when to return to a health facility. The charts describe the following steps: Assess the young infant or child Classify the illness Identify treatment Treat the infant or child Counsel the mother Give follow-up care These steps are probably similar to the way you care for sick children now, though you may have learned different words to describe them.
The step called Assess the Young Infant or Child means taking a history and doing a physical examination. Classify the Illness means making a decision on the severity of the illness.
You will select a category, or Classification, for each of the childs major symptoms, which corresponds to the severity of the disease. Classifications are not specific disease diagnoses. Instead, they are categories that are used to determine treatment. The charts recommend appropriate treatment for each classification. When using this process, selecting a classification on the chart is sufficient to allow you to Identify Treatment for a young infant or child.
Treat means giving treatment in clinic, prescribing drugs or other treatments to be given at home, and also teaching the mother how to carry out the treatments. Counsel the mother includes assessing how the child is fed and telling her about the foods and fluids to give the child and when to bring the child back to the clinic.
This course trains you to use the charts and gives you clinical practice managing sick young infants and children. After the course, the charts will help you recall and apply what you have learned when you manage sick young infants and children at your clinic. It is a case management process for a first-level facility such as a clinic, a health centre or an outpatient department of a hospital. The course uses the word clinic throughout to mean any such setting.
You will learn to manage sick children according to the case management charts, including: Assessing signs and symptoms of illness, and nutritional and immunization status, Classifying the illness, Identifying treatments for the childs classifications and deciding if a child needs to be referred, Giving important pre-referral treatments such as a first dose of an antibiotic, vitamin A, quinine injection, and treatment to prevent low blood sugar and referring the young infant or child, Providing treatments in the clinic, such as first dose of antibiotic, oral rehydration therapy, vitamin A, and immunization, warming the young infant by skin to skin contact, Teaching the mother to give specific treatment at home, such as an oral antibiotic or antimalarial, and Counselling the mother about feeding and when to return.
Providing treatment to sick young infants and children who have a severe classification but referral is not possible. When a young infant or child comes for scheduled follow-up, reassessing the problem and providing appropriate care. Most exercises provide clinical information describing a sick young infant or child and ask questions. Some exercises use photographs or video. You will complete a module by reading it and working through the exercises. For approximately half of each day, you will go to nearby clinics to observe and practice managing sick young infants and children.
In these clinical sessions you will assess, classify and treat sick young infants and children, including teaching their mothers how to care for them at home. The clinical sessions give you opportunities to try the skills that you learn about in the modules. You may ask questions and receive guidance if difficulties arise. By the end of the course, you will have experience in managing young infants and children according to the case management process and can feel comfortable continuing at your own clinic.
A facilitator will guide you through the activities and exercises in the modules, lead group discussions and review your individual work on the modules. A facilitator will also supervise your practice during clinical sessions.
You are encouraged to discuss any questions or problems with a facilitator. If not, you may begin by asking the childs name and age. Decide which age group the child is in: - Age up to 2 months - Age 2 months up to 5 years If the child not yet 2 months of age, the child is considered a young infant.
Up to 2 months means that the child has not yet completed 2 months of age. For example, this age group includes a child who is 1 month and 29 days old but not a child who is 2 months old. Up to 5 years means that the child has not yet had his fifth birthday. For example, this age group includes a child who is 4 years and 11 months but not a child who is 5 years old. In the next module, Assess and Classify the Sick Young Infant, you will learn how to assess and classify a young infant.
Active neurological disease of the central nervous system: Epilepsy and other current diseases of the brain or spinal cord. This does not include permanent, old neurological problems from cerebral palsy, polio, or injuries. The immune system works poorly, and the patient may have various symptoms and diseases such as diarrhoea, fever, wasting, pneumonia. Amoebiasis: Amoebic dysentery; dysentery caused by the amoeba E. Allergies: Problems such as sneezing, a rash, or difficult breathing that affect certain people when specific things are breathed in, eaten, injected, or touched.
Antidiarrhoeal drugs: Drugs that are claimed to stop or decrease diarrhoea, such as antimotility drugs. These drugs are not useful for children with diarrhoea.
Some are dangerous. Antifolate drugs: Drugs that act against folate. Both cotrimoxazole trimethoprim-sulfamethoxazole and the antimalarial sulfadoxine-pyramethamine Fansidar are antifolate drugs.
Antimotility drugs: Drugs that slow the movement of contents through the bowel by reducing its muscular activity Axillary temperature: Temperature measured in the armpit. Cerebral malaria: Falciparum malaria affecting the brain. Checking questions: Questions intended to find out what someone understands and what needs further explanation.
Chest indrawing: When the lower chest wall lower ribs goes in when a child breathes in. Severe chest indrawing: Chest indrawing that is very deep and easy to see. In a young infant, mild chest indrawing is normal, but severe chest indrawing is a sign of serious illness. Classify: As used in this course, to select a category of illness and severity called a classification based on a childs signs and symptoms.
Clinic: As used in this course, any first-level outpatient health facility such as dispensary, rural health post, health centre, or the outpatient department of a hospital. Complementary foods: Foods given in addition to breastmilk, starting when a child is 6 months of age. By age 6 months, all children should be receiving a nutritious, thick complementary food, such as cereal mixed with oil and bits of meat, vegetables, or fish. Complementary foods are sometimes called weaning foods.
Corneal rupture: Bursting of the cornea, that is, the clear outer layer of the eye. Digital watch: A watch that shows the time in digits numerals instead of with moving hands.
IMNCI Training Modules 1-9
Logbook [pdf kb] Background The basis for the distance learning options for both ICATT and paper-based distance learning IMCI is that potentially IMCI could be scaled up in a short period without health workers needing to leave their clinics for the traditional 2-week period. Distance learning IMCI will reduce the cost of running IMCI course significantly and address health workers that normally will not be able to leave their station. Distance learning IMCI facilitates learning while continuing to provide clinical service to their communities; health workers can study on their own time, on their own pace and saves them from travel. Distance learning IMCI is a self-learning programme that is mainly driven by the learner. It is based on an inquiry model that emphasizes group learning, mentoring, use of mobile phone alerts and on-the job learning. Early implementation using these paper-based IMCI materials has shown to be feasible, acceptable and cost-saving in several countries.
Integrated Management of Neonatal and Childhood Illness (IMNCI)
IMCI set of distance learning modules