Describe IMNCI case management process using acute respiratory infection as example according to park

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IMNCI Case Management Process - According to Park's Textbook of Preventive and Social Medicine

Background: What is IMNCI?

The Integrated Management of Neonatal and Childhood Illness (IMNCI) is the Indian adaptation of the WHO/UNICEF's IMCI strategy. It is renamed "IMNCI" because India extended the programme to include the first 7 days of life. It is the central pillar of child health interventions under the RCH-II/NRHM strategy.

Key highlights of the Indian adaptation:

Inclusion of 0-7 days age group in the programme
Incorporates national guidelines on malaria, anaemia, vitamin-A supplementation and immunization
Training of health personnel begins with sick young infants up to 2 months
Almost equal proportion of training time for sick young infant and sick child
Is skill-based

The strategy has three main components:

Improvement in case-management skills of health staff through locally adapted IMNCI guidelines
Improvements in the health system for effective management of childhood illness
Improvements in family and community practices

The Integrated Case Management Process

The case management process is illustrated in Fig. 13 of Park's:

IMNCI Integrated Case Management Process - Park's Textbook

The complete IMNCI case management process involves the following six steps (Park's, Ch. 8):

Step A: ASSESS

Check for danger signs first, then ask about common conditions, examine the child, and check nutrition and immunization status.

General danger signs (any one = Very Severe Disease):

Not able to drink or breastfeed
Convulsions
Abnormally sleepy or difficult to wake
Vomiting everything

Step B: CLASSIFY (Colour-coded triage)

Each illness is classified using a 3-colour system:

Colour	Meaning	Action
Pink	Urgent pre-referral treatment needed	Refer urgently to hospital
Yellow	Specific medical treatment needed	Treat at outpatient health facility
Green	Simple home management	Counsel caretaker, home care

Step C: TREAT

After classifying, identify specific treatments. Give first dose of drugs in the clinic. If referral is needed, give pre-referral treatment before transfer.

Step D: COUNSEL

Teach the caretaker how to give oral drugs, how to feed and give fluids during illness, and how to treat local infections at home. Advise when to return immediately and schedule a follow-up date.

Step E: ASSESS FEEDING & NUTRITIONAL STATUS

Assess breast-feeding practices, counsel to solve feeding problems, and counsel the mother about her own health.

Step F: FOLLOW-UP

When the child is brought back as requested, give follow-up care and reassess for new problems.

ARI as an Example of the Case Management Process

ARI (cough or difficult breathing) is one of the five core IMCI conditions. The process unfolds as follows:

STEP 1 - History Taking

Age of the child
Duration of cough
Ability to drink (in child 2 months to 5 years); stopped feeding well (in child < 2 months)
History of measles, fever, convulsions
Excessive drowsiness or difficulty to wake
Irregular breathing or periods of apnoea

STEP 2 - Physical Examination (Assess)

Look and listen for:

(1) COUNT BREATHS IN ONE MINUTE - Fast breathing thresholds:

Age	Fast Breathing
< 2 months	≥ 60 breaths/minute
2 months to < 12 months	≥ 50 breaths/minute
12 months to < 5 years	≥ 40 breaths/minute

Note: In young infants, repeat the count if ≥ 60/minute, as their breathing is often erratic.

(2) LOOK FOR CHEST INDRAWING - Lower chest wall goes IN when child breathes in. Indicates greater effort to breathe. In young infants, mild chest indrawing is normal due to soft chest wall bones.

(3) LOOK AND LISTEN FOR STRIDOR - Harsh noise on breathing IN; caused by narrowing of larynx, trachea or epiglottis (croup).

(4) LOOK FOR WHEEZE - Soft whistling noise on breathing OUT; caused by narrowing of lower air passages. If recurrent wheezing (> 1 episode in past year), classify as recurrent wheeze.

(5) Assess level of consciousness - Abnormally sleepy or difficult to wake

(6) Feel for fever or low body temperature

STEP 3 - Classify (for child 2 months to 5 years)

TABLE 3 - Management of Pneumonia (2 months to 5 years):

Signs	Classification	Treatment
Chest indrawing (first episode)	SEVERE PNEUMONIA (Pink)	Refer URGENTLY; first dose antibiotic; treat fever/wheeze if present
Fast breathing, NO chest indrawing	PNEUMONIA - not severe (Yellow)	Home care + oral antibiotic; treat fever/wheeze; return in 2 days
No chest indrawing AND no fast breathing	NO PNEUMONIA: Cough or Cold (Green)	Home care; treat fever/wheeze; if cough > 30 days, refer for assessment

For Very Severe Disease (any danger sign present):

Signs	Classification	Treatment
Unable to drink, convulsions, abnormally sleepy, stridor in calm child, or severe malnutrition	VERY SEVERE DISEASE (Pink)	Refer URGENTLY; first dose antibiotic; treat fever; treat wheeze

STEP 4 - Classify (for young infant < 2 months)

In young infants, fast breathing cut-off is ≥ 60 breaths/minute. Any pneumonia in a young infant is considered severe and requires immediate hospital referral.

TABLE 4 - Classification for young infant:

Signs	Classification
Fast breathing (≥ 60/min)	SEVERE PNEUMONIA
No fast breathing (< 60/min)	NO PNEUMONIA

Severe signs in young infants include: convulsions/abnormally sleepy, stridor when calm, severe chest indrawing, grunting, poor feeding, cyanosis.

STEP 5 - Treat

(A) Pneumonia in child 2 months to 5 years:

First-line: Oral Amoxicillin or Co-trimoxazole for 5 days (home treatment)
If condition worsens or does not improve after 48 hours: switch to IM injections of cloxacillin and gentamycin

(B) Severe pneumonia (2 months to 5 years):

Urgent referral to hospital
Pre-referral: first dose of antibiotic

(C) Pneumonia in young infant < 2 months:

Must be hospitalized
Co-trimoxazole may be started before referring
In hospital: IM Benzyl Penicillin OR Ampicillin AND Gentamycin as per Table 7

Antibiotic	Dose	Age < 7 days	Age 7 days to 2 months
Inj. Benzyl Penicillin OR	50,000 IU/kg/dose	12 hourly	6 hourly
Inj. Ampicillin AND	50 mg/kg/dose	12 hourly	8 hourly
Inj. Gentamycin	2.5 mg/kg/dose	12 hourly	8 hourly

(D) No Pneumonia (AURI - Cough or Cold):

Antibiotics NOT recommended (majority viral; increase resistance; no clinical benefit)
Symptomatic treatment and home care only
Counsel the mother on home care

STEP 6 - Reassessment (Follow-Up) at 2 Days

For a child on oral antibiotics for pneumonia:

Assessment	Signs	Action
Worse	Unable to drink, chest indrawing, other danger signs	Refer URGENTLY
The same	No improvement	Change antibiotic OR refer
Improving	Breathing slower, less fever, eating better	Finish 5 days of antibiotic

STEP 7 - Counsel (Home Care for ARI)

Continue breast-feeding and fluids
Soothe the throat with a safe remedy (e.g. honey in water or warm tea for children ≥ 1 year)
Clear the nose if it interferes with feeding
Do NOT give: anti-histamines, decongestants, cough suppressants
When to return immediately: if child becomes unable to drink, breathing worsens, develops fast breathing, or is not improving after 2 days

Summary: Why ARI Illustrates IMNCI Well

ARI demonstrates the IMNCI logic perfectly because:

The same presenting complaint (cough/breathing difficulty) can range from a simple cold (Green) to severe life-threatening pneumonia (Pink), requiring very different actions
The same symptoms in different age groups (< 2 months vs 2 months to 5 years) are classified differently
Overlapping conditions (wheezing, fever, malnutrition) are addressed simultaneously - the hallmark of the integrated approach
The colour-coded system guides a first-level health worker to make rational, standardized treatment decisions without requiring advanced diagnostics

Source: Park's Textbook of Preventive and Social Medicine, Chapter 11 (ARI) and Chapter 8 (IMNCI/IMCI)

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