---

IMNCI - Integrated Management of Neonatal and Childhood Illness

---

1. Background and Origin

---

2. Rationale / Why IMNCI?

• Most sick children present with signs and symptoms of more than one condition simultaneously (diarrhoea + malnutrition + fever, etc.)
• A single diagnosis is often not possible or appropriate
• Treatment is complicated by the need to combine therapies
• An integrated approach is therefore necessary - looking beyond single-disease treatment
• Evidence from NFHS-III showed: ARI (17%), diarrhoea (13%), fever (27%), undernutrition (43%) were the commonest morbidities in children under 3 years in India
• Coverage of measles vaccination in 12-23 month children was also low

---

3. Indian Adaptations (IMNCI vs. WHO IMCI)

1. Inclusion of 0-7 days age group
2. Incorporation of national guidelines on malaria, anaemia, Vitamin A supplementation, and immunization schedule
3. Training begins with sick young infants up to 2 months
4. Training time devoted to sick young infant and sick child is almost equal
5. Skill-based training approach

---

4. Objectives of IMNCI

1. Reduce death, illness, and disability in children under 5 years
2. Promote improved growth and development
3. Improve case management skills of healthcare workers
4. Improve the health system (supply chain, referral)
5. Improve family and community health practices

---

5. Three Main Components (Pillars)

Component 1: Improving Case Management Skills of Healthcare Staff

• Health workers are trained to use IMNCI guidelines
• Covers assessment, classification, treatment, counselling, follow-up

Component 2: Improving the Health System

• Referral pathways, drug supply, laboratory support
• Training and supervision systems

Component 3: Improving Family and Community Practices

• Teaching families when to seek care
• Promoting key family practices (breastfeeding, nutrition, hygiene, immunization, home management)

---

6. Two Age Groups in IMNCI

---

7. The IMNCI Case Management Process - 6 Steps

Step 1: ASSESS the condition

• History taking and physical examination using a structured checklist
• For children 2 months - 5 years, assess:
  • General danger signs (convulsions, lethargy/unconsciousness, inability to drink/breastfeed, vomiting everything)
  • Main symptoms: Cough/difficulty breathing, Diarrhoea, Fever, Ear problems
  • Nutrition and immunization status, potential feeding problems
  • Other problems
• For young infants (0-2 months), assess for:
  • Possible serious bacterial infection
  • Jaundice
  • Diarrhoea
  • Feeding problem/low weight
  • Immunization status

Step 2: CLASSIFY the illness

• Uses a colour-coded triage system (traffic-light system):
  • 🔴 Pink - Severe classification - Urgent pre-referral treatment and referral
  • 🟡 Yellow - Moderate classification - Specific medical treatment and advice at outpatient facility
  • 🟢 Green - Mild classification - Simple advice on home management

Step 3: IDENTIFY treatment

• After classifying all conditions, identify specific treatments
• If pink: give essential pre-referral treatment (e.g., first dose antibiotic, oral anti-malarial, IM vitamin K), then refer
• If yellow: develop integrated treatment plan, give first dose of drugs in clinic
• If green: advise on home management
• If immunization needed: give it

Step 4: TREAT

• Give oral drugs
• Treat local infections at the facility
• Teach caretaker how to give oral drugs at home
• Instruct on feeding and fluid management during illness

Step 5: COUNSEL the mother/caretaker

• Ask and listen to problems already being done
• Praise what is being done correctly
• Advise and teach new skills
• Check understanding
• Counsel about her own health
• Assess breastfeeding practices
• Teach danger signs to return immediately

Step 6: FOLLOW UP

• Give dates for scheduled return visit
• On return: give follow-up care and reassess for new problems

---

8. General Danger Signs (Children 2 Months - 5 Years)

1. Convulsions (current or in this illness)
2. Lethargy or unconsciousness
3. Inability to drink or breastfeed
4. Vomiting everything

---

9. Classification Tables (Key Examples)

Cough / Difficulty Breathing

• 2 months - 12 months: ≥50 breaths/min
• 12 months - 5 years: ≥40 breaths/min

Diarrhoea

Fever

Malnutrition Assessment

---

10. Sick Young Infant (0 up to 2 months) - Key Assessments

Possible Serious Bacterial Infection (PSBI) / Sepsis

• Convulsions
• Respiratory rate ≥60/min
• Severe chest in-drawing
• Nasal flaring
• Grunting
• Bulging fontanelle
• Purulent umbilical discharge with redness
• Temperature >37.5°C or <35.5°C (or feels hot/cold)
• Many/severe skin pustules
• Lethargic or unconscious
• Reduced movement

Jaundice

• Jaundice appearing <24 hrs - Severe (Pink), refer
• Jaundice appearing >24 hrs, not reaching palms/soles - Jaundice (Yellow), counsel, follow up
• Yellow palms and soles = Severe jaundice (Pink)

Feeding Problem / Low Weight

• Weight <2000 g or extremely small
• Not feeding well (poor attachment, less than 8 feeds/day, receives other food/drink)
• Exclusive breastfeeding counselling is key

---

11. Variants: F-IMNCI and C-IMNCI

Facility-Based IMNCI (F-IMNCI)

• Integration of facility-based care with IMNCI package
• Empowers health personnel to manage newborn and childhood illness at health facility level
• Focuses on inpatient management of: asphyxia, sepsis, LBW, pneumonia, diarrhoea, malaria, meningitis, severe malnutrition
• Master trainers at state and district level = paediatricians from tertiary hospitals and medical colleges

Community IMNCI (C-IMNCI)

• Targets community-level care
• Implemented at:
  • Household level
  • Sub-centre level through ANMs
  • PHC level through medical officers, nurses, LHVs
• Focusses on preventive, promotive, and curative aspects

Pre-service IMNCI

• Being included in curriculum of medical colleges across India
• Accepted as strategy to scale up IMNCI by Government of India
• Helps provide trained IMNCI manpower in both public and private sectors

---

12. Levels of Care and Facility-Based Newborn Care

---

13. Key Drugs Used in IMNCI

---

14. Counselling for Feeding

• Exclusive breastfeeding for first 6 months
• Initiation of breastfeeding within 1 hour of birth
• Appropriate complementary feeding from 6 months
• Continue breastfeeding up to 2 years and beyond
• Feed the child more frequently during illness and extra food after illness
• How to correctly attach infant to breast

---

15. When to Return Immediately (Danger Signs Taught to Caretakers)

• The child is unable to drink or breastfeed
• The child becomes sicker
• Child develops fever
• Child has fast or difficult breathing
• Blood in stool
• Drinking poorly

---

16. Limitations of IMNCI Guidelines

• Does not address all major reasons a sick child presents to clinic
• Does not cover trauma or acute emergencies from accidents/injuries
• HIV/AIDS not addressed specifically (though diarrhoea and respiratory infections in HIV children are managed by standard guidelines)
• Children with chronic problems or uncommon illnesses may need special/referral care
• Case management is only effective if families bring children early to trained providers

---

17. Associated Programmes Linked to IMNCI

---

Summary Table: IMNCI at a Glance

---