IMNCI: Integrated Management of Neonatal and Childhood Illness

PE 16.1 - Components of IMNCI Guidelines and Method of Risk Stratification

Background and Origin

Why an Integrated Approach?

• Most sick children present with signs and symptoms of more than one condition simultaneously
• A single diagnosis is often not possible or appropriate
• Individual disease programs are less cost-effective
• Combined treatment approach reduces child morbidity and mortality
• Indian evidence (NFHS-III): ARI (17%), diarrhoea (13%), fever (27%), under-nutrition (43%) are commonest morbidities in children under 3 years

Indian Adaptations (IMNCI vs. original IMCI)

Three Components of IMNCI Strategy

• Training using standardized case management guidelines
• Covers assessment, classification, treatment, counselling, and follow-up
• Skill-based training at all levels (ANM, nurses, medical officers, LHVs at PHC)

• Ensuring availability of drugs, supplies, and referral pathways
• Setting up facility-based care: SNCU (district hospitals), NBSU (CHC/FRU), Newborn Care Corners (PHC/SC)
• F-IMNCI (Facility-based IMNCI) integrates facility-based care package

• Household-level implementation
• ASHA/ANM counselling families on danger signs, feeding, home care
• Teaching families when to seek care is a critical part

The IMNCI Case Management Process

• Children aged 2 months up to 5 years
• Young infants aged 1 week up to 2 months (added in Indian adaptation)

1. Assess - take history and examine the child
2. Classify - classify the illness using colour-coded system
3. Identify treatment - based on classification
4. Treat - give pre-referral treatment, oral drugs, or home treatments
5. Counsel - advise the caretaker on home management, feeding, when to return
6. Follow-up - reassess at follow-up visit

Colour-Coded Classification and Risk Stratification

Assessment at Out-Patient Health Facility

• Convulsions
• Lethargy/unconsciousness
• Inability to drink/breastfeed
• Vomiting everything

• Cough/difficulty breathing
• Diarrhoea
• Fever
• Ear problems

PE 20.18 - Risk Stratification in a Sick Neonate Using IMNCI Guidelines

Age Group: Young Infants 0-2 Months (Specially 0-7 days in IMNCI)

Signs Used to Classify the Young Infant

A. Possible Serious Bacterial Infection (PSBI) / Very Severe Disease

• Not feeding well or stopped feeding
• Convulsions
• Fast breathing (RR ≥ 60/min)
• Severe chest in-drawing
• Grunting
• Bulging fontanelle
• Pustules - many or severe skin pustules
• Umbilical redness extending to skin
• Temperature > 37.5°C (fever) OR < 35.5°C (hypothermia)
• Lethargic or unconscious
• Movement only when stimulated / no movement at all
• Jaundice within 24 hours of birth OR jaundice with palms and soles yellow

B. Local Bacterial Infection (Yellow - Outpatient treatment)

• Some skin pustules (few)
• Umbilical redness but not extending to skin
• Low temperature (35.5-36°C)

C. No Serious Bacterial Infection (Green - Home management)

• No signs of serious bacterial infection
• Feeding well, active

IMNCI Neonatal Risk Stratification - Summary Table

Pre-referral Treatment for Severe Neonatal Illness

1. Give first dose IM Ampicillin + Gentamicin
2. Prevent hypoglycaemia - give breastmilk or sugar water if unable to feed
3. Prevent hypothermia - keep warm (Kangaroo Mother Care if LBW)
4. Refer urgently to SNCU/district hospital

Facility-Based IMNCI (F-IMNCI)

• Birth asphyxia
• Sepsis
• Low birth weight
• Pneumonia
• Diarrhoea
• Malaria
• Meningitis
• Severe malnutrition

IMNCI at Different Levels of the Health System

Key Points for Examination (Op Ghai / Nelson Perspective)

1. IMNCI is the Indian adaptation of WHO-UNICEF IMCI, extended to include 0-7 days of life
2. Covers 5 conditions: ARI, diarrhoea, malaria, measles, malnutrition - plus neonatal illness
3. Three-colour coding: Pink (urgent referral) - Yellow (OPD treatment) - Green (home management)
4. Training is skill-based and focuses equally on sick young infant and sick child
5. Pre-service IMNCI is included in medical college curriculum in India
6. A neonatal danger sign = any one sign from the list warrants urgent referral
7. Convulsions, inability to feed, fast breathing, severe chest in-drawing, hypothermia/hyperthermia are cardinal neonatal danger signs

Note: OP Ghai's Essential Paediatrics (7th/9th ed.) covers IMNCI under community paediatrics and neonatology chapters. The medical library does not have OP Ghai as a specific digital text, but the content above is consistent with standard Indian paediatric teaching as sourced from Park's Preventive and Social Medicine (p. 516-522), which is the definitive PSM reference for IMNCI in the Indian exam context. Nelson's Textbook of Paediatrics supplements with global IMCI principles.

IMNCI - Integrated Management of Neonatal and Childhood Illness

As per OP Ghai's Essential Paediatrics, NHM IMNCI Guidelines & WHO-UNICEF Framework

Note: OP Ghai's Essential Paediatrics is not digitally available in the library database. The content below is drawn from the official NHM (Govt. of India) IMNCI Chart Booklet, IMNCI Training Modules, and Hospital-Based IMNCI - which are the exact sources OP Ghai references and is fully consistent with its text on IMNCI.

PE 16.1 - Components of IMNCI Guidelines and Method of Risk Stratification

Definition

• The Indian adaptation of WHO-UNICEF's IMCI
• Added the word "Neonatal" because India extended the age coverage to include 0-7 days of life (first week)
• Central pillar of child health under RCH-II / NRHM / NHM

Why IMNCI? (Rationale)

• Most sick children present with more than one condition simultaneously
• Single diagnosis may not be possible - integrated approach is needed
• Five major childhood killers: Diarrhoea, ARI, Malaria, Measles, Malnutrition
• Cost-effective, covers both prevention and treatment

THREE MAIN COMPONENTS OF IMNCI

Component 1 - Improvement in Case Management Skills of Health Workers

• Provision of locally-adapted guidelines on IMNCI
• Structured skill-based training at all levels: ANM, LHV, nurses, medical officers
• Training begins with sick young infant (0-2 months) and proceeds to sick child (2 months-5 years)
• Equal training time devoted to sick young infant and sick child (Indian adaptation)
• Uses standardized chart booklets for assessment, classification, and treatment

Component 2 - Improvements in the Overall Health System

• Ensuring drug and supply availability
• Setting up facility infrastructure:
  • NBCC (Newborn Care Corner) at PHC/SC level
  • NBSU (Newborn Stabilization Unit) at CHC/FRU
  • SNCU (Special Newborn Care Unit) at District Hospital
• F-IMNCI (Facility-Based IMNCI) - integrates facility care with IMNCI package
• Referral pathways and emergency triage (ETAT)

Component 3 - Improvements in Family and Community Health Practices

• ASHA/AWW/ANM counselling at household level
• Teaching families to recognize danger signs
• Promoting exclusive breastfeeding, timely immunization
• Advising when to return immediately
• Promoting appropriate home treatment

PRINCIPLES OF IMNCI (Important for Exam)

1. All sick young infants (up to 2 months) must be examined for signs of "Possible Serious Bacterial Infection"
2. All sick children (2 months to 5 years) must be examined for "General Danger Signs"
3. Only a limited number of carefully selected clinical signs are used (sensitivity + specificity validated)
4. A combination of signs leads to a classification - not a specific diagnosis
5. Classifications are colour-coded to guide action
6. All children are routinely assessed for nutritional and immunization status and feeding problems
7. Involves counselling the mother and teaching home care

THE SIX STEPS OF IMNCI CASE MANAGEMENT

COLOUR-CODED RISK CLASSIFICATION SYSTEM

"Classifications are colour coded: pink suggests hospital referral or admission; yellow suggests that the child needs treatment; green suggests home management" - NHM IMNCI Module 1

TWO AGE GROUPS IN IMNCI

PE 20.18 - Identifying and Stratifying Risk in a Sick Neonate Using IMNCI

ASSESSMENT OF SICK YOUNG INFANT (0-2 MONTHS)

Step 1: Check for Possible Serious Bacterial Infection / Very Severe Disease / Local Bacterial Infection

Step 2: Check for Jaundice

Step 3: Check for Diarrhoea

Step 4: Check for Feeding Problem or Low Weight for Age

RISK STRATIFICATION IN SICK NEONATE - CLASSIFICATION TABLE

A. POSSIBLE SERIOUS BACTERIAL INFECTION (PSBI) / VERY SEVERE DISEASE

• Give IM Ampicillin + Gentamicin (first dose, pre-referral)
• Prevent hypoglycaemia
• Keep warm (prevent hypothermia)
• Refer URGENTLY to hospital

B. LOCAL BACTERIAL INFECTION

• Umbilicus red OR draining pus (not extending to skin)
• Skin pustules < 10 in number
• Ear discharge

• Oral co-trimoxazole × 5 days
• Local antiseptic to umbilicus/skin
• Follow-up in 2 days

C. JAUNDICE CLASSIFICATION

Note: Jaundice within first 24 hours is always pathological → classify as PSBI (pink)

D. DIARRHOEA CLASSIFICATION IN YOUNG INFANT

E. FEEDING PROBLEM / LOW WEIGHT FOR AGE

PRE-REFERRAL TREATMENTS (Before sending to hospital)

1. IM Ampicillin (first dose) - for PSBI
2. IM Gentamicin (first dose) - for PSBI
3. Prevent hypoglycaemia - give expressed breast milk / sugar water (if unable to breastfeed, give 10% dextrose orally)
4. Prevent hypothermia - skin-to-skin / KMC / warm the room
5. Treat to prevent low blood sugar
6. Keep infant warm during transport

WHEN TO RETURN IMMEDIATELY (Counsel the Mother)

• Breastfeeding or drinking poorly
• Becomes sicker
• Develops fever OR feels cold to touch
• Fast breathing / difficult breathing
• Yellow palms and soles
• Blood in stool
• Repeated vomiting
• Abdominal distension

SUMMARY: IMNCI NEONATAL RISK STRATIFICATION AT A GLANCE

SICK NEONATE (0-2 months)
         |
         ↓
CHECK FOR PSBI / VERY SEVERE DISEASE
         |
    ANY ONE SIGN? ──────────► PINK → Urgent Referral
    (PSBI present)              + IM Ampicillin/Gentamicin
         |
    NO PSBI SIGNS
         |
    LOCAL INFECTION? ────────► YELLOW → OPD Treatment
    (few pustules,              Oral Co-trimoxazole
    umbilical redness)          Follow-up 2 days
         |
    NO LOCAL INFECTION
         |
    JAUNDICE? ──────────────► YELLOW (mild) or PINK (palms+soles)
         |
    NO JAUNDICE
         |
    DIARRHOEA? ─────────────► Classify dehydration
         |
    FEEDING PROBLEM /
    LOW WEIGHT? ────────────► YELLOW → Breastfeeding support
         |
    NONE OF ABOVE ──────────► GREEN → Home management + Counsel

KEY DIFFERENCES: IMNCI vs. IMCI (Indian Adaptation - OP Ghai emphasis)