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IMNCI - Introduction, Categories, and Latest Updates

What is IMNCI?

• It is the Indian adaptation of the global IMCI (Integrated Management of Childhood Illness) strategy, renamed to IMNCI because it extends coverage to include 0-7 days of age (neonates), which the original IMCI did not.
• It is the central pillar of child health interventions under RCH II / NRHM (National Rural Health Mission).
• Covers children from birth to 5 years of age, in two groups:
  • Birth to 2 months (sick young infant)
  • 2 months to 5 years (sick child)

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Why IMNCI? - Rationale

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Three Components of IMNCI

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The Case Management Process (Steps)

1. Assess - History taking, checking danger signs, assessing main symptoms
2. Classify - Using color-coded triage (Pink/Yellow/Green)
3. Identify treatment - Based on classification
4. Treat - Pre-referral treatment or outpatient treatment or home management
5. Counsel - Feeding, fluids, when to return
6. Follow-up - Reassess child on return visit

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Color-Coded Classification System

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IMNCI Classification Categories

For Children 2 Months to 5 Years

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

• Severe pneumonia or very severe disease (Pink - refer)
• Pneumonia (Yellow - oral amoxicillin)
• No pneumonia: cough or cold (Green - home care)
• Breathing rate thresholds: ≥50/min for 2 months-1 year; ≥40/min for 1-5 years = fast breathing

• Severe dehydration (Pink)
• Some dehydration (Yellow - ORS Plan B)
• No dehydration (Green - Plan A)
• Persistent diarrhea: severe vs. non-severe
• Dysentery (bloody diarrhea - cotrimoxazole)

• Very severe febrile disease / cerebral malaria (Pink)
• Malaria (Yellow - antimalarials)
• Fever: malaria unlikely (Yellow - evaluate)
• Measles with complications (Pink or Yellow)
• Measles (Yellow)

• Mastoiditis (Pink - refer)
• Acute ear infection (Yellow)
• Chronic ear infection (Yellow - local treatment)
• No ear problem (Green)

• Severe malnutrition or severe anemia (Pink)
• Very low weight / anemia (Yellow)
• Not low weight (Green)

For Sick Young Infant (Birth to 2 Months)

• Possible serious bacterial infection / very severe disease (Pink)
• Local bacterial infection (Yellow - topical)
• Unlikely serious bacterial infection (Green)

• Severe jaundice (Pink)
• Jaundice (Yellow)
• No jaundice (Green)

• Not able to feed / severe malnutrition (Pink)
• Feeding problem / low weight (Yellow)
• No feeding problem (Green)

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Key Indian Adaptations (IMNCI vs. IMCI)

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IMNCI Variants / Program Levels

1. Community-Based IMNCI

2. Pre-service IMNCI

3. Facility-Based IMNCI (F-IMNCI)

• Birth asphyxia
• Neonatal sepsis
• Low birth weight
• Pneumonia
• Diarrhea
• Malaria
• Meningitis
• Severe acute malnutrition

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Facility-Level Newborn Care (linked to IMNCI)

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Latest Updates (2024-2026)

• Hospital-Based IMNCI 3rd Edition (October 2024) was released in Bhutan, incorporating updated triage protocols for emergency danger signs: poisoning, severe pain, respiratory distress, restlessness/irritability/lethargy, visible severe wasting, bilateral foot edema, and major burns. The hospital module emphasizes Emergency Triage, Assessment and Treatment (ETAT) as the first step for all arriving sick children, followed by IMNCI module-based care.
• Neonatal mortality contributing >70% of infant deaths, with >2/3 occurring in the first week of life, continues to drive expansion of the birth-to-7-days component.
• Facility-based IMNCI continues to evolve with greater integration into SNCU/NBSU networks and linkage to the Rashtriya Bal Swasthya Karyakram (RBSK) for 4D conditions (defects at birth, diseases, deficiencies, developmental delays).
• The injectable gentamicin by ANMs for neonatal sepsis (as pre-referral or completion of antibiotic course) is an important community-level IMNCI update under India's National Health Mission.

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IMNCI Case Scenario: Sick Young Infant (0-2 Months)

For Undergraduate Medical Students

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CASE PRESENTATION

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Baby Aryan, a 25-day-old male infant, is brought by his mother to the health worker with the complaints of not feeding well for 2 days and fever since yesterday.

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History

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Presenting Complaints

• Not feeding well / stopped breastfeeding since 2 days
• Fever since yesterday (felt hot to touch)
• Baby is "different" - not as active as before, cries less
• Mother noticed pus discharge from the umbilical stump

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STEP 1 - ASSESS (IMNCI Assessment Protocol for 0-2 Months)

A. Check for General Danger Signs First

B. Ask and Look for Symptoms

• Respiratory rate: 62 breaths/minute (normal <60 for this age)
• Mild chest indrawing present
• Grunting noted

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STEP 2 - CLASSIFY (IMNCI Color-Coded Classification)

Category 1: Bacterial Infection

Baby Aryan's Classification: PINK - Possible Serious Bacterial Infection

• Not feeding well (unable to breastfeed)
• Lethargy (reduced activity)
• Fever (>37.5°C axillary or >38°C rectal)
• Fast breathing (>60/min)
• Umbilical infection with surrounding redness extending to skin

Category 2: Jaundice

Baby has mild jaundice at day 25 - pathological, classify as Yellow at minimum (assess severity clinically)

Category 3: Feeding Problem / Low Birth Weight

Baby Aryan = 2.35 kg + not feeding well = YELLOW (but this is overridden by PINK from PSBI)

Category 4: Diarrhea - Not present in this case

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STEP 3 - IDENTIFY TREATMENT

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STEP 4 - TREAT (Pre-referral Treatment Before Transfer)

Immediate Pre-referral Treatment at Health Centre

Note for UG exam: The ANM can administer the first dose of IM gentamicin as a pre-referral intervention. If the family refuses referral or referral is not possible, a 7-day course of gentamicin can be completed at the sub-centre as per updated IMNCI India guidelines.

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STEP 5 - AT REFERRAL HOSPITAL (F-IMNCI)

Investigations

Definitive Treatment

• Supportive care: IV fluids (maintenance), thermal care, oxygen if SpO2 <90%
• Breastfeeding: Resume as soon as infant can swallow safely
• Phototherapy: For pathological jaundice
• Monitor: Temperature, heart rate, respiratory rate, oxygen saturation, blood glucose 4-hourly

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STEP 6 - COUNSEL THE MOTHER

1. Explain the diagnosis - Baby has a serious infection, needs hospital care
2. Danger signs to watch for and return immediately:
   • Baby cannot feed at all
   • Convulsions
   • Becomes more lethargic
   • Develops fast breathing or stops breathing
   • Becomes very cold or very hot
3. Continue breastfeeding - reassure that breast milk is safe and protective
4. Cord care - keep cord clean and dry; never apply cow dung, ash, or oil
5. KMC (Kangaroo Mother Care) - skin-to-skin contact keeps baby warm and promotes feeding

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STEP 7 - PREVENTION (IMNCI Framework)

At the Household Level

At Community/Health Worker Level

At Facility Level

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IMNCI Summary Table for 0-2 Months (Exam Quick Reference)

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Key Exam Points

1. IMNCI for 0-2 months covers birth to 59 days - India extended to 0 days (vs. WHO IMCI which started at 1 week)
2. PSBI = Possible Serious Bacterial Infection - the single most important classification in this age group
3. Fast breathing threshold for <2 months = ≥60 breaths/minute
4. Antibiotic of choice in PSBI = IM Ampicillin + IM Gentamicin before referral
5. Hypothermia (<35.5°C axillary) is equally dangerous as fever in neonates - both classify as PSBI
6. Umbilical infection (omphalitis) extending to surrounding skin = always PINK
7. Jaundice at >14 days of age is always pathological until proven otherwise
8. ASHA makes 6 home visits post-delivery (days 1, 3, 7, 14, 21, 28) as part of HBNC under IMNCI
9. If referral refused: ANM can complete a 7-day gentamicin course at sub-centre level
10. Weight gain check: Healthy neonate regains birth weight by day 10-14; failure to do so = flag

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