BACKGROUND OF IMNCI Dr.Salma

LEARNING OUTCOMES At the end of this lecture the student will be able to: Describe background, objective, component and principle of IMNCI. State the Family and community practices that promote child survival, growth and development. Summarize the importance of its application .

KEY FACTS 5.6 million children under age five died in 2016, 15,000 every day. 7 in 10 of these deaths are due to the 5 major killers of children: Acute respiratory infections (mostly pneumonia), diarrhea, measles, malaria and malnutrition- and often to a combination of these conditions. About 45% of all child deaths are linked to malnutrition. More than half of these early child deaths are due to conditions that could be prevented or treated with access to simple, affordable interventions. (WHO)

CONT; Most child deaths (and 70% in developing countries) result from one or more of the following five causes: Perinatal mortality refers to the number of stillbirths and deaths in the first week of life (early neonatal mortality). The perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth. Perinatal and maternal health are closely linked. World health report 1999

Rational For an Evidence Base Syndromic Approach To Case Management Prevention and treatment strategies proven effective for saving young lives such as Childhood vaccinations reduced deaths due to measles. ORS reduction in diarrhea deaths. Effective antibiotics have saved millions of children with pneumonia. Prompt treatment of malaria and breastfeeding practices have reduced childhood deaths.

CONT; A single diagnosis may not be appropriate. Treatment needs to combine therapy for several conditions. A more integrated approach to managing sick children is needed to achieve better outcomes Child health programmes need to move beyond addressing single diseases to addressing the overall health and well-being of the child. While each of these interventions has shown great success, accumulating evidence suggests. 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

CONT; During the mid-1990s, (WHO) in collaboration with UNICEF and many other agencies, institutions and individuals, responded to this challenge by developing a strategy known as the Integrated Management of Childhood Illness (IMNCI). Major reason for developing the IMNCI strategy not only the needs of curative care, the strategy also addresses aspects of nutrition, immunization, and other important elements of disease prevention and health promotion.

What is IMNCI? IMNCI is an integrated approach to child health that focuses on the well-being of the whole child. IMNCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMNCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilitators.

[ Dark area =Children 0-4 years, White area = All other age groups ] CONT; The IMNCI clinical guidelines target children less than 5 years old—this age group that bears the highest burden of deaths from common childhood diseases Proportion of Global Burden of Selected Diseases Born by Children Under 5 Years [ Dark area =Children 0-4 years, White area = All other age groups ]

The objectives To reduce death and the frequency and severity of illness and disability among children under five years of age. To improved growth and development among children under five years of age. 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 . By bringing sick children to a doctor as soon as symptoms arise.

Components of the integrated approach Improvements in the case-management skills of health staff through the provision of locally adapted guidelines on integrated management of 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. improving the case management skills of health workers through the provision of clinical guidelines on the integrated management of childhood illness, adapted to the local context, and training to promote their use;  Improving the health system by:ensuring the availability of essential drugs and other supplies improving the organization of work at the health facility level improving monitoring and supervision; improving family and community practice through the education of mothers, fathers, other caregivers and members of the community, with a focus on health-seeking behavior, compliance, care at home and overall health promotion.

Family and community practices that promote child survival, growth and development Exclusive breastfeeding Complementary feeding Micronutrients Hygiene Immunization Malaria: use of bednets Antenatal care Home care for illness Parents, if correctly informed and counseled, 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 .By bringing sick children to a doctor as soon as symptoms arise.

The principles of integrated care All sick children 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 Children age 2 months up to 5 years: cough or difficult breathing,diarrhoea, fever, ear problems; Young infants age up to 2 months: bacterial infection, jaundice and diarrhoea).

All sick young infants and children 2 months up to 5 years must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems.

CONT; Only a limited number of carefully selected clinical signs are used , based on evidence of their sensitivity and specificity to detect disease. A combination of individual signs leads to a child’s classification(s) rather than a diagnosis. Classification(s) indicate the severity of condition(s). They call for specific actions based on whether the child (a) should be urgently referred to another level of care, (b) requires specific treatments ( antibiotic/antimalarial treatment), (c) may be safely managed at home.   Sensitivity and specificity measure the diagnostic performance of a clinical sign compared with that of the gold standard, which by definition has a sensitivity of 100% and a specificity of 100%. Sensitivity measures the proportion or percentage of those with the disease who are correctly identified by the sign. In other words, it measures how sensitive the sign is in detecting the disease. (Sensitivity = true positives / [true positives + false negatives]) Specificity measures the proportion of those without the disease who are correctly called free of the disease by using the sign. (Specificity =true negatives / [true negatives + false positives])

Cont; The classifications are colour coded: “pink” suggests hospital referral or admission, “yellow” indicates initiation of treatment, “green” calls for home treatment The IMNCI guidelines address most, but not all, of the major reasons a sick infant or child is brought to a clinic such as an infant or child returning with chronic problems or less common illnesses, the management of trauma or other acute emergencies due to accidents or injuries, care at birth .

CONT; IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children. Guidelines to counsel the caretakers about home care, including counseling about feeding, fluids and when to return to a health facility. "those drugs that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford."

Where should IMNCI be applied ? IMNCI should be applied 1st level health facilities (clinics, rural and urban health centers, MCH centers), outpatient departments of hospitals .

AGE GROUPS COVERED BY IMCI Birth up to 5 years. The case management process is presented in 2 different sets of charts: 1. A set for children age 2 months up to 5 years (up to 5 years means that the child has NOT yet reached his or her 5th birthday. For example a child who is 4 years 11 months but not a child who is 5 years old). This set is presented on 3 charts titled: ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD and COUNCEL THE MOTHER

2 . A set for young infants age up to 2 months (up to 2 months means that the infant is NOT yet 2 months of age. An infant who is 2 months old would be included in the group 2 months up to 5 years). This set is presented on a chart titled: ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

WHY NOT TO USE IMNCI FOR CHILDREN AGE 5 YEARS OR MORE? Much of the treatment advice in IMNCI may be helpful for a child age 5 years or more. However, because of differences in the clinical signs of older and younger children who have these illnesses, the assessment and classification process, using this clinical signs, is not recommended for older children

When correctly applied, IMNCI: Promotes the accurate identification of childhood illnesses in outpatient settings. Ensures appropriate combined treatment of all major childhood illnesses. Strengthens the counseling of mothers or caretakers. Strengthens the provision of preventive services. Speeds up the referral of severely ill children. Aims to improve the quality of care of sick children at the referral level.

Summary To reduce death and the frequency and severity of illness and disability among children under five years of age. (WHO) in collaboration with UNICEF and many other agencies, developing a strategy known as the Integrated Management of of Neonatal and Childhood Illness (IMNCI).

Assignment Instruction :Write on loose sheet What are the preventive and treatment intervention to reduce child mortality?

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