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Course: Pediatric Nursing

Topic: Integrated Management of Childhood Illness

The Nurses International Community

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Module Goals

Learners will be able to:

Define: Integrated Management of Childhood Illness (IMCI).
Identify the components of IMCI.
Discuss the significance of IMCI approach to child care.
Identify the elements necessary for implementation of IMCI approach.
Explain the role of the community health worker in caring for the sick child within the community.
Explain care coordination within the IMCI approach to child care.

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Integrated Management of Childhood Illness (IMCI)

In most developing countries, lack of many diagnostic tools in first-level facilities force health providers to rely on child’s history, signs, and symptoms to determine best care with the available resources

Thus, IMCI strategy was designed by WHO and UNICEF to address this issue and improve access and quality of care for newborns and children in primary health care services.

World Health Organization, n.d.

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Integrated Management of Childhood Illness (IMCI)

IMCI Aims to:

Reduce preventable mortality.
Minimize illness and disability.
Promote healthy growth and development of children.

Includes both preventive and curative elements that can be implemented by families, in communities and in health facilities.

World Health Organization, n.d.

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IMCI (Continued)

In health facilities:

Promotes accurate identification of childhood illnesses in outpatient settings.
Ensures appropriate combined treatment of all major illnesses.
Strengthens counselling of caretakers.
Speeds up referral of severely ill newborns and children.

In home setting:

Promotes appropriate care seeking behaviors.
Improved nutrition, and support for early childhood development.
Prevention of illness.
Correct implementation and adherence to treatment.

World Health Organization, n.d.

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Integrated Management of Childhood Illness (IMCI)

Addresses conditions that are a major cause of death, severe illness or disability in children under age 5.

Acute respiratory infections—including pneumonia;
Diarrheal diseases
Meningitis and sepsis
Malaria
HIV/AIDS
Measles
Ear infections
Malnutrition, and
Anaemia

IMCI therefore is not comprehensive pediatrics but focuses on public child health priorities in under age 5.

World Health Organization, n.d.

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Critical Thinking Question

Which of the following best explains the importance of IMCI? (Select all that apply)

Addresses conditions that are a major cause of death, severe illness or disability in children under age 5.
Strengthens counselling of caretakers and speeds up referral of severely ill newborns and children.
Reduces preventable mortality and morbidity and promotes healthy growth and development of children.
Provides comprehensive pediatric care that can take the place of primary care for young children.
Includes preventative and curative elements that can be implemented by families, in communities and in health facilities.

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IMCI Strategy Components

World Health Organization, n.d.

Three key components:

Improve case management skills of healthcare providers.
Improve health systems to provide quality care.
Improve family and community health practices for health, growth and development.

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IMCI Implementation

Requires great deal of coordination among health programmes and services at national and sub-national levels.

Involves working closely with and within ministries of health, local governments, and communities to plan for implementation based on the local context.

World Health Organization, n.d.

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IMCI Implementation (Continued)

Key requirements for implementation of IMCI:

Adoption of national policy and standards with an integrated approach to child health and development.
Regular review and updating of IMCI clinical guidelines based on country specific epidemiology, medicines and commodities, relevant policies, and local foods and language.
Training, mentoring and support supervision of health workers in integrated assessment, treatment and effective counseling of caregivers.

World Health Organization, n.d.

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IMCI Implementation (Continued)

Key requirements (Continued)

Availability of the essential medicines, laboratory tests and equipment for prevention and case management.
Strengthening referral pathways, and management of severely ill referred from outpatient clinics to the hospital.
Empowering families and communities to:

Prevent disease.
Seek timely care from qualified health care providers.
Provide adequate home care for sick children.
Support children's’ healthy growth and development.

World Health Organization, n.d.

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Impact of IMCI in Child Health

Evidence shows that full implementation contributes to reduction in child mortality.

Cochrane review by Gera et al in 2016 found 15% reduction in child mortality when implemented at scale in health facilities and communities.

Implementation of key components is essential to achieve Sustainable Development Goals, especially in countries with high burden of preventable childhood mortality.

World Health Organization, n.d.

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Critical Thinking Question

Which of the following are the three key components of IMCI?

Select all that apply:

Improve case management skills of healthcare providers
Improve coping strategies of the child and parents
Improve health systems to provide quality care
Improve family and community health practices for health, growth and development

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IMCI: Integrated Case Management Process

Case management process used by trained health professionals in first-level facility.
Relies on case detection using simple clinical signs and empirical treatment.

As few clinical signs as possible are used.
Signs are based on expert clinical opinion and research results, and strike a careful balance between sensitivity and specificity.
Treatments are developed according to action oriented classifications rather than exact diagnosis.

World Health Organization, 2005

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Example of treatment developed according to action oriented classification rather than exact diagnosis:

First step is asking and looking/feeling for signs/symptoms.

If health professionals observed following signs/symptoms:

• Not able to feed at all or not feeding well or

• Convulsions or • Severe chest indrawing or

• High body temperature (38°C* or above) or

• Low body temperature (less than 35.5°C*) or

• Movement only when stimulated or no movement at all or

• Fast breathing (60 breaths per minute or more) in infants less than 7 days old

Then, the child signs/symptoms are classified as ‘Possible Serious Bacterial Infection’ or ‘Very Severe Disease’. Classification is not a diagnosis as they are solely based on signs/symptoms, and not diagnostic tests.

So, the actions healthcare professional should undertake for treatment of the above case is:

➜ Give first dose of intramuscular antibiotics.

➜ Treat to prevent low blood sugar.

➜ Advise the mother how to keep the infant warm on the way to the hospital.

➜ Refer URGENTLY to hospital. OR

➜ If referral is REFUSED or NOT FEASIBLE, treat in the clinic until referral is feasible. (See chart on p. 13)

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IMCI: Integrated Case Management Process (Continued)

IMCI guidelines directs illness management:

Provides instructions for routine assessment of a child for general danger signs, common illnesses, malnutrition and anaemia, and to look for other problems.
In addition to treatment, the guidelines incorporate basic activities for illness prevention.
Guides health professionals in interviewing caretaker, accurately identifying clinical signs, choosing appropriate treatments, and providing counselling and preventive care.

World Health Organization, 2005

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Elements of Integrated Case Management Process

Assess child’s health condition
Classify child’s illnesses using color coded triage system

Urgent pre-referral treatment and referral (red), or
Specific medical treatment and advice (yellow), or
Simple advice on home management (green)

Identify specific treatment, develop integrated treatment plan.
Provide initial treatment

Before transfer of urgent referral.
Those requiring care at home, first dose of drugs should be administered at clinic.

World Health Organization, 2005

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Elements of Integrated Case Management Process (Continued)

Provide education/counselling to caretaker .

Administration of oral drugs, feeding, giving fluids during illness.
Treatment of local infections at home.
Recognitions of signs that mandate immediate medical attention.
Follow-up date and time.

Assess feeding, including breastfeeding practices.
Provide follow-up care and reassess child’s condition.

World Health Organization, 2005

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IMCI: Limitations

World Health Organization, 2005

Address most, but not all, of the major reasons a sick child is brought to a clinic.

IMCI handbook does not address:

Chronic problems or less common illnesses requiring special care.
Does not include management of trauma or other acute emergencies due to accidents or injuries.

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What Would the Nurse Do?

Which of the following interventions would a nurse in a primary care facility of a rural area carry out while caring for a 5 year old girl with signs of infection who is accompanied by her mother? (Select all that apply)

Conduct head to toe physical exam of the child
Administer first dose of antibiotic as per IMCI guideline
Make appropriate referral to the nearby specialist
Assess breastfeeding practice of the mother
Provide counselling on prevention of infection

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IMCI: Community Health Care Provider’s Roles

(Community Nurses and other Providers)

Know national IMCI guidelines and case management process.

Acquire required knowledge and skills.
Stay current with evidence based practice on care and treatment of child illness.

Know availability and deficiencies of resources in the community for timely management and referral of sick child.

Effective communication with family/caretaker.

Welcoming, reassuring, respectful, empathetic, compassionate.

World Health Organization, 2005

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IMCI: Community Health Care Provider’s Roles (Continued)

Coordinate care with child, family/caretaker, referral centers.
Educate/counsel child/family/caretaker.

Signs/symptoms of child illnesses to seek medical attention in timely manner.
Treatment of child at home where appropriate.
Preventative measures that support proper child growth and development.

Document care provided, keep the records safe and confidential.

Reason of child’s visit, treatment provided, referral if made, education/counselling provided.

World Health Organization, 2005

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IMCI: Community Health Care Provider’s Roles (Continued)

World Health Organization, 2005

Advocate for:

Adequate resources: healthcare facilities, trained health professionals, essentials medications, equipments.
Adequate training of local healthcare providers, refresher training.
Community needs for healthy growth and development of the child.

Participate in research, and evaluation of the effectiveness of IMCI in the community.

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IMCI Handbook/Guidelines

Integrated Management of Childhood Illness: distance learning course (2014): https://apps.who.int/iris/handle/10665/104772

Read modules 1-9

IMCI management of the sick young infant aged up to 2 months (2019): https://apps.who.int/iris/handle/10665/326448

Read the entire document

IMCI guidelines for treatment protocols may vary across countries, So, know and adhere to IMCI guidelines of own country!

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What Would the Nurse Do?

Which of the following actions falls under the roles and responsibilities of a nurse caring for a sick child in a rural primary health care facility? (Select all that apply)

Assess the child for need of referral
Make inquiries about child care services available in the community
Check the inventory of essential medicines of the primary health care facility
Conduct nutrition education sessions for the child’s parent

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

World Health Organization. (n.d.). Integrated management of childhood illness. https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/child-health/integrated-management-of-childhood-illness

World Health Organization. (‎2005)‎. Handbook : IMCI integrated management of childhood illness. World Health Organization. https://apps.who.int/iris/handle/10665/42939

World Health Organization. (‎2014)‎. Integrated Management of Childhood Illness: distance learning course. World Health Organization. https://apps.who.int/iris/handle/10665/104772
World Health Organization (2019). Integrated Management of Childhood Illness: management of the sick young infant aged up to 2 months. IMCI chart booklet, Licence under CC BY-NC-SA 3.0 IGO. https://apps.who.int/iris/handle/10665/326448

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