Imci-Chn Notes

Community-Integrated Management of Childhood Illness (CIMCI)

For WHOM?
Community Children: ❑ One week to 2 months ❑ Age 2 months to 5 years

Main Concerns: • Cough or Difficult Breathing (ARI) • Diarrhea • Malaria • Measles • Ear Infections • Malnutrition • Breastfeeding • Preventive Activities: Vaccinations & Vitamin A

Algorithm:

Check for Danger Signs

Assess Main Symptoms

Assess Immunization, Nutrition and feeding problems and other problems

Classify conditions and Identify treatment actions

Referral Facility Out Patient Facility Home Management (pink) (yellow) (green)

Out-patient Management: Children 2 months to 5 years • History-taking • General Danger Signs • Main Symptoms • Nutritional Status • Immunization Status • Other Problems

• History-taking • General Danger Signs • Main Symptoms • Nutritional Status • Immunization Status • Other Problems

• Convulsions • Unconscious or lethargic • Unable to drink or breastfeed • Vomits everything

• History-taking • General Danger Signs • Main Symptoms • Nutritional Status • Immunization Status • Other Problems

❖ Cough or difficult breathing ❖ Diarrhea ❖ Fever ❖ Ear problems

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems Assess for: • Respiratory rate • Lower chest wall in-drawing • Stridor

Classification of Cough or Difficult Breathing

|(pink) |(pink) |
|Any danger sign or |Severe Pneumonia |
|Chest in-drawing or |or |
|Stridor |Very Severe Disease |
|(yellow) |(yellow) |
|Fast Breathing |Pneumonia |
|(green) |(green) |
|No signs of pneumonia or |No Pneumonia |
|very severe disease |Cough or Cold |

Interventions: • Give the 1st dose of an appropriate antibiotic • Give Vitamin A • Treat the child to prevent the lowering of his or her blood sugar level • Refer the child URGENTLY to a hospital • Give an appropriate antibiotic for 5 days • Soothe the throat and relieve the cough with a safe remedy • Advice the mother regarding when to return to the health center • Follow-up in 2 days • If the coughing persists for more than 30 days, refer to a hospital for assessment • Soothe the throat and relieve the cough with a safe remedy • Advise the mother regarding when to return to the health center • Follow-up in 5 days if no improvement is observed • If the coughing persists for more than 30 days, refer to a hospital for assessment • Soothe the throat and relieve the cough with a safe remedy • Advise the mother regarding when to return to the health center • Follow-up in 5 days if no improvement is observed

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems Assess for • General condition • Sunken eyes • Reaction when offered a drink • Elasticity of the skin
Classification of Dehydration
| (pink) |(pink) |
|2 of these signs: | |
|Lethargic or unconscious | |
|Sunken eyes | |
|Not able to drink or drinking poorly | |
|Skin pinch go back very slowly | |
| |Severe Dehydration |
|(yellow) |(yellow) |
|2 of these signs: | |
|Restless, irritable |Some Dehydration |
|Sunken eyes | |
|Skin pinch go back slowly | |
|(green) |(green) |
|Not enough signs to classify |NO Dehydration |

Interventions:
If the child has no other severe classification: • Give fluid for severe dehydration OR
If the child has another severe classification: • Refer the child URGENTLY to a hospital, with the mother giving the child frequent sips of ORS on the way. Advise the mother to continue breastfeeding the child.
If the child is 2 yrs old or older, and there is cholera in your area: • Give the child an antibiotic for cholera • Give fluid and food • Advice the mother regarding when to return to the health center immediately. • Follow-up in 5 days if no improvement is observed • Give fluid and food • Advice the mother regarding when to return to the health center immediately. • Follow-up in 5 days if no improvement is observed

• Give fluid and food at home to treat the diarrhea

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems Assess for: • Stiff neck • Risk of malaria • Runny nose • Duration of fever • Risk of measles

Classification of Fever
|(pink) |(pink) |
|Any danger sign or stiff neck |Very Severe Febrile Disease |
|(pink) |(pink) |
|Any danger sign or clouding of cornea or deep/extensive mouth |Severe Complicated |
|ulcers |Measles |
|(yellow) |(yellow) |
|fever @ 37.5 and above in high malaria risk area | |
|no runny nose, no measles and no other causes of fever in low |Malaria |
|malaria risk areas | |
|(yellow) |(yellow) |
|obvious causes of fever in no malaria risk areas |Possible Bacterial |
| |Infection |
|(yellow) |(yellow) |
|pus draining from eye or mouth ulcers |Measles with eye or mouth complication |
|(green) |(green) |
|In low malaria risk area |Fever - malaria unlikely |
|-Runny nose present or | |
|-Measles present or | |
|-other causes of fever present | |
|(green) |(green) |
|No obvious causes of fever in no malaria risk area |Uncomplicated Fever |
|(green) |(green) |
|Measles now or in the last three months |Measles |

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems

Assess for: • Tender swelling behind the ear • Ear pain • Ear discharge or pus

Classification of Ear Problems
|(pink) |(pink) |
|- Tender swelling behind the ears |Mastoiditis |
|(yellow) |(yellow) |
|Ear discharge in less than 14 days | |
|Or ear pain |Acute Ear Infection |
|(yellow) |(yellow) |
|Ear discharge for more then 14 days |Chronic Ear Infection |
|(green) |(green) |
|NO ear pain and NO ear discharge |NO EAR Infection |
|seen draining from the ears | |

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems

Assessing the child’s feeding • Breast feeding frequency and night feeds • Types of complimentary food or fluids, frequency of feeding, and whether feeding is active • Feeding patterns during the current illness

History-taking
General Danger Signs
Main Symptoms
- Cough or difficult breathing
- Diarrhea
- Fever
- Ear problems
Nutritional Status
Immunization Status
Other Problems

Assess for immunization status of the child.

No immunization to CHILDREN: • Being referred urgently to the hospital • No live vaccines (BCG, polio, measles) to those with immunodeficiency diseases, or immuno-suppressed due malignant disease, or therapy with immuno-suppressant agents or irradiation • No DPT2 or DPT3 to those with convulsions or shock within three days after a previous dose • No DPT to those with recurrent convulsions or other active neurological disease of the CNS

Out-patient Management: Children 1 week to 2 months • Check for possible bacterial infection • Assess for presence of diarrhea • Check for feeding problems or low birth weight • Check for immunization status • Check for other problems

Classification of Bacterial Infections • Convulsions • Fast breathing • Severe chest in-drawing POSSIBLE • Nasal flaring SERIOUS • Grunting BACTERIAL • Bulging fontanelle INFECTION • Pus drainage from ear • Umbilical redness extending to skin • Fever or hypothermia • Many or severe skin pustules • Lethargy or unconsciousness • Less than the normal movement

• Red umbilicus or draining pus Local Bacterial • Skin pustules infection

Classification of Feeding Problems or Low Weight

• Not able to feed Possible • No attachment at all Bacterial • No sucking at all Infection

• Not well attached to breast • Not sucking effectively Feeding • Fed fewer than 8 times in 24 hours problems • Receiving other food or drinks or low • Low weight for age weight • Thrush

• Not low weight for age and no NO FEEDING PROBLEMS • other signs of inadequate feeding

For all children before referral:
Give breast milk or sugar water

|Convulsions |Diazepam (10mg/2ml) 0.1 ml/kg |
|Severe pneumonia/ |Cotrimoxazole or amoxicillin |
|Mastoiditis | |
|Severe Complicated Measles |Vitamin A |
|Severe malnutrition | |
|Malaria |First line anti-malarial |
| |Chloroquine and Primaquine |
| | |
| |Second-line anti-malarial |
| |Sulfadoxine and Pyrimethamine |