INTEGRATED

MANAGEMENT OF
CHILDHOOD ILLNESS

What is IMCI?
IMCI is an integrated approach to child health

that focuses on the well-being of the whole

child.
IMCI aims to reduce death, illness and
disability, and to promote improved growth and
development among children under five years
of age.
IMCI includes both preventive and curative
elements that are implemented by families and
communities, as well as by health facilities.

ESTIMATED IMCI COVERAGE 2009

RATIONALE FOR AN INTEGRAL

APPROACH
Every yearalmost 10 million children die before
they reach their fifth birthday. A majority of
these deathscaused byjust five preventable
and treatable conditions:
pneumonia
diarrhea
malaria
measles
malnutrition

CORE IMCI
INTERVENTION

IMCI BENEFITS

Address major child health problems

Responds to demand
Promotes prevention as well as cure
Is cost-effective
Promotes cost saving
Improves equity

Who can use IMCI?

The IMCI process can be used by all doctors,

nurses and other health professionals who

see young infants and children less than five
years old.
It is a case management process for a firstlevel facility, such as a clinic, health center or
an outpatient department of a hospital.

Steps in Integrated Care

Management

ASSESS
CLASSIFY
TREATMENT
COUNSEL FOLLOW-UP

Step 1: ASSESS
Good communication with the mother of the

child
Check for any general danger sign, which
would indicate any life threatening condition
Ask specific questions about the most
common conditions affecting a childs health
If the answers are positive, examine child
properly
Check child for other health problems

Step 2: CLASSIFY

- Based on the results of the assessment a

health-care provider classifies a child's
illnesses using a specially developed
colorcoded triage system. Because many
children have more than one condition, each
condition is classified according to whether
it requires:

Step 2: CLASSIFY
After identifying all the conditions present, a
health-care provider identifies specific
treatments for the sick child or sick young infant
If urgent referral, essential treatment to be
given before referral is identified
If specific treatment, a treatment plan is
developed, and the drugs to be administered at
the clinic are identified. The content of the
advice to be given to the mother is decided on.
If no serious conditions, the mother should
be correctly advised on the appropriate actions
to be taken for care of the child at home.

Step 3: TREAT
The health worker:
gives pre-referral treatment for sick children
being referred;
gives the first dose of relevant drugs to the
children who are in need of specific treatment,
and teaches the mother how to give oral drugs,
how to feed and give fluids during illness, and
how to treat local infections at home;
provides advice on the home management of
sick children at home;
if needed, asks the mother or other caregiver to
return with the child for follow-up on a specific
date.

Step 4: COUNSEL
If the follow-up care is indicated the health-

care provider teaches the mother when to

return to the clinic,the health workeralso
teaches the mother how to recognize signs
indicating thatthe child should be brought
back to the clinic immediately.
When indicated, a health-care provider
assesses feeding, including breastfeeding
practice, and provides counselling to solve
any feeding problems found. This also
includes counselling the mother about her
own health.

Step 5: FOLLOW-UP
Some children need to be seen more thanonce
for a current episode of illness. When such
children are brought back to the clinic, a healthcare provider gives appropriate follow-up care,
as indicated in IMCI guidelines, and if
necessary, reassess the child for any new
problems.

EXAMPLE for GEN DANGER SIGN:

Fatima is 18 months old. She weighs 11.5 kg, her length

is 84 cm. Her temperature is 37.5C. The health worker

asked, "What are the child's problems?" The mother said
"Fatima has been coughing for 6 days, and she is having
trouble breathing." This is the initial visit for this illness.
The health worker checked Fatima for general danger
signs. The mother said that Fatima is able to drink. She
has not been vomiting. She has not had convulsions
during this illness and she does not have convulsions
now. The health worker asked, "Does Fatima seem
unusually sleepy?" The mother said, "Yes." The health
worker clapped his hands. He asked the mother to shake
the child. Fatima opened her eyes, but did not look
around. The health worker talked to Fatima, butthe
childdid not watchthe health worker'sface.Fatima
stared blankly and appeared not to notice what was
going on around her.

SAMPLE: CONVULSION

Baster is a 2-year-old boy. He weighs 12 kg and his

height is 87 cm. His temperature is 39.5C. He was

brought to the clinic because he had convulsions
this morning.
The health worker asked How many times has
Baster had the convulsions during this current
illness? The mother said, Just once this morning.
Then the health worker asked, Has Baster had the
convulsions for a few minutes or for a long time more than 15 minutes? The mother said: The
convulsions seemed to last for a long time but may
be it was not more than 5 minutes.
The boy is able to drink, has not vomited does not
have convulsions now, and is not lethargic or
unconscious.
Would you classify the child as VERY SEVERE
DISEASE?

CONVULSION
Chin aged 4 years was brought to the clinic

because he had convulsions when he woke up in

the morning. The convulsions lasted for about 5
minutes. He had another episode of convulsions
on the way to the clinic. The second episode of
convulsions was somewhat shorter than the first
episode.
Chin weighs 14 kg and his height is 103 cm. His
temperature is 37C. The boy is able to drink, has
not vomited does not have convulsions now, and
is not lethargic or unconscious.
Would you classify the child as VERY SEVERE

DISEASE?

SAMPLE EXERCISE
Justin is 4 years old. He weighs 10 kg. His

height is90 cm. His temperature is 38C.

The health worker asks about the child's
problems. Justin's parents say, "He is
coughing and has ear pain." This is his initial
visit for this problem.
The health worker asks, "Is your child able to
drink or breastfeed?" The parents answer,
"Yes." "Does Justin vomit everything?" she
asks. The parents say, "No." The health
worker asks, "Has he had convulsions?" They
say, "No." The health worker looks at Justin.
The child does not have convulsions,and is
not lethargic or unconscious.

EXERCISE

Salina is 15 months old. She weighs 8.5 kg. She is 71 cm in

length.Her temperature is 38.5C.

The health worker asks, "What are the child's problems?"
The mother says, "Salina has been coughing for 4 days, and
she is not eating well." This is Salina's initial visit for this
problem.
The health worker checks Salina for general danger signs.
He asks, "Is Salina able to drink or breastfeed?" The mother
says, "No. Salina does not want to breastfeed." The health
worker gives Salina some water. She is too weak to lift her
head. She is not able to drink from a cup.
Next he asks the mother, "Is she vomiting?" The mother
says, "No." The healthworkersees that Salina does not
have convulsions now, sohe asks, "Has she had
convulsions?" The mother says, "No."
The health worker looks to seewhether Salina is lethargic
or unconscious. When the health worker and the mother are
talking, Salina watches them and looks around the room.

EXERCISE 2:

Namukasais 8 months old. She weighs 6 kg. She

is61 cm in length. Her temperature is 38.5C.

The health worker asks, "What are the child's
problems?" The mother says, "Namukasa has
hada cough for3 days, and she is very weak."
This is Namukasa's initial visit for this problem.
The health worker checks Namukasa for general
danger signs. He asks, "Is Namukasa able to drink
or breastfeed?" The mother says, "No. Namukasa
does not want to breastfeed. She will not take any
other drinks I offer her." The health worker offers
Namukasa some water. She is too weak to drink.

Next he asks the mother, "Is she vomiting?" The

mother says, "No." He sees thatNamukasadoes

not have convulsions now, sohe asks, "Has she
had convulsions?" The mother says, "No."
The health worker looks to seewhether
Namukasa is lethargic or unconscious.
Namukasa's eyes are open, but when the health
worker andher mother are talking she does
notlook at them. When the health worker
touches her, she does not respond.

Gyatsu is 6 months old. He weighs 5.5 kg. His

length is 63 cm.His temperature is 38C.

His mother says he has had acough for 2 days.
The health worker checks for general danger
signs.
The mother says that Gyatsu is able to
breastfeed. He has not vomited during this illness.
He has not had convulsions. Gyatsu is not
lethargic or unconscious.
The health worker says to the mother, "I want to
check Gyatsu's cough. You said he has had a
cough for 2 days now. I am going to count his
breaths. He will need to remain calm while I do
this."
The health worker counts 58 breaths per
minute.She doesnot see chest indrawing.She
doesnot hear stridor or wheezing.

Wambui is 8 months old. She weighs 6 kg. her

length is 69 cm.Her temperature is 39C.

Her father tells the health worker, "Wambui has
had acough for 3 days. She is having trouble
breathing. She is very weak." The health worker
says, "You have done the right thing to bring your
child today. I will examine her now."
The health worker checks for general danger
signs.
The mother says, "Wambui will not breastfeed.
She will not take any other drinks I offer her."
Wambui does not vomit everything and has not
had convulsions. Wambui is lethargic. She does
not look at the health worker or her parents when
they talk.
The health worker counts 55 breaths per minute.
He sees chest indrawing. He decides thatWambui
has stridor because he hears a harsh noise when

Pano has had diarrhea for five days.

The boy:
has no blood in the stool
is irritable
has sunken eyes
drinks eagerly when offered water
has a skin pinch that goes back slowly
A. Severe DHN B. Some DHN C. No DHN D.
Severe persistent Diarrhea E. Persistent
diarrhea F. Dysentery

Jane has had diarrhea for 3 days.

The girl:
has no blood in the stool
isnot lethargic or unconscious
isnot irritable or restless
has sunkeneyes
is able to drink, but is not thirsty
has askin pinch that goes back immediately
Selectthe diarrhea classification(s) that the
child has: A. Severe DHN B. Some DHN C. No
DHN D. Severe persistent Diarrhea E. Persistent
diarrhea F. Dysentery

Ear problem Case sample:

Mira is 3 years old. She weighs 13 kg and her height is

86 cm. Her temperature is 37.5 C. Her mother came

to the clinic because Mira had felt hot for 2 days.Mira
was crying last night and complained that her ear was
hurting. The health worker checked and found no
general danger signs. Mira does not have a cough or
difficulty breathing. She does not have diarrhea.
Her malaria risk is high. Her fever was classified as
MALARIA. Next the health worker asked about Mira's
ear problem. The mother said she is sure Mira has ear
pain. The child cried most of the night because her ear
hurt. There has not been ear discharge. The health
worker did not see any pus draining from the child's
ear. She felt behind the child's ears and found no
tender swelling.

Case Sample: Rita

Rita is 3 years old. She weighs 13 kg. Her height is90 cm.

Her temperature is 37.5C. Her mothercomes to the clinic

today because Rita has felt hot for the past 2 days. She was
crying last night and complained that her ear was hurting.
The health worker checks and finds no general danger
signs.
Rita does not have a cough or difficulty breathing. She does
not have diarrhea. Her malaria risk is high. Her malaria
diagnostic test is negative and herfever is classified as
FEVER: NO MALARIA.
Next the health worker asks about Rita's ear problem. The
mother says she is sure Rita has ear pain. The child cried
most of the night because her ear hurt. There has been
discharge coming from Rita's ear on and off for about a
year, says the mother. The health worker does not see any
pus draining from the child's ear. He feels behind the child's
ears and feels atender swelling behind one ear.

Case 2: Dana
Dana is 18 months old. She weighs 9 kg. She is

81cm in length. Her temperature is 37C. Her

mother says that Dana had discharge coming from
her ear for the past 3 days.
Dana does not have any general danger signs. She
does not have a cough or difficulty breathing. She
does not have diarrhea and she does not have
fever.
The health worker asks about Dana's ear problem.
The mother says that Dana does not have ear pain,
but the discharge has been coming from the ear for
3 or 4 days. The health worker sees pus draining
from the child's right ear. He does not feel any
tender swelling behind either ear.