IMCI

Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, measles and

malnutrition cause more than 70% of deaths in children under 5 years
of age.
There are feasible and effective ways that health workers in health
centers can care for children with these illnesses and prevent most of
these deaths.
WHO and UNICEF used updated technical findings to described
management of these illnesses in a set of integrated guidelines,
instead of separate guidelines for each illness.

Ten countries that early lead in implementing IMCI:

1. BOLIVIA
2. DOMINICAN REPUBLIC
3. EQUADOR
4. INDONESIA
5. NEPAL
6. PERU
7. PHILIPPINES
8. TANZANIA
9. UGANDA
10. ZAMBIA
HOW IMCI STARTED?
1995 IMCI was developed by WHO UNICEF to all developing
countries.
1997 IMCI was brought to the Philippines thru the Department of
Health Region I, III,X, XI (funded by United States Agency for
International Development (USAID) )
2001 - Integration of IMCI to Nursing & Midwifery Curriculum
(attended by the Academe from different Nursing & Midwifery schools)
Participating Agencies
DOH Lead Agency
Commission on Higher Education Department (CHED)
Association of Deans of Philippines College of Nursing (ADPCN)
Association of Philippine School of Midwifery (APSOM)
Philippine Regulation Commission (PRC)
YEAR 2001
Educational Institution : Pilot Schools (Initial)
1. Nursing Education

MINDANAO - San Pedro Colleges, Davao City

VISAYAS
- St. Paul College, Iloilo City
NCR
- University of Sto. Tomas, Manila
- Baliuag University ,Bulacan

2. Midwifery Education
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

World Citi Colleges, Quezon City

Saint Joseph College, Cavite City
University of the Visayas
Tecarro College

YEAR 2004
Expansion Schools (additional) held in Subic, Zambales
1. UERM, Manila
2. Benguet University
3. Bicol University
4. Palawan University
I.M.C.I.
is an integrated approach to child s health that focuses on the wellbeing of the whole child.
aims to reduce death, illness and disability, and to promote improved
growth and
development among children under (5)five years of age
.
it includes both preventive and curative elements that are
implemented by families
and communities as well as by health facilities.

IDEAS OR REASON OF WHO IN CONCEPTAULIZING IMCI

1. inequality on child health the right of the child is not equally
distributed. It may be due to the following :
Lack of facilities
Lack of funding
Lack of materials and equipment
Lack of personnel (know-how)
2. WHO believes that most cases of mortality/morbidity among children
are all preventable such as measles, diarrhea, etc.
3. Illness must be evidence based; the approach in the management of
children is based on fact.
Evidence based syndromic approach to case management
I. It determines the health problem as to the severity of the
childs condition and as to what action is to be taken
considering the following:
Available resources
Cannot be managed at home
II.
It promotes adjustment of the curative intervention to the
capacity and functions of health systems.
III.
Promotes active involvement of family member and the
community in the health care process.
OBJECTIVE OF THE IMCI
1. To reduce significantly global mortality and morbidity associated w/ the
major causes of disease in children.
2. To contribute to healthy growth and development of children.
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

COMPONENTS OF IMCI AS AN INTEGRATED APPROACH

Strategy includes both preventive and curative interventions that aim
to improve practices in Health facilities, Health system and at Home.
1. 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. ( health
personnel training)
2. Improvements in the overall health system required for effective
management of childhood illness ( Health care system)
3. Improvement in the family and community health care practices.
( Hygiene, change in beliefs and practices, breast feeding,
micronutrient supplementation, etc)
PRINCIPLES OF INTEGRATED CARE
1. All sick children must be examined for the GENERAL DANGER SIGNS
which indicate the need for immediate referral or admission to the
hospital.
4 GENERAL DANGER SIGNS
Unable to drink/breast feed
If the child had a convulsion
Lethargic/Unconscious
Vomits everything
2. All sick children must be routinely assessed for major symptoms:
MAJOR SYMTOMS
A. Cough/DOB
B. Diarrhea
C. Fever
D. Ear problem
E. Bacterial infection
F. Jaundice
3. Only a limited number of carefully selected clinical signs are used,
based on evidence of their sensitivity and specificity to detect disease.
4. A classification is used rather than diagnosis
PINK : urgent referral
YELLOW : requires specific treatment
GREEN : home management
5. IMCI guidelines address most, but not all the major reasons a sick child
is brought to a clinic ( some of those not included are the following)
Chronic problem/less common illness requiring special care
Trauma or acute emergencies
6. Limited number of essential drugs and encoyurages active
participation of caretaker in the treatment of children.
7. Counseling of the caretaker about the health of the child which
includes:
Feeding
Fluid to be taken
Home management
When to return to a health facility
2 CATEGORIES OF CASE MANAGEMENT PROCEDURES:
a. 2 months up to 5 years
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

b. Birth up to 2 months
4 GENERAL DANGER SIGNS
1. UNABLE TO DRINK/BREASTFEED
Instruct the mother to breastfeed he child
Ask the mother about the previous time she breastfed her
child
Offer the child fluids to drink
2. CHECK WHETHER THE CHILD IS LETHARGIC OR UNCONSCIOUS
Awake but does not take any notice of his surrounding or does
not respond to sounds or movements
Offer the child a toy to play and observe the action/movement
of the child.
3. CHECK FOR CONVULSION
Ask the mother or caretaker about the past and previous
convulsion of her child while transmitting to the facilities
4. CHECK FOR VOMITING
Instruct the mother to breastfeed and offer the child fluids and
then observe if the child vomits or not.
NOTE: If either one of the general sign is present, you immediately make a
referral or bring the child to the hospital.
IMPORTANT STEPS IN THE ASSESSMENT OF A SICK CHILD
1. History taking
2. Checking for general danger signs
3. Checking for major symptoms
4. Checking nutritional status
5. Assessing the childs feeding
6. Checking immunization status
7. Assessing other problems

IMCI UPDATES
WHY UPDATE THE EXISTING IMCI?
NEW KNOWLEDGE ON CLINICAL MANAGEMENT OF CHILDHOOD
DISEASES ARE AVAILABLE
IMPLEMENTATION OF IMCI HAS IDENTIFIED PROBLEMS AND QUESTIONS
WHICH WERE ADDRESSES BY OPERATIONAL RESEARCH
EPIDEMIOLOGY OF DS. HAS EVOLVED THUS A REVISED VERSION HAS
TO ACCOMMODATE AND REFLECT THESE CHANGES.
TECHNICAL UPDATES ADAPTED IN PHILIPPINE IMCI
Antibiotic treatment on non severe and severe pneumonia

IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

 Low osmolarity ORS and antbiotics treatment for bloody

diarrhea/dysentery
Treatment of ear infections
Infant feeding
Treatment of helminthiasis
Management of sick young infant aged up to 2 mos.

1. ACUTE RESPIRTORY INFECTION

First-line/Second-line antibiotic for non severe pneumonia
FIRST-LINE
PREVIOUS: Cotrimoxazole
UPDATED: Amoxicillin
SECOND-LINE
PREVIOUS: Amoxicillin
UPDATED: Cotrimoxazole
Duration of antibiotic treatment from 5 days = 3 days
Frequency of administration of antibiotics from 3x =2x a day
Updated treatment
First line : Oral amox. to be given in 25mg/kg dose twice
daily in children 2-59 months of age for 3 days
Second line: Oral cotri. to be given 2x daily for 3 days
Technical basis:
3 days treatment is equally effective as the 5 days
treatment.
Reduces cost of treatment
Improves compliance
Reduces antimicrobial resistance in the community
Use of oral amox. vs. injectable penicillin in children with severe
pneumonia.
Where referral is difficult and injectiobn is not available,
oral amox in 45mg/kg/dose 2x daily should be given to
children with severe pneumonia for 5 days.
Technical Basis: clinical outcomes with oral amoxicillin was
comparable to injectable penicillin in hospitalized children
with severe pneumonia
Gentamicin + Ampicillin VS. Chloramphenicol for very Severe
Pneumonia
Injectable ampi +injec. Gentamicin is a better of choice
than injectable chloramphenicol for very severe
pneumonia in children 2-59 months of age.
A pre-referral dose of 7.5 mg/kg IM Gentamicin and
50mg/kg injectable ampicillin can be used.
Inclusion of WHEEZE
For children w/ wheeze and fast breathing and/or
lower chest wall indrawing.
Give a trial of rapid acting inhaled Bronchodilator
( up to 3 cycles 5-20 mins apart) before they

IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

are classified as pneumonia and before receiving

prescribed antibiotics.
0.5 ml Salbutamol diluted in 2.0 ml of sterile
water per dose nebulization should be used
PNEUMONIA = if WHEEZE ( even if it
disappeared after rapid acting bronchodilator)
give an inhaled bronchodilator for 5 days.
Technical Basis:
WHO supported studies on the assessment and
management of wheeze in children 1-59 months
of age presenting with cough and/ or difficult
breathing in several countries.
Findings showed that a large number of children
w/ wheeze were classified as pneumonia and
were prescribed antibiotics unnecessarily
Bronchodilators are being underutilized in
children w/ wheeze
Majority of children w/ wheeze who respond to a
trial of inhaled bronchodilatiors continue to do
well when sent home w/o an antibiotic.
2. DIARRHEAL DISEASES
A. Use of low osmolarity oral rehydration salts
Technical basis
Efficacy of ORS sol. for treatment of acute no cholera in
children is improved by reducing its Na+ concentration to 75
mEq/L, its glucose concentration to 75 mmol/L and its total
osmolarity to 245 mosm/L
The need for unscheduled supplemental IV is reduced by
33%, stool output is reduced by about 20%, and the
incidence of vomiting by about 30%.
B. Use of antibiotics in the management of BLOODY DIARRHEA
CIPROFLOXACIN for 3 days is the most appropriate drug in place
of NALIDIXIC ACID ( Nalidixic acid =4doses/day x 5 days) which
leads to rapid development of resistance.
DOSE: 15mg/kg BW 2x a day for 3 days PO.
Ciprofloxacin is several thousand-fold greater than Nalidixic Acid.
Considered for its safety, efficacy and reduced cost.
C. Second line Antibiotic for Cholera : ERYTHROMYCIN
D. Giving of ZINC supplement
E. Dose: 2 months up to 6 months tab daily for 10 14 days
6 months or more 1 tab daily for 10 14 days
F. Giving of multivitamins and minerals ( w/ zinc) for 14 days is added
in the treatment of persistent diarrhea.
G. Technical Basis:
o Reduced duration and severity of diarrhea episode
o Lowered incidence of diarrhea in 2-3 months
3. MALARIA
A. First line Antimalarial drug = ARTEMETHER + LUMEFANTRINE
B. Treatment schedule for uncomplicated P. falciparum malaria
DAY 1-3 > Artemether + Lumefantrine ( Coartem )
DAY 4 > Primaquine, Single dose only ( contraindicated in
children < 1y/o.
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

C. Treatment schedule for confirmed P. vivax cases

DAY 1-3 > Chloroquine for 3 days
DAY 4- 17 > Primaquine for 14 days
D. Mixed p. falciparum and P. vivax
DAY 1-3 > Artemether + Lumefantrine
DAY 4-17 > Primaquine
E. Treatment of drug-resistant malaria
In case of parasitological or clinical failure to a given drug,
refer pt. to the next level w/ proper documentation
BLOOD SMEAR RESULT: including parasite count on day
7,14,21, and 28.
F. Pre-referral treatment:
Artesumate suppository for uncomplicated P. falciparum
malaria in infants or young children who cannot swallow.
4. EAR INFECTIONS
A. CHRONIC EAR INFECTION: should be treated w/ quinolone ear drop
for at least 2 weeks in addition to dry the ear by wicking.
B. ACUTE EAR INFECTION: oral amoxicillin is a better choice fo the
management of suppurative otitis media in countries where
antimicrobial resistance to cotrimoxazole is high.
C. Technical Basis:
Topical antibiotic were found to be better than systemic
antibiotics in resolving otorrhea and eradicating middle ear
bacteria
The safety of tapical quinolones in children has been
documented w/o good evidence of a risk of ototoxicity.
5. MALNUTRITION AND ANEMIA
A. MUAC mid upper arm circumference less than 110mm is now
considered and indicator for severe malnutrition.
B. Use of the new WHO growth standards.
C. Inclusion of management of severely malnourished children where
referral is not possible.
Where a child is classified as having severe malnutrition and
referral is not possible, the IMCi guidelines should be adapted
to include management at fest level facilities.
Modified milk diet id given
6. INFANT FEEDING
A. EXCLUSIVE BREASTFEEDING: at least 8 times in 24 hours.
Breastfeed as often as the child wants, day and night up to 6
months (180 days) of age
Breastfeed when the child shows signs of hunger: beginning to
fuss, sucking fingers, or moving the lips.
Do not give other foods or fluids.
Only if the child is older than 4 months, and appears hungry after
breastfeeding, and is not gaining weight adequately, add
complementary foods (listed under 6 months up to 23 months).
Give 1 or 2 tablespoons of these foods 1 or 2 times per day after
breastfeeding.
B. COMPLEMENTARY FEEDING: 6 months up to 23 months
Breastfeed as often as the child wants.
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

 Give adequate servings of complementary foods: 3 times per day

if breastfed, with 1-2 nutritious snacks, as desired, from 9 to 23
months.
Give foods 5 times per day if not breastfed with 1 or 2 cups of
milk.
Give small chewable items to eat with fingers. Let the child try to
feed itself, but provide help.
C. MANAGEMENT OF SEVERE: MALNUTRITION WHERE malnutrition and
referral is not possible.
Where a child is classified as having severe,the IMCI REFERRAL IS
NOT POSSIBLE guidelines should be adapted to include
management at first-level facilities.
D. HIV AND INFANT FEEDING
In areas where HIV is a public health problem all women should
be encouraged to receive HIV testingand counselling.
If a mother is HIV-infected and replacement feeding is
acceptable, feasible, affordable, sustainable and safe for her and
her infant, avoidance of all breastfeeding is recommended.
Otherwise, exclusive breastfeeding is recommended during the
first months of life.
The child of an HIV-infected mother who is not being breastfed
should receive complementary foods as recommended above.
7. HELMINTH INFESTATION IN CHILDREN BELOW 24 MONTHS
A. ALBENDAZOLE & MEBENDAZOLE can be safely use in children 12
months or older
B. Give 500mg Mebendazole or 400mg Albendazole in single dose
8. MANAGEMENT OF SICK YOUNG INFANT AGED UO TO 2 MONTHS
SICK YOUND INFANT AGED UP TO 2 MONTHS
PREVIOUS
UPDATED
AGE
1 wk up to 2
Birth up to 2 months
months
MAIN
PINK
PINK
GREEN
Possible
serious
Very
Severe
Severe
disease or
SYMPTOM
Bacterial
Infection

ASSESSMENT
SIGNS FOR
BACT.
INFECTION

12 SIGNS

Disease

local infection
unlikely

7 SIGNS

9. CHECKING FOR JAUNDICE IS ADDED IN THE PROTOCOL

A. Classification
PINK: Severe Jaundice
YELLOW: Jaundice
GREEN: No Jaundice
B. Very severe disease: 7 Signs
o Not feeding well
o Convulsion
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IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN

o
o
o
o
o

Fast breathing ( 60bpm or more)

Severe chest indrawing
Fever ( 37.5 c )
Low body temperature ( < 35.5c)
Movement only when stimulated or no movement at all

IMCI REVIEW/UPDATES|BY: MARK JOSEPH V. LIWANAG, RN