Integrated Management of Neonatal and Childhood Illness

Dr.Anup John ThomasAssistant Professor

Department of PediatricsMGMC & RI

Developments Related To Child Health

• 1974 : Expanded Programme on Immunization(EPI)

• 1984 : Universal Immunization Programme(UIP)

• 1985 : Oral Rehydration Therapy(ORT)• 1992 : Child Survival and Safe

Motherhood(CSSM)• 1997 : Reproductive and Child Health(RCH-1)• 2005 : NRHM and RCH II• 2013 : RMNCH+A Strategy • 2013 : National Health Mission • 2014 : India New-born Action Plan (INAP)

Integrated Management of Childhood Illness:

• World Health Organization (WHO), UNICEF & other

International Partner came out with a new strategy Known as

Integrated Management of Childhood Illness (IMCI) in 1995.

• An effort to bring health equity for child health.

• The strategy emphasises on integrated approach for treating

the sick children.

• Emphasizes on improving the family and community practices

as well as care provided by the health system for better care

of child.

The generic IMCI guidelines were adapted and the Indian version was named Integrated Management of Neonatal and Childhood Illness (IMNCI).

IMNCI strategy is one of the main interventions under RCH-II/NRHM, that focuses on preventive, promotive and curative aspects of program.

Perinatal conditions, acute respiratory infections (ARI), diarrhea, measles and malnutrition are the commonest causes of morbidity in young children.

Inclusion of 0-7 days age group (as against 1 week to 5 years in

IMCI) to address the neonatal mortality challenge.

The order of training was reversed, starting from the young infant (0-2 months) to the older child (2 months-5 years).

The total duration of training was reduced from 11 days to 8 days out of which, half of the training time was earmarked for the management of the young infants, 0 to 2 months.

Incorporating National guideline on Malaria, Anemia, Vit. A supplementation and Immunization schedule.

Home-based care of newborns and young infants was included.

The major highlights of Indian adaptations were as follows:

Difference B/w IMCI and IMNCIFeatures Generic IMCI India IMNCICoverage of 0 – 6 days No YesBasic health worker module No YesHome visit module by provider for care of newborn and young infants

No Yes

Home visit training No YesDuration of training on newborn and young infants

2 to 11 days 4 to 8 days

Sequence of training, behavior change communication

Child first than young infants Newborn/ young infants than child

Why IMNCI?•To Reduce infant and child mortality rates• Improving child health & survival

India is still among high infant mortality Rate countries but there has been significant decline in the IMR from 204 during 1911-1915 to 129 per 1000 live births in 1970 and remained static at around 127 for many years.

As of 2015 data India’s Infant Mortality Rate is 38 per 1000 live births. 5

Malnutrition*54%

MAJOR CAUSES OF NEONATAL AND CHILDHOOD MORBIDITY

43%

27%

17%

13%

Malnutrition

Fever

ARI

Diarrhoea

Why Integrated Approach?• Integrated approach is child centred.• Five conditions : Pneumonia, Diarrhoea, Measles, Malaria

and Malnutrition are major cause of Death.• 3 out of 4 children seeking health care in developing countries

suffers from one of these condition.• Children likely to be suffering from more than one condition.• Often combination of theses conditions leads to fatal result.• Making a single diagnosis may be difficult.• Such children often need combined therapy for successful

treatment.

Advantages of Integrated Approach:

• Speeds up the urgent treatment and treatment seeking practices.

• Prompt recognition of serious condition, hence prompt referral.

• Involves parents in effective care of baby at home.• Involves prevention of diseases by active immunization,

Improved nutrition and Exclusive Breastfeeding practices.• Highly cost effective.• It avoids wastages of resources by using most appropriate

medicines and treatment.• It reduces duplication of effort. • Partial Success of Individual disease control programme.

Inadequacies in Health system:Health worker skills:

– Incomplete examinations and counselling.– Poor communication between health workers and parents.– Irrational use of drugs.

Health system issues:

- Access to health services and Scarce availability of Skilled Worker

- Availability of appropriate drugs and vaccines

- Supervision / organization of work Community and family practices:

– Delayed care seeking– Poor knowledge of when to return to a health facility– Seeking assistance from unqualified providers – Poor adherence to health worker advice and treatment

Objectives

1) Reducing infant mortality. 2) Reducing the incidence and seriousness of

illnesses and health problems. 3) Improving growth and development during the first five years of a child's life

COMPONENTS

What Needs to be done in IMNCI Improve health worker skills

Improve health systems Improve family and community practices

Case management standards and guidelines

District and block planning management

Appropriate Care seeking

Training of facility- based public health care providers

Availability of IMNCI drugs Nutrition

IMNCI roles for private providers

Quality improvement and supervision at health facilities – public and private

Home case management and adherence to recommended treatment

Maintenance of competence among trained health workers

Referral pathways and services Community services planning and monitoring

Health information system

Beneficiaries of IMNCI

Newborns and infants

(under 2 months)

Young children (2month

s-5 years)

IMNCI Package:• Care of Newborns and Young Infants (infants under 2 months):

– Keeping the child warm.– Initiation of breastfeeding immediately after birth and counselling for

exclusive breastfeeding and non-use of pre lacteal feeds.– Cord, skin and eye care.– Recognition of illness in newborn , management and/or referral.– Immunization.

• Home visits in the postnatal period:– Home visits by health workers (ANMs, AWWs, ASHAs ).– Three home visits are to be provided to every newborn:

• first visit on the day of birth (day 1).• Next two visit on day 3 and day 7.

– For low birth weight babies, 3 more visits: on Day 14, 21 and 28.– care of mothers during the post-partum period.

Care of Infants (2 months to 5 years)

– Management of diarrhoea, acute respiratory infections (pneumonia), malaria, measles, acute ear infection, malnutrition and anaemia.

– Recognition of illness / at risk conditions and management/referral.– Prevention and management of Iron and Vitamin A deficiency.– Feeding Counselling for all children below 2 years– Feeding Counselling for malnourished children between 2 to 5 years.– Immunization.

• Who will provide IMNCI Services ?– The health workers in the community (ANM, AWW, ASHA ) or– Providers at the facility (PHC/CHC/FRU).

Components of IMNCI:

Training:

- IMNCI is skill based training based on a participatory

approach combining classroom sessions with hands-on

clinical sessions in both facility and community setting.

– Two categories of training are included:

• One for medical officers

• A second for front-line functionaries including ANM’s

and Anganwadi Workers (AWW’s).

Improvements to the health system. The essential elements include:

– Ensuring availability of health workers / providers at all levels.– Ensuring availability of the essential drugs.– Improve referral to identified referral facility.– Referral mechanism to ensure hassle free transfer to higher level of

care when needed. – Awareness of Health worker for when and where to refer a sick child.– The staff at appropriate health facilities must identify and

acknowledge the referral slips and give priority care to the sick children.

– Functioning referral centres, especially where healthcare systems are weak need to be reinforced or private/public partnerships established

– Ensuring supervision and monitoring through follow up visits by trained supervisors

– On-the-job supportive supervision.

Improvement of Family and Community Practices: ( Community IMNCI)

• Counselling of families and creating awareness among Communities . This includes:

– Promoting healthy behaviours such as breastfeeding, illness recognition, early care seeking etc.

– Counselling of care givers and families as part of management of the sick child when they are brought to the health worker/health facility.

– During Home Visits - identification of sickness and improving newborn and child care practices.

• Collaboration/coordination with other Departments, Self Help Groups etc:– Community ownerships and participation is of paramount importance.

Work distribution

Case Management Process In IMNCI, only a limited number of carefully-selected clinical signs are

considered, based on their sensitivity and specificity, to detect the disease. A combination of these signs helps in arriving at the child's classification, rather than a diagnosis.

Classification(s) also indicates the severity of the condition. The classifications

are color coded:

A. PINK CLASSIFICATION: suggests hospital referral or admission (Child needs urgent referral)

B. YELLOW CLASSIFICATION: indicates initiation of treatment (Child needs specific medical treatment and advise)

C. GREEN CLASSIFICATION: calls for home treatment (Child needs no medicine, advise home care)

A sick young infant up to 2 months of age is assessed for Possible bacterial infections, diarrhea , jaundice

Children of age 2 months to 5 years: Cough or difficult breathing, diarrhea, fever &ear

problems

Active participation of caretakers in the treatment

Use of limited number of essential drugs

ELEMENTS:-Assess Danger signs, nutrition and immunization status Other problemsClassify as per Color CodingIdentify Specific TreatmentProvide Treatment Pre referral Medical treatment Home ManagementCounsel Feeding problems Mother’s healthFollow-up care(

IMCI case management at first level health facility, referral level, and home :

Management Algorithm:

The IMNCI Process for Children < 2 Months of Age

The IMNCI case management Process: for children 2 months to 5 years of Age

F- IMNCI: (facility based IMNCI)

• What? Facility Based Care for severely ill children is complementary to

primary care for providing a continuum of care for severely ill children. Integration of existing IMNCI package and the Facility Based Care

package in to one package.

• WHY? Majority of the health facilities (24x7 PHCs, FRUs, CHCs and District

hospitals) do not have trained paediatricians. F-IMNCI training will help in skill building of the medical officers and

staff nurses posted in these health facilities to provide IMNCI care.

TRAININGS in F- IMNCI • Focus on Skill Development

50% of training time is spent on building skills by “hands-on training” involving actual case management and counselling.

Remaining 50% in classroom for building theoretical understanding of essential health intervention.

• Training at two levels:– In service training for the existing staff.– Pre-Service Training– For including F-IMNCI in the pre-service teaching

of doctors and nurses. • Personnel to be Trained: There are 2 types of trainings under F-IMNCI:

PRE-TRAINING STATUS PACKAGE TO BE USED DURATION

IMNCI not trained F-IMNCI complete package

11 days

IMNCI trained Facility based care package of F-IMNCI

5 days

• Training of Trainers:– Faculty from the departments of Paediatrics and community medicine

of the medical colleges.– The trainers at district level include all the paediatricians in the district.

• Facilitator to trainees ratio: – Participant to facilitator ratio of 1:4-6 (one trainer to 4 – 6

participants).

• Training Institutions:– The Departments of Pediatrics and Preventive & Social Medicine in

each college. • Pre-service Training:

– Include training on F-IMNCI for the undergraduate students and intern. Also for Nursing students.

C - IMNCI: Community and Household IMNCI:

• Community IMCI is basically Component 3 of the IMCI Package.

• It aims at improving family and community practices by promoting those Practices with the greatest potential for improving child survival, growth and development.

• Evidence that 80% of deaths of children under five years of age occur at home with little or no contact with health providers.

• C-IMCI seeks to strengthen the linkage between health services and communities, to improve selected family and community practices and to support and strengthen community-based activities.

Key family practices:

• 16 key family practices identified Under Four Broad Heading:The promotion of growth and development of the child:

– Exclusive Breastfeeding for six months. Good quality complementary foods after six months. Continue breastfeeding for two years or longer.

– Ensure enough micronutrients – such as vitamin A, iron and zinc – in diet or through supplements.

– Promote mental and social development by responding to a child’s needs for care and by playing, talking and providing a stimulating environment.

Disease prevention:– Dispose of all faeces safely, wash hands after defecation, before preparing meals

and before feeding children.– Protect children in malaria endemic areas, by ensuring that they sleep under

Insecticide - treated bed nets.– Provide appropriate care for HIV/AIDS affected people, especially orphans, and

Take action to prevent further HIV infections.

Appropriate care at home:– Continue to feed and offer more fluids, including breast milk to children when

they are sick.– Appropriate home treatment for infections.– Protect children from injury and accident and provide treatment when

necessary.– Prevent child abuse and neglect, and take action when it does occur.– Involve fathers in the care of their children and in the reproductive health of

the family.

Care-seeking outside the home:– Recognize when sick children need treatment outside the home and seek care

from appropriate providers. – Complete a full course of immunization before first birthday.– Follow the health provider’s advice on treatment, follow-up and referral. – Ensure that every pregnant woman has adequate antenatal care, and seeks

care at the time of delivery and afterwards.

IMNCI +

The objectives of the newborn and child health strategy are: – Increase coverage of skilled care at birth for newborns in conjunction with

maternal care.– Implement a newborn and child health package of preventive, promotive

and curative interventions using a comprehensive IMNCI approach:At the level of all:– Sub-centres.– Primary health centers.– Community health centers.– First referral units

• At the household level in rural and poor peri urban settings in at least 125 districts (through AWWs / ASHAs)– Implement the medium-term strategic plan for the UIP (Universal

Immunization Program).– Strengthen and augment existing services in areas where IMNCI is yet to

be implemented.

Why IMNCI ‘Plus’

RCH 2 NEW BORN and CHILD HEALTH PACKAGE:

What “IMNCI +” Adds• Inpatient care component for facilities to ensure effective care

of sick neonates and children who require hospitalization.

• IMNCI package not cover the vital care of the neonates at birth in home and facility settings.

• IMNCI approach includes counselling for immunization, but the implementation of immunization in India cannot be adequately done by the IMNCI contacts alone. Therefore, a comprehensive immunization plan will be required.

• The new initiative of jssk would provide completely free and cashless services to pregnant women including normal deliveries and caesarean operations and sick new born (up to 30days after birth ) in government health institutions in both rural and urban areas.

• Jssk initiative is estimated to benefit more than one core pregnant women & new born who access public health institutions every years in both urban & rural areas.

Janani Shishu suraksha karyakram (JSSK)

The free Entitlements under JSSK include:

• free and cashless Delivery

• free C section

• free treatment of sick new born up to 30days

• free drugs consumable , Diagnostics , Diet during stay

in health institution – 3days ND, 7days- CS

• free transport Home to Health institutions

Cont.…

• Every year 12 lakh new-born babies die in India.

• India lunched a program on 15sept.2009 train the

health care providers at district hospitals. CHC, PHC,

across the country in management of – prevention of

infection, hypothermia (temperature management)

early initiation of breast-feeding of the new borns.

NAVJAAT SHISHU SURAKSHA KARYAKRAM(NSSK)

India New-born Action Plan (INAP) • Builds on existing commitments under the National Health Mission and 'Call to Action‘ for Child Survival and

Development • Aligns with the Global Every New-born Action Plan (ENAP); defines commitments based on specific contextual needs of

the country • Aims at attaining Single Digit Neonatal Mortality Rate by 2030, five years ahead of the global plan• Emphasizes strengthened surveillance mechanism for tracking stillbirths• Focuses on ending preventable new-born deaths, improving quality of care and care beyond survival • Prioritizes those babies that are born too soon, too small, or sick—as they account for majority of all new-born deaths • Aspires towards ensuring equitable progress for girls and boys, rural and urban, rich and poor, and between districts

and states • Identifies major guiding principles under the overarching principle of Integration:

– Equity– Gender– Quality of Care– Convergence– Accountability– Partnerships

• Defines six pillars of interventions: – Pre-conception and antenatal care – Care during labour and child birth– Immediate new-born care– Care of healthy new-born– Care of small and sick new-born– Care beyond new-born survival

• Serves as a framework for states/districts to develop their own action plan with measurable indicators.

Progress since the Launch of the National Rural Health Mission (NRHM) - 2005

• Janani Suraksha Yojana (JSY) has increased the number of women delivering in public health facilities to 107 lakhs each year.

• 470 new maternal and child health wings (30/50/100 bedded) have been sanctioned in the public health system, adding more than 28,000 beds.

• A nationwide network of facility-based new-born care has been established at various levels:– 14,135 New-born Care Corners at the point of child birth;– 1,810 New-born Stabilization Units; 548 Special New-born Care Units (SNCUs) for sick and small new-

borns, with care to more than 6 lakhs new-borns being provided in SNCUs each year.• Janani Shishu Suraksha Karyakram (JSSK) has entitled all pregnant women and infants to free

delivery, drugs, diagnostics, treatment, food, and transportation to and from facilities. • 38,300 public health facilities constructed/ upgraded and more than 20,000 ambulances have

been sanctioned. • The total number of technical HR supported under NRHM increased to 3.45 lakhs which

includes 30,429 doctors/specialists including AYUSH doctors, 38,421 staff nurses, 21,965 para-medics and 2.39 lakhs ANMs.

• Incentivized Home-Based Newborn Care programme has been launched in 2011: – 8.95 lakhs ASHAs selected and more than 6 lakhs ASHAs trained to improve newborn practices at the

community level– early detection and referral of sick newborn babies by making home visits as per schedule during the

first 42 days after birth.