REPORT

ON

INSERVICE EDUCATION
On

IMNCI Guidelines
(INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS)

SUBMITTED TO: SUBMITTED BY:

Ms.Seema Rani Ms. Akansha John
Associate Professor Community Health Nursing
Rufaida College of Nursing Rufaida College of Nursing
Jamia Hamdard, New Delhi Jamia Hamdard, New Delhi.

On 09/07/2019
Timing: 11am-1pm

INTRODUCTION

INTRODUCTION
Bringing down Infant and Child Mortality Rates and improving Child Health & Survival has
been an important goal of the Family Welfare Programmes in India. During the period 1977 to
1992 programmes like universal immunization programme; oral rehydration therapy (ORT)
programme and programme for prevention of deaths due to acute respiratory infections (ARI)
were implemented as vertical programmes. These programmes were integrated in 1992 under the
Child Survival and Safe Motherhood Programmes and have continued to be a part of the
Reproductive & Child Health Programme implemented since 1997.

Over the last 3 decades the annual number of deaths among children less than 5 years of age has
decreased by almost a third. However, this reduction has not been evenly distributed throughout
the world. Every year more than 10 million children die in developing countries before they
reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory infections
(mostly pneumonia), diarrhea, measles, malaria, or malnutrition - and often to a combination of
these illnesses.

In India, common illnesses in children under 3 years of age include fever (27%), acute
respiratory infections (17% ), diarrhea (13% ) and malnutrition (43%) – and often in combination
(National Family Health Survey 2.

To increase the awareness among ANM and health worker an in service education was
organized by M.Sc. Nursing students of Rufaida College of Nursing under the Supervision of
Ms. Alka Mishra Public Health Nurse, Community Health Department, Safdurjung Hospital
New Delhi

The main aim of the in-service education was to enhance the knowledge of health worker and
ANMs on guidelines of IMNCI.
Objectives of the in-service education

 Provide knowledge on the guidelines of IMNCI

 Assess the knowledge of health worker
 Preparation and submission of A.V Aids and reports.
Methodology used
 Planned teaching program
 Pre and post test of health worker
 Analysis and Interpretation of the data collected
 Preparation of the report

OPENING SESSION

The program was initiated by Ms Akansha John who described the topic in brief to the health
workers and introduced the other student who are going to provide information to the health
workers and ANMs. She asked a few questions to the audience to rule out the basic knowledge
or understanding level.

INTRODUCING OF TOPIC

INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS

INTRODUCTION

Bringing down Infant and Child Mortality Rates and improving Child Health & Survival has
been an important goal of the Family Welfare Programmes in India. During the period 1977 to
1992 programmes like universal immunization programme; oral rehydration therapy (ORT)
programme and programme for prevention of deaths due to acute respiratory infections (ARI)
were implemented as vertical programmes. These programmes were integrated in 1992 under the
Child Survival and Safe Motherhood Programmes and have continued to be a part of the
Reproductive & Child Health Programme implemented since 1997.

Over the last 3 decades the annual number of deaths among children less than 5 years of age has
decreased by almost a third. However, this reduction has not been evenly distributed throughout
the world. Every year more than 10 million children die in developing countries before they
reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory infections
(mostly pneumonia), diarrhoea, measles, malaria, or malnutrition - and often to a combination of
these illnesses.

In India, common illnesses in children under 3 years of age include fever (27% ), acute
respiratory infections (17% ), diarrhoea (13% ) and malnutrition (43%) – and often in
combination (National Family Health Survey 2.

COMPONENTS OF THE INTEGRATED APPROACH

The IMNCI strategy includes both preventive and curative interventions that aim to improve
practices in health facilities, the health system and at home. At the core of the strategy is
integrated case management of the most common neonatal and childhood problems with a focus
on the most common causes of death.

The strategy includes three main components:

  Improvements in the case-management skills of health staff through the provision of
locally-adapted guidelines on Integrated Management of Neonatal and Childhood Illness
and activities to promote their use
 Improvements in the overall health system required for effective management of
neonatal and childhood illness
 Improvements in family and community health care practices.

THE PRINCIPLES OF INTEGRATED CARE

Depending on a child’s age, various clinical signs and symptoms differ in their degrees of
reliability and diagnostic value and importance. Therefore, the IMNCI guidelines recommend
case management procedures based on two age categories:

 Young infants age up to 2 months

 Children age 2 months up to 5 years

The IMNCI are based on the following principles:

 All sick young infants up to 2 months of age7 must be assessed for “possible bacterial
infection /jaundice”. Then they must be routinely assessed for the major symptom
“diarrhoea”.
 All sick children age 2 months up to 5 years must be examined for “general danger signs”
which indicate the need for immediate referral or admission to a hospital. They must then
be routinely assessed for major symptoms: cough or difficult breathing, diarrhoea, fever
and ear problems.
 All sick young infants and children 2 months up to 5 years must also be routinely
assessed for nutritional and immunization status, feeding problems, and other potential
problems.

An essential component of the IMNCI is the counselling of caretakers about home care,
including counselling about feeding, fluids and when to return to a health facility.

The Integrated Case Management Process

 The case management process is presented on a series of charts, which show the
sequence of steps and how to perform them.
 The charts describe the following steps:
1. Assess the young infant or child Means taking a history and doing a physical
examination.
2. Classify the illness “Classify the Illness” means making a decision on the severity of the
illness and assigning to a Colour, or “Classification,” which corresponds to the severity
of the disease Classifications are not specific disease diagnoses. Instead, they are colour
coded categories that are used to determine treatment
3. Identify treatment: the charts recommend appropriate treatment for each colour coded
classification
4. Treat the infant or child “Treat” means giving treatment in clinic, prescribing drugs or
other treatments to be given at home, and also teaching the mother how to carry out the
treatments.
5. Counsel the mother assessing how the child is fed and telling her about the foods and
fluids to give the child and when to bring the child back to the clinic.
6. Give follow-up care
ASSESSMENT OF SICK YOUNG INFANTS

Young infants have special characteristics that must be considered when classifying their
illnesses. They can become sick and die very quickly from serious bacterial infections. They
frequently have only general signs such as few movements, fever or low body temperature. Mild
chest in drawing is normal in young infants because their chest wall is soft. For these reasons,
you will assess, classify and treat the young infant somewhat differently than an older infant or
young child.

The assessment procedure for this age group includes a number of important steps that must be
taken by the health care provider, including:

(1) History taking and communicating with the caretaker about the young infant’s problem
(2) Checking for possible bacterial infection / jaundice
(3) Checking for diarrhoea
(4) Checking for feeding problem or malnutrition
(5) checking immunization status
(6) assessing other problems.

COMMUNICATING WITH THE CARETAKER

The steps to good communication are:

 Listen carefully to what the caretaker says. This will show them that you take their
concerns seriously.
 Use words the caretaker understands. Try to use local words. Avoid medical
terminology and unfamiliar words.
 Give the caretaker time to answer questions. S/he may need time to reflect and decide if
a clinical sign is present.
 Ask additional questions when the caretaker is not sure about the answer. A caretaker
may not be sure if a symptom or clinical sign is present. Ask additional questions to help
her/him give clear answers.

Communicating - History taking

A mother (or other family member such as the father, grandmother, sister or brother) usually
brings a young infant to the clinic because the infant is sick. But mothers also bring their infants
for well-baby visits, immunization sessions and for other problems. The steps on the ASSESS &
CLASSIFY THE SICK YOUNG INFANT chart describe what you should do when a mother
brings her young infant to the clinic because the infant is sick. The chart should not be used for a
well infant brought for immunization or for an infant with an injury or burn. This chart also
should not be used for taking care of the newborn at birth.

When you see the mother and her sick infant:

* Greet the mother appropriately and ask her to sit with her infant. You need to know the
infant's age so you can choose the right case management chart. Look at the infant's record to
find the infant's age.

- If the infant is up to 2 months, assess and classify the young infant according to the steps on
the ASSESS AND CLASSIFY THE SICK YOUNG INFANT chart.

- If the child is age 2 months up to 5 years, assess and classify the child according to the steps on
the ASSESS AND CLASSIFY THE SICK CHILD

CHECKING FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE

In this step you are looking for signs of bacterial infection, especially a serious infection. A
young infant can become sick and die very quickly from serious bacterial infections such as
pneumonia, sepsis and meningitis.

It is important to assess the signs in the order on the chart, and to keep the young infant calm.
The young infant must be calm and may be asleep while you assess the first five signs, that is,

 count breathing
 look for chest indrawing
 nasal flaring
 grunting and
 bulging fontanels.
To assess the next few signs, you will pick up the infant and then undress him, look at the skin
all over his body and measure his temperature. By this time he will probably be awake. Then
you can see whether he is lethargic or unconscious and observe his movements.

Clinical Assessment

Many clinical signs point to possible bacterial infection in sick young infants. The most
informative and easy to check signs are:

Convulsions (as part of the current illness). Convulsions may be associated with meningitis or
other life-threatening conditions. All young infants who have had convulsions during the present
illness should be considered seriously ill. Convulsion in young infants may not be characterized
by tonic-clonic movements and up rolling of eyeballs, they may instead present as repetitive
jerky movements of the eyes, lip smacking or a staring look.

Fast breathing. Count the breaths in one minute to decide if the young infant has fast breathing.
The young infant must be quiet and calm when you look and listen to his breathing. If the young
infant is frightened, crying or angry, you will not be able to obtain an accurate count of the
infant's breaths. Tell the mother you are going to count her infant's breathing. Remind her to
keep her infant calm. If the infant is sleeping, do not wake him. To count the number of breaths
in one minute, use a watch with a second hand or a digital watch. Put the watch where you can
see the second hand and glance at the second hand as you count the breaths the young infant
takes in one minute. Look for breathing movement anywhere on the infant's chest or abdomen.
Usually you can see breathing movements even on an infant who is dressed. If you cannot see
this movement easily, ask the mother to lift the infant's shirt. If the young infant starts to cry, ask
the mother to calm the infant before you start counting. If you are not sure about the number of
breaths you counted (for example, if the young infant was actively moving and it was difficult to
watch the chest, or if the young infant child was upset or crying), repeat the count. Young
infants usually breathe faster than older children do. The cut-off rate to identify fast breathing in
this age group is 60 breaths per minute or more. If the count is 60 breaths or more, the count
should be repeated, because the breathing rate of a young infant is often irregular. The young
infant may occasionally stop breathing for a few seconds, followed by a period of faster
breathing. If the second count is also 60 breaths or more, the young infant has fast breathing.

LOOK for severe chest in-drawing.

If you did not lift the young infant's shirt when you counted the infant's breaths, ask the mother
to lift it now. Look for chest in-drawing when the young infant breathes IN. Look at the lower
chest wall (lower ribs). The young infant has chest in-drawing if the lower chest wall goes IN
when the infant breathes IN. Chest in-drawing occurs when the effort the young infant needs to
breathe in is much greater than normal. In normal breathing, the whole chest wall (upper and
lower) and the abdomen move OUT when the young infant breathes IN. When chest in-drawing
is present, the lower chest wall goes IN when the young infant breathes IN.

 Nasal flaring: Nasal flaring is widening of the nostrils when the young infant breathes in.
 Grunting: Grunting is the soft, short sounds a young infant makes when breathing out.
Grunting occurs when an infant is having difficulty in breathing.
 Bulging fontanels. Look at and feel the anterior fontanelle when the infant is not crying
and held in an upright position. A bulging fontanelle may indicate that the young infant
has meningitis, a possible serious bacterial infection.
 Pus draining from the ear: Look for pus draining from either of the ears.
 Umbilicus red or draining pus: There may be some redness of the end of the umbilicus
or the umbilicus may be draining pus (The cord usually drops from the umbilicus by one
week of age).
 Skin pustules: Examine the skin on the entire body. Skin pustules are red spots or
blisters that contain pus. Presence of 10 or more skin pustules or a large boil indicate a
possible serious bacterial infection.
 Temperature: A thermometer that measures to a minimum of 35ºC can be used to
measure temperature. Keep the bulb of the thermometer high in the axilla and then hold
the young infant’s arm against his body for 5 minutes before reading the temperature. If
you do not have a thermometer, feel the infant's abdomen or axilla (underarm) and
determine if it feels hot or cold to touch.

Fever or hypothermia may both indicate bacterial infection. Fever (axillary temperature more
than 37.5°C) is uncommon in the first two months of life. Fever in a young infant may indicate a
serious bacterial infection, and may be the only sign of a serious bacterial infection. Young
infants can also respond to infection by dropping their axillary temperature to below 35.5°C.

 Lethargy or unconsciousness: Young infants often sleep most of the time, and this is
not a sign of illness. Even when awake, a healthy young infant will usually not watch his
 mother and a physician/health worker while they talk, as an older infant or young child
would. A lethargic young infant is not awake and alert when he should be. He may be
drowsy and may not stay awake after a disturbance. If a young infant does not wake up
during the assessment, flick the sole 2-3 times. Look to see if the child wakens and
whether he stays awake. If the young infant shows no response or does not stay awake
after some response, he is lethargic or unconscious.

Jaundice is the visible manifestation of chemical bilirubinemia. Yellow discoloration of skin is

visible in a neonate when serum bilirubin is more than 5 mg/dl. Almost all neonates may have
‘physiological jaundice’ during the first week of life due to several physiological changes taking
place after birth. Physiological jaundice usually appears between 48-72 hours of age, maximum
intensity is seen on 4-5th day in term and 7th day in preterm neonates. Physiological jaundice
does not extend to palms and soles, and does not need any treatment.

To look for jaundice, press the infant’s skin over the forehead with your fingers to blanch,
remove your fingers and immediately look for yellow discoloration under natural light. If there is
yellow discoloration, the infant has jaundice.

 Yellow palms and soles Press the infant’s palms with your fingers to blanch, remove
your fingers and look for yellow discoloration under natural light. Repeat the process to
look for yellow soles.

Occurrence of jaundice in the first 24 hours of life and yellow discoloration of palms and soles at
any time is always pathological and requires urgent referral. Severe jaundice beyond the first
week may be a result of cholestasis

Classify Young Infant for Possible Bacterial Infection/ Jaundice:

For all Young Infants:

1. Look at the pink row:

1. Does the young infant have any of the signs of possible serious bacterial
infection?
 If the young infant has any of the signs of possible serious bacterial infection,
select the severe classification, POSSIBLE SERIOUS BACTERIA INFECTION.
2. If the young infant does not have the severe classifications, look at the yellow row. If the
young infant has any of the signs in yellow row, select the classification LOCAL BACTERIAL
INFECTION.

3. There is no green row under Possible Bacterial Infection.

For Young Infant with Jaundice:

 Look at the pink row:

 If the young infant has any signs of severe jaundice, select the sever classification,
SEVERE JAUNDICE.
 If the young infant does not have any signs of severe classifications, look at the
yellow row and select the classification JAUNDICE.

Temperature between 35.5- 36.4oC

 There is no green row under Jaundice.

 For Young Infant with Temperature between 35.5 – 36.4 0C:
 There is only yellow classification for temperature between 35.5 – 36.4 0C, LOW BODY
TEMPERATURE.

DIARRHOEA

A young infant is considered to have diarrhea if the stools have changed from usual pattern and
are many and watery (more water than faecal matter). The normally frequent or loose stools of a
breastfed baby are not diarrhea.

A young infant with diarrhea can be placed in one of the following 3 categories:

(1) Acute watery diarrhea;

(2) Dysentery (bloody diarrhea); and

(3) Persistent diarrhea (diarrhea that lasts more than 14 days).

All young infants with diarrhea should be assessed for:

(a) Signs of dehydration;

(b) Duration of diarrhea; and

(c) Blood in the stool.

Clinical Assessment

All infants with diarrhea should be assessed to determine the duration of diarrhea, if blood is
present in the stool and if dehydration is present. A number of clinical signs are used to
determine the level of dehydration:

Infant’s general condition. Depending on the degree of dehydration, an infant with diarrhea may
be lethargic or unconscious or look restless/ irritable. Only infants who cannot be consoled and
calmed should be considered restless or irritable.

 Sunken eyes: The eyes of a dehydrated infant may look sunken. In a severely
malnourished infant who is visibly wasted, the eyes may always look sunken, even if the
infant is not dehydrated. Even though the sign “sunken eyes” is less reliable in a visibly
wasted infant, it can still be used to classify the infant's dehydration.
 Elasticity of skin: Check elasticity of skin using the skin pinch test. When released, the
skin pinch goes back either very slowly (longer than 2 seconds), or slowly (skin stays up
even for a brief instant), or immediately. In an infant with severe malnutrition, the skin
may go back slowly even if the infant is not dehydrated. In an overweight infant, or an
infant with edema, the skin may go back immediately even if the infant is dehydrated.

After the infant is assessed for dehydration, the caretaker of an infant with diarrhea should be
asked how long the infant has had diarrhea and if there is blood in the stool. This will allow
identification of infants with persistent diarrhea and dysentery.

 Standard Procedures for Skin Pinch Test?

 Locate the area on the child's abdomen halfway between the umbilicus and the side of the
abdomen; then pinch the skin using the thumb and first finger.
 Place your hand in such a way that when the skin is pinched, the fold of skin will be in a
line up and down the child's body and not across the child's body.
 It is important to firmly pick up all of the layers of skin and the tissue under them for one
second and then release it.
Classification of Dehydration

Based on a combination of the above clinical signs, infants presenting with diarrhea are
classified into three categories:

 A young infant with SEVERE DEHYDRATION has any two of the following signs: is
lethargic or unconscious, has sunken eyes, or a skin pinch goes back very slowly.
 Those with SOME DEHYDRATION have any combination of two of the following
signs: restless/irritable, sunken eyes, skin pinch goes back slowly.
 Those infants with diarrhea who do not have enough signs to classify as severe or some
dehydration are classified as NO DEHYDRATION.

Two of the following signs:

a) Lethargic or unconscious
b) Sunken eyes
c) Skin pinch goes back very slowly

CHECKING FOR FEEDING PROBLEMS & MALNUTRITION

All sick young infants seen in outpatient health facilities should be assessed for weight and
adequate feeding, as well as for breast-feeding technique.

Clinical Assessment

Assessment of feeding and malnutrition in young infants has two parts.

 In the first part you ask the mother questions to determine if she is having difficulty
feeding the infant, what the young infant is fed and how often. You also determine
weight for age.
 In the second part, if an infant has difficulty feeding, or is breastfed less than 8 times in
24 hours, or being given other foods or drinks, or low weight for age, then breastfeeding
should be assessed. Assessment of breastfeeding in young infants includes checking if the
infant is able to attach, if the infant is suckling effectively (slow, deep sucks, with some
pausing), and if there are ulcers or white patches in the mouth (thrush).
  Infants who are Very Low Weight for Age should be referred to a hospital. Infants who
are Low Weight for Age need special attention to how they are fed and on keeping them
warm.

Classification of Feeding Problems and Malnutrition

Based on an assessment of feeding and weight, a sick young infant may be classified into three
categories:

 NOT ABLE TO FEED – POSSIBLE SERIOUS BACTERIAL INFECTION OR

SEVERE MALNUTRITION. The young infant who is not able to feed, or not attaching
to the breast at all or not suckling effectively at all or very low weight for age , has a life-
threatening problem. This could be caused by a bacterial infection or another illness. A
young infant who is very low weight for age is at a high risk of death. The infants who
are not able to feed or have very low weight for age should be referred to a hospital
after receiving the same pre-referral treatment as infants with POSSIBLE SERIOUS
BACTERIAL INFECTION.
 Infants with FEEDING PROBLEMS OR LOW WEIGHT are those infants who are not
attaching well to the breast, not suckling effectively, getting breast milk fewer than eight
times in 24 hours, receiving other foods or drinks than breast milk, or thrush
(ulcers/white patches in mouth) or those who have low weight for age or where the
mother has breast or nipple problems.
 Not able to feed or ? No attachment at all or ? Not suckling at all or ? Very low weight
for age

NOT ABLE TO FEED – POSSIBLE SERIOUS BACTERIAL INFECTION OR SEVERE

MALNUTRITION

 Not well attached to breast

 Not suckling effectively
 Less than 8 breastfeeds in 24 hours
 Receiving other foods or drinks
  Thrush (ulcers or white patches in mouth)
 Low weight for age
 Breast or nipple problems

FEEDING PROBLEM OR LOW WEIGHT

Appropriate counseling of the mother should be based on the identified feeding problem. Ensure
follow-up for any feeding problem or thrush in two days and follow- up low weight for age in 14
days.

Infants with NO FEEDING PROBLEM

They are those who are breastfed exclusively at least eight times in 24 hours and whose weight is
not classified as low weight for age. The young infant’s weight is not necessarily normal for age
but the infant is not in the high risk category.

CHECKING IMMUNIZATION STATUS

Immunization status should be checked in all sick young infants. A young infant who is not sick
enough to be referred to a hospital should be given the necessary immunizations before s/he is
sent home.

Note: Do not give OPV 0 to an infant who is more than 14 days old. If an infant has not received
OPV 0 by the time s/he is 15 days old, OPV should be given at age 6 weeks old as OPV 1.

TREATMENT OF SICK YOUNG INFANTS

The first step is to IDENTIFY TREATMENT required for the young infant according to the
classification. All the treatments required are listed in the "Identify Treatment" column of the
ASSESS & CLASSIFY THE SICK YOUNG INFANT chart. If a sick young infant has more
than one classification, treatment required for all the classifications must be identified.

For some young infants, the ASSESS & CLASSIFY THE SICK YOUNG INFANT chart says
"Refer URGENTLY to hospital." By hospital, we mean a health facility with inpatient beds,
supplies and expertise to treat a very sick young infant. Referral may mean admission to the
inpatient department of the same facility where the young infant has been examined as an
outpatient.

REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS OF AGE

All infants and children with a severe classification (pink) are referred to a hospital as soon as
assessment is completed and necessary pre-referral treatment is administered.

Possible pre-referral treatments include:

 First dose of intramuscular or oral antibiotics

 Keeping the infant warm on the way to the hospital
 Prevention of hypoglycemia with breast-milk or sugar water
 Frequent sips of ORS solution on the way to the hospital

COUNSELLING A MOTHER OR CARETAKER

ADVICE THE MOTHER HOW TO CARE FOR HER CHILD AT HOME Limit your advice to
what is relevant to the mother at this time. Use language that the mother will understand. If
possible, use pictures or real objects to help explain. For example, show amounts of fluid in a
cup or container.

Advice against any harmful practices that the mother may have used. When correcting a harmful
practice, be clear, but also be careful not to make the mother feel guilty or incompetent. Explain
why the practice is harmful.

Some advice is simple. For example, you may only need to tell the mother to return with the
infant for follow-up in 2 days. Other advice requires that you teach the mother how to do a task.
Teaching how to do a task requires several steps.

Think about how you learned to write, cook or do any other task that involved special skills. You
were probably first given instruction. Then you may have watched someone else. Finally you
tried doing it yourself.
When teach a mother how to treat an infant, use 3 basic teaching steps:

1. Give information.

2. Show an example.

3. Let her practice.

Give information: Explain to the mother how to do the task. For example, explain to the mother
how to prepare ORS

Show an example: Show how to do the task. For example, show the mother a packet of ORS and
how to mix the right amount of water with ORS

Let her practice: Ask the mother to do the task while you watch. For example, have the mother
mix ORS solution. It may be enough to ask the mother to describe how she will do the task at
home.

Counseling about Other Feeding Problems

 If a mother is breastfeeding her infant less than 8 times in 24 hours, advise her to increase
the frequency of breastfeeding. Breastfeed as often and for as long as the infant wants,
day and night.
 If the infant receives other foods or drinks, counsel the mother about breastfeeding more,
reducing the amount of the other foods or drinks, and if possible, stopping altogether.
Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle.
 If the mother does not breastfeed at all, consider referring her for breastfeeding
counseling and possible re-lactation. If the mother is interested, a breastfeeding
counselor may be able to help her to overcome difficulties and begin breastfeeding again.
 Advise a mother who does not breastfeed about choosing and correctly preparing
dairy/locally appropriate animal milk. Also advise her to feed the young infant with a
cup, and not from a feeding bottle.
 Follow -up any young infant with a feeding problem in 2 days. This is especially
important if you are recommending a significant change in the way the infant is fed.
ASSESSMENT OF SICK CHILDREN

The assessment procedure for this age group includes a number of important steps that must be
taken by the health care provider, including:

(1) History taking and communicating with the caretaker about the child’s problem;

(2) Checking for general danger signs;

(3) Checking main symptoms;

(4) Checking for malnutrition;

(5) Checking for anemia;

(6) Assessing the child’s feeding;

(7) Checking immunization status; and

(8) Assessing other problems.

CHECKING FOR GENERAL DANGER SIGNS

A sick child brought to an outpatient facility may have signs that clearly indicate a specific
problem. For example, a child may present with chest in drawing and cyanosis, which indicate
severe pneumonia. However, some children may present with serious, non-specific signs called
"general danger signs" that do not point to a particular diagnosis.

The following danger signs should be routinely checked in all children.

 The child has had convulsions during the present illness. Convulsions may be associated
with meningitis, cerebral malaria or other life-threatening conditions. On the other hand,
convulsions may be the result of fever and in this instance; they do little harm beyond
frightening the mother. All children who have had convulsions during the present illness
should be considered seriously ill because the more serious causes of convulsions cannot
be differentiated from febrile convulsions without investigations conducted in a hospital.
 The child is unconscious or lethargic. An unconscious child is likely to be seriously ill. A
lethargic child, who is awake but does not take any notice of his or her surroundings or
does not respond normally to sounds or movement, may also be very sick. These signs
may be associated with many conditions.
 CHECKING MAIN SYMPTOMS

After checking for general danger signs, the health care provider must check for the following
main symptoms:

(1) Cough or difficult breathing;

(2) Diarrhoea;
(3) Fever; and
(4) Ear problems.

The first three symptoms are included because they often result in death. Ear problems are
included because they are considered one of the main causes of childhood disability.

COUGH OR DIFFICULT BREATHING

Respiratory infections can occur in any part of the respiratory tract such as the nose, throat,
larynx, trachea, air passages or lungs. A child with cough or difficult breathing may have
pneumonia or another severe respiratory infection. Pneumonia is an infection of the lungs. Both
bacteria and viruses can cause pneumonia. In developing countries, pneumonia is often due to
bacteria. The most common are Streptococcus pneumoniae and Hemophilus influenzae. Children
with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized
infection).
Many children are brought to the clinic with less serious respiratory infections. Most children
with cough or difficult breathing have only a mild infection. For example, a child who has a cold
may cough because nasal discharge drips down the back of the throat. Or the child may have a
viral infection of the bronchi called bronchitis. These children are not seriously ill. They do not
need treatment with antibiotics. Their families can manage them at home.

A child presenting with cough or difficult breathing should first be assessed for general danger
signs. This child may have pneumonia or another severe respiratory infection.

Clinical Assessment

Three key clinical signs are used to assess a sick child with cough or difficult breathing:

 Respiratory rate, which distinguishes children who have pneumonia from those who do
not
 Lower chest wall in-drawing, which indicates severe pneumonia
 Strider, which indicates those with severe pneumonia who require hospital admission.

Lower chest wall in-drawing, defined as the inward movement of the bony structure of the chest
wall with inspiration, is a useful indicator of severe pneumonia. It is more specific than
“intercostals in-drawing,” which concerns the soft tissue between the ribs without involvement
of the bony structure of the chest wall.

Strider is a harsh noise made when the child breathes IN. Strider happens when there is a
swelling of the larynx, trachea or epiglottis. These conditions are often called croup. This
swelling interferes with air entering the lungs. It can be life threatening when the welling causes
the child’s airway to be blocked. A child who has strider when calm has a dangerous condition.

Classification of Cough or Difficult Breathing

Based on a combination of the above clinical signs, children presenting with cough or difficult
breathing can be classified into three categories:

 Those who require referral for possible SEVERE PNEUMONIA OR VERY SEVERE
DISEASE.

This group includes children with any general danger sign, or lower chest indrawing or strider
when calm. Children with SEVERE PNEUMONIA OR VERY SEVERE DISEASE most likely
will have invasive bacterial organisms and diseases that may be life-threatening. This warrants
the use of injectable antibiotics.

 Those who require antibiotics as outpatients because they are highly likely to have
bacterial PNEUMONIA.

DIARRHOEA

Diarrhoea is the next symptom that should be routinely checked in every child brought to the
clinic. Diarrhoea occurs when stools contain more water than normal. It is common in children,
especially those between 6 months and 2 years of age. It is more common in babies under 6
months who are drinking cow’s milk or infant formulas. Frequent normal stool passing is not
diarrhoea. The number of stools normally passed in a day varies with the diet and age of the
child. In many regions diarrhoea is defined as three or more loose or watery stools in a 24-hour
period.

A child presenting with diarrhoea should first be assessed for general danger signs and the child's
caretaker should be asked if the child has cough or difficult breathing.

A child with diarrhoea may have three potentially lethal conditions:

(1) Acute watery diarrhoea (including cholera)

(2) Dysentery (bloody diarrhoea)
(3) Persistent diarrhoea (diarrhoea that lasts 14 days or more).

All children with diarrhoea should be assessed for:

(a) Signs of dehydration

(b) How long the child has had diarrhoea
(c) Blood in the stool to determine if the child has dysentery.

Clinical Assessment

All children with diarrhoea should be checked to determine the duration of diarrhoea, if blood is
present in the stool and if dehydration is present. A number of clinical signs are used to
determine the level of dehydration:
  Child’s general condition. Assess if the child is lethargic or unconscious or is restless
/irritable.
 Sunken eyes. Child’s reaction when offered to drink. A child is not able to drink if s/he
is not able to take fluid in his/her mouth and swallow it. For example, a child may not be
able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the
child is weak and cannot drink without help. S/he may be able to swallow only if fluid is
put in his/her mouth. A child has the sign drinking eagerly, thirsty if it is clear that the
child wants to drink. Notice if the child reaches out for the cup or spoon when you offer
him/her water. When the water is taken away, see if the child is unhappy because s/he
wants to drink more. If the child takes a drink only with encouragement and does not
want to drink more, s/he does not have the sign “drinking eagerly, thirsty.”
 Elasticity of skin. Check elasticity of skin using the skin pinch test. When released, the
skin pinch goes back either very slowly (longer than 2 seconds), or slowly (skin stays up
even for a brief instant), or immediately. In a child with marasmus (severe malnutrition),
the skin may go back slowly even if the child is not dehydrated. In an overweight child,
or a child with oedema, the skin may go back immediately even if the child is
dehydrated.

After the child is assessed for dehydration, the caretaker of a child with diarrhoea should be
asked how long the child has had diarrhoea and if there is blood in the stool. This will allow
identification of children with persistent diarrhoea and dysentery.

Classification of Dehydration

Based on a combination of the above clinical signs, children presenting with diarrhoea are
classified into three categories:

 SEVERE DEHYDRATION: A child is severely dehydrated if he/she has any

combination of two of the following signs: is lethargic or unconscious, is not able to
drink or is drinking poorly, have sunken eyes, or a skin pinch goes back very slowly.
Patients have severe dehydration if they have a fluid deficit greater than 10 percent of
their body weight.
 SOME DEHYDRATION: Children who have any combination of the following two
signs are included in this group: restless/irritable, sunken eyes, drinks eagerly/thirsty,
skin pinch goes back slowly. Children with some dehydration have a fluid deficit
 equalling 5 to 10 percent of their body weight. This classification includes both "mild"
and "moderate” dehydration, which are descriptive terms used in most paediatric
textbooks.
 NO DEHYDRATION.

EAR PROBLEMS

Ear problems are the next condition that should be checked in all children brought to the
outpatient health facility. A child with an ear problem may have an ear infection. When a child
has an ear infection, pus collects behind the eardrum and causes pain and often fever. If the
infection is not treated, the eardrum may burst. The pus discharges, and the child feels less pain.
The fever and other symptoms may stop, but the child suffers from poor hearing because the
eardrum has a hole in it. Usually the eardrum heals by itself. At other times the discharge
continues, the eardrum does not heal and the child becomes deaf in that ear.

Sometimes the infection can spread from the ear to the bone behind the ear (the mastoid) causing
mastoiditis. Infection can also spread from the ear to the brain causing meningitis. These are
severe diseases. They need urgent attention and referral.

Classification of Ear Problems

 ACUTE EAR INFECTION

Pus is seen draining from the ear and discharge is reported for 14 days or more

 CHRONIC EAR INFECTION

NO ear pain and NO ear discharge seen draining from the ear

 NO EAR INFECTION
CHECKING FOR MALNUTRITION

Identifying children with malnutrition and treating them can help prevent many severe diseases
and death. Some malnutrition cases can be treated at home. Severe cases need referral to hospital
for systemic antibiotic therapy, treatment and prevention of complications, special feeding or
specific treatment of a disease contributing to malnutrition (such as tuberculosis).

After assessing for general danger signs and the four main symptoms, all children should be
assessed for malnutrition

There are two main reasons for routine assessment of nutritional status in sick children:

(1) To identify children with severe malnutrition who are at increased risk of mortality and
need urgent referral to provide active treatment
(2) To identify children with sub-optimal growth (stunting) resulting from ongoing deficits in
dietary intake plus repeated episodes of infection and who may benefit from nutritional
counseling and resolution of feeding problems.

CLASSIFICATION OF NUTRITIONAL STATUS

Using a combination of the simple clinical signs above, children can be classified in one of the
following categories:

 Children with SEVERE MALNUTRITION exhibiting visible severe wasting or oedema

of both feet are at high risk of death from various severe diseases and need urgent referral
to a hospital where their treatment can be carefully monitored.
 Children with VERY LOW WEIGHT for age also have a higher risk of severe disease
and should be assessed for feeding problems. This assessment should identify common,
important problems with feeding that can be corrected if the caretaker is provided
effective counseling and acceptable feeding recommendations based on the child’s age.
 Children who are not very low weight for age and who show no signs of severe
malnutrition are classified as having NOT VERY LOW WEIGHT. Because children less
than 2 years old have a higher risk of feeding problems and malnutrition than older
children do, their feeding should be assessed. If problems are
 Visible severe wasting or edema of both feet
CHECKING IMMUNIZATION, VITAMIN A AND FOLIC ACID SUPPLEMENTATION
STATUS

The immunization status of every sick child brought to a health facility should be checked.
Illness is not a contraindication to immunization. In practice, sick children may be even more in
need of protection provided by immunization than well children. A vaccine’s ability to protect is
not diminished in sick children.

After checking immunization status, determine if the child needs vitamin A supplementation
and/or prophylactic iron folic acid supplementation.

Illness is not a contraindication to immunization. A vaccine’s ability to protect is not diminished

in sick children.

TREATMENT PROCEDURES FOR SICK CHILDREN

IMNCI classifications are not necessarily specific diagnoses, but they indicate what action needs
to be taken. In the IMNCI guidelines, all classifications are color coded: pink calls for hospital
referral or admission, yellow for initiation of treatment, and green means that the child can be
sent home with careful advice on when to return. After completion of the assessment and
classification procedure, the next step is to identify treatment.

REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS

All infants and children with a severe classification (pink) are referred to a hospital as soon as
assessment is completed and necessary pre-referral treatment is administered.

Successful referral of severely ill children to the hospital depends on effective counselling of the
caretaker. If s/he does not accept referral, available options (to treat the child by repeated clinic
or home visits) should be considered. If the caretaker accepts referral, s/he should be given a
short, clear referral note, and should get information on what to do during referral transport,
particularly if the hospital is distant.
FREQUENCY AND PERCENTAGE DISTRIBUTION OF SAMPLES
UNDER STUDY:
Percentage distribution of age groups:

Age Frequency Percent

<20 year 0 0%
20-30 year 0 0%
30-40 year 1 25%
>40 year 3 75%

Age
3.5

3
3

2.5

Frequency
2
Percent

1.5

1
1
75%

0.5
25%
0 0% 0 0%
0
<20 year 20-30 year 30-40 year >40 year
Percentage distribution of religion:
Religion Frequency Percent
Hindu 3 75%
Muslim 0 0%
Christian 1 25%
Others 0 0%

Religion
3.5

3
3

2.5

2 Frequency
Percent

1.5

1
1
75%

0.5
25%
0 0% 0 0%
0
Hindu Muslim Christian Others
Percentage distribution of Educational status:

Educational status Frequency Percent

Primary 0 0%
Secondary 2 50%
Graduate 2 50%
Graduate and above 0 0%

Educational Status
Frequency Percent

2 2

50% 50%

0 0% 0 0%
Primary Secondary Graduate Graduate and above
Percentage distribution of marital status:

Marital Frequency Percent

Unmarried 0 0%
Married 4 100%
Divorce 0 0%
Widow 0 0%

Marital Status

3.5

2.5

1.5

0.5

0
Unmarried Married Divorce Widow

Frequency Percent
CONCLUSION:
 Most of are in the age group of >40 years.(75)
 Most of the samples are having secondary and graduate educational status. (50%)

Evaluation:
 Evaluation of in-service education was done by statistically analyzing pretest and
posttests score. Result showed improvement in knowledge of health worker among
guidelines of IMNCI.

PRETEST AND POST TEST SCORE ANALYSIS

TEST SCORE PERCENTAG MEAN MEAN DIFFERENCE

TYPE E
PRE TEST 20 0.8% 5

POST TEST 37 1.48% 9.25 4.25

RESULT: 
 The mean pre- test score was 5 & mean post test score was 9.25 with a mean difference
of 4.25.
 Hence the teaching program was found to be effective in improving the knowledge of
health workers regarding IMNCI guidelines

ACHIEVEMENTS
The following were the objectives that the students achieved during camp:

 Interactions with health worker and ANMs.

 Conduction of discussion and proving information with health worker and ANMs.
 Organized programs in Defence Colony Health Centre
 Prepared and submitted impact assessment reports
SUMMARY
We have discussed about components, its principle, its case management process, assessment of
young infant, checking possible sign of infection of different diseases, and management of that
disease.
CONCLUSION
The in-service education was a huge learning experience for us. The most important benefit of
the in-service education was that we learnt to work as a team. During this program we provide
information about the IMNCI and its guidelines. Ms. Alka Misha Public Health Nurse supervised
in planning to execution, gave necessary instruction in between assisted in in-service education.