Integrated management of neonatal and childhood illnesses (IMNCI)
Mukesh Agrawal
is a novel healthcare strategy, developed by WhO in consultation with UNICEF and other international agencies in mid-1990s, to facilitate early diagnosis, appropriate case management and timely referral of sick children at primary health care level, as well as to ensure basic preventive interventions.
Need: Experience and available data shows that:
• Acute respiratory infections, diarrhoea, infections, e.g. measles or malaria, and malnutrition account for ~3/4th cases of morbidity and mortality in under-5 children in developing countries.
• Since clinical features of these diseases often overlap and most of them are interrelated, arriving at a single diagnosis is neither easy nor desirable from the treatment point of view.
• Effective and simple interventions are available to manage most of these conditions, e.g. ORS, etc.
Concept: IMNCI is a move away from 'single disease' diagnosis to a 'holistic or syndromic' approach, different from conventional approach on following grounds:
• Holistic: IMNCI stresses on assessment of child as a whole, rather than for specific diseases.
• Clinical: A sick child is assessed on the basis of simple clinical signs for primary problems and their severity, rather than by elaborate laboratory workup.
• Syndromic: Considering usual presence of coexisting problems, illness is considered as a syndrome rather than specific diagnosis.
• Simple therapeutic interventions based on preevaluated protocols are used to manage these children.
Objectives: IMNCI aims to:
• Reduce under-5 morbidity and mortality, specially in developing and resource-limited countries.
• Address overall health of child rather than a single disease, to avoid duplication of efforts and wastage of resources.
Components: Major emphasis under IMNCI is on development of cases management skills of health staff and improvement in community health care practices.
Important components of IMNCI are:• Development of standard case management guidelines for detection of common health problems and their severity, based on simple clinical signs and empirical treatment protocols.
• Adoption of these guidelines after suitable modifications according to local disease patterns, community health care practices and resources.
• Training of field health staff to effectively implement these guidelines in practice and provide them with course material/public education material.
• Ensuring regular supply of common drugs and basic equipments at field level.
• Improvement of quality-care at referral centers.
• Maintenance of case-management skills with periodic trainings, checks and supervision.
• Follow-up evaluation for lacunae in approach and implementation (a continuous process).
General process: Important steps in IMNCI case management process for sick children, brought at first level health care facility are as follows (Fig. 29.1).
a. Assessment of the child for danger signals, main symptoms, nutrition, immunization and other problems.
b. Classification of the illness in order to determine the treatment plan, using a color-coded triage system, i.e. pink for referral, yellow for treatment at primary health care facility and green for home management.
c. Referral of the seriously sick children to nearby higher health-center after necessary pre-referral treatment
d. Treatment of other cases with less severe illnesses at first-level health care facility or at home, along with counseling of caretaker regarding further treatment, follow-up and preventive interventions.
Considering variations in common health problems and reliability of common disease indicators in different age groups, separate sets of IMNCI case management guidelines have been recommended for—(a) sick children between 2 months up to 5 years of age, and (b) sick infants below 2 months of age.
WHO has revised these guidelines in 2014 and Government of India has adopted them since 2021, as discussed in following sections.
Integrated Management of Neonatal and Childhood Illnesses
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Fig. 29.1: The integrated case management process of IMNCI for child 2 months up to 5 years of age.