Introduction And Rationale
- Definition: IMNCI is an integrated approach to child health that focuses on the well-being of the whole child, rather than a single disease entity. It is a syndromic case management approach developed by WHO and UNICEF, designed to reduce death, illness, and disability, and to promote improved growth and development among children under five years of age.
- Core Rationale: In developing countries, the majority of childhood deaths are caused by five preventable/treatable conditions: acute respiratory infections (pneumonia), diarrhea, measles, malaria, and malnutrition. Children often present with overlapping signs and symptoms (e.g., a child with malaria and pneumonia simultaneously), making single-disease diagnosis difficult for frontline workers. IMNCI provides an evidence-based, syndromic triage system.
Differences Between Generic WHO IMCI And Indian IMNCI
The Government of India adapted the generic IMCI to suit the national epidemiological profile, creating IMNCI. Key Indian adaptations include:
- Inclusion Of Early Neonatal Period: Generic IMCI covers children 1 week to 5 years. Indian IMNCI covers infants from 0 days to 2 months (Young Infant) and 2 months to 5 years (Child). This was crucial because over 50% of infant mortality in India occurs in the neonatal period.
- Addition Of Malaria And Anemia: Aligned with the National Vector Borne Disease Control Programme (NVBDCP) guidelines.
- Dengue Hemorrhagic Fever: Added to the algorithm due to endemicity.
- Malnutrition Assessment: Integrated with the use of MUAC (Mid-Upper Arm Circumference) and WHO Z-score growth charts.
- Management Of Young Infants: Expanded to include comprehensive assessment of bacterial infections, jaundice, and breastfeeding counseling.
The Case Management Process
The IMNCI strategy utilizes a sequential, structured case management process for every sick child:
- Assess: Take a history, check for danger signs, and perform a focused physical examination (Ask, Look, Listen, Feel).
- Classify: Based on the presence or absence of specific signs, classify the illness into color-coded categories.
- Identify Treatment: Determine the specific treatments needed for the classification.
- Treat: Administer pre-referral drugs, perform procedures, or teach the mother how to give treatment at home.
- Counsel The Mother: Provide advice on feeding, fluids, and when to return immediately.
- Follow-up: Reassess the child at specified intervals.
Color Coding And Triage System
IMNCI uses a universal three-tier color-coded triage system to guide immediate action.
| Color Code | Urgency | Action Required |
|---|---|---|
| PINK (Severe) | Urgent | Requires Urgent Referral to a higher facility. Administer pre-referral treatment (e.g., first dose of antibiotics, prevention of hypoglycemia) before transfer. |
| YELLOW (Moderate) | Action | Specific medical treatment and advice. Can be managed at the Outpatient/PHC level with prescribed oral drugs and close follow-up. |
| GREEN (Mild) | Safe | Simple advice and home care. Management by the caregiver at Home. |
Part 1: Management Of The Sick Young Infant (0 Up To 2 Months)
The assessment of the young infant involves checking for Possible Severe Bacterial Infection (PSBI), jaundice, diarrhea, and feeding problems.
1. Assess For Possible Severe Bacterial Infection (PSBI)
Signs to Assess: Convulsions, Fast breathing (≥60 breaths per minute), Severe chest indrawing, Nasal flaring, Grunting, Bulging fontanelle, 10 or more skin pustules OR a large pustule, Umbilical redness extending to the skin, Temperature >37.5°C (fever) or <35.5°C (hypothermia), Lethargic or unconscious, Less than normal movement.
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Any one of the signs of PSBI present. | POSSIBLE SEVERE BACTERIAL INFECTION (PSBI) | - Give first dose of Intramuscular (IM) Ampicillin and Gentamicin. - Treat to prevent hypoglycemia. - Keep infant warm. - Refer URGENTLY to hospital. |
| Umbilical redness or draining pus OR < 10 skin pustules. | LOCAL BACTERIAL INFECTION | - Give oral Amoxicillin for 5 days. - Teach mother to treat local infections at home. - Follow up in 2 days. |
| None of the above signs. | SEVERE INFECTION UNLIKELY | - Advise mother on home care. - Advise when to return immediately. |
2. Assess For Jaundice
Signs to Assess: Yellowing of skin or eyes, timeline of onset (first 24 hours vs. later), extent of jaundice (palms and soles).
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Jaundice appears in first 24 hours of life OR Yellow palms and soles at any age. | SEVERE JAUNDICE | - Treat to prevent hypoglycemia. - Keep infant warm. - Refer URGENTLY to hospital. |
| Jaundice appears after 24 hours of age AND palms and soles are NOT yellow. | JAUNDICE | - Advise mother on home care and frequent breastfeeding. - Follow up in 2 days. - If >14 days old, refer to hospital for prolonged jaundice assessment. |
| No jaundice. | NO JAUNDICE | - Advise on home care. |
3. Assess For Diarrhea In Young Infant
Signs to Assess: Lethargy/unconsciousness, sunken eyes, skin pinch return time.
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Two of: Lethargic/unconscious, Sunken eyes, Skin pinch goes back very slowly (>2 secs). | SEVERE DEHYDRATION | - If facility has IV capabilities, start IV fluids (Plan C). - If not, refer URGENTLY with mother giving frequent sips of ORS on the way. |
| Two of: Restless/irritable, Sunken eyes, Skin pinch goes back slowly. | SOME DEHYDRATION | - Treat with ORS (Plan B). - Reassess after 4 hours. - Advise to continue breastfeeding. |
| Not enough signs to classify as some or severe. | NO DEHYDRATION | - Give fluid and food to treat diarrhea at home (Plan A). - Advise when to return. |
4. Assess Feeding Problem Or Malnutrition
Signs to Assess: Difficulty feeding, breastfed <8 times in 24 hours, receiving other foods/drinks, low weight for age, thrush (ulcers/white patches in mouth). Check attachment (chin touching breast, mouth wide open, lower lip turned outward, more areola visible above than below). Check suckling (slow, deep sucks with pauses).
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Not attached well OR Not suckling effectively OR <8 breastfeeds/24 hrs OR receives other foods/drinks OR Low weight for age OR Thrush. | FEEDING PROBLEM OR LOW WEIGHT | - Counsel mother on correct positioning and attachment. - Advise on increasing frequency to ≥8 times/24 hours. - Treat thrush with Nystatin or Gentian Violet. - Follow up in 2 days for feeding problem or 14 days for low weight. |
| No feeding problem AND Weight for age is not low. | NO FEEDING PROBLEM | - Praise the mother. - Advise on exclusive breastfeeding. |
Part 2: Management Of The Sick Child (2 Months Up To 5 Years)
1. Check For General Danger Signs
Before assessing specific symptoms, ALWAYS check for General Danger Signs. The presence of ANY general danger sign automatically classifies the child into a PINK (Urgent Referral) category.
- Lethargic or unconscious.
- Convulsions (current or history during this illness).
- Unable to drink or breastfeed.
- Vomits everything.
2. Assess Cough Or Difficult Breathing
Signs to Assess: Count respiratory rate for one full minute. Look for chest indrawing. Listen for stridor or wheeze. Fast Breathing Cut-offs:
- 2 months up to 12 months: ≥50 breaths per minute.
- 12 months up to 5 years: ≥40 breaths per minute.
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Any general danger sign OR Chest indrawing OR Stridor in a calm child. | SEVERE PNEUMONIA OR VERY SEVERE DISEASE | - Give first dose of appropriate antibiotic (IM Ampicillin/Gentamicin or Oral Amoxicillin depending on severity). - Prevent hypoglycemia. - Refer URGENTLY to hospital. |
| Fast breathing. | PNEUMONIA | - Give oral Amoxicillin for 5 days. - Soothe the throat and relieve cough. - Advise when to return immediately. - Follow up in 2 days. |
| No signs of pneumonia or very severe disease. | NO PNEUMONIA: COUGH OR COLD | - If wheezing, give trial of rapid-acting bronchodilator. - Soothe the throat and relieve cough with a safe remedy. - Follow up in 5 days if not improving. |
3. Assess Diarrhea
Signs to Assess: Duration (>14 days = persistent), blood in stool (dysentery), lethargy, sunken eyes, thirst (drinks eagerly vs. unable to drink), skin pinch.
Dehydration Classification
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Two of: Lethargic/unconscious, Sunken eyes, Unable to drink/drinks poorly, Skin pinch very slow. | SEVERE DEHYDRATION | - Give IV fluids for severe dehydration (Plan C). - If cholera in area, give antibiotic for cholera. |
| Two of: Restless/irritable, Sunken eyes, Drinks eagerly/thirsty, Skin pinch slow. | SOME DEHYDRATION | - Give fluid, zinc supplements, and food (Plan B). - Reassess after 4 hours. |
| Not enough signs for severe or some dehydration. | NO DEHYDRATION | - Give extra fluid and food to treat diarrhea at home (Plan A). - Give Zinc supplements for 14 days. |
Persistent Diarrhea And Dysentery
- Diarrhea lasting ≥ 14 days AND Dehydration present: SEVERE PERSISTENT DIARRHEA (Refer Urgent).
- Diarrhea lasting ≥ 14 days AND NO Dehydration: PERSISTENT DIARRHEA (Advise on feeding, multivitamin, follow up 5 days).
- Blood in stool: DYSENTERY (Give oral Ciprofloxacin/appropriate antibiotic for Shigella for 3 days, follow up 2 days).
4. Assess Fever
Signs to Assess: History of fever (or feels hot/temp >37.5°C), duration of fever, malaria risk in the area. Look for stiff neck. Look for signs of Measles (generalized rash AND one of: cough, runny nose, red eyes). Look for Dengue (bleeding from nose/gums, skin petechiae, positive tourniquet test).
Fever Classification (High/Low Malaria Risk)
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Any general danger sign OR Stiff neck. | VERY SEVERE FEBRILE DISEASE | - Give first dose of IM Artesunate (if malaria positive/high risk). - Give first dose of appropriate antibiotic. - Prevent hypoglycemia. - Refer URGENTLY. |
| Positive Blood Smear/RDT OR High Malaria Risk (without danger signs). | MALARIA | - Give oral antimalarial (ACT). - Give Paracetamol for fever >38.5°C. - Follow up in 3 days if fever persists. |
| Negative Blood Smear/RDT OR Low Malaria Risk AND No runny nose/measles/other cause. | FEVER - MALARIA UNLIKELY | - Give Paracetamol for high fever. - Advise when to return immediately. - Follow up in 3 days if fever persists. |
Measles Classification (If Rash Present)
- Any general danger sign OR clouding of cornea OR deep/extensive mouth ulcers: SEVERE COMPLICATED MEASLES (Give Vitamin A, first dose antibiotic, Apply Tetracycline eye ointment, Refer URGENTLY).
- Pus draining from eye OR mouth ulcers: MEASLES WITH EYE OR MOUTH COMPLICATIONS (Give Vitamin A, treat eye/mouth, follow up 3 days).
- Measles now or within last 3 months (no complications): MEASLES (Give Vitamin A).
Dengue Assessment (If Fever >2 days in Endemic Area)
- Bleeding from nose/gums OR petechiae OR persistent vomiting OR abdominal pain OR cold/clammy skin: SEVERE DENGUE (Give ORS, prevent hypoglycemia, Refer URGENTLY).
- Positive tourniquet test without bleeding: SUSPECTED DENGUE (Give Paracetamol, strictly avoid NSAIDs/Aspirin, follow up daily).
5. Assess Ear Problem
Signs to Assess: Ear pain, ear discharge (duration <14 days or ≥14 days), tender swelling behind the ear (mastoiditis).
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Tender swelling behind the ear. | MASTOIDITIS | - Give first dose of antibiotic. - Give Paracetamol for pain. - Refer URGENTLY. |
| Pus seen draining from ear for < 14 days OR Ear pain. | ACUTE EAR INFECTION | - Give oral antibiotic for 5 days. - Give Paracetamol for pain. - Dry the ear by wicking. - Follow up in 5 days. |
| Pus seen draining from ear for ≥ 14 days. | CHRONIC EAR INFECTION | - Dry the ear by wicking. - Treat with topical Quinoline drops. - Follow up in 5 days. |
| No ear pain and no pus. | NO EAR INFECTION | - No specific treatment. |
6. Assess Malnutrition And Anemia
Signs to Assess: Visible severe wasting, Edema of both feet, MUAC (Mid-Upper Arm Circumference), Weight-for-height/Weight-for-age Z-scores, Palmar pallor.
| Signs Present | Classification | Action/Treatment |
|---|---|---|
| Visible severe wasting OR Edema of both feet OR MUAC < 11.5 cm OR WFH < -3 SD. | SEVERE ACUTE MALNUTRITION (SAM) | - If complications present / failed appetite test: Refer URGENTLY to NRC. - If no medical complications: Manage in community with RUTF, Amoxicillin, follow up weekly. |
| MUAC 11.5 cm to < 12.5 cm OR WFH -3 SD to -2 SD. | MODERATE ACUTE MALNUTRITION (MAM) | - Assess feeding and counsel. - Provide supplementary nutrition. - Follow up in 14 days. |
| Severe palmar pallor. | SEVERE ANEMIA | - Refer URGENTLY to hospital for blood transfusion assessment. |
| Some palmar pallor. | ANEMIA | - Give Iron and Folic Acid (IFA) drops/syrup. - Give Albendazole if child > 1 year. - Follow up in 14 days. |
Pre-Referral Treatment Principles
When a child is classified in the PINK category, immediate life-saving interventions must be provided before transfer to prevent mortality during transit.
- First Dose of Appropriate Antibiotic: Usually IM Ampicillin + Gentamicin for infants, or IM Ceftriaxone.
- Prevention of Hypoglycemia: Administer 50 ml of 10% Glucose solution or breastmilk orally/via NG tube.
- Artesunate: IM Artesunate for severe febrile illness in high-risk malaria areas.
- Diazepam/Midazolam: PR Diazepam or IM Midazolam for actively convulsing children.
- Vitamin A: Immediate dose for severe complicated measles or severe malnutrition with eye signs.
Counseling The Mother
IMNCI places heavy emphasis on empowering the caregiver. Counseling encompasses:
- Assess the Child’s Feeding: Ask about breastfeeding frequency, complementary foods (consistency, frequency, active feeding).
- Feeding Recommendations: Promote exclusive breastfeeding up to 6 months, and introduction of nutrient-dense complementary foods at 6 months while continuing breastfeeding up to 2 years.
- Fluid Requirements During Illness: Advise the mother to increase fluid intake (including breastmilk) to prevent dehydration.
- When to Return Immediately:
- Any sick child: Not able to drink/breastfeed, becomes sicker, develops a fever.
- Child with Cough: Develops fast breathing or difficult breathing (chest indrawing).
- Child with Diarrhea: Blood in stool or drinking poorly.
Follow-Up Guidelines
Crucial for cases classified as YELLOW.
- 2 Days: Pneumonia, Dysentery, Malaria (if fever persists), Local bacterial infection, Feeding problem.
- 3 Days: Measles with eye/mouth complications.
- 5 Days: Persistent diarrhea, Acute ear infection, Cough/cold not improving.
- 14 Days: Malnutrition (MAM), Anemia, Low weight for age.
F-IMNCI (Facility Based IMNCI) Integration
While IMNCI is designed for outpatient and peripheral centers, F-IMNCI is the protocol for inpatient hospital management of children referred with PINK classifications. It details:
- Emergency Triage Assessment and Treatment (ETAT): Sorting patients into Emergency signs (ABCDE approach), Priority signs, and Non-urgent cases.
- Inpatient Management: Standardized protocols for treating severe pneumonia, SAM with medical complications (at NRCs), severe malaria, and neonatal sepsis in the ward setting.