|Year : 2007 | Volume
| Issue : 2 | Page : 108-110
Integrated management of neonatal and childhood illness: An overview
GK Ingle, Chetna Malhotra
Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Submission||22-Jul-2006|
G K Ingle
Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ingle G K, Malhotra C. Integrated management of neonatal and childhood illness: An overview. Indian J Community Med 2007;32:108-10
Annually, over 10 million children in low- and middle-income countries die before they reach their fifth birthday. Seven in ten under-five deaths in such countries are from illnesses such as diarrheal dehydration, acute respiratory infections, measles, malaria, and malnutrition. All these five conditions can either be treated or prevented.  Despite this, more than 25,000 under-five children die from these illnesses each day. Factors that contribute to illness are poor living conditions like lack of safe water supply, poor hygiene, overcrowding; inability of parents to recognize danger signs; and delay in seeking appropriate treatment. The problem is compounded by the poor quality of care provided at the health facilities.  Projections based on 1996 analysis in the Global Burden of Disease indicate that these conditions will continue to make major contributions to childhood mortality through the year 2020 unless significant greater efforts are made to control them. 
Children brought for medical treatment are often found suffering from more than one morbid condition, making a single diagnosis impossible. These children require a combined therapy for successful treatment. Thus, the need of the hour is an integrated strategy that combines the treatment of major childhood illnesses, with involvement of parents in provision of home-based care, prevention of disease through immunization, improved nutrition, and breast feeding. This integrated strategy led to the formation of "The Integrated Management of Childhood Illness (IMCI)" in 1992 by UNICEF and WHO. It was based on the rationale that decline in child mortality rates is not necessarily dependent on the use of sophisticated and expensive technologies but rather on a holistic approach that combines the use of strategies that are cheap and can be made universally available and accessible to all.  According to the World Bank Report 1993, for situations where laboratory support and clinical resources are limited, such an approach is more realistic and cost-effective, and therefore, has the potential to make the greatest impact on the global burden of disease.  An evaluation of IMCI strategy in 12 countries over the world revealed that the training of healthcare workers improved the quality of care significantly. For example, in Tanzania, IMCI was associated with a 13% reduction in under-five mortality over a two-year period and stunting was reduced significantly. In Bangladesh, the utilization of government facilities improved substantially due to its availability. This strategy has now been implemented in more than 100 countries. 
In India, there are nearly 17 lakh child deaths each year, and child mortality rates are one of the highest in the world. The Government of India recognized the need to strengthen child-health activities in the country and decided to launch IMCI. A core group was constituted comprising representatives from Indian Academy of Paediatric (IAP), National Neonatology Forum of India (NNF), National Anti-Malaria Program (NAMP), Department of Women and Child Development (DWCD), Child-in Need Institute (CINI), WHO, UNICEF, eminent Pediatricians and Neonatologists and the representatives from the Ministry of Health and Family Welfare (MOHFW), and the Government of India. The generic IMCI guidelines were adapted and the Indian version was named Integrated Management of Neonatal and Childhood Illness (IMNCI). The major adaptations were as follows:
i) The entire age group of 0 to 59 months (as against 2 weeks to 59 months in IMCI) was included to address the neonatal mortality challenge.
ii) The order of training was reversed, starting from the young infant (0-2 months) to the older child (2 months-5 years).
iii) 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, which contributes to a lot to the mortality rate.
iv) Home-based care of newborns and young infants was included.
The management guidelines were made consistent with the current policies of MOHFW, DWCD, and NAMP.  Separate training material, e.g., training module, chart booklet, photo booklet, and video was developed for the health and nutrition workers and for the physicians. The training material for the health workers was also translated in Hindi, Marathi, Gujarati, and Tamil. 
The major objectives of IMNCI strategy are to reduce mortality and the frequency and severity of illness and disability and contribute to improve growth and development during the first five years of a child's life. The guidelines represent an evidence-based, syndromic approach of case management that includes rational, effective, and affordable use of drugs and diagnostic tools. The syndromic approach is used to determine the health problem(s) of the child, severity of child's condition, and the actions taken. It also promotes the adjustment of interventions to the capacity of the health system and the active involvement of family members and the community in the health care process. 
IMNCI includes both preventive and curative interventions. The strategy has the following three components: 
- Health-worker component: Improvements in the case-management skills of health staff through the provision of locally adapted guidelines
- Health-service component: Improvements in the overall health system required for effective management of neonatal and childhood illness
- Community component: Improvements in family and community health care practices.
IMNCI does not imply that the health workers will not treat individual diseases. Rather, it implies that the workers will broaden their approach to consider and respond to the child and manage the different factors that could be contributing to child's sickness. These guidelines recommend standardized case management procedures based on two age categories: (i) upto 2 months and (ii) 2 months to 5 years. 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: "pink" suggests hospital referral or admission, "yellow" indicates initiation of treatment, and "green" calls for home treatment. A sick young infant up to 2 months of age is assessed for possible bacterial infection, jaundice, and diarrhea. A sick child aged 2 months to 5 years is assessed for general danger signs and major symptoms like cough or difficult breathing, diarrhea, fever, and ear problems. All the children are also routinely assessed for nutritional and immunization status, feeding problems, and other potential problems. 
The management procedures in IMNCI involve the use of only a limited number of essential drugs in order to promote their rational use. The mother is given clear instructions on how to give oral drugs and to treat the child at home when hospital admission is either not required or is not possible. She is also directed to return for follow-up visits as per the IMNCI protocol. 
The IMNCI strategy provides for home-based care for newborns and young infants. The home care component for newborns aims to promote exclusive breast feeding, prevent hypothermia, improve recognition of illnesses by parents, and reduce delays in seeking care. As per the IMNCI protocol, a health worker has to make at least three home visits for all newborns, the first visit should be within 24 hrs of birth, second on day 3-4 and third at day 7-10. Three additional visits are scheduled for newborns with low birth weight at day 14, 21, and 28. 
IMNCI strategy promotes the accurate identification of childhood illnesses in outpatient setting and ensures appropriate combined treatment of all major illnesses, strengthens counseling of caretakers, and speeds up the referral of severely-ill children. At a referral facility, the strategy aims to improve the quality of care provided to sick children. In the home setting, it promotes appropriate care-seeking behaviors, improved nutrition and preventive care, and the correct implementation of recommended care. 
In India, IMNCI is a component of the World Bank-supported Reproductive and Child Health (RCH) II program. It is being implemented through a joint effort of UNICEF, National Rural Health Mission (NRHM), Government and other child survival partners. IMNCI was first piloted in six districts from end of 2002 to 2004. For training the physicians, the first training of trainers (TOT) was carried out for three batches at Kalawati Saran Child Hospital, Delhi and for two batches in Vellore district. For conducting the training of workers, TOT was conducted in Jhalawar, Valsad, and Vellore districts. The health and nutrition workers of one primary health center (PHC) of Osmanabad and two sub-centers of Shivpuri were also trained. Implementation of IMNCI has been initiated in the states and union territories of Delhi, Gujarat, Haryana, Jharkahand, Madhya Pradesh, Maharashatra, Nicobar Islands, Orissa, Rajasthan, Tamil Nadu, and Uttaranchal. IMNCI training for undergraduate medical students has been introduced in five medical schools. The National Institute of Public Cooperation and Child Development (NIPCCD), India, has also introduced IMNCI in the pre-service curriculum of Integrated Child Development Services (ICDS) workers. The faculty of the Council for Technical Education and Vocational Training-the apex national institution responsible for training paramedical staff-were trained in IMNCI. The Indira Gandhi National Open University has also included IMNCI in distance learning courses for doctors and paramedics. Collaboration with Emergency and Humanitarian Action Unit has resulted in the production of an orientation package on IMCI for health workers who provide health care to children in disaster situations.  IAP has now formed the IAP National Task Force in HIV/AIDS to look into the feasibility of adaptation of pediatric HIV care in IMNCI. 
The major strength of IMNCI strategy is that it makes use of evidence-based management decisions like oral rehydration therapy for diarrhea, childhood vaccinations to reduce deaths due to diphtheria, pertussis, and measles and antibiotic treatment for pneumonia. Other strong points of IMNCI are the hands-on clinical training for 50% of training time, feasibility of its incorporation into pre-service education and in service training, focus on communication and counseling skills, and locally adapted recommendation for infant and young child feeding. By improving the coordination and quality of services provided by existing child health and other programmes, the IMNCI strategy will increase the effectiveness of care and simultaneously reduce the cost. IMNCI has the potential of lowering the burden on hospitals, particularly, in urban areas where access to care is not a limiting factor. It offers a model for improving one aspect of service delivery that could be applied to other aspects of health care. On the other hand, a critical appraisal of IMNCI revealed that it has failed to address the key issues of safe home delivery, training of traditional birth attendants, creating facilities for a triage system at primary, secondary, and tertiary care levels, a referral system with linkages between these levels, care of newborn at birth and childhood injuries.  There is also a need to evaluate the content, duration, and period of training of IMNCI.
The major challenges before IMNCI are the feasibility of provision of health care using IMNCI at sub-center and village level by ANMs and Anganwadi workers (AWWs) considering the irregular supply of drugs and logistics, lack of proper supervision, sustaining what is initiated through indicator-based monitoring, making home-based care of young infants operational by ANMs and AWWs and a high staff turnover. An assessment of the effectiveness of IMNCI was initiated in 2005 by Government of India and WHO. 
The program aims to reach out to 1 million people and provide a comprehensive newborn and child care package at all levels of care in 250 of the country's 602 districts by 2010.  At the sub-center level, it shall be implemented through ANMs; at PHCs, through medical doctors, nurses, and Lady Health Visitors; at First Referral Units, through medical officers and nurses; and at the village/household level through the AWWs. 
Thus, IMNCI offers a strategy for improving the state of health of children in India. This approach could help the country in achieving the Millennium Development Goals of reducing the under-five mortality.
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