3. Integrated Management of Childhood Illness (IMCI)

3.2. Cough and Difficult Breathing

When a child presents with cough, the parent is asked about the presence of fast breathing. Fast breathing results when lung compliance is reduced by infiltrate or consolidation associated with pneumonia or bronchiolitis. Research has established respiratory rate (breaths per minute) thresholds for fast breathing: 60 in an infant up to 2 months, 50 in child 2 months to 12 months, and 40 in a child 12 months to 5 years. When the child is calm, respirations should be counted for 1 minute. One minute timers are available to facilitate the accurate counting of breaths/minute. Subcostal chest indrawing (retractions) is associated with decreased oxygen saturation that affects the central nervous system respiratory drive center, which controls the force of the diaphragm. In addition to checking for fast breathing and chest indrawing, it is important to listen for stridor and wheezing. The child is classified having severe pneumonia or another very severe disease (PINK) if there is any general danger sign or stridor in a calm child. This child needs to be referred urgently to the hospital and receive a first dose of an antibiotic. If the child has fast breathing and or chest indrawing , the child is classified as having pneumonia (YELLOW) and is given oral amoxicillin (or an appropriate alternative) for 5 days. Wheezing children are given a trial with a rapid acting bronchodilator for up to 3 times. Children without any signs of pneumonia or danger signs are classified as having an upper respiratory infection or cold (GREEN) and receive home care with a safe cough remedy. If their wheezing responded to a therapeutic rapid acting bronchodilator trial they are given a rapid acting bronchodilator for 5 days. (See IMCI chart for cough or difficult breathing in the appendix.)

Diarrhea

When a child presents with diarrhea, the classification of severity is based on whether there is blood in the stool, how long the child has had diarrhea, and the presence of the following clinical signs: unconscious, lethargy, restless, irritable, sunken eyes, ability and way of drinking, skin turgor. These signs are used to classify the severity of dehydration. IMCI management of diarrhea is reviewed in module 6.

Fever and Measles

When a child presents with fever by history or a temperature higher than 37.5 C., the severity classification is based on the duration of the fever, whether the child had measles within the past 3 months, and the following signs: a stiff neck, runny nose, any bacterial cause of the fever, signs of measles. The classification takes into account whether the child lives in an area with malaria and if the child now has measles or had within the last 3 months. The management of malaria and measles is reviewed later in this module. (See IMCI chart for fever in the appendix)

Ear infection

When a child presents with ear pain or ear discharge the classification considers if there is tender swelling behind the ear suggesting mastoiditis. A child with mastoiditis is classified as PINK and referred urgently to a hospital with the first dose of an appropriate antibiotic. Acute ear pain or ear discharge is considered yellow and the ear infection is treated with an antibiotic for 5 days. When the ear drainage has lasted more than 14 days the ear infection has become chronic and is managed by ear wicking and topical quinolone eardrops for 14 days. (The IMCI chart on ear infection is found in the appendix)

Malnutrition and Anemia

The child is assessed for acute malnutrition based on finding edema of both feet, the weight for length percentile ( Z score) using WHO growth standards and the mid upper arm circumference for children older than 6 months. Anemia is recognized by palmar pallor. The severity classification is made on the basis of these findings plus the presence of any medical problem/complication identified earlier in the IMCI decision making process. The IMCI management of malnutrition and anemia is reviewed in module 8.

HIV infection

In areas of the world with a high prevalence of HIV infection, IMCI checks for a possible HIV infection noting the mother and child’s HIV status ( virology test and serology test). The IMCI approach to HIV infection is reviewed later in this module.

Immunization Status, Feeding and Mother’s Health

IMCI then checks the child’s immunization status and assesses feeding if the child is less than 2 years old.

Other Problems

Asking about other parental concerns and problems is helpful. Mother’s health is always valuable as this has a direct impact on the child’s health.