The Case Management Process

IMCI categorizes children into two groups for management purposes:

• Sick Young Infants (1 week to 2 months): IMCI primarily focuses on infants in this age range. Newborns under one week old are typically excluded as their illnesses are often related to factors during pregnancy, labor, and delivery, which require different management approaches.

• Sick Children (2 months to 5 years): This category encompasses children from two months up to their fifth birthday.

IMCI is specifically designed for use by healthcare providers (including doctors and nurses) who are working in primary healthcare settings such as clinics, health centers, or outpatient departments of hospitals, to manage sick children and infants.

The IMCI case management process involves a series of key steps:

1. Assessment of the Child/Young Infant: This involves gathering the child’s medical history and conducting a physical examination to understand their condition.

2. Illness Classification: Based on the assessment, the healthcare provider determines the severity of the illness and assigns it to a specific category of classification. This classification reflects the urgency and type of care needed.

3. Treatment Identification: Once the illness is classified, the appropriate treatment strategy is identified based on IMCI guidelines.

4. Treatment Administration: The identified treatment is then provided to the child or young infant.

5. Maternal Counseling: Crucially, the mother or caregiver receives counseling on how to care for the child, administer any home treatments, and recognize danger signs.

6. Follow-up Care Planning: Arrangements for follow-up care are made to monitor the child’s progress and address any ongoing issues.

Assessing the child involves history taking and physical examination to get a complete picture of the child’s health status.

Classifying the illness is about determining the seriousness of the condition. It’s a decision-making process where the healthcare provider selects a classification category that reflects the disease’s severity. It is important to note that these classifications are not specific diagnoses. Instead, they guide treatment decisions. For example, “severe febrile disease” is a classification that could encompass conditions like cerebral malaria, meningitis, or septicemia. The recommended treatment for this classification is designed to address all potential underlying causes.

Steps in Integrated Case Management according to IMCI guidelines:

STEP 1: ASSESS

The ‘Assess’ section within the IMCI chart booklet guides healthcare workers on how to effectively take a patient’s history and conduct a physical examination.

• Establish effective communication with the child’s mother or caregiver to gather accurate information.

• Initially, screen for general danger signs. These are indicators of potentially life-threatening conditions that require immediate attention.

• Ask specific questions focusing on common childhood illnesses such as diarrhea, pneumonia, and fever.

• If any danger signs or positive responses to specific questions are identified, prioritize a focused physical examination to detect life-threatening illnesses.

• Evaluate the child’s nutritional and immunization status to identify any related needs.

• The assessment should be comprehensive, including checks for other health problems beyond the primary complaint.

STEP 2: CLASSIFY

The ‘Classify’ section (often labeled ‘signs and classify’) in the IMCI chart provides a list of clinical signs of various illnesses alongside their corresponding classifications. “Classify” here means the health worker needs to decide on the severity of the illness based on observed signs and symptoms.

• Based on the assessment findings, classify each of the child’s illnesses using a specially designed color-coded triage system.

• Because children frequently present with multiple health issues, each identified condition is classified to indicate the required level of care:

COLOUR CLASSIFICATION

• PINK: Indicates a severe classification. Requires urgent admission to hospital or pre-referral treatment followed by immediate referral to a higher-level facility.

• YELLOW: Indicates a classification that requires specific medical treatment at the health facility and advice to the caregiver on home care.

• GREEN: Indicates a non-serious classification. In most cases, medications are not needed. Focus is on providing simple advice on home management to the caregiver.

STEP 3: IDENTIFY TREATMENT

The ‘Identify Treatment’ section assists healthcare providers in quickly and accurately determining the appropriate treatments for each identified classification.

• If a child or young infant has multiple classifications, it’s essential to consult multiple treatment tables within the IMCI guidelines to ensure all conditions are addressed appropriately.

COLOUR CLASSIFICATION

• PINK: For children requiring urgent referral, determine and administer essential pre-referral treatment to stabilize the child’s condition before transfer.

• YELLOW: For children needing specific treatment at the facility, develop a treatment plan, identify necessary medications for clinic administration, and determine the essential advice to provide to the mother or caregiver for ongoing care.

• GREEN: If no serious conditions are classified (green), concentrate on delivering appropriate advice to the mother or caregiver regarding actions needed for the child’s care at home.

STEP 4: TREAT

The ‘Treat’ section details how to implement the treatments identified for each classification. ‘Treat’ encompasses administering treatments within the healthcare facility, prescribing medications or other treatments for home use, and importantly, educating the mother/caregiver on how to correctly administer home treatments.

COLOUR CLASSIFICATION

• PINK: When a child or young infant needs hospital admission or referral, it is crucial to administer essential treatment before the admission or referral process to improve their condition en route.

• YELLOW: If specific treatment is required, create a treatment plan, administer the necessary medications at the facility, advise on treatment to be given at home, and provide thorough counseling to the mother/caregiver.

• GREEN: When the classification is green and no serious conditions are present, the primary action is to advise the mother/caregiver on appropriate home care practices for the child.

STEP 5: COUNSEL

• If follow-up care is necessary, clearly instruct the mother/caregiver on when to return to the clinic for a follow-up appointment. Also, thoroughly educate them on danger signs – indications that necessitate immediately bringing the child or young infant back to the facility.

• Conduct an assessment of the child’s feeding practices, with a focus on breastfeeding, and provide counseling to address any identified feeding problems. This step also includes offering counseling to the mother about her own health and well-being.

STEP 6: FOLLOW-UP

• Certain children or young infants may require more than one visit for the same illness. Identify these individuals and ensure they are brought back for appropriate follow-up care as indicated in the IMCI guidelines. During follow-up visits, re-assess the child or young infant for any new health concerns that may have arisen.

The IMCI guidelines are also designed to empower healthcare workers to:

• Recognize children who need additional follow-up visits to monitor their recovery.

• Deliver appropriate follow-up care based on specific guidance within the IMCI protocols.

• Provide effective counseling to mothers regarding their own health needs and well-being.

• Offer counseling on preventative and treatment measures to promote ongoing child health.

• When necessary, re-evaluate the child for any new health issues that may have emerged since the initial consultation.