CB-IMNCI APPROACHES

INTRODUCTION
 CB-IMNCI is an integration of CB-IMCI and CB-NCP Programs as per the
decision of MOH on 2071/6/28 (October 14, 2015).
 This integrated package of child-survival intervention addresses the major
problems of sick newborn such as birth asphyxia, bacterial infection,
jaundice, hypothermia, low birth-weight, counseling of breastfeeding.
 It also maintains its aim to address major childhood illnesses like
Pneumonia, Diarrhea, Malaria, Measles and Malnutrition among under 5
year’s children in a holistic way.
 In CB-IMNCI program, FCHVs are expected to carry out health promotional
activities for maternal, newborn and child health and dispensing of essential
commodities like distribution of iron, zinc, ORS, chlorhexidine which do not
require diagnostic skills, and immediate referral in case of any danger signs
appeared among sick newborn and children.
 Health workers will counsel and provide the health services like
management of non-breathing cases, low birth weight babies, common
childhood illnesses, and management of neonatal sepsis.
 Also, the program has provisioned for the post-natal visits by trained health
workers through primary health care outreach clinic.
GOALS OF CB-IMNCI
 Improve newborn and child survival and healthy growth and development.
OBJECTIVES
 To reduce neonatal morbidity and mortality by promoting essential newborn
care services
 To reduce neonatal morbidity and mortality by managing major causes of
illness
 To reduce morbidity and mortality by managing major causes of illness
among under 5 years children.
  To reduce neonatal morbidity and mortality by promoting essential newborn
care services
 To reduce neonatal morbidity and mortality by managing major causes of
illness
 To reduce morbidity and mortality by managing major causes of illness
among under 5 years children.
TARGETS
 Reduction of Under-five mortality rate (per 1,000 live births) to 28 by 2020
 Reduction of Neonatal mortality rate (per 1,000 live births) to 17.5 by 2020

MAJOR INTERVENTION
Newborn Specific Interventions
 Promotion of birth preparedness plan
 Promotion of essential newborn care practice and postnatal care to mothers
and newborns
 Identification and management of non-breathing babies at birth
 Identification and management of preterm and low birth weight babies
 Management of sepsis among young infants (0-59days) including diarrhea
Child Specific Interventions
 Case management of children aged between 2-59 months for 5 major
childhood killer diseases
 (Pneumonia, Diarrhoea, Malnutrition, Measles and Malaria)
Strategies
1. Quality of care through system strengthening and referral services for
specialized care
2. Ensure universal access to health care services for new born and young infant
3. Capacity building of frontline health workers and volunteers
 4. Increase service utilization through demand generation activities
5. Promote decentralized and evidence-based planning and programming

VISION
CB-IMNCI vision to provide targeted services to 90% of the estimated
population by2020 as shown in the diagram below

APPROCHES
 Assess a child
 Classify a child’s illnesses
 Identify treatments for the child.
 Treatment instructions
 counsel the mother to solve any feeding problems and her own health
 When a child is brought back to the clinic give follow-up careand if
necessary, reassess the child for new problems
1.Assessment of child:
 A child by checking first for danger signs, asking questions about common
conditions, examining the child, and checking nutrition and immunization
status.
 Assessment includes checking the child for other health problems.
2. Classification of disease:
A child illness is classified using a color-coded triage system. Because many
children have more than one condition, each illness is classified according to
whether it requires:
 -urgent pre-referral treatment and referral {red},
or
 -Specific medical treatment and advice (yellow),
or
simple advice on home management (green).
3. Selection of treatment:
 identify Specific treatments for the child.
 If a child requires urgent referral, give essential treatment before the patient
is transferred.
 If a child needs treatment at home, develop an integrated treatment plan for
the child and give the first dose of drugs in the clinic.
 If a child should be immunized, give immunizations.
4. Health teaching/counselling:
 Provide practical treatment instructions, including teaching the mother how
to give oral drugs, how to feed and give fluids during illness, and how to
treat local infections at home.
 Give her health education and teach her hygienic practices.
 Ask the caretaker to return for follow-up on specific date, and teach her how
to recognize signs that indicate the child should return
immediately to the health facility.
 Assess feeding, including assessment of breastfeeding practices, and counsel
to solve any feeding problems found.
5. follow up services/visit
 When a child is brought back to the clinic as requested, give follow-up care
and, if necessary, reassess the child for new problems.

DIARRHOEA
 Diarrheal disease is the second leading cause of death in children under five
years old. It is both preventable and treatable.
 Each year diarrhea kills around 525 000 children under five.
 A significant proportion of diarrheal disease can be prevented through safe
drinking-water and adequate sanitation and hygiene.
 Globally, there are nearly 1.7 billion cases of childhood diarrheal disease
every year.
 Diarrhea is a leading cause of malnutrition in children under five years old.
 Diarrhea is defined as the passage of three or more loose or liquid stools per
day (or more frequent passage than is normal for the individual). Frequent
passing of formed stools is not diarrhea, nor is the passing of loose, "pasty"
stools by breastfed babies.
PLAN A – TREATMENT AT HOME

 Instruct mother to feed the baby frequently.

 Educate the mother to wash her hands before feeding her baby and after
cleaning soiled linen.
WHEN TO RETURN:
The mother should be asked to take the child to the health worker if the child
does not get better in 3 days or develop any of the following danger sign.
 Many watery stools
 Repeated vomiting
 Marked thirst, fever
 Eating or drinking poorly
 Blood in stool
PLAN B (SOME DEHYDRATION)
 All cases with obvious sign of dehydration need to be treated in a health
center or hospital.
 However oral fluid therapy should be commenced promptly and continue
during transport.
 It has following components:
 Correction of the existing water and electrolyte deficit as indicated by the
presence of sign of dehydration(rehydration therapy
 Replacement of ongoing losses due to continuing diarrhea to prevent
recurrence of dehydration (maintenance therapy)
PLAN B
MAINTENANCE THERAPY
 This begins when sign of dehydration disappears usually within 4 hours.
ORS should be administered in volume equal to diarrhea losses;
approximately 10-20 ml per kg body weight for each liquid stool.
 Offer plain water in between
 ORS is administered till diarrhea stops
 Breast feed even during rehydration and offer semi solid foods soon after
deficit replacement

PLAN C- SEVERE DEHYDRATION

TREATMENT FOR INFANTS (2MONTHS AND BELOW)
DOSAGE/AMPICILLIN DOSAGE
weight Ampicillin
(50 mg/kg – 250 mg vial)
1.3 ml distill water dissolve in 250 mg vial
1-< 1.5 kg 0.4 ml
1.5-<2 kg 0.5 ml
2-<2.5kg 0.7ml
2.5-<3 kg 0.8ml
3-<3.5 kg 1.0ml
3.5-4 kg 1.1 ml
4-4.5 kg 1.3 ml

GENTAMYCINDOSAGE

GENTAMYCIN DOSAGE for infants(5 mg/kg)

Body weight Dose : 80 mg / 2 ml vial

Upto 2.5 kg 10 mg everyday for 7 days

>2.5 kg 15 mg everyday for 7 days

TREATMENT OF A CHILD ABOVE 2 MONTHS

ANTIBIOTICS FOR CHOLERA

ciprofloxacin is the first line antibiotics
erythromycin is the 2nd line antibiotics

Age/weight Ciprofloxacin twice a day erythromycin four times a

for 3 days day for 3 days

250 mg -tablet 250 mg tablet

2-5 years( 10-19 kg) 1 1

 Dosage of antibiotics
 Antibiotic = ciprofloxacin
*donot give ciprofloxacin if the child has pneumonia and acute ear infection as
well

AGE/WEIGHT CIPROFLOXACIN
( TWICE A DAY FOR 3 DAYS)
TABLET-250 mg
6 month-5 years 1

Vitamin A dosage
 For persistent diarrhoea

Age Vitamin A capsule 200,000 I.U

6-12 months ½ capsule

1 years 1 capsule
-5 years

FOLLOW UP
 Persistent diarrhea : after 5 days
Ask mother:
 Has diarrhea stopped?
 Frequecy of diarrhea?
TREATMENT:
• If the diarrhea has not stopped ( if the child passes loose stool3 or more than
3 times a day ) , reassess the child. Treat the needful and refer to the hospital
• If the diarrhea has stopped ( if the child passes loose stool less than 3 times a
day) , instruct the mother to feed her baby as usual

FOLLOW UP OFDYSCENTRY : 3RD DAY

Enquire:
- Frequency of stool?
- Amount of blood in the stool?
- As fever reduced?
- Stomach pain
Treatment:
 If the child seems dehydrated, assess and rehydrate accordingly
 If the frequency ,amount of blood , fever, stomach pain has not improved or
has increased , refer to the hospital
 If the symptoms has reduced, inform the mother to complete the dose of
medicine.
PNEUMONIA
 Pneumonia is a form of acute respiratory infection that affects the lungs.
 When an individual has pneumonia, the alveoli are filled with pus and fluid,
which makes breathing painful and limits oxygen intake.
 Pneumonia is the single largest infectious cause of death in children
worldwide.
 Pneumonia killed 920 136 children under the age of 5 in 2015, accounting
for 16% of all deaths of children under five years old.
 Pneumonia affects children and families everywhere, but is most prevalent
in South Asia and sub-Saharan Africa.
Causes:
 Pneumonia is caused by a number of infectious agents, including viruses,
bacteria and fungi. The most common are:
 Streptococcus pneumoniae – the most common cause of bacterial pneumonia
in children;
 Haemophilus influenzae type b (Hib) – the second most common cause of
bacterial pneumonia;
 respiratory syncytial virus is the most common viral cause of pneumonia
Transmission
 They may spread via air-borne droplets from a cough or sneeze
CLINICAL FEATURES :
 In children under 5 years of age, who have cough and/or difficult breathing,
with or without fever. Wheezing is more common in viral infections.
 Very severely ill infants may be unable to feed or drink and may also
 experience unconsciousness, hypothermia and convulsions.

 If wheezing is present and if the child is fast breathing :

 Give Salbutamol (inhaled bronchodilator) 3 times for every 15-20 minutes
 Reassess the child.

age of the child Fast breathing is

2-12 months 50 breaths per minute or more

Above 12 months 40 breaths per minute or more

APPROPRIATE ANTIBIOTIC FOR PNEUMONIA

AMOXICILLIN
TWICE A DAY FOR 5 DAYS

AGE/WEIGHT Tab 250 mg Syr. 125mg/5ml

2-6 months(4-6 kg) ¾ 7.5 ml

6-12months(6-8KG) 1 10 ml

6-12 months (8-10 kg) 1.5 15 ml

1-3 year (10-14 kg) 2 -

3-5 year (10-19 kg) 2.5 -

DOSAGE OF SALBUTAMOL(oral broncho dilator)

AGE DOSAGE ; 2 MG

2 month to 1 year ½ tab thrice a day for 5 days

1 year to 5 months 1 tablet thrice a day for 5 days

FOLLOW UP
Pneumonia
 In 3rd day
 Assess the danger signs
 Assess if the child has difficulty in breathing
 count breathing rate
 Auscultate stridor/wheezing
 Has the fever reduced
Treatment:
 If stridor/wheezing persist along with other danger signs, give
ampicillin/gentamycin and refer to the hospital
 If child has not improved , refer him to the hospital if the child had measles
within 3 months ,refer him)
 If the child has improved, ask to continue the antibiotics
 DOSAGE OF AMPICILLIN AND GENTAMYCIN

Age/weight Ampicillin Gentamycin

50 mg per kg 7.5mg per kg

2-4months (4-<6) kg 1ml 1 ml

4-12 months(6-<10)kg 2ml 1.5ml

1-3 years(10-<14 )kg 3ml 2ml

3-5 years(14-<19)kg 4ml 3ml

MALNUTRITION
 Malnutrition refers to deficiencies, excesses, or imbalances in a person’s
intake of energy and/or nutrients. The term malnutrition addresses 3 broad
groups of conditions:
 Undernutrition: which includes wasting (low weight-for-height), stunting
(low height-for-age) and underweight (low weight-for-age);
 micronutrient-related malnutrition: which includes micronutrient
deficiencies (a lack of important vitamins and minerals) or micronutrient
excess; and
 Overweight: obesity and diet-related noncommunicable diseases (such as
heart disease, stroke, diabetes).
Scope of the problem
 In 2016, an estimated 155 million children under the age of 5 years were
suffering from stunting, while 41 million were overweight or obese.
 Around 45% of deaths among children under 5 years of age are linked to
undernutrition. These mostly occur in low- and middle-income countries. At
 the same time, in these same countries, rates of childhood overweight and
obesity are rising.
Who is at risk?
 Every country in the world is affected by one or more forms of malnutrition.
Combating malnutrition in all its forms is one of the greatest global health
challenges.
 Infants, children are at particular risk of malnutrition
 Poverty amplifies the risk of, and risks from, malnutrition. People who are
poor are more likely to be affected by different forms of malnutrition. Also,
malnutrition increases health care costs, reduces productivity and slows
economic growth, which can perpetuate a cycle of poverty and ill health.

ANEMIA
 Anemia is a condition in which the number of red blood cells or their oygen-
carrying capacity is insufficient to meet physiologic needs, Iron deficiency is
thought to be the most common cause of anemia globally, although other
conditions, such as folate, vitamin B12, parasitic infections, can cause
anemia.
VITAMIN A DOSE- FOR 6 MONTHS AND ABOVE\
IRON DOSE
 OD for 14 days

AGE/WEIGHT Iron/folate syrup

Ferrous fumarate and folate acid 0.5 mg/5 ml

2-4 months(4-6 kg) 1ml

4-12months(6-10kg) 1.5 ml

1-3 years(10-14kg) 2 ml

3-5 years(14-19kg) 2.5 ml

ALBENDAZOLE
 If the child has not received Albendazole from past 6 months ,give him 4oo
mg of albendazole .
 If the child is 1-2 years give him half tablet i.e (200mg)and if the child is
above 2 years give him 400 mg of tablet.
FOLLOW UP FOR ANEMIA
 AFTER 14 DAYS
 Give iron tablet. Instruct mother to come back to the health post and collect
iron tablets in 14 days.
 Give iron tablets every 14 days for 2 months
 If the pallor did not reduce, refer to the hospital
MALARIA
 Malaria is a life-threatening disease caused by parasites that are transmitted
to people through the bites of infected female Anopheles mosquitoes. It is
preventable and curable.
 Malaria is caused by Plasmodium parasites. The parasites are spread to
people through the bites of infected female Anopheles mosquitoes, called
"malaria vectors." There are 5 parasite species that cause malaria in humans,
and 2 of these species – P. falciparum and P. vivax – pose the greatest threat.
 In 2017, there were an estimated 219 million cases of malaria in 87
countries.
 The estimated number of malaria deaths stood at 435 000 in 2017
TRANSMISSION
 In most cases, malaria is transmitted through the bites of female Anopheles
mosquitoes
INCUBATION PERIOD
 The duration of the incubation period varies with the species of the parasite,
and in natural infections (in mosquito-transmitted malaria) this is
 12 (9-14) days for falciparum malaria,
 14 (8-17) days for vivax malaria,
 17 (16-18) days for ovale malaria
CLINICAL FEATURES
 COLD STAGE : The onset is with lassitude, headache, nausea and chilly
sensation followed in an hour or so by rigors. The temperature rises rapidly
to 39-41°C. Headache is often severe and commonly there is vomiting.
 In early part of this stage, skin feels cold; later it becomes hot. Parasites are
usually demonstrable in the blood. The pulse is rapid and may be weak. This
stage lasts for 1/4-1 hour.
 HOT STAGE : The patient feels burning hot and casts off his clothes. The
skin is hot and dry to touch. Headache is intense but nausea commonly
 diminishes. The pulse is full and respiration rapid. This stage lasts for 2 to 6
hours.
 SWEATING STAGE : Fever comes down with profuse sweating. The
temperature drops rapidly to normal and skin is cool and moist. The pulse
rate becomes slower, patient feels relieved and often falls asleep. This stage
lasts for 2-4 hours.
TREATMENT
MEDICINES
1. SEVERE COMPLICATED MALARIA
Artemisinin Suppository (Artesurate Single dose)

Weight in K.G Age Artemisinin

suppository

5-8.9 0-12 months 50 mg

9-19 13-42 months 100 mg

20+ 43-59 months 200 mg

2. Uncomplicated Falciparum Malaria

 Artemisinin based Combination Therapy
 AL-Coartem R is the first line of drugs for such cases.
 Quinine Sulphate is the second choice of drugs
 AL-Coartem R is contraindicated to children below 1 year of age and below
5 k.g weight.
 In such case the child should be administered with Quinine Sulphate 10mg
per kg per body weight (TID for 7 days) (after food)
 If the patient treated with AL-Coartem R doest respond well to the medicine
for 14 days, such cases should be treated with Quinine Sulphate 10mg per kg
per body weight (TID for 7 days) (after food)
Side effects of quinine sulphate
 Tinnitus
 Dizziness
 Diarrhoea/constipation
 Hypoglycemia (infants)
Doses of AL (CoartemR) by kg.body weight

Body Day 1 Day 2 Day 3

weight(kg)
FIRST DOSE 8 hours later
( O HOUR)
Twice daily-12 hours
apart
5-14 1 tab 1 tab 1 tab 1 tab

15-24 2 tab 2 tab 2 tab 2 tab

 * AL (CoartemR) IS ADMINISTERED TO THE PATIENTS OF

UNCOMPLICATED,CONFIRMED BY (MICROSCOPY OR RDT)P
FALCIPARUM MALARIA.

3. Non Falciparum Malaria 0r P.Vivax Malaria

 Dose of chloroquine and primaquine by age group
 Medicine should be given at 0 hpur,6 hours,24 hours, and 48 hour

Days Drug Wt. 4-10 kg Wt.10-19 kg

< 1 year 1-4 year 4-5 year
1 Chloroquine ½ 1 2
tablet
2 Chloroquine ½ 1 2
tablet
3 Chloroquine ½ ½ 1
tablet
  Chloroquine syrup for young children
 One tea spoonful =5ml of chloroquine syrup =50 mg. Chloroquine base

Day age in years (dose of chloroquine syrup)

Less than 1 year (wt. 4-10kg) 1-4 years (wt.10-19 kg)

1 7.5 ml 15ml

2 7.5 ml 15ml

3 7.5 ml 7.5 ml

 if the child vomited within 30 minutes of medication, medicines should be

given again
 Child may complain of itching but it wont be that dangerous
 Chloroquine shouldnot be administered empty stomach
FOLLOW UP
 MALARIA (HIGH/LOW RISK MALARIA)
 If fever persisists for 3 days or repeats after 14 days
 Reassess the child.
 Reassess the causes for fever
TREATMENT:
If the neck is stiffed or any general danger sign is present, treat is as it is
If the fever is not because of malaria, treat as it is
If the fever is because of malaria:
 Start with 2nd line of drugs. (if not available,refer to the hospital ) if the
fever continues, advise to come in 2 days
 If the fever continues for 7 days or more, refer for diagnosis
MEASLES
 MEASLES is an acute highly infectious disease of childhood caused by a
specific virus of the group myxoviruses.
 It is clinically characterized by fever and catarrhal symptoms of the upper
respiratory tract (coryza, cough), followed by a typical rash.
 Measles is associated with high morbidity and mortality in
developing countries.
 Measles occurs only in humans.
 Measles is transmitted via droplets from the nose, mouth or throat of
infected persons.
 Initial symptoms, which usually appear 10–12 days after infection, include
high fever, a runny nose, bloodshot eyes, and tiny white spots on the inside
of the mouth. Several days later, a rash develops, starting on the face and
upper neck and gradually spreading downwards.
 Severe measles is more likely among poorly nourished young children,
especially those with insufficient vitamin A, or whose immune systems have
been weakened by HIV/AIDS or other diseases.
 The most serious complications include blindness, encephalitis (an infection
that causes brain swelling), severe diarrhoea and related dehydration, and
severe respiratory infections such as pneumonia.
 global measles deaths have decreased by 84 percent worldwide in recent
years — from 550,100 deaths in 2000 to 89,780 in 2016 — measles is still
common in many developing countries, particularly in parts of Africa and
Asia.
 An estimated 7 million people were affected by measles in 2016.
 The overwhelming majority (more than 95%) of measles deaths occur in
countries with low per capita incomes and weak health infrastructures.
TREATMENT

TETRACYCLIN OINTMENT DOSE

 Clean eyes Thrice a day
 Wash your hands
 Instruct the child to close the eyes
 Take a clean cloths and clean the pus from both eye
Apply tetracyclin ointment thrice a day
 Instruct the child to see above
 Apply little ointment near the lower lid
 Wash hand again
 Treat until redness of the eye vanishes
 Donot apply other ointments
GENTIAN VIOLET
 Twice a day
 Wash your hands
 Soak a sterile cloth in a warm water , place it in your tip of the finger and
clean the wound
 Apply (0.25%) gentian violet in those wounds
 Wash hand again
FOLLOW UP
 FOR MEASLES WITH EYE AND MOUTH COMPLICATIONS :
3RD DAY
 Check:
 Eyes are red or not. And if pus is present in the eyes’
 Check for mouth ulcer
 Check for mouth odour
EYE INFECTION TREATMENT
 If pus is draining from the eyes,ask mother how did she cleaned eye at
home? If her way is correct refer to the hospital.
 If the way of treating was not correct ,teach mother how to apply medicines
 If pus is not draining,but redness is present, continue the treatment
 If pus is not draining and redness is absent, close the treatment
TREATMENT FOR MOUTH ULCER
 If the ulcer is deep and has extended , if halitosis exists, refer for the
treatment
 If the ulcer is same as it was earlier or has improved , continue with the
ointment