IMNCI

Integrated Management of Neonatal and Childhood Illness

Dr. Arun Mitra
Department of Community Medicine

2026-07-07

Session Roadmap

  • What and Why of IMNCI?
  • The IMNCI approach: age groups and colour-coded triage
  • Describe the Advantages of applying IMNCI
  • Describe the principles of Integrated Care
  • Assess and Classify the sick child
  • IMNCI in India: delivery and F-IMNCI

A Triage Scenario

You are the only health worker at a sub-centre. Three children arrive at once:

  • a 3-year-old with a cough
  • an 8-month-old who is drowsy and refusing to feed
  • a 2-year-old with a runny nose

You cannot see all three at once. Who do you attend to first?

Define IMNCI

IMNCI is a way of case detection and treatmentusing simple clinical signs/symptoms and empiricaltreatments among children under 5 years.


It is a case management process for a first-level facility such as a clinic, a health center or an outpatient department of a hospital

What Is IMNCI?

A standardised, symptom-based (syndromic) approach to assessing, classifying, and managing sick children from birth to 5 years at the primary-care level.

  • “Integrated”: a single child is assessed for all the major killers in one visit
  • Designed for a frontline worker, without a diagnosis-per-disease or laboratory back-up

Why an Integrated Approach?

  • Most sick children present with signs and symptoms related to more than one condition.

  • Single diagnosis - not possible or appropriate. Treatment complicated by the need to combine therapies

  • Many are not properly assessed & treated, parents are poorly advised.

  • Providing quality care to sick children is a serious challenge.

The malnutrition–infection vicious cycle is the best justification for integration: you cannot treat the pneumonia and ignore the wasting.

Evolution of IMNCI

  • To end preventable child mortality, WHO-UNICEF designed the Integrated Management of Childhood Illness strategy in the mid 1990s

  • Launched in countries which had >40 U-5 deaths/1000 live births

  • Laboratory and radiology services are limited or non-existent in primary health care facilities

  • To improve access & quality of care for newborns and children in primary health care services

Problem Statement

  • In 2020, 5 million U-5 deaths, mostly from preventable and treatable causes.

  • Half among newborns

  • Half of all U-5 deaths in occurred in 5 countries: Nigeria, India, Pakistan, Congo and Ethiopia.

  • Nigeria and India alone account for 1/3rd of all deaths.

SDG Goals

Goal 3.2, by 2030:

end preventable deaths of newborn and children under 5 years of age, with: - all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and  - under-5 mortality to at least as low as 25 per 1000 live births.

From IMCI to IMNCI

IMCI (WHO/UNICEF, mid-1990s) IMNCI (India)
Age range 1 week – 5 years Birth – 5 years
Emphasis Childhood illness (2 mo–5 y) Adds a strong newborn/young-infant arm
Why — A large share of India’s under-5 deaths are neonatal → the “N”

Three Components of the Strategy

  1. Improve the case-management skills of health workers (training, chart booklet)
  2. Improve the health system that delivers care (drugs, supplies, referral, supervision)
  3. Improve family and community practices (care-seeking, feeding, immunisation)

Two of the three pillars are systems and community, which is why IMNCI sits in Community Medicine, not only Paediatrics.

The IMNCI Approach

Two Age Groups, Two Forms

Age band Name Key feature
Birth up to 2 months Sick young infant Subtle signs, rapid deterioration, low threshold to refer
2 months up to 5 years Sick child General danger signs + four main symptoms

Each band has its own algorithm and case-recording form.

The Colour-Coded Classification

Colour Meaning Action
PINK Severe classification Urgent pre-referral treatment + refer
YELLOW Needs specific treatment Treat at facility / home
GREEN Mild / no severe sign Home management + counsel

Advantages of IMNCI Approach

  • Early recognition of serious conditions and prompt referral

  • Speeds up the urgent treatment and treatment seeking practices

  • Avoids wastage of resources by using most appropriate medicines and treatment

  • Reduces duplication of efforts

The Case-Management Process

A fixed sequence for every sick child:

flowchart LR
  A[Assess] --> B[Classify] --> C[Identify Rx] --> D[Treat] --> E[Counsel] --> F[Follow-up]

Classify uses the colour code; the colour tells you what to do next.

Steps

Steps

Step 1: General Danger Signs (check first)

Check before anything else. Any one means the child is severely ill:

  1. Not able to drink or breastfeed
  2. Vomits everything
  3. Convulsions
  4. Lethargic or unconscious

Any one danger sign → urgent referral. The “any one” rule, just like the SAM criteria.

The Four Main Symptoms

Main symptom What you look for Severe (PINK) example
Cough / difficult breathing Fast breathing, chest indrawing, stridor Chest indrawing → severe pneumonia
Diarrhoea Dehydration, duration, blood Severe dehydration; dysentery
Fever Cause, duration, measles, stiff neck Very severe febrile disease
Ear problem Pain, discharge, swelling behind ear Mastoiditis

Cough or Difficult Breathing

  • Assess for fast breathing, chest indrawing, and stridor
  • Chest indrawing or stridor → severe pneumonia (PINK)

Fast breathing thresholds (examinable):

  • 2 months up to 12 months → ≥ 50 breaths/min
  • 12 months up to 5 years → ≥ 40 breaths/min

Diarrhoea

  • Classify dehydration: severe / some / none (skin pinch, sunken eyes, ability to drink)
  • Also identify persistent diarrhoea (≥14 days) and dysentery (blood in stool)

[→ Malnutrition L2] Zinc plus low-osmolarity ORS for 14 days shortens childhood diarrhoea.

Fever & Ear Problem

  • Fever: assess cause and duration; look for measles and for stiff neck (very severe febrile disease / meningitis)
  • Ear problem: ear pain or discharge; a tender swelling behind the ear suggests mastoiditis

Then Check: Malnutrition, Anaemia, Immunisation

  • Acute malnutrition: oedema of both feet, MUAC (6–59 months), weight-for-height, visible severe wasting
  • Anaemia: palmar pallor (severe vs some)
  • Immunisation status, vitamin A, and any other problems

Identify Treatment, Treat, Counsel, Follow Up

  • Treat: for PINK children, give pre-referral treatment first — first antibiotic dose, prevent low blood sugar, keep warm, treat convulsions
  • Counsel: feeding and fluids during illness, and the danger signs that mean “return immediately”
  • Follow-up: a scheduled return visit to reassess and reclassify

Why a Separate Algorithm

  • Signs in a young infant are non-specific and deterioration is rapid
  • So the threshold to refer is deliberately low
  • The three priorities: infection, jaundice, feeding

PSBI / Very Severe Disease

Any one of the following → PINK → refer after pre-referral treatment:

  • Not feeding well
  • Convulsions
  • Fast breathing (≥ 60 breaths/min)
  • Severe chest indrawing
  • Fever (≥ 37.5°C) or low body temperature (< 35.5°C)
  • Movement only when stimulated, or no movement at all

Jaundice, Feeding & Low Weight

  • Jaundice: severe jaundice → refer
  • Feeding problem or low weight for age: assess the breastfeed — attachment, positioning, effective suckling

Who Delivers IMNCI

  • Introduced under RCH-II (2005), now implemented within the National Health Mission
  • Delivered by a trained team: Medical Officers, ANMs, Anganwadi Workers, ASHAs
  • Home-Based Newborn Care (HBNC) by ASHAs complements the young-infant arm in the community

F-IMNCI (Facility-Based)

  • Trains Medical Officers and staff nurses at CHC / FRU / district hospital
  • To manage the sick young infants and children referred by outpatient IMNCI
  • Bridges the community algorithm and inpatient care

[→ Malnutrition L2] F-IMNCI at the facility and the NRC for complicated SAM are the two arms of the same referral level, both under POSHAN 2.0 / child survival.

Algorithm

Algorithm

Case Study

An 11-month-old girl, cough for 3 days. On assessment: drinks eagerly, respiratory rate 54/min, no chest indrawing, no stridor. MUAC 11.2 cm, no oedema, appetite present, immunisation up to date.

  • Does she have any general danger sign?
  • Classify her breathing. What colour?
  • Classify her nutritional status. What colour, and what pathway?
  • What treatment and counselling, and when should she return?

Case: Working Through It

  • Danger sign? None (drinks, no vomiting, no convulsions, alert)
  • Breathing: RR 54 at 11 months is fast (≥ 50), no indrawing/stridor → Pneumonia (YELLOW): oral amoxicillin, return in 3 days
  • Nutrition: MUAC 11.2 cm with appetite and no oedema → uncomplicated SAM → RUTF (CMAM), not a hospital referral
  • Counsel: feeding and fluids; return immediately if any danger sign appears

Key Takeaways

  • IMNCI is integrated and syndromic: one child assessed for all major killers; India’s version adds the neonate
  • Check general danger signs first — any one means urgent referral
  • Four main symptoms, plus malnutrition, anaemia, immunisation
  • Colour decides the pathway: PINK refer, YELLOW treat, GREEN counsel
  • IMNCI is the front door to the NRC / CMAM / POSHAN 2.0 system from the Malnutrition lectures

References

  • MoHFW (India) — IMNCI Student Handbook and Physician Chart Booklet; F-IMNCI Participant’s Manual (implemented under RCH-II / NHM).
  • WHO / UNICEF — Integrated Management of Childhood Illness Chart Booklet (2014); IMCI handbook.
  • Park’s Textbook of Preventive and Social Medicine — RCH / IMNCI chapters (latest edition).

Thank You