1. Introduction to IMNCI

Every year, millions of children under the age of five die from preventable or treatable illnesses. This staggering statistic highlights the critical need for effective child health strategies worldwide. The Integrated Management of Neonatal and Childhood Illnesses (IMNCI) strategy, developed by the World Health Organization (WHO) and UNICEF, stands as a cornerstone in the global effort to combat this crisis. For nursing students, understanding and mastering the principles and application of the IMNCI guidelines is not just an academic exercise; it’s a fundamental step towards becoming competent, compassionate, and life-saving healthcare professionals. This guide aims to provide a comprehensive overview of IMNCI, focusing on its relevance to nursing practice and equipping students with the knowledge to make a tangible difference in child health outcomes.

1.1 What is IMNCI?

IMNCI, a joint initiative by WHO and UNICEF launched in the mid-1990s, represents a paradigm shift from single-disease programs to a more holistic approach to child health. It focuses on the most common causes of child mortality: pneumonia, diarrhea, malaria, measles, and malnutrition, particularly in resource-limited settings. The IMNCI guidelines provide a systematic framework for managing sick neonates (birth up to 2 months) and children (2 months up to 5 years). A core tenet of IMNCI is that many childhood deaths and illnesses can be prevented or effectively treated with relatively simple, affordable interventions if identified and managed correctly and promptly. This strategy empowers healthcare workers, including nurses, with the skills to assess a child for a comprehensive set of signs, classify the illness based on severity using a color-coded triage system, identify appropriate treatments, counsel caregivers, and arrange follow-up care. The advantage of this integrated approach is its efficiency and effectiveness in addressing co-existing conditions, thereby improving the overall quality of care.

1.2 Goals and Objectives

The overarching goals of IMNCI are broad and impactful, aiming to significantly improve the health and survival rates of young children. These goals are supported by specific, actionable objectives:

• Primary Goals:
  • To reduce mortality and the frequency and severity of illness and disability in children under five years of age.
  • To promote improved growth and development among young children.
• Specific Objectives:
  • To improve the case management skills of healthcare workers through the provision and use of evidence-based IMNCI guidelines and training.
  • To strengthen health systems by ensuring the availability of essential drugs and supplies, improving the organization of care, and enhancing supervision and monitoring.
  • To improve family and community health practices concerning child health and nutrition, including care-seeking behaviors, home management of illnesses, and preventive care.

Achieving these objectives requires a multi-faceted approach involving training, health system support, and community engagement, all guided by the comprehensive IMNCI guidelines.

1.3 Significance for Nursing Practice

IMNCI holds profound significance for nursing practice, particularly for nurses working in primary healthcare settings, community health, and pediatrics. Nurses are often the first point of contact for sick children and their families, making their role in implementing the IMNCI guidelines pivotal. This strategy:

• Empowers Nurses: It provides nurses with clear, structured protocols for assessment, classification, and treatment, enabling them to make informed clinical decisions confidently.
• Enhances Clinical Skills: Training in IMNCI sharpens nurses’ diagnostic skills for common childhood illnesses, differentiating between mild conditions manageable at home and severe illnesses requiring urgent referral.
• Promotes Holistic Care: IMNCI encourages nurses to look beyond a single complaint and assess the child for overall health, nutritional status, immunization, and developmental needs.
• Strengthens Counseling Role: A key component of the IMNCI guidelines is counseling caregivers on home care, feeding, fluid intake, danger signs, and when to return for follow-up, enhancing the nurse’s role as an educator and health promoter.
• Facilitates Teamwork and Referral: IMNCI protocols clarify when referral is necessary, improving collaboration between different levels of the health system.
• Contributes to Public Health Goals: By effectively managing childhood illnesses, nurses directly contribute to reducing child mortality and morbidity rates in their communities.
• Ethical Practice: Adherence to IMNCI guidelines supports ethical nursing practice by ensuring evidence-based, standardized care for all children, promoting advocacy for the child’s best interest.

For nursing students, a thorough understanding of IMNCI is essential for developing core competencies in pediatric care and for preparing to address the significant health challenges faced by children globally. The consistent application of IMNCI guidelines is a hallmark of quality pediatric nursing.

2. Core Components of IMNCI Strategy

The IMNCI strategy is not merely a set of clinical protocols; it is a comprehensive framework built on three interconnected components. These pillars work synergistically to ensure that children receive appropriate care at health facilities and that families and communities are empowered to promote child health and development. Understanding these components helps nursing students appreciate the multifaceted nature of the effort to improve child survival by applying the IMNCI guidelines effectively.

2.1 Improving Health Worker Skills (Case Management)

This component is central to IMNCI and directly impacts nursing practice. It focuses on equipping healthcare workers, including nurses, with the necessary skills to manage sick children effectively using standardized IMNCI guidelines. The training emphasizes a systematic approach to case management, which typically involves six key steps:

1. Assess: This involves a thorough evaluation of the child. Nurses take a detailed history from the caregiver, check for general danger signs (e.g., inability to drink or breastfeed, vomiting everything, convulsions, lethargy or unconsciousness), assess main symptoms (cough or difficult breathing, diarrhea, fever, ear problem), and evaluate nutritional status, immunization status, feeding practices, and any other problems. This assessment is guided by the IMNCI guidelines flowchart.
2. Classify: Based on the signs and symptoms identified during the assessment, the child’s illness is classified using a color-coded system. This system, detailed in the IMNCI guidelines, helps determine the severity of the illness:
   • Pink (Urgent Referral): Indicates a very severe disease requiring immediate referral to a hospital after pre-referral treatment.
   • Yellow (Specific Medical Treatment and Advice): Indicates a condition that can be managed at the health facility with specific medication (e.g., oral antibiotics, ORS) and counseling for the caregiver.
   • Green (Simple Advice on Home Management): Indicates a mild condition that can be managed at home with simple advice on care, feeding, and when to return if the child worsens.
3. Identify Treatment: For each classification, the IMNCI guidelines specify the appropriate actions and treatments. This may include prescribing oral drugs, giving injections (pre-referral), administering fluids, or providing specific advice on nutrition and home care.
4. Treat/Refer: Nurses administer the necessary treatments for children classified as Yellow or Green. For children classified as Pink, nurses provide essential pre-referral treatments (e.g., first dose of an antibiotic, managing hypoglycemia or hypothermia) and facilitate urgent referral.
5. Counsel: Counseling caregivers is a critical step. Nurses provide clear instructions on how to administer treatments at home, how to feed the child and give fluids, signs that indicate the child should return to the health facility immediately, and when to come for a follow-up visit. This is a cornerstone of the IMNCI guidelines for ensuring continuity of care.
6. Follow-up: For certain conditions or classifications (especially Yellow and those referred who return), follow-up visits are scheduled to reassess the child’s condition, ensure treatment adherence, and address any new problems. The IMNCI guidelines outline when these follow-ups are necessary.

The use of IMNCI chart booklets, flowcharts, and job aids is essential for health workers to consistently apply these case management steps.

2.2 Improving Health Systems

Effective case management by skilled health workers can only succeed if the broader health system supports it. This component of the IMNCI strategy focuses on ensuring that health facilities are equipped and organized to deliver quality child health services. Key aspects include:

• Availability of Essential Drugs and Supplies: This means ensuring a consistent supply of essential medicines (like oral rehydration salts (ORS), zinc, antibiotics, antimalarials, vitamin A), vaccines, and basic equipment (thermometers, weighing scales, timers for counting respiratory rate) at primary health care facilities. Nurses play a role in managing these supplies and advocating for their availability.
• Organization of Health Services: This involves streamlining patient flow within health facilities to reduce waiting times, ensuring appropriate staffing levels, and establishing clear and functional referral pathways for severely ill children. Adherence to IMNCI guidelines for referral needs a robust system.
• Supervision and Support: Regular supportive supervision for health workers is crucial to maintain high standards of care, provide on-the-job training, solve problems, and monitor the implementation of IMNCI guidelines.
• Health Information Systems: Effective monitoring and evaluation rely on good data. This includes recording cases, treatments, referrals, and outcomes, which helps in tracking progress and identifying areas for improvement in the application of the IMNCI guidelines.

Nurses contribute to this component by participating in quality improvement initiatives, advocating for necessary resources, and ensuring efficient use of available supplies and well-organized patient care.

2.3 Improving Family and Community Practices

Child health is significantly influenced by practices at the household and community levels. The third component of IMNCI aims to promote key family and community practices that protect children’s health and ensure they receive appropriate care when needed. These practices include:

• Exclusive Breastfeeding: Promoting exclusive breastfeeding for the first six months of life and continued breastfeeding with appropriate complementary foods thereafter. The IMNCI guidelines emphasize assessing feeding practices.
• Appropriate Complementary Feeding: Educating caregivers on providing nutritious, safe, and age-appropriate complementary foods starting from six months.
• Immunization: Encouraging timely and complete immunization for all children as per the national schedule.
• Hygiene and Sanitation: Promoting practices like handwashing with soap, safe water handling, and proper disposal of feces.
• Home Management of Minor Illnesses: Teaching caregivers how to manage common, mild illnesses like coughs/colds or mild diarrhea at home with appropriate fluids and feeding.
• Care-Seeking Behavior: Educating families to recognize danger signs in sick children and seek timely care from a trained health worker or facility. This is vital for the effectiveness of the IMNCI guidelines.
• Adherence to Treatment and Advice: Ensuring caregivers understand and follow the treatment and counseling provided by health workers.
• Malaria Prevention: In malaria-endemic areas, promoting the use of insecticide-treated nets (ITNs) and seeking prompt treatment for fever.

Nurses play a vital role in this component through health education during clinic visits, counseling sessions, and community outreach activities. Community health workers and volunteers are also key partners in disseminating these messages and supporting families. When communities understand the principles behind the IMNCI guidelines, overall child health improves.

3. IMNCI Guidelines for Common Neonatal and Childhood Illnesses

This section forms the heart of understanding IMNCI for nursing students. It delves into the practical application of the IMNCI guidelines for assessing, classifying, and managing the most common illnesses affecting neonates and children under five. Remember, the approach is always systematic: Assess → Classify → Identify Treatment → Treat/Refer → Counsel → Follow-up. These IMNCI guidelines are standardized and evidence-based, designed to be used by nurses and other first-level health workers. Always refer to the latest local adaptation of the IMNCI chart booklet for specific drug dosages and protocols.

3.1 Neonatal Care (Birth to 2 months)

Neonates (young infants aged 0 up to 2 months, or 0-59 days) are uniquely vulnerable due to their immature immune systems and rapid physiological changes. The IMNCI guidelines for this age group are distinct and emphasize prompt identification of severe illness. The main conditions assessed are possible serious bacterial infection (PSBI) or very severe disease, jaundice, diarrhea, and feeding problems or low weight.

3.1.1 Possible Serious Bacterial Infection (PSBI) / Very Severe Disease

• Assessment: Ask about convulsions. Look and listen for: fast breathing (60 breaths per minute or more), severe chest in-drawing, nasal flaring, grunting. Check for fever (temperature ≥37.5°C or ≥99.5°F) or hypothermia (temperature <35.5°C or <95.9°F by axillary route, or feels cold to touch). Observe for lethargy or unconsciousness, reduced movement, or if the infant stopped feeding well. Look for severe jaundice (yellow palms and soles), signs of local infection (umbilicus red or draining pus, skin pustules).
• Classification: According to the IMNCI guidelines, if any of these signs (convulsions, fast breathing, severe chest in-drawing, nasal flaring, grunting, fever, hypothermia, lethargy/unconsciousness, stopped feeding well, or signs of severe local infection suggesting sepsis) are present, classify as VERY SEVERE DISEASE or POSSIBLE SERIOUS BACTERIAL INFECTION (PSBI). (Pink classification)
• Treatment: URGENT REFERRAL to hospital is mandatory. Before referral:
  • Give first dose of appropriate injectable antibiotics (e.g., intramuscular Gentamicin AND Ampicillin as per local IMNCI guidelines).
  • Treat to prevent low blood sugar (e.g., breastfeed or give expressed breast milk; if not possible, sugar water).
  • Keep the infant warm (skin-to-skin contact).
  • Counsel mother on transport and care during referral.
• Counseling: Explain the need for urgent referral, how to keep the infant warm during transport, and importance of continuing feeds if possible.
• Follow-up: If referred, care continues at hospital. If for some unavoidable reason referral isn’t possible immediately, manage per specific “referral not possible” protocols in the IMNCI guidelines, which often involve daily reassessment by a trained provider.

3.1.2 Jaundice in the Young Infant

• Assessment: Ask when jaundice started (first 24 hours of life or later). Look for yellow discoloration of the sclera, skin, palms, and soles. Deeper yellow and appearing on palms/soles indicates more severe jaundice.
• Classification (as per IMNCI guidelines):
  • SEVERE JAUNDICE (Pink): Any jaundice appearing on palms and soles OR jaundice appearing within the first 24 hours of life.
  • JAUNDICE (Yellow): Jaundice present, but not on palms/soles and appeared after 24 hours of life.
• Treatment:
  • Severe Jaundice: URGENT REFERRAL. Advise mother to continue frequent breastfeeding.
  • Jaundice: Advise mother to continue frequent breastfeeding (8-12 times a day) to help clear bilirubin. Counsel on signs of worsening jaundice or illness that require immediate return. Follow-up in 1-2 days as per specific IMNCI guidelines or if jaundice worsens.
• Counseling: Importance of frequent feeding, danger signs (worsening jaundice, poor feeding, lethargy), and when to return.
• Follow-up: Crucial for infants with Jaundice (Yellow) to monitor progression.

3.1.3 Diarrhea in Young Infants

• Assessment: Ask if the infant has diarrhea. Look for signs of dehydration: Is the infant lethargic or unconscious? Are eyes sunken? Offer fluid: Is the infant not able to drink or drinking poorly, or drinking eagerly/avidity? Pinch the skin of the abdomen: Does it go back very slowly (≥2 seconds), slowly, or quickly?
• Classification (Dehydration, per IMNCI guidelines):
  • SEVERE DEHYDRATION (Pink): Two or more of: lethargic/unconscious, sunken eyes, not able to drink/drinking poorly, skin pinch goes back very slowly.
  • SOME DEHYDRATION (Yellow): Two or more of: restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly.
  • NO DEHYDRATION (Green): Not enough signs for Some or Severe Dehydration.
• Treatment:
  • Severe Dehydration: URGENT REFERRAL. If infant can drink, give ORS on the way. If breastfeeding, continue.
  • Some Dehydration: Give ORS solution (amount guided by weight/age as per IMNCI guidelines, e.g., Plan B). Advise on continued breastfeeding and home ORS. Follow-up.
  • No Dehydration: Advise on increased fluids (exclusive breastfeeding more frequently and for longer durations). Counsel on signs of dehydration requiring return. Zinc supplementation is usually not recommended by IMNCI guidelines for young infants unless specified by local policy for specific situations like cholera.
• Counseling: Focus on exclusive breastfeeding, recognizing danger signs of dehydration.
• Follow-up: Necessary if Some Dehydration, or if diarrhea persists.

3.1.4 Feeding Problem or Low Weight

• Assessment: Ask caregiver about feeding difficulties. Observe a breastfeed: check for attachment (mouth wide open, lower lip turned out, chin touching breast, more areola visible above than below), effective suckling (slow, deep sucks, sometimes pausing). Weigh the infant and plot on growth chart. Check for thrush (white patches in mouth).
• Classification (as per IMNCI guidelines):
  • NOT ABLE TO FEED / NO ATTACHMENT / SIGNS OF SEVERE MALNUTRITION (Pink): Infant not able to feed at all, or no attachment during observation, or has signs of visible severe wasting / edema often linked to other severe illness. (Usually part of PSBI).
  • NOT FEEDING WELL / POOR ATTACHMENT / THRUSH / LOW WEIGHT FOR AGE (Yellow): Poor attachment, not suckling effectively, presence of thrush, or weight-for-age below -2 Z-score (or as per local criteria).
  • FEEDING WELL / NOT LOW WEIGHT FOR AGE (Green): Good attachment and suckling, no thrush, adequate weight.
• Treatment:
  • Not Able to Feed / No Attachment / Severe Signs: Usually part of Very Severe Disease management (Urgent Referral). May need nasogastric feeding if unable to suckle.
  • Not Feeding Well / Poor Attachment / Thrush / Low Weight: Counsel on correct breastfeeding positioning and attachment. Treat thrush if present (e.g., Nystatin). Advise on increasing frequency of feeds. If formula-fed, counsel on safe preparation. Follow-up closely (e.g., in 1-2 days for feeding problem, 7 days for low weight check). The IMNCI guidelines stress supportive feeding counseling.
  • Feeding Well: Praise mother, continue routine care.
• Counseling: Essential for teaching proper breastfeeding techniques, hygiene for expressed milk or formula, recognizing feeding cues.
• Follow-up: Very important for monitoring weight gain and resolving feeding issues.

3.2 Children Aged 2 Months up to 5 Years

For children in this age group, the IMNCI guidelines systematically address common killers like pneumonia, diarrhea, malaria (in endemic areas), measles, and malnutrition, alongside other prevalent issues like ear infections.

3.2.1 Pneumonia / Cough or Difficult Breathing

• Assessment: Ask: Does the child have cough or difficult breathing? For how long? Look and listen for:
  • General danger signs (unable to drink/breastfeed, vomits everything, convulsions, lethargic/unconscious).
  • Fast breathing: Count breaths in one minute when the child is calm.
    • Age 2-12 months: ≥ 50 breaths/minute is fast.
    • Age 12 months – 5 years: ≥ 40 breaths/minute is fast.
  • Chest in-drawing (lower chest wall goes IN when child breathes IN).
  • Stridor in a calm child (harsh noise when breathing IN).
• Classification (as per IMNCI guidelines):
  • SEVERE PNEUMONIA OR VERY SEVERE DISEASE (Pink): Any general danger sign OR chest in-drawing OR stridor in a calm child.
  • PNEUMONIA (Yellow): Fast breathing. (No GDS, no chest in-drawing, no stridor).
  • NO PNEUMONIA: COUGH OR COLD (Green): No signs of pneumonia or severe disease (i.e., no GDS, no fast breathing, no chest in-drawing, no stridor).
• Treatment:
  • Severe Pneumonia or Very Severe Disease: Give first dose of an appropriate antibiotic (e.g., injectable Ampicillin or Benzylpenicillin, or oral Amoxicillin if referral extensively delayed AND child can take oral medication – refer to specific IMNCI guidelines for pre-referral antibiotics). Refer URGENTLY to hospital. Treat fever if present. Manage wheeze if present with rapid-acting bronchodilator.
  • Pneumonia: Give an oral antibiotic (e.g., Amoxicillin for 5 days – dosage by weight/age as per IMNCI guidelines). Soothe the throat and relieve cough with a safe remedy (e.g., breastmilk for infants, honey for children >1 year). Advise mother on home care, when to return immediately. Follow-up in 2-3 days.
  • No Pneumonia: Cough or Cold: If cough >14 days, assess for TB or asthma. Otherwise, advise mother on home care (soothe throat, relieve cough, monitor for worsening). Counsel when to return. No antibiotics. Many IMNCI guidelines stress avoiding unnecessary antibiotics.
• Counseling: For Pneumonia (Yellow), teach how to give oral antibiotic, importance of completing the course, home remedies for cough, fluids, continued feeding, and danger signs for immediate return (fast/difficult breathing, unable to drink, worsening).
• Follow-up: For Pneumonia (Yellow), assess in 2-3 days. If worsening, refer. If same, change antibiotic or refer. If improving, complete antibiotic course.

3.2.2 Diarrhea

• Assessment: Ask: Does the child have diarrhea? For how long? Is there blood in the stool? Look and feel for:
  • General condition: Lethargic or unconscious? Restless or irritable?
  • Eyes: Sunken?
  • Thirst: Offer fluid. Unable to drink or drinks poorly? Drinks eagerly, thirsty?
  • Skin pinch: Pinch abdominal skin. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Quickly?
• Classification (Dehydration, as per IMNCI guidelines):
  • SEVERE DEHYDRATION (Pink): Two or more of the following: Lethargic/unconscious, sunken eyes, unable to drink/drinks poorly, skin pinch goes back very slowly.
  • SOME DEHYDRATION (Yellow): Two or more of the following: Restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly.
  • NO DEHYDRATION (Green): Not enough signs for Some or Severe Dehydration.
  Additionally, classify for duration and blood:
  • SEVERE PERSISTENT DIARRHEA (Pink): Diarrhea lasting 14 days or more WITH dehydration.
  • PERSISTENT DIARRHEA (Yellow): Diarrhea lasting 14 days or more WITHOUT dehydration.
  • DYSENTERY (Yellow/Pink): Blood in stool. (Pink if with severe dehydration, Yellow if with some/no dehydration but still needs specific antibiotic). The IMNCI guidelines are clear on this.
• Treatment (based on dehydration & type, as per IMNCI guidelines):
  • Severe Dehydration: If child has Severe Dehydration, needs URGENT referral for IV fluids (IMNCI Plan C). If referral takes time and child can drink, start ORS on the way. Also treat for dysentery if blood in stool.
  • Some Dehydration: Give ORS solution in clinic (IMNCI Plan B – specific amounts over 4 hours). Give zinc supplementation (10mg for <6mo, 20mg for ≥6mo, for 10-14 days). Counsel on home ORS (Plan A for continued losses), feeding, when to return. If Dysentery, add appropriate antibiotic (e.g., Ciprofloxacin).
  • No Dehydration: Advise home fluid management (IMNCI Plan A – ORS after each loose stool, food-based fluids like soup, rice water), give zinc supplementation, continue feeding (age-appropriate), counsel when to return. If Dysentery, add antibiotic. If Persistent Diarrhea, specific dietary advice and possible referral if not improving.
• Counseling: The “4 Rules of Home Treatment” for diarrhea: 1. Give extra fluid (ORS/recommended home fluids). 2. Give Zinc. 3. Continue feeding. 4. When to return (danger signs: not able to drink/breastfeed, becomes sicker, develops fever, blood in stool if not already present). The IMNCI guidelines emphasize these.
• Follow-up: For Some Dehydration (after 4 hours of Plan B), persistent diarrhea (e.g., 5 days), dysentery (e.g., 2-3 days).

3.2.3 Fever (including Malaria where prevalent)

• Assessment: Ask: Does the child have fever? For how long? If more than 7 days, has fever been present every day? Has the child had measles within the last 3 months? Look and feel for: General danger signs, stiff neck. In malaria risk areas: Ask about travel history to a malaria area. Check for palmar pallor (anemia). The IMNCI guidelines provide specific pathways for malaria risk vs no malaria risk.
• Classification (as per IMNCI guidelines):
  • Generalized (No Malaria Risk or Malaria Test Negative):
    • VERY SEVERE FEBRILE DISEASE (Pink): Any general danger sign OR stiff neck.
    • FEVER: NO MALARIA (Yellow): Fever present, but no GDS, no stiff neck.
  • Malaria Risk Area (or Malaria Test Positive):
    • VERY SEVERE FEBRILE DISEASE / SEVERE COMPLICATED MALARIA (Pink): Any general danger sign OR stiff neck. (Often indicates severe malaria, meningitis, or sepsis).
    • MALARIA (Yellow): Fever (or history of fever in last 3 days in high transmission areas) AND positive malaria test OR no other obvious cause of fever in high transmission areas where tests are unavailable. No signs of very severe febrile disease.
    • FEVER: MALARIA UNLIKELY (Yellow/Green): Fever present but malaria test negative (in low/moderate risk) or other cause of fever apparent. Could still be classified as FEVER Yellow if other signs present.
  • Measles Context: Current measles or measles within 3 months + fever is also classified, looking for complications.
• Treatment (as per IMNCI guidelines):
  • Very Severe Febrile Disease/Severe Complicated Malaria: Give first dose of an appropriate pre-referral antibiotic (e.g., Ceftriaxone or Ampicillin+Gentamicin). Give first dose of an appropriate antimalarial for severe malaria (e.g., injectable Artesunate or Quinine) if suspected. Treat convulsions. Give Paracetamol for high fever (≥38.5°C). Refer URGENTLY.
  • Malaria (Yellow): Give recommended first-line oral antimalarial (e.g., ACT). Give Paracetamol for high fever. Advise on fluids and feeding. Counsel on when to return. Follow-up in 2-3 days or if fever persists. The local IMNCI guidelines will specify the antimalarial.
  • Fever: No Malaria / Malaria Unlikely (Yellow/Green): Give Paracetamol for high fever. Advise on home care (fluids, tepid sponging if very high fever, feeding). Look for other causes of fever (e.g., ear infection, UTI, pneumonia). Counsel on when to return. If fever persists >3 days, re-evaluate.
• Counseling: How to give antimalarials/antibiotics, Paracetamol for fever, importance of fluids and feeding, danger signs for immediate return (e.g., worsening, convulsions, unable to drink).
• Follow-up: For Malaria, follow-up usually in 2-3 days. If fever persists, re-assess according to IMNCI guidelines.

3.2.4 Malnutrition and Anemia

• Assessment: Look for: Visible severe wasting (very thin, no fat, skin and bones). Edema of both feet (check for pitting). Measure weight-for-height/length Z-score (WHZ) or Mid-Upper Arm Circumference (MUAC for children 6-59 months). Check for palmar pallor (sign of anemia). Check appetite (for severe acute malnutrition without medical complications). The IMNCI guidelines integrate these checks.
• Classification (as per IMNCI guidelines):
  • SEVERE COMPLICATED MALNUTRITION (Pink): Visible severe wasting OR edema of both feet OR WHZ < -3 SD OR MUAC < 115mm (for 6-59m) AND any medical complication (e.g., general danger sign, severe pneumonia, severe dehydration, high fever, severe anemia, or failed appetite test).
  • SEVERE UNCOMPLICATED MALNUTRITION (Yellow): Visible severe wasting OR edema of both feet OR WHZ < -3 SD OR MUAC < 115mm (for 6-59m) AND NO medical complications AND child passes appetite test (able to eat prescribed amount of Ready-to-Use Therapeutic Food – RUTF).
  • MODERATE ACUTE MALNUTRITION (MAM) (Yellow): WHZ between -3 and -2 SD OR MUAC between 115mm and 124mm (for 6-59m). No edema.
  • NO ACUTE MALNUTRITION (Green): WHZ ≥ -2 SD OR MUAC ≥ 125mm. No edema.
  • ANEMIA:
    • SEVERE ANEMIA (Pink/Yellow): Severe palmar pallor. (Pink if with complications, Yellow if less severe but needs referral or specific treatment not available at clinic). Often requires referral for investigation/transfusion.
    • ANEMIA (Yellow): Some palmar pallor.
    • NO ANEMIA (Green): No palmar pallor.
• Treatment (as per IMNCI guidelines):
  • Severe Complicated Malnutrition: URGENT REFERRAL for inpatient care (stabilization phase with therapeutic milks like F-75, F-100, management of infections and electrolyte imbalances).
  • Severe Uncomplicated Malnutrition: Manage in outpatient therapeutic program (OTP) with RUTF, routine medical treatment (e.g., amoxicillin, deworming, measles vaccine if due). Close follow-up.
  • Moderate Acute Malnutrition: Enroll in supplementary feeding program (SFP) if available. Nutritional counseling on enriched diet. Follow-up.
  • Severe Anemia: Refer URGENTLY (especially if signs of heart failure).
  • Anemia: Iron supplementation for 3 months, deworming, nutritional counseling on iron-rich foods. Vitamin A. Follow-up to check hemoglobin/pallor.
• Counseling: For all children, nutritional counseling is key. For malnutrition, specific advice on therapeutic/supplementary foods, frequency of feeding, hygiene. For anemia, how to give iron, iron-rich foods. The IMNCI guidelines emphasize comprehensive feeding advice.
• Follow-up: Weekly for SAM in OTP, bi-weekly/monthly for MAM, as per protocol for anemia.

3.2.5 Ear Problem

• Assessment: Ask: Does the child have an ear problem? Is there ear pain? Is there ear discharge? If yes, for how long? Look and feel for: Pus draining from the ear. Tender swelling behind the ear.
• Classification (as per IMNCI guidelines):
  • MASTOIDITIS (Pink): Tender swelling behind the ear.
  • ACUTE EAR INFECTION (Yellow): Ear pain OR pus seen draining from the ear for less than 14 days.
  • CHRONIC EAR INFECTION (Yellow): Pus seen draining from the ear for 14 days or more.
  • NO EAR INFECTION (Green): No ear pain and no ear discharge, no tender swelling.
• Treatment (as per IMNCI guidelines):
  • Mastoiditis: Give first dose of an appropriate antibiotic (e.g., injectable Ceftriaxone or Benzylpenicillin). Give Paracetamol for pain. Refer URGENTLY.
  • Acute Ear Infection: Give an oral antibiotic (e.g., Amoxicillin) for 5-7 days. Give Paracetamol for pain. Advise on home care (dry wicking if discharge). Follow-up in 5 days.
  • Chronic Ear Infection: No oral antibiotic unless other indications. Teach caregiver to dry wick the ear carefully, 3 times daily. May prescribe topical quinolone ear drops (e.g., Ciprofloxacin drops) if available as per local IMNCI guidelines. Counsel on keeping ear dry. Follow-up in 5 days.
  • No Ear Infection: No specific treatment needed.
• Counseling: How to give antibiotics/pain relief, importance of dry wicking for chronic infection, keeping water out of ear, when to return.
• Follow-up: For acute and chronic ear infections to check improvement.

3.2.6 Immunization Status and Other Problems

• Assessment: Always check the child’s immunization card or ask the caregiver about the child’s immunization status. Ask if the caregiver has any other concerns or if the child has any other problems.
• Action (as per IMNCI guidelines):
  • Provide any due immunizations according to the national schedule. If child is sick with a mild illness (e.g., Green classification), immunizations can usually be given. For severe illness (Pink), defer until recovery unless specific IMNCI guidelines advise otherwise (e.g., Measles vaccine during an outbreak even if child is moderately ill).
  • Counsel on the importance of completing the immunization schedule.
  • Address any other minor problems based on local protocols or provide appropriate advice.

4. Bereavement Counseling for Families

Despite the best efforts and adherence to IMNCI guidelines, neonatal and child deaths unfortunately occur. In these profoundly difficult moments, nurses have a crucial role in providing compassionate bereavement support to grieving families. This support can significantly impact a family’s ability to cope with their loss. Bereavement counseling is an essential, though often challenging, aspect of holistic nursing care.

4.1 Understanding Grief and Loss

Grief is a natural and multifaceted response to loss. Bereavement is the state of having lost a loved one, while mourning refers to the outward expression of grief, often influenced by cultural and social norms. When a child dies, parents and family members experience an incredibly intense and complex form of grief.

Common grief reactions include:

• Emotional: Sadness, anger, guilt, anxiety, loneliness, helplessness, shock, numbness, yearning.
• Physical: Hollowness in the stomach, tightness in chest/throat, oversensitivity to noise, fatigue, sleep disturbances, appetite changes.
• Cognitive: Disbelief, confusion, preoccupation with the deceased, difficulty concentrating, hallucinations (briefly seeing or hearing the child).
• Behavioral: Crying, social withdrawal, restlessness, treasuring objects belonging to the child.

It’s vital for nurses to understand that grief is unique to each individual and family. There is no “right” way or “normal” timeframe to grieve. Factors influencing grief include the circumstances of death (sudden vs. prolonged illness), the age of the child, the parents’ previous experiences with loss, their cultural and religious beliefs, and the strength of their support systems. While models like Kübler-Ross’s stages of grief (denial, anger, bargaining, depression, acceptance) can offer some insight, they are not linear or prescriptive, and not everyone experiences all stages or in that order. The comprehensive care implied by the IMNCI guidelines should extend to empathetic support when outcomes are unfavorable.

4.2 The Nurse’s Role in Bereavement Support

Nurses are often present during or immediately after a child’s death, placing them in a unique position to offer initial bereavement support. Key nursing actions include:

• Providing a Safe and Private Environment: Offer a quiet space for the family to grieve, away from busy clinical areas.
• Active Listening and Empathetic Presence: Being present, listening without judgment, and conveying empathy through words and actions can be incredibly comforting. Sometimes, simply sitting with the family in silence is supportive.
• Validating Feelings: Acknowledge the intensity of their pain and reassure them that their feelings are normal reactions to a devastating loss (e.g., “It’s understandable to feel so overwhelmed right now”).
• Providing Clear Information: If appropriate and desired by the family, provide honest and clear information about what happened, avoiding medical jargon. This aspect of care is important even when life-saving IMNCI guidelines could not alter the outcome.
• Facilitating Memory-Making: Offer opportunities for the family to spend time with their child, hold them, and create memories if they wish. This can include offering to take photos, create hand or footprints, or keep a lock of hair or a special blanket.
• Offering Practical Assistance: Help with practical matters like contacting other family members, clergy, or spiritual advisors, or understanding hospital procedures.
• Assessing Coping and Support Systems: Gently inquire about their support systems (family, friends, community) and assess their immediate coping abilities.
• Recognizing Complicated Grief: Be aware of signs that may indicate complicated or prolonged grief (e.g., persistent inability to function, intense suicidal thoughts) and know the referral pathways for specialized counseling or support groups.
• Self-Care for Nurses: Dealing with child loss is emotionally taxing for healthcare providers. Nurses need to practice self-care strategies and seek support from colleagues or supervisors to prevent burnout and compassion fatigue.

4.3 Communication Strategies

Effective and compassionate communication is paramount when supporting bereaved families. Small nuances in language can make a significant difference.

Key Communication Dos:

• Use the child’s name: This acknowledges the child as an individual.
• Allow for silence: Don’t feel the need to fill every pause. Silence gives space for reflection and emotion.
• Offer choices: Where possible, give families choices regarding care after death or memory-making.
• Be genuine: Authenticity is more valuable than trying to say the “perfect” thing.

Key Communication Don’ts (Avoid Clichés and Minimizing Language):

• Don’t say: “I know how you feel” (unless you truly have experienced a similar loss). Instead, try: “I can only imagine how painful this must be.”
• Don’t offer platitudes like: “It was God’s will,” “They are in a better place,” “You’re young, you can have other children,” or “At least they didn’t suffer long.” These can feel dismissive.
• Don’t minimize their pain or try to “fix” it.
• Don’t rush the conversation or appear hurried.
• Don’t be afraid to show your own emotion professionally and appropriately; it can convey genuine empathy.

If breaking bad news is part of the nurse’s role (this often falls to physicians but nurses support the process), it should be done according to established protocols (e.g., SPIKES), ensuring privacy, clarity, and support. These communication skills are as vital as the clinical skills learned through IMNCI guidelines.

4.4 Cultural Sensitivity in Bereavement Care

Grief and mourning are profoundly shaped by cultural, religious, and spiritual beliefs. Nurses must provide care that is sensitive and respectful of these diverse practices.

• Mourning Rituals: Different cultures have specific rituals related to death, burial, and mourning periods. Some may involve specific ways of handling the body, specific prayers, or community gatherings.
• Expressions of Grief: The way grief is expressed varies widely. Some cultures encourage open displays of emotion, while others value stoicism.
• Beliefs about Death: Understanding of death, the afterlife, and the meaning of loss differs across belief systems.
• Role of Family/Community: The involvement of extended family and community in bereavement support can vary.

To provide culturally sensitive care:

• Ask, Don’t Assume: Respectfully ask the family about any specific cultural, religious, or spiritual needs or practices they would like to observe (e.g., “Are there any specific rituals or practices that are important to you at this time?”).
• Be Flexible: Accommodate requests for rituals or family presence whenever possible within hospital policy.
• Access Resources: Utilize hospital chaplains, spiritual care services, or cultural liaisons if available and desired by the family.
• Self-Awareness: Be aware of your own cultural biases and how they might influence your interactions.

Respecting these differences is fundamental to providing truly family-centered bereavement care, a principle that complements the child-focused IMNCI guidelines.

5. Practical Application: Case Studies and Scenarios

The following case studies and scenarios are designed to help you, as nursing students, integrate your knowledge of the IMNCI guidelines and bereavement counseling principles. Consider how you would apply the Assess-Classify-Treat-Counsel-Follow-up framework and compassionate care in each situation.

Case Study 1: Child with Severe Pneumonia and Malnutrition

Description: Amina, a 1-year-old (12 months) girl, is brought to your rural health clinic by her distressed mother. The mother reports Amina has had a cough for 4 days, is breathing fast, and “doesn’t want to eat.” On examination, you note Amina is lethargic. Her respiratory rate is 56 breaths/minute. You observe chest in-drawing. She appears very thin with visible severe wasting (ribs prominent, very little subcutaneous fat). You check for palmar pallor, which is present. Her temperature is 38.0°C. Her immunization card shows she is up-to-date.

Discussion Points/Questions for Students:

1. Assessment:
   • What are the general danger signs present? (Lethargy is a general danger sign).
   • What are the signs related to cough/difficult breathing? (Cough, fast breathing for her age [threshold for 12m-5y is ≥40/min, she has 56/min], chest in-drawing).
   • What are the signs of malnutrition? (Visible severe wasting, mother reports poor appetite). Lack of WHZ/MUAC here means relying on visible signs initially.
   • Any signs of anemia? (Palmar pallor).
2. Classification (based on IMNCI guidelines):
   • For cough/difficult breathing: Presence of a general danger sign (lethargy) and chest in-drawing classifies her as SEVERE PNEUMONIA OR VERY SEVERE DISEASE (Pink).
   • For nutritional status: Visible severe wasting with a medical complication (severe pneumonia, lethargy) classifies her as SEVERE COMPLICATED MALNUTRITION (Pink).
   • For anemia: Palmar pallor suggests ANEMIA (Yellow), but in context of severe illness, this would be managed as part of overall referral.
3. Immediate Treatments and Pre-referral Care (as per IMNCI guidelines):
   • URGENT REFERRAL to hospital.
   • Give first dose of an appropriate antibiotic for severe pneumonia (e.g., injectable Ampicillin + Gentamicin, or Benzylpenicillin as per local IMNCI guidelines). If oral Amoxicillin is the only pre-referral option and child is lethargic, this is challenging and highlights referral urgency.
   • Treat fever: Give Paracetamol.
   • Address potential hypoglycemia due to poor feeding and severe illness: Offer breastmilk or sugar water carefully if able to swallow; otherwise, this needs IV at referral.
   • Keep warm.
4. Counseling Messages for Mother:
   • Explain clearly and calmly why Amina needs to go to the hospital immediately (she is very sick and needs special care).
   • Explain any pre-referral treatments given.
   • Advise on how to keep Amina warm and continue offering fluids/breastmilk during transport.
   • Reassure her and address her distress empathetically while emphasizing the need for quick action.
5. Addressing Mother’s Distress: Acknowledge her worry. Speak calmly. Provide clear reasons for referral. Offer practical support for referral if possible (e.g., helping arrange transport).

Scenario 1: Neonatal Death and Supporting the Family

Description: Baby David, born at 36 weeks gestation, develops severe respiratory distress shortly after birth. Despite resuscitation efforts and adherence to neonatal care protocols (part of comprehensive IMNCI guidelines for young infants), he sadly passes away within two hours of birth. His parents, Sarah and Tom, are present and are visibly devastated.

Nursing Actions/Considerations for Students:

1. Immediate Priorities:
   • Ensure a private, quiet space for Sarah and Tom.
   • Offer your condolences sincerely (“I am so very sorry for the loss of your baby, David.”).
   • Provide empathetic presence; be there for them.
   • Assess their immediate emotional and physical needs (e.g., offering water, a comfortable chair).
2. Communication (Supporting Physician or Leading if appropriate):
   • Use clear, gentle language. Refer to baby David by his name.
   • Allow them to express their emotions freely. Listen more than you talk.
   • Avoid clichés or minimizing their pain.
   • Answer their questions honestly if they have any, or facilitate communication with the physician.
3. Memory-Making Opportunities:
   • Ask if they would like to hold David. Prepare him gently (e.g., wrapped in a warm blanket).
   • Offer to take handprints, footprints, or a lock of hair.
   • Offer to take photographs if they wish.
   • Respect their decision if they decline these offers.
4. Cultural Considerations:
   • Gently ask if they have any specific cultural or religious rituals they would like to observe or if they would like a chaplain/spiritual advisor contacted.
5. Applying Empathetic Principles: Focus on active listening, validation of their feelings, and non-judgmental support. The human connection is paramount, beyond specific IMNCI guidelines for clinical care.
6. Follow-up Bereavement Support:
   • Provide information on available bereavement support services or counseling (hospital social worker, support groups).
   • Explain any necessary administrative procedures gently.
   • If appropriate within your facility, arrange for a follow-up call or visit.

Case Study 2: Child with Dehydrating Diarrhea and Fever in Malaria Area

Description: Four-year-old Kofi is brought to the clinic with a 3-day history of watery diarrhea (6-8 stools/day) and fever. They live in a high malaria transmission area. Kofi is restless and irritable. His eyes are sunken, and he drinks water eagerly when offered. A skin pinch on his abdomen goes back slowly. His temperature is 39°C. No GDS. Rapid diagnostic test (RDT) for malaria is positive.

Discussion Points/Questions for Students:

1. Assessment: Key signs for diarrhea/dehydration? Signs for fever/malaria?
2. Classification (using IMNCI guidelines): How would you classify his dehydration status? How for fever/malaria?
3. Treatment Plan: What is the IMNCI Plan for his dehydration? What antimalarial is appropriate? How to manage fever? Detail the fluids and drug administration. Importance of zinc.
4. Counseling: What are the key messages for Kofi’s mother regarding home care (fluids, feeding, medication, danger signs)? Adherence to IMNCI guidelines for counseling is vital.
5. Follow-up: When should Kofi return for follow-up for diarrhea and malaria?

Scenario 2: Young Infant with Possible Serious Bacterial Infection (PSBI)

Description: A 15-day-old infant, Maria, is brought in by her grandmother. The grandmother reports Maria “has not been feeding well” for the past day and “feels hot.” On examination, Maria’s axillary temperature is 37.8°C. She moves only when stimulated and her breathing rate is 65/minute. You do not observe severe chest in-drawing. Umbilicus appears clean.

Discussion Points/Questions for Students:

1. Assessment: What are the key signs of severe illness in this young infant according to IMNCI guidelines?
2. Classification: How would you classify Maria’s illness?
3. Management: What immediate actions are critical? What pre-referral treatments are indicated by the IMNCI guidelines?
4. Counseling: What do you urgently need to explain to the grandmother?

Case Study 3: Caregiver Counseling Challenge – Resistance to Referral

Description: You have assessed 8-month-old Omar who has cough and difficult breathing. He has chest in-drawing and his breathing is 60/minute. You classify him as SEVERE PNEUMONIA (Pink) and explain to his mother that he needs urgent referral to the hospital. The mother is hesitant, saying the hospital is far, expensive, and she has other children at home to care for. Previous experiences at the hospital were not positive for her.

Nursing Actions/Considerations for Students:

1. Empathetic Communication: How would you acknowledge her concerns while still emphasizing the seriousness of Omar’s condition?
2. Reinforcing Need for Referral: How can you use your knowledge of IMNCI guidelines to explain the risks of not going to the hospital?
3. Problem-Solving: Can you help her explore solutions for transport, childcare, or cost (if any clinic/community support exists)?
4. Building Trust: How can you build trust to encourage adherence to the referral advice?
5. Documentation: If she ultimately refuses referral despite all efforts, how would you document this (while still providing any possible interim care as per “referral not possible” protocols in IMNCI guidelines, if applicable and safe)?

6. (Optional) Global Best Practices in IMNCI and Bereavement Support

The implementation of IMNCI guidelines and bereavement support varies globally, but successful programs often share common themes of adaptation to local contexts, strong community involvement, and continuous quality improvement. Sharing these can inspire innovation and better practice.

IMNCI Implementation:

• Country-Level Adaptation: Successful countries often meticulously adapt the generic IMNCI guidelines to their specific epidemiological profile, health system capacity, and cultural context. For example, India’s adaptation (F-IMNCI – Facility-Based IMNCI) includes facility-specific elements. (NHM India)
• Community IMNCI (c-IMCI): Extending care beyond facilities, c-IMCI involves training community health workers (CHWs) to identify sick children, provide home-based care for mild conditions, recognize danger signs, and facilitate timely referral. This has been impactful in areas with limited access to health facilities.
• Use of mHealth and eHealth: Mobile applications and digital tools are increasingly used to support health workers in adhering to IMNCI guidelines, for data collection, and for remote supervision. For example, some tools help with correct classification or drug dosage calculation. (e-IMNCI tool example)
• Integrated Training: Combining IMNCI training with other essential child health interventions like nutrition programs or Expanded Program on Immunization (EPI) can be more efficient.
• Quality Improvement Collaboratives: Regular meetings, data review, and peer learning among health workers to improve adherence to IMNCI guidelines and problem-solve implementation challenges.
• Evidence from Zimbabwe: Studies in countries like Zimbabwe have examined the effect of the IMNCI strategy, highlighting improvements in child survival in contexts with high mortality rates. (NCBI PMC)

Bereavement Support:

• Culturally Tailored Programs: Developing bereavement support services that respect and incorporate local cultural and religious mourning practices. This includes training healthcare providers in culturally competent communication.
• Peer Support Groups: Connecting bereaved parents with others who have experienced similar losses can provide invaluable emotional support and reduce feelings of isolation.
• Hospital-Based Bereavement Teams: Some hospitals have dedicated multidisciplinary teams (nurses, doctors, social workers, chaplains) to provide comprehensive bereavement care, from the moment of death through follow-up.
• Memory-Making Initiatives: Standardizing and sensitizing staff to routinely offer memory-making options (photos, hand/footprints, memory boxes).
• Training for Healthcare Professionals: Specific training modules for nurses and doctors on breaking bad news, empathetic communication, and self-care when dealing with patient death. (NCBI Bookshelf – Grief and Loss)
• Acknowledging Sibling Grief: Providing resources or guidance for parents on how to support grieving siblings.

Learning from these global experiences can help refine and improve local implementation of IMNCI guidelines and bereavement care practices, ultimately benefiting children and their families.

7. Conclusion: Empowering Nursing Students

The Integrated Management of Neonatal and Childhood Illnesses strategy is more than just a set of protocols; it is a powerful, evidence-based approach that has saved millions of young lives globally. For you, as nursing students, mastering the IMNCI guidelines and developing skills in compassionate bereavement counseling are fundamental to providing high-quality, holistic care to children and their families. The journey through understanding assessment, classification, treatment, and counseling, guided by the structured yet adaptable framework of IMNCI, will equip you to face common pediatric challenges with confidence and competence.

Nurses stand at the forefront of child health, often serving as the first and most consistent point of contact for families in need. Your ability to accurately apply the IMNCI guidelines, to communicate effectively, to advocate for your young patients, and to provide comfort in times of profound loss, will define the impact you make. The challenges are significant, but so too is the potential for positive change. Embrace the knowledge and skills presented in this guide, commit to continuous learning, and remember that your dedication will contribute to healthier futures for children everywhere. The consistent and skilled application of IMNCI guidelines is a critical tool in this endeavor.

8. References

(Note: This is an illustrative list based on the provided search snippets. A full article would require more comprehensive and specific citations. URLs are based on information available in the search results.)

• World Health Organization (WHO). (n.d.). Integrated management of childhood illness. https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/child-health/integrated-management-of-childhood-illness
• WHO Eastern Mediterranean Regional Office (EMRO). (n.d.). The three components of IMCI. https://www.emro.who.int/child-health/imci-strategy/three-components.html
• National Health Mission (NHM), India. (n.d.). Integrated Management of Neonatal & Childhood Illnesses. https://nhm.gov.in/index4.php?lang=1&level=0&linkid=493&lid=759
• Chisumpa, V. H., Odland, J. Ø., & Krettek, A. (2024). Integrated management of neonatal and childhood illness strategy implementation in Zimbabwe: A multifaceted analysis. *PLOS Global Public Health, 4*(3), e0002148. https://pmc.ncbi.nlm.nih.gov/articles/PMC10021544/
• Open University. (n.d.). Integrated Management of newborn and Childhood Illness Module. (General reference to Open University IMNCI materials seen in search results) Example OpenLearn Create Link
• Pandey, D., et al. (2023). E-IMNCI: a novel clinical diagnostic support system approach to improve quality of IMNCI service delivery. *BMC Medical Informatics and Decision Making, 23*(1), 238. https://pmc.ncbi.nlm.nih.gov/articles/PMC10603548/
• NCBI Bookshelf. (n.d.). *Chapter 17 Grief and Loss – Nursing Fundamentals.* https://www.ncbi.nlm.nih.gov/books/NBK591827/ (Illustrative for bereavement topics)
• NCBI Bookshelf. (n.d.). *Nursing Grief and Loss – StatPearls.* https://www.ncbi.nlm.nih.gov/books/NBK518989/ (Illustrative for bereavement topics)
• WHO/UNICEF. (Various Years). *IMNCI Chart Booklet* (General reference – specific versions vary by country and year, e.g., the 2014 version). Many search results pointed to Chart Booklets from WHO or NHM India.
• Fondation Mérieux. (2019). *WHO/UNICEF Integrated Management of Childhood Illness (IMCI) Perspective and Future Directions.* (Referencing a presentation PDF on IMCI). Link to PDF

9. Further Reading

• WHO IMNCI Main Page: For the latest IMNCI guidelines, resources, training materials, and updates. WHO Child Health – IMCI
• UNICEF Child Health Page: Information on UNICEF’s role in child survival and IMNCI implementation. UNICEF Health
• IMNCI Chart Booklets: Search for your country-specific “IMNCI Chart Booklet” or the generic WHO versions. These are essential field guides for applying IMNCI guidelines. An example is the Indian NHM chart booklet. NHM India IMNCI Chart Booklet (PDF)
• Textbooks on Pediatric Nursing:
  • Wong’s Nursing Care of Infants and Children by Hockenberry, M.J., Wilson, D., & Rodgers, C.C.
  • Maternal Child Nursing Care by Perry, S.E., Hockenberry, M.J., Lowdermilk, D.L., & Wilson, D.
• Resources on Grief and Bereavement:
  • The Dougy Center: The National Center for Grieving Children & Families (www.dougy.org)
  • Compassionate Friends: Supporting Family After a Child Dies (www.compassionatefriends.org)