Middle - Mortality Areas: Integrated Management of Childhood Illnesses
Middle - Mortality Areas: Integrated Management of Childhood Illnesses
Middle - Mortality Areas: Integrated Management of Childhood Illnesses
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1
8
2.02
Integrated Management of Childhood Illnesses
09/30/16
Dr. Ma. Eufemia Collao
OUTLINE
I.
Regional Child Survival Strategy
Middle-‐mortality
areas
a. Overall health status of children 1%
b. Immediate causes of death Other
incl.
injuries
c. Essential package of child survival
interventions 18% 20% Neonatal
Conditions
II. IMCI
ARI
a. IMCI components 13%
b. Integrated case management process Diarrhea
III. IMCI For Young Children (2 Mos – 5 Yrs)
a. General danger signs 48% Measles
b. Four main symptoms
c. Malnutrion and anemia
d. HIV infection
IV. Child’s Immunization and Vitamin A
V. Assess Other Problems
VI. Essential Drugs and Supply
VII. IMCI For Young Infants up to 2 Months
REGIONAL CHILD SURVIVAL STRATEGY
OVERALL HEALTH STATUS OF CHILDREN IN WPR
TREND IN INFANT MORTALITY REDUCTION TOWARDS
TARGET 2015 MDG, WPR
• Philippines positioned towards the middle
• Reduction of IMR from 1990 to 2002 has been quite
substantial but needs to be lowered further
• IMR is still far from the targeted reduction by 2015.
• Philippines is better off in IMR reduction compared to Lao,
Papua New Guinea, Cambodia and other countries
• Lagging behind the reduction achieved by Japan,
Singapore, Korea and other countries
• Deaths in perinatal and neonatal periods dominate the U5MR
UNDER FIVE MORTALITY RATE
• The perinatal period - highest number of disabilities
• Highest risk - first day of birth
• 40 - 80% of neonatal deaths – due to low birth weight
• Malnutrition is the highest attributable causal factor of all
childhood deaths in children under 5
• Diarrhea and Acute Respiratory Infection (ARI) -most important
immediate causes of death from communicable diseases
PREDISPOSING FACTORS
1. Inadequate Care for Women
Currently, most women seek antenatal care (ANC) in the
2nd or 3rd trimester
2. High Fertility, Poor Birth Spacing
2.5 times chance of surviving infancy if >3 years interval
3. Community and Environment
• Indoor, outdoor and personal hygiene are major
contributors to ARI/CDD
• Positioned at the middle • Parentless/orphans are 6-7 times greater chance of dying
• Philippines has lower UFMR than Cambodia, Papua New in infancy
Guinea, Lao, etc.
• Worse than Vietnam, Singapore, Japan, Malaysia 4. Improper Infant and Young Child Feeding
• The transition between intrauterine and extrauterine life
IMMEDIATE CAUSES OF DEATH • Infants not breastfed have 6-fold increased chance of dying
in first two months
High-‐mortality
areas • Protection against infections
2% 1% 5. Lack of Access to Safe Water, Sanitation
Other
incl.
injuries • WPRO/ EAPRO has 3 of the 10 countries ‘worst off’ for
Neonatal
Conditions water safety (Cambodia, PNG, Laos)
18% 27% • Cambodia worst off in toilet sanitation
ARI • 1 billion people in the region live without adequate
sanitation = 305,000 metric tons of fresh excreta deposited
20% Diarrhea outside each day
32% Measles 6. Lack of Access to Basic Social Services
• Pockets of poor immunization rates, poor access to
HIV/AIDS
appropriate management of diarrhea and pneumonia
Page 1 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
UNDERLYING CAUSES - Iron supplementation
- Iodine
1. Undernutrition supplementation –
• Conditions interfering with nutrient absorption that lead to iodized salt
deficiencies prior to and throughout pregnancy (e.g., malaria, - For kids-EPI - would prevent
hookworm, Tb, utis, HIV/AIDS, etc.) (5) - For moms- Tetanus approximately
Low Birth Weight toxoid schedule: 3% of child
Immunization of
o Significantly increased mortality risk in the neonatal and early 5dose: 1st prenatal, 4 deaths
children and
infancy period wks after, 6 wks after,
o Cognitive function impairment mothers
1 year after, Another
o Predicts underweight later in life year after
o Risk for adult diseases - Case management of - save
(6) diarrhea à save approximately
2. Poor intrauterine nutrition Integrated approx. 21% of child 21% of child
Stunting management of lives lives
• Persists into adulthood sick children - Case management of
• Intergenerational effect: associated with an increase in pneumonia and
surgically assisted births, and birth of LBW babies neonatal sepsis
• Associated with poor cognitive and motor development (7) - reduce child
Use of mortality by
3. Increasing inequity insecticide approximately
• Poor being marginalized in the delivery of health care treated bed nets 13%
• Inequity within countries often large in malarious
areas
CHILD SURVIVAL ACTIONS BY COUNTRY GROUP
GROUP INTERVENTION
1: Laos, • Essential package for child survival
Cambodia, • Deworming of children 6-59 mos. and
Papua New pregnant women
Guinea
2: Philippines, • Essential package for child survival w/
Vietnam, geographic targeting in underserved areas
China • Institutional deliveries w/ comprehensive
newborn care
• Deworming of children 6-59 months, and
4. Policy environment pregnant women
• Lack of supportive laws or poor implementation of the laws • Promotion of childhood safety
• There isn’t much laws to support the marginalized sector of the • Introduction of new or underused vaccines
community (HiB, rotavirus, conjugate pneumococcal
vaccine)
5. Constraints financing for child survival 3: Japan, • Essential package for child survival with
• Public spending in health is only 1.9 % of GDP in comparison South Korea, targeting of the socio-economically
to global average of 3.2 % Australia underprivileged and marginalized
• Policies not driven by concepts of public goods, or of human • Institutional deliveries with newborn care
rights based approaches • Promotion of child safety
• Introduction of new or underused vaccines
6. Human resource constraints (HiB, rotavirus, conjugate pneumococcal
• Underpaid, demotivated health workers vaccine)
• Inequitably distributed
7. Social norms and gender issues INTEGRATED MANAGEMENT OF
• Women are underfed, poorly educated, overworked CHILDHOOD ILLNESSES (IMCI)
ESSENTIAL PACKAGE OF CHILD SURVIVAL **From 3B 2016
INTERVENTIONS • Strategy has been introduced in an increasing number of
countries in the region since 1995
Package Notes Rationale • A major strategy for child survival, healthy growth and
(1) - Antenatal care - prevent development
Skilled - Skilled attendance at approximately • Based on the combined delivery of essential interventions at
attendance delivery 13% of child community, health facility and health systems levels
during - Immediate deaths • Includes elements of prevention as well as curative and
pregnancy, postpartum care addresses the most common conditions that affect young
childbirth and - Includes facilities as children
immediate well • Strategy was developed by the World Health Organization
postpartum (WHO) and United Nations Children’s Fund (UNICEF)
- Early initiation of - would prevent • In the Philippines, IMCI was started on a pilot basis in 1996,
breastfeeding (within approximately thereafter more health workers and hospital staff were
(2) capacitated to implement the strategy at the frontline level
one hour of birth) 20% of child
Care of the • Vigorous implementation in the country only started in 2005
- Temperature control deaths
newborn • Why INTEGRATED?
(36.5 °C - < 37.5°C)
- Low birth weight o There are important relationships between the illnesses
management o Effective case management needs to consider all of the child’s
- Exclusive symptoms so that any problem of the child will not be overlooked
breastfeeding up to 6
(3)
mos. of age;; not even
Breastfeeding
water is given
and
- 8 feedings in a day
complementary
- When is the best time
feeding
to give complefood?
When CN X and CN
XI are already intact
(4) - Vitamin A
Micronutrient supplementation (6-
supplementation 59 months old)
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FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
CAUSE OF DEATHS AMONG CHILDREN UNDER FIVE YEARS o Psychosocial stimulation
OLD • For disease prevention
o Immunization
o Handwashing
o Sanitary disposal of feces
o Use of insecticide-treated bednets
o Dengue prevention and control
• For appropriate home care
o Continue feeding
o Increase fluid intake
o Appropriate home treatment
• For seeking care
o Follow health workers advice
o When to seek care
o Prenatal consultation
o Postnatal (postpartum)
consultation
INTEGRATED CASE MANAGEMENT PROCESS
In doc’s ppt (2000 PH Health Statistics):
1. Pneumonia
2. Accidents
3. Septicemia
4. Measles
5. Nutritional disorders
6. Diarrhea
7. Meningitis
8. Congenital anomalies
9. Malignant neoplasm
10. Perinatal causes
SITUATION IN FIRST-LEVEL HEALTH FACILITIES
• Overlap of conditions
• Irregular flow of patients
• Diagnostic tools are minimal or non-existent
• Drugs and equipment are scarce
• Health workers have few opportunities to practice complicated
clinical procedures
• Relies on history and signs and symptoms
FEATURES OF IMCI 1. Assess the child or young infant
• Check for danger signs
• Not necessarily dependent on the use of sophisticated and • Ask about the main symptoms
expensive technologies • If a main symptom is reported, assess further
• A more integrated approach to managing sick children • Check nutrition and Immunization status
• Move beyond addressing single diseases to addressing the • Check for other problems
overall health and well-being of the child 2. Classify the condition
• Careful and systematic assessment of common symptoms and 3. Identify treatment actions (color coded)
specific clinical signs to guide rational and effective actions • PINK (urgent hospital referral/admission)
• Integrates management of most common childhood problems o Identify urgent pre-referral treatments- needed prior to
(pneumonia, diarrhea, measles, malaria, dengue hemorrhagic referral of the child according to classification
fever, malnutrition and anemia, ear problems) • YELLOW (Outpatient Treatment)
• Adjusts curative interventions to the capacity and functions of the o Identify treatment need for the child’s classification;;
health system (evidence-based syndromic approach) identify specific medical treatments and/or advice
• Involves family members and the community in the health care • GREEN (supportive home care)
process 4. Treat the child
• Treat the child- give urgent pre-referral treatments needed
OBJECTIVES OF IMCI • Refer the child
Explain
to
the
child’s
caretaker
the
need
1. Reduce deaths and frequency and severity of illness and • for referral
disability • Treat the child
2. Contribute to the growth and development of children • Give the first dose of oral drugs in the clinic and/or advice the
child’s caretaker
COMPONENTS OF IMCI • Teach the caretaker how to give oral drugs and how to treat
1. Improving case • Standard guidelines the local infections at home
management • Training (pre-service/in-service) • If needed, give immunizations
skills of health • Follow-up after training 5. Counsel the mother
workers • Role of private providers • Assess the child’s feeding, including breast-feeding practices
2. Improving the • Essential drug supply and and solve feeding problems, if present
health system to management • Advise about feeding and fluids during illness and about
deliver IMCI • Organization of work in health when to return to a health facility
facilities • Counsel the mother about her own health
• Management and supervision 6 Give follow-up care
• Referral system
3. Improving TARGETS
• For physical growth and mental
family and development
community o Breastfeeding 1. Young Infants - Age 1 week up to 2 months
practices 2. Young Children - Age 2 months up to 5 yrs
o Complementary feeding
o Micronutrient supplementation • 2 months up to 12 months
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FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
• 12 months up to 5 years Tablet Syrup Tablet Syrup
80mg TMP 40mg TMP 250mg 125mg/5
IMCI FOR YOUNG CHILDREN (2 MOS – 5 YRS) 400mg SMX 200mg SMX mL
2-12m 1/2 5.0mL 1/2 5.0mL
12m-5y 1 7.5mL 1 10.0mL
GENERAL DANGER SIGNS
1. Lethargy or unconsciousness
VITAMIN A SUPPLEMENTATION FOR PNEUMONIA/VERY
• Assessed by clapping, moving the extremities
SEVERE DISEASE
2. Inability to drink or breastfeed
• Poor attachment, inability to suck Age 100,000 IU Vit. A 200,000IU Vit. A
3. Vomiting 6-12mos 1 capsule 1/2 capsule
• Vomits everything that he intakes 12mos-5yrs 2 capsules 2 capsule
4. Convulsions
GIVE INHALED SALBUTAMOL FOR WHEEZING
FOUR MAIN SYMPTOMS USE OF A SPACER*
• A spacer is a way of delivering the bronchodilator drugs
1. Cough and difficulty of breathing effectively into the lungs. No child under 5 years should be
2. Diarrhea given an inhaler without a spacer. A spacer works as well as a
3. Fever nebuliser if correctly used.
4. Ear problem o From salbutamol metered dose inhaler (100 mcg/puff)
give 2 puffs.
COUGH AND DIFFICULTY OF BREATHING o Repeat up to 3 times every 15 minutes before classifying
• Observe for subcostal retractions, nasal flaring, grunting, pneumonia.
and stridor • Spacers can be made in the following way:
• Respiratory rate o Use a 500ml drink bottle or similar.
Cut a hole in the bottle
o Less than 2 months: ≥ 60 base in the same shape as the mouthpiece of the
o 2-12 months: ≥50 inhaler.
This can be done using a sharp knife.
Cut the bottle
o 12 months to 5 years: ≥40 between the upper quarter and the lower 3/4 and disregard
Classify as… the upper quarter of the bottle.
Cut a small V in the border of
the large open part of the bottle to fit to the child's nose and
be used as a mask.
Flame the edge of the cut bottle with a
candle or a lighter to soften it.
In a small baby, a mask can
be made by making a similar hole in a plastic (not
polystyrene) cup. Alternatively commercial spacers can be
used if available.
• To use an inhaler with a spacer:
o Remove the inhaler cap. Shake the inhaler well.
o Insert mouthpiece of the inhaler through the hole in the bottle
or plastic cup.
o The child should put the opening of the bottle into his mouth
and breath in and out through the mouth.
o A carer then presses down the inhaler and sprays into the
bottle while the child continues to breath normally.
o Wait for three to four breaths and repeat.
o For younger children place the cup over the child's mouth
and use as a spacer in the same way.
* If a spacer is being used for the first time, it should be primed
by 4-5 extra puffs from the inhaler.
DIARRHEA
• Loose, watery stools (3 or more times)
• Dehydration
o General condition (active? restless/irritable?
lethargic?)
o Sunken fontanels
o Sunken eyes (ask if nangangalumata or hindi?)
o Thirst : Offer the child fluid then check if child is
not able to drink or drinking poorly?
o Skin elasticity (pinch the para-rectal area of
abdomen, along the line, for 1 second then let go
to observe
*If pulse oximeter is available, determine oxygen saturation and Normal: Goes back immediately
refer if < 90%.
Slow: 2 secs
** If referral is not possible, manage the child as described in the Very slow: ≥ 3 secs
pneumonia section of the national referral guidelines or as in WHO • Persistent diarrhea
Pocket Book for hospital care for children. o Diarrhea lasting ≥ 2 weeks
***Oral Amoxicillin for 3 days could be used in patients with fast • Dysentery
breathing but no chest indrawing in low HIV settings.
o Diarrhea with blood in the stool, with or without
**** In settings where inhaled bronchodilator is not available, oral mucus
salbutamol may be tried but not recommended for treatement of o In the Philippines, most common cause is
severe acute wheeze. Shigella and NOT Amebiasis
TREATMENT
• Soothe the Throat, Relieve the Cough with a Safe Remedy
• Safe remedies to recommend:
o Breastmilk for exclusively breastfed infant
o TLC (tamarind, luya, calamansi)
• Harmful remedies to discourage:
o Codeine cough syrup
o Other cough syrups
• Oral and nasal decongestants
Tx FOR PNEUMONIA OR VERY SEVERE DISEASE
Age Cotrimoxazole Amoxicillin
q 12 hours x 5 days q 8hrs x 5 days
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FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
CLASSIFICATION FOR DEHYDRATION • Rehydration therapy using IV fluids or using a nasogastric tube
(NGT) is recommended ONLY for children who have SEVERE
DEHYDRATION.
• The treatment of the severely dehydrated child depends on:
o the type of equipment available at your clinic, or at a nearby
clinic or hospital;;
o the training you have received;; and
o whether the child can drink
SOME DEHYDRATION- TREATMENT PLAN B
(Determine amount of ORS to be given in 4 hours)
Age Up to 4 mos 4 mos-12 12 mos-2 2 years-
mos years 5years
Weight < 6 kg 6- <10 kg 10- <12 12-19 kg
kg
In mL 200-400 400-700 700-900 900-14000
• The approximate amount of ORS can also be calculated by
multiplying the child’s weight (in kg) by 75.
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then continue, but more
slowly.
• Continue giving extra fluids until the diarrhea stops.
• Reassess after 4 hours and classify the child for dehydration.
If the mother must leave before completing treatment:
• show her how to prepare the ORS solution at home
• show her how much to give to finish the 4 hour treatment at
home
• give her enough ORS packets to complete rehydration
NO DEHYDRATION- TREATMENT PLAN A
AGE AMOUNT OF FLUID TYPE OF FLUID
< 2 yrs 50-100 ml (¼-½ cup) after ORS, rice water,
each loose stool yogurt, soup with
salt
THREE RULES OF HOME TREATMENT 2-10 yrs 100-200 ml (½-1 cup) after
1. Give extra fluid each loose stool
2. Continue feeding • Explain to the mother that the diarrhea should stop soon.
3. Return immediately if the child develops danger signs • ORS solution will not stop diarrhea. It replaces the fluid and
WHAT TO TELL TO THE MOTHER salts the child loses for every loose stool and prevents the
• Breastfeed frequently and longer for each feed child from getting sicker.
• If the child is exclusively breastfed, give ORS or clean water TELL THE MOTHER TO
in addition to breastmilk • Give frequent small sips from a cup or spoon. Use a spoon to
• If the child is exclusively breastfed, it is important for this child give fluid to a young child.
to be breastfed more frequently than usual. Also give ORS • If the child vomits, wait 10 minutes before giving more fluid.
solution or clean water. Then resume giving the fluid, but more slowly.
• Breastfed children under 4 months should first be offered a • Continue giving extra fluid until the diarrhea stops.
breastfeed, then given ORS.
• If the child is NOT exclusively breastfed, give 1 or more of the
following: CLASSIFICATION FOR PERSISTENT DIARRHEA
o ORS
o Food-based fluids
o Clean Water
• In most cases, a child who is not dehydrated does not really
need ORS solution. Give him extra food-based fluids such as
soups, rice water or “am” and yoghurt drinks and clean water
(preferably given along with food).
SEVERE DEHYDRATION- TREATMENT PLAN C
AGE INITIAL PHASE SUBSEQUENT PHASE
(30 ml/kg) (70 ml/kg)
Infants 1 hour 5 hours
(<12 mos)
Older children 30 minutes 2 ½ hours
*Repeat once if radial pulse is still very weak or
After 5 days: Ask:
imperceptible.
• If the diarrhea has NOT stopped (3 or more stools) does a full
• Reassess the child every 1-2 hours. If hydration status is not
reassessment, give the treatment, and then refer to hospital.
improving, give the IV drip more rapidly.
• If the diarrhea has stopped (< 3 stools per day), tell the mother to
• Also give ORS (5ml/kg/hr) as soon as the child can drink.
follow the usual feeding recommendations for the child’s age.
• Reassess the infant after 6 hours & a child after 3 hours.
Classify dehydration. CLASSIFICATION FOR DYSENTERY
If trained to use a nasogastric tube for rehydration?
• Start hydration by tube (or mouth) with ORS solution. Give
(20ml/kg/hr) for 6 hours. (Total of 120ml/kg)
• Reassess the child every 2 hours.
o If there is repeated vomiting or increasing abdominal After 2 days: Ask:
distention, give the fluid more slowly. • if the child is dehydrated, treat hydration
o If hydration status is not improving after 3 hours, send the • if the number of stools, amount of stools, fever, abdominal pain
child for IV therapy. or eating is same or worse:
• After 6 hours, reassess the child. Classify dehydration. o Change to 2nd line antibiotics & give for 5 days
• Can you give Intravenous fluids (IV) immediately? o Advise to return in 2 days
• Severely dehydrated children need to have water and salts EXCEPTIONS to treating dysentery for Shigella with the
quickly replaced. second-line oral antibiotic:
• Intravenous fluids are usually used for this purpose. 1. Child is less than 12 months old
2. Was dehydrated on the first visit
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FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
3. Had measles within the last 3 months CLASSIFICATION FOR HIGH OR LOW RISK MALARIA
Treatment:
• Refer urgently to the hospital: • Give first dose quinine
• If fewer stools, less blood in stools, less fever, less abdominal for severe malaria
pain & eating better, continue antibiotics. (under medical
supervision or if a
FEVER hospital is not
• Axillary: ≥ 37.5 °C accessible within 4
• If thermometer is not available, use the back of the hand hours)
to feel the abdomen and armpit • Give first dose of
• Check for Stiff neck (place baby comfortably seated on appropriate antibiotic
• Any general VERY SEVERE • Treat the child to
mother’s lap, then drop a ball in front of the child and danger sign FEBRILE
observe if he will follow the ball falling, his chin touching prevent low blood
• Stiff Neck DISEASE sugar
his neck baseà no stiff neck)
• Give one dose of
• Risk of malaria and other endemic infections, e.g.
dengue hemorrhagic fever (for malaria, ask for history of Paracetamol in health
travel to endemic place w/in 1 month) center for high fever
• Measles (ask for history 3 months back) (38.5C or above)
• Duration of fever (e.g. typhoid fever – remittent ang fever • Send a blood smear
pattern meaning bumababa pero hindi nag-normal ang with the patient
temperature) • Refer URGENTLY to a
ASSESS FEVER hospital
• A child has the main symptom of fever if:
o the child has history of fever • Give recommended
o the child feels hot first line oral
o the child has an axillary temperature of 37.5 or above antimalarial
• Does the child have fever? (By history, or feels hot or • Give one dose of
temperature 37.5C and above) paracetamol in clinic
for high fever (38.5°C
Decide Malaria Risk: Ask:
or above)
o Does the child live in a malaria area?
• Give appropriate
o Has the child visited malaria area in the past 4 weeks?
antibiotic treatment for an
o If yes to either, obtain a blood smear. • Malaria test
MALARIA identified bacterial cause
• Then ask POSITIVE
of fever
o For how long does the child have fever?
• Advise mother when to
o If >7 days, has the fever been present every day?
return immediately
o Has the child had measles within the last 3 months?
• Follow-up in 3 days if
• Look and Feel:
fever persists
o Look and feel for stiff neck.
o Look for runny nose • If fever is present
everyday for more than 7
• Look for signs of Measles:
days, REFER for
o Generalized rash.
assessment
o One of these: cough, runny nose or red eyes
• Give one dose of
• If the child has MEASLES now or within the last three
paracetamol in clinic
months:
for high fever (38.5°C
o Look for mouth ulcers.
or above)
o Are they deep and extensive?
o Look for pus draining from the eye. • Give appropriate
• Malaria test antibiotic treatment for
• Look for clouding of the cornea
NEGATIVE any identified bacterial
Decide Dengue Risk: Yes or No
• Other FEVER – NO cause of fever
If Dengue Risk:
causes of MALARIA • Advise mother when to
• Then Ask:
fever return immediately
o Has the child had any bleeding from the nose
PRESENT • Follow-up in 2 days if
or gums or in the vomitus or stools?
fever persists
o Has the child had black vomitus or stools?
o Has the child had abdominal pain? • If fever is present
o Has the child been vomiting? everyday for more than 7
days, REFER for
• Look and Feel:
assessment
o Look for bleeding from nose or gums.
o Look for skin petechiae
o Feel for cold clammy extremities. CLASSIFICATION FOR NO MALARIA RISK AND NO TRAVEL
TO MALARIA RISK AREA
• If none of the above ASK or LOOK and FEEL signs
are present and the child is 6 months or older and
fever present for more than 3 days. • Give first dose of
• Perform Torniquet Test appropriate antibiotic
o Assesses capillary fragility. • Treat the child to
o You inflate the blood pressure cuff to a point prevent low blood
midway between the systolic and diastolic blood • Any general VERY SEVERE sugar
pressures for five minutes. danger sign FEBRILE • Give one dose of
o After deflating the cuff, wait for the skin to return to • Stiff Neck DISEASE Paracetamol in health
its normal color, and then count the number of center for high fever
petechiae visible in a one-inch-square area on the (38.5C or above)
ventral surface of the forearm. • Refer URGENTLY to a
o Twenty or more petechiae in the one-inch square hospital
patch constitute a POSITIVE TEST.
o Classify Dengue with/without warning signs and • Give one dose of
Severe Dengue) paracetamol in clinic
for high fever (38.5°C
or above)
• Give appropriate
• No general
antibiotic treatment for
danger signs FEVER
any identified bacterial
• No stiff neck
cause of fever
• Advise mother when to
return immediately
• Follow-up in 2 days if
fever persists
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FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
• If fever is present • Anemia
everyday for more than 7 o Palmar pallor- observe palms and compare it with yours
days, REFER for • Feeding and breastfeeding
assessment • Immunization status
CLASSIFICATION FOR MEASLES
SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Any general • Give vitamin A
danger sign • Give first dose of an
or appropriate antibiotic
SEVERE
• Clouding of • If clouding of the cornea
COMPLICATE
cornea or or pus draining from the
D
• Deep or eye, apply tetracycline
MEASLES****
extensive eye ointment
mouth • Refer URGENTLY to a
ulcers hospital
• Give vitamin A
• If pus draining from the
• Pus draining MEASLES
eye, treat eye with
from the eye WITH EYE OR
tetracycline eye
or MOUTH
ointment
• Mouth COMPLICA-
• If mouth ulcers, treat with
ulcers TIONS****
Gentian violet
• Follow-up in 3 days
• Measles
now / w/in MEASLES • Give vitamin A
last 3 mos
**** Other important complications of measles - pneumonia, stridor,
diarrhoea, ear infection, and acute malnutrition - are classified in other
tables.
EAR PROBLEM
• Tender swelling behind the ear FORMS OF MALNUTRITION
• Ear pain Protein Energy • deficiency of calories and or protein in
• Ear discharge or pus (acute or chronic) Malnutrition a child’s diet
• Tragal tenderness-external ear • Forms of PEM
• If child tugs the ear often o marasmus
o kwashiorkor
• Give the first dose of • PEM is present if:
an appropriate o The child is severely wasted
antibiotics o The child develop edema
• Tender swelling
MASTOIDITIS • Give first dose of o The child do not grow well and
behind the ear
Paracetamol for pain become stunted
• Refer URGENTLY to Nutrient Deficiency • anemia (lack of iron)
hospital • Vitamin A deficiency
• Pus is seen
• Give an oral
draining from PROTEIN ENERGY MALNUTRIRION
antibiotic for 5 days.
the ear and MARASMUS • occur at all ages, more common at 0-2
(Amoxycillin)*
discharge is ACUTE EAR years old
• Give Paracetamol for
reported for INFECTION • child is not getting enough energy from
pain.
less than 14 his regular diet
• Dry the ear by wicking.
days, or • balanced starvation
• Follow up in 5 days.
• Ear pain • result of unsuccessful breast feeding
• Pus is seen or insufficient breast supply
draining from • Topical quinolone ear
• severely wasted
the ear and CHRONIC drops for at least two
• gross loss of subcutaneous fat;; ― all
discharge is EAR weeks
skin and bone;; ― loose skin folds in
reported for 14 INFECTION • Dry the ear by wicking.
buttocks
days or more. • Follow up in 5 days. • potbelly and winged scapulae
• poor appetite
• No ear pain and NO EAR • No treatment
• apathetic
no pus is seen INFECTION
KWASHIORKOR • usually 1 -3 years old
draining from
the ear. • results from a low protein diet
• Oral amoxycillin is a better choice for the management of • presence of bipedal is a cardinal sign
suppurative otitis media in countries where antimicrobial • Common signs :
resistance to cotrimoxazole is high o Hair changes
• Oral amoxicillin is a better choice for acute ear infections - sparse
where antimicrobial resistance to cotrimoxazole is high;; - straight
Reduces the risk of mastoiditis in populations where it is more - dyspigmented (light brown,
common reddish brown blonde)
- flag sign (light and dark bands in
hair)
MALNUTRITION AND ANEMIA
o Diffuse depigmentation – flaky paint
MALNUTRITION
or enamel dermatoses
• A pathological state secondary to relative or absolute deficiency o Puffy and moon faced
or excess of one or more essential nutrients o Anemia
• It can also develop in children with diet lacking in the
recommended amounts of essential vitamins and minerals (iron)
o Visible severe wasting
o Edema of both feet (press the dorsal area)
o Weight for age (Mean +/- 3SD)
o Check for sagging at the gluteal area
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 7 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
CHECK FOR ACUTE MALNUTRITION • When introducing recommended foods, ensure that the child
Look and feel: completes his daily ration of RUTF before giving other foods.
Look for signs of acute malnutrition • Offer plenty of clean water, to drink from a cup, when the child
• Look for oedema of both feet.
is eating the ready-to-use therapeutic food.
• Determine WFH/L* ___ z-score.
• Measure MUAC**____ mm in a child 6 months or RECOMMENDED AMOUNTS OF RUTF
older. CHILD’S WEIGHT PACKETS PER PACKETS PER
(kg) DAY WEEK SUPPLY
If WFH/L less than -3 z-scores or MUAC less than 115 mm, (92 PACKETS
then: CONTAINING
• Check for any medical complication present: 500kcal)
o Any general danger signs
4.0-4.9 kg 2.0 14
o Any severe classification 5.0-6.9 kg 2.5 18
o Pneumonia with chest indrawing 7.0-8.4 kg 3.0 21
• If no medical complications present: 8.5-9.4 kg 3.5 25
o Child is 6 months or older, offer RUTF*** to 9.5-10.4 kg 4.0 28
eat. Is the child: 10.5-11.9 kg 4.5 32
§ Not able to finish RUTF portion? >12.0 kg 5.0 35
§ Able to finish RUTF portion?
o Child is less than 6 months, assess ANEMIA
breastfeeding: • Reduction in the number of RBCs of an individual or a reduction
§ Does the child have a breastfeeding in the amount of hemoglobin for each RBC
problem? • A child can also develop anemia as a result of:
o infections
*WFH/L is Weight-for-Height or Weight-for-Length determined by o parasites such as hookworm or whipworm that can cause
using the WHO growth standards charts.
blood loss from the gut and lead to anemia
** MUAC is Mid-Upper Arm Circumference measured using MUAC o repeated episodes of malaria or if malaria was inadequately
tape in all children 6 months or older.
treated, anemia may develop slowly
***RUTF is Ready-to-Use Therapeutic Food for conducting the o often, anemia in these children is due to both malnutrition and
appetite test and feeding children with severe acute malanutrition. malaria.
CLASSIFICATION OF NUTRITIONAL STATUS CHECK FOR ANEMIA
• Look for palmar pallor. Is it:
• Edema of both feet o Severe palmar pallor*?
o Some palmar pallor?
COMPLICATED SEVERE
ACUTE MALNUTRITION
OR
• WFH/L less than -3 z-
scores OR MUAC less • Give first dose *Assess for sickle cell anaemia if common in your area.
than 115 mm AND any appropriate antibiotic
one of the following: • Treat the child to CLASSIFICATION OF ANEMIA
o Medical
complication prevent low blood
present or
sugar
SEVERE ANEMIA
5 days
• Give ready-to-use
therapeutic food for a • Give iron**
• WFH/L less than -3 z-
ANEMIA
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 8 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
HIV INFECTION o Ultimate goal is eradication of disease. Physicians, therefore,
must maintain timely immunization, (both active and passive)
CHECK FOR HIV INFECTION as high priority in the care of infants and children;; and must
Ask complete the course of immunizations
• Has the mother or child had an HIV test? • Decide if child needs an immunization today or if the mother
IF YES:
should be told to come back with the child at a later date for
Decide HIV status: immunization.
• Mother: POSITIVE or NEGATIVE • Follow DOH Vaccination Schedule
• Child: SCHEDULE VACCINE GIVEN
o Virological test POSITIVE or NEGATIVE Within first 72 hrs BCG, HepB1
o Serological test POSITIVE or NEGATIVE At 6 weeks of age DPT1, OPV1, HepB2
At 10 weeks of age DPT2, OPV2
If mother is HIV positive and child is negative or unknown, At 14 weeks of age DPT3, OPV3, HepB3
ASK: Measles (can give at 6mos if +
At 9 months of age
• Was the child breastfeeding at the time or 6 weeks epidemic) plus Vitamin
before the test?
o This provides maximal immunity to the 7 EPI diseases before
• Is the child breastfeeding now?
the child’s 1st birthday.
• If breastfeeding ASK: Is the mother and child on o Give the recommended vaccine when the child is at the
ARV prophylaxis? appropriate age for each dose.
o All children should receive all the recommended immunizations
IF NO, THEN TEST: before their 1st birthday.
• Mother and child status unknown: TEST mother.
o If the child does not come for an immunization at the
recommended age, give necessary immunization any time
• Mother HIV positive and child status unknown:
after the child reaches that age.
TEST child.
o No need to repeat the whole schedule
• Fully Immunized Child (FIC) by 1 year of age should have:
CLASSIFICATION OF HIV STATUS
o 1 dose BCG, 3 doses Hepa B, 3 doses DPT, 3 doses OPV, 1
dose measles + Hib + Rotavirus vaccine (for marginally
• Initiate ART
depressed) + PCV
treatment and HIV
care
VACCINE DOSE ROUTE AREA
• Give cotrimoxazole BCG 0.05 mL ID R deltoid
prophylaxis* DPT 0.5 mL IM Upper outer thigh
• Assess the child’s OPV 2-3 drops PO Oral
• Positive
feeding and provide HepaB 0.5 mL IM Upper outer thigh
virological test
CONFIRMED appropriate Measles 0.5 mL SQ Arm/triceps
in child OR
HIV counselling to the • Penta Immunization: HiB, Diptheria, Pertussis, Tetanus, HepB
• Positive
INFECTION mother
and OPV
serological test
• Advise the mother on • BCG laterality: left arm-given at school age;; right arm-infant
in a child 18
home care • Vitamin K at left, HepB at right thigh
months or older
• Assess or refer for TB
IMMUNIZATION
• For Treatment: A single dose of Vitamin A should be given to the
• Disease prevention means immunizing infants and young
child in the health center.
children against preventable viral and bacterial diseases
• For Supplementation: Give 1 dose in the health center if the:
• Goal of immunization: to confer long lasting immunity against
o child is 6 months or older
infectious diseases
o child has not received a dose of Vit.A in the past 6 months
o Immediate goal is prevention of disease in individuals or
groups
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 9 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
AGE VITAMIN A CAPSULE
100, 000 IU 200, 000 IU *NOT DISCUSSED
2 – 6 months 50, 000 IU IMCI FOR YOUNG INFANTS UP TO 2 MONTHS
6 – 12 months 1 cap ½ cap
For 3-5 days for IMCI (evidence-based) (60 breaths per intramuscular
POSSIBLE SERIOUS
UNLIKELY
DISEASE/
(500mg/2.5ml)
LOCAL
VERY
o If referral is not possible or delayed, repeat of very severe • Advise mother to
ampicillin injection every 6 hours disease or local give home care
o When there is strong suspicion of meningitis, dose bacterial infection
of ampicillin can be increased 4 times
• Gentamicin: 7.5 mg/kg once daily
CHECK FOR DIARRHEA
Gentamicin
Ampicillin
Age or Wt 2ml/40mg/ml ASSESS
500 mg vial
vial • The normally frequent or loose stools of a breastfed baby is not
2-4 mos (4-<6 diarrhea
1ml 0.5-1.0 ml
kg) • The mother of a breastfed baby can recognize diarrhea because
4-12 mos (6- the consistency or frequency of the stools is different than normal
2ml 1.1-1.8 ml
<10 kg) • Assessment is similar to the assessment of diarrhea for an older
12 mos-3yrs infant or young child, but fewer signs are checked.
3ml 1.9-2.7 ml
(10-<14kg) • Thirst is not assessed. This is because it is not possible to
3-5yrs (14- distinguish thirst from hunger in a young infant.
5ml 2.8-3.5 ml
19kg)
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 10 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
• Diarrhea in a young infant is classified in the same way as an SIGNS CLASSIFY AS IDENTIFY
older infant of young child. • Not able to • Give first dose of
• Classify dehydration. feed or intramuscular antibiotics.
NOT ABLE
• Choose an additional classification if the infant has diarrhea for • No • Treat to prevent low blood
TO FEED
14 days or more, or blood in the stool. attachment sugar.
POSSIBLE
• Note that there is only one possible classification for at all or • Advise the mother how to
SERIOUS
persistent diarrhea in a young infant. This is because any • Not keep the young infant warm
BACTERIAL
young infant who has persistent diarrhea has suffered with suckling at on the way to hospital.
INFECTION
diarrhea in a large part of his life and should be treated. all. • Refer URGENTLY to
hospital.
CLASSIFICATION OF DEHYDRATION
• Not well • Advise the mother to
attached to breastfeed as often and for
SIGNS CLASSIFY AS TREATMENT breast or as long as the infant wants,
Two of the • Not day and night.
ff: suckling o If not well attached or not
• Movemen effectively suckling effectively, teach
SEVERE DEHYDRATION
ff signs: mouth).
• If infant has any severe o Advise about correctly
• Restless
classification: prepared breastmilk
• Sunken
o Refer to hospital with substitutes and using a
eyes
mother giving frequent cup
• Skin
sips of ORS on the way. • If thrush, teach the mother to
pinch o Continue breastfeeding. treat thrush at home
goes
• Advise mother when to • Advise mother to give home
back
return immediately care for the young infant
slowly
• Follow-up in 2 days if not • Follow-up any feeding
improving problem or thrush in 2 days
• Give fluids to treat diarrhea • Follow-up low weight for age
• Not
at home and continue in 14 days
DEHYDRA-
enough
breastfeeding (Plan A) • Not low
TION
signs to
NO
• Advise mother when to weight for • Advise mother to give home
classify
return immediately age and no NO care for the young infant.
as some
• Follow-up in 2 days if not other signs FEEDING • Praise the mother for feeding
or severe
improving of PROBLEM the infant well.
inadequate
CLASSIFY DIARRHEA* feeding.
• Diarrhea lasting for >14 days
Severe • If the young infant is dehydrated, treat IMMUNIZATION AND VITAMIN A STATUS
Persistent dehydration before referral unless the infant • Administer any Immunization that the young infant needs
Diarrhea also has possible serious bacterial infection • Tell the mother when to bring the infant for the next immunization
• refer to hospital SCHEDULE
• Blood in the stool • BCG • HepB-0
• Treat for 5 days with an oral antibiotic Birth
• OPV-0
recommended for Shigella in your area • DPT+HiB-1 • RTV1
• Refer urgently to hospital with mother giving • OPV-1 • PCV1
Dysentery 6 weeks
frequent sips of ORS on the way. Advise the • HepB-1
mother to continue breastfeeding
• 200,000 IU to the MOTHER within 6 weeks of
• Advice the mother to keep the young infant
delivery
warm at all times
• Follow up in 2 days
*no longer found in IMCI March 2014
FEEDING PROBLEM OF LOW WEIGHT
ASSESS
How to assess breastfeeding:
• First decide whether to assess the infant’s breastfeeding
• If an infant: Has any difficulty feeding?
• Is breastfeeding less than 8 times in 24 hours
• Is taking any other foods or drinks, or Is low weight for age, &
• Has no indications to refer urgently to the hospital: ASSESS
BREASTFEEDING
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 11 of 12
FAMILY & COMMUNITY MEDICINE 3
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES
TRANSCRIBERS: Banchiran, Casas, Luciano, Macose, Pineda*, Pre Page 12 of 12