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Integrated Managementof Childhood Illness

LESTER A. DENIEGA M.D.LESTER A. DENIEGA M.D.

DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS

USTFMSUSTFMS

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1. Skilled attendance during pregnancy, childbirth and

the immediate postpartum

2. Care of the newborn

3. Breastfeeding and complementary feeding4. Micronutrient supplementation

5. Immunization of children and mothers

6. Integrated management of sick children

7. Use of insecticide treated bed nets (in malarious areas)

Essential Package of Child Survival

Interventions

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Distribution of deaths of children

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Immediate Causes of Death in

Underfive Children, WPR

Source: Child Health Epidemiologist and research group (CHERG) estimates of under-five

deaths, 2000-03

Under-

nutrition

53%

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Immediate Causes

deaths in perinatal and neonatal periodsdominate the U5MR; the perinatal period is also

associated with the highest number of

disabilities; highest risk is in the first day of birth;

40 - 80% of neonatal deaths are associated with

low birth weight;

malnutrition remains the highest attributable

causal factor of all childhood deaths in childrenunder 5;

most important immediate causes of death from

communicable diseases remain diarrhoea and

ARI

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What is the IMCI ?

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Objectives of the Global Child

Health Programme

To reduce significantly global mortality and

morbidity associated with the major causes ofdisease in children

To contribute to healthy growth and

development of children

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Overall Case Management

ProcessOutpatient

1 - assessment

2 - classification and identification of treatment3 - referral, treatment or counseling of the childs

caretaker (depending on the classification identified

4 - follow-up care

Referral Health Facility

1 - emergency triage assessment and treatment

2 - diagnosis, treatment and monitoring of patient

progress

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The Integrated Case Management Process

Treatment

treat local infection

give oral drugs

advise and teach

caretaker

follow up

Outpatient Health

Facility

Home

Caretaker iscounselled on:

home treatment

feeding &fluids

when to return

immediately

follow-up

check for danger signsassess main symptoms

assess nutrition and Immunization status

and potential feeding problems

Check for other problems

classify conditions and

identify treatment actions

Outpatient Health Facility

Urgent referral

pre-referral treatment

advise parents

refer child

Outpatient Health Facility

emergency triage &

treatment

Diagnosis & treatmentmonitoring & ff-up

Referral facility

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IMCI CASE MANAGEMENT

PROCESS Assess by checking for danger signs

(or possible bacterial infection in a

young infant) asking questions aboutcommon conditions, examining the

child, and checking nutrition and

immunization status. Ask other healthproblems

Classify using a color-coded triage

system

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IMCI CASE MANAGEMENT

PROCESS Identify specific treatments

Provide practical treatment

instructions including teaching how togive oral drugs, how to feed and give

fluids and how to treat local infections at

home

Counsel to solve any feeding problemsafter assessing feeding

Give follow-up care when a child is

brought back as requested

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Target Groups

Sick young infant

1 week up to 2 months

Sick young children

2 months up to 5 years

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SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS

FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic

ASK THE CHILDS AGE

IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years

USE THE CHART:

ASSESS, CLASSIFY AND TREAT

THE SICK YOUNG INFANT

USE THE CHART:

ASSESS AND CLASSIFYTHE SICK CHILD

TREATTHE CHILD

COUNSEL THE MOTHER

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THE SICK CHILD AGE 2

MONTHS TO 5 YEARS:

ASSESS AND

CLASSIFY

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Ask the mother or caretaker about the childs problem.

If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for theproblem, give follow-up care according to PART VII)

.

Check for signs of malnutrition and anaemia and classify the childs nutritional status

Check the childs immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child(PART V), and Counsel the Mother (PART VI)

SUMMARY OF ASSESS AND CLASSIFY

Check for General Danger Signs

Check for signs of malnutrition and anaemia and classify the childs nutritional status

Check the childs immunization status and decide if the child needs any immunizations today.

Ask mother/caretaker about 4 main symptoms:

1. cough or difficult breathing2. Diarrhea

3. Fever

4. Ear problem

When a main symptom is present:Assess the child further for signs related to the main sx,

and

Classify the illness acc. to the signs (present or absent)

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FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC

GREET the mother appropriately and

ask about her child.

LOOK to see if the childs weight and

temperature have been recorded

ASK the mother what the childs problems are

DETERMINE if this is an initial visit or a follow-up visit for this problem

IF this is an INITIAL VISIT for theproblem

ASSESS and CLASSIFY the child followingthe guidelines in this part of the handbook (PART II)

GIVE FOLLOW-UP CARE according to theguidelines in PART VII of this handbook

When a child is brought to the clinic

IF this is a FOLLOW-UP VISIT for the problem

Use Good Communication skills:

(see also Chapter 25) Listen carefully to what the mother tells you. Use words the mother understands

Give the mother time to answer the questions.---Ask additional questions when the mother is

not sure about her answer.

*Record Important Information

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GENERAL DANGER SIGNS

ForALL sick children ask the mother about the childs problem, then

CHECK FOR GENERAL DANGER SIGNS

CHECK FOR GENERAL DANGER SIGNS

A child with any general danger sign needs URGENTattention; complete the

assessment and any pre-referral treatment immediately so referral is not delayed

ASK: LOOK:

Is the child able to drink or breastfeed? See if the child is lethargic orunconscious

Does the child vomit everything?

Is the child had convulsions?

Make surethat a

child with

anydangersign is

referredafter

receivingurgent

pre-referral

treatment.

Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear

problems.CHECK for malnutrition and anaemia, immunization status and for other problems.

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DANGER SIG

NSConvulsions: associated with meningitis, cerebral

malaria or other life-threatening conditions

Unconscious or lethargic: A lethargic child who isawake but does not take any notice of his or hersurroundings or does not respond normally tosounds or movements

Unable to drink: s/he is too weak or because s/hecannot swallow

Vomits everythingIf a child has one or more of these signs, s/he must

be considered seriously ill and will almost alwaysneed referral

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Checking theMain Symptoms:

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Checking the Main Symptoms

1. Cough or difficult breathing

3 clinical signs

Respiratory rate

Lower chest wall indrawing Stridor

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Nasal

passages

Windpipe

or trachea

Lungs

Parts of the Respiratory System

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Inside the alveolus

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ASK: Does the child have cough or difficult breathing?

IfYES

IFYES, ASK:

F

or how long?

LOOK, LISTEN, FEEL:

Count the breaths in one minuteLook for chest indrawing

Look and listen for stridor

Child

mustbe

calm

If the child is: Fast breathing is:

2 mos 12 mos. 50 breaths/min or more12 mos 5 yrs 40 breaths/min or more

Classify childs illness using the color-coded

classification table for cough or difficult breathing

IfNO

Ask aboutnext main

symptoms:

diarrhea,

fever, ear

problems

Cough or Difficult Breathing

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Treatment

Soothe the Throat, Relieve the Cough witha Safe RemedySafe remedies to recommend:

Breastmilk for exclusively breastfed infanttamarind, calamansi, ginger

Harmful remedies to discourage:

Codeine cough syrup

Other cough syrups

Oral and nasal decongestants

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Treatment for Pneumonia or

Very Severe DiseaseCotrimoxazoleGive 2 times daily

for 5 days

AmoxycillinGive 3 tim es daily

for 5 days

Age orWeight

Adult

tab.80mgTMP

400 mgSMX

Syrup

40 m gTMP

200 mg

SMX

Tablet

250 m g

Syrup

125mg/5 m l

2 -12 mos 1/2 5 .0 ml. 1/2 5 .0 ml

12mos-5yrs 1 7.5 ml 1 10 ml.

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Pathogen Antimicrobial

ARI PathogensARI Pathogens

Streptococcus pneumoniaeStreptococcus pneumoniae

Hemophilus influenzaeHemophilus influenzae

Gram (+) cocciGram (+) cocci

Staphylococcus aureusStaphylococcus aureus

Staphylococcus epidermidisStaphylococcus epidermidis

Chloramphenicol

Cotrimoxazole

Penicillin

Chloramphenicol

Cotrimoxazole

Ampicillin

Oxacillin

Cotrimoxazole

Ciprofloxacin

Vancomycin

Oxacillin

Cotrimoxazole

Vancomycin

7.0

11.8

18.4

4.0

11

3.0

24.2

20.9

13.1

3.0

3

9

6

5

11

5

18

8

6

0.7

47

42

0.3

3

9

9

3

18

13

18

8

7

0

51

50

0

5

15

5

5

36

10

17

6

8

0

39

37

0

% Resistance

2000 2002 2003 2004

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Vitamin A

Supplementation

for Severe Pneumonia or Very SevereDiseaseV itam in A CapsuleAge

100,000 IU 200,000 IU

6 to 12 m os. 1 capsule capsule

12 mo s-5 yrs 2 capsules 1 capsule

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DIARRHEA

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Anatomy of the GastrointestinalSystem

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DiarrheaForALL sick children ask the mother about the childs problem, check for general danger signs,

ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHOEA?

If NO If YES

Does the child have diarrhoea?

IF YES, ASK: LOOK, LISTEN, FEEL:

F

or how long?

Look at the childs general condition.Is the child:

Is there blood in the

stool Lethargic or unconscious?

Restless or irritable?

Look for sunken eyes.

Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

Pinch the skin of the abdomen.

Does it go back:

Very slowly (longer than 2 seconds)?

Slowly?

CLASSIFY the childs illness using the colour-coded classification tables for diarrhoea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and

anaemia, immunization status and for other problems.

Classify DIARRHOEA

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2. Diarrhea

Dehydration General condition

Sunken eyes

Thirst Skin elasticity

Persistent diarrhea

Dysentery

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Clinical Types of Diarrhea and

its major dangers Acute watery diarrhea (includes cholera): lasts several

hours or days; main danger is dehydration

Acute bloody diarrhea: dysentery causing major

damage to intestinal mucosa, sepsis and malnutrition

Persistent diarrhea: lasts 14 days or longer that resultsin malnutrition and serious non-intestinal infection

Diarrhea with severe undernutrition: major dangers

are:severe systemic infection, dehydration, heart failure,vitamin and mineral deficiency

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.

WHO document 2005

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4 Key Elements for effective

clinical management of acute diarrhea Replacement of fluids, usually by ORT to

prevent dehydration in the home and to treatdehydration

Continued feeding, especially breastfeeding,during diarrhea episodes and inconvalescence

No use of antidiarrheal drugs and selective

use of antibiotics Effective instruction of the childs mother on

how to take care of the sick child at home

the indications for follow-up

methods of preventing future episodes of diarrhea

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Four Rules for

Home Treatment of Diarrhea

(Treatment Plan A)

Rule 1: Give more fluids than usual

Rule 2: Zinc supplementation at 20mg/day for 10-14 days

(10 mg for infants < 6 months)

Rule 3: Continue to feed the child Rule 4: When to return to the clinic

Diarrhea Treatment Guidelines for Clinic-Based Health Care Workers

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Tell the Mother:

(a) Breastfeed frequently and longer for each feed.

(b) If the child is exclusively breastfed, give ORS or

clean water in addition to breastmilk.

(c) If the child is NOT exclusively breastfed, give 1 or

more of the following:

ORS

Food-based fluids

Clean Water

No Dehydration

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Fluids that normally contain

salt

ORS solution

Salted drinks (salted rice

water, salted yoghurt drink)

Vegetable or chicken soup

with salt

Fluids that do not contain

salt

Plain water

Water in which a cereal has

been cooked

Unsalted soup

Yoghurt drinks without salt

Green coconut water

Weak tea

Unsweetened fresh fruit

juice


WHO document 2005

FLUIDS TO GIVE

Wherever possible, these should include at least one

fluid that normally contains salt

Plain clean water should also be given

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XX XX FLUIDS NOT TO BE GIVENFLUIDS NOT TO BE GIVEN XXXX

Drinks sweetened with sugar

Commercial carbonated beverages

Commercial fruit juices Sweetened tea

Other fluids to avoid

Those with stimulant, diuretic and purgative effect

Coffee Some medicinal teas or infusions


WHO document 2005

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Treatment Plan AAge Amount of Fluid Type of Fluid

< 2 yrs 50-100 ml (- cup) after each loose stool2-10 yrs 100-200 ml (-1 cup) after each loose stool

ORS, rice water, yogurt,soup with salt

No Dehydration

Give frequent small sips from a cup.

If the child vomits, wait 10 minutes. Then continue, butmore slowly.

Continue giving extra fluids until the diarrhea stops.

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Treatment Plan B(Determine amount of ORS to be given in 4 hours)

Age Up to 4 mos 4mos - 12mos 12mos 2years 2 years 5years

Some Dehydration

< 6kg 6 - < 10kg 10 -

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Approximate amount ofORS

solution to

give in the first 4 hoursAge Less

than 4

mos.

4-11

months

12-23

months

2 4

years

5 14

years

15 years

older

Weight Lessthan 5

kg.

5-7.9kgs.

8 10.9kgs.

11-15.9kgs.

16-29.9kgs.

30 kgs.or more

In ml 200 -

400

400 -

600

600 -

800

800 -

1200

1200 -

2200

2200 -

4000

In local

measure

TPB

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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.

Some Dehydration

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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 completerehydration.

Some Dehydration

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Severe Dehydration

Can you give Intravenousfluids (IV) immediately?

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Severe Dehydration

Treatment Plan C

To treat severe dehydration (IV fluid: pLRS)

Age Initial Phase Subsequent Phase

(30 ml/kg) (70 ml/kg)

Infants (

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If trained to use anasogastric tube for

rehydration?

Severe Dehydration

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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. If there is repeated vomiting or increasing

abdominal distention, give the fluid more

slowly.

If hydration status is not improving after 3hours, send the child for IV therapy.

After 6 hours, reassess the child.

Classify dehydration.

Severe Dehydration

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Etiologic Agents for most cases of diarrheaOrganism Proportion of cases Effectiveness of

antibiotics in TxRotavirus

ETEC

No agent found

Shigella

Campylobacter spp

Vibrio Cholera

Nontyphoid salmonella

Up to 50% in health

facilities; 5-10% in

community

Up to 25% in all ages

25% or more5 10%

5-15%

5 10% in endemic areas

Up to 10% of cases

Not effective

Not effective

Not effective

Effective

Effective only if given

early in course of

disease

Effective

Not effective in usual

uncomplicated diarrhea

WHO

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4 conditions where antimicrobials

are indicated

Cholera - Tetracycline

Shigella dysentery - Nalidixic acid

Giardiasis - Metronidazole

Amoebiasis - Metronidazole

A ti i bi l % i t f E t i

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Antimicrobial % resistance of Enteric

pathogensPathogenS. typhi

AntimicrobialChloramphenicol

Cotrimoxazole

Ampicillin

20020

3

2

20031

0

0

20040

1

1

Nontyphoidal

Salmonella

Chloramphenicol

Cotrimoxazole

Ampicillin

Ciprofloxacin

16

15

24

4

21

31

47

8

18

20

2

0

Shigella Chloramphenicol

Ampicillin

Cotrimoxazole

Nalidixic acid

Ciprofloxacin

78

73

0

43

50

78

0

12

60

50

67

0

0

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CLASSIFICATION TABLE FOR DEHYDRATION

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Two of the following signs:

Lethargic or unconsciousSunken eyes

Not able to drink or drinking

poorly

Skin pinch goes back very

slowly

SEVERE

DEHYDRATION

If child has no other severe classification:

Give fluid for severe dehydration (Plan C).OR

If child also has another severe classification:

Refer URGENTLY to hospital with mother

giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding

If child is 2 years or older and there is cholera in

your area, give antibiotic for cholera.

Two of the following signs:

Restless, irritable

Sunken eyes

Drinks eagerly, thirsty

Skin pinch goes back slowly

SOME

DEHYDRATION

Give fluid and food for some dehydration (Plan B).

If child also has a severe classification:

Refer URGENTLY to hospital with mother

giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding

Advise mother when to return immediately.Follow-up in 5 days if not improving.

Not enough signs to

classify as some or

severe dehydration. NO

DEHYDRATION

Give fluid and food to treat diarrhoea at home

(Plan A).

Advise mother when to return immediately.

Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR DEHYDRATION

SIGNS CLASSIFY ASIDENTIFY TREATMENT

(Urgent pre-referral treatments are in bold print.)

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No Dehydration

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Some Dehydration

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Severe Dehydration

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

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Dehydration present SEVERE

PERSISTENT

DIARRHOEA

Treat dehydration before referral unless

the child has another severe

classification.

Refer to hospital.

No dehydration PERSISTENT

DIARRHOEA

Advise the mother on feeding a child who

has PERSISTENTDIARRHOEA.

Follow-up in 5 days.



CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

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After 5 days:Ask:

If the diarrhoea has NOT stopped (3 or

more stools) do a full reassessment, givethe treatment, then refer to hospital.

If the diarrhoea has stopped (< 3 stools

per day) Tell the mother to follow the usualfeeding recommendations for the childsage.

Persistent Diarrhea

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Blood in thestool DYSENTERY

Treat for 5 days with

an oral antibioticrecommended for

Shigella in your area.

Follow-up in 2 days.

CLASSIFICATION TABLE FOR DYSENTERY



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After 2 days:Ask:

if the child is dehydrated, treathydration.

if the number of stools, amount ofstools, fever, abdominal pain or eating

is same or worse: Change to 2nd lineantibiotics & give for 5 days. Advise toreturn in 2 days.

Dysentery

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EXCEPTIONS:

If the child is less than 12 months old or

was dehydrated on the 1st

visit or hadmeasles within the last 3 months. REFER

TO HOSPITAL.

If fewer stools, less blood in stools, less

fever, less abdominal pain & eating better,

continue antibiotics.

Dysentery

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Session 4-c

Fever

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3. Fever

Stiff neck Risk of malaria and other endemic

infections, e.g. dengue hemorrhagic fever

Runny nose

Measles Duration of fever (e.g. typhoid fever)

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Assess FEVER

A child has the main symptom of fever

if:

the child has history of fever

the child feels hot

the child has an axillary temperature of

37.5 or above

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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk

Ask:

Does the child live in a malaria area?

Has the child visited malaria area in the past 4 weeks?

If yes to either, obtain a blood smear.

Then Ask:

For how long does the child hasfever?

If >7 days, has the fever beenpresent everyday?

Has the child had measles withinthe last 3 months?

Look and Feel:

Look and feel for stiff neck. Look for runny nose

Look for signs of Measles:

Generalized rash.

One of these: cough, runny nose or

red eyes

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If the child has measles now or within thelast three months:

Look for mouth ulcers.

Are they deep and extensive?

Look for pus draining from the eye.

Look for clouding of the cornea.

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Then Ask:

Has the child had anybleeding from the nose or

gums or in the vomitus orstools?

Has the child had blackvomitus or stools?

Has the child had abdominalpain?

Has the child been vomiting?

Look and Feel:

Look for bleeding from nose orgums.

Look for skin petechiae Feel for cold clammy

extremities.

If none of the above ASK or LOOK

and FEEL signs are present and

thechild is 6 months or older and

fever

present for more than 3 days.

Perform Torniquet Test.

Decide Dengue Risk: Yes or NoIf Dengue Risk:

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Decide Malaria Risk:

If the child has

measles now or within

the last three months:

Decide Dengue Risk: Yes

or No

If Dengue Risk:

Classify

FEVER

Malaria Risk(including travel to

malaria area)

No Malaria

Risk

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Deciding Malaria Risk

Malaria is caused by parasites in the

blood called plasmodia Plasmodium falciparum

Transmitted by Anopheles mosquito

Know the malaria risk in your areas.

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Malaria Risk Areas

1. Palawan

2. Davao Oriental

3. Davao del Norte

4. Compostela Valley5. Tawi-tawi

6. Sulu

7. Agusan del Sur

8. Mindoro Occidental9. Kalinga Apayao

10. Agusan del Norte

11.Isabela

12.Cagayan

13.Quezon

14.Ifugao15.Zamboanga del Sur

16.Bukidnon

17.Misamis Oriental

18.Quirino19.Mountain Province

20.Basilan

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Classify FEVER

Classify

FEVER

Malaria Risk(including travel to

malaria area)

No Malaria

Risk

Malaria Risk Any general danger sign

or

Stiff Neck

VERY SEVERE

FEBRILE

DISEASE/MALARIABlood smear (+)

If blood smear not done:

NO runny nose and,

NO measles, and NO

other

causes of fever

MALARIA

Blood smear (-), or

Runny nose, or

Measles or

Other causes of fever.

FEVER:

MALARIA UNLIKELY

No Malaria Risk Any general danger sign

or

Stiff Neck

VERY SEVERE

FEBRILE DISEASE

No sign of very severe FEVER:

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Malaria Risk

Any generaldanger

sign or

Stiff Neck

VERY SEVERE

FEBRILE

DISEASE

/MALARIA

Give first dose of Quinine (under medicalsupervision or if a hospital is not accessible

withing 4 hours)

Give first dose of appropriate antibiotics.

Treat the child to prevent low blood sugar.

Give one dose of Paracetamol in health center

for

high fever (38.5C or above.)

Send a blood smear with the patient.

ReferURGENTLY to a hospital.

Blood smear (+)

If blood smear notdone:

NO runny nose

and,

NO measles, and

NO other causes

of fever

MALARIA

Treat the child with an oral antimalarial.

Give one dose of Paracetamol in health centerfor

high fever (38.5C or above.)


Follow up in 2 days if fever persists.

If the fever is present every day for more than

7 days, refer for assessment.

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Malaria Risk

Blood smear(-), or

Runny nose,

or

Measles or

Other causes

of fever.

FEVER:

MALARIA

UNLIKELY

Give one dose of Paracetamol inhealth center for high fever (38.5C

or above.)

Advise mother when to return

immediately.


If the fever is present every day for

more than 7 days, refer for

assessment.

Treat other causes of fever.

TREAT THE CHILD:

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TREATTHE CHILD:

Antimalarial Agents Give an Oral Antimalarial

1st line Antibiotics: Chloroquine and Primaquine

2nd line Antibiotics: Sulfadoxine andPyrimethamine

If Chloroquine:

The child should be watched closely for 30 minutes. If thechild vomits, give another dose.

Itching is a possible side effect of the drug.

If Sulfadoxine and Pyrimethamine:

Give single dose in health center.

Antimalarial Agents

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Antimalarial AgentsCHLOROQUINE

Give for 3 days

PRIMAQUINE

Single dose

for P.falciparum

PRIMAQUINE

Daily for 14

days for P.vivax

SULFADOXINE +

PYRIMETHAMINE

Single dose

AGE Tablet

(150mg base)Tablet

(15mg base)

Tablet

(15mg base)

Tablet

(500mg Sulfadoxine

25mg Pyrimethamine)Day 1 Day 2 Day 3

2 months up

to 5 months

(4 -

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TREATTHE CHILD:

Antimalarial Agents

Chloroquine is given for 3 days.

Explain to the mother that itching is a

possible side effect. It is NOT

dangerous. The mother should continueto give the drug.

TREAT THE CHILD:

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TREATTHE CHILD:

Antimalarial Agents

If the species of malaria is identified

through blood smear, give the following:

P. falciparum single dose Primaquine with

the first dose of Chloroquine

P. vivax first dose of Primaquine with

Chloroquine and give mother enough for

one dose each day for the next 13 days.

TREAT THE CHILD:

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TREATTHE CHILD:

Antimalarial Agents

If you do not have the blood smear or

you do not know which species ofmalaria is present, treat as P. falciparum.

Do not give Primaquine to children under12 months of age.

TECHNICAL UPDATES:

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TECHNICAL UPDATES:

Antimalarial AgentsTECHNICAL BASIS: Artemisinin BasedCombination TherapiesBased on available safety and efficacy data, the followingtherapeutic options are available and have potential for

deployment (in prioritized order) if costs are not an issue: Arthemether lumefantrine (Coarthem TM)

Artesunate (3 days) + amodiaquine

Artesunate (3 days) + SP in areas where SP remains high

SP + Amodiaquine in areas where both SP andAmodiaquine remain high. This mainly limited to West

Africa.

TECHNICAL UPDATES:

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TECHNICAL UPDATES:

Antimalarial Agents

Administer intramuscular antibiotic if the

child cannot take an oral antibiotic

Quinine for severe malaria

Breastmilk or sugar to prevent low blood

sugar.

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Give an Intramuscular Antibiotic

A child may need an antibiotic before

he leaves for the hospital, if he/she:

is not able to drink or breastfeed

vomits everything

has convulsions

is abnormally sleepy or difficult toawaken

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Give an Intramuscular Antibiotic

Age orWeight

CHLORAMPHENICOLDose: 40 mg/kg

Add 5 ml sterile water to vial containing 1000mg

= 5.6 ml at 180mg/ml

2 4 months (4 -

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Give Quinine for Severe Malaria

Quinine is the preferred agent because it

is rapidly effective.

Quinine is more safe and effective than

intramuscular Chloroquine.

Possible side effects of Quinine injections

are:sudden drop in blood pressure,

dizziness, ringing in the ears and a sterileabscess.

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For children being referred with very severe febriledisease/Malaria:

Give the 1st dose of IM Quinine and refer the childurgently to the hospital

If referral is not possible:

Give the 1st dose of IM Quinine

The child should remain lying down for 1 hour

Repeat the Quinine injection 4 to 8 hours later, andthen every 12 hours until the child is able to take an

oral antimalarial. Do not continue Quinine injection for more than 1

week.

DO NOT GIVE QUININE TO A CHILD LESS THAN 4MONTHS OF AGE.

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Age orWeightINTRAMUSCULAR QUININE

300 mg/ml (In 2 ml ampules)

4 months 12 months

(6 -

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TREAT THE CHILD:

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TREATTHE CHILD:

To Prevent Low Blood Sugar

To make Sugar Water:

Dissolve 4 level teaspoons of sugar (20grams)

in a 200 ml cup of clean water.

If the child is not able to swallow:

Give 50 ml of sugar water by nasogastric

tube.

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No Malaria RiskAny general

danger sign or

Stiff Neck

VERY

SEVERE

FEBRILE

DISEASE

Give first dose of appropriate antibiotics.

Treat the child to prevent low blood sugar.

Give one dose of Paracetamol in healthcenter for high fever (38.5C or above.)

Refer URGENTLY to a hospital.

No sign of

very severe

febrile disease

FEVER:

NO MALARIA

Give one dose of Paracetamol in health

center for high fever (38.5C or above.)


immediately.


If the fever is present every day for more

than 7 days, refer for assessment.

Does the child have fever?

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(by history, or feels hot or temperature 37.5C

and above)

Decide MalariaRisk:

If the child hasmeasles now orwithin the last

threemonths:

Decide DengueRisk: Yes or No

If Dengue Risk:

Classify

FEVER

Severe

Complicated

Measles

Measles with

Eye or Mouth

Complications

Measles

If dengue Risk, classify page 77 of the module Assess

and Classify the Sick Child Age 2 months up to 5 years


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If the child has

measles now

or within the

last three

months:

Look for mouth

ulcers: are they

deep and

extensive

Look for pus

draining from the

eyeLook for clouding

of the cornea


If

measles

nowor within

last

three

months,

classify

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Measles

Fever and generalized rash are the mainsigns of measles.

Highly infectious.

Over crowding and poor housingincreases the risk of developing

measles. Caused by a virus that infects the layers

of cells that line the lung, gut, eye,mouth and throat.

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Measles

Complications of measles occur in about 30% ofall cases

diarrhea (including dysentery and persistentdiarrhea)

pneumonia and stridor mouth ulcers

ear infection

severe eye infection (which may lead to

corneal ulceration and blindness) Encephalitis occurs in about 1/1000 cases. (look

for danger signs such as convulsions, abnormallysleepy or difficult to awaken)

Classify MEASLES

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Classify MEASLESClouding of the

cornea

Deep extensive

mouth ulcers

SEVERE

COMPLICATED

MEASLES

Give Vitamin A

Give first dose of an appropriate

antibiotics

If clouding of the cornea or pus

draining

from the eye, apply Tetracycline eye

ointment

Refer URGENTLY to the hospitalPus draining from

the eye

Mouth ulcers

MEASLES WITH EYE

OR MOUTH

COMPLICATIONS

Give Vitamin A

Give first dose of an appropriate

antibiotics

If pus draining from the eye, apply

Tetracycline eye ointment

If mouth ulcers, teach the mother totreat

with gentian violet

Follow up in two days

Measles now or

within the last 3

months

MEASLES Give Vitamin A

Children with Measles

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Kopliks spots

TREAT THE CHILD:

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TREATTHE CHILD:

Give Vitamin ATREATMENT

Give one dose of Vitamin A in the Health

Center

SUPPLEMENTATION

Give one dose of Vitamin A in the Health

Center if:

Child is 6 months of age or older

Child has not received a dose of

Vitamin A in the past 6 months

TREAT THE CHILD:

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TREATTHE CHILD:

Give Vitamin A

AGEVitamin A Capsule

100,000 IU 200,000 IU

2 6 months 50,000 IU

6 12 months 1 cap 1/2 cap

1 5 years 2 caps 1 cap

200,000 IU = 6 drops

100,000 IU = 3 drops


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Decide Malaria Risk:

If the child has measles

now or within the last three

months:

ClassifyFEVER

Severe DHF

Fever; DHFUnlikely

Torniquet Test 1.3gp

Torniquet Test 2.3gp

Decide Dengue Risk:

Yes or No

If Dengue Risk:

T i t T t

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Tourniquet Test

Inflate blood

pressure cuff to a

point midway

between systolicand diastolic

pressure for 5

minutes

Positive test: 20 ormore petechiae per

1 inch (6.25 cm )

Classify DENGUE

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HEMORRHAGIC FEVERbleeding from the nose

or gums

Bleeding in the

vomitus or stools

Skin petechiae

Cold clammy

extremities

Capillary refill morethan 3 seconds

abdominal pain or

Vomiting or

Positive torniquet test

SEVERE DENGUE

HEMORRHAGIC

FEVER

If skin petechiae or abdominal pain

or vomiting or positive torniquet test

are the only positive signs, give ORS

If any other signs of bleeding are

present, give fluids rapidly as in Plan

C

Treat the child to prevent low blood

sugarRefer all chioldren URGENTLY to the

hospital

DO NOT GIVE ASPIRIN

No signs of severe

dengue hemorrhagic

fever

FEVER; DENGUE

HEMORRHAIC

FEVER UNLIKELY


immediately

Follow up in 2 days if fever persists

or child shows signs of bleeding.

DO NOT GIVE ASPIRIN

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Delayed capillary refill may be the first sign of intravascular

volume depletion. Hypotension usually is a late sign in

children. This child's capillary refill at 6 seconds was delayedwell beyond a normal duration of 2 seconds.

S i 4 d

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Session 4-d

Ear Problem

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4. Ear problems

Tender swelling behind the ear Ear pain

Ear discharge or pus (acute or

chronic)

A EAR PROBLEM

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Assess EAR PROBLEM

A child with ear problem is assessed for:

Ear pain

Ear discharge If present, how long has the child has

had ear discharge

Tender swelling behind the ear, a signof mastoiditis

A EAR PROBLEM

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Assess EAR PROBLEM

Then Ask: Does the child have an ear problem?IfYES, ASK:

Is there ear pain?

Is there ear discharge? If yes, for how long?

LOOK and FEEL:

Look for pus draining from the ear.

Feel for tender swelling behind the ear.

Ask about ear problem in ALL sick children.

Classif EAR PROBLEM

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Classify EAR PROBLEMTender swelling behind

the ear

MASTOIDITIS Give the first dose of an appropriate

antibiotics

Give first dose of Paracetamol for pain

Refer URGENTLY to hospital

Pus is seen draining

from the ear and

discharge is reported

for less than 14 days, or

Ear pain

ACUTE EAR

INFECTION

Give an antibiotic for 5 days.

(Amoxicillin)*

Give Paracetamol for pain.Dry the ear by wicking.

Follow up in 5 days.

Pus is seen draining

from the ear and

discharge is reported

for 14 days or more.

CHRONIC EAR

INFECTION

topical quinolone ear drops for at least

two weeks

Dry the ear by wicking.

Follow up in 5 days.

No ear pain and no pus

is seen draining from

the ear.

NO EAR INFECTION No additional treatment.

*Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high.

TECHNICAL UPDATES:

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Chronic Suppurative Otitis Media

TECHNICAL BASIS: aural toilet combined with antimicrobial

treatment is more effective than aural toiletalone

topical antibiotics were found to be better thansystemic antibiotics in resolving otorrhea anderadicating middle ear bacteria

topical quinolones were found to be better thantopical non-quinolones

topical ofloxacin or ciprofloxacin vsintramuscular gentamicin, topical gentamicin,tobramycin or neomycin-polymyxin

TECHNICAL UPDATES:

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Acute Otitis Media

TECHNICAL BASIS:

oral amoxicillin as the better choice for

the management of acute ear infectionin countries where antimicrobial

resistance to cotrimoxazole is high.

reduces the risk of mastoiditis in

populations where it is more common

TREATTHE CHILD:

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Dry the Ear by Wicking Dry the ear at least 3 times daily.

Roll a clean absorbent cotton or soft tissue paper

into a wick.

Place the wick in the childs ear.

Remove the wick when wet.

Replace the wick with a clean one and repeat

these steps until the ear is dry.

Do not use a cotton-tipped applicator, a stick or a

flimsy paper that will fall apart in the ear.

TREATTHE CHILD:

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Dry the Ear by Wicking

Wick the ear 3 times daily.

Use this treatment for as many days as it

takes until the wick no longer gets wet when

put in the ear and no pus drains from the ear. Do not place anything (oil, foil or other

substances) in the ear between wicking

treatments.

Do not allow the child to go into swimming.

Malnutrition and Anemia

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ForALL sick children ask the mother about the childs difficult breathing, diarrhoea,

fever, ear problem and then

CHECK FOR MALNUTRITION AND ANAEMIA.

THEN CHECK FOR MALNUTRITION AND ANAEMIA

CLASSIFY the childs illness using the colour-coded-classification table for malnutrition

and anemia

Then CHECK immunization status and for other problems.

LOOK AND FEEL:

Look for visible severe wasting.

Look for palmar pallor. Is it: Severe palmar

pallor?

Some palmar pallor?

Look for oedema of both feet.

Determine weight for age.

Classify

NUTRITIONAL

STATUS

Checking Nutritional Status,

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Feeding, Immunization Status Malnutrition

visible severe wasting

edema of both feet

weight for age

Anemia

palmar pallor

Feeding and breastfeeding

Immunization status

IDENTIFY TREATMENT

CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA

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Visible severe wasting

orSevere palmar pallor or

Oedema of both feet.

SEVEREMALNUTRITION OR

SEVERE ANAEMIA

Give Vitamin A.

Refer URGENTLY to hospital.

Some palmar pallor or

Very low weight for age.

ANAEMIA OR VERY

LOWWEIGHT

Assess the

feeding according to the FOOD box on the COUNSEL

THE MOTHERchart. If feeding problem, follow-up in 5 days.

If pallor:

Give iron.

Give oral antimalarial if high malaria risk.

Give mebendazole if child is 2 years or older and

has not had a dose in the previous 6 months.


If pallor, follow-up in 14 days.

If very low weight for age, follow-up in 30 days.

Not very low weight for

age and no other signs NO ANAEMIA AND

If child is less than 2 years old, assess the

feeding and counsel the mother on feeding



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Immunization Status

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THEN CHECK THE CHILDS IMMUNIZATION STATUS

ForALL sick children ask the mother about the childs about cough or difficult

breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia

andCHECK IMMUNIZATION STATUS.

IMMUNIZATION

SCHEDULE:

AGE

Birth

6 weeks

10 weeks

14 weeks

9 months

VACCINE

BCG

DPT-1

DPT-2

DPT-3

Measles

OPV-0

OPV-1

OPV-2

OPV-3

DECIDE if the child needs an immunization today, or if the mother should be

told to come back with the child at a later date for an immunization.

Note: Remember there are no contraindications to immunization of a sick child

if the child is well enough to go home.

Then CHECK for other problems.

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Common Contraindications toCommon Contraindications to

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ImmunizationsImmunizations1. Children who are being referred urgently to the

hospital should not be immunized

2. Live vaccines should not be given to sick children with

immunodeficiency or immunosuppressed due tomalignant disease, treatment with immunosuppressive

agents or irradiation

3. DPT2 / DPT3 should not be given to children who

have had convulsions or shock within 3 days of a

previous dose of DPT

4. DPT should not be given to children with recurrent

convulsions or another active neurological disease of

the CNS.


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ImmunizationImmunization

OPV:

If the child had diarrhea, give a dose ofOPV but do

not count the dose. Ask the mother to return in 4

weeks for the missing dose ofOPV

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OTHER PROBLEMS

For all sick children ask the mother about the child\s problem,

check for general danger signs, ask about cough or difficult breathing

diarrhea, fever, ear problem, and then check for malnutrition

and anemia, immunization status AND

ASSESS OTHER PROBLEMS

TREAT any other problems according to your training,

experience and clinic policy.

REFER the child for any other problem that you cannot manage

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Assessing Other Problems

Meningitis

Sepsis

Tuberculosis

Conjunctivitis Others:also mothers (caretakers) own

health

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Ask the mother or caretaker about the young

SUMMARY OF ASSESS AND CLASSIFY

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If this is an INITIAL VISIT for the problem, follow the steps below.

(If this is a follow-up visit for the problem, give follow-up care according toPART VII)

Check forPOSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker about

DIARRHOEA:

If diarrhoea is present:

assess the infant further for signs related todiarrhoea, and

classify the illness according to the signs

which are present or absent.

Check forFEEDING PROBLEM OR LOWWEIGHT and classify the

Check the infants immunization status and decide if the infant needs anyimmunization today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Infant (PART V),

and Counsel the Mother (PART VI)

ForALL sick young infants check for signs ofPOSSIBLE BACTERIAL INFECTION

How to check a young infant for possible bacterial infection

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CHECK FOR POSSIBLE BACTERIAL INFECTIONASK:

Has the infant had

convulsions?

LOOK, LISTEN, FEEL:Count the breaths in one minute.

Repeat the count if elevated.

Look for severe chest indrawing.

Look for nasal flaring

Look and listen for grunting.

Look and feel for bulging fontanelle.

Look for pus draining from the ear.

Look at the umbilicus. Is it red or draining pus?

Does the redness extend to the skin?

Measure temperature (or feel for fever or low body temperature)

Look for skin pustules. Are there many or severe pustules?

See if the young infant is lethargic or unconscious.

Look at the young infantss movements. Are they less than normal?

YOUNGINFANT

MUST BE

CALM

CLASSIFY the infants illness using the COLOUR-CODED-CLASSIFICATIONTABLE FOR POSSIBLE BACTERIALINFECTION.

Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other

problems.


(U t f l t t t i b ld i t )

CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION

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Convulsions or

Fast breathing (60 breaths per

minute or more) orSevere chest indrawing or

Nasal flaring or

Grunting or

Bulging fontanelle or

Pus draining from ear or

Umbilical redness extending tothe skin or

Fever (37.5 C* or above orfeels hot) or low bodytemperature (less than 35.5 C*

or feels cold) or

Many or severe skin pustules or

Lethargic or unconscious or

Less than normal movement.

POSSIBLE

SERIOUS

BACTERIALINFECTION

Give first dose of intramuscular antibiotics.

Treat to prevent low blood sugar.Advise mother how to keep the infant warm

on the way to hospital.

Refer URGENTLY to hospital

Red umbilicus ordraining pus or

Skin pustules.

LOCAL

BACTERIAL

INFECTION

Give an appropriate oral antibiotic.Teach the mother to treat local infections at

home.

Advise mother to give home care for the young

infant.

Follow-up in 2 days

SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 C higher.

How to assess and classify a young infant for diarrhea?

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ForALL sick young infants check for signs of possible bacterial infection andthen

ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSESS AND CLASSIFY the young infants diarrhoea using theDIARRHOEA box in the YOUNG INFANTchart. The

process is very similar to the one used for the sick child (see Chapter 8).

Then CHECK for feeding problem or low weight, immunization status and otherproblems.

ForALL sick young infants check for signs of possible bacterial infection, ask aboutdiarrhoea and then CHECK FOR FEEDING PROBLEM OR LOWWEIGHT.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

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THEN CHECK FOR FEEDING PROBLEM OR LOWWEIGHT

LOOK, LISTEN, FEEL:

g? Determine weight for age.

s,how many times in 24 hours?

ive any other foods or drinks?

e 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,

AND

Has no indications to refer urgently to hospital:

If the infant has not fed in the previous hour, ask the mother to put her

infant to the breast.O

bserve the breastfeed for 4 minutes.

(If the infant was fed during the last hour, ask the mother if she can wait

and tell you when the infant is willing to feed again.)

Is the infant able to attach?

no attachment at all not well attached good attachment

TO CHECK ATTACHMENT, LOOK FOR:

Chin touching breast

Mouth wide open

Lower lip turned outward

More areola visible above then below the mouth

(All these signs should be present if the attachment is good.)Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?

no suckling at all not suckling effectively suckling effectively

Clear a blocked nose if it interferes with breastfeeding. Look for ulcers or white patches in the mouth (thrush).

CLASSIFY the infants nutritional status using the colour-coded classification table for feeding problem or low weight.

Then CHECK immunization status and for other problems.



CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOWWEIGHT

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Not able to feed or

No attachment at all or

Not suckling at all.

NOT ABLE TO FEED

POSSIBLE

SERIOUS BACTERIALINFECTION

Give first dose of intramuscular antibiotics.

Treat to prevent low blood sugar.

Advise the mother how to keep the young infantwarm on the way to hospital.

Refer URGENTLY to hospital.

Not well attached to breast

or

Not suckling effectively or

Less than 8 breastfeeds in

24 hours or

Receives other foods or

drinks or

Low weight for age or

Thrush (ulcers or white

patches in mouth).

FEEDING PROBLEM

OR LOWWEIGHT

Advise the mother to breastfeed as often and for as long as theinfant wants, day and night.

-If not well attached or not suckling effectively, teach

correct positioning and attachment.

-If breastfeeding less than 8 times in 24 hours, advise toincrease frequency of feeding.

If receiving other foods or drinks, counsel mother aboutbreastfeeding more, reducing other foods or drinks, and using acup.

If not breastfeeding at all:

Refer for breastfeeding counselling andpossible relactation.

Advise about correctly prepared breastmilksubstitutes and using a cup.

If thrush, teach the mother to treat thrush at home.

Advise mother to give home care for the young infant.

Follow-up any feeding problem or thrush in 2 days. Follow-uplow weight for age in 14 days.

Not low weight for age and

no other signs of inadequate

feeding.

NO FEEDING

PROBLEM

Advise mother to give home care for the young infant.

Praise the mother for feeding the infant well

(Urgent pre referral treatments are in bold print.)

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TO CHECK ATTACHMENT, LOOK FOR:

Chin touching breast

Mouth wide open

Lower lip turned outward

More areola visible above then below

the mouth

(All these signs should be present if the attachment is good)

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Communicate and Counsel

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GIVEFO

LLO

W-UPCARE

Follow-up care for the sick young

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Follow up care for the sick young

infant When to return immediately Signs of any of the following:

Breastfeeding or drinking poorlyBecomes sicker

Develops a fever

Fast breathingDifficult breathing

Blood in the stool

Follow-up care for the sick young

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Follow up care for the sick young

infant

Follow-up in 2 days on antibiotics

for local bacterial infection or

dysentery

Follow-up in 2 days - with a feeding

problem or oral thrush

Follow-up in 14 days with low

weight for age

If th hild h R t f f ll i

FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

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If the child has: Return for follow-up in:

PNEUMONIA

DYSENTERY

MALARIA, if fever persists

FEVERMALARIA UNLIKELY, if fever

persists

MEASLES WITH EYE OR MOUTHCOMPLICATIONS

2 days

PERSISTENTDIARRHOEA ACUTE EAR

INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEMANYOTHER ILLNESS, if not improving

5 days

PALOR VERY 14 days

LOW WEIGHTFOR AGE 30 days

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THANK YOU!!THANK YOU!!

Documents

IMCI Nov 2009