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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSTCAP CHN 2

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CURRENT HEALTH SITUATION

1.Increasing number of childhood deaths

2.Poor situation in First-Level Health Facilities

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Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999

Malaria

Diarrhea

Measles

Pneumonia

Perinatal

OTHERS

Undernutrition54%

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Causes of Deaths among Children Under Five Years Old

Top Ten Leading Cause of Underfive Mortality 2000 Philippine Health Statistics

7.68.3

10.611.5

16.822.7

24.230.4

31.751.6

0 10 20 30 40 50 60

perinatal causesmalignant neoplasm

congeninital anomaliesmeningitis

diarrheanutritional disorders

measlessepticemiaaccidents

pneumonia

no. of Underive Deaths Per 1000LB

Source: 2000 Philippine Health Statistics

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Rationale for IMCI

Features of IMCI…

•not necessarily dependent on the use of

sophisticated and expensive technologies

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Rationale for IMCI

Features of IMCI…

•a more integrated approach to

managing sick children

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Rationale for IMCI

Features of IMCI…

•careful and systematic assessment of common symptoms and specific clinical signs to guide rational and effective

actions

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Rationale for IMCI

Features of IMCI…

•integrates management of most common childhood problems

(pneumonia, diarrhea, measles, malaria, dengue hemorrhagic

fever, malnutrition and anemia, ear problems)

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Rationale for IMCI

Features of IMCI…

•includes preventive interventions

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Rationale for IMCI

Features of IMCI…

•adjusts curative interventions to the

capacity and functions of the health system

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Rationale for IMCI

Features of IMCI…

•involves family members and the community in

the health care process

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Objectives of IMCI

(1) reduce deaths and the frequency and severity of illness and disability; and

(2) contribute to improved growth and development

IMCI Case Management

Danger signs (CANS)Main Symptoms (CDEF)Nutritional statusImmunization statusOther problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

TreatmentCounsel & Follow-up

ASK :PVA

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Target Groups

•Sick young infant▫1 week up to 2 months

•Sick young children▫2 months up to 5 years

IMCI Booklet

THE SICK CHILDAGE: 2 MONTHS UP TO 5 Y EARS

PART I

Check all sick children for general danger signs

REMEMBER:

C - CONVULSIONS

A– ABNORMALLY SLEEPY

N – NOT ABLE TO DRINK

S– (SEVERE) VOMITS EVERYTHING

Need to Refer(except in severe dehydration)

General DangerSigns

CHILD HAS A SEVERE

PROBLEM. DO NOT DELAY

TREATMENT.

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•Cough or difficulty in breathing

•Diarrhea

•Ear problem

•Fever

COUGH OR DIFFICULTY IN BREATHING

Cough or difficulty in breathing

Ask:•For how long?Look:•Chest indrawing•Stridor•Count RR

The child must be calm.

FAST BREATHING

AGE

≥ 60 breaths / min

<2 months


2 – 12 months


1-5 years

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Any general danger sign or

Chest indrawing or

Stridor in calm child.

SEVERE

PNEUMONIA

OR VERY

SEVERE DISEASE

Give first dose of an appropriate antibioticVitamin ABreastfeeding/sugar waterIf wheezing give a trial of rapid actingbronchodialator for three cycles EVERY 15 MIN before classifying pneumonia

Refer URGENTLY to hospital.

Fast breathing PNEUMONIA

•Give oral antibiotic for 3 days•If wheezing give a trial of rapid actingbronchodialator three times before classifying pneumonia•Soothe the throat and relieve the cough with a safe remedy•If recurrent wheezing refer for an assessment•If coughing for more than 30 days refer for possible TB or asthma•Advise the mother when to return immediately•Follow-up in 2 days

•No signs of pneumonia

or very severe disease.

NO PNEUMONIA:

COUGH OR COLD

If coughing more than 30 days, refer TO HOSPITAL for assessment.

Soothe the throat and relieve the cough with a safe remedy.

Advise mother when to return immediately.

Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING

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

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

1st dose of antibiotic Vitamin A Bronchodilator Breastfeeding/ sugar water URGENT REFERRAL

Any general danger sign or Chest indrawing or Stridor in a calm child

Fast breathing2 – 12 months old: ≥ 50/ minute1 year or older: ≥ 40/ minute

PNEUMONIA

Antibiotic for 3 days Bronchodialator Safe remedy If recurrent wheezing refer for an assessment If coughing for more than 30 days refer for possible

TB or asthma Advise the mother when to return immediately Advise mother on danger signs Follow up in 2 days

NO PNEUMONIA: COUGH OR COLD

If cough ≥ 30 days , refer to hospital for assessment

Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement

No signs of pneumoniaor a very severe disease

DIARRHEA

Types of Diarrhea

•ACUTE DIARRHEA•PERSISTENT DIARRHEA•DYSENTERY

ASSESS AND CLASSIFY

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Checking the Main Symptoms

2. DIARRHEA

ASK

▫ How long?▫ Is there blood in the stool

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2. DIARRHEALOOK▫ GENERAL CONDITION OF THE

CHILD Restless or irritable Abnormally sleepy or diffi cult to

awaken Sunken eyes

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2. DIARRHEALOOK▫ OFFER FLUID

Not able to drink Drinking poorly Drinking eagerly, thirsty

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2. DIARRHEALOOK▫ PINCH SK IN Very slowly Slowly immediately

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ASSESS AND

CLASSIFY

Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

SEVERE

SOME

NO

+DHN= SPD

NDHN= PD

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Severe Dehydration

SEVERE DEHYDRATION

2 or more of the following:

Abnormally sleepy/ difficult to wake Sunken eyes Not able to feed/ drinking poorly Skin pinch goes back very slowly

Classify for dehydration

Plan C if no other severe classification Refer if with other severe disease BF or ORS along the way Give Tetracycline for cholera

if there is cholera in the area and the child is 2 years or more

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Severe Dehydration

Treatment Plan CTo treat severe dehydration (IV fluid: pLRS)

Age Initial Phase Subsequent Phase(30 ml/kg) (70 ml/kg)

Infants (<12 mos) 1 hour * 5 hoursOlder children 30 minutes* 2½ hours

*Repeat once if radial pulse is still very weak or imperceptible.

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SOME DEHYDRATION

SOME DEHYDRATION

2 of the following:

Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly


Give ORS/ BF, food for some dehydration Plan B If with other severe disease, REFER Follow up in 5 days Advice when to return immediately

400-700200-400Amount

4-12 mos< 4 mosAge

Determine the amount (in ml) of Oresol to be given in 4 hours

= weight of the child (in kg) X 75, or if weight is unknown, use this chart.

Plan B: Treat some dehydration with ORS

900-1400700-900Amount

2-5 yrs12 mos-2 yrsAge

Determine the amount (in ml) of Oresol to be given in 4 hours

= weight of the child (in kg) X 75, or if weight is unknown, use this chart.

Plan B: Treat some dehydration with ORS

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No Dehydration

NO DEHYDRATION

Not enough signs to classify as SEVERE DEHYDRATION orSOME DEHYDRATION


Give ORS, zinc and food to treat diarrhea at home

Plan A Follow up in 5 days Advise mother when to return immediately

Give extra fluid.

Plan A: Treat diarrhea at home

100 – 200 ml after each LBM2 -4 yrs

50 – 100 ml after each LBMUp to 2 yrs

Continue feeding.

Know when to return.

Persistent diarrhea: 14 days or more

• Treat dehydration before referral, unless with other severe disease

• Give Vitamin A• Refer to hospital

+ Dehydration=severe persistent diarrhea

Persistent diarrhea: 14 days or more

• Advise regarding feeding• Give Vitamin A• Give vitamins and minerals including zinc for

14 days• Follow up in 5 days• Advise when to return immediately

No dehydration= persistent diarrhea

Blood in the stool = dysentery

• Oral antibiotic for shigella for 3 days (CIPROFLOXACIN)

• Follow up in 2 days• Advise when to return immediately

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•EXCEPTIONS:I f the child is less than 12 months old or was dehydrated on the 1st visit or had measles 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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•After 2 days:Ask:•if the child is dehydrated, treat hydration.

•if the number of stools, amount of stools, fever, abdominal pain or eating is same or worse: Change to 2nd line antibiotics & give for 5 days. Advise to return in 2 days.

Dysentery

FEVER

ASSESS AND CLASSIFY

Malaria risk?

Measles now or w/ in last 3 mos

Dengue risk?

VSFD:M

MALARIA

F:M unlikely

VSFD

F: NM

N MRMR

SCM M:EMC MEASLES

S DHF F: DHF unlikely

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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.

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Then Ask:

For how long does the child has fever?

I f >7 days, has the fever been present everyday?

Has the child had measles within the last 3 months?

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Look and Feel:

Look and feel for stiff neck.

Look for runny nose

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Look for signs of Measles:

• Generalized rash.

• One of these: cough, runny nose or red eyes

Fever: Ask about malaria risk

•Residing in endemic area?OR:•Travel & overnight stay in endemic area, or•Blood transfusion w/ in past 6

month

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Malaria Risk Areas

1. Palawan2. Davao Oriental3. Davao del Norte4. Compostela

Valley5. Tawi-tawi6. Sulu7. Agusan del Sur8. Mindoro

Occidental9. K alinga Apayao10. Agusan del Norte

11.Isabela12.Cagayan13.Quezon14.Ifugao15.Zamboanga del

Sur16.Bukidnon17.Misamis Oriental18.Quirino19.Mountain

Province20.Basilan

Malaria risk +

• Blood smear• Ask: Duration of fever?

Present everyday?• Look: Stiff neck

Runny noseOther signs of measles

Malaria risk + any general danger sign or stiff neck

• 1st dose of Quinine (under med. Supervision or if hospital is not accessible within 4 hours)

• 1st dose of antibiotic, Paracetamol• Treat to prevent low blood sugar• Send the blood smear with the patient• Urgent referral

Very severe febrile disease/ malaria

Malaria risk and + blood smear if no blood smear there should be

No runny nose, no measles, no other cause of fever

• Oral antimalarial• Paracetamol• Follow up in 2 days• > 7 days fever hospital for

assessment

Malaria

Malaria risk and - blood smear +runny nose or +measles or + other causes of fever

• Paracetamol for fever more than 38deg C• Follow up in 2 days• Advise when to return immediately• > 7 days fever hospital for assessment

• Treat other causes of fever

Fever: Malaria Unlikely

•No malaria risk

Any general danger sign or stiff neck

• 1st dose of antibiotic• Paracetamol for fever 38.5 deg above• Treat for low blood sugar• Urgent referral

Very severe febrile disease

•No malaria risk

No signs of severe febrile disease

• Paracetamol for fever more than 38deg C• Follow up in 2 days• Advise when to return immediately• > 7 days fever hospital for assessment

• Treat other causes of fever

Fever: No malaria

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

• Look• For mouth ulcers. Are they deep

and extensive?• For pus draining from the eyes• Look for clouding of the cornea

Measles now or w/ in last 3 monthsAny general danger sign orClouding of cornea orDeep or extensive mouth ulcers

• 1st dose of antibiotic• Vitamin A

• Apply tetracycline ointment if corneal clouding is present

• Urgent referral

Severe complicated measles

Measles now or w/ in last 3 monthsPus draining from the eye orMouth ulcers

• Vitamin A• Tetracycline eye ointment• Gentian violet• Follow up in 2 days• Advise mother when to return immediately

Measles with eye or Mouth complications

Measles now or w/ in last 3 monthsNo other signs

• Vitamin A• Advise mother when to

return immediately

Measles

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Then Ask:• Has the child had any

bleeding from the nose or gums or in the vomitus or stools?

• Has the child had black vomitus or stools?

• Has the child had abdominal pain?

• Has the child been vomiting?

Look and Feel:• Look for bleeding from nose

or gums.

• Look for skin petechiae• Feel for cold clammy

extremities.• Slow capillary refill

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.

Perform Torniquet Test.

Decide Dengue Risk: Yes or NoIf Dengue Risk:

Slow capillary refill

•Indicates poor skin perfusion•Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

Any of the danger sign orBleeding gums, nose, in vomitus or stools or

Black vomitusor stools orPersistent abdominal pain or

Persistent vomiting orSkin petechiaeor

Cold and clammy skin orSlow capillary refill or

Tourniquet test

SEVERE DENGUE HEMORRHAGIC FEVER

• If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS

• Any other signs of bleeding Plan C• Urgent referral• Treat other cause of fever• Do not give aspirin

No signs of severe DHF

• Follow up in 2 days• Advise mother when to

return immediately or when fever persist or sign of bleeding manifest

• Do not give aspirin

FEVER: Dengue Hemorrhagic Fever Unlikely

EAR PROBLEM

YES

NO

MALNUTRITION AND ANEMIA

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4. Ear problems

ASK• Does the child have ear pain?• Is there ear discharge? ▫ If yes, how long?

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4. Ear problems

LOOK• For pus draining from the earFEEL• Tender swelling behind the

ear

Structure:3 Divisions1. external ear2. middle ear3. inner ear

Tympanic membrane or “ear drum”

4. EAR PROBLEM

• 1st dose of antibiotic• Paracetamol for pain• Urgent referral

Mastoiditis

tender swelling behind ear

• Antibiotic for 5 days• Paracetamol for pain• DRY Wicking• Follow up in 5 days• Advise when to return immediately

Acute ear infection

Ear discharge < 14 days orEar pain

• Wicking• Instill Quinolone otic drops for two weeks• Follow up in 5 days• Advice the mother when to return immediately

Chronic ear infection

Ear discharge for 14 days or more

No ear pain or pus draining from ears

No Ear Infection

•No additional treatment•Advise mother when to return immediately

CHECK FOR MALNUTRITION AND ANEMIA

ASSESSANDCLASSIFYNUTRITIONAL STATUS

ASSESSAND

CLASSIFYNUTRITIONAL STATUS

If age up to 6 months and Visible severe wasting or Edema on both feetIf age 6 months and above and MUAC is less than 115 mm or has edema of both feet or severe muscle wasting

• Treat to prevent low blood sugar• Vitamin A• Urgent referral

Severe malnutrition or severe anemia

Very low for weight

• Assess feeding and counsel mother regarding feeding recommendation and care for development

• Vitamin A• Follow up in 30 days• Advise when to return immediately

Very low weight

Not very low weight for age and no other sign of malnutrition


• If feeding becomes a problem, follow up in 5 days

• Advise when to return immediately

Not very low weight

ASSESSANDCLASSIFYANEMIA

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Check for Anemia

•Look for palmar pallor

▫Severe palmar pallor▫Some palmar pallor▫No palmar pallor

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AnemiaConditions Predisposing to Anemia

•infections

•hookworm and whipworm infections

•malaria

108Children with AnemiaHow to check for Anemia

SEVERE PALMAR PALLOR

NO ANEMIA

SOME PALMAR PALLOR

ASSESSAND

CLASSIFYANEMIA

CHECK FOR ANEMIA

SEVERE PALMAR PALLOR

•Refer urgently to hospital

Severe Anemia

SOME PALMAR PALLOR


• Give IRON• Give ALBENDAZOLE/ MEBENDAZOLE if child is 1

year or older and has not received a dose for previous 6 months

• Follow up in 14 days• Advise when to return immediately

Anemia

NO PALMAR PALLOR

• If the child is less than 2 years old, assess feeding and counsel mother regarding feeding recommendation and care for development

• If feeding becomes a problem, follow up in 5 days

• Advise when to return immediately

No Anemia

THE SICK YOUNG INFANTAGE: 1 WEEK UP TO 2 MONTHSPART II

IMCI Case Management

Danger signs (CANS)Main Symptoms (BJDF)Nutritional statusImmunization statusOther problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

TreatmentCounsel & Follow-up

ASK :PVA

BACTERIAL INFECTION

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Check for very severe disease and local infection

ASK

•Is the infant having difficulty of feeding?

•Had the infant have convulsions?

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LOOK, LISTEN

Count the breaths in one minute.

Repeat the count if more than 60 bpm.

Look for severe chest in -drawing.

Measure axillary temperature.

THE CHILD MUST BE CALM

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

Does the redness extend to the skin?

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

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

LOOK, LISTEN

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Umbilicus with infection

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Normal healing of umbilicus

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normal dried umbilical stump

BACTERIAL INFECTION

Any of the followingNot feeding well or

convulsions orFast breathing 60 bpmor more

severe chest indrawingfever

low body tempMovement only when stimulated or no movement at all

• Give 1st dose of IM antibiotics• Treat to prevent low blood sugar• Refer urgently• Advise mother on how to keep infant

warm on the way to the hospital

Very severe disease

Umbilicus red or draining pus orSkin pustules

• Give oral antibiotic• Teach mother to treat local infection at home• Advise the mother to give home care for the young

infant• Assess and counsel mother on care and

development• Follow up in 2 days

Local Bacterial Infection

None of the signs of very severe disease or local bacterial infection

• Advise the mother to give home care for the young infant

• Assess and counsel the mother on care for development

Severe Disease or Local Infection UNLIKELY

ASSESS AND CLASSIFYJ AUNDICE

CHECK FOR J AUNDICE

•LOOK▫For yellow eyes or skin▫Look at palms and soles. Are they yellow?

Any jaundice if age is less than 24 hours oryellow palms and soles at any age

• Refer urgently to hospital• Treat to prevent low blood sugar• Advise how to keep the infant warm on

the way to the hospital

Severe Jaundice

•Jaundice appearing after 24 hours of age andpalms and soles NOT yellow

• Advice the mother to give home care for young infant• Advise to return immediately if palms and soles appear

yellow• If the young infant is older than 14 days, refer for

assessment• Assess and counsel the mother on care for development• Follow up in 1 day

JAUNDICE

No jaundice


• Advice the mother to give home care for young infant

No jaundice

ASSESSAND CLASSIFYDIARRHEA

CHECK FOR DIARRHEA

•ASK

▫For how long?▫Is there blood in the stool?

CHECK FOR DIARRHEA• Look and Feel

• Look at the young infant’s general condition▫ Infant’s movement

Does the infant move on his/her own Does the infant move only w hen stimulated then

stop Does the infant not move at all

▫ Is the infant restless or irritable▫Look for sunken eyes▫Pinch the skin of the abdomen. Does it

goes back Very slow ly Slowly immediately

ASSESSAND CLASSIFYDIARRHEA

Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

SEVERE

SOME

NO

SPD

Two of any of the following:Movement only when stimulated or no movement at all

sunken eyesskin pinch goes back very slowly

• If the infant does not have VERY SEVERE DISEASE, nor DYSENTERY, give fluid for severe dehydration or PLAN C

OR• If the infant also has a VERE SEVERE DISEASE, SEVERE JAUNDICE

OR DYSENTERY:• Refer urgently to hospital, with mother giving frequent sips of

ORS on the way• Advise to continue breastfeeding• Keep the infant warm

Severe Dehydration

•Two of the following signs:Restless or irritable

Sunken eyesSkin pinch goes back slowly

• Give fluid for some dehydration (PLAN B)• If the infant also has a VERE SEVERE DISEASE, SEVERE

JAUNDICE OR DYSENTERY:• Refer urgently to hospital, with mother giving

frequent sips of ORS on the way• Advise to continue breastfeeding


SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration

• Give fluid to treat diarrhea at home (PLAN A)


NO DEHYDRATION

Diarrhea: Classify

Persistent diarrhea

Diarrhea lasting for 14 days or more

• If the young infant has dehydration, treat dehydration before referral, unless infant also has VERY SEVERE DISEASE

• Refer to Hospital

SEVERE, PERSISTENT DIARRHEA

Diarrhea: Classify

Blood in the stool

Blood in the stool

• Refer urgently to Hospital, with mother giving frequent sips of ORS on the way

• Advise to continue breastfeeding

DYSENTERY

ASSESS AND CLASSIFYFEEDING PROBLEMLOW WEIGHT FOR AGE

149

Assess and Classify a Young Infant for a Feeding Problem or Low Birth Weight

ASK :

•Is the infant breastfed? ▫I f yes, how many times in a 24 hours?

•Does the infant usually receive any other food or drink? ▫I f yes, how often▫What do you use to feed the infant?

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LOOK :

•Determine the weight for age?

•Look for ulcers or white patches in the mouth (oral thrush)

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Assess and Classify a Young Infant for a Feeding Problem or Low Birth WeightASSESS BREASTFEEDING:

•Has the infant breastfed in the previous hour?▫Observe attachment

Not well attachedGood attachment

•Is the infant sucking effectively?▫Slow, deep sucks, sometimes pausing

Not sucking effectivelySucking effectively

Check for good attachment

•Chin touching the breast•Mouth wide open•Lower lip turned outward•More areola above than below

Good Wrong

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Problems Associated with Breastfeeding

•problems with attachment

•problems with sucking

•blocked nose

•ulcers or white patches in the mouth


ASSESS AND CLASSIFYFEEDING PROBLEMLOW WEIGHT FOR AGE

•Not well attached to the breast ORNot sucking effectively OR

Less than 8 breastfeeds in 24 hours ORReceives other foods or drinks OR

Low weight for ageThrush

FEEDING PROBLEM OR LOW WEIGHT FOR AGE

• If not able to attached well or not sucking effectively, teach correct positioning and attachment

• If feeding is less than 8 times a day, advised to increase frequency as often as the child wants night and day

• If giving other food and drinks, advise to reduce and counsel further regarding breastfeeding

• If not breastfeeding at all, counsel regarding breastfeeding or teach proper ways of preparing milk substitute

• Advise the mother how to feed and keep the low weight infant warm at home

• If with thrush, teach the mother how treat at home• Advise to give home care• Follow up any feeding problem or thrush in 2 days• Follow up low weight for age in 14 days• Assess and counsel the mother on care for development

Not low weight for age and no other signs of inadequate feeding


• Advise mother to give home care for the young infant

• Praise the mother for feeding the infant well

NO FEEDING PROBLEM

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant

When to return immediately

– Signs of any of the following:

– Breastfeeding or drinking poorly

– Becomes sicker

– Develops a fever

– Fast breathing

– Difficult breathing

– Blood in the stool

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 the child has: Return for follow-up in:

PNEUMONIA

DYSENTERY

MALARIA, if fever persists

FEVER—MALARIA UNLIKELY, if fever persists

MEASLES WITH EYE OR MOUTH COMPLICATIONS

2 days

PERSISTENT DIARRHOEA ACUTE EAR INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEM

ANY OTHER ILLNESS, if not improving

5 days

PALOR VERY 14 days

LOW WEIGHT FOR AGE 30 days

FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART