COMMUNITY-INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (CIMCI)

For WHOM?
Community Children: One week to 2 months Age 2 months to 5 years

Main Concerns: Cough or Difficult Breathing (ARI) Diarrhea Malaria Measles Ear Infections Malnutrition Breastfeeding Preventive Activities: Vaccinations & Vitamin A Algorithm: Check for Danger Signs

Assess Main Symptoms

Assess Immunization, Nutrition and feeding problems and other problems

Classify conditions and Identify treatment actions

Referral Facility
(pink)

Out Patient Facility

(yellow)

Home Management
(green)

Out-patient Management: Children 2 months to 5 years History-taking General Danger Signs Main Symptoms Nutritional Status Immunization Status Other Problems

General Danger Signs

Main Symptoms Nutritional Status Immunization Status Other Problems

History-taking

Convulsions Unconscious or lethargic Unable to drink or breastfeed Vomits everything

Main Symptoms
Nutritional Status Immunization Status Other Problems

History-taking General Danger Signs

Cough or difficult breathing Diarrhea Fever Ear problems

History-taking General Danger Signs

Main Symptoms

- Cough or difficult breathing

- Diarrhea - Fever - Ear problems Nutritional Status Immunization Status Other Problems

Assess for:
Respiratory rate Lower chest wall in-drawing Stridor

Classification of Cough or Difficult Breathing

(pink) (pink)

Any danger sign or Chest in-drawing or Stridor

(yellow) (yellow)

Severe Pneumonia or Very Severe Disease Pneumonia

(green)

Fast Breathing
(green)

No signs of pneumonia or very severe disease

No Pneumonia Cough or Cold

Interventions: Give the 1st dose of an appropriate antibiotic Give Vitamin A Treat the child to prevent the lowering of his or her blood sugar level Refer the child URGENTLY to a hospital Give an appropriate antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advice the mother regarding when to return to the health center Follow-up in 2 days If the coughing persists for more than 30 days, refer to a hospital for assessment Soothe the throat and relieve the cough with a safe remedy Advise the mother regarding when to return to the health center Follow-up in 5 days if no improvement is observed If the coughing persists for more than 30 days, refer to a hospital for assessment Soothe the throat and relieve the cough with a safe remedy Advise the mother regarding when to return to the health center Follow-up in 5 days if no improvement is observed

History-taking General Danger Signs

Main Symptoms
- Cough or difficult breathing

- Diarrhea
- Fever - Ear problems Nutritional Status Immunization Status Other Problems

Assess for
General condition Sunken eyes Reaction when offered a drink Elasticity of the skin

Classification of Dehydration
(pink) (pink)

2 of these signs: - Lethargic or unconscious - Sunken eyes - Not able to drink or drinking poorly - Skin pinch go back very slowly
(yellow) (yellow)

Severe Dehydration

2 of these signs: - Restless, irritable - Sunken eyes - Skin pinch go back slowly
(green) (green)

Some Dehydration

Not enough signs to classify

NO Dehydration

Interventions: If the child has no other severe classification: Give fluid for severe dehydration OR If the child has another severe classification: Refer the child URGENTLY to a hospital, with the mother giving the child frequent sips of ORS on the way. Advise the mother to continue breastfeeding the child. If the child is 2 yrs old or older, and there is cholera in your area: Give the child an antibiotic for cholera Give fluid and food Advice the mother regarding when to return to the health center immediately. Follow-up in 5 days if no improvement is observed Give fluid and food Advice the mother regarding when to return to the health center immediately. Follow-up in 5 days if no improvement is observed

Give fluid and food at home to treat the diarrhea

History-taking General Danger Signs

Main Symptoms
- Cough or difficult breathing - Diarrhea

- Fever
- Ear problems Nutritional Status Immunization Status Other Problems

Assess for:
Stiff neck Risk of malaria Runny nose Duration of fever Risk of measles

Classification of Fever
(pink) (pink)

Any danger sign or stiff neck

(pink)

Very Severe Febrile Disease

(pink)

Any danger sign or clouding of cornea or deep/extensive mouth ulcers

(yellow) (yellow)

Severe Complicated Measles

fever @ 37.5 and above in high malaria risk area no runny nose, no measles and no other causes of fever in low malaria risk areas
(yellow)

Malaria

(yellow)

obvious causes of fever in no malaria risk areas

(yellow)

Possible Bacterial Infection Measles with eye or mouth complication

(green)

(yellow)

pus draining from eye or mouth ulcers In low malaria risk area -Runny nose present or -Measles present or -other causes of fever present

(green)

Fever - malaria unlikely

(green)

(green)

No obvious causes of fever in no malaria risk area

(green)

Uncomplicated Fever
(green)

Measles now or in the last three months

Measles

History-taking General Danger Signs

Main Symptoms
- Cough or difficult breathing - Diarrhea - Fever

- Ear problems
Nutritional Status Immunization Status Other Problems

Assess for:
Tender swelling behind the ear Ear pain Ear discharge or pus

Classification of Ear Problems

(pink) (pink)

- Tender swelling behind the ears

(yellow) (yellow)

Mastoiditis Acute Ear Infection

(yellow)

(yellow)

Ear discharge in less than 14 days Or ear pain Ear discharge for more then 14 days
(green)

(green)

Chronic Ear Infection NO EAR Infection

NO ear pain and NO ear discharge seen draining from the ears
History-taking General Danger Signs Main Symptoms - Cough or difficult breathing - Diarrhea - Fever - Ear problems

Nutritional Status
Immunization Status Other Problems

Assessing the childs feeding

Breast feeding frequency and night feeds Types of complimentary food or fluids, frequency of feeding, and whether feeding is active Feeding patterns during the current illness

History-taking General Danger Signs Main Symptoms - Cough or difficult breathing - Diarrhea - Fever - Ear problems Nutritional Status

Immunization Status
Other Problems

Assess for immunization status of the child. No immunization to CHILDREN:

Being referred urgently to the hospital No live vaccines (BCG, polio, measles) to those with immunodeficiency diseases, or immuno-suppressed due malignant disease, or therapy with immuno-suppressant agents or irradiation No DPT2 or DPT3 to those with convulsions or shock within three days after a previous dose No DPT to those with recurrent convulsions or other active neurological disease of the CNS

Out-patient Management: Children 1 week to 2 months Check for possible bacterial infection Assess for presence of diarrhea Check for feeding problems or low birth weight Check for immunization status Check for other problems Classification of Bacterial Infections Convulsions Fast breathing Severe chest in-drawing Nasal flaring Grunting Bulging fontanelle Pus drainage from ear Umbilical redness extending to skin Fever or hypothermia Many or severe skin pustules Lethargy or unconsciousness Less than the normal movement

POSSIBLE SERIOUS BACTERIAL INFECTION

Red umbilicus or draining pus Skin pustules

Local Bacterial infection

Classification of Feeding Problems or Low Weight Not able to feed No attachment at all No sucking at all Not well attached to breast Not sucking effectively Fed fewer than 8 times in 24 hours Receiving other food or drinks Low weight for age Thrush Possible Bacterial Infection

Feeding problems or low weight

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

NO FEEDING PROBLEMS

For all children before referral: Give breast milk or sugar water Convulsions Severe pneumonia/ Mastoiditis Severe Complicated Measles Severe malnutrition Malaria Diazepam (10mg/2ml) 0.1 ml/kg Cotrimoxazole or amoxicillin

Vitamin A

First line anti-malarial Chloroquine and Primaquine Second-line anti-malarial Sulfadoxine and Pyrimethamine