GOOD MORNING..

Jomar P. Mallonga,RN, Ll.B., MAN

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

-WHO, 1990 -middle to low income countries: children are more likely to die 10x -common childhood illnesses: 1. Pneumonia 2. Diarrhea dehydration 3. Dengue 4. Malaria 5. Measles 6. Ear Problem deafness 7. Malnutrition/Anemia

Objectives: - to reduce death - to reduce frequency and severity of illness and disability - to contribute in the improvement of growth and development Healthy Filipino: Well Educated In control of their lives Physically healthy Productive Empowered

2 Age Categories in IMCI:

1. Young Infant up to less than 1 week up to 2 months (1 week up to 1 month and 29 days) 2. Young Child 2 months up to 5 years (2 months up to 4 years and 11 months)

Principles in IMCI:
1. All sick children must be examined for GENERAL DANGER SIGNS:

Convulsions (fits, jerky movement, spasm) Unable to drink or breastfeed (not eat) Vomiting Abnormally sleepy (difficult to awaken)

2. Assess for main symptoms: a. Cough/DOB b. Diarrhea c. Fever d. Ear problems 3. Assess for nutritional status, immunization status, vitamin A status (because they are prone to xerophthalmia night blindness), feeding problems and other potential problems. Vitamin A = start at 6 months, repeat every 6 months and supplement until 8 years old

4. Only a limited number of carefully-selected clinical signs are used. 5. A combination of individual signs leads to a childs classification(s) rather than a diagnosis. 6. The guidelines do not describe the management of trauma or other acute emergencies d/t accidents of injuries. 7. IMCI management procedures use a limited number if essential drugs and encourage active participation of caretakers. 8. An essential component of the IMCI guidelines is the counseling of caretakers.

Evidence-Based, Syndromic Approach (EB-SA)

- syndromic: signs and symptoms - supports the rational, effective and affordable use of drugs and diagnostic tools. - it is more realistic and cost effective way to manage patient.

Integrated Case Management Process

1. Assess the child or infant (ask, look and listen) 2. Classify the illness 3. Identify specific treatment 4. Treat the child 5. Counsel the mother 6. Give follow-up care (after 2, 5, 14, 30 days)

Methods in Managing Childhood Illnesses

Classify

the disease a through assessment supported with laboratory results is necessary for classification of illnesses and confirmation of the disease.

Classification of the disease are: 1. mild 2. moderate 3. severe

Treat

the patient

Treatment is a curative method of treating diseases. This vary on the condition of the patient.

Counsel

the patient

Providing health education to clients promotes health and avoid risk of infection. These are important for parents/caregivers especially who lack knowledge on health practices and risks factors that contribute to disease ailments.

Color Classificatio Level of presentation n of managemen diseases t Green Yellow Pink Mild Moderate Severe Home Care Manage at the RHU Urgent referral in Hospital

Color Coded Treatment Chart

Pink - hospital referral - perform pre-referral treatment at health center exception: severe dehydration severe persistent diarrhea

Yellow - indicates initiation of specific treatment like antibiotics, antimalarial, out patient health care facilities (RHU or Health Center)

Green - simple home care (home management)

Good Communication Skills

1. Listen carefully to what the mother tells you. 2. Use words the mother understands. 3. Give the mother time to answer the questions. 4. Ask additional questions when the mother is not sure about her answer.

ASSESS AND CLASIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE

Determine

if this is an initial or followup visit for this problem If follow-up visit, use the follow-up instructions on the TREAT THE CHILD chart If initial visit, assess the child as follows:

Ask:
Is

the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions?

Look:
See

if the child is abnormally sleepy or difficult to awaken If yes: Make sure child with any danger sign is referred after first dose of an appropriate antibiotic and other urgent treatments Exception: Rehydration of the child according to plan C may resolve danger signs so that referral is no longer needed.

COUGH OR DIFFICULTY OF BREATHING

Assesment: (Look, Listen) Count the breaths in one minute Look for chest indrawing Look and listen for stridor Look and listen for wheezing (child must be calm)

Coughing or DOB?
Severe Pneumonia/ Very Severe dse Cough and Colds Pneumonia Tx:

Any of the CUVA or FAST Safe remedies: CHEST BREATHING. - instruct INDRAWING cut off FB: - Follow up care or 1 wk-2 months: 60 after 5 days STRIDOR bpm & above 2mos-12 months: 50 bpm & above 12 months-5 y/o: 40 bpm & above

CUVACS Pre-referral Tx: 1. Give 1st dose antibiotic Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg) *meningitis ampicillin can be increased 4x 2. Give Vit. A 3. Treat the child to prevent lowering of the blood sugar - to prevent drain damage

Tx: 1. Give 3 days antibiotic. 2. If wheezing inhaled bronchodilator for 5 days (salbutamol 2nd choice) 2. Soothe the throat & relieve the cough using safe remedies: - Breastmilk -TLC Juice (Tamarind, Luya, Calamansi) 3. Instruct the mother when to return the baby immediately. 4. Follow up in 2 days

4. Follow up after 2 days. -If with CUVACS give 2nd line antibiotic or IM chloramphenicol and refer -If breathing rate is the same, fever and eating are the same change to 2nd line antibiotic and follow up after 2 days or refer -* client had measles within the last 3 months refer -If breathing becomes better, less fever or eating better complete the 3 days antibiotic

DIARRHEA

Assessment ASK Does the child have diarrhea? For how long? Is there blood in the stool? LOOK & FEEL Look at the childs general condition Is the child abnormally sleepy or difficult to awaken? Restless or irritable? Look for sunken eyeballs 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?

DIARRHEA (Young Child)

Severe Dehydration Some Dehydration (Pink) (Yellow) Condition: Lethargic or - Restless & irritable Unconscious
Tongue & Mouth: Very dry Dry Moist

No Sign of Dehydration (Green)

Well & alert

Eyes: sunken eyes

sunken eyes

normal eyes

Skin Pinch Test at Abdomen: it goes back very Slowly goes back slowly (longer than 2(less than 2 sec.) sec.) Thirst: Drinking poorly

goes back quickly (1 sec or less than 1 sec.)

Drinking eagerly

Drinking normally

DIARRHEA
(Young Child) Dysentery Persistent Diarrhea Severe Persistent Diarrhea (blood on stool) (more than 14 days) (more than 14 days) > 14 days diarrhea or >14 days diarrhea or more w/out signs of more with signs of dehydration dehydration - Well and alert Lethargic or unconscious Restless & irritable

DIARRHEA (Young Infant)

Severe Dehydration Some Dehydration No Signs of Dehydration Dysentery Severe Persistent Diarrhea Pink Yellow Green Pink Pink

Treatment for Young Infant & Child

Severe Dehydration
PINK PLAN C

Give IVF : D5LR < 12 mos. old : 100ml/kg within 6 hrs 12 mos. up to 5 y.o. : 100ml/kg within 3 hrs

Some Dehydration
YELLOW PLAN B Give ORS for the 1st 4hrs Amount of ORS = weight (kg) x 75 = ml/cc > after 4 hrs, re-assess child for signs of dehydration > if still some dehydration, continue ORS for 4 hrs

Mild vomiting during ORT = stop ORS in 10 mins, after 10 mins continue ORS but give it in a slow manner Severe Vomitting during ORT = stop ORS IVF or refer!

No Signs of Dehydration
Green PLAN A Give ORS if with watery or loose stool 1 week up to 2 y/o = 50-100 ml ORS 2 y/o up to 5 y/o = 100-200 ml ORS If theres no watery/loose stool (4 Home Rule Management): 1. Continue feeding (BRAT diet) 2. Give extra fluids; soups, milk, plain water, juice, rice water 3. Give Zinc supplement for 10-14 days to increase immune system 4. Advise mother when to return baby immediately.

PERSISTENT DIARRHEA (Young child)

Yellow 1. 2. 3. 4. Give Vit. A Multivitamin including zinc for 14 days Advise mother recommended feeding Follow-up after 5 days

after 5 days, if child still continouos to have diarrhea refer

SEVERE PERSISTENT DIARRHEA

Pink 1. Give Vitamin A 2. Give IVF = Plan C

DYSENTERY (Young Infant)

Pink Referral

Dysentery (Young Child)

Yellow 1. Give 3 days antibiotic ciprofloxacin 15mg/kg/day 2x per day 2. Follow up: 2 days NB: if child is dehydrated: treat dehydration If child condition is the same, 2nd line oral antibiotic for dysentery for 5 days Except: below 12 months, child was dehydrated during 1st visit and had measles - REFER

FEVER

Ask: Does the child have

FEVER?

A child has the main S/Sx of fever if: - Temp: 37.5C Axillary; 38C Rectal - Child feels hot - ask when was the last fever - should be w/in 72 hrs or 2-3 days Dengue: Aedes Aegypti (day biting; low flying; breeds on stagnant water; urban areas; also called Tiger mosquito) Malaria: Anopheles (night biting, high flying) Diagnostic Test: Tourniquet Test / Rumpel Leeds Test

Dengue Hemorrhagic Fever/H-Fever

FEVER Dengue risk

Severe Dengue Hemorrhagic Fever Fever: Dengue Unlikely

- Bleeding at nose, gums, stool, 1. Give paracetamol for fever vomitus of 38.5 C w/o ASA - Cold clammy extremities 2. Advise to bring if - Capillary refill more than 3 secs. BCCAPPPS occur - Abdominal pain (persistent) 3. Follow up after 2 days - Persistent vomiting - Persistent headache - Positive tourniquet test - Skin petechiae (20 & above)

Pre-referral treatment: 1. Rapid fluid replacement A. PLAN C IVF if the baby is suffering of BCC B. PLAN B ORS if with APPPS 2. Paracetamol for fever of 38.5 C without ASA 3. Treat child to prevent lowering of blood sugar 4. REFER!

FEVER High Risk Malaria risk Very Severe Febrile Disease CUVA (any) Stiff neck Malaria > Blood smear (+) P. falciparum: most fatal P. Vivax History of fever or feels hot or temp of 37.5

How to look or feel for stiff neck: 1. Tickle toes or umbilicus 2. Shine a flashlight on toes/umbilicus to encourage the child to look down. 3. Lie the child on his back then bend the head forward towards his chest.

> Give antimalarial > Give paracetamol for fever > Bring the child if theres CUVAS > Follow-up after 2 days

Pre-referral Treatment: 1. Give first dose antibiotic 2. IM Quinine 3. Give paracetamol 4. Treat lowering of blood sugar 5. REFER!

Anti-Malarial
Oral co-artemether for 2 days Give 1st dose at HC, if vomits repeat after 1 hour, 2nd dose at home after 8 hours Give it with food

FEVER Low Malaria Risk

Very Severe Febrile Malaria Fever Malaria Unlikely Disease NO runny nose (+) fever & runny nose CUVAS NO measles > Give Paracetamol for Pre-referral NO other cause of fever fever Treatment: > Advise mother when >oral co-artemether 1. Give first dose >Give Paracetamol for to return immediately antibiotic > Follow-up after 2 days fever 2. IM Quinine > Advise mother when to 3. Give return immediately paracetamol > Follow-up after 2 days 4. Treat lowering
of blood sugar 5. REFER!

Measles
Severe Complicated Measles with Eye & Measles Mouth Complications > CUVA > Clouding of cornea > With pus draining in d/t severe Vit. A the eyes deficiency (conjunctivitis) > Mouth ulcers > Mouth ulcers (deep & extensive) ( non-deep & non-extensive) Measles

Give Vit. A

*Pre-referral Tx: > Give Vit. A > Give Vitamin A > Apply tetracycline on eyes if > Apply tetracycline on eyes with eye complication TID > Give 1st dose of antibiotic > Apply Gentian Violet (half strength) on mouth BID > Refer! -Follow-up after 2 days **Dont give/apply gentian violet on mouth ulcers

COMPLICATIONS OF MEASLES
Pneumonia Stridor Diarrhea Mouth ulcers - Ear infection - Malnutrition - Eye infection (Clouding of Cornea)

DOH Program: Ligtas Tigdas Campaign

EAR PROBLEM

Ask: Does the child have an ear problem? - ear pain? (irritable & rubbing his ear) - ear discharge & how long? - tender swelling behind the ear? If Yes

Ear Problem
Mastroiditis Acute Ear Infection > tender swelling > less than 14 days behind the ear > ear discharge or ear pain **Pre-referral treatment: * give 5 days * Give 1st dose antibiotic antibiotic * dry the ear by * Give wicking (roll soft paracetamol cloth in a wick) for ear pain * give paracetamol * Refer! for ear pain * follow-up after 5 days Chronic Ear Infection > more than 14 days No Ear Infection > No ear problem

* dry ear by * No treatment wicking needed * follow-up after 5 days *Quinolone for 2 weeks

MALNUTRITION AND ANEMIA

MALNUTRITION
Severe Malnutrition Very Low Weight No VLW (VLW) > below the curve >MARASMUS > less than 2 >KWASHIORKOR y/o, assess the * Assess childs (edema on both childs feeding feeding follow up after 5 feet, moon face) days * Counsel mother * Follow up after 30 * Advise mother * Give Vitamin A when to return days * Refer! immediately

Severe Anemia > severe palmar pallor (paper white palm) * Give Vit. A * Refer!

ANEMIA Anemia
> some palmar pallor * Give Iron *Give antimalarial drug if high malarial risk Mebendazole if the child is 1 year old and has not receive dose from the last 6 months * Follow up after 14 days

No Anemia > less than 2 y/o, assess the childs feeding follow up after 5 days

RECOMMENDED FEEDING
At birth up to 6 months > exclusively breastfeed > 8 times or more than 8 times within 24 hours. SIGNS OF HUNGER: 1. Beginning to fuss. 2. Sucking fingers and fist 3. Sucking movements with their lips.

Breast milk contains: CHON Vitamin A Fat Vitamin C Lactose Iron IgA antibodies.

Breastmilk provides all the H2O an infant needs, even in a hot, dry climate.

>6 months up to 12 months: breastfeeding + 3 times a day complementary food. If not on breastfeeding: 5 times a day complementary food. >12 months up to 2 years old: breastfeeding + 5 times a day of complementary food. >At birth up to 4 months: exclusive breastfeeding 8 times in 24 hrs. >4 months up to 6 months: breastfeeding with complementary food 1-2 times a day if the child is:

If the child: - shows interest in semisolid foods - appears hungry after breast feeding. - not gaining weight appropriately. >Dried CHON: pulvurized dilis, pulvurized shrimp, pulvurized monggo. >Milk formulas should be given with a cup and spoon not in a bottle because child may develop nipple confusion >Lugaw should be thick enough to stick to the spoon.

MOTHERS CARD (pictograph)

- given to all mothers to help her remember: 1. appropriate food and fluids. 2. care for development. 3. when to return to a health worker.
Reasons why they need to return:

> Follow up visit. > Urgently / immediately. > Childs next immunization.

When to return immediately:

>Any sick child: refer if: - unable to drink / breastfeed - becomes sicker - develops fever >Child with diarrhea: refer if: - blood in stool - drink poorly >Child with fever-dengue unlikely: refer if: - BCCAPPPS

IMMUNIZATION STATUS AGE VACCINE At birth BCG 6 weeks Hepa1, DPT1, OPV1 10 weeks Hepa2, DPT2, OPV2 14 weeks Hepa3, DPT3, OPV3, 9 months Measles with Vit. A VITAMIN A STATUS Growth monitoring card (GMC): where childs Vitamin A status is recorded.

Classifications needing Vit. A > severe pneumonia or very severe disease. > persistent diarrhea. > severe complicated measles. > measles with eye and mouth complications. > measles > severe malnutrition and severe anemia. > very low weight by age.
* All children with severe classifications must be referred urgently to hospital except severe dehydration and severe persistent diarrhea.

5 important Pre-referral management 1.Give appropriate antibiotic 2.Give quinine 3.Give Vit. A 4.Treat the child to prevent low blood sugar 5.PLAN C (IVF) Classifications needing antibiotic 1.Severe pneumonia or very severe disease. 2.Very severe febrile disease or Malaria 3.Very severe febrile disease 4.Severe complicated measles 5.Mastoiditis 6.Pneumonia 7.Acute ear infection 8.Dysentery 9.Severe dehydration ( with cholera)

How to treat child at home

3 basic steps in teaching mother 1.Give information 2.Show an example 3.Let her practice ( return demonstration)

A sk questions P raise the mother A dvice again C hecking questions (to check understanding)

Summary Treatment:

1. Co-trimoxazole and Amoxicillin (Pneumonia and Acute Ear Infection) 2. Ciprofloxacin (Dysentery) 3. Tetracycline and Erythromycin (Cholera) 4. Salbutamol (Wheezing) 5. Iron (Anemia) 6. Co-Artemether (Malaria) 7. Quinolone ear drops (chronic ear infection) 8. Gentian Violet (mouth ulcer) 9. Tetracycline ointment (eye infection) 10. Vitamin A supplement 11. Mebendazole (hookworm/whipworm)

Pre-referral Treatment:

1. Gentamicin and Ampicillin (all children referred urgently) 2. Quinine (Very servere febrile disease) 3. Diazepam (Convulsion)

SICK YOUNG INFANT Common infants illness and problems a. possible serious bacterial infection or local bacterial infection. b. Diarrhea c. Feeding problems or low weight for age.

Possible serious bacterial Pre-referral treatment: infection 1. Give first dose antibiotic (IM) CUVA -Right Vastus lateralis: gentamycin F ever (axillary 37.5 C, rectal 38 -Left Vastus lateralis: benzyl / C) penicillin F ast breathing (60 bpm) 2. Keep warm U mbilical redness (extended up 3. Treat child to prevent to near skin) hypoglycemia N asal flaring/grunting 4. Refer. C hest indrawing (severe or deep) E ar pus S kin pustules (sverer or many) B ulging of fontaniels

Local bacterial infection

>Skin pustules >Umbilical redness or pus confined on affected area (local) Treatment: 1.Give 5 days antibitics P.O. 2.Apply gentian violet on affected area (FULL STRENGHT) 3.Follw-up atfer 2 days. - if the pus or redness remains, REFER. - if the pus and redness becomes worse, REFER. - if the pus and redness improved, continue 5 days antibiotic and continue treating local infections.

Reminders:
-Young infant must be calm in assessing chest indrawing, fast breathing, nasal flaring and grunting. -If the first count of RR is 60 bpm or more, repeat the count. -Mild chest indrawing is normal to young infant. -Avoid cotrimoxazole to young infant less than 1 month of age who is premature and jaundice use amoxicillin.

SEVERE JAUNDICE NO JAUNDICE >jaundice appearing JAUNDICE >any jaundice after 24 hours of life and if age less *advise than 24 hrs or >palms and soles not mother to yellow do home >Yellow care palms or sole *home care at any age *advise mother to return immediately if palms and *prevent low soles appear yellow blood sugar *3 weeks older refer to *REFER the hospital *Keep infant *follow up after 1 day warm

JAUNDICE

FEEDING PROBLEM (Young Infant)

Feeding problem or low No feeding problem weight for age -not low weight for age -receives other food or fluid -no signs of inadequate -less than 8 times feeding breastfeeding -oral thrush -not sucking effectively -not well attached -low weight for age or -thrush

Counsel mother: encourage *Praise the mother for her to increase feeding the infant well breastfeeding

Gentian Violet
-half strength: for mouth ulcers =15 ml GV+30-45ml DW=.25% concentration -full strength: skin pustules =umbilical redness or pus =15 ml GV+15 ml DW=.5% concentration

Signs of Good Sucking

a. slow b. deep sucks c. with some pausing

Breastfeeding: Signs of Good Attachment

-upper part areola is not covered a. Chin touching breast b. mouth wide open c. lower lip turned outward d. more areola visible above than below the mouth

Show her how to help the infant to attach. She should:

a. touch her infants lips with her nipple b. wait until her infants mouth is opening wide c. move her infant quickly onto her breast, aiming the infants lower lip well below the nipple. *Application of Gentian Violet

Mouth ulcers 1. Wash hands 2. Clean affected area using soft cloth dipped in salt water 3. Paint GV 4. Wash hands

Skin pustules 1. Wash hands 2. Clean affected area using soft cloth soaked with soap & water 3. Paint GV 4. Wash hands

Umbilical Redness/Pus 1. Wash hands 2. Clean affected area using 70% alcohol

3. Paint GV 4. Wash hands