Imci Session 4 - Main Symptoms

Session 4 Main Symptoms - cough or difficult breathing - diarrhea - fever - ear problems 1

Learning Objectives By the end of this session, the students will be able to: (1) recall the anatomy and pathophysiology; (2) recognize the symptoms and signs; (3) assess and classify symptoms and signs; (4) identify the correct treatment and when to refer; (5) provide counseling; and (6) specify necessary follow-up care

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Session 4-a

Cough or Difficult Breathing

3

Parts of the Respiratory System •Nasal passages •Windpipe or trachea •Lungs

4

Inside the alveolus

5

Cough or Difficult Breathing ASK: Does the child have cough or difficult breathing? If NO

If YES

IF YES, ASK: •For how long?

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Ask about next main symptoms: diarrhea, fever, ear problems

LOOK, LISTEN, FEEL: •Count the breaths in one minute •Look for chest indrawing •Look and listen for stridor

Child must be calm

If the child is: Fast breathing is: 2 mos – 12 mos. 50 breaths/min or more 12 mos – 5 yrs 40 breaths/min or more

Classify child’s illness using the color-coded classification table for cough or difficult breathing

Video of child with chest indrawing

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Video of child with stridor

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Cough or Difficult Breathing SIG N •Any general S danger

sign or •Chest indrawing or •Stridor in a calm child

•Fast breathing

No signs of pneumonia or very severe disease

9

CLASSIF Y A S SEVERE PNEUMONIA OR VERY SEVERE DISEASE

PNEUMONIA

NO PNEUMONIA: COUGH OR COLD

ID EN TIF Y Give TR TM firstEA dose ofENT an

appropriate antibiotic Refer URGENTLY to hospital

Give an appropriate oral antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 2 days If coughing > 30 days, refer 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

Treatment Soothe the Throat, Relieve the Cough with a Safe Remedy Safe

infant

remedies to recommend: Breastmilk for exclusively breastfed tamarind, calamansi, ginger

Harmful

10

remedies to discourage: Codeine cough syrup Other cough syrups Oral and nasal decongestants

Treatment for Pneumonia or Very Severe Disease Age or Weight

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Cotrimoxazole Give 2 times daily for 5 days Adult Syrup tab. 40 mg 80mg TMP TMP 200 mg 400 mg SMX SMX

Amoxycillin Give 3 times daily for 5 days Tablet Syrup 250 mg

125 mg/ 5 ml

2 -12 mos

1/2

5.0 ml.

1/2

5.0 ml

12mos-5yrs

1

7.5 ml

1

10 ml.

Vitamin A Supplementation for Severe Pneumonia or Very Severe Disease Age

12

Vitamin A Capsule 100,000 I U

200,000 I U

6 to 12 mos.

1 capsule

½ capsule

12 mos-5 yrs

2 capsules

1 capsule

Session 4-b

DIARRHEA

13

Anatomy of the Gastrointestinal System

14

Diarrhea For ALL sick children ask the mother about the child’s 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: For how long? Is there blood in the stool

LOOK, LISTEN, FEEL: Look at the child’s general condition. Is the child: 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 child’s illness using the colour-coded classification tables for diarrhoea.

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Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.

Classify DIARRHOEA

DIARRHEA Does the child have diarrhea? IF YES, ASK: For how long? Is there blood in the stool? LOOK, LISTEN, FEEL:  Look at the child’s general condition, is the child:  

  

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

Lethargic or unconscious? Restless or irritable?

Look for sunken eyes Offer the child fluid. Is the child:

Pinch the skin of the abdomen

Not able to drink or drinking poorly? Drinking eagerly, thirsty?

Does it go back: Very slowly (> than 2 secs)? Slowly?

Video of a child with sunken eyes

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Video of Skin Pinching

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CLASSIFICATION TABLE FOR DEHYDRATION SIGNS Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly

Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly Not enough signs to classify as some or severe dehydration.

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CLASSIFY AS

SEVERE DEHYDRATION

SOME DEHYDRATION

NO DEHYDRATION

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

No Dehydration

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Some Dehydration

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Severe Dehydration

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No Dehydration 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

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No Dehydration Treatment Plan A < 2 yrs 2-10 yrs

Age Amount of Fluid of Fluid 50-100 ml (¼-½ cup) after each loose stool

Type

ORS, rice water, 100-200 ml (½-1 cup) after each loose yogurt, stool soup with salt

• Give frequent small sips from a cup. • If the child vomits, wait 10 minutes. Then continue, but more slowly.

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• Continue giving extra fluids until the diarrhea stops.

Some Dehydration  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. 25

Some Dehydration If the mother must leave before completing treatment: show her how to prepare the ORS solution at home. show her how much to give to finish the 4 hour treatment at home give her enough ORS packets to complete rehydration. 26

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

Up to 4 mos WEIGHT In ml

27

< 6kg 200-400

4mos - 12mos

6 - < 10kg 400-700

12mos – 2years

10 - <12kg 700-900

2 years – 5

12-19kg 900-1400

• The approximate amount of ORS can also be calculated by multiplying the child’s weight (in kg) by 75.

Severe Dehydration

Can you give Intravenous fluids (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 (<12 mos) 1 hour 5 hours Older children 30 minutes* hours

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* 2½

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

Severe Dehydration  Reassess

the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly.

 Also

give ORS (5ml/kg/hr) as soon as the child can drink.

 Reassess

30

the infant after 6 hours & a child after 3 hours. Classify dehydration.

Severe Dehydration

If trained to use a nasogastric tube for rehydration? 31

Severe Dehydration  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 3 hours, send the child for IV therapy.

 After

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6 hours, reassess the child. Classify dehydration.

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) Treat

Dehydration

present

SEVERE PERSISTENT DIARRHOEA

dehydration before referral unless the child has another severe classification. Refer to hospital.

Advise No

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dehydration

PERSISTENT DIARRHOEA

the mother on feeding a child who has PERSISTENT DIARRHOEA. Follow-up in 5 days.

Persistent Diarrhea  After

5 days:

Ask:  If

the diarrhoea has NOT stopped (3 or more stools) do a full reassessment, give the treatment, then refer to hospital.

 If

the diarrhoea has stopped (< 3 stools per day) Tell the mother to follow the usual feeding recommendations for the child’s age.

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CLASSIFICATION TABLE FOR DYSENTERY

SIGNS

CLASSIFY AS

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

Treat Blood

in the stool DYSENTERY

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for 5 days with an oral antibiotic recommended for Shigella in your area. Follow-up in 2 days.

Dysentery  After

2 days:

Ask:  if  if

the child is dehydrated, treat hydration.

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.

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Dysentery  EXCEPTIONS:

If 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. 37

Session 4-c

Fever 38

Assess FEVER A – – –

39

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

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 has fever? 



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If >7 days, has the fever been present everyday? Has the child had measles within the 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

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

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

41

for mouth ulcers. Are they deep and extensive?

 Look

for pus draining from the eye.

 Look

for clouding of the cornea.

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

Decide Dengue Risk: Yes or No If Dengue Risk: Then Ask:  Has the child had any bleeding from the nose or gums or in the vomitus or stools? 

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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.

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.

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

Decide Malaria Risk:

Classify FEVER

Malaria Risk (including travel to malaria area)

If

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

Decide Dengue Risk: Yes or No

43 If Dengue Risk:

No Malaria Risk

Deciding Malaria Risk  Malaria

is caused by parasites in the blood called “plasmodia” – “Plasmodium falciparum”

 Transmitted  Know

44

by Anopheles mosquito

the malaria risk in your areas.

Malaria Risk Areas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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Palawan Davao Oriental Davao del Norte Compostela Valley Tawi-tawi Sulu Agusan del Sur Mindoro Occidental Kalinga Apayao Agusan del Norte

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Isabela Cagayan Quezon Ifugao Zamboanga del Sur Bukidnon Misamis Oriental Quirino Mountain Province Basilan

Classify FEVER Malaria Risk Malaria Risk (including travel to malaria area)

Classify FEVER

Any general danger sign or  Stiff Neck 

smear (+) If blood smear not done: NO runny nose and, NO measles, and NO other causes of fever

VERY SEVERE FEBRILE DISEASE/MALARIA

Blood

smear (-), or Runny nose, or Measles or Other causes of fever.

MALARIA

Blood

FEVER: MALARIA UNLIKELY

No Malaria Risk

No Malaria Risk

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Any general danger sign or  Stiff Neck 



No sign of very severe febrile disease

VERY SEVERE FEBRILE DISEASE FEVER: NO MALARIA

Malaria Risk Any general danger sign or  Stiff Neck

Give



VERY SEVERE FEBRILE DISEASE /MALARIA

first dose of Quinine (under medical supervision 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. Refer

Blood

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smear (+) If blood smear not done: NO runny nose and, NO measles, and NO other causes of fever

Treat

MALARIA

URGENTLY to a hospital.

the child with an oral antimalarial. Give one dose of Paracetamol in health center for high fever (38.5C or above.) Advise mother when to return immediately. Follow up in 2 days if fever persists. If the fever is present every day for more than 7 days, refer for assessment.

Malaria Risk Blood smear (-), or FEVER:  Runny nose, MALARIA UNLIKELY or  Measles or  Other causes of fever. 

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Give one dose of Paracetamol in health center for high fever (38.5C or above.)  Advise mother when to return immediately.  Follow up in 2 days if fever persists.  If the fever is present every day for more than 7 days, refer for assessment. Treat other causes of fever. 

TREAT THE CHILD: Antimalarial Agents 

Give an Oral Antimalarial 1st line Antibiotics: Chloroquine and Primaquine 2nd line Antibiotics: Sulfadoxine and Pyrimethamine



If Chloroquine: The child should be watched closely for 30 minutes. If the child vomits, give another dose. Itching is a possible side effect of the drug.



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If Sulfadoxine and Pyrimethamine: Give single dose in health center.

Antimalarial Agents CHLOROQUINE Give for 3 days

AGE

PRIMAQUINE Single dose for P. falciparum

PRIMAQUINE Daily for 14 days for P. vivax

Tablet

Tablet

(15mg base)

(15mg base)

Tablet (150mg base)

50

SULFADOXINE + PYRIMETHAMINE Single dose

Tablet (500mg Sulfadoxine 25mg Pyrimethamine)

Day 1

Day 2

Day 3

2 months up to 5 months (4 <7kg)

½

½

½

1/4

5 months up to 12 months (7 <10kg)

½

½

½

1/2

12 months up to 3 years (10 <14kg)

1

1

½

1/2

1/4

3/4

3 years up to 5 years (14 – 19kg)

1½

1½

1

3/4

1/2

1

TREAT THE CHILD: Antimalarial Agents  Chloroquine  Explain

is given for 3 days.

to the mother that itching is a possible side effect. It is NOT dangerous. The mother should continue to give the drug.

51

TREAT THE CHILD: Antimalarial Agents 

52

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: Antimalarial Agents  If

you do not have the blood smear or you do not know which species of malaria is present, treat as P. falciparum.

 Do

not give Primaquine to children under 12 months of age.

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TECHNICAL UPDATES: Antimalarial Agents TECHNICAL BASIS: Artemisinin Based Combination Therapies Based on available safety and efficacy data, the following therapeutic 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 and Amodiaquine remain high. This mainly limited to West Africa. 54

TECHNICAL UPDATES: Antimalarial Agents  Administer

intramuscular antibiotic if the child cannot take an oral antibiotic

 Quinine

for severe malaria

 Breastmilk

55

or sugar to prevent low blood sugar.

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 to awaken

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Give an Intramuscular Antibiotic Age or Weight

CHLORAMPHENICOL Dose: 40 mg/kg Add 5 ml sterile water to vial containing 1000mg = 5.6 ml at 180mg/ml

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2 – 4 months (4 - <6kg)

1 ml = 180 mg

4 – 9 months (6 - <8kg)

1.5 ml = 270 mg

9 – 12 months (8 -10 kg)

2 ml = 360 mg

1 – 3 years (10 - <14kg)

2.5 ml = 450 mg

3 – 5 years (14 – 19 kg)

3.5 ml = 630 mg

Give Quinine for Severe Malaria  Quinine

is the preferred 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 sterile abscess. 58

Give Quinine for Severe Malaria 

For children being referred with very severe febrile disease/Malaria: –



If referral is not possible: – – –

– –

59

Give the 1st dose of IM Quinine and refer the child urgently to the hospital 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, and then 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 4 MONTHS OF AGE.

Give Quinine for Severe Malaria

Age or Weight

60

INTRAMUSCULAR QUININE 300 mg/ml (In 2 ml ampules)

4 months – 12 months (6 - <10kg)

0.3 ml

12 months – 2 years (10 - <12kg)

0.4 ml

2 – 3 years (12 - <14kg)

0.5 ml

3 – 5 years (14 – 19kg)

0.6 ml

TREAT THE CHILD: To Prevent Low Blood Sugar  If

the child is able to breastfeed: – Ask the mother to breastfeed the child.  If the child is not able to breastfeed but is able to swallow: – Give expressed breastmilk or breastmilk substitute. If neither is available, give sugar water. Give 30 – 50 ml of milk or sugar water before departure. 61

TREAT THE CHILD: To Prevent Low Blood Sugar To make Sugar Water: Dissolve

4 level teaspoons of sugar (20 grams) in a 200 ml cup of clean water.

If

the child is not able to swallow:

–

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Give 50 ml of sugar water by nasogastric tube.

TREAT THE CHILD: Paracetamol for High Fever PARACETAMOL Age or Weight

Tablet (500mg)

Syrup (120mg/5ml)

2 months up to 3 years (4 - <14kg)

1/4

5ml (1 tsp)

1/2

10 ml (2 tsp)

3 years up to 5 years (14 – 19 kg)

63

No Malaria Risk Any general danger sign or  Stiff Neck

VERY SEVERE FEBRILE DISEASE

Give

No sign of very severe febrile disease

FEVER: NO MALARIA

Give





64

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.) Refer URGENTLY to a hospital.

one dose of Paracetamol in health center for high fever (38.5C or above.) Advise mother when to return immediately. Follow up in 2 days if fever persists. If the fever is present every day for more than 7 days, refer for assessment.

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

Decide Malaria Risk: If the child has measles now or within the last three months: Decide Dengue Risk: Yes or No

65

If Dengue Risk:

Severe Complicated Measles

Classify FEVER

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

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

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

66

Look for mouth ulcers: are they deep and extensive Look for pus draining from the eye Look for clouding of the cornea

If measles now or within last three months, classify

Measles  Fever

and generalized rash are the main signs of measles.  Highly infectious.  Over crowding and poor housing increases the risk of developing measles.  Caused by a virus that infects the layers of cells that line the lung, gut, eye, mouth and throat. 67

Measles 



68

Complications of measles occur in about 30% of all cases – diarrhea (including dysentery and persistent diarrhea) – 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, abnormally sleepy or difficult to awaken)

Classify MEASLES Clouding

of the

cornea Deep extensive mouth ulcers

Pus

draining from the

eye Mouth ulcers

Measles

69

now or within the last 3 months

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 hospital

MEASLES WITH EYE OR MOUTH COMPLICATIONS

Give

MEASLES

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 to treat with gentian violet Follow up in two days Vitamin A

Children with Measles

70

71

Koplik’s spots

TREAT THE CHILD: Give Vitamin A

72

TREATMENT  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: Give Vitamin A AGE

Vitamin A Capsule 100,000 IU

2 – 6 months

 

73

200,000 IU 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

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

Decide Malaria Risk:

Severe DHF

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

Decide Dengue Risk: Yes or No If Dengue Risk:

Classify FEVER

Fever; DHF Unlikely

Torniquet Test 1.3gp

74

Torniquet Test 2.3gp

Tourniquet Test

75



Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes



Positive test: 20 or more petechiae per 1 inch² (6.25 cm²)

Classify DENGUE HEMORRHAGIC FEVER bleeding

from the nose

or gums Bleeding in the vomitus or stools Skin petechiae Cold clammy extremities Capillary refill more than 3 seconds abdominal pain or Vomiting or Positive torniquet test No

signs of severe dengue hemorrhagic fever

76

SEVERE DENGUE HEMORRHAGIC FEVER

FEVER; DENGUE HEMORRHAIC FEVER UNLIKELY

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 sugar Refer all chioldren URGENTLY to the hospital DO NOT GIVE ASPIRIN

Advise

mother when to return immediately Follow up in 2 days if fever persists or child shows signs of bleeding. DO NOT GIVE ASPIRIN

Dengue Hemorrhagic Fever A child with dengue hemorrhagic fever or dengue shock syndrome may present severely hypotensive with disseminated intravascular coagulation (DIC), as this severely ill PICU patient did. Crystalloid fluid resuscitation and standard DIC treatment are critical to the child's survival. 77

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 delayed well beyond a normal duration of 2 seconds.

78

Session 4-d

Ear Problem

79

Assess EAR PROBLEM A – –

–

80

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 sign of mastoiditis

Assess EAR PROBLEM

81

Then Ask: Does the child have an ear problem? If YES, 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.

Classify EAR PROBLEM Tender

swelling behind

MASTOIDITIS

Give

Pus

ACUTE EAR INFECTION

Give

Pus

CHRONIC EAR INFECTION

the ear

is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain is seen draining from the ear and discharge is reported for 14 days or more.

No

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ear pain and no pus is seen draining from the ear.

NO EAR INFECTION

the first dose of an appropriate antibiotics Give first dose of Paracetamol for pain Refer URGENTLY to hospital an antibiotic for 5 days. (Amoxicillin)* Give Paracetamol for pain. Dry the ear by wicking. Follow up in 5 days. topical

quinolone ear drops for at least two weeks Dry the ear by wicking. Follow up in 5 days. 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: Chronic Suppurative Otitis Media

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TECHNICAL BASIS:  aural toilet combined with antimicrobial treatment is more effective than aural toilet alone  topical antibiotics were found to be better than systemic antibiotics in resolving otorrhea and eradicating middle ear bacteria  topical quinolones were found to be better than topical non-quinolones – topical ofloxacin or ciprofloxacin vs intramuscular gentamicin, topical gentamicin, tobramycin or neomycin-polymyxin

TECHNICAL UPDATES: Acute Otitis Media TECHNICAL BASIS:  oral amoxicillin as the better choice for the management of acute ear infection in countries where antimicrobial resistance to cotrimoxazole is high. 

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reduces the risk of mastoiditis in populations where it is more common

TREAT THE CHILD: Dry the Ear by Wicking  Dry

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the ear at least 3 times daily. – Roll a clean absorbent cotton or soft tissue paper into a wick. – Place the wick in the child’s 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.

TREAT THE CHILD: 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. 86