Integrated Management For Childhood Illnesses Notes

INTEGRATED

MANNER PREVENTIVE INTERVENTION EVIDENCE BASED SYNDROMIC APPROACH FAMILY AND COMMUNITY INVOLVEMENT

 REDUCE

DEATHS AND THE FREQUENCY AND SEVERITY OF ILLNESS AND DISABILITY  CONTRIBUTE TO IMPROVED GROWTH AND DEVELOPMENT  IMPROVE CASE MANAGEMENT SKILLS OF HEALTH WORKERS  IMPROVE HEALTH SYSTEM TO DELIVER IMCI  IMPROVE FAMILY AND COMMUNITY HEALTH PRACTICES

 All

sick children must be examined for “general danger signs” which indicate the need for immediate referral or admission to a hospital.  All sick children must be routinely assessed for major symptoms (for children age 2 months up to 5 years: cough or difficult breathing, diarrhea, fever, ear problems; for young infants age 1 week up to 2 months: bacterial infection and diarrhea). They must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems.

 Only

a limited number of carefully-selected clinical signs are used, based on evidence of their sensitivity and specificity 7 to detect disease.Careful and systematic assessment of common symptoms and well-selected specific clinical signs provide sufficient information to guide rational and effective actions.  These signs were selected considering the conditions and realities of first-level health facilities.



A combination of individual signs leads to a child’s classification(s) rather than a diagnosis. Classification(s) indicate the severity of condition(s). They call for specific actions based on whether the child (a) should be urgently referred to another level of care, (b) requires specific treatments (such as antibiotics or antimalarial treatment), or (c) may be safely managed at home. The classifications are colour coded: “pink” suggests hospital referral or admission, “yellow” indicates initiation of treatment, and “green” calls for home treatment.

The IMCI guidelines address most, but not all, of the major reasons a sick child is brought to a clinic. A child returning with chronic problems or less common illnesses may require special care. The guidelines do not describe the management of trauma or other acute emergencies due to accidents or injuries.  IMCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of children. 

 An

essential component of the IMCI guidelines is the counseling of caretakers about home management, including counseling about feeding, fluids and when to return to a health facility

OUTPATIENT HEALTH FACILITY

 





Assessment; Classification and identification of treatment Referral, treatment or counseling of the child’s caretaker Follow-up care

REFERRAL HEALTH FACILITY





 

Emergency triage assessment and treatment (ETAT); Diagnosis, treatment and monitoring of patient progress. Appropriate home management Teaching the mother Counseling the mother

Few health workers opportunities to practice complicated cases  Reliance on History and S/S  Overlap of conditions  Minimal diagnostic tools  Scarce drugs and equipment 

 YOUNG

INFANT: 1 WK TO 2 MOS  OLDER CHILDREN: 2 MOS TO 5 Y/O

Vomiting  Convulsions  Drink unable  Sleepiness ( look for) 

Cough  Diarrhea  Fever  Ear Problem  Anemia / Malnutrition 

SIGNS

CLASSIFY AS TREATMENT

GDS CHEST INDRAWING STRIDOR

SEVERE 1ST DOSE OF AB PNEUMONIA OR VIT A VERY SEVERE PREVENT LOW BS DSE REFER

SIGNS

CLASSIFY AS

TREATMENT

FAST BREATHING

PNEUMONIA

AB FOR 5 DAYS SOOTHE THROAT AND RELIEVE COUGH ADVISE WHEN TO RETURN FOLLOW-UP 2 DAYS

SIGNS

CLASSIFY AS

TREATMENT

NO SIGNS OF PNEUMONIA OR VSD

NO PNUEMONIA: REFER IF COUGH>30DAYS COUGH OR COLD SOOTHE THROAT AND RELIEVE COUGH ADVISE WHEN TO RETURN FU: 5 DAYS

SIGNS

CLASSIFY AS TREATMENT

2 OF THE FF: SEVERE DEHYDRATION SLEEPY SUNKEN EYES UNABLE TO DRINK SKIN TURGOR: VP

PLAN C REFER (IF WITH OTHER SEVERE CLASSIFICATION) AB FOR CHOLERA (2Y/O, WITH CHOLERA IN AREA)

SIGNS

CLASSIFY AS TREATMENT

2 OF THE FF: SUNKEN EYES THIRSTY S. TURGOR:POOR RESTLESS

SOME PLAN B DEHYDRATION REFER (IF WITH OTHER SEVERE CLASSIFICATION FU:5 DAYS

SIGNS

CLASSIFY AS TREATMENT

NOT ENOUGH SIGNS

NO PLAN A DEHYDRATION ZINC

SIGNS

CLASSIFY AS TREATMENT

DEHYDRATION PRESENT

SEVERE TREAT DHN PERSISTENT VIT A DIARRHEA REFER URGENTLY

NO DHN

PERSISTENT ADVISE ON FEEDING DIARRHEA VIT A ADVISE WHEN 2 RETURN FU: 5 DAYS

PLAN A AT HOME Continue feeding ZINC (10-14 DAYS) 10mg/day: less than 6 months 20mg/day:6 months above

GIVE EXTRA FLUIDS

When to return

PLAN B SOME DHN : ORESOL ORS in ml: kg wt X 75 REASSESS AFTER 4 HRS Plan A or Plan C

PLAN C

IVF TX SEVERE DHN QUICKLY INFANT: 30ml/kg(1h) 70ml/kg (5h) Children:30ml/kg(30 mins) 70ml/kg (2.5h) Reassess and Give ORS Reclassify: infants (6H) children (3H) NGT

SIGNS

CLASSIFY AS

TREATMENT

BLOOD IN STOOL

DYSENTERY ANTIBIOTIC 4 5 DAYS FOLLOW-UP IN 2 DAYS ADVISE WHEN 2 RETURN

SIGNS

CLASSIFY AS TREATMENT

GDS VERY SEVERE STIFF NECK FEBRILE DSE/ MALARIA

1ST DOSE OF AM, QUININE PREVENT LOW BS PARACETAMOL REFER

SIGNS

CLASSIFY AS TREATMENT

+ BLOOD MALARIA SMEAR NO OTHER CAUSES OF FEVER

ORAL ANTI-MALARIAL PARACETAMOL ADVISE WHEN 2 RETURN FOLLOW-UP 2 DAYS REFER IF FEVER OF 7 DAYS

SIGNS

CLASSIFY AS TREATMENT

¯BLOOD FEVER: MALARIA SMEAR UNLIKELY -OTHER CAUSES OF FEVER

PARACETAMOL ADVISE WHEN 2 RETURN FU: 2DAYS REFER IF FEVER OF 7 DAYS TREAT OTHER CAUSES

SIGNS

CLASSIFY AS TREATMENT

GDS VERY SEVERE STIFF NECK FEBRILE DSE

1ST DOSE OF AB, PREVENT LOW BS PARACETAMOL REFER

NO SIGNS FEVER: NO OF VERY MALARIA FEBRILE DSE

PARACETAMOL ADVISE WHEN 2 RETURN FOLLOW-UP 2 DAYS REFER IF FEVER OF 7 DAYS TREAT OTHER CAUSES

SIGNS

CLASSIFY AS TREATMENT

GDS SEVERE CLOUDING OF COMPLICATED MEASLES CORNEA DEEP OR EXTENSIVE MOUTH ULCERS

VIT A 1ST DOSE OF AB, PREVENT LOW BS PARACETAMOL TETRACYLCINE OINTMENT REFER

SIGNS

CLASSIFY AS TREATMENT

PUS DRAINING MEASLES WITH FROM THE EYE EYE OR MOUTH OR MOUTH COMPLICATIONS ULCERS

VIT A TETRACYCLINE/GENTIAN VIOLET PARACETAMOL ADVISE WHEN 2 RETURN FOLLOW-UP 2 DAYS

SIGNS -MEASLES

CLASSIFY AS

NOW MEASLES OR WITHIN THE LAST 3 MONTHS

TREATMENT VIT A PARACETAMOL ADVISE WHEN 2 RETURN FU: 2DAYS

SIGNS

CLASSIFY AS

BLEEDING SEVERE DENGUE HEMORRHAGIC PETECHIAE COLD CLAMMY SKIN FEVER CAPILLARY REFILL>3 SEC ABDOMINAL PAIN VOMITING + TOURNIQUET TEST

TREATMENT PLAN B: VOMITING, ABDOMINAL PAIN,PETECHIAE PLAN C: SIGNS OF BLEEDING PREVENT LOW BS REFER URGENTLY

SIGNS

CLASSIFY AS TREATMENT

-NO

FEVER: DENGUE ADVISE WHEN 2 RETURN H. FEVER FU: 2DAYS UNLIKELY NO ASPIRIN

SIGNS OF SEVERE DENGUE

SIGNS

CLASSIFY AS TREATMENT

TENDER SWELLING MASTOIDITIS BEHIND EAR

1ST DOSE ANTIBIOTIC PARACETAMOL FOR PAIN REFER URGENTLY

SIGNS

CLASSIFY AS

PUS DRAINING FROM EAR <14 DAYS OR EAR PAIN IF 14 DAYS OR MORE

ACUTE EAR INFECTION

TREATMENT

ANTIBIOTICS 4 5 DAYS PARACETAMOL WICKING CHRONIC EAR FU IN 5 DAYS INFECTION

SIGNS

CLASSIFY ASTREATMENT

-NO

NO EAR INFECTION

PUS

EAR PAIN NO

NO ADDITIONAL TX

SIGNS

CLASSIFY AS TREATMENT

VISIBLE SEVERE WASTING EDEMA OF BOTH FEET SEVERE PALMAR PALLOR

SEVERE VITAMIN A MALNUTRITION REFER URGENTLY AND ANEMIA

SIGNS

CLASSIFY AS TREATMENT

SOME PALMAR ANEMIA OR PALLOR OR VERY VERY LOW LOW WEIGHT FOR WEIGHT AGE

COUNSEL ON FEEDING PALMAR PALLOR: FE, MEBENDAZOLE, FU: 14 IF LOW WT: VIT A FU: 30 DAYS

SIGNS

CLASSIFY AS TREATMENT

-NOT

NO ANEMIA AND NOT VERY LOW WEIGHT

VERY LOW WEIGHT FOR AGE AND NO OTHER SIGNS OF MALNUTRITION

COUNSEL MOTHER ON FEEDING ADVISE WHEN TO RETURN FU: 5 DAYS

SIGNS

CLASSIFY AS TREATMENT

CONVULSIONS FAST BREATHING SEVERE CHEST INDRAWING NASAL FLARING GRUNTING BULGING FONTANNELS PUS FR EAR UMBILICAL REDNESS(SKIN) 37.5C>, <35.5C MANY OR SEVERE SKIN PUSTULES ABNORMALLY SLEEPY LESS THAN N MOVEMENT

POSSIBLE SERIOUS BACTERIAL INFECTION

1ST IM AB (BENZYLPENICILLIN AND GENTAMYCIN) PREVENT LOW BS ADVISE MOTHER HOW TO KEEP INFANT WARM REFER URGENTLY

SIGNS

CLASSIFY AS TREATMENT

RED UMBILICUS OR DRAINING PUS OR SKIN PUSTULES

LOCAL BACTERIAL INFECTION

ORAL ANTIBIOTICS TREAT LOCAL INFECTION IN HEALTH CENTER ADVISE MOTHER ABOUT HOME CARE FU: 2 DAYS

SIGNS

CLASSIFY AS TREATMENT

2 OF THE FF: SEVERE DEHYDRATION SLEEPY SUNKEN EYES SKIN TURGOR: VP

PLAN C REFER IF WITH POSSIBLE SERIOUS BACTERIAL INFECTION

SIGNS

CLASSIFY AS TREATMENT

2 OF THE FF: SUNKEN EYES S. TURGOR:POOR RESTLESS

SOME PLAN B DEHYDRATION REFER IF WITH POSSIBLE SERIOUS BACTERIAL INFECTION FU:2 DAYS

SIGNS

CLASSIFY AS TREATMENT

NOT ENOUGH SIGNS

NO PLAN A DEHYDRATION

SIGNS

CLASSIFY AS TREATMENT

DIARRHEA 14 SEVERE DAYS OR MORE PERSISTENT DIARRHEA

TREAT DHN FIRST UNLESS THERE IS POSSIBLE SERIOUS BACTERIAL INFECTION REFER URGENTLY

BLOOD IN STOOL DYSENTERY

REFER URGENTLY WITH MOTHER GIVING ORS ON THE WAY

SIGNS

CLASSIFY AS TREATMENT

NOT ABLE TO: NOT ABLE TO FEED FEED POSSIBLE ATTACH SERIOUS SUCK BACTERIAL INFECTION

1ST DOSE IM AB PREVENT LOW BS ADVISE HOW TO KEEP WARM REFER URGENTLY

SIGNS

CLASSIFY AS TREATMENT

NOT WELL ATTACHED NOT SUCKLING EFFECTIVELY LESS THAN 8 BREASTFEED IN 24 HRS RECEIVE OTHER FOODS OR DRINKS LOW WEIGHT FOR AGE THRUSH

FEEDING BREASTFEED AS OFTEN AS PROBLEMS OR POSSIBLE LOW WEIGHT TREAT THRUSH ADVISE ABOUT HOME CARE FU: 2 DAYS FEEDING OR THRUSH FU:14 DAYS LOW WEIGHT FOR AGE

SIGNS -NOT

CLASSIFY AS TREATMENT

LOW NO FEEDING WEIGHT FOR PROBLEM AGE AND NO OTHER SIGNS OF INADEQUATE FEEDING

COUNSEL MOTHER ON FEEDING

 Tell

mother the reason for giving the drugs to the child  Demonstrate how to measure a dose  Watch the mother practice measuring a dose by herself  Ask the mother to give the first dose to her child  Explain carefully how to give the drug, label and package the drug.  Explain that all the oral drug tables or syrup must be used to finish the course of treatment, even if the child gets better.  Check the mother’s understanding before she leaves the health center

1ST LINE ANTIBIOTICS

2ND LINE ANTIBIOTICS

 CHLOROQUINE

 Artemeter-

 PRIMAQUINE  SULFADOXINE

PYRIMETHAMINE

Lumefrantine

VITAMIN A

IRON 



Give one dose in 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

One dose daily for 14 days

PARACETAMOL  For MEBENDAZOLE/ALBENDAZOLE

 Give

500mg in the health center if:  Child

is 12 months up to 59 months  No dose received in the previous 6 months

Fever (38.5) and Ear Pain

 Clean

both eyes 3 times daily  Apply tetracycline eye ointment in both eyes 3 times daily  Treat until redness is gone  Do not use other eye ointments or drops or put anything else in the eye

 Roll

clean absorbent cloth into a wick  Place in child’s ear  Remove when wet  Replace with a clean one and repeat until ear is dry

 Wash

hands  Wash child’s mouth clean using cloth wet with salt water  Paint mouth with gentian violet using cotton bud  Wash hands again

SAFE REMEDIES:

HARMFUL REMEDIES:

 Breast

 Codeine

milk for exclusively breastfed infant  Tamarind, calamansi and ginger

cough

syrup  Other cough syrup  Oral and nasal decongestants

INTRAMUSCULAR ANTIMALARIAL 

CHLORAMPHENICOL INTRAMUSCULAR ANTIBIOTIC



QUININE (FOR VERY SEVERE FEBRILE DISEASE/MALARIA)

 Breastfeed

child  Give expressed breast milk or breast milk substitute  Give sugar water (4tsp sugar in 200ml water)  Give 50ml milk or sugar water by NGT  IV infusion

 Full

MALARIA

assessment of child  If child has other cause of fever: treat.  If malaria is the only cause: blood smear, 2nd -line ant malarial, follow-up in 2days

 Full

FEVERMALARIA UNLIKELY

assessment of child  If with GDS or stiff neck, treat as VERY SEVERE FEBRILE DISEASE/MALARIA  If malaria is the only cause of fever: blood smear, 1st -line ant malarial, follow-up in 2 days

FEVER: NO MALARIA

 Full

assessment of the child  If with GDS or stiff neck, treat as VERY SEVERE FEBRILE DISEASE  Follow-up in 2 days

MEASLES WITH EYE OR MOUTH COMPLICATIONS

 Look

for red eyes and pus draining from eyes  Look at mouth ulcers  Smell mouth ulcers

TREATMENT FOR EYE INFECTION 





If pus is draining from eye: ask mother to describe how treatment was done If pus gone, but redness remains: continue the treatment If no pus or redness: stop treatment

TREATMENT FOR MOUTH ULCERS 



Worse or foul-smelling: refer Same or better: continue treatment for a total of 5 days

DHF UNLIKELY   

Full assessment Tourniquet test Assess for other causes

TREATMENT 





Signs of bleeding: IVF and refer Other causes of fever, treat Fever for 7 days: refer for assessment

TREATMENT  Reassess

for ear

problem  Measure child’s temperature







If there is tender swelling or high fever: treat as mastoiditis Acute ear infection: ear pain or discharge persists: treat with 5 more days of same antibiotic Chronic ear infection: check wicking of mother

FEEDING PROBLEM   

Reassess feeding Counsel mother If very low weight for age: return in 30 days after initial visit

ANEMIA  



Give iron Continue giving iron everyday for 2 months with follow-up every 14 days If with palmar pallor after 2 months: refer for assessment

 Difficulty

in breastfeeding  Child less than 4 months taking other milk/food  Use of breast milk substitute/ cow’s milk/ evap milk  Use of feeding bottles  Lack of active feeding  Not feeding well during illness  Complementary food not enough  Child 6 months above not yet given complementary foods  Infants not exclusively breastfed

Any sick child

 Not

able to drink or breastfeed  Becomes sicker  Develops a fever

No pneumonia:cough or cold

 Fast

breathing  Difficult breathing

Diarrhea

 Blood

in stool  Drinking poorly

Fever: DHF unlikely

 Signs

of bleeding  Persistent abdominal pain  Skin petechiae  Skin rash