The Integrated Management Of Childhood Illness

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Ma. Reina Rose D. Gulmatico, RN

What is IMCI? A strategy for reducing mortality and morbidity associated with major causes of childhood illness A joint WHO/UNICEF initiative since 1992

DOH Essential Package of Child Survival Interventions 

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Skilled attendance during pregnancy, childbirth and the immediate postpartum Care of the newborn Breastfeeding and complementary feeding Micronutrient supplementation Immunization of children and mothers Integrated management of sick children Use of insecticide treated bed nets (in malarious areas)

What is IMCI? According to the World Bank, the IMCI likely to have the greatest impact in reducing the global burden of disease

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Designed to teach integrated management of sick infants and children to first level HWs in primary care settings that have NO laboratory support and only a limited number of essential drugs

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Action-oriented CLASSIFICATIONS, rather than EXACT DIAGNOSES, are used

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Using few CLINICAL SIGNS as possible which health workers of diverse background can be trained to recognize

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Case Management Process

IMCI Case Management Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems

Classificatio n Need to Refer Specific treatment Home management

Counsel & Followup

Treatmen t

Counsel caretakers Follow-up

Identify treatment Treat

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Assess and Classify the Sick Child age 2 months up to 5 years Management of the Sick Young Infant Age 1 week up to 2 months

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Classifying the Illness -

Most have three rows Each row is colored either pink, yellow, or green

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Classifying the Illness PINK - needs urgent attention and referral or admission for inpatient care - a severe classification

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Classifying the Illness YELLOW - child needs an appropriate antibiotic, an oral antimalarial, or other treatment - includes home teaching to mother

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Classifying the Illness GREEN - child does not need specific medical treatment - includes home teaching to mother

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Classifying the Illness -

Always start with the top row A child receives only one classification Always select the more serious classification

Classifying the Illness Cough or difficult breathing SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign or Chest Indrawing or Stridor in calm child

SEVERE PNEUMONIA OR Give first dose of an appropriate antibiotic Vitamin A VERY SEVERE DISEASE Give Treat the child to prevent low blood sugar

Fast breathing

PNEUMONIA

No signs of pneumonia or very severe disease

NO PNEUMONIA: COUGH If coughing more than 30 days, refer for assessment OR COLDS Soothe the throat and relieve the cough with a

Refer URGENTLY to hospital

Give an appropriate antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advise the mother when to return immediately Follow- up in two days

safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS How to select the appropriate case

***Decide which age group the child is in

Assess And Classify The Sick Child Aged 2 Months Up To 5 Years

Ask the mother what the child’s problems are • Determine child’s age • Determine if this is an initial or follow-up visit for this problem

Check for General Danger Signs • Ask – Is the child not able to drink or breastfeed? – Does the child vomit everything? – Has the child had convulsions?

• Look – Child is abnormally sleepy or difficult to awaken?

Check for General Danger Signs • If the child has a general danger sign, complete the rest of the assessment IMMEDIATELY. • There must be no delay in the treatment

Ask about Main Symptoms • Does • Does • Does • Does

the the the the

child child child child

have have have have

cough or difficult bre diarrhea? fever? an ear problem?

Assess for Malnutrition and Anemia • Visible and severe wasting – Thin, no fat – Outline of ribs easily seen – Hips small when compared to chest and abdomen – Fat of the buttocks is missing – Abdomen large or distended

Visible, severe wasting

Visible, severe wasting

Assess for Malnutrition and Anemia • Look for edema of both feet

Assess for Malnutrition and Anemia • Look for palmar pallor - some palmar pallor (pale) - severe palmar pallor (very pale that the palm looks white)

Palmar pallor

Palmar pallor

Palmar pallor

• Determine weight for age

Classify Nutritional Status SIGNS

CLASSIFY AS

TREATMENT

Visible severe wasting or Edema of both feet or Severe palmar pallor

SEVERE MALNUTRITION OR SEVERE ANEMIA

Give Vitamin A Refer URGENTLY to hospital

Some palmar pallor or Very low weight for age

ANEMIA OR VERY LOW WEIGHT

Assess the child’s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. -If feeding problem, follow- up in 5 days. If some pallor: -Give iron. -Give Mebendazole if child is 2 years or older and has not had a dose in the previous 6 months. -Follow- up in 14 days. If very low weight for age: -Give Vitamin A. -Follow-up in 30 days. Advise mother when to return immediately

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

NO ANEMIA AND NOT VERY LOW WEIGHT

If the child is less than 2 years old, assess the child’s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart, If feeding problem, follow- up in 5 days, Advise mother when to return immediately.

Check the Child’s Immunization Status Birth

BCG, Hep B-1

6 weeks

DPT-1, OPV-1, Hep B-2

10 weeks

DPT-2, OPV-2

14 weeks

DPT-3, OPV-3, Hep B-3

9 months

Measles

Check the Child’s Immunization Status Three contraindications: -BCG to a child known to have AIDS -DPT 2 or 3 to a child who has had convulsions or shock within 3 days of most recent dose -DPT to a child with recurrent convulsions or another active neurological disease of the central nervous system

Check the Child’s Immunization Status There are no contraindications to immunization of a sick child if the child is well enough to go home.

Check the Child’s Vitamin A Status VITAMIN A SUPPLEMENTATION SCHEDULE: First dose at 6 months or above Subsequent doses every 6 months.

Check the Child’s Vitamin A Status Initial dose: 100,000 IU of Vitamin A

Subsequent doses: 200,000 IU of Vitamin A every six months up to the age of 59 months

Assess child’s feeding

(has ANEMIA OR VERY LOW WEIGHT OR < 2 YEARS OLD)

• Ask – Do you breastfeed your child? • How many times during the day? • Do you also breastfeed during the night?

Assess child’s feeding • Ask – Does the child take any other food or fluids? • What foods or fluids? • How many times during the day? • What do you use to feed the child? • If low weight for age: How large are the servings? • Does the child receive his own serving? Who feeds the child and how?

Assess child’s feeding • Ask – During this illness, has the child’s feeding changed? If yes, how?

Assess care for development • Ask questions about how mother cares for her child. Compare the mother’s answers to the Recommendations for Care and Development for child’s age

Assess care for development • Ask – How do you play with your child? – How do you communicate with your child?

Assess other problems.

IDENTIFY TREATMENT

Outline • Determine if urgent referral is needed • Identify treatments needed • For patients who need urgent referral: – Identify the urgent pre-referral treatments – Explain the need for referral to the mother – Writing the referral note

Flow chart of Identifying Treatment 2.0 Identify treatment for patient who do not need urgent referral

No 1.0 Determine if urgent referral is needed

Yes

3.0 Identify urgent prereferral treatment needed

4.0 Give prereferral treatment

5.0 Refer the child

DETERMINE IF URGENT REFERRAL IS NEEDED

DETERMINE IF URGENT REFERRAL IS NEEDED Referral for Severe Classifications • Severe Pneumonia or very severe disease • Severe Dehydration • Severe Persistent Diarrhea • Very Severe Febrile Disease/ Malaria • Very Severe Febrile Disease

DETERMINE IF URGENT REFERRAL IS NEEDED Referral for Severe Classifications • Severe Complicated Measles • Severe Dengue Hemorrhagic Fever • Mastoiditis • Severe Malnutrition or Severe Anemia

Exceptions • Severe Persistent Diarrhea • Severe Dehydration If the child’s only classification is SEVERE DEHYDRATION, use Plan C to decide whether to refer the child If the child has another classification in addition to Severe Dehydration, refer the child

Referral for General Danger Signs

• Make sure child with any general danger sign is referred after first dose of an appropriate antibiotic and other urgent treatments

Remember (-) general danger signs, severe classifications, or other severe problems MEANS (-) urgent referral to a hospital

IDENTIFY TREATMENTS FOR PATIENTS WHO DO NOT NEED URGENT REFERRAL

Identify Treatment • List only the treatments that apply to the specific child being treated • Include items for follow-up • If several different times are specified for follow-up, you will look for the earliest definite time

CHECKPOINT!!! 1 2

follow up in 2 days follow up in 5 days 5 follow up in 5 days if not improving 3 follow up in 30 days 4 follow up in 2 days if fever persists

IDENTIFY and GIVE URGENT PREREFERRAL TREATMENT NEEDED

Pre-referral Treatment • • • •

Give an appropriate antibiotic Give Quinine for SEVERE MALARIA Give Vitamin A Treat the child to prevent low blood sugar

Pre-referral Treatment • Start IV fluids according to Plan C for child with severe dengue hemorrhagic fever with bleeding or cold clammy skin or capillary refill more than 3 seconds

Pre-referral Treatment • Give ORS according to Plan B for a child with SEVERE DENGUE HEMORRHAGIC FEVER severe with only petechiae or a positive tourniquet test or abdominal pain or vomiting but without cold clammy skin and with a normal capillary refill time

Pre-referral Treatment • Give an oral antimalarial • Give paracetamol for high fever (38.5°C or above) or pain from MASTOIDITIS • Apply Tetracycline eye ointment if clouding of the cornea and pus draining from eye • Provide ORS solution so that the mother can give frequent sips on the way to the hospital

REFER THE CHILD

Refer the child • Explain to the mother the need for the referral, and get her to agree • Calm the mother’s fears and help her resolve any problems

TREAT THE CHILD

Outline I. II. III. IV. V.

Select the appropriate oral drug and determine dose and schedule Use good communication skills Teach the mother to give oral drugs at home Local Treatments Health Center Treatments

COUNSEL THE MOTHER

OUTLINE • FEEDING RECOMMENDATIONS • CARE FOR DEVELOPMENT • WHEN TO RETURN • MOTHER’S OWN HEALTH

FEEDING RECOMMENDATIONS • Exclusive breastfeeding • Complementary foods

Sick child: FEEDING PROBLEMS Difficulty breastfeeding Using of feeding bottle Lack of active feeding Not feeding well during illness Not giving protein source of food in lugaw or rice Improper handling and use of breastmilk substitute

Sick child: FEEDING PROBLEMS Teaching Correct Positioning and Attachment for Breastfeeding SIGNS OF GOOD ATTACHMENT: chin touching breast mouth wide open lower lip turned outward more areola visible above than below the mouth

Good attachment?

A

B

Good attachment?

A

B

Sick child: FEEDING PROBLEMS Poor ATTACHMENT can be influenced by proper POSITIONING of the young infant during breastfeeding. SIGNS OF GOOD POSITIONING: Infant’s neck is straight or bent slightly back Infant’s body is turned towards the mother Infant’s body is close to the mother Infant’s whole body is supported

Good position?

A

B

Good position?

A

B

CARE FOR DEVELOPMENT Common Problems: • Mother cannot breastfeed • Mother does not know what her child does to play or communicate • Mother feels she does not have enough time to provide care for development

Common Problems Mother has no toys for her child to play with Child is not responding, or seems “slow” Child is being raised by someone other than the mother

When to return Follow-up visit in a specific number of days Immediately, if signs appear that suggest the illness is worsening For the child’s next immunization

When to return immediately • Any sick child: – Not able to drink or breastfeed – becomes sicker – Develops a fever

When to return immediately • If child has NO PNEUMONIA: COUGH OR COLD, also return if: – Fast breathing – Difficult breathing

When to return immediately • If child has diarrhea, also return if: – Blood in the stool – Drinking poorly

When to return immediately • If child has FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY, also return if: – – – – –

Any sign of bleeding Persistent abdominal pain Persistent vomiting Skin rashes Skin petechiae

Give Follow up Care

Thank you!