22496096 the Integrated Management of Childhood Illness

8/8/2019 22496096 the Integrated Management of Childhood Illness

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The INTEGRATEDThe INTEGRATED

MANAGEMENT OFMANAGEMENT OF

CHILDHOOD ILLNESSCHILDHOOD ILLNESS

Suzanne Y. Caete


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A strategy for reducing mortality

and morbidity associated with

major causes of childhood illness

A joint WHO/UNICEF initiative

since 1992

What is IMCI?What is IMCI?


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DOHDOH Essential Package of Child Survival InterventionsEssential Package of Child Survival Interventions

Skilled attendance duringSkilled attendance duringpregnancy, childbirth and thepregnancy, childbirth and theimmediate postpartumimmediate postpartum

Care of the newbornCare of the newborn

Breastfeeding andBreastfeeding andcomplementary feedingcomplementary feeding

Micronutrient supplementationMicronutrient supplementation

Immunization of children andImmunization of children and

mothersmothers

Integrated management of sickIntegrated management of sickchildrenchildren

Use of insecticide treated bedUse of insecticide treated bednets (in malarious areas)nets (in malarious areas)


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According to the World Bank, the

IMCI likely to have the greatest

impact in reducing the globalburden of disease

What is IMCI?What is IMCI?


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Action-orientedCLASSIFICATIONS, ratherthan EXACT DIAGNOSES,

are used





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Using few CLINICAL SIGNS aspossible which healthworkers of diverse

background can be trainedto recognize





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Case Management Process





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IMCI Case Management

Danger signsMain Symptoms

Nutritional statusImmunization status

Other problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

TreatmentCounsel & Follow-up


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Assess and Classify the SickChild age 2 months up to 5 years

Management of the Sick YoungInfant Age 1 week up to 2months

The INTEGRATED MANAGEMENT OFThe INTEGRATED MANAGEMENT OF



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- Most have three rows

- Each row is colored either pink,yellow, or green



Classifying the Illness


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PINK

- needs urgent attention andreferral or admission for inpatient

care

- a severe classification





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YELLOW

- child needs an appropriateantibiotic, an oral antimalarial, or

other treatment

- includes home teaching tomother





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GREEN

- child does not need specificmedical treatment

- includes home teaching to

mother





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- Always start with the top row

- A child receives only oneclassification

- Always select the more serious

classification





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Cough or difficult breathing


SIGNS CLASSIFY AS TREATMENT

Any general danger sign or

Chest Indrawing or

Stridor in calm child

SEVERE PNEUMONIA

OR VERY SEVERE

DISEASE

Give first dose of an appropriate antibiotic

Give Vitamin A

Treat the child to prevent low blood sugar

Refer URGENTLY to hospital

Fast breathing PNEUMONIA Give an appropriate antibiotic for 5 daysSoothe the throat and relieve the cough with

a safe remedy

Advise the mother when to return

immediately

Follow- up in two days

No signs of pneumonia or

very severe disease

NO PNEUMONIA:

COUGH OR COLDS

If coughing more than 30 days, refer for

assessmentSoothe the throat and relieve the cough with

a safe remedy

Advise mother when to return immediately

Follow-up in 5 days if not improving


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***Decide which age group the child

is in



How to select the appropriatecase


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Ask the mother what theAsk the mother what thechilds problems arechilds problems are

Determine childs ageDetermine childs age

Determine if this is an initial orDetermine if this is an initial or

followfollow--up visit for this problemup visit for this problem


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Check for General DangerCheck for General DangerSignsSigns

AskAsk

Is the childIs the child not able to drink ornot able to drink orbreastfeed?breastfeed?

Does the childDoes the child vomit everything?vomit everything?

Has the child hadHas the child had convulsions?convulsions?

LookLook

Child isChild is abnormally sleepy or difficult toabnormally sleepy or difficult toawaken?awaken?


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Check for General DangerCheck for General DangerSignsSigns

If the child has a general dangerIf the child has a general dangersign, complete the rest of thesign, complete the rest of theassessment IMMEDIATELY.assessment IMMEDIATELY.

There must be no delay in theThere must be no delay in thetreatmenttreatment


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Ask about Main SymptomsAsk about Main Symptoms

Does the child have cough or difficultDoes the child have cough or difficultbreathing?breathing?

Does the child have diarrhea?Does the child have diarrhea? Does the child have fever?Does the child have fever?

Does the child have an ear problem?Does the child have an ear problem?


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Assess for Malnutrition andAssess for Malnutrition andAnemiaAnemia

Visible and severe wastingVisible and severe wasting

Thin, no fatThin, no fat

Outline of ribs easily seenOutline of ribs easily seenHips small when compared to chest andHips small when compared to chest and

abdomenabdomen

Fat of the buttocks is missingFat of the buttocks is missing

Abdomen large or distendedAbdomen large or distended


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Visible, severe wastingVisible, severe wasting


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Visible, severe wastingVisible, severe wasting


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Look for edema of both feet


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Look for palmar pallor

- some palmar pallor (pale)- severe palmar pallor (very palethat the palm looks white)


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Palmar pallorPalmar pallor


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Palmar pallorPalmar pallor


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Determine weight for age


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Classify Nutritional StatusClassify Nutritional Status

SIGNS CLASSIFY AS TREATMENT

Visible severe wasting or

Edema ofboth feet or

Severe palmar pallor

SEVEREMALNUTRITIONOR SEVEREANEMIA

Give Vitamin A

Refer URGENTLY to hospital

Some palmar pallor or

Very low weight for ageANEMIA ORVERY LOW

WEIGHT

Assess the childsfeeding and counsel themother on feeding according to the FOOD boxon the COUNSEL THE MOTHERchart.

-Iffeeding problem, follow- up in 5 days.Ifsome pallor:

-Give iron.

-Give Mebendazole ifchild is 2 years or olderand has not had a dose in the previous 6months.

-Follow- up in 14 days.

Ifvery low weight for age:

-Give Vitamin A.

-Follow-up in 30 days.Advise mother when to return immediately

Not very low weight for ageand no other signs ofmalnutrition

NO ANEMIAANDNOT VERY LOWWEIGHT

Ifthe child is less than 2 years old, assessthe childsfeeding and counsel the motheron feeding according to the FOOD box onthe COUNSEL THE MOTHERchart,

Iffeeding problem, follow- up in 5 days,

Advise mother when to return

immediately.


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Check the ChildsCheck the ChildsImmunization StatusImmunization 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


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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 oranother active neurological disease of the

central nervous system


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There are no contraindications to

immunization of a sick child if the childis well enough to go home.


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Check the Childs Vitamin ACheck the Childs Vitamin AStatusStatus

VITAMIN A SUPPLEMENTATION

SCHEDULE:

First dose at 6 months or above

Subsequent doses every 6 months.


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Check the Childs Vitamin ACheck the Childs Vitamin AStatusStatus

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


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Assess childs feedingAssess childs feeding(hasANEMIA ORVERY LOW WEIGHT OR < 2 YEARS OLD)(hasANEMIA ORVERY LOW WEIGHT OR < 2 YEARS OLD)

AskAsk

Do you breastfeed your child?Do you breastfeed your child?

How many times during the day?How many times during the day? Do you also breastfeed during the night?Do you also breastfeed during the night?


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Assess childs feedingAssess childs feeding

AskAsk

Does the child take any other food orDoes the child take any other food or

fluids?fluids? What foods or fluids?What foods or fluids?

How many times during the day?How many times during the day?

What do you use to feed the child?What do you use to feed the child?

If low weight for age: How large are theIf low weight for age: How large are theservings?servings?

Does the child receive his own serving?Does the child receive his own serving?Who feeds the child and how?Who feeds the child and how?


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Assess childs feedingAssess childs feeding

AskAsk

During this illness, has the childsDuring this illness, has the childsfeeding changed? If yes, how?feeding changed? If yes, how?


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Assess care for developmentAssess care for development

Ask questions about how motherAsk questions about how mother

cares for her child. Compare thecares for her child. Compare themothers answers to themothers answers to theRecommendations for Care andRecommendations for Care andDevelopment for childs ageDevelopment for childs age


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Assess care for developmentAssess care for development AskAsk

How do you play with your child?How do you play with your child?

How do you communicate with yourHow do you communicate with yourchild?child?


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Assess other problems.Assess other problems.


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IDENTIFYIDENTIFYTREATMENTTREATMENT


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Flow chart of IdentifyingFlow chart of IdentifyingTreatmentTreatment

1.0Determineif urgentreferral isneeded

2.0 Identify treatment for patient whodo not need urgent referral

4.0 Give pre-referral

treatment

5.0 Refer thechild

NoNo

YesYes3.0 Identifyurgent pre-

referral treatmentneeded


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DETERMINE IF URGENTDETERMINE IF URGENT

REFERRAL IS NEEDEDREFERRAL IS NEEDED


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Referral forReferral for Severe ClassificationsSevere Classifications

Severe Pneumonia or very severe disease

Severe Dehydration

Severe Persistent Diarrhea

Very Severe Febrile Disease/ Malaria

Very Severe Febrile Disease




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Referral forReferral for Severe ClassificationsSevere Classifications

Severe Complicated Measles

Severe Dengue Hemorrhagic Fever

Mastoiditis

Severe Malnutrition or Severe Anemia




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Referral for GeneralReferral for GeneralDanger SignsDanger Signs

Make sure child with any general danger

sign is referred after first dose of an

appropriate antibiotic and other urgent

treatments


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IDENTIFYIDENTIFYTREATMENTS FORTREATMENTS FORPATIENTS WHO DOPATIENTS WHO DONOT NEED URGENTNOT NEED URGENT

REFERRALREFERRAL


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Identify TreatmentIdentify 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


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CHECKPOINT!!!

follow up in 2 days

follow up in 5 daysfollow up in 5 days if not improving

follow up in 30 days

follow up in 2 days if fever persists

1

2

35

4


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IDENTIFY and GIVEIDENTIFY and GIVE

URGENT PREURGENT PRE--REFERRAL TREATMENTREFERRAL TREATMENTNEEDEDNEEDED


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PrePre--referral Treatmentreferral Treatment

Give an appropriate antibiotic

Give Quinine for SEVERE MALARIA

Give Vitamin A

Treat the child to prevent low blood

sugar


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Start IV fluids according to Plan C for

child with severe dengue hemorrhagic

fever with bleeding or cold clammy skinor capillary refill more than 3 seconds


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Give ORS according to Plan B for a child

with SEVERE DENGUE HEMORRHAGIC

FEVER severe with only petechiae or apositive tourniquet test or abdominal

pain or vomiting but without cold clammy

skin and with a normal capillary refill

time


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Give an oral antimalarial

Give paracetamol for high fever (38.5C

or above) or pain from MASTOIDITIS Apply Tetracycline eye ointment if

clouding of the cornea and pus drainingfrom eye

Provide ORS solution so that the mothercan give frequent sips on the way to thehospital


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REFER THE CHILDREFER THE CHILD


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Refer the childRefer the child

Explain to the mother the need for the

referral, and get her to agree

Calm the mothers fears and help her

resolve any problems


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TREAT THETREAT THECHILDCHILD


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COUNSEL THECOUNSEL THEMOTHERMOTHER


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OUTLINEOUTLINE

FEEDING RECOMMENDATIONS

CARE FOR DEVELOPMENT

WHEN TO RETURN MOTHERS OWN HEALTH


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FEEDING RECOMMENDATIONSFEEDING RECOMMENDATIONS

Exclusive breastfeeding

Complementary foods

i k hildi k hild


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Sickchild:Sickchild:FEEDING PROBLEMSFEEDING PROBLEMS

Difficultybreastfeeding

Using offeedingbottle

Lack ofactive feedingNot feeding well duringillness

Not giving protein source offoodin lugaw or rice

Improper handling and use ofbreastmilksubstitute

Sick child:Sick child:


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Teaching Correct Positioning and Attachment forBreastfeeding

SIGNS OF GOOD ATTACHMENT:

chin touching breast

mouth wide open

lower lip turned outward

more areola visible above than belowthe mouth


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Good attachment?Good attachment?

A B


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Good attachment?Good attachment?

A B

Sick child:Sick child:


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Poor ATTACHMENT can be influenced byproper POSITIONING of the younginfant during breastfeeding.

SIGNS OF GOOD POSITIONING:

Infants neck is straight or bent slightly

back

Infants body is turned towards the

mother

Infants body is close to the mother

Infants whole body is supported


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Good position?Good position?

A B


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Good position?Good position?

A B


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Common Problems:Common Problems:

Mother cannot breastfeed

Mother does not know what herchild does to play orcommunicate

Mother feelsshe does not have

enough time to provide care fordevelopment

CARE FOR DEVELOPMENTCARE FOR DEVELOPMENT


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Common ProblemsCommon Problems

Mother has no toysfor her childto play with

Child is not responding, or seemsslow

Child isbeing raised bysomeoneother than the mother


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When to returnWhen to return

Follow-up visit in a specificnumber ofdays

Immediately, ifsigns appear thatsuggest the illnessis worsening

For the childs next immunization



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When to returnWhen to returnimmediatelyimmediately

Any sick child:

Not able to drink or breastfeed

becomes sicker Develops a fever



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If child has NO PNEUMONIA: COUGH OR

COLD, also return if:

Fast breathing Difficult breathing



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If child has diarrhea, also return if:

Blood in the stool

Drinking poorly



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If child has FEVER: DENGUE

HEMORRHAGIC FEVER UNLIKELY, also

return if: Any sign of bleeding

Persistent abdominal pain

Persistent vomiting Skin rashes

Skin petechiae


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Give FollowGive Followup Careup Care


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THANK YOU!

Documents

22496096 the Integrated Management of Childhood Illness