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Imci day 2

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  • These are several advantages for adopting IMCI. First, it is not dependent on sophisticated and expensive equipment for diagnosis. Second, it is an integrated approach to managing sick children instead of giving separate treatment for each symptom and using disease-specific guidelines. Third, since there are relationships between illnesses as illustrated by diarrheal episodes with malnutrition or severe diarrhea following a bout of measles and frequent episodes of cough and colds in a malnourished child, it is important that one looks at the over-all well-being of the child,. This means that apart from addressing the main symptom, or sign there is a need to address other problems affecting the child’s health. Fourth, a health worker who is at the frontline in the community is taught how to carefully consider all of the child’s symptoms in a systematic manner without overlooking other problems. S/he can determine if a child is severely ill and needs urgent referral. If not, s/he can follow the guidelines to treat the child’s illnesses. Part of the guidelines include how to counsel the mother and the caretaker. The role of the mother and /or caretaker on continuing treatment at home and when to refer immediately is very important in the management of the sick child.
  • IMCI addresses the most common causes of child mortality. These are pneumonia, diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition, anemia and ear problems. Tuberculosis is one of the major health diseases still very prevalent in the country. However, it does not cause immediate death to a child. As its manifestations are varied the various signs and symptoms being expressed become entry points towards its early detection and appropriate management. The approach in IMCI consists of many preventive interventions. For one, the health worker gives the mother a follow-up care. Immunization is resumed as soon as the danger signs have resolved. Breastfeeding is strongly endorsed as the best food to an infant. Good complementary foods are enumerated.
  • The guidelines take an evidence-based syndromic approach to case management that supports the rational and effective use of drugs and diagnostic tools. In situations where laboratory support and clinical resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients. Furthermore, it involves the family members who are taught how to administer the drugs and watch out for danger signs in need of urgent referral. The community is in turn is mobilized to collaborate in ensuring a clean and safe environment for their children.
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  • The strategy is composed of three components: 1. Improvement of case management skills of health workers 2. Improving the health system to deliver IMCI 3. Improving family and community practices 1. Improving case management skills of health workers. The first component consists of providing locally adopted guidelines and promoting its use among the barangay health workers, nurses, midwives and doctors. The role of private providers is specifically highlighted as there are doctors in the private sector whose bulk of patients are children.
  • 2. Improvements in the health system is required for the effective management of childhood illnesses. Under this component are the provision and management of essential drug supplies, organization of work in health facilities, management and supervision of health workers and an effective referral system.
  • 3. Improving family and community practices – Under this component are four purposes being addressed: a. For physical growth and development – Activities include breastfeeding, complementary feeding, micronutrient supplementation, psychosocial stimulation. b. For disease prevention – activities include immunization, sanitary disposal of feces, handwashing, insecticide treated bednets, dengue prevention. c. For appropriate home care – activities include continuous feeding, increase fluids, appropriate home treatment d. For seeking care – areas included are when to seek care, follow health workers advice, prenatal, postnatal care (postpartum)
  • 3. Improving family and community practices – Under this component is the first purpose being addressed: a. For physical growth and development – Activities to include health education on breastfeeding, complementary feeding, micronutrient supplementation, psychosocial stimulation.
  • 3. Improving family and community practices – Under this is the second purpose being addressed b. For disease prevention includes the following activities – immunization, sanitary disposal of feces, handwashing, insecticide treated bednets, dengue prevention.
  • Improving family and community practices – includes the third purpose which is being addressed. 3. For appropriate home care – activities included are continuous feeding, increase fluids, appropriate home treatment
  • 3. Improving family and community practices – includes the fourth purpose which is being addressed. d. For seeking care – includes when mothers should seek care, how mothers should follow health worker’s advice, and when to seek prenatal and postnatal care (postpartum)
  • The Integrated Case Management Process shows at a glance the various elements as they occur initially in an outpatient facility, referral facility or hospital and the community or the home. These elements begin with assessment (taking a good history and performing a physical examination), then classifying the severity of the child’s illness using a colour coded triage system, identification of specific treatment, counselling on feeding problems and on the mother’s health, and lastly giving follow-up care and if necessary reassessing the child for new problems.
  • The under five age groups are the target population of IMCI. There are special problems among 1 week old neonates until they reach 2 months of age. Majority of children belong to the category of less than 2 months old.
  • The first step after gathering the child’s weight, name and age, is to ask for general the danger signs. These are: unable to drink or breastfeed, vomiting, convulsions and lethargy.
  • The next major step is to check for the main symptoms. The specific signs to watch for under each main symptom are presented in the next four slides
  • In the overall case management process, the initial 4 steps occur in a first level facility like an OPD clinic or a community health center, or a private clinic. Subsequent steps would entail referral to the hospital when the child has the 4 general danger signs.
  • This is the summary of the Integrated Case Management Process
  • The first step in the integrated case management process is to ask for the child’s name and age. After this, the management would defer for a sick young infant one week to 2 months and a sick child 12 months to 5 years. There is a difference in the approach of a sick young infant from that of a sick child because of the different illnesses besetting each category. In the first week of life, newborn infants are often sick from conditions related to labor and delivery or they have conditions which require special management. Newborns may suffer from asphyxia, sepsis from premature ruptured membranes or other intrauterine infections or birth trauma, or they may trouble breathing due to immature lungs. Jaundice also requires special management in the first week of life. A child may present several signs for a particular problem and overlooking other symptoms one can miss other signs of disease. A child might have pneumonia, diarrhea, malaria, measles or malnutrition and yet present only as fever and difficult breathing. These diseases if undetected can cause disability or death in young children if they are not treated.
  • Ask the mother or caretaker about the child’s problem. The first visit for the problem would follow the following steps in the next slides. However, if this is a follow-up visit for the problem, one will proceed to give follow-up care. After determining if this is an initial or follow-up visit for another problem, one immediately asks about the general danger signs and observes if the child is lethargic or unconscious. It is important to listen carefully to what the mother or caretaker tells you. Using words that the mother/caretaker can understand and giving her ample time to answer the questions, one can be assured of a good history. Ask also additional questions when the mother/caretaker is not sure of her answer. If the child has no general danger signs, ask the mother/caretaker the 4 main symptoms starting from (1) does the child have cough or difficult breathing? (2) does the child have diarrhea? (3) does the child have fever? and (4) does the child have an ear problem? Next thing to check would be signs of malnutrition and anemia. Then classify the child’s immunization status and decide if the child needs any immunization today. Then ask for other problems according to one’s experience and clinical practice guidelines. Examples of other problems are: skin infections, itching, swollen neck glands or eye infections.
  • After assessing the child’s problem, one will classify the child’s illness using a color-coded triage system so that one can make a decision about the severity of the illness. For each of the child’s main symptoms, you will select a category or a classification that corresponds to the severity of the child’s illness. Because many children have more than 1 condition, each illness is classified according to whether his problem requires urgent pre-referral treatment and referral (pink row) or specific medical treatment and advice (yellow row) or a simple advice on home management (green row). After classifying how severe each of the 4 main symptoms, one proceeds to classifying the nutritional status and immunization status of the child.
  • If the child needs urgent referral, one must identify urgent pre-referral treatments the child needs before transport to a hospital for additional care.
  • If a child has only one classification, it is easy to see what to do for the child. However, many sick infants and children have more than one classification. For example, a child may have pneumonia or an ear infection at the same time. Some of the treatments may be the same but you will be the one to identify urgent pre-referral treatments. If there is no hospital in the area, you may make some decisions differently than what is described in the slides. You should only refer a child if you expect the child will actually receive better care. Sometimes, giving your best care is better than sending a child on a long trip to a hospital that may not have the supplies or expertise to care for the child. If referral is not possible or if the parents refuse to take the child, you should help the family care for the child. The child may stay near the clinic to be seen several times a day. Or a health worker may visit the home to help give drugs on schedule and to help give fluids and food. All severe classifications are colored pink and include severe pneumonia, or very severe disease, severe dehydration, severe persistent diarrhea, very severe febrile disease, severe complicated measles, mastoiditis, and severe malnutrition or severe anemia. Under this pink columns, the term “Urgent Refer to Hospitals” means that the child must immediately be referred after giving any necessary pre-referral treatments. However, if these treatments would unnecessarily delay referrals, it is advised not to give them at all. An exception would be for severe persistent diarrhea where the instruction is simply “Refer to Hospital.” This means referral is needed but not as urgently. There is time to identify treatments and give all of the treatments before referral. Another possible exemption is severe dehydration. You may keep and treat a child whose only classification is “Severe Dehydration” if the first level facility or clinic has the ability to treat the child. The child may have a general danger sign related to dehydration. For example, he may be lethargic or unconscious or unable to drink because he is severely dehydrated. If the child has another severe classification in addition to severe dehydration, the child should be urgently referred. Here, special skills and knowledge are required to rehydrate this child as too much fluid given too quickly could endanger this child’s life. In rare instances, children may have a general danger sign or signs without a severe classification. These children should be referred urgently. There are other problems that are not included in the IMCI process and it is up for you to decide if these other severe problems cannot be treated at this facility/clinic. If you cannot treat a severe problem like abdominal pain, then you will need to refer the child to the hospital. The following are urgent pre-referral treatments for sick children aged 2 months up to 5 years. (1) Give an appropriate antibiotic (2) Give quinine for severe malaria (3) Give Vitamin A (4) Treat a child to prevent low blood sugar (5) Give an oral anti-malarial (6) Give paracetamol for high fever (38.5 Celsius or above) or pain from mastoiditis (7) Apply tetracycline eye ointment (if clouding of the cornea or pus draining from the eye) (8) Provide oral rehydrating solution so that the mother can give frequent sips on the way to the hospital. The first 4 treatments above are urgent because they can prevent serious consequences such as progression of bacterial meningitis or cerebral malaria, corneal rupture due to lack of Vitamin A or brain damage from low blood sugar. The other listed treatments are also important to prevent worsening of the illness.
  • When a young child needs urgent referral, you must quickly identify and begin the most urgent treatments for that child. Urgent treatments are in bold prints in the Classification Tables. You will give just the first dose of the child before referral. Appropriate treatments are recommended for each classification. A child with the classification of very severe febrile disease could have meningitis, severe malaria, septicemia or dengue fever. The treatments listed for very severe febrile disease are appropriate because they have been chosen to cover the most likely diseases included in the classification.
  • When one refers the child to a hospital, it must be explained clearly why this must be done urgently to the mother/caretaker. A good way to ensure compliance is to calm the mother/caretaker’s fears and help resolve problems of who will take care of the child while in the hospital. Accomplishing the referral form or writing all the treatments that were given is a good practice so as to facilitate the receiving hospital of the proper management. Making a phone call to the hospital will also facilitate communication to the attending physicians on duty.
  • For patients who do not need urgent referral, you should record the treatments, advice to give to mother, and when to return for a follow-up visit. if a child has multiple classifications, identify treatment for all problems present. Some treatments are listed for more than one classifcation. An example is Vitamin A which is listed for both measles and severe malnutrition or sever anemia. If a patient ahs both of these problems, you need only list Vitamin A once on the Case recording form. However if an antibiotic is needed for more than one problem, you should identify it each time. For example: antibiotic for pneumonia, antibiotic for Shiegella. When the same antibiotic is appropriate for different problems, you can give that single antibiotic. However, 2 problems may require two different antibiotics. Some instructions that require special explanation: Malaria – children will usually be given the first line anti-malarial recommended by clinical protocols for each institution. However, if the child has cough and fast breathing (pneumonia), or another problem for which the antibiotic cotrimoxazole will be given (such as acute ear infection) cotrimoxazole will serve as treatment for malaria as well. (2) Anemia or very low weight - A child with palmar pallor should begin iron treatment for anemia. If there is high risk of malaria, a child with pallor should also be given an oral anti-malarial, even if the child does not have a fever. If the child is 2 years of age and older, and has not had a dose of mebendazole in the past 6 months, the child should also be given a dose of mebenndazole for possible hookworm or whipworm infection. If a child does not need urgent referral, check to see if the child needs non-urgent referral for further assessment. For example, for a cough which has lasted more than 30 days, or for fever which ahs lasted 7 days or more, you would record “ Refer for Assessment.” Although he mother should take the child for assessment promptly, these referrals are not as urgent. Any other necessary treatments may be done before referral.
  • This slide shows how to do the treatment steps identified on the Assess and Classify Chart. Treat means giving treatment in the first level facility or health center or private clinic, prescribing drugs or other treatment to be given at home, and also teaching the child’s mother/caretaker how to carry out the treatments.
  • This slide only highlights how it will appear on the Treat the Child Section. This describes also how: (1) give oral drugs (2) Treat local infections (3) Give intramuscular drugs (4) Treat the child to prevent low blood sugar (5) Give extra fluid for diarrhea and continue feeding (6) Give follow-up care If the child is scheduled for an immunization, it may be given depending upon the recommended contraindications being followed by the Expanded Program of Immunization.
  • If the infant is breastfeeding and was classified as feeding problem or low weight, you need to counsel the mother of the infant about any breastfeeding problems that were found during the assessment. If a mother is breastfeeding her infant less than 8 times in 24 hours, advise her to increase the frequency of breastfeeding. Breastfeed for as long as the infant wants day and night. If the infant receives other foods and drinks, counsel the mother about breastfeeding more, reducing the amount foods or drinks, and if possible, stopping altogether. Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle. If the mother does not breastfeed at all, consider referring her for breastfeeding counseling and possible relactation. If the mother seems interested, a breastfeeding may be able to help her to overcome difficulties and begin breastfeeding again. For many sick children, you will need to assess feeding and counsel the mother about feeding and fluids. Every mother/caretaker who is taking a sick young infant or child at home needs to be advised when to return to a health facility. You should advise her when to return for a follow-up visit and teach her signs that mean to return immediately for further care. During a sick child visit, listen for other problems that the mother herself may be having. The mother may need treatment or referral for her own problems.
  • Some sick children need to return for follow-up care. Their mothers are told when to come for a follow-up visit, either two days or 14 days. At the follow-up visit, you can see if the child is improving on the drug or other treatment that was prescribed. Some may not respond and may need to try a second drug. Children with persistent diarrhea also need follow up to be sure that diarrhea has stopped. Children with fever or eye infection need to be seen if they are not improving. Follow up is specially important for children with a feeding problem to be sure they are feeding fed adequately and are gaining weight. Because follow-up is important, you should make special arrangements so that follow-up visits may be convenient for mothers. If possible, mothers should not have to wait in line for a follow-up visit. Not charging for follow-up visits is another way to make follow-up convenient and acceptable to mothers. Some use a system to make it easy to find the records of children scheduled for follow-up. At the follow-up visit, you should do different steps than at a child’s initial visit for a problem. Treatments given at the follow-up visit are often different than those given at initial visit.
  • Select the appropriate case management chart according to age.
  • After the child’s name and age have been recorded.
  • This slide focuses on the signs of dehydration and how to assess for these signs. These signs are: lethargy, unconsciousness, restlessness and irritability, not able to drink, skin pinch goes back slowly or very slowly. The first step is to look at the child’s general condition. The first important sign is the child’s level of consciousness. Is the child lethargic, unconscious , irritable or restless? If the child is lethargic or unconscious, he has a general danger sign. He has the sign restless and irritable if the child is restless and irritable all the time or every time you touch him or handle him. If he is restless or irritable he cannot be consoled or calmed down. If he stops breastfeeding and he is restless and irritable, then he has the sign. Many children are upset just because they are in the clinic. Usually these children can be consoled or calmed. They do not have the sign “restless and irritable”. Look for sunken eyes . Ask the mother/caretaker if she thinks her child’s eyes look unusual. Her opinion helps you confirm that the child’s eyes are sunken. Ask the mother to offer the child some water in a cup or spoon. Watch the child drink. A child is not able to drink if he is not able to take fluid in his mouth and swallow it. This is seen when the child is lethargic or unconscious. Or the child may not be able to suck or swallow. A child is drinking poorly if the child is weak and cannot drink without help. He may be able to swallow only if fluid is put in his mouth. A child has the sign drinking eagerly, thirsty, if it is clear that the child wants to drink. Look to see if the child reaches out for the cup or spoon when you offer him water. When water is taken away, see if the child is unhappy because he wants to drink more. If the child takes a drink only with encouragement and does not want to drink more, he does not have the sign “drinking eagerly”. Ask the mother/caretaker to place the child on the examining table so that the child is flat on his back with his arms at his sides (not over his head) and his legs straight. Or ask the mother to hold the child so he is lying flat in her lap. Locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen. To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain. Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down the child’s body and not across the child’s body. Firmly pick up all of the layers of skin and the tissue under them. Pinch the skin for one second and then release it. When you release the skin, look to see if the skin pinch goes back: slowly (skin stays up for a for a brief instant) or very slowly (longer than 2 seconds) or immediately. Note: In a child with marasmus (severe malnutrition), the skin may go back slowly even if the child is not dehydrated. In an overweight child, or a child with edema, the skin may go back immediately even if the child is dehydrated. Even though skin pinch is less reliable in these children, still use it to classify the child’s dehydration.
  • This is what you will see in the chart where a sick child is asked if he has an ear problem. It is the last of the four main symptoms being asked after checking the sick child for general danger signs. Ask all sick children if they have an ear problem. If the answer is yes, ask if the child has ear pain. If the mother is not sure, ask if the child has been irritable and rubs his ear. Ask if there is an ear discharge. If there is, ask for how long. Then look for pus draining from the ear. Feel for tender swelling behind the ear. Classify the ear problem under the 4 classifications: MASTOIDITIS, ACUTE EAR INFECTION, CHRONIC EAR INFECTION, NO EAR INFECTION. If the child has tender swelling behind the ear, classify the child as having mastoiditis. Refer the child urgently to the hospital. Before he leaves for the hospital, give the first dose of an appropriate antibiotic and paracetamol for pain relief. If you see pus draining from the ear and discharge is reported for less than two (2) weeks or if there is ear pain, classify the child’s illness as ACUTE EAR INFECTION. Give the child appropriate antibiotics and paracetamol for pain relief. If pus is draining from the ear, dry the ear by wicking. If you see pus draining from the ear and discharge has been present for two (2) weeks or more, classify the child’s illness as CHRONIC EAR INFECTION. Most bacteria that cause this chronic infection are different from those that cause acute ear infections. For this reason, oral antibiotics are not usually effective against chronic infections. Do not give repeated courses of antibiotics for a draining ear. Dry the ear by wicking and follow-up in 5 days. If there is no ear pain and pus draining from the ear, the child’s illness is classified as NO EAR INFECTION. The child needs no additional treatment.
  • A mother may bring her child to the clinic or health center because the child has an acute illness. The child may not have specific complaints that point to malnutrition or anaemia. A sick child can be malnourished, but you or the child’s family may not notice the problem. A child with malnutrition has a higher risk of many types of disease and death. Even children with mild and moderate malnutrition have an increased risk of death. Identifying children with malnutrition and treating them can help prevent many severe diseases and death. Some malnutrition cases can be treated at home. Severe cases need referral to hospital for special feeding, blood transfusion or specific treatment of a disease contributing to malnutrition such as tuberculosis. In assessing the sick child’s nutritional status, use the color-coded classification table to classify the child’s illness for malnutrition and anemia. Then check for the immunization status and for other problems.
  • Check all sick children for malnutrition and anemia. Look for visible signs of wasting. A child with these signs will be very thin, has no fat, and looks like skin and bones. Remove the child’s clothes. Look for severe wasting of the muscles of the shoulders, arms, buttocks and legs. Look to see if the outline of the child’s ribs is easily seen. Look at the child’s hips. They may look small when you compare them with the chest and abdomen. Look at the child from the side to see if the fat of the buttocks is missing. When wasting is extreme, there are many folds of skins on the buttocks and thigh. It looks as if the child is wearing baggy pants. The child with visible severe wasting may still look normal. The child’s abdomen may be large or distended. Look for palmar pallor. It is a sign of anemia. To see if the child has palmar pallor, look at the skin of the child’s palm. Hold the child’s palm open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause pallor by blocking the blood supply. Compare the color of the child’s palm with your own palm and with the palms of other children. If the skin of the child’s palm is pale, the child has some palmar pallor. IF the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor. Look for edema of the both feet. This is a sign of kwashiorkor. Other signs include thin, sparse and pale hair that easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or “moon” face. Look and feel if the child has edema of both feet by using your thumb to press gently for a few seconds on the top side of each foot. The child has edema if there is a dent that remains in the child’s foot when you lift your thumb. Determine the weight for age. This compares the child’s weight with the weight of other children who are the same age. You will identify children whose weight for age is below the bottom curve of a weight for age chart. These are children who are very low weight for age. Children on or above the bottom curve of the chart can still be malnourished. But children who are below the bottom curve are very low weight and need special attention to how they are fed.
  • This picture shows a child without palmar pallor as compared with another child who has some palmar pallor (upper right hand corner). Compare the child’s hand on the right with severe palmar pallor and another child’s hand on the left without palmar pallor. (upper left hand corner). This child’s hand has severe palmar pallor. Compare that with the adult’s hands which is pinkish. (lower left hand corner).
  • This slide shows the classification table for malnutrition and anemia There are three (3) classifications for a child’s nutritional status: (1) SEVERE MALNUTRITION OR SEVERE ANEMIA, (2) ANEMIA OR VERY LOW WEIGHT and (3) NO ANEMIA AND NOT VERY LOW WEIGHT. If the child has visible severe wasting, severe palmar pallor or edema of both feet, classify the child as having SEVERE MALNUTRITION OR SEVERE ANEMIA. Children with edema of both feet may have other diseases such as nephrotic syndrome. It is not necessary to distinguish these other conditions from kwarshiorkor since they also require referral. These children are at risk of dying from pneumonia, diarrhea, measles and other severe diseases. They need urgent referral to hospital where their treatment can be carefully monitored. Before the child leaves for the hospital, give the child a dose of Vitamin A. If the child is very low weight for age or has some palmar pallor, classify the child as having ANEMIA OR VERY LOW WEIGHT. A child classified as having this has a higher risk of severe disease. When the child has only palmar pallor it can be recorded as ANEMIA or VERY LOW WEIGHT if the child is only very low weight for age. Assess the child’s feeding and counsel the mother about feeding her child according to the instructions and recommendations in the FOOD box on the COUNSEL THE MOTHER chart. A child with some palmar pallor may have anemia. Treat the child with iron. The anemia may be due to malaria, hookworm or whipworm. When there is a high risk of malaria, give an antimalarial to a child with signs of anemia. The presence of these soil-transmitted helminths will warrant giving mebendazole. Give this drug for children 2 years or older and those who have not had a dose of mebendazole for the past 6 months. A child without signs of malnutrition, is not very low for age is classified as having NO ANEMIA AND NOT VERY LOW WEIGHT. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children do. If a child is less than 2 years of age, assess the child’s feeding. Counsel the mother about feeding her child according to the recommendations in the FOOD box on the COUNSEL THE MOTHER chart.
  • For all sick children, check their immunization status. Use Expanded Program of Immunization Program guidelines in checking the child’s immunization status. Give the recommended vaccine only when the child’s age is the appropriate age for each dose. There are no contraindications to immunization of a sick child if the child is well enough to go home. If the child is going to be referred to a hospital, do not immunize the child before referral. The hospital staff at the referral site should make the decision about immunizing the child when the child is admitted. This will avoid delaying referral. Children with diarrhea who are due for OPV should receive a dose of OPV during this visit. However, do not count the dose. The child should return when the next dose of OPV is due for an extra dose of OPV. Advise the mother to be sure that the other children in the family are immunized. Give the mother tetanus toxoid, if required. Suppose the mother has an immunization card, compare the child’s immunization record with the recommended immunization schedule. Decide whether the child has had all the immunizations recommended for the child’s age. If the child is not being referred, explain to the mother that the child needs to receive an immunization(s) today. If she has no immunization card ask the mother to recall the immunizations the child has received. Use your judgment to decide if the mother gave a reliable report. If in doubt immunize the child. Give the child OPV, DPT and measles vaccine according to the child’s age. As you check the child’s immunization status, use the case recording form to check the immunizations already given and circle the immunizations needed today. If the child should return for an immunization, write the date that the child should return in the classification column and the next vaccine to be given.
  • Here is the immunization schedule being followed under the EPI by the DOH. At birth, BCG and hepatitis B first dose will be given. At 6 weeks of age – give the first doses of DPT and OPV and the second dose of Hepatitis B At 10 weeks of age – give the second doses of DPT and OPV and the third dose of Hepatitis B At 14 weeks of age – give the third doses of DPT and OPV and the booster dose of Hepatitis B At 9 months – give the first dose of measles vaccine
  • Check the immunization status just as you would for an older infant or young child. At 1 week of age BCG and Hepatitis 1 have been given. At 6 weeks of age, DPT 1 and OPV 1 should be given. In the Expanded Program of Immunization in the country BCG and Hepatitis B 1 should be given at birth because of the high prevalence of tuberculosis and hepatitis B. Giving an infant immunizations when he is too young does not guarantee that his body will be able to fight the disease very well. Also if the infant does not receive an immunization as soon as he is old enough, his risk of getting the disease increases. Sometimes health workers would consider a minor illness as a contraindication to immunization. They would send mothers away telling them to bring them back when the infant is well. This is a bad practice because it delays immunization. This leads to poor compliance on the part of the mother and the infant may run the risk of getting the infections. There are only three situations at present that are contraindicated to immunization: 1. Do not give BCG to a child known to have AIDS. 2. Do not give DPT to a child with recurrent convulsions or another active neurological disease of the central nervous system. 3. Do not give DPT 2 or DPT 3 to a child who has had convulsions or shock within 3 days of the most recent dose.
  • In these slides, you will learn how to assess a sick young infant age 1 week up to 2 months and to classify the infant’s illnesses. The process is very similar to the one you learned for the sick child age 2 months up to 5 years.
  • Classify all sick young infants for bacterial infection. Compare the infant’s signs to signs listed on the color-coded table and choose the appropriate classification. There are two possible classifications for bacterial infection: POSSIBLE SERIOUS BACTERIAL INFECTION and LOCAL BACTERIAL INFECTION. Under this classification table, a young infant with any sign in the top row is classified as POSSIBLE SERIOUS BACTERIAL INFECTION. An infant who has none of the signs gets no classification of bacterial infection. An infant with infected umbilicus or a skin infection has a LOCAL BACTERIAL INFECTION. A young infant with signs of POSSIBLE SERIOUS BACTERIAL INFECTION may have a serious disease and be at high risk of dying. The infant may have pneumonia, sepsis or meningitis It is difficult to distinguish between these infections in a young infant. Fortunately it is not necessary to make this distinction. This infant needs urgent referral to the hospital. Before referral, give a first dose of intramuscular antibiotics and treat to prevent low blood sugar. Malaria is unusual in infants of this age, so do not give pre-referral treatment for malaria. Advise the mother to keep her sick young infant warm. This is important since young infants have difficulty maintaining their body temperature. Low temperature or hypothermia can kill young infants. Young infants classified as LOCAL BACTERIAL INFECTION will need treatment with oral antibiotics at home for 5 days. The mother or caretaker will need to treat the local infection and should return for follow-up in 2 days to be sure the infection is improving. Bacterial infections can progress rapidly in young infants.
  • If the mother says the young infant has diarrhea, assess and classify for diarrhea. The normally frequent or loose stools of a breastfed baby is not diarrhea. The mother of a breastfed baby can recognize diarrhea because the consistency or frequency of the stools is different than normal. The assessment is similar to the assessment of diarrhea for an older infant or young child but fewer signs are checked. Thirst is not assessed. This is because it is not possible to distinguish thirst from hunger in a young infant. Then check for feeding problem or low weight, immunization status and other problems. Poor feeding in infancy can have lifelong effects. Growth is assessed by determining weight for age. This is important so that feeding can be improved if necessary. The best way to feed a young infant is to breastfeed exclusively. Exclusive breastfeeding means that the infant takes only breastmilk and no additional food, water or other fluids. The assessment has two parts. In the first part, you ask the mother questions. You determine if she is having difficulty feeding the infant, what the infant is fed and how often. You also determine weight for age. In the second part, you assess how the infant breastfeeds.
  • Poor feeding in infancy can have lifelong effects. Growth is assessed by determining weight for age. This is important so that feeding can be improved if necessary. The best way to feed a young infant is to breastfeed exclusively. Exclusive breastfeeding means that the infant takes only breastmilk and no additional food, water or other fluids. The assessment has two parts. In the first part, you ask the mother questions. You determine if she is having difficulty feeding the infant, what the infant is fed, how often and what is used to feed the infant . You also determine weight for age. Use a weight for age chart to determine if the young infant is low weight for age. Notice that for a young infant you should use the LOW WEIGHT FOR AGE LINE. Also remember that the young infant’s age is stated in weeks but the Weight for Age chart is labelled in months. In the second part, you assess how the infant breastfeeds. If the infant is exclusively breastfed without difficulty and is not low weight for age, there is no need to assess breastfeeding. If the infant is not breastfed at all, do not assess breastfeeding. If the infant has a serious problem, requiring urgent referral to a hospital, do not assess breastfeeding. In these situations, classify the feeding based on the information that you have gathered. If the mother’s answers or the infant’s weight indicates a difficulty, observe a breastfeed as described above. Low weight for age is often due to low birthweight. Low birthweight infants are particularly likely to have a problem with breastfeeding. Assessing breastfeeding requires careful observation. Ask the mother if the infant has breastfed in the previous hour. If not, the infant may be willing to breastfeed and you ask the mother to put her infant to the breast. Observe a whole breastfeed if possible or observe for at least 4 minutes. Observe for signs of good attachment and you will see the following: -chin is touching the breast (or very close) -mouth is wide open -lower lip is turned outward -more areola is visible above than below the mouth In addition, suckling is effective if the infant suckles with slow deep sucks and sometimes pauses. You may see or hear the infant swallowing. If you can observe how the breastfeed finishes, look for signs that the infant is satisfied. If satisfied, the infant releases the breast spontaneously (that is, the mother does not cause the infant to stop breastfeeding in any way). The infant appears relaxed, sleepy and loses interest in the breast. Sometimes nasal congestion seems to interfere with breastfeeding, clear the infant’s nose. Then check whether the infant can suckle more effectively. Lastly, look for ulcers or white patches in the mouth or oral thrush. Look inside the mouth at the tongue and inside the cheek. Thrush looks like milk curds on the inside of the cheek, or a thick white coating of the tongue. Try to wipe the white off. The white patches of thrush will remain.
  • This is the sequel to the previous slides showing how to assess and classify the problems of a sick young infant. You will compare the infant’s signs to the signs listed in each row and choose the appropriate classification. A sick young infant who is unable to feed, has no attachment to the mother’s breast and does not suck has a life-threatening problem. This could be due to a bacterial infection or another problem like neonatal tetanus. This infant requires immediate attention. The treatment is the same as for the classification POSSIBLE SERIOUS BACTERIAL INFECTION. Refer the infant urgently to the hospital, give a first dose of intramuscular antibiotic and treat the infant to prevent low blood sugar by feeding breastmilk, other milk or sugar. This classification includes infants who are low weight for age or infants who have some sign that their feeding needs improvement. They are likely to have more than one of these signs. Advise the mother of this infant to breastfeed as often and for as long as the infant wants, day and night. The infant should breastfeed until he is finished. Teach the mother about any specific help her infant needs, such as better positioning and attachment for breastfeeding or treating oral thrush. Also advise the mother how to give home care for the young infant. Lastly this infant needs to follow-up with the health worker in 2 days for any feeding problem or oral thrush and in 14 days to reassess if the infant is still low weight for age. A young infant classified as NO FEEDING PROBLEM is exclusively and frequently breastfed. The phrase “NOT LOW WEIGHT FOR AGE “ means that the infant’s weight for age is not below the line for “LOW WEIGHT FOR AGE”. It is not necessarily normal or good weight for age, but the infant is not in the high risk category that we are most concerned with.
  • In the above slide, one sees two sets of checking questions to find out what the mother understands and what needs further explanation. Avoid asking leading questions and questions that can be answered with a simple yes or no. Good checking questions require the mother to describe HOW she will treat her child. They begin with question words, such as WHY, WHAT , HOW , WHEN, HOW MANY and HOW MUCH. The poor checking questions answered with a “yes” or “no”, do not show how much a mother knows. After you ask a question, pause. Give the mother or caretaker a chance to think and then answer. Do not answer the question for her. Do not quickly ask a different question. Asking checking questions requires patience. The mother may know the answer, but she may be slow to speak. She may be surprised that you really expect her to answer. She may fear her answer will be wrong. She may feel shy to talk to an authority figure. Wait for her to answer. Give her encouragement.
  • For all infants and children who are going home, you will advise the mother or caretaker when to return immediately. This means to teach the mother or caretaker certain signs that mean to return immediately for further care. These signs are listed in the section WHEN TO RETURN on the YOUNG INFANT charts. Remember this is an extremely important section. Advise the mother to return immediately if the young infant has any of these signs: breastfeeding or drinking poorly, becomes sicker, develops a fever, fast breathing, difficult breathing, blood in the stool. In addition, advise the mother to make sure the infant stays warm at all times. Keeping a sick young infant warm (but not too warm) is very important. Low temperatures can kill young infants.
  • Follow-up means that the mother or caretaker will return in a certain number of days. This is very important for one gets to see if the treatment is working or not. Otherwise, one should give other treatment needed. If several different times are specified for follow-up, you will look for the earliest DEFINITE date. By definite date means, one that is not followed by the word “if”. For example: “ Follow up in 2 days” gives a definite time for follow-up. “ Follow-up in 2 days if fever persists” is not definite. The infant only needs to come back if the fever persists. Follow-up visits are especially important for a young infant. If you find at the follow-up visit that the infant is worse, you will refer the infant to the hospital. A young infant who receives antibiotics for local bacterial infection or dysentery should return for follow-up in 2 days. A young infant who has a feeding problem or oral thrush should return in 2 days. An infant with a low weight for age should return for follow-up in 14 days. If the young infant has dysentery, classify and treat dehydration as you would at an initial assessment. If the infant is dehydrated, use the classification table on the YOUNG INFANT chart to classify the dehydration and select a fluid plan. If the signs are the same or worse, refer the infant to the hospital. If the infant has developed fever, give intramuscular antibiotics before referral, as for POSSIBLE SERIOUS BACTERIAL INFECTION. If the infant’s signs are improving, tell the mother to continue giving the infant the antibiotic. Make sure the mother or caretaker understands the importance of completing the 5 days of treatment.

Transcript

  • 1. IMCI Day 2 Nelia B. Perez RN, MSN PCU - MJCN
  • 2. Features of IMCI…Features of IMCI… • not necessarily dependent on the use of sophisticated and expensive technologies • a more integrated approach to managing sick children • move beyond addressing single diseases to addressing the overall health and well-being of the child 2
  • 3. Features of IMCI…Features of IMCI… • careful and systematic assessment of common symptoms and specific clinical signs to guide rational and effective actions • integrates management of most common childhood problems (pneumonia, diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and anemia, ear problems) • includes preventive interventions3
  • 4. Features of IMCI…Features of IMCI… • adjusts curative interventions to the capacity and functions of the health system (evidence-based syndromic approach) • involves family members and the community in the health care process 4
  • 5. Objectives of IMCIObjectives of IMCI (1) reduce deaths and the frequency and severity of illness and disability; and (2) contribute to improved growth and development 5
  • 6. IMCI ComponentsIMCI Components 1. Improving case management skills of health workers • standard guidelines • training (pre-service/in-service) • follow-up after training • role of private providers 6
  • 7. IMCI ComponentsIMCI Components 2. Improving the health system to deliver IMCI • essential drug supply and management • organization of work in health facilities • management and supervision • referral system 7
  • 8. IMCI ComponentsIMCI Components 3. Improving family and community practices • for physical growth and mental development • for disease prevention • for appropriate home care • for seeking care 8
  • 9. IMCI ComponentsIMCI Components 3. Improving family and community practices -For physical growth and mental development • Breastfeeding • Complementary feeding • Micronutrient supplementation • Psychosocial stimulation 9
  • 10. IMCI ComponentsIMCI Components 3. Improving family and community practices - For disease prevention •immunization •handwashing •sanitary disposal of feces •use of insecticide-treated bednets •dengue prevention and control 10
  • 11. IMCI ComponentsIMCI Components 3. Improving family and community practices - For appropriate home care • continue feeding • increase fluid intake • appropriate home treatment 11
  • 12. IMCI ComponentsIMCI Components 3. Improving family and community practices - For seeking care •Follow health workers advice •When to seek care •Prenatal consultation •Postnatal (postpartum) consultation 12
  • 13. The Integrated Case Management ProcessThe Integrated Case Management Process 13 Treatment •treat local infection •give oral drugs •advise and teach caretaker •follow up Outpatient Health Facility Home Caretaker is counselled on: •home treatment •feeding &fluids •when to return •immediately •follow-up •check for danger signs •assess main symptoms •assess nutrition and Immunization status and potential feeding problems •Check for other problems •classify conditions and • identify treatment actions Outpatient Health Facility Urgent referral •pre-referral treatment •advise parents •refer child Outpatient Health Facility •emergency triage & treatment •Diagnosis & treatment •monitoring & ff-up Referral facility
  • 14. • Sick young infant • 1 week up to 2 months • Sick young children • 2 months up to 5 years 14
  • 15. Assessing the Sick ChildAssessing the Sick Child 15 General Danger Signs • lethargy or unconsciousness • inability to drink or breastfeed • vomiting • convulsions
  • 16. Checking the Main SymptomsChecking the Main Symptoms - cough and difficult breathing - diarrhea - fever - ear problem 16
  • 17. Checking the Main SymptomsChecking the Main Symptoms 1. Cough or difficult breathing 3 clinical signs • Respiratory rate • Lower chest wall indrawing • Stridor 17
  • 18. Checking the Main SymptomsChecking the Main Symptoms 2. Diarrhea • Dehydration • General condition • Sunken eyes • Thirst • Skin elasticity • Persistent diarrhea • Dysentery 18
  • 19. Checking the Main SymptomsChecking the Main Symptoms 3. Fever • Stiff neck • Risk of malaria and other endemic infections, e.g. dengue hemorrhagic fever • Runny nose • Measles • Duration of fever (e.g. typhoid fever) 19
  • 20. Checking the Main SymptomsChecking the Main Symptoms 4. Ear problems • Tender swelling behind the ear • Ear pain • Ear discharge or pus (acute or chronic) 20
  • 21. Checking Nutritional Status, Feeding,Checking Nutritional Status, Feeding, Immunization StatusImmunization Status • Malnutrition • visible severe wasting • edema of both feet • weight for age • Anemia • palmar pallor • Feeding and breastfeeding • Immunization status 21
  • 22. Assessing Other ProblemsAssessing Other Problems • Meningitis • Sepsis • Tuberculosis • Conjunctivitis • Others: also mother’s (caretaker’s) own health 22
  • 23. IMCI Essential Drugs and SupplyIMCI Essential Drugs and Supply • Appropriate antibiotics • Quinine • Vitamin A • Paracetamol • Oral antimalarial • Tetracycline eye ointment • ORS • Mebendazole or albendazole • Iron • Vaccines • Gentian violet23
  • 24. 24 Overall Case Management ProcessOverall Case Management Process Outpatient 1 - assessment 2 - classification and identification of treatment 3 - referral, treatment or counseling of the child’s caretaker (depending on the classification identified 4 - follow-up care Referral Health Facility 1 - emergency triage assessment and treatment 2 - diagnosis, treatment and monitoring of patient progress
  • 25. 25 SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESS For all sick children age 1 week up to 5 years who are brought to a first-level health facility ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems. CLASSIFY the child’s illnesses: Use a colour-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status. IF URGENT REFERRAL is needed and possible IF NO URGENT REFERRAL isneeded or possible IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) needed for the child’s classifications. . IDENTIFY TREATMENT needed for the child’s classifications: Identify specific medical treatments and/or advice. TREAT THE CHILD: Give urgent pre- referral treatment (s) needed. TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advise the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. If neede give immunizations. REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital. COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health. FOLLOW-UP care: Give follow-up care when the child returns to the clinic and,if necessary, reassess the child for new problems.
  • 26. 26 Summary of the Integrated caseSummary of the Integrated case Management ProcessManagement Process For all sick children age 1 week up to 5 years who are brought to a first-level health facility
  • 27. 27 Summary of the Integrated caseSummary of the Integrated case Management ProcessManagement Process ASSESS the Child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems
  • 28. 28 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process Classify the child’s illness: Use a color-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status.
  • 29. 29 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process IF URGENT REFERRAL is needed and possible
  • 30. 30 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process IDENTIFY URGENT PRE- REFERRAL TREATMENT(S) Needed prior to referral of the child according to classification
  • 31. 31 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process TREAT THE CHILD: Give urgent pre-referral treatment(s) needed.
  • 32. 32 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital
  • 33. 33 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process IF NO URGENT REFERRAL is needed or possible
  • 34. 34 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process IDENTIFY TREATMENT needed for the child’s classifications: identify specific medical treatments and/or advice
  • 35. 35 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advice the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give immunizations.
  • 36. 36 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a healthy facility. Counsel the mother about her own health.
  • 37. 37 Summary of the Integrated CaseSummary of the Integrated Case Management ProcessManagement Process FOLLOW-UP CARE: Give follow-up care when the child returns to the clinic and, if necessary, re- asses the child for new problems.
  • 38. 38 SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic ASK THE CHILD’S AGE IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years USE THE CHART: œ ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT USE THE CHART: œ ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD COUNSEL THE MOTHER
  • 39. THE SICK CHILD AGE 2 MONTHS TO 5 YEARS: ASSESS AND CLASSIFY
  • 40. Ask the mother or caretaker about the child’s problem. If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to PART VII) Check for general danger signs. Ask the mother or caretaker about the four When a main symptom is present: main symptoms: œ assess the child further for signs related to œ cough or difficult breathing, the main symptom, and œ diarrhoea, œ classify the illness according to the signs œ fever, and œ ear problem which are present or absent. Check for signs of malnutrition and anaemia and classify the child’s nutritional status Check the child’s immunization status and decide if the child needs any immunizations today. Assess any other problems. Then: Identify Treatment (PART IV), Treat the Child (PART V), and Counsel the Mother (PART VI) SUMMARY OF ASSESS AND CLASSIFY
  • 41. Ask the mother or caretaker about the 4 main symptoms: cough or difficult breathing diarrhoea fever, and ear problem SUMMARY OF ASSESS AND CLASSIFY When a main symptom is present: Assess the child further for signs related to the main symptom, and Classify the illness according to the signs which are present or absent
  • 42. FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC GREET the mother appropriately and ask about her child. LOOK to see if the child’s weight and temperature have been recorded ASK the mother what the child’s problems are DETERMINE if this is an initial visit or a follow-up visit for this problem IF this is an INITIAL VISIT for the problem ASSESS and CLASSIFY the child following the guidelines in this part of the handbook (PART II) GIVE FOLLOW-UP CARE according to the guidelines in PART VII of this handbook When a child is brought to the clinic IF this is a FOLLOW-UP VISIT for the problem Use Good Communication skills: (see also Chapter 25) — Listen carefully to what the mother tells you. — Use words the mother understands — Give the mother time to answer the questions. ---Ask additional questions when the mother is not sure about her answer. Record Important Information
  • 43. When the child is brought to the clinic Use Good Communication Skills: • Listen carefully to what the mother tells you • Use words the mother understands • Give mother time to answer questions • Ask additional questions when mother not sure of answer Record important information
  • 44. GENERAL DANGER SIGNS For ALL sick children ask the mother about the child’s problem, then CHECK FOR GENERAL DANGER SIGNS CHECK FOR GENERAL DANGER SIGNS A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed ASK: LOOK: Is the child able to drink or breastfeed? See if the child is lethargic or unconscious Does the child vomit everything? Is the child had convulsions? Make sure that a child with any danger sign is referred after receiving urgent pre- referral treatment . Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear problems.CHECK for malnutrition and anaemia, immunization status and for other problems.
  • 45. GENERAL DANGER SIGNS 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 lethargic or unconscious
  • 46. Cough or Difficult Breathing If NO If YES IF YES, ASK: LOOK, LISTEN, FEEL: œ For how long? œ Count the breaths in one minute. œ Look for chest indrawing œ Look and listen for stridor } Classify COUGH or DIFFICULT BREATHIN G If the child is: Fast breathing is: 2 months up 50 breaths per to 12 months minute or more 12 months up 40 breaths per to 5 years minute or more CHILD MUST BE CALM CLASSIFY the child’s illness using the colour-coded classification table for cough or difficult breathing. Then ASK about the main symptoms : fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems 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 COUGH?
  • 47. Cough or Difficult Breathing? IF YES, ASK: • For how long? LOOK, LISTEN, FEEL: • Count the breaths in one minute. 2-12 mos = fast breathing >/= 50/min 12 mos-5yrs = fast breathing >/= 40/min • Look for chest indrawing • Look and listen for stridor Classify COUGH or DIFFICULT BREATHING
  • 48. •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. •Refer URGENTLY to hospital. •Fast breathing PNEUMONIA •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. No signs of pneumonia or very severe disease. NO PNEUMONIA: COUCH OR COLD •If coughing more than 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 CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)
  • 49. 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 DIARRHEA? If NO If YES Does the child have diarrhea? IF YES, ASK: LOOK, LISTEN, FEEL: œ For how long? œ Look at the child’s general condition. Is the child: œ Is there blood in the stool Lethargic or unconscious? Restless or irritable? œ Look for sunken eyes. œ Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? œ 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 diarrhea. Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition an anaemia, immunization status and for other problems. Classify DIARRHEA
  • 50. Child with dehydration
  • 51. 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: 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 (> than 2 secs)? Slowly?
  • 52. Two of the following signs:Two of the following signs: Lethargic or unconsciousLethargic or unconscious Sunken eyesSunken eyes Not able to drink or drinkingNot able to drink or drinking poorlypoorly Skin pinch goes back verySkin pinch goes back very slowlyslowly SEVERESEVERE DEHYDRATIONDEHYDRATION If child has no other severe classification:If child has no other severe classification: —— Give fluid for severe dehydration (Plan C).Give fluid for severe dehydration (Plan C). OROR If child also has another severe classification:If child also has another severe classification: —— Refer URGENTLY to hospital with motherRefer URGENTLY to hospital with mother giving frequent sips of ORS on the way.giving frequent sips of ORS on the way. Advise the mother to continue breastfeedingAdvise the mother to continue breastfeeding If child is 2 years or older and there isIf child is 2 years or older and there is cholera in your area, give antibiotic forcholera in your area, give antibiotic for cholera.cholera. Two of the following signs:Two of the following signs: Restless, irritableRestless, irritable Sunken eyesSunken eyes Drinks eagerly, thirstyDrinks eagerly, thirsty Skin pinch goes back slowlySkin pinch goes back slowly SOMESOME DEHYDRATIONDEHYDRATION Give fluid and food for some dehydration (Plan B).Give fluid and food for some dehydration (Plan B). If child also has a severe classification:If child also has a severe classification: —— Refer URGENTLY to hospital with motherRefer URGENTLY to hospital with mother giving frequent sips of ORS on the way.giving frequent sips of ORS on the way. Advise the mother to continue breastfeedingAdvise the mother to continue breastfeeding Advise mother when to return immediately.Advise mother when to return immediately. Follow-up in 5 days if not improving.Follow-up in 5 days if not improving. Not enough signs toNot enough signs to classify as some orclassify as some or severe dehydration.severe dehydration. NONO DEHYDRATDEHYDRAT IONION Give fluid and food to treat diarrhoeaGive fluid and food to treat diarrhoea at home (Plan A).at home (Plan A). Advise mother when to returnAdvise mother when to return immediately.immediately. Follow-up in 5 days if not improving.Follow-up in 5 days if not improving. CLASSIFICATION TABLE FOR DEHYDRATION SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)
  • 53. DehydrationDehydration presentpresent SEVERESEVERE PERSISTENTPERSISTENT DIARRHEADIARRHEA Treat dehydration before referralTreat dehydration before referral unless the child has anotherunless the child has another severe classification.severe classification. Refer to hospital.Refer to hospital. No dehydrationNo dehydration PERSISTENTPERSISTENT DIARRHEADIARRHEA Advise the mother on feeding a childAdvise the mother on feeding a child who has PERSISTENT DIARRHOEA.who has PERSISTENT DIARRHOEA. Follow-up in 5 days.Follow-up in 5 days. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA
  • 54. Blood in theBlood in the stoolstool DYSENTERYDYSENTERY Treat for 5 days with anTreat for 5 days with an oral antibioticoral antibiotic recommended forrecommended for Shigella in your area.Shigella in your area. Follow-up in 2 days.Follow-up in 2 days. CLASSIFICATION TABLE FOR DYSENTERY SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)
  • 55. Fever For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing, diarrhoea and then ASK: DOES THE CHILD HAVE FEVER? If NO If YES Does the child have fever? ( by history or feels hot or temperature 37.5 °C** or above) IF YES: Decide the Malaria Risk: high or low THEN ASK: LOOK AND FEEL: œ For how long? œ Look or feel for stiff neck. œ If more than 7 days, has œ Look for runny nose. fever been present every day? Look for signs of MEASLES œ Has the child had measles within the last 3 months? œ Generalized rash and œ One of these: cough, runny nose, or red eyes. If the child has measles now or œ Look for mouth ulcers. within the last 3 months: Are they deep and extensive? œ Look for pus draining from the eye. œ Look for clouding of the cornea. CLASSIFY the child’s illness using the colour-coded classification tables for fever. Then ASK about the next main symptom: ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.
  • 56. FeverDoes the child have FEVER? IF YES, decide the malaria risk: high or low THEN ASK: •For how long? •If more than 7 days, has fever been present every day? •Has the child had measles within the last 3 months? If the childIf the child LOOK AND FEEL:LOOK AND FEEL: Look for runny noseLook for runny nose Look or feel for stiff neckLook or feel for stiff neck LOOK FOR SIGNS OF MEASLESLOOK FOR SIGNS OF MEASLES has measles now or within the last 3has measles now or within the last 3 monthsmonths -Rash-Rash -Mouth ulcers-Mouth ulcers -Cough-Cough -Pus from eyes-Pus from eyes -Runny nose -Clouding of cornea-Runny nose -Clouding of cornea -Red eyes-Red eyes LOOK FOR SIGNS OF DENGUE/DHF -bleeding tendencies -flushing -(+) tourniquet test -rash
  • 57. •Any general danger sign •Stiff neck VERY SEVERE FEBRILE DISEASE •Give first dose of an appropriate antibiotic. •Treat the child to prevent low blood sugar. •Give one dose of paracetamol in clinic for high fever (38.5° C or above). •Refer URGENTLY to hospital. •NO general danger sign AND •NO Stiff neck. FEVER— MALARIA UNLIKELY •Give one dose of paracetamol in clinic for high fever (38.5° C or above). •Advise mother when to return immediately. •Follow-up in 2 days if fever persists. •If fever is present every day for more than 7 days, REFER for assessment. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A MALARIA RISK AREA
  • 58. •Any general danger sign or •Clouding of cornea or •Deep or extensive mouth ulcers. SEVERE COMPLICATED MEASLES*** •Give vitamin A. •Give first dose of an appropriate antibiotic. •If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment. •Refer URGENTLY to hospital. •Pus draining from the eye or •Mouth ulcers MEASLES WITH EYE OR MOUTH COMPLICATIONS* ** •Give vitamin A. •If pus draining from the eye, treat eye infection with tetracycline eye ointment. •If mouth ulcers, treat with gentian violet. •Follow-up in 2 days. •Measles now or within the last 3 months. MEASLES •Give vitamin A. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR MEASLES (IF MEASLES NOW OR WITHIN THE LAST 3 MONTHS) *** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in other tables.
  • 59. Fever With Rashes
  • 60. For ALL sick children ask the mother about the ask about cough or difficult breathing, diarrhoea, fever and then ASK: DOES THE CHILD HAVE AN EAR PROBLEM? Does the child have an ear problem? IF YES ASK: •Is there ear pain? •Is ther ear discharge? If yes, for how long? LOOK AND FEEL: •Look for pus draining from the ear. •Feel for tender swelling behind the ear. CLASSIFY the child’s illness using the colour-coded-classification table for ear problem. Then CHECK for malnutrition and anaemia, immunization status and for other problems. If NO If YES Ear Problem
  • 61. Ear Problem 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 AND FEEL: Look and pus draining fromLook and pus draining from the earthe ear Feel for tender swellingFeel for tender swelling behind the ear.behind the ear.
  • 62. •Tender swelling behind the ear. MASTOIDITIS •Give first dose of an appropriate antibiotic. •Give first dose of paracetamol for pain. •Refer URGENTLY to hospital. •Pus is seen draining from the ear and discharge is reported for less than 14 days, or •Ear pain. ACUTE EAR INFECTION •Give an oral antibiotic for 5 days. •Give paracetamol for pain. •Dry the ear by wicking. •Follow-up in 5 days. •Pus is seen draining from the ear and discharge is reported for 14 days or more. CHRONIC EAR INFECTION •Dry the ear by wicking. •Follow-up in 5 days. •No ear pain and No pus seen draining from the ear. NO EAR INFECTION No additional treatment SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR EAR PROBLEM
  • 63. For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea, fever, ear problem and then CHECK FOR MALNUTRITION AND ANAEMIA. THEN CHECK FOR MALNUTRITION AND ANAEMIA CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition and anemia Then CHECK immunization status and for other problems. LOOK AND FEEL: •Look for visible severe wasting. •Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? •Look for oedema of both feet. •Determine weight for age. Classify NUTRITIONAL STATUS Malnutrition and Anemia
  • 64. Malnutrition and Anemia CHECK FOR MALNUTRITION AND ANEMIA LOOK AND FEEL: • Look for visible severe wasting • Look for palmar pallor. Is it: • Severe palmar pallor? • Some palmar pallor? • Look for edema of both feet • Determine weight for age CLASSIFY NUTRITIONAL STATUS
  • 65. Child with Anemia and Malnutrition
  • 66. •Visible severe wasting or •Severe palmar pallor or •Oedema of both feet. SEVERE MALNUTRITION OR SEVERE ANAEMIA •Give Vitamin A. •Refer URGENTLY to hospital. •Some palmar pallor or •Very low weight for age. ANAEMIA OR VERY LOW WEIGHT •Assess the feeding according to the FOOD box on the COUNSEL THE MOTHER chart. — If feeding problem, follow-up in 5 days. •If pallor: — Give iron. — Give oral antimalarial if high malaria risk. — Give mebendazole if child is 2 years or older and has not had a dose in the previous 6 months. •Advise mother when to return immediately. •If pallor, follow-up in 14 days. If very low weight for age, follow-up in 30 days. •Not very low weight for age and no other signs or malnutrition. NO ANAEMIA AND NOT VERY LOW WEIGHT •If child is less than 2 years old, assess the 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. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA
  • 67. THEN CHECK THE CHILD’S IMMUNIZATION STATUS For ALL sick children ask the mother about the child’s about cough or difficult breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia and CHECK IMMUNIZATION STATUS. IMMUNIZATION SCHEDULE: AGE Birth 6 weeks 10 weeks 14 weeks 9 months VACCINE BCG DPT-1 DPT-2 DPT-3 Measles OPV-0 OPV-1 OPV-2 OPV-3 DECIDE if the child needs an immunization today, or if the mother should be told to come back with the child at a later date for an immunization. Note: Remember there are no contraindications to immunization of a sick child if the child is well enough to go home. Then CHECK for other problems. Immunization Status
  • 68. Immunization Status CHECK IMMUNIZATION STATUS: IMMUNIZATION SCHEDULE • Birth - BCG, HepB1 • 6 weeks - DPT1, OPV1, HepB2 •10 weeks - DPT2, OPV2, HepB3 •14 weeks - DPT3, OPV3, HepBbooster •9 mos - measles
  • 69. How to check the Immunization Status • If an infant has not received any immunization, then give • BCG • DPT 1 , OPV 1 • Hepatitis B 1
  • 70. THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS: ASSESS AND CLASSIFY
  • 71. Ask the mother or caretaker about the youngAsk the mother or caretaker about the young If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to PART VII) Check for POSSIBLE BACTERIAL INFECTION and classify the illness. Ask the mother or caretaker about DIARRHOEA: If diarrhoea is present: •assess the infant further for signs related to diarrhoea, and •classify the illness according to the signs which are present or absent. Check for FEEDING PROBLEM OR LOW WEIGHT and classify the Check the infant’s immunization status and decide if the infant needs any immunization today. Assess any other problems. Then: Identify Treatment (PART IV), Treat the Infant (PART V), and Counsel the Mother (PART VI) SUMMARY OF ASSESS AND CLASSIFY
  • 72. CHECK FOR POSSIBLE BACTERIAL INFECTION For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION ASK: •Has the infant had convulsions? LOOK, LISTEN, FEEL: •Count the breaths in one minute. Repeat the count if elevated. •Look for severe chest indrawing. •Look for nasal flaring •Look and listen for grunting. •Look and feel for bulging fontanelle. •Look for pus draining from the ear. •Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin? •Measure temperature (or feel for fever or low body temperature) •Look for skin pustules. Are there many or severe pustules? •See if the young infant is lethargic or unconscious. •Look at the young infants’s movements. Are they less than normal? YOUNG INFANT MUST BE CALM CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION. Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other problems. How to check a young infant for possible bacterial infection
  • 73. •Convulsions or •Fast breathing (60 breaths per minute or more) or •Severe chest indrawing or •Nasal flaring or •Grunting or •Bulging fontanelle or •Pus draining from ear or •Umbilical redness extending to the skin or •Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or •Many or severe skin pustules or •Lethargic or unconscious or •Less than normal movement. POSSIBLE SERIOUS BACTERIAL INFECTION •Give first dose of intramuscular antibiotics. •Treat to prevent low blood sugar. •Advise mother how to keep the infant warm on the way to hospital. •Refer URGENTLY to hospital •Red umbilicus or draining pus or •Skin pustules. LOCAL BACTERIAL INFECTION •Give an appropriate oral antibiotic. •Teach the mother to treat local infections at home. •Advise mother to give home care for the young infant. •Follow-up in 2 days SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) *These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
  • 74. For ALL sick young infants check for signs of possible bacterial infection and then ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA? IF YES: ASSESS AND CLASSIFY the young infant’s diarrhoea using the DIARRHOEA box in the YOUNG INFANT chart. The process is very similar to the one used for the sick child (see Chapter 8). Then CHECK for feeding problem or low weight, immunization status and other problems. How to assess and classify a young infant for diarrhea?
  • 75. For ALL sick young infants check for signs of possible bacterial infection, ask about diarrhoea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT. THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT ASK: LOOK, LISTEN, FEEL: œ Is there any difficulty feeding? œ Determine weight for age. œ Is the infant breastfed? If yes,how many times in 24 hours? œ Does the infant usually receive any other foods or drinks? If yes, how often? œ What do you use to feed the infant? IF AN INFANT: Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to hospital: ASSESS BREASTFEEDING: œ Has the infant If the infant has not fed in the previous hour, ask the mother to put her breastfed in the infant to the breast. Observe the breastfeed for 4 minutes. previous hour? (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.) œ Is the infant able to attach? no attachment at all not well attached good attachment TO CHECK ATTACHMENT, LOOK FOR: — Chin touching breast — Mouth wide open — Lower lip turned outward — More areola visible above then below the mouth (All these signs should be present if the attachment is good.) Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? no suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding. œ Look for ulcers or white patches in the mouth (thrush). CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight. Then CHECK immunization status and for other problems.
  • 76. •Not able to feed or • No attachment at all or •Not suckling at all. NOT ABLE TO FEED POSSIBLE SERIOUS BACTERIAL INFECTION •Give first dose of intramuscular antibiotics. •Treat to prevent low blood sugar. •Advise the mother how to keep the young infant warm on the way to hospital. •Refer URGENTLY to hospital. •Not well attached to breast or •Not suckling effectively or •Less than 8 breastfeeds in 24 hours or •Receives other foods or drinks or •Low weight for age or •Thrush (ulcers or white patches in mouth). FEEDING PROBLEM OR LOW WEIGHT • Advise the mother to breastfeed as often and for as long as the infant wants, day and night. -If not well attached or not suckling effectively, teach correct positioning and attachment. -If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. • If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup. •If not breastfeeding at all: — Refer for breastfeeding counselling and possible relactation. — Advise about correctly prepared breastmilk substitutes and using a cup. • If thrush, teach the mother to treat thrush at home. • Advise mother to give home care for the young infant. •Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days. •Not low weight for age and no other signs of inadequate feeding. NO FEEDING PROBLEM •Advise mother to give home care for the young infant. •Praise the mother for feeding the infant well. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT
  • 77. Communicate and Counsel
  • 78. How will you prepare the ORS solution? Do you remember how to mix the ORS? GOOD CHECKING QUESTIONS POOR QUESTIONS How often should you breastfeed your child? Should you breastfeed your child? On what part of the eye do you apply Have you used ointment on your child the ointment? before? How much extra fluid will you give after each Do you know how to give extra loose stool? fluids? Why is it important for you to wash your hands? Will you remember to wash your hands?
  • 79. GIVE FOLLOW-UP CARE
  • 80. Follow-up care for the sick young infant • When to return immediately • Signs of any of the following: • Breastfeeding or drinking poorly • Becomes sicker • Develops a fever • Fast breathing • Difficult breathing • Blood in the stool
  • 81. Follow-up care for the sick young infant• Follow-up in 2 days – on antibiotics for local bacterial infection or dysentery • Follow-up in 2 days - with a feeding problem or oral thrush • Follow-up in 14 days – with low weight for age
  • 82. CATEGORIES OF PROVINCES CONSIDERED WITH MALARIA • Category A – Provincews with no significant improvement in malaria situation in the last 10 years or situation worsened in the last 5 yrs; average no. of cases >1000 in the last 10 yrs - Kalinga - Mindoro Occ - Compostela valley - Apayao - Palawan - Saranggani - Mt. Province - Quezon - Zamboanga del Sur - Ifugao - Misamis Or - Agusan del Sur - Isabela - Davao del Norte - Agusan del Norte - Cagayan - Davao del Sur - Surigao del Sur - Quirino - Davao oriental - Tawi-tawi - Zambales - Bukidnon - Sulu - Basilan
  • 83. • Category B – Provinces where situation has improved in the last 5yrs or average no. of cases 100 to <1000 cases/yr - Abra - Laguna - Pangasinan - Camarines Norte - Ilocos norte - Camarines Sur - Nueva Vizcaya - Sultan Kudarat - Nueva Ecija - So. Cotabato - Bulacan - North Cotabato - Bataan - Lanao del Sur - Mindoro Or - Lanao del Norte - Rizal - Maguindanao - Aurora - Zamboanga del Norte - Tarlac - Romblon
  • 84. Category C – Provinces with significant reduction in cases in the last 5 yrs - Benguet - Antique - Ilocos Sur - Sorsogon - La Union - Negros Occ - Pampanga - Negros Or - Batangas - Eastern Samar - Cavite - Western Samar - Marinduque - Misamis Occ - Masbate - Surigao del Norte - Batanes - Albay
  • 85. Category D – Provinces that are malaria-free although some are still potentially malarious sue to toe presence of the vector. Cebu Iloilo Biliran Bohol Capiz Leyte Norte and and Sur Catanduanes Guimaras Aklan Siquijor Northern Samar Camiguin
  • 86. Thank you!