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Imci Day1

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  • This session presents the overall case management process to be followed in IMCI. This said process begin with the assessment, classification, treatment or referral and follow-up care in an out-patient facility
  • 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.
  • This is a follow-up visit table found in the “WHEN TO RETURN” box on the COUNSEL chart. It is a summary of the schedules for follow-up visits for a sick child. It is advisable that the mother or caretaker comes for follow-up at the earliest time listed for the child’s problems. Suppose the mother or caretaker tells you that it is a follow-up visit, ask also if the child has in addition, a new problem. For example, the child has come for follow-up of pneumonia, but now he has developed diarrhea, he has a new problem. This child requires a full assessment. Check for general danger signs and assess all the main symptoms and the child’s nutritonal status. Classify and treat the child for diarrhea (new problem) as you would at an initial visit. Reassess and treat the pneumonia according to the follow-up box. If the child does not have a new problem, locate the follow-up box that matches the child’s previous classification. Then follow the instructions in that box.
  • This is a case recording form used for sick young infants age 1 week up to 2 months. Note the differences in the signs, classification, treatments and counselling in this recording form from that of the sick young child age 2 months to 5 years. Fill out the spaces provided for the name, age, weight (kg), temperature ( °C). Then ask the mother or caretaker what the infant’s problem is and if the visit is an initial visit or a follow-up visit. If it is a new problem, go to assessing the signs and encircling each sign if present. Classify the child’s illness according to the color coded classification tables. Assess also breastfeeding and immunization status. On the other side of the form is a space where one writes the treatment corresponding to the classification to which the sick young infant’s condition falls. Note that between the Assess and Classify columns is a line which is your guide in folding the form. As this part is folded, the reverse side will correspond to the Treat column where you will write that specific treatment prescribed to the classification of the infant’s illness. Fill out the space for the date of follow-up and the immunization that must be given for the present consult.
  • This is a case recording form used for sick young infants age 1 week up to 2 months. Note the differences in the signs, classification, treatments and counselling in this recording form from that of the sick young child age 2 months to 5 years. Fill out the spaces provided for the name, age, weight (kg), temperature ( °C). Then ask the mother or caretaker what the infant’s problem is and if the visit is an initial visit or a follow-up visit. If it is a new problem, go to assessing the signs and encircling each sign if present. Classify the child’s illness according to the color coded classification tables. Assess also breastfeeding and immunization status. On the other side of the form is a space where one writes the treatment corresponding to the classification to which the sick young infant’s condition falls. Note that between the Assess and Classify columns is a line which is your guide in folding the form. As this part is folded, the reverse side will correspond to the Treat column where you will write that specific treatment prescribed to the classification of the infant’s illness. Fill out the space for the date of follow-up and the immunization that must be given for the present consult.
  • This is the reverse side of the case recording form used for sick young infants age 1 week up to 2 months. Note that under the Treat column are spaces on which one will write the treatment corresponding to the SIGNS and CLASSIFY AS columns in the color coded charts of the infant’s illness.
  • This is a case recording form used for sick child age 2 months up to 5 years. Note the differences in the signs, classification, treatments and counselling in this recording form from that of the sick child age 1 week up to 2 months. Fill out the spaces provided for the name, age, weight (kg), temperature ( °C). Then ask the mother or caretaker what the child’s problem is and if the visit is an initial visit or a follow-up visit. If it is a new problem, go to assessing the signs and encircling each sign if present. Check for general danger signs, then assess for the presence of the 4 main symptoms, malnutrition and anemia, immunization status and feeding problems (if the child has anemia or very low weight or is less than 2 years old). Classify the child’s illness according to the color coded classification tables. On the other side of the form is a space where one writes the treatment corresponding to the classification to which the sick child’s condition falls. Note that between the Assess and Classify columns is a line which is your guide in folding the form. As this part is folded, the reverse side will correspond to the Treat column where you will write that specific treatment prescribed to the classification of the infant’s illness. Fill out the space for the date of follow-up and the immunization that must be given for the present consult. Finally fill out the space on the feeding advice.
  • This is a case recording form used for sick child age 2 months up to 5 years. Note the differences in the signs, classification, treatments and counselling in this recording form from that of the sick child age 1 week up to 2 months. Fill out the spaces provided for the name, age, weight (kg), temperature ( °C). Then ask the mother or caretaker what the child’s problem is and if the visit is an initial visit or a follow-up visit. If it is a new problem, go to assessing the signs and encircling each sign if present. Check for general danger signs, then assess for the presence of the 4 main symptoms, malnutrition and anemia, immunization status and feeding problems (if the child has anemia or very low weight or is less than 2 years old). Classify the child’s illness according to the color coded classification tables. On the other side of the form is a space where one writes the treatment corresponding to the classification to which the sick child’s condition falls. Note that between the Assess and Classify columns is a line which is your guide in folding the form. As this part is folded, the reverse side will correspond to the Treat column where you will write that specific treatment prescribed to the classification of the infant’s illness. Fill out the space for the date of follow-up and the immunization that must be given for the present consult. Finally fill out the space on the feeding advice.
  • This is the reverse side of the case recording form used for sick young infants age 1 week up to 2 months. Note that under the Treat column are spaces on which one will write the treatment corresponding to the SIGNS and CLASSIFY AS columns in the color coded charts of the infant’s illness.

Imci Day1 Imci Day1 Presentation Transcript