ARI control programme

1. Dr.G.Rajkumar
Professor Paediatrics

2. ARI CONTROL PROGRAMME
• LRTI- mortality < 5 years
• In developing countries the cause is bacterial in
50-60%
• Preschool-H.influenzae, Pneumococci,
Staphylococci
• Sensitive to amoxicillin, cotrimoxazole and death
can be prevented

3. WHO CRITERIA
• For all countries with IMR > 40/1000 live
births
• Criteria-Rapid respiration with or without difficulty
• Rapid respiration
• 60 < 2 months
• 50 2-12 months
• 40 > 1-5 years
• Difficulty in respiration is lower chest indrawing

4. WHO Classification for treatment of children aged
2momths-5 years
Signs, symptoms Classification Therapy Where
to treat
Cough or cold
No fast breathing,
chest indrawing or
indications of severe
illness
No pneumonia Home
remedies
Home
Increased respiratory
rate
60 < 2 months
50 2-12 months
40 > 1-5 years
Pneumonia Cotrimoxazole
or
amoxicillin
Home
Chest indrawing Severe pneumonia IV/IM
penicillin
Hospital
Cyanosis, severe
chest indrawing,
inability to feed
Very severe
pneumonia
I V penicillin +
gentamycin
Hospital

5. • In children with cough between 2months to 5
years
• Examine for rapid respiration
• Difficulty in breathing
• Cyanosis
• Difficulty in feeding

6. • RR normal
• No chest indrawing
• Feeding well
• URI
• Symptomatic management

7. • RR increased
• Chest indrawing
• No hypoxia
• Feeding well
• No danger signs
• Ambulatory treatment- Amox-40mg/kg/dose BD
for 5 days

8. • Severe chest indrawing
• Evidence of hypoxia
• Danger signs-lethargy, cyanosis, poor feeding,
seizures
• Severe pneumonia
• Admission
• IV penicillin or ampicillin & gentamycin for 5
days
• IV ceftriaxone second line

9. < 2months
Severe pneumonia if any of the following
• Fever ≥ 380 C
• Seizures
• Abnormally sleepy
• Difficult to wake
• Stridor
• Wheezing
• Not feeding
• Tachypnoea
• Chest indrawing
• Altered sensorium
• Central cyanosis
• Grunting
• Apnoeic spells
• Distended abdomen
• IV Ampicillin +
getamycin

12. ASSESSMENT OF SICK CHILDREN
The assessment procedure for 2months- 5 years
includes
(1) history taking and communicating with the
caretaker about the child’s problem;
(2) checking for general danger signs;
(3) checking main symptoms;
(4) checking for malnutrition;
(5) checking for anaemia;
(6) assessing the child’s feeding;
(7) Checking immunization status; and
(8) assessing other problems.

13. If a child has one or more of these signs, s/he must be considered
seriously ill and will almost always need referral.

14. CHECK FOR GENERAL DANGER SIGNS
ASK: Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions during this illness?
LOOK: Is the child
a) lethargic or
b) unconscious
A child with any general danger sign requires
urgent attention: complete the assessment, start
pre-referral treatment and refer urgently. Test for
low blood sugar– then treat or prevent.

15. CHECKING MAIN SYMPTOMS
After general danger signs, check for the main
symptoms:
(1) cough or difficult breathing;
(2) diarrhoea;
(3) fever; and
(4) ear problems.
The first three symptoms -often result in death.
Ear problems - main causes of childhood disability.

16. A child with cough or difficult breathing may
have pneumonia or another severe respiratory
infection.
Pneumonia -Both bacteria and viruses can
cause pneumonia.
In developing countries, often due to
Streptococcus pneumoniae and Hemophilus
influenzae.
Children with bacterial pneumonia may die from
hypoxia or sepsis

17. • Identify almost all cases of pneumonia by
checking for these two clinical signs:
• Fast breathing and
• Chest indrawing.
• When children develop pneumonia, their lungs
become stiff and the body’s responses to stiff
lungs and hypoxia (too little oxygen) is fast
breathing.
• When the pneumonia becomes more severe, the
lungs become even stiffer Chest indrawing may
develop.
• Chest indrawing is a sign of severe pneumonia.

18. CLINICAL ASSESSMENT
Three key clinical signs
Respiratory rate, which distinguishes children who have
pneumonia from those who do not;
Lower chest wall indrawing, which indicates severe
pneumonia; and
Stridor, which indicates those with severe pneumonia who
require hospital admission.
No single clinical sign has a better combination of
sensitivity and specificity to detect pneumonia in
children under 5 than respiratory rate, specifically
fast breathing.
Even auscultation by an expert is less sensitive as a
single sign.

19.  Lower chest wall indrawing, defined as the
inward movement of the bony structure of the
chest wall with inspiration, is a useful indicator
of severe pneumonia.
 It is more specific than “intercostal indrawing,”
which concerns the soft tissue between the ribs
without involvement of the bony structure of the
chest wall

20. • Chest indrawing should only be considered
present if it is consistently present in a calm
child.
• Agitation, a blocked nose or breastfeeding can
all cause temporary chest indrawing.
• Any chest indrawing, even if it is not severe, is
an indicator of severe pneumonia in a child age
2 months up to 5 years.
• Stridor happens when there is a swelling of the
larynx, trachea or epiglottis.
• A child who has stridor when calm has a
dangerous condition.

22. Soothe the Throat, Relieve the Cough with a Safe Remedy
• Safe remedies to recommend:
- Breast milk for exclusively breastfed infant
- Honey and lemon
• Harmful remedies to discourage:
- Herbal smoke inhalation
- Vicks® drops by mouth

29. Fatima is 18 months old. She weighs 11.5 kg. Her temperature is
37.5 C. The physician asked, "What are the child's problems?"
The mother said "Fatima has been coughing for 6 days, and she
is having trouble breathing." This is the initial visit for this illness.
The physician checked Fatima for general danger signs. The
mother said that Fatima is able to drink. She has not been
vomiting. She has not had convulsions during this illness. The
physician asked, "Does Fatima seem unusually sleepy?" The
mother said, “NO." The physician clapped his hands. He asked
the mother to shake the child. Fatima opened her eyes, looked
around. The physician talked to Fatima, she watched his face.
The physician asked the mother to lift Fatima's shirt. He then
counted the number of breaths the child took in a minute. He
counted 44 breaths per minute. The physician did not see any
chest indrawing. He did not hear stridor.
Classification ?
Pneumonia

30. MAHIMA is 18 months old. She weighs 11.5 kg. Her
temperature is 37.5 C. The physician asked, "What are the
child's problems?" The mother said "Fatima has been coughing
for 6 days." This is the initial visit for this illness.
The physician checked Fatima for general danger signs. The
mother said that Fatima is able to drink. She has not been
vomiting. She has not had convulsions during this illness. The
physician asked, "Does Fatima seem unusually sleepy?" The
mother said, “No." The physician clapped his hands. He asked
the mother to shake the child. Fatima opened her eyes, looked
around. The physician talked to Fatima, she watched his face.
The physician asked the mother to lift Fatima's shirt. He then
counted the number of breaths the child took in a minute. He
counted 28 breaths per minute. The physician did not see any
chest indrawing. He did not hear stridor.
Classification ?
Cough or Cold

31. Manisha is 18 months old. She weighs 11.5 kg. Her temperature is
37.5 C. The physician asked, "What are the child's problems?" The
mother said "Fatima has been coughing for 6 days, and she is having
trouble breathing." This is the initial visit for this illness.
The physician checked Fatima for general danger signs. The mother
said that Fatima is able to drink. She has not been vomiting. She has
not had convulsions during this illness. The physician asked, "Does
Fatima seem unusually sleepy?" The mother said, "Yes." The
physician clapped his hands. He asked the mother to shake the child.
Fatima opened her eyes, but did not look around. The physician
talked to Fatima, but she did not watch his face. She stared blankly
and appeared not to notice what was going on around her.
The physician asked the mother to lift Fatima's shirt. He then
counted the number of breaths the child took in a minute. He
counted 42 breaths per minute. The physician did not see any chest
indrawing. He did not hear stridor.
Classification ?
Severe pneumonia or very severe disease