Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Upcoming SlideShare
handbook IMCI - integrated management of childhood illness
Next
Download to read offline and view in fullscreen.

12

Share

Download to read offline

Integrated healt

Download to read offline

PEDIATRIC NURSING

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

Integrated healt

  1. 1. Alexandria University IMCI Lecture 1 EMRO- WHO IMCI Lecture 1 Integrated Management of Childhood Illness
  2. 2. IMCI Lecture 1Alexandria University EMRO- WHO The IMCI process relies on: • Case detection using simple clinical signs based on expert clinical opinion and results of research. • Empirical treatment developed according to action-oriented classifications rather than exact diagnosis and covering the most likely diseases covered by each classification.
  3. 3. IMCI Lecture 1Alexandria University EMRO- WHO Age Groups Covered By IMCI IMCI process can be used by health providers (doctors and nurses) who see sick infants and children aged up to 5 years: – Children aged 2 months up to 5 years – Infants from birth up to 2 months
  4. 4. IMCI Lecture 1Alexandria University EMRO- WHO Where Care for Children Is Provided? Home 1st level health facility Specialized hospital I M C ICommunity Component REFERRAL CARE
  5. 5. IMCI Lecture 1Alexandria University EMRO- WHO Where should IMCI be applied? At 1st level health facilities: – Clinics – Rural and urban health centers – MCH centers – Outpatient departments of hospitals Since children with potentially fatal illnesses are brought to these 1st level facilities.
  6. 6. IMCI Lecture 1Alexandria University EMRO- WHO Diseases Covered By IMCI • Cough or difficult breathing • Diarrhea • Throat problems • Ear Problems • Fever & Measles 3/4 of Episodes of Childhood illness MALNUTRITION
  7. 7. IMCI Lecture 1Alexandria University EMRO- WHO Diseases NOT covered by IMCI • The IMCI guidelines address the most important but NOT ALL of the major reasons a sick child is brought to the clinic • The IMCI encourages the health provider to assess problems not included in IMCI charts. These are considered under the box : ASSESS OTHER PROBLEMS
  8. 8. IMCI Lecture 1Alexandria University EMRO- WHO The IMCI Wall Charts • For sick children aged 2 months – 5 years: •Assess and Classify the sick child •Treat the child •Counsel the mother • For sick infants from birth to 2 months: •Assess, Classify and Treat the sick young infant
  9. 9. Alexandria University IMCI Lecture 1 EMRO- WHO Assess & Classify the Sick Child, Age 2 months up to 5 years
  10. 10. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  11. 11. Alexandria University IMCI Lecture 1 EMRO- WHO Step by Step through the IMCI charts: ASSESS & CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS, TREAT THE CHILD, and COUNSEL THE MOTHER: • General Danger Signs • Cough or Difficult breathing • Diarrhea • Throat Problems • Ear Problems • Fever & Measles • Malnutrition and/or Anemia • Check for child immunization • Assess Other problems • Treat the Child • Give follow-up care • Counsel the Mother
  12. 12. IMCI Lecture 1Alexandria University EMRO- WHO General Danger Signs CHECK for GENERAL DANGER SIGNS in ALL Children
  13. 13. Alexandria University IMCI Lecture 1 EMRO- WHO General Danger Signs • Checking for General danger signs • Unable to drink or breastfeed • Vomits every thing • Has the child had convulsions? • Unconscious, lethargic • Classification of general danger signs
  14. 14. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  15. 15. IMCI Lecture 1Alexandria University EMRO- WHO ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE   •          Determine if this is an Initial or Follow Up visit for this problem            If Follow Up visit, use the follow up instruction on the TREAT THE CHILD CHART            If Initial visit, assess the child as follows:   CHECK FOR GENERAL DANGER SIGNS ASK LOOK •          Is the child able to drink or breast- feed? •          Does the child vomit every thing? •          Has he had had convulsions? (during present illness) •          See if the child is lethargic or unconscious •          See if the child is convulsing now
  16. 16. IMCI Lecture 1Alexandria University EMRO- WHO Unable to Drink or Breastfeed? • Ask the mother to describe exactly what happens when she offers the child something to drink • If you are not sure, ask the mother to offer her child a drink of clean water or breast milk and look to see if the child is swallowing it . The child is unable to suck or swallow when he is offered a drink or breast milk
  17. 17. IMCI Lecture 1Alexandria University EMRO- WHO Vomits Everything ? • Not able to hold down food, fluids or oral drugs. • ALL what goes down comes back up • A child who vomits several times but can hold down some fluids does not have this general danger sign. Not able to hold anything down AT ALL
  18. 18. IMCI Lecture 1Alexandria University EMRO- WHO Has the child had convulsions? • Ask the mother if the child has had convulsions during the current illness. • Use words the mother understands.
  19. 19. IMCI Lecture 1Alexandria University EMRO- WHO Convulsions (cont…) • Explain what do you mean exactly by “convulsions”. • In a convulsing child the arms and legs stiffen. The child may loose consciousness or may not be able to respond to spoken directions.
  20. 20. IMCI Lecture 1Alexandria University EMRO- WHO Unconscious ? • An unconscious child is a child who cannot be awakened. • The child does NOT respond when he is : •Touched •Shaken, or •Spoken to
  21. 21. IMCI Lecture 1Alexandria University EMRO- WHO UNCONSCIOUS CHILD
  22. 22. IMCI Lecture 1Alexandria University EMRO- WHO Lethargic ? • A lethargic child is NOT awake and alert when he should be. • He is drowsy and does not show interest in what is happening around him. Difficulty in maintaining the aroused state
  23. 23. IMCI Lecture 1Alexandria University EMRO- WHO Lethargic (cont…) • Often a lethargic child does not look to his mother or watch your face when you talk • A lethargic child may stare blankly and appears not to notice what is going around him.
  24. 24. IMCI Lecture 1Alexandria University EMRO- WHO    LETHARGIC CHILD
  25. 25. IMCI Lecture 1Alexandria University EMRO- WHO ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE   •          Determine if this is an Initial or Follow Up visit for this problem            If Follow Up visit, use the follow up instruction on the TREAT THE CHILD CHART            If Initial visit, assess the child as follows:   CHECK FOR GENERAL DANGER SIGNS ASK LOOK •          Is the child able to drink or breast- feed? •          Does the child vomit every thing? •          Has he had had convulsions? (during present illness) •          See if the child is lethargic or unconscious •          See if the child is convulsing now
  26. 26. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  27. 27. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY GENERAL DANGER SIGNS: SIGNS CLASSIFY AS TREAT •       Any Danger Sign VERY SEVERE DISEASE     Treat convulsions IF present now     Complete assessment immediately     Give 1st dose of appropriate antibiotic     Treat child to prevent low blood sugar     Refer URGENTLY to hospital
  28. 28. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  29. 29. IMCI Lecture 1Alexandria University EMRO- WHO Cough OR Difficult Breathing Then ASK About: COUGH OR DIFFICULT BREATHING
  30. 30. Alexandria University IMCI Lecture 1 EMRO- WHO Acute Respiratory Infections (ARI)•Importance Definition Role of IMCI •Pneumonia Recognition • Fast breathing • Chest indrawing •Wheezing Causes • Why Added ? •How to classify Cough or Difficult breathing? Severe pneumonia or very severe disease Pneumonia Nopneumonia, Cough or cold
  31. 31. IMCI Lecture 1Alexandria University EMRO- WHO “Cough OR Difficult Breathing,” NOT “Cough AND Difficult Breathing”  Fewer than 25 percent of children with cough also have difficult breathing  Many causes of difficult breathing are not related to cough  Using both can cause false positives
  32. 32. IMCI Lecture 1Alexandria University EMRO- WHO Acute Respiratory Infections ( ARI ) • Common cause of mortality. • Common cause of morbidity. • Commonest reason for irrational drug prescription. Global & National Health Problem
  33. 33. IMCI Lecture 1Alexandria University EMRO- WHO Insure Adequate Case Management • Identify those who need URGENT REFERRAL • Identify cases of PNEUMONIA. • Rationalize the use of DRUGS • Breast feeding and optimal nutrition • Vaccination and Vitamin A supplementation Role of IMCI in ARI
  34. 34. IMCI Lecture 1Alexandria University EMRO- WHO Pneumonia: Severity Recognition is based on: • Fast breathing, and • Lower chest wall indrawing
  35. 35. IMCI Lecture 1Alexandria University EMRO- WHO WHY FAST BREATHING ? • Simplicity • Ease in training • Reliability Good Predictor of PNEUMONIA In the sick child 2 months – 5 years  * * ““Sensitivity & specificity around 80%”Sensitivity & specificity around 80%” Sensitivity= proportion of those with the disease who are correctly identified by sign Specificity= proportion of those without the disease who are correctly called free of the disease by using the sign.
  36. 36. IMCI Lecture 1Alexandria University EMRO- WHO FAST BREATHING !FAST BREATHING ! Why not other signs of pneumonia?Why not other signs of pneumonia? •Fever is poor predictor of pneumonia. •Auscultation is less sensitive indicator and needs skill
  37. 37. IMCI Lecture 1Alexandria University EMRO- WHO CUT-OFF POINTS for FAST BREATHING If the child is: FAST BREATHING IS: •2 months up to 12 months •12 months up to 5 years 50 breaths per minute or more 40 breaths per minute or more •Best to count rate in a quiet and alert child •Fever can affect respiratory rates, but do not wait for fever to subside
  38. 38. IMCI Lecture 1Alexandria University EMRO- WHO 60 50 40 Cut-offs of Fast Breathing
  39. 39. IMCI Lecture 1Alexandria University EMRO- WHO LOWER CHEST WALLLOWER CHEST WALL INDRAWINGINDRAWING Index of : Severe Pneumonia or very severe disease Reasonable sensitivity & specificity " 89%".
  40. 40. IMCI Lecture 1Alexandria University EMRO- WHO Lower Chest Wall Indrawing • Studies found that lower chest wall indrawing best identified children who required referral, admission or further assessment. • Must be definite, present all the time
  41. 41. IMCI Lecture 1Alexandria University EMRO- WHO Wheezing: Causes • Under age 2 - Bronchiolitis • Older children plus those with recurrent attacks of wheeze - bronchial asthma or reactive airways disease –Transient wheezers –Persistent wheezers • Other respiratory infections • Inhaled foreign body • Tuberculous node compressing bronchus
  42. 42. IMCI Lecture 1Alexandria University EMRO- WHO Wheezing: Why Added ?? • Morbidity from asthma is a problem in Egypt • Will reduce unnecessary referral to hospital • Rapid-acting bronchodilators are available at first-level facilities • Health workers are trained to recognize audible wheeze and use bronchodilators • Health worker can recognize when a child with recurrent wheeze is not responsive in the first- level health facility
  43. 43. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  44. 44. IMCI Lecture 1Alexandria University EMRO- WHO THEN ASK ABOUT MAIN SYMPTOMS Does the child have Cough or Difficult breathing? IF YES, ASK LOOK and LISTEN •       For how long •       Count the breaths in one minute •       Look for chest indrawing •       Look and listen for stridor •       Look and listen for wheeze Child must be calm
  45. 45. 22 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFY IDENTIFY TREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE • Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: • Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions? THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? ASSESS LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now. SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) • Any general danger sign. VERY SEVERE DISEASE Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*. 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 IF YES,ASK: • For how long? CHILD MUST BE CALM LOOK AND LISTEN: • Count the breaths in one minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze Classify COUGH or DIFFICULT BREATHING • Any general danger sign OR • Stridor in calm child OR • Chest indrawing (If chest indrawing and wheeze go directly to”Treat Wheezing” then reassess after treatment . SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.* • Fast breathing (If wheeze, go directly to “Treat Wheezing” then reasess after treatment. PNEUMONIA Give an appropriate antibiotic for 5 days. Treat wheezing if present. 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 2 days. • No signs of pneumonia or very severe disease (If wheeze, go directly to “Treat Wheezing” NO PNEUMONIA: COUGH OR COLD Treat wheezing if present. 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 2 days if wheezing. Follow-up in 5 days if not improving
  46. 46. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFFY COUGH OR DIFFICULT BREATHING: •       Any danger sign, OR •       Stridor in calm child, OR •       Chest indrawing ( If Wheeze, go directly to treat wheeze, then reassess) SEVERE PNEUMONIA OR VERY SEVERE DISEASE     Give 1st dose of appropriate antibiotic     Treat wheezing, if present     Treat child to prevent low blood sugar     Refer URGENTLY to hospital •       Fast breathing (If Wheeze, go directly to treat wheeze, then reassess) PNEUMONIA     Give appropriate antibiotic for 5 days     Treat wheezing, if present     If coughing more than 30 days ,refer for assessment     Relieve cough with a safe remedy     Advise mother when to return immediately     Follow up in 2 days•       No signs of pneumonia or very severe disease (If Wheeze, go directly to treat wheeze) NO PNEUMONIA :COUGH OR COLD     Treat wheezing, if present     If coughing more than 30 days ,refer for assessment     Relieve cough with a safe remedy     Advise mother when to return immediately     Follow up in 2 days, if wheezing     Follow up in 5 days if not improving
  47. 47. IMCI Lecture 1Alexandria University EMRO- WHO CHEST INDRAWING FAST BREATHING SEVERE PNEUMONIA OR VERY SEVERE DISEASE ±±
  48. 48. IMCI Lecture 1Alexandria University EMRO- WHO Severe Pneumonia OR Very Severe Disease Urgently Refer Children with Cough OR Difficult Breathing AND –Lower chest wall indrawing OR –Stridor when calm OR –Any general danger sign Recognition:
  49. 49. IMCI Lecture 1Alexandria University EMRO- WHO FAST BREATHINGFAST BREATHING • No General Danger Sign. • No Lower Chest Wall indrawing. • No Stridor while calm. • No General Danger Sign. • No Lower Chest Wall indrawing. • No Stridor while calm. PNEUMONIAPNEUMONIA +
  50. 50. IMCI Lecture 1Alexandria University EMRO- WHO No Pneumonia, Cough or Cold Antibiotics No signs of Pneumonia or Very Severe Disease
  51. 51. IMCI Lecture 1Alexandria University EMRO- WHO Diarrhea Then ASK About : DIARRHEA
  52. 52. Alexandria University IMCI Lecture 1 EMRO- WHO Diarrhea Diarrhea Assessment Dehydration Assessment • Classification Home Fluids Selection • Fluids to avoid Persistent Diarrhea Definition • Causes Classification Dysentery Classification Antibiotics
  53. 53. IMCI Lecture 1Alexandria University EMRO- WHO Assessment of Diarrhea D E H Y D R A T I O N F o r A ll P E R S I S T E N T D I A R R H E A C o n d i t i o n a l D Y S E N T E R Y C o n d i t i o n a l D I A R R H E A
  54. 54. IMCI Lecture 1Alexandria University EMRO- WHO
  55. 55. IMCI Lecture 1Alexandria University EMRO- WHO Does the child have diarrhea? IF YES ASK: •For how long? •Is there blood in the stools LOOK AND FEEL: •Look at the child’s general condition, Is he: –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 on the abdomen. Does it go back : –Very slowly (longer than 2 seconds)? –Slowly?
  56. 56. IMCI Lecture 1Alexandria University EMRO- WHO
  57. 57. IMCI Lecture 1Alexandria University EMRO- WHO Dehydration • Sensorium (lethargic,unconscious OR restless, irritable) • Sunken Eyes (ask caretaker as well) • Drinking (poorly OR eagerly) • Skin Pinch (very slowly OR slowly OR immediately) – Pinched in longitudinal manner – Pinched between the thumb and the bent fore-finger Assessment is based on 4 signs:
  58. 58. IMCI Lecture 1Alexandria University EMRO- WHO Assessment for dehydration Simplified to only 2 out of 4 possible signs • Term "Floppy" is eliminated – variability of interpretation; adds little to "lethargic" or "unconscious". • Tears & dryness of tongue are excluded – have been excluded: add little in sensitivity or specificity. • Characterization of the eyes: modified – were reduced: differentiation between "very sunken" and "sunken" eyes is often problematic and arbitrary. • Skin pinch: more qualified – was further qualified: measured in the abdomen and given a time parameter.
  59. 59. IMCI Lecture 1Alexandria University EMRO- WHO Unconscious child
  60. 60. IMCI Lecture 1Alexandria University EMRO- WHO   Lethargic child
  61. 61. IMCI Lecture 1Alexandria University EMRO- WHO Sunken Eyes
  62. 62. IMCI Lecture 1Alexandria University EMRO- WHO Skin Pinch returns Very Slowly (> 2 seconds
  63. 63. IMCI Lecture 1Alexandria University EMRO- WHO Dehydration • Mistakes in taking a skin pinch: – Pinching either too close to the midline or too far laterally – Pinching the skin in an horizontal direction – Not pinching the skin long enough – Releasing the skin so that the finger and thumb remain in a closed position • Classification of skin pinches: – Normal — it goes back immediately – Slowly — the fold is visible for less than 2 second – Very slowly — the fold is visible for more than 2 seconds. Assessment
  64. 64. IMCI Lecture 1Alexandria University EMRO- WHO 1-         CLASSIFY FOR DEGREE OF DEHYDRATION Two of the following signs: •       Lethargic or unconscious •       Sunken eyes •       Drinks poorly or unable to drink •       Skin pinch goes back very slowly SEVERE DEHYDRATION     If child has no other severe classification: Give fluids for severe dehydration (Plan C) OR    If child has also another severe classification: Refer URGENTLY to hospital while giving ORS sips -Advise to continue breastfeeding Two of the following signs: •       Restless, irritable •       Sunken eyes •       Thirsty, drinks eagerly •       Skin pinch goes back slowly SOME DEHYDRATION     Give fluids and food for some dehydration (Plan B)    If child has also a severe classification: - Refer URGENTLY to hospital while giving frequent ORS sips -Advise to continue breastfeeding     Advise when to return immediately     Follow up in 5 days IF not improving •       NO enough signs to classify as some or severe dehydration NO DEHYDRATION     Give fluids and food to treat diarrhea at home (Plan A)     Advise when to return immediately     Follow up in 5 days IF not improving
  65. 65. IMCI Lecture 1Alexandria University EMRO- WHO Home Fluids For Oral Rehydration • Home Fluids for Diarrhea Must Be: – Safe when given in large volumes – Easy to prepare – Acceptable color and palatability – Effective in preventing dehydration Selectio n:
  66. 66. IMCI Lecture 1Alexandria University EMRO- WHO • Ideal home fluids contain: – salts and nutrients (sodium, potassium, chloride, and bicarbonate) – calories to replenish diet • Examples of home fluids: – ORS solution – salted soup – salted drinks Home Fluids For Oral Rehydration Selection:
  67. 67. IMCI Lecture 1Alexandria University EMRO- WHO • Other acceptable home fluids that do not contain salt: – plain clean water – water in which a cereal has been cooked (unsalted) – soup (unsalted) – yoghurt-based drinks (unsalted) – green coconut water – weak tea (unsweetened) – fresh fruit juice (unsweetened) Home Fluids For Oral Rehydration Selection:
  68. 68. IMCI Lecture 1Alexandria University EMRO- WHO • Fluids causing hypernatremia – most soft and carbonated drinks – sweetened fruit drinks – sweetened tea(s) • Fluids with stimulant, diuretic or purgative effects – coffee – some medicinal teas or infusions Home Fluids For Oral Rehydration Fluids to avoid:
  69. 69. IMCI Lecture 1Alexandria University EMRO- WHO
  70. 70. IMCI Lecture 1Alexandria University EMRO- WHO Persistent Diarrhea • Diarrhea that occurs for 14 or more days • Less than 10 percent of all diarrhea • Associated with 30 to 50 percent of diarrhea deaths • Malnutrition greatly increases the risk of death Definition:
  71. 71. IMCI Lecture 1Alexandria University EMRO- WHO •Proximate Causes • Secondary disaccharidase deficiency • Salmonella sp. • Shigella sp. • Enteroadherent E. coli • Cryptosporidium •Contributing Factors • Protein energy malnutrition • Micronutrient deficiencies • Immunodeficiency Persistent Diarrhea Causes:
  72. 72. IMCI Lecture 1Alexandria University EMRO- WHO 2-CLASSIFY FOR PERSISTENT DIARRHEA •       Dehydration present SEVERE PERSISTENT DIARRHEA     Treat dehydration before referral unless the child has another severe classification     Refer to hospital •       No dehydration PERSISTENT DIARRHEA     Advise mother on feeding child with Persistent Diarrhea     Give multivitamin / mineral supplement     Advise mother when to return immediately     Follow up in 5 days
  73. 73. IMCI Lecture 1Alexandria University EMRO- WHO 3. CLASSIFY FOR DYSENTERY •Blood in the stools DYSENTERY •Treat for 5 days with an oral antibiotic recommended for Shigella •Advise mother when to return immediately •Follow-up in 2 days
  74. 74. IMCI Lecture 1Alexandria University EMRO- WHO Antibiotics for Dysentery • Effective for Shigella species and for Salmonella in infants under one year of age • Early Treatment with Antibiotics: – shortens the duration of the illness – reduces risk of serious complications & death Antibiotics:
  75. 75. IMCI Lecture 1Alexandria University EMRO- WHO Antimicrobials against Shigella EFFECTIVE • Co-Trimoxazole • Nalidixic acid • Pivmecillinam • Ceftriaxone • Ciprofloxacin • Other quinolones INEFFECTIVE • Metronidazole • Streptomycin • Chloramphenicol • Sulfonamide • Cepholosporins • Aminoglycosides • Nitrofurans
  76. 76. IMCI Lecture 1Alexandria University EMRO- WHO SUMMARY: HOW TO CLASSIFY DIARRHEA? There are 3 Classification for diarrhea: • Classify for the DEHYDRATION (for ALL Children) • Classify for PERSISTENT DIARRHEA (Conditioned) • Classify for DYSENTERY (Conditioned)
  77. 77. IMCI Lecture 1Alexandria University EMRO- WHO THROAT PROBLEM CHECK for THROAT PROBLEM in ALL CHILDREN
  78. 78. Alexandria University IMCI Lecture 1 EMRO- WHO Throat Problems •Sore Throat & Pharyngitis • Overview • Management Issue • Sensitivity & Specificity of signs •Role of IMCI •Classification of Throat Problem •Treatment
  79. 79. IMCI Lecture 1Alexandria University EMRO- WHO is more than just a sore throat. ? Pharyngit is
  80. 80. IMCI Lecture 1Alexandria University EMRO- WHO • Main reason to treat streptococcal sore throat is prevention of rheumatic fever and rheumatic heart disease • Ideal prevention of rheumatic fever entails treatment of streptococcal pharyngitis with penicillin • Streptococcal sore throat and rheumatic fever are still important issues in children older than 5 years in Egypt • Cases of rheumatic fever have been reported in children less than 5 years in Egypt Sore Throat: Overview
  81. 81. IMCI Lecture 1Alexandria University EMRO- WHO Not all, Sore throats are streptococcal ! However
  82. 82. IMCI Lecture 1Alexandria University EMRO- WHO Should We Treat All SoreAll Sore ThroatsThroats With Antibiotics ?Antibiotics ? • Cost • Side effects • Resistance • Super - infection
  83. 83. IMCI Lecture 1Alexandria University EMRO- WHO • Only 15-20% sore throats are Group A Streptococcus (GAS) • Lack of reliable clinical signs leads to over-treatment of sore throats • Children under 3 often have non-specific signs such as fever and crusts around nose • GAS infections generally rare in children under 2 years Sore Throat: Management Issues
  84. 84. IMCI Lecture 1Alexandria University EMRO- WHO • Sensitivity and specificity tend to move in opposite directions • Clinical diagnosis of GAS infection is difficult without rapid diagnostic test or routine culture Clinical feature Sensitivity % Specificity % History of fever 92.3 14.4 Temp >38ºC 37.4 66.0 Exudate 31.0 31.0 Enlarged node 81.3 45.1 Tender node 33.6 82.2 Exudate or large node 84.1 40.1 Exudate/large node & tender node 12.1 93.9 Sore Throat: Management Issues
  85. 85. IMCI Lecture 1Alexandria University EMRO- WHO For Accurate Diagnosis: • Throat culture • Ag detection • ASO Titre Expensive, Not available at PHC level
  86. 86. IMCI Lecture 1Alexandria University EMRO- WHO THEN, HOW WILL IMCI HELP ? •Select few definite signs. •In countries with HIGH prevalence RF or RHD, Better rely on high sensitivity of sign, not to miss any case. •In countries with Low prevalence, rely on high specificity of sign to avoid over-treatment
  87. 87. IMCI Lecture 1Alexandria University EMRO- WHO
  88. 88. IMCI Lecture 1Alexandria University EMRO- WHO IN ALL CHILDREN: Check for throat problem ASK: LOOK AND FEEL •       Does the child have sore throat? •       Feel for enlarged tender lymph nodes on the front of the neck •       Look for red (congested) throat •       Look for white or yellow exudate on the throat and tonsils.
  89. 89. IMCI Lecture 1Alexandria University EMRO- WHO
  90. 90. IMCI Lecture 1Alexandria University EMRO- WHO
  91. 91. IMCI Lecture 1Alexandria University EMRO- WHO
  92. 92. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY THROAT PROBLEM: •       TWO of the following: •       Red (congested) throat •       White or yellow exudate on the throat and tonsils •       Enlarged tender lymph nodes on the front of neck STREPTOCOCCAL SORE THROAT    Give benzathine penicillin     Soothe the throat with a safe remedy     Give paracetamol for pain     Advise when to returm immediately     Follow up in 5 days IF not improving •       Insufficient criteria to classify as streptococcal sore throat NON STREPTOCOCCAL SORE THROAT     Soothe the throat with a safe remedy     Give paracetamol for pain     Advise when to returm immediately     Follow up in 5 days IF not improving •       No throat signs or symptoms (with or without fever) NO THROAT PROBLEM     Continue assessment of the child
  93. 93. IMCI Lecture 1Alexandria University EMRO- WHO • Treatment to prevent RHF and RHD, but also reduces duration of symptoms and signs, and anorexia • Single dose of IM Benzathine penicillin remains best treatment – levels of penicillin remain elevated for up to 10 days – can prevent a sore throat developing for up to 21 days later – administration can be very painful and incorrect administration can cause sterile abscesses, sciatic nerve injury • Penicillin V or amoxicillin are alternatives but more expensive and 10-day compliance is poor Sore Throat: Treatment
  94. 94. IMCI Lecture 1Alexandria University EMRO- WHO EAR PROBLEM ASK about : EAR PROBLEM
  95. 95. Alexandria University IMCI Lecture 1 EMRO- WHO EAR PROBLEM •Types of ear infection •External otitis • Ask • Look •Otitis media • Ask • Look •Symptoms & Signs Used in IMCI •Classification of ear problem •Treatment
  96. 96. IMCI Lecture 1Alexandria University EMRO- WHO
  97. 97. IMCI Lecture 1Alexandria University EMRO- WHO Ear Infection ? • External ear : Otitis Externa • Middle ear : Otitis Media
  98. 98. IMCI Lecture 1Alexandria University EMRO- WHO Diagnosis of External Otitis • Agonizing Ear Pain – Out of proportion of inflammation – Triggered by manipulating the tragus – Itching is a precursor of inflammation • Discharge: Serous or Purulent • Conduction Hearing loss: difficult to test in young children (NOT INCLUDED IN IMCI) ASK
  99. 99. IMCI Lecture 1Alexandria University EMRO- WHO Diagnosis of External Otitis • Discharge: Serous or Purulent • Ear Canal: ** •Erythema •Edema •Otoscopy: very painful **SUBJECTIVE SIGNS, NOT INCLUDED IN IMCI LOOK
  100. 100. IMCI Lecture 1Alexandria University EMRO- WHO Diagnosis of Otitis Media • Agonizing Ear Pain • Discharge (Otorrhea): Purulent • Other NON SPECIFIC Symptoms: •Fever •Irritability OR Lethargy •Anorexia, Nausea, Vomiting, Diarrhea •Headache ? ASK
  101. 101. IMCI Lecture 1Alexandria University EMRO- WHO Diagnosis of Otitis Media • Discharge: Purulent • Pneumatic Otoscopy:** •Calm cooperative child •Good positioning •Clean empty ear canal •Experienced physician++ **DIFFICULT TO ACHIEVE, NOT INCLUDED IN IMCI LOOK
  102. 102. IMCI Lecture 1Alexandria University EMRO- WHO We are left with: ASK •Agonizing ear Pain •Ear Discharge LOOK •Pus Draining from the ears FEEL: •Tender swelling behind ear (Mastoid) These are used in IMCI
  103. 103. IMCI Lecture 1Alexandria University EMRO- WHO MASTOIDITIS
  104. 104. IMCI Lecture 1Alexandria University EMRO- WHO
  105. 105. IMCI Lecture 1Alexandria University EMRO- WHO ASSESS EAR PROBLEM: Does the child have an ear problem? IF YES ASK: LOOK AND FEEL •       Is there agonising ear pain? •       If there ear discharge? If YES, for how long? •       Look at pus draining from the ear •       Feel for tender swelling behind the ear.
  106. 106. IMCI Lecture 1Alexandria University EMRO- WHO
  107. 107. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY EAR PROBLEM: •       Tender swelling behind the ear MASTOIDITIS    Give 1st dose of appropr. antibiotic    Give 1st dose of paracetamol for pain    Treat child to prevent low blood sugar    Refer URGENTLY to hospital •       Pus seen draining from ear and Discharge reported for less than 14 days OR •       Agonising ear pain ACUTE EAR INFECTION    Give antibiotic for 10 days     Give paracetamol for pain     Dry the ear by wicking     Advise when to return immediately     Follow up in 5 days •       Pus seen draining from ear and Discharge reported for 14 days or more CHRONIC EAR INFECTION     Dry the ear by wicking     Refer to ENT Specialist •       No ear pain and •       No pus seen draining from the ear NO EAR INFECTION     Advise mother to go to ENT specialist for assessment
  108. 108. IMCI Lecture 1Alexandria University EMRO- WHO Stepwise Antibiotics in Otitis Media (Nelson Textbook of Pediatrics) AMOXICILLIN (high dose) First line antibiotic recommended in IMCI If it fails AMOXICILLIN-CLAVULANATE If it fails CEFTRIAXONE
  109. 109. IMCI Lecture 1Alexandria University EMRO- WHO
  110. 110. IMCI Lecture 1Alexandria University EMRO- WHO FEVER ASK about FEVER
  111. 111. Alexandria University IMCI Lecture 1 EMRO- WHO Fever Febrile Illness Causes Fever After Five Days Referral Classification of Fever Overvie Stiff neck Classification of fever
  112. 112. IMCI Lecture 1Alexandria University EMRO- WHO • Fever as a secondary cause – management of the condition results in management of the fever – pneumonia, measles, dysentery, ear infections, runny nose • Fever associated with severe illnesses which use danger signs for classification and treatment – meningitis, septicemia, sepsis Febrile Illness Causes:
  113. 113. IMCI Lecture 1Alexandria University EMRO- WHO • Non-localizing signs do not allow for distinction at a first-level health facility • Danger signs identify a seriously ill child who needs to be referred • Meningitis, septicemia • Severe pneumonia or Very serere disease • Mastoiditis • Severe complicated Measles, etc Febrile Illness
  114. 114. IMCI Lecture 1Alexandria University EMRO- WHO • Conditions do not have any obvious simple clinical sign but have fever in common • Prevalence too low to include specific signs and symptoms for each condition Fever after Five Days Referral
  115. 115. IMCI Lecture 1Alexandria University EMRO- WHO • Differentiates between simple viral fevers and other diseases where the only presenting symptom is fever • Detects conditions needing diagnostic and therapeutic intervention – Tuberculosis – Urinary tract infection – Typhoid, Brucellosis, Osteomyelitis, etc. Fever after Five Days Referral in Order To:
  116. 116. IMCI Lecture 1Alexandria University EMRO- WHO
  117. 117. IMCI Lecture 1Alexandria University EMRO- WHO   Does the child have fever? (by history or feels hot or temperature 37.5o C or more) IF YES, ASK LOOK AND FEEL •       For how long? •       If more than  5 days, has fever     been present every day? •       Has the child had measles     within the last 3 months? •       Look or feel for stiff neck   Look for signs of Measles: •       Generalised rash and   •       One of these: cough, runny nose,     or red eyes.  If the child has measles now or within the last 3 months: •       Look for mouth ulcers       Are they deep and extensive? •       Look for pus draining from the  eye •       Look for clouding of the cornea
  118. 118. IMCI Lecture 1Alexandria University EMRO- WHO Looking and Feeling for STIFF NECK
  119. 119. IMCI Lecture 1Alexandria University EMRO- WHO
  120. 120. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY FEVER: •       Any generalised     danger sign  OR   •       Stiff neck VERY SEVERE FEBRILE DISEASE    Give 1st dose of appropiate antibiotic (I.M)    Treat child to prevent low blood sugar    Give one dose of paracetamol in clinic for fever 38o C or above     Refer URGENTLY to hospital •       Apparent bacterial  cause of fever, e.g −      Pneumonia −      Dysentery −      Acute ear infection −      Strept. sore throat −      Abscess,  cellulitis,etc. FEVER- POSSIBLE BACTERIAL INFECTION     Give paracetamol for fever (38o C or more)     Treat apparent cause of fever .     Advise mother when to return immediately     Follow Up in 2 days IF fever persists     If fever is present every day for more than     5 days, refer for assessment.   •       No apparent  bacterial     cause of fever FEVER- BACTERIAL INFECTION UNLIKELY     Give paracetamol for fever (38o C or more)     Advise mother when to return immediately     Follow Up in 2 days IF fever persists     If fever is present every day for more than     5 days, refer for assessment
  121. 121. IMCI Lecture 1Alexandria University EMRO- WHO
  122. 122. IMCI Lecture 1Alexandria University EMRO- WHO MALNUTRITION & ANEMIA CHECK For MALNUTRITION and ANEMIA in ALL CHILDREN
  123. 123. Alexandria University IMCI Lecture 1 EMRO- WHO MALNUTRITION & ANEMIA •Anemia Clinical signs for classification Sensitivity and specificity of signs •Nutritional status Iceberg of malnutrition Weight for age as indicator Other indicators Growth Monitoring •Checking for Malnutrition and Anemia Wasting Edematous feet Weight for age curve Pallor •Classification of nutritional status of anemia
  124. 124. IMCI Lecture 1Alexandria University EMRO- WHO • Severe anemia: classified using severe palmar &/Or mucous membrane pallor • Anemia: classified using some palmar &/Or mucous membrane pallor • Study in Alexandria (2000-01) proved that: Anemia Clinical Signs for Identification: Clinical Sign Sensitivity Specificity Severe Palmar Pallor 60.6% 96.4% Some Palmar Pallor 87.3% 47.7% Severe Conjunctival Pallor 52.7% 98.1% Some Conjunctival Pallor 49.9% 64.0% Severe Lip Pallor 42.9% 97.8% Some Lip Pallor 53.1% 57.1%
  125. 125. IMCI Lecture 1Alexandria University EMRO- WHO Studies in Alexandria, Gambia, Bangladesh,Kenya & Uganda concluded that: • Best sensitivity obtained for “Some palmar pallor” • Best specificity obtained for severe conjunc. pallor • Sensitivity of severe palmar pallor similar to or better than that of conjunctival pallor • Specificity about the same for both severe palmar and conjunctival pallor. • Using both signs together decreased sensitivity but increased the specificity in both severe and some pallor.
  126. 126. IMCI Lecture 1Alexandria University EMRO- WHO • All children should be assessed for nutritional status • Low weight requiring home management or nutritional counseling • Severe malnutrition needing referral – Marasmus indicated by severe visible wasting – Edematous malnutrition (kwashiorkor) indicated by edema of both feet Nutritional Status
  127. 127. IMCI Lecture 1Alexandria University EMRO- WHO Mild & Moderate forms severe               forms The Iceberg of Malnutrition
  128. 128. IMCI Lecture 1Alexandria University EMRO- WHO • Weight for height assessments most accurate but not routinely performed • Weight for age Z-score can be viewed as a proxy estimate for weight for height Weight for Age as Indicator
  129. 129. IMCI Lecture 1Alexandria University EMRO- WHO • Low WFA (<-2 Z-score) – Population-based nutritional surveys only – For comparison of different areas and time – Not for patient-based disease • Mid upper arm circumference (MUAC) – Not as effective as WFH gold standard – Prone to errors: even half a centimeter could result in wrong classification – Useful for screening an emergency situation Other Indicators
  130. 130. IMCI Lecture 1Alexandria University EMRO- WHO • Could provide valuable information about a child’s current growth -- potential powerful tool • No consensus on quantitative definition of growth faltering – Weight loss between 2 monthly measurements – Weight gain over 3 monthly measurements – Falling off the curve • Efficacy difficult to demonstrate – No effect on nutritional status – Health workers have difficulty recognizing “faltering” Growth Monitoring Limitations:
  131. 131. IMCI Lecture 1Alexandria University EMRO- WHO
  132. 132. IMCI Lecture 1Alexandria University EMRO- WHO THEN CHECK FOR MALNUTRITION AND ANEMIA LOOK AND FEEL Classify •       Look for visible severe wasting •       Look for edema of both feet •       Determine weight for age  NUTRITIONAL STATUS       LOOK Classify ANEMIA •       Look for palmar and/or mucous membrane     pallor. Is it: −      Severe palmar and / or m. m. pallor? −      Some palmar and / or m. m. pallor?  
  133. 133. IMCI Lecture 1Alexandria University EMRO- WHO
  134. 134. IMCI Lecture 1Alexandria University EMRO- WHO
  135. 135. IMCI Lecture 1Alexandria University EMRO- WHO LOW WEIGHT FOR AGE
  136. 136. IMCI Lecture 1Alexandria University EMRO- WHO
  137. 137. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY NUTRITIONAL STATUS •       Visible severe wasting    OR •       Edema of both feet SEVERE MALNU- TRITION    Give vitamin A    Treat the child to prevent low blood sugar     Refer URGENTLY to hospital       •       Low weight for age LOW WEIGHT     Assess the child’s feeding & counsel  mother     according to FOOD box on the  COUNSEL THE MOTHER chart     If there is feeding problem: Follow up in  5 days     Advise when to return immediately   •       Not low weight for age  and no other signs of  malnutrition NOT LOW WEIGHT     If child is less than 2 years old, assess   feeding & counsel mother according to  FOOD box on the COUNSEL THE MOTHER chart     If there is feeding problem: Follow up in  5 days
  138. 138. IMCI Lecture 1Alexandria University EMRO- WHO CLASSIFY ANEMIA •       Severe palmar and /or     mucous membrane  pallor SEVERE ANEMIA    Treat the child to prevent low blood sugar     Refer URGENTLY to hospital   •       Some palmar and /or     mucous membrane  pallor ANEMIA     Give iron     Advise when to return immediately     Follow up in  14  days •       No palmar or mucous     membrane pallor NO ANEMIA     If child is aged from  6 – 30 months,  give     ONE dose of iron weekly  (supplementation)
  139. 139. IMCI Lecture 1Alexandria University EMRO- WHO CHECK THE CHILD IMMUNIZATION STATUS CHECK IMMUNIZATION and VITAMIN A Supplementation status In ALL CHILDREN
  140. 140. IMCI Lecture 1Alexandria University EMRO- WHO CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A SUPPLEMENTATION STATUS AGE VACCINE VITAMIN A Before 3 months 2 months 4 months 6 months 9 months 18-24 months BCG OPV-1 OPV-2 OPV-3 OPV-4 OPV (Booster) DPT-1 DPT-2 DPT-3 Measles DPT (Booster) HBV-1 HBV-2 HBV-3 MMR 100,000 U 200,000 U     ASSESS OTHER PROBLEMS
  141. 141. IMCI Lecture 1Alexandria University EMRO- WHO TREAT THE CHILD Give an Appropriate Oral Antibiotic….. Teach the Mother to Give Oral Drugs at Home… Teach Mother to Treat Local Infections at Home… Treatments Given in Clinic Only…. Give Extra Fluid for Diarrhea Continue Feeding… Immunize Every Child, as Needed…
  142. 142. IMCI Lecture 1Alexandria University EMRO- WHO GIVE FOLLOW-UP CARE Pneumonia, No pneumonia-Wheeze Dysentery, Persistent Diarrhea Sore throat, Ear Infection, Fever, Measles Feeding Problems, Low weight Pallor
  143. 143. IMCI Lecture 1Alexandria University EMRO- WHO COUNSEL THE MOTHER FOOD: •Assess Child’s Feeding •Feeding Recommendations during Illness & Health •Counsel the Mother about Feeding Problems FLUID •Advise the Mother to Increase Fluid During Illness Counsel the Mother About Her Own Health Advise the Mother when to Return to Health Worker 
  144. 144. IMCI Lecture 1Alexandria University EMRO- WHO
  • NyikoNdleve

    Sep. 26, 2019
  • LaizaBayeta

    Sep. 12, 2019
  • AyubaLami

    Jan. 17, 2019
  • abdirahmanosman522

    Jul. 25, 2018
  • VirgieVillamoraribal

    Dec. 10, 2017
  • VictorEffiom1

    Sep. 20, 2017
  • SarabanTahura1

    Jul. 20, 2017
  • MohamedAli615

    Mar. 21, 2017
  • AnnemBharath

    Feb. 15, 2017
  • adilyousafzai

    Oct. 5, 2016
  • JewelManchester

    Aug. 8, 2016
  • aj1210

    Oct. 1, 2015

PEDIATRIC NURSING

Views

Total views

1,635

On Slideshare

0

From embeds

0

Number of embeds

13

Actions

Downloads

160

Shares

0

Comments

0

Likes

12

×