powerpoint presentation from FMS conference 2013

1. Holistic/IntegratedHolistic/Integrated
Approach to SickApproach to Sick
Under 5 y.o. ChildrenUnder 5 y.o. Children
DR. ISKANDAR FIRZADA B. OSMANDR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM),MD (USM), MMed (Family Medicine) (USM),
MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),
Fellow in Adolescent Health (Melbourne)Fellow in Adolescent Health (Melbourne)
Pakar Perubatan KeluargaPakar Perubatan Keluarga
Klinik Kesihatan Jaya GadingKlinik Kesihatan Jaya Gading
Kuantan, PAHANGKuantan, PAHANG

2. Millennium Development GoalsMillennium Development Goals
(MDG) by 2015 – UN/WHO(MDG) by 2015 – UN/WHO

3. Integrated Management of ChildhoodIntegrated Management of Childhood
Illness (IMCI) ProgramIllness (IMCI) Program
Developed by WHO & UNICEF withDeveloped by WHO & UNICEF with
objectives;objectives;
• reduce death & frequency & severity ofreduce death & frequency & severity of
illness & disability associated with majorillness & disability associated with major
causes of disease in children,causes of disease in children,
• promote healthy growth & developmentpromote healthy growth & development
of children.of children.

4. Management of childhood illness:Management of childhood illness:
Rationale for an integrated strategyRationale for an integrated strategy

6. Major causes of death under five, 2002Major causes of death under five, 2002
ARI 18%
Diarrhoea 15%
Malaria 10%
Measles 5%HIV/AIDS 4%
Perinatal 23%
Other 25%
Deaths associated with
malnutrition
54%
6

7. TheseThese 55 conditions are also the main reasonconditions are also the main reason
for seeking care in 3 out of 4 sick childrenfor seeking care in 3 out of 4 sick children
who come to a health facilitywho come to a health facility

10. Presenting complaint or sign can bePresenting complaint or sign can be
associated with a number of conditions;associated with a number of conditions;
Presenting complaint Possible cause/ associated conditionPresenting complaint Possible cause/ associated condition
Cough and/orCough and/or PneumoniaPneumonia
Fast breathingFast breathing Severe anaemiaSevere anaemia
P. falciparum malariaP. falciparum malaria
Drowsy orDrowsy or Cerebral malariaCerebral malaria
UnconsciousnessUnconsciousness MeningitisMeningitis
Severe dehydrationSevere dehydration
Very severe pneumoniaVery severe pneumonia
Measles rashMeasles rash PneumoniaPneumonia
DiarrhoeaDiarrhoea
Ear infectionEar infection
‘‘Very sick’ young infantVery sick’ young infant PneumoniaPneumonia
MeningitisMeningitis
SepsisSepsis

11. Integrated Strategy -Integrated Strategy -
RationaleRationale
• A single diagnosis may not be adequateA single diagnosis may not be adequate
or appropriate in management of theseor appropriate in management of these
children.children.
• IMCI looks at all relevant symptoms &IMCI looks at all relevant symptoms &
considers them in combination to decideconsiders them in combination to decide
on best treatment for child.on best treatment for child.
• IMCI looks at whole child & addressesIMCI looks at whole child & addresses
overall health of child for better outcome.overall health of child for better outcome.

12. The IMCI StrategyThe IMCI Strategy

13. 1.1. Improving case management skills ofImproving case management skills of
health workers (doctors, nurses, medicalhealth workers (doctors, nurses, medical
assistants) through provision of clinicalassistants) through provision of clinical
guidelines & training.guidelines & training.
2.2. Improving the health system for effectiveImproving the health system for effective
management of childhood illness.management of childhood illness.
3.3. Improving family & communityImproving family & community
practices.practices.
IMCI Strategy - 3 componentsIMCI Strategy - 3 components

14. In the health facilities;In the health facilities;
• Promotes accurate identification of childhoodPromotes accurate identification of childhood
illness.illness.
• Ensures appropriate combined treatment of allEnsures appropriate combined treatment of all
major illnesses.major illnesses.
• Strengthens counselling of caretakers &Strengthens counselling of caretakers &
provision of preventive services.provision of preventive services.
• Speeds up referral of severely ill children.Speeds up referral of severely ill children.
In the home setting, it promotes;In the home setting, it promotes;
• Appropriate care seeking behaviour.Appropriate care seeking behaviour.
• Improved nutrition & preventive care.Improved nutrition & preventive care.
• Correct implementation of prescribed care.Correct implementation of prescribed care.
IMCI StrategyIMCI Strategy

17. IMCI ClinicalIMCI Clinical
GuidelinesGuidelines

18. IMCI Clinical GuidelinesIMCI Clinical Guidelines
• Strategy focuses on improving caseStrategy focuses on improving case
management of sick child in first levelmanagement of sick child in first level
health facilities through provision ofhealth facilities through provision of
clinical guidelines & training.clinical guidelines & training.
• Clinical guidelines are based on expertClinical guidelines are based on expert
clinical opinion & research results.clinical opinion & research results.
• Guidelines are based on seven principles.Guidelines are based on seven principles.

19. IMCI Guidelines - Principles
1.1. All sick children are examined for generalAll sick children are examined for general
danger signs which indicate the need fordanger signs which indicate the need for
immediate referral or admission to hospital.immediate referral or admission to hospital.
2.2. All sick children are routinely assessed for majorAll sick children are routinely assessed for major
symptoms;symptoms;
• 2 months to 5 years: cough or difficult2 months to 5 years: cough or difficult
breathing, diarrhoea, fever & ear problems.breathing, diarrhoea, fever & ear problems.
• Newborn up to 2 months: bacterial infection &Newborn up to 2 months: bacterial infection &
diarrhoea.diarrhoea.
All sick children are also assessed for nutritionalAll sick children are also assessed for nutritional
& immunisation status, feeding problems & other& immunisation status, feeding problems & other
problems (not covered in IMCI guidelines).problems (not covered in IMCI guidelines).

20. 3.3. Limited number of carefully selectedLimited number of carefully selected
clinical signs are used, based onclinical signs are used, based on
evidence of sensitivity & specificity ofevidence of sensitivity & specificity of
these signs to detect disease.these signs to detect disease.
These signs are also selected consideringThese signs are also selected considering
the conditions & realities of first levelthe conditions & realities of first level
health facilities.health facilities.
IMCI Guidelines - Principles

21. 4.4. A combination of clinical signs leads to aA combination of clinical signs leads to a
child’s classification(s), rather thanchild’s classification(s), rather than
diagnosis.diagnosis.
Classification(s) indicate severity ofClassification(s) indicate severity of
condition(s) & call for specific actionscondition(s) & call for specific actions
based on whether the child;based on whether the child;
• should be urgently referred to hospital,should be urgently referred to hospital,
• require specific treatment likerequire specific treatment like
antibiotics or oral rehydration, orantibiotics or oral rehydration, or
• may be safely managed at home.may be safely managed at home.
IMCI Guidelines - Principles

22. Guidelines - ClassificationsGuidelines - Classifications

23. 5.5. Guidelines address most, but not all, of majorGuidelines address most, but not all, of major
reasons sick child is brought to clinic.reasons sick child is brought to clinic.
Guidelines do not describe management ofGuidelines do not describe management of
trauma or acute emergencies due totrauma or acute emergencies due to
injuries/accidents.injuries/accidents.
5.5. Management procedures use limited number ofManagement procedures use limited number of
essential drugs & encourage active participationessential drugs & encourage active participation
of caretakers in treatment of children.of caretakers in treatment of children.
6.6. An essential component of the guidelines isAn essential component of the guidelines is
counselling of the caretakers about homecounselling of the caretakers about home
management, including counselling aboutmanagement, including counselling about
feeding, fluids & when to return to health facility.feeding, fluids & when to return to health facility.
IMCI Guidelines - Principles

24. • Depending on child’s age, various clinicalDepending on child’s age, various clinical
signs & symptoms have different degreessigns & symptoms have different degrees
of reliability & diagnostic value &of reliability & diagnostic value &
importance.importance.
• Case management procedures based onCase management procedures based on
2 age categories;2 age categories;
• child aged 2 months up to 5 years.child aged 2 months up to 5 years.
• newborn up to 2 monthsnewborn up to 2 months
Case Management Guidelines

25. IMCI CaseIMCI Case
Management ProcessManagement Process

26. Includes number of important elements;Includes number of important elements;
• AssessmentAssessment
• ClassificationClassification
• Identification of treatment, referral,Identification of treatment, referral,
treatment, counsellingtreatment, counselling
• Follow-up careFollow-up care
IMCI Case Management
Process

27. IMCI Case Management
Process

28. Complaint/Symptoms/SignsComplaint/Symptoms/Signs
Check for Danger Signs!Check for Danger Signs!
Ask/Assess 4 Main Symptoms:Ask/Assess 4 Main Symptoms:
Cough or Difficult Breathing?Cough or Difficult Breathing?
Diarrhoea?Diarrhoea?
Fever?Fever?
Ear Problem?Ear Problem?
Then check for Malnutrition & AnaemiaThen check for Malnutrition & Anaemia
Then check for Immunisation & Deworming statusThen check for Immunisation & Deworming status
Assess other problemsAssess other problems

30. IMCI Case Management
Process

31. IMCI Case Management
Process

32. Complaint/Symptoms/SignsComplaint/Symptoms/Signs
Check for Very Severe Disease!Check for Very Severe Disease!
Check for Local Bacterial InfectionCheck for Local Bacterial Infection
Then check for JaundiceThen check for Jaundice
Then check for ImmunisationThen check for Immunisation
Assess other problemsAssess other problems
Then ask/assess for DiarrhoeaThen ask/assess for Diarrhoea
Then check for Feeding Problem orThen check for Feeding Problem or
Low Weight for AgeLow Weight for Age

33. IMCI Case Management
Process

34. DR. ISKANDAR FIRZADA B. OSMANDR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM),MD (USM), MMed (Family Medicine) (USM),
MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),
Fellow in Adolescent Health (Melbourne)Fellow in Adolescent Health (Melbourne)
Thank YouThank You