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Imnci

The document discusses the Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy developed by WHO and UNICEF to reduce child mortality. It focuses on the first component of IMNCI, which is improving health worker skills in integrated case management. The IMNCI uses a syndromic approach to classify and treat sick young infants and children based on symptoms. It promotes assessment of general danger signs, malnutrition, feeding problems and treatment using locally adapted guidelines. Health workers are trained to identify classifications indicated by color codes to determine necessary treatment, counseling or referral.

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INTEGRATEDMANAGEMENTOFNEONATALANDINTEGRATEDMANAGEMENTOFNEONATALAND CHILDHOODILLNESSCHILDHOODILLNESS Soumya Ranjan Parida Basic B.Sc. Nursing 4th year Sum Nursing College
INEQUITIES OF CHILD HEALTH Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999. 27% 17% 13% 43% Fever ARI Diarrhoea malnutriton In India morbidity pattern in children under 3 year of age 7% 8% 15% 19% 20% 3%28% 54% MALARIA MEASLES DIARRHOEA PNEUMONIA PERINATAL HIV/AIDS OTHERS MALNUTRITION
RATIONAL FOR IMNCI SYNDROMIC APPROACH TO CASE MANAGEMENT •Limited supplies and equipments negligible laboratory facilities, level the doctors with few opportunities to practice complicated clinical procedures. •Many children presents with overlapping signs and symptoms of diseases, a single diagnosis may not be feasible or appropriate, specially at first level health facilities. •So IMCI strategy was developed by WHO and UNCIEF with may other agencies during mid 1990’s. •This strategy has be expanded in India to include all neonates ( IMNCI). OBJECTIVES OF IMNCI STRATEGY •To reduce death and the frequency and severity of illness and disabilities and to contribute to improved growth and development. 54% ARI Diarrhoea 85% 79% Malaria 89% Measles Why the IMNCI clinical guidelines target children less than 5 year old •Percentage of deaths occurring among Children under 5 year All other age groups Cont…….
IMNCI Syndromic approach used to determine •Health problems the child may have, •Severity of the child’s condition •Actions that can be taken to care for the child (e.g. refer the child immediately, manage with available resources, or manage at home. In addition IMNCI promotes : •Adjustment of interventions to the capacity of health system •Active involvement of family members and the community in the health care process. Cont……..
COMPONENTS OF THE INTEGRATED APPROACH The strategy includes three main components : •Improvement in the case management skills of health staff through the provision of locally adapted guidelines on Integrated Management of Neonatal and Childhood Illness and activities to promote their use; •Improvements in the overall health system required for effective management of neonatal and childhood illness; •Improvement in family and community health care practices. This document is focused on achieving the first of these components.
PRINCPLES OF INTEGRATED CARE Depending on a child’s age, various clinical signs and symptoms differ in their degree of reliability and diagnostic value and importance. Therefore, the IMNCI guidelines recommend case management procedures based on two age categories : •Young infants age up to 2 months •Children age 2 months upto 5 months The IMNCI guidelines are based on following principles: •All sick young infants upto 2 months of age must be assessed of “possible bacterial infection/jaundice”and“diarrhoea” •All sick children age 2 months upto 5 years must be examined for “general danger signs” which indicate the need for immediate referral or admission to a hospital. They must then be routinely assessed for major symptoms: cough or difficult breathing, diarrhoea, fever and ear problems. •All sick young infants and children 2 months upto 5 years must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems. •Only a limited number of carefully selected clinical signs are used. Cont…….
•A combination of individual signs leads to an infant’s or a child ‘s classification (s) rather than a diagnosis. The classifications are colour coded: “pink” suggests hospital referral or admission, “yellow” indicates initiation of specific treatment, and green calls for home management. •The IMNCI guidelines address most, but not all the major reasons a sick infant or child is brought to a clinic. •IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children. An essential component of the IMNCI guidelines is the counseling of caretakers about home care, including counseling about feeding, fluids and when to return to a health facility. Cont…….
IMNCI Case management process Summary of the Integrated Case management process For all sick children age up to 5 years who are brought to a first level health facility ASSESS the child : Check for danger signs (or possible bacterial infection/Jaundice). Ask about main symptoms. It a main symptoms is reported, assess further. Check nutrition and immunization status. Check for other problems CLASSIFY the child illness : Use a colour-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status. IF URGENT REFERRAL is needed for possible IF NO URGENT REFERRAL is needed for possible IDENTIFY UREGENT PRE- REFERRAL TRATMENT (S) Needed for the child’s classifications TREAT THE CHILD: Give urgent peripheral treatment(s) needed. IDENTIFY TRATMENT (S) Needed for the child classifications:identify specific medical treatment and/or advice TREAT THE CHILD: Give the first dose of oral drugs in the clinic ad/or advice the child caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. IF needed , give immunization COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practice, and solve feeding problems, if present. Advice about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health. REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretakers fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital. FOLLOW-UP care :Give follow-up care when the child returns to the clinic and, if necessary, reassess the child for new problems.
THE INTEGRATED CASE MANAGEMENT PROCESS FOR THE SICK YOUNG INFANT TO 2 MONTH OF AGE OUTPATIENT HEALTH FACILITY CHECK FOR POSSIBLE BACTERIAL INFECTION/JAUNDICE Assess the SYMPYOMS * Diarrhoea Check for FEEDING PROBLEM or MALNUTRITION and IMMUNIZATION STATUS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Colour-Coded Treatment Chart PINK Urgent Referral OUTPATIENT HEALTH FACILITY •Pre-referral Treatment •Advise Parents •Refer young infant PINK Urgent Referral REFERRAL FACILITY •Emergency Triage and Treatment •Diagnosis Treatment •Monitoring and Follow-up YELLOW Treatment at outpatient health facility OUTPATIENT HEALTH FACILITY •Treat Local Infection •Give Oral Drugs •Advise and Teach Caretaker •Follow-up GREEN Home Management HOME Caretaker is counseled how to below: •Give oral drugs •Treat local infections •Continue exclusive breastfeeding •Keep the young infant warm •When to return immediately •Follow-up
THE INTEGRATED CASE MANAGEMENT PROCESS FOR THE SICK CHILD FROM AGE 2 MONTHS UPTO 5 YEARS OUTPATIENT HEALTH FACILITY CHECK FOR DANGERS SIGNS •Convulsions •Lethargy/Unconsciousness •Inability to Drink/Breastfeed •Vomiting Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Colour-Coded Treatment Chart Assess MAIN SYMPTOMS •Cough/Difficulty Breathing •Diarrhea •Fever •Ear Problems PINK Urgent Referral OUTPATIENT HEALTH FACILITY •Pre-referral Treatment •Advise Parents •Refer child PINK Urgent Referral REFERRAL FACILITY •Emergency Triage and Treatment (ETAT) •Diagnosis Treatment •Monitoring and Follow-up YELLOW Treatment at outpatient health facility OUTPATIENT HEALTH FACILITY •Treat Local Infection •Give Oral Drugs •Advise and Teach Caretaker •Follow-up GREEN Home Management HOME Caretaker is counseled how to below: •Give oral drugs •Treat local infections at home •Continue feeding •When to return immediately •Follow-up
CHECK FOR POSSIBLE BACTERIAL INFECTION/JAUNDICE SIGNS CLASSIFY AS IDENTIFY TREATMENT Classify ALL YOUNG INFANTS And if the infant has Jaundice And if the temp. is between 35.5-36.40 C -Convulsion or -Fast breathing (60 breath per minute more or -Severe chest in drawing or -Nasal flaring or -Grunting or -Bulging fontanelle or -10 or more skin pustules or a big boil or -If axillary temperature 37.50 c or above or temp. less than 35.50 C. -Lethagic or unconscious or -Less than normal movements POSSIBLE SERIOUS BACTERIAL INFECTION -Give first dose of I.M. ampicillin and Gentamicin -Treat to prevent low blood sugar -Warm the young infant by skin to skin contact if temp.less than 36.50 C. -Advice mother how to keep the young Infant warm on the way to the hospital. - Refer urgently to the hospital. -Umbilicus red or draining pus or -Pus discharge from ear or -<10 skin pustules LOCAL BACTERIAL INFECTION -Give oral co-trimoxazole or amoxycllin for 5 days -Teach mother to treat local infection at home -Follow up in two days. -Palms and soles yellow or -Age < 24 hours or -Age 14 days or more SEVERE JAUNDICE -Treat to prevent low blood sugar -Warm the young infant by skin to skin contact if temperature less than 36.50 C. Advice mother how to keep the young infant warm on the way to hospital. - Refer URGENTLY to hospital -Palms and soles not yellow JAUNDICE -Advice mother to give home care for the young infant. Advice mother when to return immediately. Follow up in two days. -Temperature between 35.5 to 36.40 c LOW BODY TEMPERATURE -Warm the young infant using skin to skin contact for one hour and REASSESS. if no improvement refer - Treat to prevent low blood sugar ASSESS AND CLASSIFY THE SICK YOUNG INFANT AGE UPTO 2 MONTHS
Does the young infant have diarrhoea ? ClassifyDIARRHOEA? For DEHYDRATION Two of the following signs : -Lethargic or unconscious -Sunken eyes -Skin pinch goes back very slowly SEVERE DEHYDRATION -If infant has low weight or another sever classification -Give first dose of intramuscular ampicillin and gentamicin * Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way * Refer mother to continue breast feeding * Advice mother to keep the young infant warm on the way to the hospital OR -If infant does not have low weight or any other severe classification: * Give fluid for severe dehydration (Plan C) and then refer to hospital after rehydration. Two of the following signs : -Restless, irritable -Sunken eyes -Skin pinch goes back very slowly SOME DEHYDRATION -If infant has low weight or another sever classification -Give first dose of intramuscular ampicillin and gentamicin * Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way * Refer mother to continue breast feeding * Advice mother to keep the young infant warm on the way to the hospital OR -If infant does not have low weight or any other severe classification: * Give fluid to some dehydration (Plan B) * Advice mother when to return immediately * Follow-up in two days - Not enough signs to classify or sever dehydration NO DEHYDRATION -Give fluid to treat diarrhea at home ( Plan A) -Advice mother when to return immediately. -Follow up in 5 days if not improving. and if diarrhea 14 days or more - Diarrhea lasting 14 days or more SEVERE PERSISTENT DIARRHOEA -Give first dose of intramuscular ampicillin and gentamicin if the young infant has low weight, dehydration or another severe classification. -Treat to prevent low blood sugar. -Advise how to keep infant warm on the way to the hospital. -Refer to hosptial# . and if blood in stool - Blood in stool SEVERE DYSENTERY -Give first dose of intramuscular ampicillin and gentamicin if the young infant has low weight, dehydration or another severe classification. -Treat to prevent low blood sugar. -Advise how to keep infant warm on the way to the hospital. -Refer to hospital# .
THEN CHECK FOR FEEDING PROBLEM & MALNUTRITION Classify FEEDINGS - Not able to feed or -Not attachment at all or -Not sucking at all or -Very low weight for age NOT ABLE TO FEED POSSIBLE SERIOUS BACTERIAL INFECTION OR SEVERE MALNUTRITION -Give first dose of intramuscular ampicillin and gentamicin - Treat to prevent low blood sugar. - Warm the young infant by skin to skin contact if temperature less than 36.50 C while arranging referral. - Advice mother how to keep the young infant warm on the way to hospital. - Refer URGENTLY to hospital# - Not well attached to breast or - Not suckling effectively or -Less than 8 breastfeeds in 24 hours or -Receives other foods or drinks or -Thrush (ulcer or white patches in mouth) or -Low weight for age or -Breast or nipple problems FEEDING PROBLEM OR LOW WEIGHT FOR AGE -If not well attached nor not sucking effectively, teach correct positioning and attachment. -If breastfeeding less than 8 times in 24 hours, advice to increase frequency of feeding. -If receiving other food or drinks, counsel mother about beast feeding more, reducing other food or drinks and using a cup and spoon. * If not breastfeeding at all advice mother about giving locally appropriate animal milk and teach the mother to feed with a cup and spoon. -If thrush, teach the mother to teat thrush at home. -If low weight for age, teach the mother how to keep the young infant with low weight warm at home. -If breast or nipple problem, teach the mother to treat breast or nipple problems. -Advice mother to give home care for the young infant -Advice mother when to return immediately. -Follow up any feeding problem or thrush in 2 days. -Follow up low weight for age in 14 days. - Not low weight for age and no other signs of inadequate feeding NO FEEDING PROBLEM -Advice mother to give home care for the young infant. -Advice mother when to return immediately. -Praise the mother for feeding the infant well.
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ? Classify COUGH or DIFFICULT BREATHINGS SIGNS CLASSIFY AS IDENTIFY TREATMENT - Any general danger sign or -Chest indrawing or -Stridor in calm child. SEVERE PNEUMONIA OR VERY SEVERE DISEASE -Give first dose of injectable chloramphenicol -Refer URGENTLY to hospital# -Fast breathing PNEUMONIA -Give cotrimoxazole for 5 days -Soothe the throat and relieve the cough with a safe remedy if child is 6 month or older -Advice mother when to return immediately -Follow up in 2 days. - No signs of pneumonia or very severe disease NO PENUMONIA COUGH OR COLD -If coughing more than 30 days, refer for assessment. -Soothe the throat and relieve the cough with a safe home remedy if child is 6 months or older. -Advice mother when to return immediately -Follow-up in 5 days if not improving. ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UPTO 5 YEARS
DOES THE CHILD HAVE DIARRHOEA ? ClassifyDIARRHOEA? For DEHYDRATION Two of the following signs : -Lethargic or unconscious -Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly SEVERE DEHYDRATION -If Child has no other sever classification -Give fluid for severe dehydration (Plan C) - if child also has another severe classification : Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Advice mother to continue breast feeding. - If child in 2 years or older and there is cholera in your area, give doxycycline for cholera. Two of the following signs : -Restless, irritable -Sunken eyes -Drinks eagerly, thristy -Skin pinch goes back very slowly SOME DEHYDRATION - Give fluid and food for some dehydration (Plan B) -if child also has another severe classification : Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Advice mother to continue breast feeding. -Advice to mother when to returnimmediately -Follow-up in 5 days if not improving - Not enough signs to classify as some or sever dehydration NO DEHYDRATION -Give fluid to treat diarrhea at home ( Plan A) -Advice mother when to return immediately. -Follow up in 5 days if not improving. and if diarrhea 14 days or more and if blood in stool - Dehydration present SEVERE PERSISTENT DIARRHOEA - Treat dehydration before referral unless the child has another severe classification -Refer to hospital# . - No dehydration PERSISTENT DIARRHOEA -Advice the mother on feedings child who has PERSISTENT DIARRHOEA. -Give single dose of vitamin A. -Give zinc sulphate 20 mg daily for 14 days -Follow up in 5 days. - Blood in stool DYSENTERY -Treat for 5 days with cotrimoxazole -Follow up in 2 days
DOES THE CHILD HAVE FEVER ClassifyFEVER High Malaria risk -Any general danger sign or -Stiff neck or -Bulging fontanelle VERY SEVERE FEBRILE DISEASE -Give first dose of IM quinine after making a blood smear -Give first dose of IV or IM chloramphenicol ( if not possible give oral amoxycillin). -Treat the child to prevent low blood sugar -Give one dose of PCM in clinic for high fever (temp.38.50 C or above) -Refer URGENTLY to hospital FEVER MALARIA -Give oral antimalarial for high malaria risk area after making a blood smear. -Give one dose of PCM in clinic for high fever -Advice mother when to return immediately. -Follow-up in two days if fever persist -If fever present every day for more than 7 days , refer for assessment. Low Malaria risk -Any general danger sign or -Stiff neck or -Bulging fontanelle VERY SEVERE FEBRILE DISEASE -Give first dose of IM quinine after making a blood smear -Give first dose of IV or IM chloramphenicol ( if not possible give oral amoxycillin). -Treat the child to prevent low blood sugar -Give one dose of PCM in clinic for high fever (temp.38.50 C or above) -Refer URGENTLY to hospital FEVER -No runny nose and NO measles and No other cause of fever MALARIA -Give oral antimalarial for low malaria risk area after making a blood smear. -Give one dose of PCM in clinic for high fever -Advice mother when to return immediately. -Follow-up in two days if fever persist -If fever present every day for more than 7 days , refer for assessment. -Runny nose present or -Measles Present or -Other cause of fever present FEVER MALARIA UNLIKELY -Give one dose of PCM in clinic for high fever. -Advise mother when to return immediately -Follow-up in two days if fever persists -If fever is present every day for more than 7 days refer for assessment.
IF MEASLES now or within last 3 months classify - Any general danger sign or -Clouding of cornea or -Deep or extensive mouth ulcers SEVERE COMPLICATED MEASLES -Give first dose of Vitamin A. -Give first dose of injectable chloreamphenicol (if not possible give oral amoxycillin) -If clouding of cornea or pus draining from the eye, apply tetracycline eye ointment -Refer URGENTLY to hospital# -Pus draining from the eye or -Mouth ulcers MEASLES WITH EYE OR MOUTH COMPLICATIONS -Give first dose of Vitamin A. -If pus draining from the eye, apply tetracycline eye ointment -If mouth ulcer treat with gentian violet -Follow-up in two days - Measles now or within the last three months MEASLES -Give first dose of Vitamin A DOES THE CHILD HAVE FEVER DOES THE CHILD HAVE AN EAR PROBLEM ClassifyEARPROBLEM - Tender swelling behind the ear MASTOIDITIS -Give first dose of injecable chloramphenicol(if not possible give oral amoxycillin) - Give first dose of PCM for pain - Refer URGENTLY to hospital# -Pus draining from the ear and discharge is reported for less than 14 days or -Ear pain ACUTE EAR INFECTION -Give cotrimoxazole for 5 days. - Give PCM for pain -Dry the ear by wicking -Follow up in 5 days - Pus draining from the ear and discharge is reported for 14 days or more CHRONIC EAR INFECTION -Dry the ear by wicking -Follow up in 5 days -No ear pain -No pus draining for ear NO EAR INFECTION -No additional treatment
CHECK FOR MALNUTRITIONClassifyNUTRITIONALSTATUSClassifyANAEMIA - Visible severe wasting or -Oedema of both feet SEVERE MALNUTRITION -Give single dose of vitamin A. -Prevent low blood sugar -Refer urgently to hospital -While referal is being organized, warm the child -Keep the child warm on the way to hospital -Malnutrition grade II,III,IV VERY LOW WEIGHT -Assess and counsel for feeding -Advise mother when to return immediately -Follow-up in 30 days -If feeding problem follow up in 5 days N normal weight for age or malnutrition grade I NOT VERY LOW WEIGHT -If child is less than 2 year old asses the child’s feeding and counsel the mother feeding according to the food box on the COUNSEL THE MOTHER chart. -If feeding problem follow up in 5 days -Advice mother when to return immediately. CHECK FOR ANAEMIA Severe palmer pallor SEVERE ANAEMIA -Refer URGENTLY TO HOSPITAL -Some palmer pallor ANAEMIA -Give iron folic acid therapy for 14 days. -Assess the child feeding and counsel the mother feeding according to FOOD BOX on the COUNSEL THE MOTHER chart. -Advice mother when to return immediately. -Follow up in 14 days - No palmer pallor NO ANAEMIA -Give prophylactic iron folic acid if child 6 month or older
CHECK THE CHILD’S IMMUNIZATION, PROPHYLACTIC VITAMIN A & IRON FOLIC ACID SUPPLEMENTATION STATUS IMMUNIZATION SCHEDULED Age Vaccine Birth BCG+ OPV-0 6 week DPT-1+OPV-1(HepB-1**) 10 week DPT-2+OPV-2(HepB-2**) 14 weeks DPT-3+OPV-3(HepB-3**) 9 months Measles + Vitamin A 16-18 month DPT Booster +OPV+Vitamin A 60 Months DT PROPHYLACTIC VITAMIN A Give a single dose of vitamin A One lac at 9 months with measles immunization Two lac at 16-18 months with DPT booster Two lac at 24 months Two lac at 30 months Two lac at 36 months PROPHYLACTIC IFA Give 20mg elemental iron + 100 µg folic acid (1 tab. of pediatric IFA or 5 ml of IFA syrup or 1 ml of IFA drops) for a total of 100 days in a year after the child has recovered from acute illness if -The child is 6 months of age or older and -Has not received Pediatric IFA tab./syrup/drop for 100 days in last one year
COUNSEL THE MOTHER - FEEDING RECOMMENDATION DURING SICKNESS AND HEALTH Up to 6 months of age 6 months up to 12 months 12 months upto 2 years 2 years and older •Breastfeed as often as the child wants, day and night at least 8 times in 24 hours •Do not give any other foods or fluids not even water Remember •Continue breastfeeding if the child is sick •Breastfeeding as often as the child want. •Give at least one katori serving* at a time of : - Mashed roti/rice/bread/bisuit mixed in sweetened undiluted milk OR -Mashed roti/rice/bread mixed in thick dal with added ghee/oil or kichri with added oil/ghee. Add cooked vegetable also in the servings OR -Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk or -Mashed boiled/fried potatoes -Offer banana/biscuit/cheeko/mango/papaya * 3times per day if breastfed. * 5 times per day if not breastfed. Remember: •Keep the child in your lap and feed with your own hands. •Wash your own and child's hand wit soap and water every time before feeding *Breastfeed as often as the child wants •Offer food from family pot •Give at least 11/2 katori at a time of : - Mashed roti/rice/bread/bisuit mixed in sweetened undiluted milk OR -Mashed roti/rice/bread mixed in thick dal with added ghee/oil or kichri with added oil/ghee. Add cooked vegetable also in the servings OR -Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk or -Mashed boiled/fried potatoes -Offer banana/biscuit/cheeko/mango/pa paya * 5 times per day Remember •Sit by the side of child and help him to finish the serving •Wash your own and child’s hand wit soap and water every time before feeding *Give family foods at 3 meals each day *Also twice daily,give nutrition food between means, such as: banana/biscuit/che eko/mango/papaya as snacks. Remember *Ensure that the child finishes the serving *Teach your child wash his hand with soap and water everytime before feeding
- GIVE FOLLOW UP CARE FOR THE SICK CHILD -PENUMONIA After 2 days Check the child for general danger signs Assess the child for cough or difficult breathings Ask •Is the child breathing slower ? •Is there less fever? •Is there child eating better? Treatment : -If chest indrawing or a general danger sign, give a dose of second line antibiotic or intramuscular cholramphenicol.Then refer URGENTLY to hospital. -If breathing rate, fever and eating are the same, change to the second line antibiotic and advice the mother to return in 2 days or refer. (if this child has measles within the last 3 months, refer). -If breathing slower, less fever, or eating better, complete the 5 days of antibiotic. -PERSISTENT DIARRHOEA After 5 days Ask •Has the diarrhoea stopped? •How many loose stools is the child having per day? Treatment : -If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to hospital. -If the diarrhea has stopped (child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child’s age. Continue oral zinc for a total of 14 days.
-DIARRHOEA After 5 days Ask •Has the diarrhoea stopped? •How many loose stools is the child having per day? Treatment : -If diarrhoea persists, assess the child for diarrhoea and manage as on initial visit. -If diarrhoea has stopped, tell the mother to follow the usual feeding recommendations for the child’s age. -DYSENTERY After 2 days Assess the child for diarrhoea Ask •Are there fewer stools ? •Is there less blood in the stool? •Is there less fever? •Is there less abdominal pain? •Is the child eating better? Treatment : -If the child is dehydrate treat dehydration -If number of stools, amount of blood in stools, fever, abdominal pain or eating is the same or worse. Change to second-line oral antibiotic recommended for shigella in your area. Give it for 5 days. Advise the mother to return in 2 days. Exception – If the child : - is less than 12 months old or had measles within the last 3 months. (Refer to hospital) -If fewer stools, less blood in the stool,less fever, less abdominal pain, and eating better, continue giving the same antibiotic until finished. -If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same or worse after treatment with nalidixic acid/second line drug.(refer to hospital)
-MALARIA ( Low or High Malaria Risk) If fever persists after 2 days, or returns within 14 days Treatment : -If the child has any general danger sign or stiff neck. Treat as very severe FEBRILE DISEASE. -If the child has any cause of fever other than malaria, provide treatment. -If malaria is the only apparent cause of fever: * Treatment within the second line oral antimalarial( if no second line antimalarial is available.refer to hospital). Advice the mother to return again in 2 days if the fever persists. Continue primaquine if P.vivax was positive for a total of 5 days. * If fever has been present for 7 days, refer for assessment. -FEVER- MALARIA UNLIKELY ( Low Malaria Risk ) If fever persists after 2 days Treatment : -If the child has any general danger sign or stiff neck. Treat as very severe FEBRILE DISEASE. -If the child has any cause of fever other than malaria, provide treatment. -If malaria is the only apparent cause of fever: * Treatment within the first line oral antimalarial. Advice the mother to return again in 2 days if the fever persists. * If fever has been present for 7 days, refer for assessment.
-MEASLES WITH EYE OR MOUTH COMPLICATIONS After 2 days: Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Check for foul smell from the mouth.. Treatment for eye infection: -If pus is draining from the eye,ask the mother to describe how she has treated the eye infection, if treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct treatment. -If the pus is gone but redness remains,continue the treatment . -If no pus or redness, stop the treatment . Treatment for Mouth Ulcer: -If mouth ulcer are worse, or there is a very foul smell from the mouth, refer to hospital. -If mouth ulcer are the same or better,continue using half strength gentian violet for a total of 5 days. -EAR INFECTION After 5 days: Reassess for ear problem. Measure the child temperature. Treatment : -If there is tender swelling behind the ear or high fever (38.50 C or above), refer URGENTLY to hospital. -Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow up in 5 days. -Chronic ear infection : Check that the mother is wicking the ear correctly. If ear discharge getting better encourage her to continue. If no improvement, refer to hospital for assessment. -If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the 5 days of antibiotic,tell her to use of it before stopping.
-FEDDING PROBLEM After 5 days: Reassess feeding Ask about any feeding problems found on the initial visit. -Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding ask her to bring the child back again. -If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child weight gain. -VERY LOW WEIGHT After 30 days: Weigh the child and determine if the child is still very low weight for age. Reassess feeding. Treatment : -If the child is no longer very low weight for age, praise the mother and encourage her to continue. -If the child is still very low weight for age, counsel the mother about any feeding problem found. Ask the mother to return again in one month. Continue to seethe child monthly until the child is feeding well and gaining weight regularly or is no longer very low weight for age. Exception : If you do not think that feeding will improve or if the child has lost weight, refer the child. -ANAEMIA After 14 days: -Give iron folic acid. Advice mother to return in 14 days for more iron folic acid. -Continue giving iron folic acid every 14 days for 2 months. -If the child has palmer pallor after 2 months, refer for assessment.
<50% 51-60% 61-70% 71-80%
Imnci
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Imnci

  • 1.
  • 2.
    INEQUITIES OF CHILDHEALTH Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999. 27% 17% 13% 43% Fever ARI Diarrhoea malnutriton In India morbidity pattern in children under 3 year of age 7% 8% 15% 19% 20% 3%28% 54% MALARIA MEASLES DIARRHOEA PNEUMONIA PERINATAL HIV/AIDS OTHERS MALNUTRITION
  • 3.
    RATIONAL FOR IMNCISYNDROMIC APPROACH TO CASE MANAGEMENT •Limited supplies and equipments negligible laboratory facilities, level the doctors with few opportunities to practice complicated clinical procedures. •Many children presents with overlapping signs and symptoms of diseases, a single diagnosis may not be feasible or appropriate, specially at first level health facilities. •So IMCI strategy was developed by WHO and UNCIEF with may other agencies during mid 1990’s. •This strategy has be expanded in India to include all neonates ( IMNCI). OBJECTIVES OF IMNCI STRATEGY •To reduce death and the frequency and severity of illness and disabilities and to contribute to improved growth and development. 54% ARI Diarrhoea 85% 79% Malaria 89% Measles Why the IMNCI clinical guidelines target children less than 5 year old •Percentage of deaths occurring among Children under 5 year All other age groups Cont…….
  • 4.
    IMNCI Syndromic approachused to determine •Health problems the child may have, •Severity of the child’s condition •Actions that can be taken to care for the child (e.g. refer the child immediately, manage with available resources, or manage at home. In addition IMNCI promotes : •Adjustment of interventions to the capacity of health system •Active involvement of family members and the community in the health care process. Cont……..
  • 5.
    COMPONENTS OF THEINTEGRATED APPROACH The strategy includes three main components : •Improvement in the case management skills of health staff through the provision of locally adapted guidelines on Integrated Management of Neonatal and Childhood Illness and activities to promote their use; •Improvements in the overall health system required for effective management of neonatal and childhood illness; •Improvement in family and community health care practices. This document is focused on achieving the first of these components.
  • 6.
    PRINCPLES OF INTEGRATEDCARE Depending on a child’s age, various clinical signs and symptoms differ in their degree of reliability and diagnostic value and importance. Therefore, the IMNCI guidelines recommend case management procedures based on two age categories : •Young infants age up to 2 months •Children age 2 months upto 5 months The IMNCI guidelines are based on following principles: •All sick young infants upto 2 months of age must be assessed of “possible bacterial infection/jaundice”and“diarrhoea” •All sick children age 2 months upto 5 years must be examined for “general danger signs” which indicate the need for immediate referral or admission to a hospital. They must then be routinely assessed for major symptoms: cough or difficult breathing, diarrhoea, fever and ear problems. •All sick young infants and children 2 months upto 5 years must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems. •Only a limited number of carefully selected clinical signs are used. Cont…….
  • 7.
    •A combination ofindividual signs leads to an infant’s or a child ‘s classification (s) rather than a diagnosis. The classifications are colour coded: “pink” suggests hospital referral or admission, “yellow” indicates initiation of specific treatment, and green calls for home management. •The IMNCI guidelines address most, but not all the major reasons a sick infant or child is brought to a clinic. •IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children. An essential component of the IMNCI guidelines is the counseling of caretakers about home care, including counseling about feeding, fluids and when to return to a health facility. Cont…….
  • 8.
    IMNCI Case managementprocess Summary of the Integrated Case management process For all sick children age up to 5 years who are brought to a first level health facility ASSESS the child : Check for danger signs (or possible bacterial infection/Jaundice). Ask about main symptoms. It a main symptoms is reported, assess further. Check nutrition and immunization status. Check for other problems CLASSIFY the child illness : Use a colour-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status. IF URGENT REFERRAL is needed for possible IF NO URGENT REFERRAL is needed for possible IDENTIFY UREGENT PRE- REFERRAL TRATMENT (S) Needed for the child’s classifications TREAT THE CHILD: Give urgent peripheral treatment(s) needed. IDENTIFY TRATMENT (S) Needed for the child classifications:identify specific medical treatment and/or advice TREAT THE CHILD: Give the first dose of oral drugs in the clinic ad/or advice the child caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. IF needed , give immunization COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practice, and solve feeding problems, if present. Advice about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health. REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretakers fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital. FOLLOW-UP care :Give follow-up care when the child returns to the clinic and, if necessary, reassess the child for new problems.
  • 9.
    THE INTEGRATED CASEMANAGEMENT PROCESS FOR THE SICK YOUNG INFANT TO 2 MONTH OF AGE OUTPATIENT HEALTH FACILITY CHECK FOR POSSIBLE BACTERIAL INFECTION/JAUNDICE Assess the SYMPYOMS * Diarrhoea Check for FEEDING PROBLEM or MALNUTRITION and IMMUNIZATION STATUS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Colour-Coded Treatment Chart PINK Urgent Referral OUTPATIENT HEALTH FACILITY •Pre-referral Treatment •Advise Parents •Refer young infant PINK Urgent Referral REFERRAL FACILITY •Emergency Triage and Treatment •Diagnosis Treatment •Monitoring and Follow-up YELLOW Treatment at outpatient health facility OUTPATIENT HEALTH FACILITY •Treat Local Infection •Give Oral Drugs •Advise and Teach Caretaker •Follow-up GREEN Home Management HOME Caretaker is counseled how to below: •Give oral drugs •Treat local infections •Continue exclusive breastfeeding •Keep the young infant warm •When to return immediately •Follow-up
  • 10.
    THE INTEGRATED CASEMANAGEMENT PROCESS FOR THE SICK CHILD FROM AGE 2 MONTHS UPTO 5 YEARS OUTPATIENT HEALTH FACILITY CHECK FOR DANGERS SIGNS •Convulsions •Lethargy/Unconsciousness •Inability to Drink/Breastfeed •Vomiting Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Colour-Coded Treatment Chart Assess MAIN SYMPTOMS •Cough/Difficulty Breathing •Diarrhea •Fever •Ear Problems PINK Urgent Referral OUTPATIENT HEALTH FACILITY •Pre-referral Treatment •Advise Parents •Refer child PINK Urgent Referral REFERRAL FACILITY •Emergency Triage and Treatment (ETAT) •Diagnosis Treatment •Monitoring and Follow-up YELLOW Treatment at outpatient health facility OUTPATIENT HEALTH FACILITY •Treat Local Infection •Give Oral Drugs •Advise and Teach Caretaker •Follow-up GREEN Home Management HOME Caretaker is counseled how to below: •Give oral drugs •Treat local infections at home •Continue feeding •When to return immediately •Follow-up
  • 11.
    CHECK FOR POSSIBLEBACTERIAL INFECTION/JAUNDICE SIGNS CLASSIFY AS IDENTIFY TREATMENT Classify ALL YOUNG INFANTS And if the infant has Jaundice And if the temp. is between 35.5-36.40 C -Convulsion or -Fast breathing (60 breath per minute more or -Severe chest in drawing or -Nasal flaring or -Grunting or -Bulging fontanelle or -10 or more skin pustules or a big boil or -If axillary temperature 37.50 c or above or temp. less than 35.50 C. -Lethagic or unconscious or -Less than normal movements POSSIBLE SERIOUS BACTERIAL INFECTION -Give first dose of I.M. ampicillin and Gentamicin -Treat to prevent low blood sugar -Warm the young infant by skin to skin contact if temp.less than 36.50 C. -Advice mother how to keep the young Infant warm on the way to the hospital. - Refer urgently to the hospital. -Umbilicus red or draining pus or -Pus discharge from ear or -<10 skin pustules LOCAL BACTERIAL INFECTION -Give oral co-trimoxazole or amoxycllin for 5 days -Teach mother to treat local infection at home -Follow up in two days. -Palms and soles yellow or -Age < 24 hours or -Age 14 days or more SEVERE JAUNDICE -Treat to prevent low blood sugar -Warm the young infant by skin to skin contact if temperature less than 36.50 C. Advice mother how to keep the young infant warm on the way to hospital. - Refer URGENTLY to hospital -Palms and soles not yellow JAUNDICE -Advice mother to give home care for the young infant. Advice mother when to return immediately. Follow up in two days. -Temperature between 35.5 to 36.40 c LOW BODY TEMPERATURE -Warm the young infant using skin to skin contact for one hour and REASSESS. if no improvement refer - Treat to prevent low blood sugar ASSESS AND CLASSIFY THE SICK YOUNG INFANT AGE UPTO 2 MONTHS
  • 12.
    Does the younginfant have diarrhoea ? ClassifyDIARRHOEA? For DEHYDRATION Two of the following signs : -Lethargic or unconscious -Sunken eyes -Skin pinch goes back very slowly SEVERE DEHYDRATION -If infant has low weight or another sever classification -Give first dose of intramuscular ampicillin and gentamicin * Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way * Refer mother to continue breast feeding * Advice mother to keep the young infant warm on the way to the hospital OR -If infant does not have low weight or any other severe classification: * Give fluid for severe dehydration (Plan C) and then refer to hospital after rehydration. Two of the following signs : -Restless, irritable -Sunken eyes -Skin pinch goes back very slowly SOME DEHYDRATION -If infant has low weight or another sever classification -Give first dose of intramuscular ampicillin and gentamicin * Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way * Refer mother to continue breast feeding * Advice mother to keep the young infant warm on the way to the hospital OR -If infant does not have low weight or any other severe classification: * Give fluid to some dehydration (Plan B) * Advice mother when to return immediately * Follow-up in two days - Not enough signs to classify or sever dehydration NO DEHYDRATION -Give fluid to treat diarrhea at home ( Plan A) -Advice mother when to return immediately. -Follow up in 5 days if not improving. and if diarrhea 14 days or more - Diarrhea lasting 14 days or more SEVERE PERSISTENT DIARRHOEA -Give first dose of intramuscular ampicillin and gentamicin if the young infant has low weight, dehydration or another severe classification. -Treat to prevent low blood sugar. -Advise how to keep infant warm on the way to the hospital. -Refer to hosptial# . and if blood in stool - Blood in stool SEVERE DYSENTERY -Give first dose of intramuscular ampicillin and gentamicin if the young infant has low weight, dehydration or another severe classification. -Treat to prevent low blood sugar. -Advise how to keep infant warm on the way to the hospital. -Refer to hospital# .
  • 13.
    THEN CHECK FORFEEDING PROBLEM & MALNUTRITION Classify FEEDINGS - Not able to feed or -Not attachment at all or -Not sucking at all or -Very low weight for age NOT ABLE TO FEED POSSIBLE SERIOUS BACTERIAL INFECTION OR SEVERE MALNUTRITION -Give first dose of intramuscular ampicillin and gentamicin - Treat to prevent low blood sugar. - Warm the young infant by skin to skin contact if temperature less than 36.50 C while arranging referral. - Advice mother how to keep the young infant warm on the way to hospital. - Refer URGENTLY to hospital# - Not well attached to breast or - Not suckling effectively or -Less than 8 breastfeeds in 24 hours or -Receives other foods or drinks or -Thrush (ulcer or white patches in mouth) or -Low weight for age or -Breast or nipple problems FEEDING PROBLEM OR LOW WEIGHT FOR AGE -If not well attached nor not sucking effectively, teach correct positioning and attachment. -If breastfeeding less than 8 times in 24 hours, advice to increase frequency of feeding. -If receiving other food or drinks, counsel mother about beast feeding more, reducing other food or drinks and using a cup and spoon. * If not breastfeeding at all advice mother about giving locally appropriate animal milk and teach the mother to feed with a cup and spoon. -If thrush, teach the mother to teat thrush at home. -If low weight for age, teach the mother how to keep the young infant with low weight warm at home. -If breast or nipple problem, teach the mother to treat breast or nipple problems. -Advice mother to give home care for the young infant -Advice mother when to return immediately. -Follow up any feeding problem or thrush in 2 days. -Follow up low weight for age in 14 days. - Not low weight for age and no other signs of inadequate feeding NO FEEDING PROBLEM -Advice mother to give home care for the young infant. -Advice mother when to return immediately. -Praise the mother for feeding the infant well.
  • 14.
    DOES THE CHILDHAVE COUGH OR DIFFICULT BREATHING ? Classify COUGH or DIFFICULT BREATHINGS SIGNS CLASSIFY AS IDENTIFY TREATMENT - Any general danger sign or -Chest indrawing or -Stridor in calm child. SEVERE PNEUMONIA OR VERY SEVERE DISEASE -Give first dose of injectable chloramphenicol -Refer URGENTLY to hospital# -Fast breathing PNEUMONIA -Give cotrimoxazole for 5 days -Soothe the throat and relieve the cough with a safe remedy if child is 6 month or older -Advice mother when to return immediately -Follow up in 2 days. - No signs of pneumonia or very severe disease NO PENUMONIA COUGH OR COLD -If coughing more than 30 days, refer for assessment. -Soothe the throat and relieve the cough with a safe home remedy if child is 6 months or older. -Advice mother when to return immediately -Follow-up in 5 days if not improving. ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UPTO 5 YEARS
  • 15.
    DOES THE CHILDHAVE DIARRHOEA ? ClassifyDIARRHOEA? For DEHYDRATION Two of the following signs : -Lethargic or unconscious -Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly SEVERE DEHYDRATION -If Child has no other sever classification -Give fluid for severe dehydration (Plan C) - if child also has another severe classification : Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Advice mother to continue breast feeding. - If child in 2 years or older and there is cholera in your area, give doxycycline for cholera. Two of the following signs : -Restless, irritable -Sunken eyes -Drinks eagerly, thristy -Skin pinch goes back very slowly SOME DEHYDRATION - Give fluid and food for some dehydration (Plan B) -if child also has another severe classification : Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Advice mother to continue breast feeding. -Advice to mother when to returnimmediately -Follow-up in 5 days if not improving - Not enough signs to classify as some or sever dehydration NO DEHYDRATION -Give fluid to treat diarrhea at home ( Plan A) -Advice mother when to return immediately. -Follow up in 5 days if not improving. and if diarrhea 14 days or more and if blood in stool - Dehydration present SEVERE PERSISTENT DIARRHOEA - Treat dehydration before referral unless the child has another severe classification -Refer to hospital# . - No dehydration PERSISTENT DIARRHOEA -Advice the mother on feedings child who has PERSISTENT DIARRHOEA. -Give single dose of vitamin A. -Give zinc sulphate 20 mg daily for 14 days -Follow up in 5 days. - Blood in stool DYSENTERY -Treat for 5 days with cotrimoxazole -Follow up in 2 days
  • 16.
    DOES THE CHILDHAVE FEVER ClassifyFEVER High Malaria risk -Any general danger sign or -Stiff neck or -Bulging fontanelle VERY SEVERE FEBRILE DISEASE -Give first dose of IM quinine after making a blood smear -Give first dose of IV or IM chloramphenicol ( if not possible give oral amoxycillin). -Treat the child to prevent low blood sugar -Give one dose of PCM in clinic for high fever (temp.38.50 C or above) -Refer URGENTLY to hospital FEVER MALARIA -Give oral antimalarial for high malaria risk area after making a blood smear. -Give one dose of PCM in clinic for high fever -Advice mother when to return immediately. -Follow-up in two days if fever persist -If fever present every day for more than 7 days , refer for assessment. Low Malaria risk -Any general danger sign or -Stiff neck or -Bulging fontanelle VERY SEVERE FEBRILE DISEASE -Give first dose of IM quinine after making a blood smear -Give first dose of IV or IM chloramphenicol ( if not possible give oral amoxycillin). -Treat the child to prevent low blood sugar -Give one dose of PCM in clinic for high fever (temp.38.50 C or above) -Refer URGENTLY to hospital FEVER -No runny nose and NO measles and No other cause of fever MALARIA -Give oral antimalarial for low malaria risk area after making a blood smear. -Give one dose of PCM in clinic for high fever -Advice mother when to return immediately. -Follow-up in two days if fever persist -If fever present every day for more than 7 days , refer for assessment. -Runny nose present or -Measles Present or -Other cause of fever present FEVER MALARIA UNLIKELY -Give one dose of PCM in clinic for high fever. -Advise mother when to return immediately -Follow-up in two days if fever persists -If fever is present every day for more than 7 days refer for assessment.
  • 17.
    IF MEASLES now orwithin last 3 months classify - Any general danger sign or -Clouding of cornea or -Deep or extensive mouth ulcers SEVERE COMPLICATED MEASLES -Give first dose of Vitamin A. -Give first dose of injectable chloreamphenicol (if not possible give oral amoxycillin) -If clouding of cornea or pus draining from the eye, apply tetracycline eye ointment -Refer URGENTLY to hospital# -Pus draining from the eye or -Mouth ulcers MEASLES WITH EYE OR MOUTH COMPLICATIONS -Give first dose of Vitamin A. -If pus draining from the eye, apply tetracycline eye ointment -If mouth ulcer treat with gentian violet -Follow-up in two days - Measles now or within the last three months MEASLES -Give first dose of Vitamin A DOES THE CHILD HAVE FEVER DOES THE CHILD HAVE AN EAR PROBLEM ClassifyEARPROBLEM - Tender swelling behind the ear MASTOIDITIS -Give first dose of injecable chloramphenicol(if not possible give oral amoxycillin) - Give first dose of PCM for pain - Refer URGENTLY to hospital# -Pus draining from the ear and discharge is reported for less than 14 days or -Ear pain ACUTE EAR INFECTION -Give cotrimoxazole for 5 days. - Give PCM for pain -Dry the ear by wicking -Follow up in 5 days - Pus draining from the ear and discharge is reported for 14 days or more CHRONIC EAR INFECTION -Dry the ear by wicking -Follow up in 5 days -No ear pain -No pus draining for ear NO EAR INFECTION -No additional treatment
  • 18.
    CHECK FOR MALNUTRITIONClassifyNUTRITIONALSTATUSClassifyANAEMIA -Visible severe wasting or -Oedema of both feet SEVERE MALNUTRITION -Give single dose of vitamin A. -Prevent low blood sugar -Refer urgently to hospital -While referal is being organized, warm the child -Keep the child warm on the way to hospital -Malnutrition grade II,III,IV VERY LOW WEIGHT -Assess and counsel for feeding -Advise mother when to return immediately -Follow-up in 30 days -If feeding problem follow up in 5 days N normal weight for age or malnutrition grade I NOT VERY LOW WEIGHT -If child is less than 2 year old asses the child’s feeding and counsel the mother feeding according to the food box on the COUNSEL THE MOTHER chart. -If feeding problem follow up in 5 days -Advice mother when to return immediately. CHECK FOR ANAEMIA Severe palmer pallor SEVERE ANAEMIA -Refer URGENTLY TO HOSPITAL -Some palmer pallor ANAEMIA -Give iron folic acid therapy for 14 days. -Assess the child feeding and counsel the mother feeding according to FOOD BOX on the COUNSEL THE MOTHER chart. -Advice mother when to return immediately. -Follow up in 14 days - No palmer pallor NO ANAEMIA -Give prophylactic iron folic acid if child 6 month or older
  • 19.
    CHECK THE CHILD’SIMMUNIZATION, PROPHYLACTIC VITAMIN A & IRON FOLIC ACID SUPPLEMENTATION STATUS IMMUNIZATION SCHEDULED Age Vaccine Birth BCG+ OPV-0 6 week DPT-1+OPV-1(HepB-1**) 10 week DPT-2+OPV-2(HepB-2**) 14 weeks DPT-3+OPV-3(HepB-3**) 9 months Measles + Vitamin A 16-18 month DPT Booster +OPV+Vitamin A 60 Months DT PROPHYLACTIC VITAMIN A Give a single dose of vitamin A One lac at 9 months with measles immunization Two lac at 16-18 months with DPT booster Two lac at 24 months Two lac at 30 months Two lac at 36 months PROPHYLACTIC IFA Give 20mg elemental iron + 100 µg folic acid (1 tab. of pediatric IFA or 5 ml of IFA syrup or 1 ml of IFA drops) for a total of 100 days in a year after the child has recovered from acute illness if -The child is 6 months of age or older and -Has not received Pediatric IFA tab./syrup/drop for 100 days in last one year
  • 20.
    COUNSEL THE MOTHER -FEEDING RECOMMENDATION DURING SICKNESS AND HEALTH Up to 6 months of age 6 months up to 12 months 12 months upto 2 years 2 years and older •Breastfeed as often as the child wants, day and night at least 8 times in 24 hours •Do not give any other foods or fluids not even water Remember •Continue breastfeeding if the child is sick •Breastfeeding as often as the child want. •Give at least one katori serving* at a time of : - Mashed roti/rice/bread/bisuit mixed in sweetened undiluted milk OR -Mashed roti/rice/bread mixed in thick dal with added ghee/oil or kichri with added oil/ghee. Add cooked vegetable also in the servings OR -Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk or -Mashed boiled/fried potatoes -Offer banana/biscuit/cheeko/mango/papaya * 3times per day if breastfed. * 5 times per day if not breastfed. Remember: •Keep the child in your lap and feed with your own hands. •Wash your own and child's hand wit soap and water every time before feeding *Breastfeed as often as the child wants •Offer food from family pot •Give at least 11/2 katori at a time of : - Mashed roti/rice/bread/bisuit mixed in sweetened undiluted milk OR -Mashed roti/rice/bread mixed in thick dal with added ghee/oil or kichri with added oil/ghee. Add cooked vegetable also in the servings OR -Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk or -Mashed boiled/fried potatoes -Offer banana/biscuit/cheeko/mango/pa paya * 5 times per day Remember •Sit by the side of child and help him to finish the serving •Wash your own and child’s hand wit soap and water every time before feeding *Give family foods at 3 meals each day *Also twice daily,give nutrition food between means, such as: banana/biscuit/che eko/mango/papaya as snacks. Remember *Ensure that the child finishes the serving *Teach your child wash his hand with soap and water everytime before feeding
  • 21.
    - GIVE FOLLOWUP CARE FOR THE SICK CHILD -PENUMONIA After 2 days Check the child for general danger signs Assess the child for cough or difficult breathings Ask •Is the child breathing slower ? •Is there less fever? •Is there child eating better? Treatment : -If chest indrawing or a general danger sign, give a dose of second line antibiotic or intramuscular cholramphenicol.Then refer URGENTLY to hospital. -If breathing rate, fever and eating are the same, change to the second line antibiotic and advice the mother to return in 2 days or refer. (if this child has measles within the last 3 months, refer). -If breathing slower, less fever, or eating better, complete the 5 days of antibiotic. -PERSISTENT DIARRHOEA After 5 days Ask •Has the diarrhoea stopped? •How many loose stools is the child having per day? Treatment : -If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to hospital. -If the diarrhea has stopped (child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child’s age. Continue oral zinc for a total of 14 days.
  • 22.
    -DIARRHOEA After 5 days Ask •Hasthe diarrhoea stopped? •How many loose stools is the child having per day? Treatment : -If diarrhoea persists, assess the child for diarrhoea and manage as on initial visit. -If diarrhoea has stopped, tell the mother to follow the usual feeding recommendations for the child’s age. -DYSENTERY After 2 days Assess the child for diarrhoea Ask •Are there fewer stools ? •Is there less blood in the stool? •Is there less fever? •Is there less abdominal pain? •Is the child eating better? Treatment : -If the child is dehydrate treat dehydration -If number of stools, amount of blood in stools, fever, abdominal pain or eating is the same or worse. Change to second-line oral antibiotic recommended for shigella in your area. Give it for 5 days. Advise the mother to return in 2 days. Exception – If the child : - is less than 12 months old or had measles within the last 3 months. (Refer to hospital) -If fewer stools, less blood in the stool,less fever, less abdominal pain, and eating better, continue giving the same antibiotic until finished. -If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same or worse after treatment with nalidixic acid/second line drug.(refer to hospital)
  • 23.
    -MALARIA ( Lowor High Malaria Risk) If fever persists after 2 days, or returns within 14 days Treatment : -If the child has any general danger sign or stiff neck. Treat as very severe FEBRILE DISEASE. -If the child has any cause of fever other than malaria, provide treatment. -If malaria is the only apparent cause of fever: * Treatment within the second line oral antimalarial( if no second line antimalarial is available.refer to hospital). Advice the mother to return again in 2 days if the fever persists. Continue primaquine if P.vivax was positive for a total of 5 days. * If fever has been present for 7 days, refer for assessment. -FEVER- MALARIA UNLIKELY ( Low Malaria Risk ) If fever persists after 2 days Treatment : -If the child has any general danger sign or stiff neck. Treat as very severe FEBRILE DISEASE. -If the child has any cause of fever other than malaria, provide treatment. -If malaria is the only apparent cause of fever: * Treatment within the first line oral antimalarial. Advice the mother to return again in 2 days if the fever persists. * If fever has been present for 7 days, refer for assessment.
  • 24.
    -MEASLES WITH EYEOR MOUTH COMPLICATIONS After 2 days: Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Check for foul smell from the mouth.. Treatment for eye infection: -If pus is draining from the eye,ask the mother to describe how she has treated the eye infection, if treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct treatment. -If the pus is gone but redness remains,continue the treatment . -If no pus or redness, stop the treatment . Treatment for Mouth Ulcer: -If mouth ulcer are worse, or there is a very foul smell from the mouth, refer to hospital. -If mouth ulcer are the same or better,continue using half strength gentian violet for a total of 5 days. -EAR INFECTION After 5 days: Reassess for ear problem. Measure the child temperature. Treatment : -If there is tender swelling behind the ear or high fever (38.50 C or above), refer URGENTLY to hospital. -Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow up in 5 days. -Chronic ear infection : Check that the mother is wicking the ear correctly. If ear discharge getting better encourage her to continue. If no improvement, refer to hospital for assessment. -If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the 5 days of antibiotic,tell her to use of it before stopping.
  • 25.
    -FEDDING PROBLEM After 5days: Reassess feeding Ask about any feeding problems found on the initial visit. -Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding ask her to bring the child back again. -If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child weight gain. -VERY LOW WEIGHT After 30 days: Weigh the child and determine if the child is still very low weight for age. Reassess feeding. Treatment : -If the child is no longer very low weight for age, praise the mother and encourage her to continue. -If the child is still very low weight for age, counsel the mother about any feeding problem found. Ask the mother to return again in one month. Continue to seethe child monthly until the child is feeding well and gaining weight regularly or is no longer very low weight for age. Exception : If you do not think that feeding will improve or if the child has lost weight, refer the child. -ANAEMIA After 14 days: -Give iron folic acid. Advice mother to return in 14 days for more iron folic acid. -Continue giving iron folic acid every 14 days for 2 months. -If the child has palmer pallor after 2 months, refer for assessment.
  • 27.