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- 1. Section 1 General Principles for Management of Sick Children
- 2. Section Objectives • State the causes of under 5 mortality in Nepal • Describe the linkage of CB-IMNCI with FB-IMNCI Programme • Describe the management process of sick children referred to hospital • Describe various concepts of effective communication skills and counseling • Demonstrate effective communication skills while counseling • Describe the infection prevention measures involved in care of newborn and children
- 3. Under five mortality • Every year more than 10 million children die in developing countries before they reach their fifth birthday. • In Nepal, the under-five mortality rate is 39 per 1000 live births. (NDHS 2016) • Majority of these deaths occur within the neonatal period. • The neonatal mortality rate is 21 per 1000 live births and infant mortality rate is 32 per 1000 live births.
- 4. Under five mortality • Though Nepal met its Millennium Development Goal target of reducing under-5 mortality to 54 deaths per 1,000 live births by 2015, it has a long way to go to meet the Sustainable Development Goal target of reducing under-five mortality to 28 deaths per 1,000 live births. • More challenging is the goal of reducing neonatal mortality rate below 12 per 1000 live births.
- 5. Under five mortality • The most common causes of infant and child mortality in developing countries including Nepal are perinatal conditions, pneumonia, diarrhoea, malaria, measles and malnutrition • Many of these deaths may be prevented by early referral of sick children to health facility and providing appropriate treatment.
- 6. Child mortality in Nepal • Causes of under five mortality Prematurity 30% Sepsisand other infectious conditions of the newborn 7% Birthasphyxia and birthtrauma 11% Congenital anomalies 4% Acutelower respiratory infections 15% Diarrhoealdiseases 6% Other communicable, peri natal and nutritional conditions 8% Otherdiseases (Meningitis, injuries ,pertusis, measles, non-communicable diseases) 19%
- 7. Discussion • How sick children are received in your facility? • How are they assessed? • Which children are referred? • How are they referred?
- 8. Linkage of CB-IMNCI with FB- IMNCI Program
- 9. Linkage of CB- IMNCI with FB- IMNCI Disease/Problem addressed CB-IMNCI Protocol Classifications FB-IMNCI Protocol Diagnosis Emergency Conditions Very Severe Disease (when 1 of 4 General Danger Signs present) • Convulsion • Vomits everything • Lethargic or Unconscious • Unable to suck or feed Emergency Triage Assessment and Treatment (ETAT)-ABCD approach • Airway and Breathing Problem • Shock (Circulation) • Coma and Convulsion • Dehydration (severe) Cough or Difficulty Breathing • Red: Severe Pneumonia or Very Severe Disease • Yellow: Pneumonia • Green: Cough and Cold • Pneumonia and its complications • Upper Respiratory Infection • Bronchiolitis • Bronchial Asthma • Croup
- 10. Linkage of CB- IMNCI with FB- IMNCI Disease/Problem addressed CB-IMNCI Protocol Classifications FB-IMNCI Protocol Diagnosis Diarrhoea •Acute Diarrhoea Red: Severe Dehydration Yellow: Some Dehydration Green: No Dehydration •Severe Persistent Diarrhoea •Persistent Diarrhoea •Dysentery • Acute watery diarrhea • Cholera • Dysentery • Persistent Diarrhoea Fever and Ear Problems Red: Very Severe Febrile Disease or Severe Malaria or Severe Complicated Measles Yellow: Malaria or Measles with mouth or eye complications Green: Measles or Fever Red: Mastoiditis Yellow: Acute or Chronic Ear Infection Green: No ear infection Meningitis Septicemia Typhoid fever UTI Measles Mastoiditis, Acute Otitis Media, Chronic Otitis Media Malaria Dengue Kala-azar
- 11. Linkage of CB- IMNCI with FB- IMNCI Disease/Probl em addressed CB-IMNCI Protocol Classifications FB-IMNCI Protocol Diagnosis Malnutritio n and Anemia Red: Severe Acute Malnutrition, Severe Anemia Yellow: Moderate Acute Malnutrition, Anemia Green: No malnutrition, No anemia SAM (6 months to 5 years) SAM (< 6 months) MAM Nutritional Anemia Others Red: HIV Infected Yellow: HIV Exposed Green: No HIV Infection TB HIV/AIDS Suspected poisoning Developmental delay Common surgical problems
- 12. Linkage of CB- IMNCI with FB- IMNCI Disease/Probl em addressed CB-IMNCI Protocol Classifications FB-IMNCI Protocol Diagnosis Newborn Care Essential Newborn Care Management of asphyxiated newborn Examination of Newborn Red: Possible Serious Bacterial Infection, Severe Janundice, Severe Hypothermia Yellow: Local Bacterial Infection, Jaundice, Hypothermia Green: No Infection Red: Severe dehydration, Severe Persistent Diarrhoea, Dysentery Yellow: Some dehydration Green: No dehydration Yellow: Breastfeeding Problem or LBW Green: No breastfeeding Problem Care of normal newborn at birth Examination of newborn Breast feeding and assisted feeding SNCU admission and discharge criteria Preterm and LBW Hypothermia Hypoglycemia Jaundice Respiratory distress Neonatal Sepsis Management of asphyxiated newborn Neonatal seizure Hemodynamic compromise (shock) Assessment and management of newborn requiring special care
- 13. Integrated Approach to Management of Sick Children
- 14. Integrated approach to management of sick child • Self reading
- 15. Integrated approach to the management of sick children- summary Triage for emergency signs and treat History and Examination Point of care/ Bedside investigation if required Differential diagnosis Hospitalization or referral Inpatient treatment Monitor for response to treatment or complications Not improving or new complication Revise treatment or treat complications or referral Improvement Continue treatment counsel and plan discharge Discharge and arrange followup
- 16. Safe transport of sick children
- 17. Introduction • Important part of overall care of a child • Constraints – Facilities are scarce and not easily available – Families have poor resources – Organized transport services are not available. At times the baby may have to be transported on foot or on bullock cart. – No health provider is available to accompany the baby – Facilities are not fully geared up to receive sick neonates – Communication systems are non-existent or inefficient
- 18. Preparation before transport 1. Assess and stabilize Utmost important If unstable, deteriorate on way a. Temperature b. Airway- position neck, suction secretions, check for chest movements c. Breathing- Tactile stimulation, BMV
- 19. Preparation before transport 1. Assess and stabilise d. Circulation- Fluid boluses, dopamine if needed e. Fluids- Maintenance, replace ongoing loss f. Medications- Antibiotics, anticonvulsants, Vit K in newborn g. Feeding Breastfeeding, cup or gavages If not able to feed, then only give IVF
- 20. Preparation before transport 2. Write a note a. Details of baby’s condition b. Need for referral c. Treatment given to the baby 3. Encourage mother to accompany
- 21. 4. Arrange a provider to accompany Doctor/ nurse/ health worker 5. Communication a. Explain the condition, prognosis, reasons for referral b. Explain where to go and indicate whom to contact c. Inform the referral facility beforehand if possible
- 22. Care during transport 1. Stabilise prior to transfer 2. Maintenance of warm chain a) KMC b) Properly covered in cloth c) Transport incubator 3. Prevention of hypoglycemia a) Breastfed if able to suck b) Spoon fed/ NG tube if not able to suck c) If not able to feed, intravenous fluid
- 23. Care during transport 4. Maintenance of airway and breathing a. Keep the neck of the baby in slight extension b. Do not cover baby’s mouth and nose c. Wipe secretions from nose and mouth with cotton or cloth covered finger d. Check breathing- Watch breathing,, tactile stimulation or BMV 5. Educate parents about danger sign while transport
- 24. Transfer checklist • Checklist 1.1( Page 2 of participants workbook)
- 25. Referral note for neonate and children • Chart 1.3 and 1.4
- 27. Introduction • Techniques you can use to show the mother or family that you care and respect them and that you want to help • Also involve body language, every gesture or action you make should be culturally appropriate.
- 28. Role Play • Participants workbook- Role play 1 and 2( Page 6 and 7 of participants workbook)
- 29. Good communication skill 1. Showing respect Greet mother appropriately and ask her to sit with her baby Treat the mother as someone who can understand her baby’s health problems and can make good decisions about care 2. Not being judgmental Never blame a mother/caregiver for the baby’s problem, cultural practices, or past decisions she has made. 3. Speaking clearly and using words the mother understands Communication should be understood by both the health worker and the mother. If possible, speak with the woman in the language with which she is most comfortable.
- 30. Good communication skill 4. Listening actively Listen to what the mother says and how she says it Maintain silence for some time. Give the mother time to think, asK questions, and talk. Offer feedback to encourage the mother to continue. Summarize what the mother has said. Provide praise and encouragement for positive behaviours or practices 5. Use body language Smile. Maintain eye contact while talking and listening. Speak gently. If culturally suitable and acceptable, touch the mother gently on her arm or shoulder.
- 31. Good communication skill 6. Encouraging the woman to voice her concerns and ask questions Answer her questions honestly 7. Respecting the mother’s right to make decisions about her own health care and that of her baby It is your responsibility to give the woman all the information she needs to make a decision, not to make the decision for her 8. Listening to what the mother has to say Give her enough time to tell you what she thinks is important.
- 32. Types of information to be provided during hospitalization • Communication begins right at the time of admission of the child to the hospital till the time child is discharged or referred to higher center and during follow up visit. • Information must be provided • The reasons for admission • Initial diagnosis of the patient at the time of admission • Outline management plan
- 33. Types of information to be provided during hospitalization • Initial/current prognosis • Daily progression • Changing clinical course /adverse event • Information and consent regarding any intervention/procedure • Reasons for referral and care during transport in case of emergency referral to higher centres • Follow up information in case of discharge
- 34. Rules to be followed • Remember information provided should be Practical and in simple language easily understood by the parents/relatives Should be of immediate relevance Do not flood the parents with too much information at a single contact
- 35. Rules to be followed • Remember information provided should be Avoid use of technical words Information provided may require repetition for the parents to understand it Timing of providing information is crucial. Fix up a specific time daily
- 36. Rules to be followed • Remember information provided should be Discussion should be unhurried and relaxed Preferably provide bedside information so that the parents are oriented to the current situation of the baby
- 37. Rules to be followed • Remember information provided should be Any bad news/adverse event should be disclosed in a quiet and private setting Documentation of the information provided to the parents is important. Hence document and put the signature of parents especially after explaining poor prognosis/adverse events.
- 38. Levels of communication • Communication at the time of admission Discussion should be done after stabilization of the child. Give honest opinion about the condition of the baby. • Communication during stay Communicate with the parents about the condition, treatment plan of patient Every morning and evening and clear their doubts and queries about the condition of the child more frequently if required. Mother should also be involved in the care of the child whenever possible.
- 39. Levels of communication • Communication in case of death If the child is critically ill, the family members should have been prepared for any eventuality As soon as possible sit down with the parents to tell them about the condition of the child. The exact cause of death should be informed to the parents in the simple language
- 40. Levels of communication • Communication on discharge Give standardize information to ensure that every family member receive uniform information The family may be counselled regarding care, nutrition, immunization and follow up Parents should be encouraged to contact the hospital for any queries and write contact number in discharge sheet.
- 41. Levels of communication • Communication at the time of referral to a higher centre Explain clearly to the parents about clinical condition and reasons why the child needs referral. Explain where to go, how to go and whom to contact on reaching. Explain the care that baby requires during transport.
- 42. Communication skills • Checklist 1.2 ( Page 6 of participants workbook)
- 43. Counseling • Components –Introduces self –Tells reason for admission –Initial diagnosis –Outline management plans –Tells about the prognosis
- 44. Counseling • Components – Daily progression if not admitted the same day – Changing clinical course – Adverse events – Information and consent of any interventional procedure – Reason for referral – Follow up information in case of discharge
- 45. Counseling • Checklist 1.3 for counseling ( Page 7)
- 46. Role Play • Participants workbook- Role play 1 and 2( Page 6 and 7 of participants workbook)
- 48. Introduction • Leading cause of death in neonates and children • Every hospital should have written policies of infection prevention • Prevention of infection is more cost effective than treating infection
- 49. Sources of infection • Touching – Touching an object that is dirty or contaminated spreads germs and contaminates the hands. • Blood and body secretion – By a mother to her baby during pregnancy, birth, or with breastfeeding. – By contact with blood or amniotic fluid from an infected person.
- 50. Sources of infection • Air – Infectious germs coughed into the air by an infected person and passed to others who breathe in the air. • Food and water – Contaminated food and water (bottle feeding)
- 51. Common precautions • Follow universal precautions • Consider every person as potentially infectious • Wash hand and wear gloves before every procedure • Wear protective clothing • Use aseptic technique • Protect yourself from blood and other body fluids during deliveries and procedures
- 52. Common precautions • Practice safe waste disposal • Prevent injuries with sharps • Use clean clothes • Keep the newborn unit/patient care room clean • Isolate babies with infection to prevent nosocomial infections • Keep separate spirit and povidone iodine swab containers, stethoscope, measuring tape and thermometer for each baby
- 53. Common precautions • Change IV set daily (as per feasibility) • Use syringe, suction catheter once only • Feeding tubes can be left alone as long as baby can keep (maximum upto 7 days) • Do not keep fomites on the baby cot • Change the solution in suction bottles and sterile water in oxygen chamber every day and sterilize the bottle daily by dipping in 2% gluteraldehyde for 4-6 hrs
- 54. Common precautions • Do not use a single dextrose/saline bottle for >24 hours. • There should be a separate IV fluid bottle for each baby. • Label the bottle with date and time of opening. • Use syrup within 1 week of opening. • Antibiotics vials to be changed after 24 hours. • Use separate IV set for giving antibiotics.
- 55. Requirements for infection prevention • Running water supply • Soap • Elbow or foot operated taps • Strict hand washing practice • Adequate amount of disposables such as; sterile gloves, needle and syringe
- 56. Requirements for infection prevention • Disinfectant/antiseptic solutions. • Instrument decontamination with 0.5% chlorine solution (virex) for 10 minutes • Strict adherence to asepsis routines and good housekeeping. • Rational use of antibiotics.
- 57. Handwashing
- 58. Introduction • 2 minutes before entering the unit • 20 seconds before and after touching babies
- 59. Indications • Before and after caring/touching for newborn and before any treatment procedure. (You can use hand sanitizer if below indications are not present. Follow the same steps as handwashing) • Whenever hands (or any other skin area) are contaminated with blood or other body fluids • After removing gloves, because they may have holes • After changing soiled napkins or clothing • Keep nails short and do not apply nail polish
- 60. Handwashing Palm to palm right palm over left and vice versa Palm to palm, finger interlaced Back of fingers to opposing finger interlocked Rotational rubbing of Rt thumb Rotational rubbing of tips of clasped in left palm right fingers and thumb over left palm and vice versa
- 61. Handwashing • See Checklist 1.3( Page 8 of participants workbook)
- 63. Indication • Receiving baby at delivery • Cutting cord and applying 4% chlorhexidine gel • Eye care • Invasive procedure – Blood sampling – Venous cannulation – Urethral catheterization for urine collection – Starting IV lines and giving IV/IM injections – Giving skin, umbilical or eye care when infected
- 65. Wearing sterile gloves • See checklist 1.4( Page 9 of participants workbook)
- 66. Other infection prevention measures • Skin preparation • Safe disposal of waste • Terminal Disinfection • Methods of cleaning different equipment ( Table 1.2) • Recommended colour code for container, labelling and international signs for segregation of health care waste( Table 1.3)
- 67. Thank you