001 holistic approach sick under 5 y.o.


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001 holistic approach sick under 5 y.o.

  1. 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. 2. Millennium Development GoalsMillennium Development Goals (MDG) by 2015 – UN/WHO(MDG) by 2015 – UN/WHO
  3. 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. 4. Management of childhood illness:Management of childhood illness: Rationale for an integrated strategyRationale for an integrated strategy
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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.
  9. 9. The IMCI StrategyThe IMCI Strategy
  10. 10. 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
  11. 11. 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
  12. 12. IMCI ClinicalIMCI Clinical GuidelinesGuidelines
  13. 13. 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.
  14. 14. 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).
  15. 15. 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
  16. 16. 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
  17. 17. Guidelines - ClassificationsGuidelines - Classifications
  18. 18. 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
  19. 19. • 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
  20. 20. IMCI CaseIMCI Case Management ProcessManagement Process
  21. 21. 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
  22. 22. IMCI Case Management Process
  23. 23. 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
  24. 24. IMCI Case Management Process
  25. 25. IMCI Case Management Process
  26. 26. 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
  27. 27. IMCI Case Management Process
  28. 28. 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