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Imci Chart Booklet Up Date

Imci Chart Booklet Up Date

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Introduction
The Integrated Management ofChildhood Illness (IMCI) strategy isthe primary child-care approach ofchoice for South Africa.
1,2
IMCI trainingwas introduced into South Africa in1996 by WHO and UNICEF. Since then8695 health workers have been trainedin IMCI – mainly primary health carenurse practitioners, but also primarycare doctors and paediatricians. Thebasic 11-day course comprisesclassroom activities, assessingchildren both in an outpatient settingand paediatric ward.
3
A compact 4-day course has been developed fordoctors and is being taught in somemedical schools. IMCI has been verywell received by nurse practitionerand doctor alike in empowering themto make easy, evidence-baseddecisions in the management of sickchildren at first contact level. Howevermany doctors continue to work withchildren without knowledge of IMCI.Thus, the purpose of this review istwo-fold:Firstly, many doctors working inhospitals receive referrals fromclinic-based IMCI nurse practi-tioners. Doctors need to beinformed what an IMCI classi-fication means. For example,children are commonly referredwith a classification of “
Severe Pneumonia or Very Severe Disease 
”. What does this mean?How should the doctor managethis child?Secondly, this review introducessome of the basic IMCI skills. Anunderstanding of these skills couldbe helpful for doctors working withsick children in general practice,clinics, community health centresor in an outpatient setting. However,to become a skilled IMCIpractitioner, it is essential for adoctor to attend an IMCI course.
The IMCI approach
IMCI focuses on illnesses that causethe majority of deaths in childrenunder-6 years, many of which arepreventable or readily treatable usingsimple interventions: These arepneumonia, diarrhoea, meningitis,malaria, malnutrition, anemia and HIV/AIDS. This is called a “child survival”approach. Other important aspects ofchild health are also addressed suchas ear infections, the sick young infant(under 2 months), breast-feeding andfeeding assessment.Doctors attending a 4-day IMCIcourse work from two maindocuments: Firstly, a short textbookcalled IMCI: A Handbook for MedicalPractitioners.
4
The second is a deskreference, used by all nurses anddoctors practicing IMCI, called theChart Booklet.
5
These were developedby WHO and adapted to the SouthAfrican setting. The Chart Bookletcontains all the information needed toconduct a comprehensive primarychild-care consultation and is availableon the website . The key informationin the Chart Booklet has beensummarized into Table I of this review.Table I is designed as an easyreference on the wall of theconsultation room. The rest of thisreview revolves around the informationin Table I.As can be seen in Table I, the IMCIpractitioner asks pertinent questions,examines the child and will then
assess 
these signs. Depending on thesigns present, one or often more
classifications 
are made. Classificationis similar to a diagnosis but is context-specific: For example, in a primarycare setting, a classification of
Suspected Meningitis 
is made in afeverish child with neck stiffness. Onlywhen this child is referred to hospitalwhere a lumbar puncture can beperformed and the cerebro-spinal fluid
SA Fam Pract 2005;47(8)
32
A review of IntegratedManagement of ChildhoodIllness (IMCI)
Kerry T,
MBChB, MFamMed, DipMid COG(SA)uMgungundlovu Health District, KwaZulu-Natal.
Keywords:
IMCI, case management, sick children, pneumonia, diarrhoea, fever,malnutrition, anemia, HIV/AIDS, sick young infant, feeding assessment.
Correspondence:
Dr. Kerry T, District Medical Manager, uMgungundlovu Health District, KwaZulu-Natal.PO Box 21741, Mayors Walk, Pietermaritzburg, 3208, Tel:033 3426675, Fax:033 3943235, e-mail: kerry@futurenet.co.za
 
(SA Fam Pract 2005;47(8): 32-38) 
Review
 
examined under the microscope cana
diagnosis 
be made. The classi-fications are graded into levels ofseriousness and are colour-coded. Asevere classification, coloured red,requires urgent treatment and referralto hospital. The less seriousclassification, coloured yellow, requiressome treatment at home such asamoxycillin for
Pneumonia.
The leastsevere classification, coloured green,requires supportive treatment at home.
Assessing children between 2months and 5 years
The IMCI practitioner performs theconsultation in a systematic manner,checking the important systems in thesame order as in Table I. Start bychecking for the 4
General Danger Signs 
(GDS)
.
These are: A child whois unable to drink or breastfeed; a childwho vomits everything taken by mouth;convulsions in this illness; a child whois lethargic or even unconscious. Ifone or more of these signs are present,the child is likely to be seriously ill andrequire hospital care.The practitioner then asks for all 4of the main symptoms, even if thecaregiver does not mention them.These are: cough or difficult breathing,diarrhoea, fever and ear problem. Therelevant symptoms and signs are listedin the left hand column of Table I.
Cough
is one of the most commonpresenting complaints among sickchildren. The practitioner needs to beable to efficiently identify whichchildren do not just have coryza, butmay have pneumonia. When makinga classification, always start with thesevere, red row: Then very sickchildren will not be missed – IMCI islike a safety net catching the very sickchildren. A child with cough or difficultbreathing together with a GDS, chestindrawing or stridor would be assignedto the severe, red classification, called
Severe Pneumonia or Very Severe Disease.
Chest indrawing is an inwardmovement of the lower chest wall whenthe calm child breathes in (Figure 1).If the child has none of these signs,but has fast breathing, then theclassification is
Pneumonia.
The cut-off rates for breathing rate decreasewith age and are written in Table I forthe older child and the sick younginfant. The breathing should becounted for a full minute in a calmchild. The breathing rate has beenshown to be much more reliable indiagnosing pneumonia than listeningwith a stethoscope.
6
A child with noneof the severe signs and a normalbreathing rate is classified as
Coughor Cold 
. Using these simple signs, itis easy to decide which child needsreferral to hospital, an oral antibioticor supportive care at home. Treatmentis listed in the right hand column. Fulldosages for all medicines used canbe found in the Chart Booklet. Thepresence of a wheeze is alsoconsidered together with cough.
Diarrhoea
is also a commonchildhood illness. The first step is todecide on the degree of dehydration:4 signs are assessed: generalcondition (restless/ irritable or lethargic/unconscious), sunken eyes, skin pinch(slow or very slow if the skin returnsto normal only after 2 seconds) andresponse to a cup of Oral RehydrationSolution (ORS) (drinking eagerly orunable to drink). As can be seen inTable I, at least 2 signs need to bepresent to classify the child as either
Diarrhoea with Severe Dehydration
or
Diarrhoea with Some Dehydration
.Plan C is used to treat
Severe 
SA Fam Pract 2005;47(8)
33
Review
Figure 1:
Chest Indrawing
 
SA Fam Pract 2005;47(8)
34
Review
ASSESS 
Any General Danger Sign
ORChest IndrawingORStridor in a calm childFast breathingNo signs of pneumonia or verysevere disease
Two of the following signs:
Lethargic or unconsciousSunken eyesNot able to drink or drinkingpoorlySkin pinch goes back veryslowly (>2 secs)
Two of the following signs:
Restless or irritableSunken eyesChild drinks eagerly and is thirstySkin pinch goes back slowlyNot enough signs to classifyas severe or some dehydrationChild has signs of dehydrationChild has history of weightlossNo dehydrationNo history of weight lossChild has signs of dehydrationChild less than 12 months ofageBlood in stool
Any General Danger Sign
ORStiff neck ORBulging fontanelleNo General Danger Signs and..No stiff neck or bulgingfontanelle
Any General Danger Sign
ORStiff neckORBulging fontanelle(Malaria rapid test or positiveor negative or not done)Rapid malaria test positiveRapid malaria test not doneRapid malaria test negative
CLASSIFY 
SEVERE PNEUMONA ORVERY SEVERE DISEASEPNEUMONIACOUGH OR COLDDIARRHOEA WITHSEVERE DEHYDRATIONDIARRHOEA WITH SOMEDEHYDRATIONNO VISIBLEDEHYDRATIONSEVERE PERSISTENTDIARRHOEAPERSISTENT DIARRHOEASEVERE DYSENTERYDYSENTERYSUSPECTEDMENINGITISFEVER, OTHER CAUSESUSPECTED SEVEREMALARIAMALARIAPOSSIBLE MALARIAFEVER, OTHER CAUSE
TREATMENT 
Give ceftriaxone IMI (80mg/kg)and if child < 6 mths also give co-trimoxazoleGive O2and check blood sugarIf stridor, nebulize with adrenalinKeep child warm and referURGENTLY to hospitalGive amoxycillin for 5 daysConsider symptomatic HIVFollow up in 2 daysSoothe the throat and relieve thecoughIf coughing for more than 21 daysconsider TB or asthmaFollow-up 5 days if not betterStart Fluids for Plan CRefer URGENTLY to hospitalGive frequent sips of ORS on theway, continue breastfeedingKeep the child warmGive fluids: Plan BContinue breastfeeding or feedingFollow up in 2 days if not improvingGive fluid and food to Rx diarrhoeaat home: Plan AFollow up in 5 days if not improvingRx for dehydration if presentRefer URGENTLY to hospitalGive Vit A unless given in last monthGive frequent sips of ORS on the wayCounsel the mother about feedingGive Vit A unless given in last monthConsider symptomatic HIV infectionFollow up in 5 daysRx for dehydration if presentRefer URGENTLY to hospitalGive frequent sips of ORS on the wayNalidixic acid for 5 daysFollow up in 2 daysGive ceftriaxone IMI (80mg/kg)Check blood sugarRx the feverRefer URGENTLY to hospitalRx the cause of the feverRx the feverFollow up in 2 days if fever persistsIf child > 12 months, give first doseof co-artemetherGive ceftriaxone IMIRefer URGENTLY to hospitalIf child <12 months refer URGENTLYto hospital for malaria RxIf child >12 months, give co-artemether at clinic and then for 3days at homeRx feverFollow up in 2 days if the feverpersistsRefer for malaria testingRx feverRx the fever and the causeFollow up in 2 days if fever persists
CHECK FOR GENERAL DANGERSIGNS: ASK
Is the child able to drink or breastfeed?Does the child vomit everything?Convulsions in this illness?Is the child lethargic or unconscious?
DOES THE CHILD HAVE COUGHOR DIFFICULT BREATHING?
For how long?Count the breaths in one minuteLook for chest indrawingLook and listen for stridor orwheeze
Age Fast breathing
2 - 12 mths = 50 or > breaths/min1 5 yrs = 40 or > breaths/min
DOES THE CHILD HAVEDIARRHOEA?
For how long?If >14 days, has child lost weight?Is there blood in the stool?What Rx is the mother giving?Look at child’s general conditionLook for sunken eyes.Offer the child fluids.Pinch the skin of the abdomen
CLASSIFY FOR DEHYDRATION
(All children with diarrhoea)
CLASSIFY FOR PERSISTENTDIARRHOEA
(If diarrhoea for 14 or more days)
CLASSIFY FOR DYSENTERY
(If diarrhoea with blood)
DOES THE CHILD HAVE A FEVER?
For how long?Examine for stiff neckExamine for bulging fontanelleLook for other causes of fever
IF EXPOSED TO MALARIA, ALSOCLASSIFY FOR MALARIA
Do a rapid malaria test if available
Summary of IMCI Case Management
Table I:
Summary of IMCI Case Management
CHILD 2 MONTHS TO 5 YEARS:
1234

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