Republic of the Philippines Department of Health July 30, 2008 DEPARTMENT CIRCULAR No.

2008________ FOR: THE UNDERSECRETARIES, ASSISTANT SECRETARIES, SECRETARY OF HEALTH FOR ARMM, CHDs/BUREAU/SERVICE/PROGRAM/PROJECT DIRECTORS, MEDICAL CENTER & SPECIALTY HOSPITAL CHIEFS, EXECUTIVE DIRECTOR OF THE NATIONAL NUTRITION COUNCIL, ASSOCIATION OF DEANS OF PHILIPPINE COLLEGES OF NURSING (ADPCN Inc.), ASSOCIATION OF PHILIPPINE SCHOOLS OG MIDWIFERY (APSOM) MEMBER SCHOOLS, ASSOCIATION OF PHILIPPINE MEDICAL SCHOOLS, AND OTHERS CONCERNED. SUBJECT: TECHNICAL UPDATE ON THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) PROTOCOL. Over the years since IMCI has been introduced, much has been learnt through the adaptation and implementation processes in countries. The Department of Child and Adolescent Health and Development (CAH) and other institutions have undertaken work to evaluate the evidence base for the technical guidelines of the IMCI strategy. Research results have emerged and these results lead to the updating the technical guidelines on IMCI. CAH conducted a series of meetings and in 2004 it was recommended that CAH finalize the IMCI updates on the basis of the best available and country program feedback, prioritizing those updates most likely to reduce child mortality. The World Health Organization came up with document on IMCI Technical Updates entitled: “Technical Updates of the Guidelines on Integrated Management of Childhood Illness, Evidence and Recommendations for further Adaptations”, 2005. The adaptation of the recommendations underwent consultations with experts on child health. The technical updates were considered necessary for the following reasons: • • • • New knowledge becomes available through research into clinical management of childhood diseases. Research results should be examined in a systematic manner to improve and update the IMCI guidelines. IMCI guidelines should be reviewed with regard to experiences and lessons learned through the adaptation and implementation process. Implementation of IMCI has identified problems and questions, some of which have been addressed through operational research in regions and countries. Since the development of the IMCI guidelines, the epidemiology of diseases has evolved and thus a revised version has to accommodate and reflect these changes. For example, the prevalence of HIV/AIDS has increased significantly over the last 10 years and specific aspects require updating in the context of IMCI.

Primaquine. Zinc supplementation during the episodes of acute diarrhea reduced the duration and severity of the episode. 75mmol/L glucose concentration and has a total osmolarity of 245 mOsm/L. studies showed that zinc supplementation given for 10-14 days lowered the incidence of diarrhea in the following 2-3 months. Use of Zinc supplements for 10-14 days in the management of diarrhea. Oral antibiotic for non-severe pneumonia should be given for three (3) days instead of 5 days to sick children 2-59 months old. In addition.Cough or Difficult Breathing • Three days antibiotic treatment of non-severe and severe pneumonia. Even though antibiotics may provide a small benefit for acute ear infection in children. Oral Amoxicillin is first-line antibiotic for the management of acute ear infection and is given two times a days for three (3) days. Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol of severe pneumonia in children 2-59 months old of age. In the treatment of bloody diarrhea (Dysentery) Ciprofloxacin is the most appropriate drug in place of Nalidixic acid which leads to rapid development of resistance. Main Symptom 2 – Diarrhea • Use of Reformulated Oral Rehydration Salts which should contain 75mEq/L. Ciprofloxacin is given in a dose of 15 mg/kg two times per day for three (3) days. ear problem is recommended. Sulfadoxine and Pyrimethamine. Giving of multivitamins and minerals (including Zinc) for 14 days is added in the treatment protocol of PERSISTENT DIARRHEA in addition to continue feeding and follow-up. A pre-referral dose of 7. Shorter courses of antibiotic were found to be equally effective as the five-day duration.5mg/kg intramuscular injection gentamicin and 60 mg/kg injection ampicillin can be used. Inclusion of zinc in the management of diarrhea could prevent 300.The current technical update have compiled new evidence and recommended adaptation in the following six areas: SICK CHILDREN AGED 2 MONTHS TO 59 MONTHS Main Symptom 1. reduces cost of treatment in the addition to improving compliance and reduces the antimicrobial resistance in the community. Main Symptom 3 – Fever • First line antibiotic for Malaria – Chloroquine.000 children dying every year. Use of amoxicillin and first line antibiotic and Cotrimoxazole as a second line antibiotic in the treatment of pneumonia. very severe disease. Malnutrition and Anemia . Second line Antibiotic – Artemeter-Lumefantrine Main Symptom 4 – Ear Problem • Chronic ear infection to be treated with topical quinolone ear drops for at least two weeks in addition to dry ear by wicking. oral amoxicillin plays an important role in reducing the risk of mastoiditis.

If MUAC is not available. then follow the every six months dose. bitot’s spot. If the child has no appetite. Once appetite is restored. Feed for a few days 11ml/kg every 2 hours. Make up the volume to 1. look visible severe wasting. Give first dose at age 6 moths or above. xeropthalmia. TREATMENT: for nightblindness. Add water up to 1000ml and 20ml WHO mineral and vitamin solution.• Where available. MUAC (Mid-upper arm circumference) less than 110mm is now an indicator for severe malnutrition. Malnutrition and anemia presented in two separate algorithms Use of WHO Growth standards instead of the international Reference Standard (explanation of the WHO GPRS) Management of severe malnutrition where referral is not possible. a modified milk diet is give. subsequent dose after 6 months.000ml by adding previously boiled water. This is made by dried skimmed milk (DSM) sugar and oil. New Immunization Schedule: Age Birth 6 weeks 10 weeks 14 weeks 9 months Vaccine BCG HepB1 OPV1 HepB2 DPT1 OPV2 _____ DPT2 OPV3 HepB3 DPT3 Measles VITAMIN A Capsule Distribution Schedule: PROPHYLAXIS. give subsequent dose every 6 months. . a diet with 80g dried skimmed milk. 50g sugar and 60g of oil is prepared. Mix: 25g dried skimmed milk 70g sugar 35g rice flour 27g oil and some water Boil: 5-7 minutes Allow to cool and then add 20 ml WHO vitamin mineral for severe malnutrition and mix again. manage the child at the health center. corneal xerosis Give 1 capsule today Give 1 capsule tomorrow Give 1 capsule 2 weeks after. Increase progressively the feeds up to 200ml/kg in 6 feeds (30ml/kg every 4 hours adjusted to the child’s appetite).

Otherwise. The seven signs include: not feeding well. affordable. sustainable and safe for her and her infant. Checking for JAUNDICE is added in protocol for Sick Young Infant aged up to 2 months. MPM. If a woman is HIV infected and replacement feeding is acceptable.Routine Worm Treatment Give every child Mebendazole/Albendazole every 6 months from the age of one (1) year. SICK YOUNG INFANT AGED UP TO 2 MONTHS The first symptom to manage among sick young infants. or as a “rider agenda” to scheduled symposia. check for possible bacterial infection was changed to check to very severe diseases and local bacterial infection and the signs to look for in the assessment of this symptom was reduced from 12 to 7 signs. MPH. or fast breathing (60bpm or more). VILLAVERDE. Continuing breastfeeding up to 2 years and beyond. Addition of safe. JAUNDICE (yellow row) and NO JAUNDICE (green row). Infant and Young Child Feeding Policy Early initiation of breastfeeding within the first hour of life. Classifications include SEVERE JAUNDICE (pink row). LGU meetings/sessions. adequate complementary foods at age 6 completed months while. Sever disease (yellow). workshops. or no movement at all. training. or movement only when stimulated. avoidance of all breastfeeding is recommended. or low body temperature (less than 35.D. Please be guided accordingly. Sever disease or local bacterial infection unlikely (green). UPDATES ON INFANT FEEDING HIV and Infant Feeding In areas where HIV is public health problem all women should be encouraged to receive HIV testing and counseling. M. or severe chest indrawing.. Exclusive breastfeeding up to six months. By the Authority of the Secretary of Health: MARIO C. for a. The new classifications include: Very sever disease (pink). feasible. Updated IMCI training materials will also be developed and distributed to the different stakeholders on IMCI. or fever (37. CESO II Undersecretary of Health . The updates in the IMCI protocol will be disseminated to all concerned including the academe now integrating IMCI in the curriculum through organized meetings. exclusive breastfeeding is recommended during the first 6 months of life.5 C).5 C or above). or convulsion.

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