INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) Steps in the IMCI Case Management Process: 1. Assess and Classify 2.

Identify Treatment 3. Treat 4. Counsel the Mother 5. Follow-Up A. Assess and Classify Sick Children 2 months up to 5 Years 1. Determine which age group the child belongs: 1 week up to 2 months 2 months up to 5 years 2. Record the childs data : Name, Age in months, Weight in kg., temperature, etc. 3. Ask the mother what the childs problems are. 4. Determine if this is an initial or follow up visit: Initial visit 1st visit for this episode of an illness or problem Follow-up visit- the child has been seen a few days ago for the same illness - if the childs condition improved, still the same or is getting better 4. Check for general danger signs: a. not able to drink or breastfeed too weak to drink and is not able to suck or swallow when offered a drink or Breast-feed if not sure: ask mother to offer child a drink of clean water or breast milk A child may have difficulty sucking when his nose is blocked. If the nose is blocked, clean it. b. vomits everything a child is not able to hold anything down at all if in doubt, offer the child water c. convulsions (during this illness) arms and legs stiffen because muscles are contracting the child may lose consciousness or not be able to respond to spoken directions or handling, even if eyes are open fits or spasms or jerky movements Note: Shiver is not convulsion. There is no loss of consciousness. d. abnormally sleepy or difficult to awaken drowsy and does not show interest in what is happening around him stare blankly and appear no to notice what is going on around him does not respond when touched, shaken or spoken to Note: 1. If the child is asleep and has cough or difficult breathing, count the number of breaths first before you try to wake the child. 2. If there is any general danger sign, complete the assessment and any pre-referral treatment immediately so referral is not delayed. 5. Assess and classify cough or difficult breathing 2 Common Causes of Pneumonia 1. Stretococcus pnemoniae 2. Hemophilus influenzae 2 Causes of Death 1. hypoxia too little oxygen 2. sepsis generalized infection Health workers can identify almost all causes of pneumonia by checking for 2 clinical signs: 1. fast breathing bodys response to stiff lungs and hypoxia 2. chest indrawing Assess cough or difficult breathing:

Does the child have cough or difficult breathing? fast or noisy or interrupted? * If the answer is NO, look back to see if you think the child has cough or difficult breathing. how long? chronic cough more than 30 days - may be sign of tuberculosis, asthma, whooping cough or another problem fast breathing a. count the breaths in one minute 1. child must be quiet and calm 2. no feeding, crying or angry Ask the mother to lift the childs shirt. If you are not sure about the number of breaths you counted, repeat the count. b. cut-off for fast breathing: if the child is: 2 months up to 12 months 12 months up to 5 years fast breathing is: 50 breaths/ minute or more 40 breaths/ minute or more

Determine if the child is breathing IN or breathing OUT chest indrawing the lower chest wall goes IN when the child breaths IN NORMAL: the whole chest wall and abdomen move OUT when the child breaths IN Best position : lying down Conditions : clearly visible Note: intercostals indrawing or intercostals retractions and subcostal indrawing are not chest indrawing. Look or listen for stridor. Stridor harsh noise made when the child breaths IN - happens when there is swelling of the larynx, trachea, or epiglottis Put your ear near the childs mouth and look at the movement of the abdomen to determine if child is breathing IN or OUT wet noise - blocked nose wheezing - harsh noise while breathing OUT; not stridor CLASSIFY COUGH OR DIFFICULT BREATHING 6. Assess and classify diarrhea diarrhea loose or watery stool - defined as 3 or more loose or watery stools in a 24 hour period Assess:

how long? blood in stool signs of dehydration

If YES, asses for: dehydration persistent diarrhea 14 days or more Dysentery Asses for dehydration: Abnormally sleepy or difficult to awaken Restless and irritable: (all the time) Sunken eyes: If not sure, ask the mother if the childs eyes look unusual. Offer the child fluid : Not able to drink - if he is not able to take fluid in his mouth and swallow it Drinking poorly if the child is weak and cannot drink without help. Drinking eagerly, thirsty reaches out for the cup or spoon when you offer water. Pinch the skin of the abdomen: Goes back very slowly longer than 2 seconds

Goes back slowly the skin stays up for even a brief time after release. CLASSIFY DIARRHEA FOR ;: DEHYDRATION PERSISTENT DIARRHEA DYSENTERY 7. Assess Fever: A child has the main symptom fever if: - the child has history of fever no fever now but had fever within 72 hours or - the child feels hot or - the child has an axillary temperature of 37.5 C or above Decide malaria risk: child lives in malarious area or has been in a malaria risk area in the past 4 weeks.

Look or feel for stiff neck: - look to see if the child moves and bends his neck easily as he looks around or - draw the childs attention to his toes or - gently support his back and bend the head forward toward hid chest. Look for runny nose ( not history of runny nose) Look for signs of Measles: generalized rash and any one of the following: cough, runny nose, or red eyes. Measles rash: begins behind the ears and on the neck, spreads to the face, and to the rest of the body; does not have vesicles or pustules; does not itch. If the child has measles now or within the last 3 months, assess for: - mouth ulcers painful open sore on the inside of the mouth and lips or tongue - pus draining from the eye - clouding of the cornea hazy area in the cornea Assess for Dengue Hemorrhagic Fever all children two months of age or older.Look and feel for signs of bleeding and shock: - bleeding from the nose and gums - skin petechiae small hemorrhages in the skin; look like small dark red spots or patches in the skin; not raised, not tender; if you stretch the skin they do not lose their color. - Cold and clammy extremities - If with cold and clammy extremities, check for slow capillary refill ( longer than 3 seconds - Perform the tourniquet test if: there are no signs in the ASK or LOOK and FEEL, the child is 6 months or older, and the fever is present for more than 3 days. CLASSIFY FEVER 8. Assess Ear Problem Assess the child for : - Ear pain - Ear discharge ; Present less than 2 weeks Acute ear infection Present 2 weeks or more Chronic Ear Infection - Tender swelling behind the ear CLASSIFY EAR PROBLEM 9. Check for malnutrition and anemia: Look for visible severe wasting a child with visible severe wasting has marasmus, a form of severe malnutrition.. A child has this sign if he is thin, has no fat, and looks like skin and bones. Look for palmar pallor a sign of anemia

Some palmar pallor the skin on the childs palm is pale Severe palmar pallor the palm is very pale or so pale that it looks white Look and feel for edema of both feet the child may have kwashiorkor, a form of severe malnutrition. Determine weight for age: Very low weight for age childs weight is below the bottom curve of a weight for age chart. CLASSIFY NUTRITIONAL STATUS 10. Check the childs immunization status. 11. Check the childs Vitamin A status. 12. Assess other Problems.

B. Management of the Sick Young Infant Age 1 Week Up to 2 Months 1. Assess the sick young infant Check the young infant for possible bacterial infection. 1. Ask if the child had convulsion at any time after birth. 2. Count the number of breaths in one minute. Fast breathing is 60 breaths per minute or more. 3. Look for severe chest indrawing. Mild chest indrawing is normal in a young infant or young child. Severe chest indrawing is very deep and easy to see. 4. Look for nasal flaring widening of the nostrils when the young infant breaths in. 5. Look and listen for grunting soft, short sounds when breathing out. 6. Look and feel for bulging fontanelle. Fontanelle is the soft spot on the top of the young infants head, where the bones of the head have not formed completely. 7. Look at the umbilicus is it red or draining pus? 8. Measure temperature or feel for fever or low body temperature. Fever (axillary temperature 37.5 C or more; rectal temperature 38 C or more). Hypothermia ( axillary temperature below 35.5 C; rectal temperature below 36 C). 9. Look for skin pustules red spots or blisters which contain pus. A severe pustule is large of has redness extending beyond the pustule. 10. LOOK: See if the child is abnormally sleepy or difficult to awaken. 11. LOOK at the young infants movement. Are they less that normal? CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION Assess Diarrhea For how long? Is there blood in the stool? Look at the young infants general condition. Is it Abnormally sleepy or difficult to awaken or Restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back very slowly? Or slowly?

CLASSIFY DIARRHEA Check for feeding problem or low weight. Assess Breastfeeding. 4 Signs of Good Positioning; - with infants head and body straight

facing her breast, with infants nose opposite her nipples with infants body close to her body supporting infants whole body, not just neck and shoulders

4 Sign of Good Attachment: - Chin touching breast - Mouth wide open - Lower lip turned outward - More areola visible above than below the mouth. Suckling effectively the infant suckles with slow, deep sucks and sometimes pauses. You may see or hear the infant swallowing. Not suckling effectively he is taking only rapid, shallow sucks. You may see indrawing of the cheeks. You do not see or hear swallowing. Not suckling at all not able to suck breastmilk into his mouth and swallow. Look for ulcers or white patches in the mouth (thrush). Thrush looks like milk cuds on the inside of the cheek, or thick white coating of the tongue. Try to wipe it off. Milk curds will be removed but thrush will remain. Check the Young Infants Immunization Status Assess Other Problems