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Topic: Integrated Management of Childhood Illnesses

Lecturer: Dra. Gillian

OBJECTIVES
I.
II.
III.
IV.

Understand the IMCI approach to common
pediatric illnesses
Recognize the general danger signs in sick
children
Demonstrate knowledge on when to refer a
IS IMCI?
sick child toWHAT
the hospital
Be able to assess and provide initial
management for the sick child

Problem: Every year, more than 10 million children in
developing countries, like the Philippines, die before they
reach their 5th birthday
Solution: Integrated Management of Childhood
Illness (IMCI)

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A strategy for reducing mortality and morbidity
associated with major causes of childhood illness.
A joint WHO/UNICEF initiative since 1992

Topic: Integrated Management of Childhood Illnesses
Lecturer: Dra. Gillian

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IMCI clinical guidelines target children < 5 years old
– the age group the highest burden of deaths from
common childhood diseases
Why is IMCI
medical education?
IMCI needed
StrategyinComponents

1. Prioritizes: most frequent and serious health
problems
2. Provides a link to real-life situations
3. Promotes rapid recognition and rapid action
4. Links preventive and curative care
5. Provides additional skills

6. Emphasizes action-oriented and affordable
intervention
7. Links health professionals and the health system

Topic: Integrated Management of Childhood Illnesses
Lecturer: Dra. Gillian

5. Assess other problems

PART I: THE SICK CHILD (2 months - 5 years old)
Assess and Classify the Sick Child: 2months-5 years old
1. Check for General Danger Signs
2. Ask about Main Symptoms
3. Check for Malnutrition and Anemia
4. Check Immunization Status

Topic: Integrated Management of Childhood Illnesses
Lecturer: Dra. Gillian

1. Check for General Danger Signs



not able to drink
has convulsion
abnormally sleepy
vomits everything

 MAKE SURE A CHILD WITH ANY GENERAL
DANGER SIGN IS REFERRED TO A HOSPITAL

What is Anne’s classification for cough?  Ask for: Duration . Her mother also reported that she vomited 2x but is still able to drink fluid.5kg.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Her 2. Her mother brought her to the health center of Main cough for 1 week with fever. Gillian  After first dose of an appropriate antibiotic and other urgent treatments Main Symptoms  coughing/difficulty of breathing  diarrhea Main Symptom: Cough/Difficulty of Breathing  fever  ear problem CASE #1: Anne is an 18-month old infant.because Ask about Symptoms respiratory rate is 50. weighing 11.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian  Look and Feel:  Respiratory rate  Chest indrawing  Stridor PNEUMONIA: Follow Up Pneumonia: Treatment .

Gillian .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

an 11-month old. and head nodding. is irritable. Her mother also reported that she vomits every time she is fed. After 2 days.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Anne was brought back to the health center due to persistent cough. He drinks eagerly when offered ORS. Her respiratory rate is 60. before they are classified as pneumonia and prescribed antibiotics. has diarrhea x 4 days. Gillian  Additional Recommendation:  Children with wheeze and fast breathing and/or lower chest indrawing: a trial of rapid acting inhaled bronchodilator (up to 3 cycles). What is the classification of Joel’s diarrhea? Main Symptoms: DIARRHEA . You noted chest indrawing. weighing 8 kg. He has no blood in the stool. You did skin pinch test and it went back slowly. What is Anne’s classification for cough? CASE #2: Joel. alar flaring. and has sunken eyeballs.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian  Ask:  Duration  Is there blood in stool?  Look and Feel:  General condition/ Sensorium  Sunken eyes  Ability to drink  Skin pinch PINCH TEST .

Pinch the skin of the abdomen halfway between the umbilicus and the side 2. Pinch for 1 second. then release and observe  very slow = longer than 2 seconds . Gillian 1.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Gillian DIARRHEA: Management .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian Weight (kg) x 75 = amount of ORS DIARRHEA: Severe Dehydration (Plan C) .

show mother how to give frequent sips during the trip  If NO IV treatment is available nearby and you are trained to insert nasogastric tube or if child can drink: .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian = 6 hours = 3 hours  If you can give IV fluids:  If you cannot give IV fluids and IV treatment is available nearby (w/in 30 minutes travel):  REFER URGENTLY  Provide ORS if child can drink.

Gillian   MAKE SURE A CHILD WITH DIARRHEA WHO HAS ANOTHER SEVERE CLASSIFICATION (ie.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Severe pneumonia) IS REFERRED TO A HOSPITAL Advice mother to give frequent sips of ORS on the way and continue breastfeeding Use of Low Osmolarity ORS  NOTE!! .

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian   Countries should now use and manufacture the low sodium ORS for all children with diarrhea but keep the same label to avoid confusion Composition of ORS Zinc in the Management of Diarrhea  Along with increased fluids and continued feeding. all children with diarrhoea should be given zinc supplementation for 10-14 days  DOSE: 20mg per day in children > 6 months 10mg per day in infants < 6 months  If diarrhea > 14 days .

Gillian On follow up: PERSISTENT DIARRHEA On follow up: DYSENTERY (SHIGELLA) .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

has fever x 4 days. a 3-year old.most appropriate drug in place of Nalidixic acid which leads to rapid development of resistance On follow up: BLOOD IN STOOL CASE #3: Joy. weighing 13 kg. . Gillian  Ciprofloxacin . She vomited 3x and has abdominal pain.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian Mother reports she noticed red flat spots on her child’s arms and legs that morning. cough.5 0C?  Travel to a Malaria area  History of measles within the last 3 months  Look and Feel:  Stiff neck  Runny nose. What is Joy’s most likely diagnosis?  Ask:  Does the child feel hot or has temp > 37. red eyes  Generalized rash Main symptoms: FEVER  Decide:  Malaria  Measles  Dengue Fever .

Gillian MALARIA .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

due to high multi-drug resistance VIVAX MALARIA  Can also cause severe morbidity  should also be diagnosed and treated Treatment of both FALCIPARUM and VIVAX MALARIA should follow national guidelines .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian  MEASLES (now or within 3 months) MALARIA: Treament   FALCIPARUM MALARIA (most countries)  ARTEMISININ-based combination therapies .

skin petecia. abdominal pain. Gillian       Bleeding from nose or gums Bleeding in stools or vomitus Black stools or vomitus Skin petechia Cold clammy extremities Capillary refill > 2secs  Persistent abdominal pain  Persistent vomiting SEVERE DENGUE HEMORRHAGIC FEVER  If persistent vomiting. or positive torniquet test are the only present signs  GIVE ORS (PLAN B)  If with other signs of bleeding  GIVE FLUIDS (PLAN C)  Treat to prevent low blood sugar  REFER ALL CHILDREN URGENTLY TO A HOSPITAL!!! .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Gillian  DO NOT give Aspirin!!! PERSISTENT FEVER .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

 Duration  Look and Feel:  Pus draining from ear  Tender swelling at the back of the ear Main Symptom: EAR PROBLEM  Ask  Is there ear discharge? . Gillian CASE #4: Sally. She cannot sleep and complains of right ear pain.there was tender swelling behind it. a 3-year old 10 kg child came in for check up of her ear problem.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.When the health worker felt for Sallys ear.The mother said that there was on and off ear discharges for about a year.

ACUTE EAR INFECTION . Gillian Management:  Oral AMOXICILLIN is a BETTER CHOICE for acute ear infection where antimicrobial resistance to Cotrimoxazole is high 2.Daily TOPICAL ANTISEPTICS OR ANTIBIOTICS after aural toilet for 2 weeks: most cost-effective treatment for otorrhoea .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.EAR DISCHARGE. should be used in the classification of acute ear infection . CHRONIC EAR INFECTION . not ear pain.TOPICAL QUINOLONES: effective in resolving otorrhoea without the risk of ototoxicity - TECHNICAL UPDATES ON EAR INFECTIONS 1.

He does not have edema of both feet.8 °C. weighing 6 kg.  Look and Feel:  Visible signs of severe wasting . There is some palmar pallor. and is classified as diarrhoea with SOME DEHYDRATION. Gillian Addition of oral antibiotics has NO PROVEN Main.Determine weight for age .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.Edema of both feet . His temperature is 36. Check for Malnutrition and Anemia CASE #5: Dan is 1-year old boy. The child visible severe wasting. He has had diarrhoea for 5 days.) for his age (1 year).Symptoms: MALNUTRITION BENEFIT 3. Use the Weight for Age chart to determine classification of Dan’s weight (6 kg.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian Marasmus Kwashiorkor .

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.child would also return earlier if there was a feeding problem  Assess: weight  Next follow-up: after 1 month Main Symptoms: ANEMIA . Gillian  A child who was classified with VERY LOW WEIGHT should return for follow-up after 30 days .

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian  Look and Feel:  Palmar pallor. classify as: o severe palmar pallor o some palmar pallo ANEMIA: Treatment  Iron treatment  For treatment of anemia: give one dose daily for 14 days. Iron supplement . then reassess.

Gillian  Mebendazole treatment  Give 500 mg mebendazole tablets as a single dose in clinic if : o hookworm/whipworm are a problem in children in your area o the child is 2 years of age or older o the child has not had a dose in the previous 6 months  Follow-up for pallor after 14 days .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Assess other problems . IMMUNIZATION 5.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. refer the child for assessment. Continue to give the mother iron when she returns every 14 days for up to 2 months. Gillian    Give the mother additional iron for the child and advise her to return in 14 days for more iron. If after 2 months the child still has palmar pallor.

Check for FEEDING PROBLEM or LOW WEIGHT 3. Check for Possible BACTERIAL INFECTION 2. Assess other problems  Ask: History of convulsion  Look and Feel:  Nasal flaring or grunting  Fast breathing (> 60 bpm)  Severe chest indrawing  Pus draining from ear  Umbilical redness extending to skin 1. Gillian SERIOUS BACTERIAL INFECTION PART II: THE SICK INFANT (1 week – 2 months old)  Assess and Classify the Sick Infant: 1week – 2 months old 1.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Check Immunization Status 4. Check for possible BACTERIAL INFECTION  Many skin pustules .

Gillian  Less than normal activity  Fever or hypothermia LOCAL INFECTON  BACTERIAL Bulging fontanelle  Lethargic or unconscious  TREATMENT:  REFER URGENTLY to a hospital after first dose of intramuscular antibiotics  Prevent low blood sugar  Keep baby warm  Look and Feel:  Umbilical redness  Draining pus from umbilicus  Skin pustules  TREATMENT:  Give appropriate antibiotic  Teach mother how to treat local infection .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. classify. and treat using chart for sick child  Refer all infants with persistent diarrhea URGENTLY JAUNDICE  Ask: Onset of jaundice  Look: At the palms and soles if jaundiced DIARRHEA . Gillian  Follow-up in 2 days  Assess.

Check for FEEDING PROBLEM or LOW WEIGHT  Feeding Problem or Low Weight for Age  Ask: .Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.what do you feed the infant? Look and Feel: . Gillian  2.determine birth weight for newborns .difficulty in feeding? .determine weight for age .given other food? How often? .breastfed? How often in 24 hrs? .breastfed at night? .

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian  If an infant:  Has any difficulty feeding?  Is breastfeeding less than 8 times in 24 hours?  Is taking any other foods or drinks. or  Is low weight for age. or low birth weight (2500 grams or less)  Is in the first week of life .

EFFECTIVE SUCKLING . Gillian  AND Has NO indications to refer urgently to hospital: Assess BREAST.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.FEEDING Assess BREAST.FEEDING for GOOD ATTACHMENT  Look for: 1.

TRUSH ­ White patches in the mouth Update on Infant Feeding: . Gillian ­ ­ Slow deep sucks with occasional pause Clear blocked nose 2.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.Exclusive breastfeeding for 6 months should be strongly promoted Feeding Problem or Low Weight for Age .

Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Gillian Weight-for-Age Chart for Boys .

5 kg.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. His weight is 2.  What will you advice regarding Mico’s feeding? .  Plot Mico’s weight for age ang classify. He is brought to the clinic because of umbilical redness and pus which began 3 days ago. Gillian CASE #6: Mico is a 6-week-old infant.

Gillian 3.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Check IMMUNIZATION Status Immunization .

Assess other problems --END-- . Gillian’s lecture powerpoint  IMCI manual 4. Gillian Reference:  Dra.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra.

Gillian 4.Topic: Integrated Management of Childhood Illnesses Lecturer: Dra. Assess other problems .