CHN 211 3.

Subunit (purified antigen)

a. Protein-based
Community Health Nursing b. Polysaccharide
c. Conjugate
4. Toxoid (inactivated toxins)
DOH RELATED PROGRAMS
EPI | TYPES OF VACCINES
EXPANDED PROGRAM ON
Type of vaccine Examples
IMMUNIZATION Live – attenuated BACTERIA: BCG
VIRUS: OPV
EPI | IMMUNIZATION - Measles
- Rotavirus
WHO MEANING - Yellow fever
 Immunization is the process whereby a Inactivated BACTERIA: wP
person is made immune or resistant to an VIRUS: IPV
infectious disease, typically by the Sub – unit
administration of a vaccine. : protein based BACTERIA: aP
VIRUS: HepB
 Immunization is a proven tool for : polysaccharide Pneumococcal,
controlling and eliminating life-threatening Meningococcal,
infectious diseases Salmonella typhi
: conjugate BACTERIA
 Immunization is likewise known as : Haemophilius
vaccination or inoculation influenzae type b (Hib)
: Pneumococcal (PCV-
MEANING
7, PCV-10, PCV-13)
 The condition of being secure against any
particular disease. Toxoid BACTERIA
: Tetanus toxoid (TT)
 Immunity is the ability of the human body : Diphtheria toxoid
to tolerate the presence of material
indigenous to the body, and to eliminate
foreign material.
EPI | EXPANDED PROGRAM ON
Two basic mechanisms for acquiring immunity: IMMUNIZATION

1. Active immunity is protection that is RATIONALE

produced by the persons own immune
The Expanded Program on Immunization (EPI)
system. This type of immunity usually lasts
was established in 1976 to ensure that
for many years, often during a lifetime
infants/children and mothers have access to
2. Passive immunity is protection by routinely recommended infant/childhood vaccines.
products produced by an animal or human
Six vaccine preventable diseases were initially
and transferred to another human, usually
included in the EPI:
by injection.
TB, poliomyelitis, diphtheria, tetanus, pertussis,
EPI | VACCINE
and measles
 A vaccine helps the body’s immune system
EPI | SUPPORTING LEGISLATIONS
to recognize and fight pathogens like viruses
or bacteria, which then keeps us safe from • R.A. 10152 (Mandatory Infants and
the diseases they cause. Children Health Immunization Act of 2011)
- mandates basic immunization covering the
Types of Vaccines:
vaccine-preventable diseases
1. Live-attenuated vaccines (LAV)
2. Inactivated vaccines (killed antigen)
 • R.A. 7846 - Provided for compulsory
immunization against hepatitis B for infants
and children below 8 years old.
- Provided for hepatitis B
immunization within 24 hours after birth of
babies of women with hepatitis B.
EPI | GOALS OF THE PROGRAM
The following are the specific goals of the
program
1. To immunize all infants/children against
the most common vaccine-preventable
diseases.
2. To sustain the polio-free status of the
Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus.
5. To control diphtheria, pertussis, hepatitis B,
and German measles.
6. To prevent extrapulmonary TB among
children.
EPI | DISEASES
1. Tuberculosis (TB)
2. Diphtheria
3. Poliomyelitis (polio)
4. Measles
5. Pertussis
6. Tetanus
7. Hepatitis B
8. Yellow fever
EPI | TUBERCULOSIS
Case Definition
: A child with history of contact with a suspect or
confirmed case of pulmonary tuberculosis
: Any child who does not return to normal health
after measles or whooping cough
: Abdominal swelling with a hard painless mass and
free fluid
: Painful firm or soft swelling in a group of
superficial lymph nodes
: Loss of weight, cough, and wheeze which does not
respond to antibiotic therapy for acute respiratory
disease.
: Any bone or joint lesion or slow onset
: Signs suggesting meningitis or disease in the
central nervous system
Agent – Mycobacterium tuberculosis
Reservoir – Man, Diseased cattle
Sources of Infection – Droplet infection, that is
through inhalation of bacilli from patients
Occurrence
: Worldwide
: Mortality and morbidity higher in developing
countries
Transmissible Period – A person who excretes
tubercle bacilli is communicable.
The degree of communicability depends upon:
• The number of bacilli in the air
• Virulence of bacilli
• Environmental conditions like
overcrowding
Duration of Natural Immunity
: Not known
: Reactivation of old infection commonly causes
disease
Risk Factor for Infection
• Low access to care
• Immunodeficiency
• Malnutrition
• Alcoholism
• Diabetes
EPI | DIPHTHERIA – It is an acute pharyngitis,
acute nasopharyngitis or acute laryngitis with a
pseudo membrane.
Agent – Corynebacterium diphtheria
Reservoir – Man
Sources of Infection – By respiratory droplets
from discharge of a case or carrier
Occurrence – Worldwide (Endemic in developing
countries with unimmunized populations)
Transmissible Period
: May last for 2-3 weeks
: Maybe shortened in patients with antibiotics
treatment
*Diphtheria transmission is increased in schools,
hospitals, households and in crowded areas
Duration of Natural Immunity – Usually
lifelong
Risk Factor for Infection
: Crowding
: Low socio-economic status
EPI | POLIOMYELITIS (POLIO)
A suspect cases of polio is defined as any patient
below 15 years of age with acute flaccid paralysis
(including those diagnosed to have Guillain-Barre
Syndrome) for which no other cause can be
immediately identified.
Agent
Poliovirus type 1,2 & 3
Reservoir
Man. Mostly children
Sources of Infection
: Fecal-oral route
: Oral route through pharyngeal secretion
: contact with infected persons
Reservoir - Humans
Sources of Infection - Close respiratory contact
and aerosolized droplets
Occurrence – Worldwide, Mortality and
morbidity higher in developing countries
Transmissible Period - 4 days before until 2
days after rash
Duration of Natural Immunity - Lifelong after
attack
Risk Factor of Infection – Crowding, Low socio-
economic status
EPI | PERTUSSIS
History of severe cough and history of any of the
following:
• Cough persisting 2 or more weeks
• Fits of coughing, and
• Cough followed by vomiting
Agent – Bordetella pertussis
Reservoir – Man

Occurrence Sources of Infection – primarily by direct

: Cyclical
: Worldwide
: Morbidity and mortality higher in developing
countries
Transmissible Period
: 7 to 16 days before onset of symptoms
: first few days after onset of symptoms
Duration of Natural Immunity
: Type specific immunity lifelong
Risk Factor for Infection
: Poor environmental hygiene
EPI | MEASLES
contact with discharges from respiratory mucous
membranes of infected persons.
- Airborne route probably by droplets.
- Indirect contact with articles freshly soiled with
the discharges of infected persons.
Occurrence – Worldwide, Morbidity higher in
developing countries
Transmissible Period
- Highly communicable in early catarrhal stage,
before paroxysmal cough
- Antibiotics may shorten the period of
communicability from 7 days after exposure to 3
weeks after onset of typical paroxysms to only 5 to 7
days after onset of therapy.

A highly communicable disease with the history of Duration of Natural Immunity - Usually
the following: lifelong
Risk Factors for Infection – Young age
- Generalized blotchy rash, lasting for three of crowding
more days
- Fever (above 38⁰C or “hot” to touch and EPI | NEONATAL TETANUS

Any of the ff: Cough, Runny nose, Red A newborn with history with all three of the
eyes/conjunctivitis following:

Agent - Rubeola virus 1. Normal suck for the first two days of life.
2. Onset of illness between 3 to 26 days.
 3. Inability to suck followed by stiffness of the
body and/or convulsions
Agent - Clostridium Tetani
Reservoir – soil, intestinal canals of animals (esp.
horses), man
Sources of Infection - Unhygienic cutting of
umbilical cord, improper handling of cord stump
esp. when treated with contaminated substance
Occurrence
- Worldwide
- Morbidity higher in developing countries more
common in agricultural and underdeveloped areas
where contact with animal excreta is more likely
Transmissible Period
- Susceptibility is general
- immunity can be obtained after 2 primary doses of
tetanus toxoid at 4 weeks interval in mothers one
month before delivery
- three booster doses increase antibody levels in
mother
Duration of Natural Immunity
- No immunity induced by infection
Risk Factor for Infection
- Contamination of umbilical cord
- Agricultural work
EPI | HEPATITIS B
It is the liver infection caused by type B of hepatitis
virus. It attacks the liver often resulting in
inflammation.
Sources of Infection
- From child to child or mother to child after birth
- From mother to child during birth
- through sharing unsterilized needles, knives or
razors
- through sexual intercourse
Agent - Hepatitis B virus
Reservoir – Man
Occurrence
- In the Philippines, approximately 12% of the
population are chronic carriers
- Most Filipinos are infected before the age of 6
years
- Some infected infants are not able to develop
immunity and become chronic carriers
- Hepatitis B is especially dangerous for children
Duration of Natural Immunity – If develops,
lifelong
Transmissible Period
- Infants born to immune mothers may be
protected up to 5 months
- Recovery from clinical attack is not always
followed by lasting immunity
- Immunity is often acquired through inapparent
infection or complete immunization series with
diphtheria toxoid.
Risk Factors for Infection
- HBeAG + mother
- Multiple sexual partners
EPI | YELLOW FEVER
- Yellow fever is an acute viral hemorrhagic
disease transmitted by infected mosquitoes.
- The "yellow" in the name refers to the jaundice
that affects some patients.
- Symptoms of yellow fever include fever,
headache, jaundice, muscle pain, nausea,
vomiting and fatigue.
- A small proportion of patients who contract the
virus develop severe symptoms and
approximately half of those die within 7 to 10
days.
- The virus is endemic in tropical areas of Africa
and Central and South America.
- Large epidemics of yellow fever occur when
infected people introduce the virus into heavily
populated areas with high mosquito density
and where most people have little or no
immunity, due to lack of vaccination. In these
conditions, infected mosquitoes of the Aedes
aegypti specie transmit the virus from person
to person.
- Yellow fever is prevented by an extremely
effective vaccine, which is safe and affordable.
- A single dose of yellow fever vaccine is
sufficient to confer sustained immunity and
life-long protection against yellow fever
disease.
- A booster dose of the vaccine is not needed.
- The vaccine provides effective immunity within
10 days for 80-100% of people vaccinated, and
within 30 days for more than 99% of people
vaccinated.
EPI | Vaccine Contents and Form EPI | EXPANDED PROGRAM ON
IMMUNIZATION
Vaccine Contents Form
Immunization Schedule for Infants and
BCG (Bacillus Live, Freeze-dried,
Calmette- attenuated reconstituted with a Young Children
Guerin) bacteria special diluent Antigen Age Dose Route Site

Hepatitis B RNA- Cloudy, liquid, in an auto- BCG vaccine At birth 0.05 ID Right
vaccine recombinant, disable injection syringe if ml deltoid
using available region
Hepatitis B (arm)
surface
antigen (HBs Hepatitis B At birth 0.5 ml IM Anterol
Ag) vaccine ateral
thigh
DPT-HepB- Diphtheria Liquid, in an auto-disable muscle
Hib toxoid, injection syringe
inactivated DPT-HepB-Hib 6 weeks, 0.5 ml IM Anterol
(Pentavalent pertussis 10 ateral
vaccine) (Pentavalent weeks, thigh
bacteria,
vaccine) 14 weeks muscle
tetanus toxoid,
recombinant
DNA surface Oral polio 6 weeks, 2 Oral Mouth
antigen, and vaccine 10 drops
synthetic weeks,
conjugate of 14 weeks
Haemophilus
influenzae B Anti-measles 9-11 0.5 ml SUBQ Outer
bacilli vaccine months part of
the
Oral polio Live, Clear, pinkish liquid (AMV1) upper
vaccine attenuated arm
virus
(trivalent) Measles- 12-15 0.5 ml SUBQ Outer
mumps-rubella months part of
Anti-measles Live, Freeze-dried, vaccine the
vaccine attenuated reconstituted with a (AMV2) upper
(AMV1) virus special diluent arm
Measles- Live, Freeze-dried, Rotavirus 6 weeks, 1.5 ml Oral Mouth
mumps- attenuated reconstituted with a vaccine 10 weeks
rubella viruses special diluent
vaccine
(AMV2) EPI |Schedule and manner of administering
infant immunizations.
Rotavirus Live, Clear, colorless liquid, in
vaccine attenuated a container with an oral - Use only sterile syringe and needle per client
virus applicator
- There is no need to restart a vaccination series
Tetanus Weakened Sometimes slightly turbid regardless of the time that has elapsed between
toxoid toxin in appearance: Clear, doses.
colorless liquid;
sometimes slightly - All the EPI antigens are safe and effective when
turbid… administered simultaneously.
- same immunization session but at different
sites
NOT recommended:
- to mix different vaccines in one syringe
- to use a fluid vaccine for reconstitution of a
freeze-dried vaccine.
*If more than one injection has to be given on the
same limb: > injection sites should be 2.5-5cm
apart.
Recommended sequence of co- Estimated number of infants=total population x 2.7 %
administration:
- OPV first followed by Rotavirus vaccine, then Estimated number of 12¿ 59 month old children=total popula
other appropriate vaccines. Estimated number of pregnant women=total population x 3.
OPV administration:  
- drops of vaccine straight from the dropper onto
the child’s tongue
*DO NOT let the dropper touch the tongue.
- Only monovalent hepatitis B vaccine must
be used for the birth dose.
- Pentavalent vaccine must not be used for the
birth dose because DPT and Hib vaccine should
not be given at birth.
- Shall be given:
AMV1 ASAP
AMV2 one month after the AMV1
*Children who have not received AMV1 as
scheduled
*children whose parents/caregivers do not
know whether they have received AMV1
- All children entering day care centers/
preschool and Grade I (Shall be screened for
measles immunization)
- First dose of Rotavirus vaccine:
- >administered only to infants aged 6 weeks
to 15 weeks.
- The second dose >administered only to infants
aged 10 weeks up to a maximum of 32 weeks.
- Administer the entire dose of the Rotavirus
vaccine slowly down one side of the mouth with EPI | COLD CHAIN
the tip of the applicator directed toward the
back of the infant’s mouth. 1. Vaccines buildsdes immunity when
*To prevent spitting or failed swallowing, potent.
stimulate the rooting or sucking reflex of the
To retain the potency, must be:
young infant.
- properly stored
*For infants aged 5 months or older, lightly
- handled
stroke the throat in a downward motion to
- transported.
stimulate swallowing.
Maintain the COLD CHAIN
EPI | TARGET SETTING
- system for ensuring potency of vaccine from time
Goal of EPI in the Philippines: of manufacture to time it is given to eligible client.
- 100% immunization of infants/children against
Person responsible: Cold Chain Officer
the most common vaccine-preventable diseases
COLD CHAIN Equipment and Supplies:
In RHU/health center level the public
health nurse is responsible for:  Freezer/refrigerator
- Preparing vaccine requirements  Transport box
- Overseeing vaccine allocation
 Vaccine bags/carriers
“Vaccine requirement is calculated based
on eligible population.”  Cold chain monitors*
  Thermometers (Check temperature 2x in a
day)
 Cold packs
On a stem or bulb thermometer, coloured fluid in
the bulb:
- moves up the scale warmer
- down the scale colder.
COLD CHAIN REQUIREMENTS
COLD CHAIN REQUIREMENTS FREEZE SENSITIVITY
OPV – 15 °C. – 25 °C (Stored in freezer)
In vaccine bag: placed in contact with cold packs
All other vaccines including MEASLES,
MMR, & ROTAVIRUS VACCINE:
>+2 ⁰C. to +8⁰C stored the body/compartment
of refrigerator
>Stocked neatly on the shelves of refrigerator.
*DO NOT stock vaccines at refrigerator door Hepatitis B vaccine, Pentavalent vaccine,
shelves. Rotavirus vaccine & TT
- Keep diluents cold by storing them in the
DAMAGED BY FREEZING refrigerator in the lower or door shelves.
Hepatitis B vaccine, Pentavalent vaccine, Rotavirus
vaccine & TT
- should NOT be stored in freezer.
- Wrap containers of these vaccines with paper
before putting them in the vaccine bag with cold
packs.

How to Maintain Correct Temperature in

Cold Boxes and Vaccine Carriers

HEAT SENSITIVITY

Load front-loading refrigerator with freezer
on top as follows:
1. Measles, MR, MMR, BCG and OPV on the
top shelf
2. DTP, DT, Td, TT, HepB, DTP-HepB, Hib,
DTP-HepB+Hib, meningococcal, yellow
fever, and JE vaccines on the middle
shelves
3. Diluents next to the vaccine with which
they were supplied
Loading ice-lined refrigerators (ILR)
All the vaccines should be stored in the basket
provided with the refrigerator
1. Measles, MR, MMR, BCG and OPV in the
bottom only
2. Freeze-sensitive vaccines (DTP, TT, HepB,
DTP-HepB, Hib, DTP- hepB+Hib,
meningococcal, yellow fever, and JE
vaccines) in the top only.
Other considerations to maintain potency
1. Observe the first expiry- first out (FEFO) policy.
2. Duration of storage & transport: health
center/RHU with a refrigerator – storage should
not exceed one month
3. Duration of storage & transport: Transport
boxes, vaccines can be kept only up to maximum of
5 days.
Vaccine Carriers
• Smaller than cold boxes;
• Easier to carry if walking
• They do not stay cold as long as a cold box –
maximum for 48 hours with the lid closed.
VACCINE VIAL MONITOR (VVM)
VVM is a round disc of heat-sensitive material
placed on a vaccine vial to register cumulative heat
exposure.
VVM – Direct relationship exists between rate of
color change and temperature:
the lower the temperature, the slower the color
change;
the higher the temperature, the faster the color
change.
Reconstitute freeze-dried vaccines – Discard
reconstituted freeze-dried vaccines 6 hours after
reconstitution or at the end of immunization
session, whichever comes sooner.
OPEN-VIAL POLICY (DOH)/ MULTI –
DOSE VIAL
- Any vial of the applicable vaccines opened/used in
a session (fixed or outreach) can be used at more
than one immunization session up to four weeks
(28 days) provided.
MULTI DOSE LIQUID VACCINES:
OPV, Pentavalent vaccine, Hepatitis B vaccine, and
TT *
from which one or more doses have been taken
following standard sterile procedures
MULTI DOSE VIAL may be opened for 1 or 2
clients if the health worker feels that a client cannot
come back for the scheduled immunization session,
following standard sterile procedures
MULTI DOSE LIQUID VACCINES may be used
in the next immunization sessions for up to
maximum of 4 weeks, provided …. that all
conditions are met:
 expiry date has not passed.
 vaccinenot been contaminated.
 vials have been stored under appropriate
cold chain conditions.
 vaccine vial septum has not been submerged
in water.
 VVM on the vial, if attached, has not reached
the discard point
PROTECT BCG FROM SUNLIGHT and placing the vials on table and not moving them
ROTAVIRUS VACCINE FROM LIGHT further.
Exposure to Ultraviolet Light Causes Loss of
Potency.
- must always be protected against sunlight or
fluorescent (neon) light.
- BCG, measles, MR, MMR and rubella vaccines
- These are equally sensitive to light (as well as to
heat)
- Normally, these vaccines are supplied in vials
made from dark brown glass

Procedure:
1. Prepare a frozen control sample
- Take a vial of vaccine same type /batch of
vaccine you want to test. FREEZE vial until
the contents are solid (at least 10 hours at
-10°C). Then let it thaw.
- This is the control sample. Mark the vial
clearly.
2. Choose a test sample Take a vial (s) of
vaccine from the batch (es) that you suspect
has been frozen.
- This is the test sample.
Shake the control and test samples
- Hold the control sample and the test sample
together in one hand and shake vigorously for 10–
15 seconds.
- Allow to rest Leave both vials to rest by
CHN 211 Community Health Nursing
(DOH PROGRAMS) Integrated
Management of Childhood Illness
INTRODUCTION
The WHO/UNICEF guidelines for Integrated
Management of Childhood Illness (IMCI) offer simple
and effective methods to prevent and manage the
leading causes of serious illness and mortality in young
children.
The clinical guidelines promote evidence-based
assessment and treatment, using a syndromic approach
that supports the rational, effective and affordable use
of drugs. The guidelines include methods for checking a
child’s immunization and nutrition status; teaching
parents how to give treatments at home; assessing a
child’s feeding and counselling to solve feeding
problems; and advising parents about when to return to
a health facility. The approach is designed for use in
outpatient clinical settings with limited diagnostic tools,
limited medications and limited opportunities to
practice complicated clinical procedures.
In each country, the IMCI clinical guidelines are
adapted:
- To cover the most serious childhood illnesses
typically seen at first-level health facilities
- To make the guidelines consistent with national
treatment guidelines and other policies
- To make the guidelines feasible to implement
through the health system and by families caring for
their children at home.
Foreword
Since the 1970s, the estimated annual number of
deaths among children less than 5 years old has
decreased by almost a third. This reduction, however,
has been very uneven. And in some countries rates of
childhood mortality are increasing. In 1998, more than
50 countries still had childhood mortality rates of over
100 per 1000 live births.1 Altogether more than 10
million children die each year in developing countries
before they reach their fifth birthday.
Seven in ten of these deaths are due to acute
respiratory infections (mostly pneumonia), diarrhoea,
measles, malaria, or malnutrition— and often to a
combination of these conditions.
What is IMCI?
– A strategy for reducing mortality and morbidity
associated with major causes of childhood illness.
– A joint WHO/UNICEF initiative since 1992.
– Currently focused on first level health facilities.
– Comes as a generic guideline for management which
been adapted to each country.
INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESS
Pneumonia, diarrhea, dengue hemorrhagic fever,
malaria, measles and malnutrition cause more than
70% of the deaths in children under 5 years of age. All
these are preventable diseases in which when managed
and treated early could have prevented these deaths.
There are feasible and effective ways that health worker
in health centers can care for children with these
illnesses and prevent most of these deaths. WHO and
UNICEF used updated technical findings to describe
management of these illnesses in a set of integrated
guidelines for each illness. They then developed this
protocol to teach the integrated case management
process to health worker who see sick children and
know which problems are most important to treat.
Therefore, effective case management needs to
consider all of a child’s symptoms.
OBJECTIVES
– To reduce significantly global morbidity and
mortality associated with the major causes of illnesses
in children.
– To contribute to healthy growth and development of
children.
The CASE MANAGEMENT PROCESS is used to assess
and classify two age groups:
- age 1 week up to 2 months
- age 2 months up to 5 years
And how to use the process shown on the chart will
help us to identify signs of serious disease such
pneumonia, diarrhea, malaria, measles, DHF,
meningitis, malnutrition and anemia.
THE CASE MANAGEMENT PROCESS
•The charts describes the following steps;
1. assess the child or young infant
2. classify the illness
3. identify the treatment
4. treat the child
5. counsel the mother
6. give follow up care
THE CLASSIFICATION TABLE
– The classification tables on the assess and classify
have 3 ROWS.
– COLOR of the row helps to IDENTIFY RAPIDLY whether
the child has a SERIOUS DISEASE requiring URGENT
ATTENTION.
– Each row is colored either:
PINK – means the child has a severe classification and
needs urgent attention and referral or admission for
inpatient care.
YELLOW – means the child needs a spec eds a specific
medical treatment such as an appropriate antibiotic, an
oral anti-malarial or other treat other treatment; also
teaches the mother how to give oral drugs l drugs or to
treat local infections at home. The health worker
teaches the mother how to care for her child at home
and when she should return.
GREEN – not given a specific medical treatment such
as t such as antibiotics or treatments. The health
worker h worker teaches the mother how her how to
care for her child at home.
Always start at the top of the classification table. If the
child has signs from more than 1 row always select the
more serious classification.
WHY NOT USE THE PROCESS FOR CHILDREN AGE 5
YEARS OR MORE?
– The case he cases management process is designed
for children < 5yrs of age, although. Much of the advice
on treatment of pneumonia, diarrhea, malaria, measles
and malnutrition, is also applicable to older children,
the ASSESSMENT AND CLASSIFED CLASSIFICATION of
older children would differ. For example, the cut off rate
for determining fast breathing would be d would be
different because normal breathing rates are slower in
older chi older children. Chest indrawing is no indrawing
is not a reliable sign of severe pneumonia as children
get older and the bones of the chest become more firm.
– In addition, certain treatment recommendations or
advice to mothers on hers on feeding would differ for
>5yrs r >5yrs old. The drug dosing, he drugs dosing
tables only apply to chi ply to children up to 5yrs old.
The feeding advice for older children may differ and
they may have ay have different feeding problems.
– Because of differences in the clinical signs of older and
younger children who have these illnesses, the
assessment and classification process using these
clinical signs is not recommended for older children.
WHY NOT USE THIS PROCESS FOR YOUNG INFANTS
AGE < 1 WEEK OLD?
– The process on young infant chart is designed for
infants age 1 week up to 2 months. It greatly differs
from older infants and young children. In the first week
of life, newborn infants are often sick from conditions
related to labor and delivery. Their conditions require
special treatment.
IDENTIFICATION AND PROVISION OF TREATMENT
- Curative component adapted to address the most
common life- threatening conditions in each country
- Rehydration (diarrhea, DHF)
- Antibiotics (pneumonia, “severe disease”)
- Antimalarial treatment
- Vitamin A (measles, severe malnutrition)
PROMOTIVE AND PREVENTIVE ELEMENTS
- Reducing missed opportunities for immunization
(vaccination given if needed)
- Breastfeeding and other nutritional counseling
- Vitamin A and iron supplementation
- Treatment of helminth infections
The Integrated Case Management Process
Overall Case Management Process
Outpatient
1 – assessment
2 - classification and identification of treatment
3 - referral, treatment or counseling of the child’s
caretaker (depending on the classification identified)
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of patient’s
progress
SUMMARY OF THE INTEGRATED CASE
MANAGEMENT PROCESS
 For all sick children age 1 week up to 5 years who are
brought to a first level health facility.
ASSESS the Child:
Check for danger signs (or possible bacterial
infection).
Ask about main symptoms.
If a main symptom is reported, assess further.
Check nutrition and immunization status.
Check for other problems
Classify the child’s illness:
Use a color-coded triage system to classify the
child’s main symptoms and his or her nutrition or
feeding status.
IF URGENT: REFERRAL is needed and possible
IDENTIFY URGENT PRE- REFERRAL TREATMENT(S)
Needed prior to referral of the child according to
classification.
TREAT THE CHILD: Give urgent pre-referral treatment(s)
needed.
REFER THE CHILD:
Explain to the child’s caretaker the need for
referral.
Calm the caretaker’s fears and help resolve any
problems. Write a referral note.
Give instructions and supplies needed to care for
the child on the way to the hospital.
IF NO URGENT REFERRAL is needed or Possible
IDENTIFY TREATMENT needed for the child’s
classifications: identify specific medical treatments
and/or advice.
TREAT THE CHILD:
Give the first dose of oral drugs in the clinic and/or
advice the child’s caretaker.
Teach the caretaker how to give oral drugs and
how to treat local infections at home.
If needed, give immunizations.
COUNSEL THE MOTHER:
Assess the child’s feeding, including breastfeeding
practices, and solve feeding problems, if present.
Advise about feeding and fluids during illness and
about when to return to a health facility.
Counsel the mother about her own health.
FOLLOW-UP CARE: Give follow-up care when the child
returns to the clinic and, if necessary, reasses the child
for new problems.
SELECTING THE APPROPRIATE CASE
MANAGEMENT CHARTS
THE SICK CHILD AGE 2 MONTHS TO 5 YEARS:
ASSESS AND CLASSIFY
SUMMARY OF ASSESS AND CLASSIFY
Ask the mother or caretaker about the 4 main
symptoms:
cough or difficult breathing
diarrhea
fever, and
ear problem
When a main symptom is present:
Assess the child further for signs related to the
main symptom, and
Classify the illness according to the
signs which are present or absent
When a child is brought to the clinic
Use Good Communication Skills:
Listen carefully to what the mother tells you
Use words the mother understands
Give mother time to answer questions
Ask additional questions when mother not sure of
answer
Record important information
GENERAL DANGER SIGNS
When a child is brought to the clinic
ASK:
Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions?
LOOK:
See if the child is lethargic or unconscious
Cough or difficult breathing?
IF YES, ASK:
For how long? LOOK, LISTEN, FEEL:
Count the breaths in one minute.
2-12 mos = fast breathing >/= 50/min
12 mos-5yrs = fast breathing >/= 40/min
Look for chest indrawing
Look and listen for stridor
Classify COUGH or DIFFICULT BREATHING

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT

BREATHING

DIARRHEA
Does the child have diarrhea? IF YES, ASK:
For how long?
Is there blood in the stool?
LOOK, LISTEN, FEEL:
Look at the child’s general condition, is the child:
Lethargic or unconscious? Restless or irritable?
Look for sunken eyes Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking
eagerly, thirsty?
Pinch the skin of the abdomen.
Does it go back: Very slowly (> than 2 secs)? Slowly? CLASSIFICATION TABLE FOR DEHYDRATION
CLASSIFICATION TABLE FOR PERSISTENT
DIARRHEA

CLASSIFICATION TABLE FOR DYSENTERY

FEVER
Does the child have FEVER?
IF YES, decide the malaria risk: high or low THEN ASK:
For how long?
If more than 7 days, has fever been present every
day?
Has the child had measles within the last 3
months?
If the child LOOK AND FEEL:
Look for runny nose
Look or feel for stiff neck
LOOK FOR SIGNS OF MEASLES
 has measles now or within the last 3 months
-Rash -Mouth ulcers
-Pus from eyes -Runny nose
-Red eyes -Clouding of cornea
-Runny nose -Cough
-Red eyes
LOOK FOR SIGNS OF DENGUE/DHF
-----bleeding tendencies
flushing
(+) tourniquet test
rash
CLASSIFICATION TABLE FOR NO MALARIA RISK
AND NO TRAVEL TO A MALARIA RISK AREA

CLASSIFICATION TABLE FOR MEASLES (IF MEASLES

NOW OR WITHIN THE LAST 3 MONTHS)

FEVER WITH RASHES

Ear Problem
Does the child have an EAR PROBLEM?
IF YES, ASK:
Is there ear pain?
Is there ear discharge? If yes, for how long?
LOOK AND FEEL:
Look and pus draining from the ear
Feel for tender swelling behind the ear
CLASSIFICATION TABLE FOR EAR PROBLEM

Malnutrition and Anemia

CHECK FOR MALNUTRITION AND ANEMIA
LOOK AND FEEL:
Look for visible severe wasting
Look for palmar pallor. Is it:
Severe palmar pallor?
Some palmar pallor?
Look for edema of both feet
Determine weight for age CLASSIFICATION TABLE FOR MALNUTRITION AND
CLASSIFY NUTRITIONAL STATUS ANAEMIA
Immunization Status
CHECK IMMUNIZATION STATUS: IMMUNIZATION
SCHEDULE

• Birth - BCG, HepB1

• 6 weeks - DPT1, OPV1, HepB2
• 10 weeks - DPT2, OPV2, HepB3
• 14 weeks - DPT3, OPV3, HepBbooster
• 9 mos - measles
How to check the Immunization Status
>If an infant has not received any immunization,
then give
–BCG
–DPT 1 , OPV 1
–Hepatitis B 1
THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2
MONTHS: ASSESS AND CLASSIFY
SUMMARY OF ASSESS AND CLASSIFY
How to check a young infant for possible bacterial
infection?

CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL

INFECTION
How to assess and classify a young infant for
diarrhea?

CLASSIFICATION TABLE FOR FEEDING PROBLEM

OR LOW WEIGHT
Communicate and Counsel

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant
When to return immediately
–Signs of any of the following:
–Breastfeeding feeding or drinking poorly
–Becomes sicker
–Develops a fever
–Fast breathing
–Difficult breathing
–Blood in the stool
Follow-up in 2 days – on antibiotics for local bacterial
infection or dysentery
Follow-up in 2 days - with a feeding problem or oral
thrush
Follow-up in 14 days – with low weight for age
NEWBORN SCREENING
– A simple procedure to find if a baby has a congenital
metabolic disorder even before clinical signs and
symptoms are present.
PURPOSE
•To know the metabolic disorder that may occur to
newborn that may lead to mental retardation or even
death if left untreated
• To be able to identify newborn with metabolic
disorders because they look normal at birth
• To treat genetic metabolic disorder as early as after
birth
OBJECTIVE OF NEWBORN SCREEN
• Newborn has access to newborn screening
• Sustainable newborn screening system
• All health practitioners are aware of the
advantages
• Parents recognize their responsibility
HISTORY OF NBS IN THE PHILIPPINES
RA 9288: NEWBORN SCREENING ACT OF 2004
• Protect the rights of children to survival and full
and healthy development as normal individuals
• Provide for a comprehensive, integrative and
sustainable national newborn screening system to
ensure that every baby born in the Philippines is
offered the opportunity to undergo newborn
screening and be spared from heritable conditions.
NEWBORN SCREENING REFERENCE CENTER (NSRC)
• They are responsible for the national testing
database and case registries, training, technical
assistance and continuing education for laboratory staff
in all newborn screening centers
NBS PROCEDURE
• Law provides that NBS be done after 24 hours of
life, but not later than three days from complete
delivery of the newborn
• Specimen for NBS is obtained through a heel prick
• A few drops of blood are taken from the baby’s heel
blotted on a special absorbent filter card and then sent
to a newborn screening center
 Sample for NBS may be obtained by a
physician, nurse, medical technologist or trained
midwife
 Normal (negative) NBS Results are available by
7-14 working days from the time samples are received
at NSC.
NBS SCREENING PROCEDURE
PULSE OXIMETRY
– This is a test that measures the amount of oxygen in
the newborn’s blood and can detect some heart
problems called Critical Congenital Heart Disease
(CCHD).
NEWBORN HEARING SCREENING
• Is designed to identify hearing loss in infants shortly
after birth
• Done prior to discharge from the hospital or birth
clinics
• Methods
• Auditory brainstem response (ABR) evaluation
• Otoacoustic emission (OAE)
* two different test can used to screen for hearing
loss in newborns
* both tests are quick (5-10minutes), safe and
comfortable with no activity required from newborn.
RA 9709 UNIVERSAL NEWBORN HEARING AND
INTERVENTION ACT OF 2009
– An act establishing a universal newborn hearing
screening program for the prevention, early diagnosis
and intervention of hearing loss
UNIVERSAL NEWBORN HEARING SCREENING
PROGRAM (UNHSP)
• Ensure all newborns have access to hearing loss
screening
• Establish network among pertinent government and
private sector stakeholders for policy development,
implementation, monitoring, and evaluation to promote
UNHSP.
• Provide continuing capacity building
• Establish and maintain a newborn hearing screening
database
• Ensures linkages to diagnosis and the community
system of early intervention services
• Develop public policy in early hearing detection
• Develop models which ensure effective screening,
referral and linkage with appropriate diagnostic,
medical and qualified early intervention services,
providers, and programs within the community.
OTOACOUSTIC EMISSIONS TEST (OAE)
• Used to determine if certain parts of the newborn’s
ear respond to sound
• During the test, a miniature earphone and
microphone are placed in the ear and sounds are
played. When a newborn has normal hearing, an echo is
reflected back into the ear canal, which can be
measured by the microphone. If no echo is detected, it
can indicate hearing loss.
AUDITORY BRAIN STEM RESPONSE TEST (ABR) Mineralocorticoids – (aldosterone) which regulate
• Used to evaluate the auditory brain stem and the sodium and potassium levels
brain’s response to sound. Androgens – (testosterone) male sex hormones
• During the test, miniature earphones are placed in TYPES OF CONGENITAL ADRENAL HYPERPLASIA
the ear and sounds are played. Band-Aid-like electrodes • Classic CHA – can be detected usually in infancy
are placed along the newborn’s head to detect the • Non-classic CAH –milder and more common, and
brain’s response to the sounds. If the newborn’s brain may not become evident until childhood or early
does not respond consistently to the sounds, there may adulthood
be a hearing problem. SIGNS AND SYMPTOMS:
• A fetus affected by congenital adrenal hyperplasia
DISORDERS TESTED FOR NBS will produce excessive male hormones during
• CONGENITAL HYPOTHYROIDISM development
• CONGENITAL ADRENAL HYPERPLASIA • If the fetus is female, this will result in virilization of
• GALACTOSEMIA the external genitalia
• PHENYLKETONURIA • Female baby may be born with ambiguous genitalia
• GLUCOSE-6-PHOSPHATE- DEHYDROGENASE • Adrenal crisis
DEFICIENCY (G6PD) • if the infant has untreated, they will produce
• MAPLE SYRUP URINE DISEASE excessive levels of male hormones such as testosterone
CONGENITAL HYPOTHYROIDISM NURSING INTERVENTIONS
• Occurs when a newborn or infant is born without • Allow the parents to grief
the ability to make normal amounts of thyroid • Provide emotional support
hormone • Allow the parents to understand about the disease
• It usually occurs about 1 in 3000 – 4000 children • Provide education for parents and child about the
CAUSES said condition
• Impaired neurological function GALACTOSEMIA
• Stunted growth • Is a recessive hereditary metabolic disorder in
• Physical deformities which the enzyme necessary to convert galactose
SIGNS AND SYMPTOMS into glucose is missing
- less active • Clinical Manifestations
- sleep more than normal Poor growth
- difficulty in feeding Jaundice
- constipation Bleeding
NURSING INTERVENTIONS Feeding difficulties
• Maintain a stable weight Cataracts
• Educate the client and family regarding body weight Liver and spleen damage
changes NURSING INTERVENTIONS
• Collaborate with dietician to determine client’s - Milk substitution
caloric needs - Dietary restrictions
• Encourage the intake of foods rich in fiber - Read food labels
• Encourage a low cholesterol, low calorie and low - Client education
saturated fat diet
• Reduce fatigue PHENYLKETONURIA
• Is an inborn error of metabolism that results in
CONGENITAL ADRENAL HYPERPLASIA decreased metabolism of the amino acid
• Refers to a group of genetic disorder that affect the phenylalanine
adrenal glands and a high level of male hormones • If untreated
• Hormones:  Intellectual disability
Cortisol – regulates the body’s response to illness,  Seizures
stress or injury
  Behavioral problems • Legumes (bitsuelas, garbansos, monggo beans)
 Mental disorders • Soya foods(taho, tokwa, soy sauce)
• Tonic water
SIGNS AND SYMPTOMS
• A musty odor in the breath, skin, urine MAPLE SYRUP URINE DISEASE
• Seizures – Is an inherited disorder in which the body is unable to
• Skin rashes (eczema) process certain protein building blocks(amino acid)
• Fair skin and blue eyes properly.
• Abnormally small head • Leucine - contributes to regulation of blood- sugar
NURSING INTERVENTIONS levels; growth and repair of muscle and bone tissue;
- Diet growth hormone production; and wound healing.
- Emotional support • Isoleucine - This is the oxygen-carrying pigment
- Health education inside of red blood cells. It may help control blood
- Guidance from a dietitian sugar. It may also boost energy and endurance.
- Safety • Valine - is an α-amino acid that is used in the
biosynthesis of proteins.
GLUCOSE-6-PHOSPHATE- DEHYDROGENASE
SIGNS AND SYMPTOMS
DEFICIENCY (G6PD)
• Poor appetite
– Is a genetic metabolic abnormality caused by
• Trouble sucking during feeding
deficiency of the enzyme glucose-6-phosphate
• Weight loss
dehydrogenase
• High pitched cry
SIGNS AND SYMPTOMS
• Urine that smells sweet like maple syrup or burnt
• Rapid heart rate
sugar
• Shortness of breath
• Sleeping longer or more often
• Urine that is dark or yellow-orange
• Tiredness
• Fever
• Irritability
• Fatigue
• Vomiting
• Dizziness
• Development delay
• Paleness
NURSING INTERVENTIONS
• Jaundice
- Dietary therapy
NURSING INTERVENTION
- No restrictions in Activity
- If the client is sick like cough, colds or other bacterial
- Hemodialysis/peritoneal dialysis
or viral infection, tell the doctor that the client has
- Medication
G6PD
- Keep the list of oxidative substances in a handy
place and check food, beverage and medicine against
the list
- Memorize the signs and symptoms of hemolytic
anemia
- Do not ignore infections
- As the child gets older, tell him/her condition and
educate the child to be careful about what to eat
- If you ingested or were exposed to any medication
and your urine became tea colored, inform the doctor
immediately
- If you have yellowish discoloration in the skin, sclera
or any part of the body, consult the doctor immediately
- Avoid foods contraindicated to G6PD
• Fava beans
• Red wine
STANDARD 6 TEST

When do typical signs and symptoms appear?

SUMMARY TREATMENT
EXPANDED NEWBORN SCREENING
– The expanded newborn screening program will
increase the screening panel of disorders from six(6)
to twenty eight (28).
– Expanded newborn screening will screen for
additional disorders falling under various groups of
conditions namely:
• HEMOGLOBINOPATHIES
• DISORDER OF AMINO ACID
• ORGANIC ACID METABOLISM
• DISORDERS OF FATTY ACID OXIDATION
• DISORDERS OF CARBOHYDRATE METABOLISM
• DISORDER OF BIOTIN METABOLISM
• CYSTIC FIBROSIS
ESSENTIAL INTRAPARTAL NEWBORN
CARE
– An evidence based standards for safe quality care of
birthing mothers and their newborns within 48 hours
of intrapartum period and a week of life for the
newborn.
PURPOSES:
Assess and evaluate the newborn as he or she
transitions from intrauterine life to extrauterine life.
Evaluate and monitor the newborn, system- by-
system for normal versus abnormal functioning,
providing maintenance of normal and potential
treatment of abnormal findings.
Foster bonding between infant and parent/s.
Provide a safe environment at all times.
EINC practices during Intrapartum Period:
1. Continuous maternal support, by a companion of
her choice, during labor and delivery
2. Mobility during labor – the mother is still mobile,
within reason, during this stage
3. Position of choice during labor and delivery
4. Non-drug pain relief, before offering labor
anesthesia
5. Spontaneous pushing in a semi-upright position
6. Episiotomy will not be done, unless necessary
7. Active management of third stage of labor (AMTSL)
8. Monitoring the progress of labor with the use of
partograph
Time Bound and Non-immediate NBC
• Immediate and Thorough Drying
• Early Skin-to-Skin Contact
• Properly Timed Cord Clamping
• Non-separation of Newborn from Mother for Early
Breastfeeding.
Immediate and Thorough Drying
Within 1st 30 secs (Immediate Thorough Drying)
Call out the time of birth
Dry the newborn thoroughly for at least 30seconds
Wipe the eyes, face, head, front and back, arms
Remove the wet cloth
Do a quick check of breathing while drying.
(do not suction unless the mouth or nose is blocked)
WHEN TO DO THE AGPAR SCORING?
1st Minute – to assess the general condition of the
Newborn
5th Minute - to assess Newborn’s adaptation
10th Minute - if the 5th minute APGAR is score
is less than 4
AGPAR SCORING

Essential Intrapartum Newborn Care

• December 2009, the Secretary of the Department of
Health Francisco Duque signed Administrative Order
2009-0025, which mandates implementation of the
EINC Protocol in both public and private hospitals. ACROCYNANOSIS
• Unang Yakap campaign was launched. Circumoral Cynanosis – a condition where there is
Former Newborn Care VS. Updated Newborn Care a bluish discoloration of the skin due to decreased
Immediate and Routine NBC oxygenation or blood circulation.
A- Airway
T-Thermoregulation
A- APGAR scoring
I- Initial Identification
B- Bathing
A- Anthropometric Measurement
C- Crede’s Prophylaxis
K- Vit. K Administration
U- Umbilical Cord Care
P- Prints
Early Skin-to-Skin Contact (after 30secs of Drying)
Position the newborn prone on the mother’s
abdomen or chest.
Cover the newborn’s back with a dry blanket.
Cover the newborn’s head with a bonnet.
Avoid any manipulation, e.g. routine suctioning that
may cause trauma or infection
Place identification band on ankle.
SKIN TO SKIN CONTACT
• Provide warmth/prevent hypothermia
• Improves bonding
• Provides protection from infection by exposure of
the baby to good bacteria of the mother
• Increases the blood sugar of the baby
Medications
- Administer erythromycin, tetracycline or 2.5%
povidone drops (to prevent ophthalmia neonatorum)
- Give Vitamin K Prophylaxis, Vit K 1mg IM
- Inject Hepatitis B and BCG vaccination. (Hep B IM
and BCG intradermally)
- Examine newborn for, Birth injuries, malformations
or defects.
- Do cord care
• Wash Hands
• Fold diaper below stump, keep cord stump open
to keep it dry.
• Explain to the mother that she should seek
medical attention if umbilicus is red or draining pus.
• Teach the mother to treat local umbilical
infections as per doctor's order

• Contributes to the over all success of breastfeeding 4 Newborn Protocol

Properly Timed Cord Clamping(1-3 mins) 1st 30sec. (Dry) Hypothermia

Remove the first set of gloves.
2nd 30sec. (SSC) Hypoglycemia/Infection
After the umbilical pulsations have stopped, clamp
the cord using a sterile plastic clamp or tie at 2 cm from
the umbilical base. 1-3mins. (CCC Anemia
Clamp again at 5 cm from the base. )
After clamping, provide 10 IU oxytocin IM to the 90mins. (SSC) Promote Breast Feeding
mother
Cut the cord close to the plastic clamp.
Points to Remember: Unnecessary Procedures
Do not milk the cord towards the baby > Routine Suctioning – Suctioning has no benefit if the
Cut the cord close to the plastic clamp so that there amniotic fluid is clear. A dirty bulb can be a source of
is no need for a 2nd “trim” infection.
Do not apply any substance onto the cord > Early bathing – WHO recommends to perform
Check for two arteries and one vein (AVA) bathing after 6 hours after delivery.
> Footprinting – is proven inadequate for newborn
Non-separation of Newborn from Mother for identification purposes.
Early Breastfeeding > Giving sugar water, formula or other prelacteals and
- Within 90 mins the other use of bottles or pacicier.
- Leave the newborn in skin-to-skin contact (SSC) > Application of alcohol, medicine and other
- Observe for feeding cues, including tonguing, licking, subtances on the cord stump.
rooting
- Point these out to the mother and encourage her to
nudge the newborn towards the breast.
- P.T.R
• Minimize handling by health workers
• Do not throw away colostrum
- Weighing, bathing, eye care, examinations,
injections (hepatitis B, BCG) should be done after the
first full breastfeed is completed.
- Postpone washing until at least 6 hours.
Summary of Time-bound ENC

MEDICATIONS
 CREDE'S PROPHYLAXIS  BCG (BACILLUS CALMETTE GUERINE)
– ERYTROMYCIN/ TERAMYCIN OPTHALMIC OINTMENT – 0.01 ML INTRADERMAL DELTOID (LEFT)
– TO PREVENT OPTHALMIA NEONATORUM – TO PREVENT FROM LUNG PROBLEM
– applied from inner to outer canthus of the eyes
 VITAMIN K ANTHROPOMETRIC MEASUREMENT
PURPOSE:
– Promote blood clothing.
– Prevent bleeding.
– Prevent Hypofibrenogenimea.
– DRUG OF CHOICE: PHYTOMENADIONE,
AQUAMEPHYTON.
– ROUTE: IM (90%)
– SITE: Left-Vastus lateralis (common) Rectus Femoris
(alternative site)
– DOSSAGE:
PRE TERM - 0.05 CC VITAL SIGNS
FULLTERM - 0.1 CC > Check patency of the anus
POST TERM – 0.1 CC > Weight: 2.5kg-3.5kg
 HEPA B. > Check vital signs
– 0.5ML INTRAMUSCULAR INJECTION. Temperature: 37.2
– VASTUS LATERALIS Pulse rate: intrauterine: 120-160 beats per min
right after birth: 180
1 hour after birth: 120-140
 Respiration: at birth: 80 cycles per min at rest: 30-
60 cycles per min BP 80/46-100/50