INTEGRATED MANAGEMENT OF CHILDHOOD DISEASE

https://books.google.com.ph/books/about/Handbook_IMCI.html?
id=4Zhk4Y6UshcC&printsec=frontcover&source=kp_read_button&hl=en&redir_
esc=y#v=onepage&q&f=false

 IMCI as a strategy deal with the management of common childhood illnesses

in an integrated manner.
 It includes preventive interventions, adjusting curative interventions to the
capacity and functions of the health system and it involves the family
members and the community in the health care process.

BRIEF HISTORY OF IMCI

 IMCI was first developed in 1992 by the United Nations Children’s Emergency
Fund (UNICEF) and the World Health Organization (WHO), with the aim or
preventing or early detection and treatment of the leading cause of childhood
deaths.
 The IMCI initiative adopted a broad, cross-cutting approach recognizing that in
most morbidity or mortality cases, more than one underlying cause
contributes to the illness of the child.
 Though it focuses on treatment, IMCI also emphasizes the prevention of
illness through education on the importance of immunization, micronutrient
supplementation, and improved nutrition - especially oral rehydration therapy
(ORT), breastfeeding, and infant feeding.
 IMCI seeks to reduce childhood mortality and morbidity by improving family
and community practices for the home management of illness, and improving
case management of skills of health workers in the bigger health system.
 IMCI is implemented by working with local governments and ministries of
health to plan and adapt the principles of this approach to particular
circumstances,
 IMCI was introduce in the Philippines in 1995 as a strategy to reduce child
death and promote growth and development.
 Philippine implementation started only in 1997 with approximately more than
4,000 trained workers on IMCI.
GOALS of IMCI:
 To reduce the infant and under- five mortality rate by at least one third in
2010.
 To reduce the infant-and under-five mortality rate by at least two-thirds in
2015.

STEPS INVOLVE:
 Adopting an integrated approach to child health and development in the
national health policy;
 Adapting the standard IMCI clinical guidelines to the country’s needs,
available drugs, policies and to the local foods and language used by the
population;
 Upgrading care in the local clinics by training health workers in new methods
to examine and treat children, and to effectively counsel parents;
 Making upgraded care possible by ensuring that enough of the right low-cost
medicines and simple equipment are available;
 Strengthening care in hospitals for those children too sick to be treated in
outpatient clinics; and
 Developing support mechanisms within communities for preventing disease,
for helping families to care for sick children, and forgetting children to clinics
or hospitals when needed.

Three main Components:

1. Improving case management skills of health care staff.
2. Improving overall health systems
3. Improving family and community health practices.

THE CASE MANAGEMENT PROCESS:

 The case management process is presented in a series of charts which show
the sequence of steps and provide information for performing them. The
charts describe the following steps:
1. Assess the child or young infant
2. Classify the illness
3. Identify treatment
4. Treat the child/Refer
5. Counsel the mother
6. Give follow-up care
IMCI Color-coded System
 Color Presentation Classification of Level of Management
Diseases
Green Mild Home Care
Yellow Moderate Manage at the RHU
Pink Severe Urgent referral to hospital

IMCI STRATEGY
1. Focused assessment
a. Danger signs - unable to drink or breastfeed; vomits everything taken in;
has convulsions, abnormally sleepy or difficult to awaken.
b. Main symptoms - cough or cold, fast breathing, stridor, chest in-drawing;
diarrhea, signs of dehydration; fever; signs and symptoms associated with
malaria, measles, dengue; and ear pain, mastoiditis
c. Nutritional status
d. Immunization status
e. Other problems
2. Classification
a. Urgent referral (Pink/Red)
b. Specific Treatment (Yellow)
c. Home Management (Green)
3. Treatment includes identifying the treatment, treating, counseling and follow-
up, and counseling the caretakers and follow-up

Focus of IMCI
 Pneumonia
 Dengue
 Diarrhea
 Malaria
 Measles
 Malnutrition

AGE Categories of the IMCI

 Depending on a child’s age, various clinical signs and symptoms have different
degrees of reliability and diagnostic value and importance. Therefore, the
IMCI guidelines recommend case management procedures based on two age
categories:
 a. Children aged 2 months up to 5 years
b. Young infants aged 1 week up to 2 months

Outpatient Management of Children Aged 2 months up to 5 years

Assessment procedure:
1. History taking and communicating with the caregiver.
2. Checking for general danger signs

CHECK FOR FOUR GENERAL DANGER SIGNS:

 Vomits everything
 Unable to drink or breastfeed
 Convulsions
 Unconscious or lethargic

 Seriously Ill Child - if a child has one or more of the above-mentioned signs,
he/she must be considered seriously ill and will always need URGENT referral
to a hospital.

3. Checking for Main symptoms.

1. Cough or difficult breathing;
2. Diarrhea;
3. Fever; and
4. Ear problems

Cough or difficulty breathing. A child presenting with cough or difficult breathing

should first be assessed for general danger signs.

Clinical Assessment. Three Key Clinical signs are used to assess a sick child with
cough or difficult breathing:

 Respiratory rate - distinguishes children who have pneumonia from those

who do not
 Lower chest wall indrawing - indicates severe pneumonia
 Stridor - indicates severe pneumonia and requires hospital admission

Cut-off rates for fast breathing

 the point at which breathing is considered to be fast are written below
 Rouena
S. Child’s age Cut-off rate for fast breathing
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
Villarama, (2009). Integrated Management of Childhood Illness (IMCI) Condensed Module. C&E Publishing, Inc.
Date retrieved: October 24, 2020
Lowest chest wall indrawing, or the inward movement of the bony structures of
the chest wall with inspiration, is a useful indicator of severe pneumonia.
 It is more specific than “intercostal indrawing”, which concerns the soft tissue
between the ribs without involvement of the bony structure of the chest wall.
 Chest indrawing should only be considered present if it is consistently present
in a calm child.
 Take note that agitation, a blocked nose, or breastfeeding can all cause
temporary chest indrawing.

Stridor is a harsh noise made when the child inhales (breath in).
 Children who have stridor when calm have a substantial risk of obstruction
and should be referred immediately.
 Some children with mild croup have stridor only when crying or agitated.

Wheezing is a noise heard when the child exhales (breaths out).

 A wheezing sound is most often associated with asthma.
 Mortality from asthma is relatively uncommon.

Classification of cough or difficult breathing:

Severe pneumonia or very severe disease - those who require referral

 This group includes children with any general danger sign, or lower chest
indrawing or stridor when calm.
 Children with severe pneumonia or very severe disease will most likely
have invasive bacterial organisms and diseases that may be life-
threatening.
 This warrants the use of injectable antibiotics.
Pneumonia - those who require antibiotics as out-patient because they are highly
likely to have bacterial infection.
 This group includes all children with a fast respiratory rate for age.
 Fast breathing, as defined by the WHO, detects about 80% of children with
pneumonia who need antibiotic treatment.
Cough or cold - do not require antibiotics; a simple home remedy to relieve cough
is preferred.
 A child with cough and cold normally improves in one or two weeks.
However, a child with chronic cough (more than 30 days) needs to be
further assessed (and, if needed, referred) to exclude tuberculosis,
asthma, whooping cough, or another problem.

Diarrhea
 A child presenting with diarrhea should be first be assessed for general danger
signs and the child’s caretaker should be asked if the child has cough or
difficult breathing.
 Diarrhea is the next symptom that should be routinely checked in every child.
 Diarrhea in children may assume any of these three potentially lethal forms:
1. Acute watery diarrhea (including cholera)
2. Dysentery (bloody diarrhea), and
3. Persistent diarrhea (diarrhea that lasts more than 14 days)
 All children with diarrhea should be assessed for:
a. Signs of dehydration
b. How long the child has had diarrhea; and
c. Blood in the stools to determine if the child has dysentery.
Clinical assessment:
 All children with diarrhea, should be checked to determine the duration of
diarrhea, if blood is present in the stools and if dehydration is present.
The following clinical signs are used to determine the level of dehydration:
1. Child’s general condition
 Depending on the degree of dehydration, a child with diarrhea may be
lethargic or unconscious (this is also a general danger signs)) or may look
restless/irritable.
 Only children who cannot be consoled and calmed should be considered
restless or irritable.
2. Sunken eyes
 The eyes of a dehydrated child may look sunken.
 In a severely malnourished child who is visibly wasted (marasmus), the eyes
may always look sunken, even if the child is not dehydrated.
3. Child’s reaction when offered to drink. The following are the categories of a
child’s ability to drink:
 a. A child is not able to drink if he/she is not able to take fluid in his/ her
mouth and swallow it, as in cases of lethargy or unconscious.
b. A child is drinking poorly if the child is weak and cannot drink without
help. He/she may be able to swallow only if fluid is put in his/her mouth
c. A child is drinking eagerly, thirsty if it is clear that the child wants to drink.
 notice if the child reaches out for the cup or spoon when you offer
him/her water.
 When the water is taken away, see if the child is unhappy because he/she
wants to drink more.
 If the child takes a drink only with encouragement and does not want to
drink more, he/she does not have the sign “drinking eagerly, thirsty.”
4. Elasticity of skin. Check elasticity of skin using the skin pinch test. When
released, the skin pinch goes back.
The following are the categories of skin elasticity based on the skin pinch test.
a. Very slowly - skin goes back after more than 2 seconds, or
b. Slowly - skin stays up even for a brief instant, or
c. Immediately
 In a child with marasmus (severe malnutrition), the skin may go back slowly,
even if the child is not dehydrated. However, the skin may go back
immediately even if the child is dehydrated if he or she is overweight or has
edema.
 After the child is assessed for dehydration, ask the caretaker how long the
child has had diarrhea and if there is blood in the stools to identify persistent
diarrhea and dysentery.

Standard Procedure for Skin Pinch Test

 Locate the area on the child’s abdomen halfway between the umbilicus and
the side of the abdomen; then, pinch the skin using the thumb and first finger.
 The fold of the skin should be in a line-up and down the child’s body, not
across.
 All layers of the skin and the tissue under them should be picked up for one
second and then released.

Classification of Dehydration
1. Severe dehydration - requires immediate IV infusion, nasogastric or oral fluid
replacement according to WHO treatment guidelines described in Plan C.
A fluid deficit of ≥10% of the body weight leads to severe dehydration. A child is
severely dehydrated if he/she has a combination of two or any of the following:
 Lethargic or unconscious
 Not able to drink or drinking poorly
 Sunken eyes
 Skin pinch that goes back very slowly

2. Some dehydration - requires active oral treatment with ORS solution according
to WHO treatment guidelines described in Plan B.

Children who have a combination of any of two of the following signs are included
in this group:
 Restless/irritable
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back slowly
Children with some dehydration have a fluid deficit of 5 to 10 percent of their
body weight. This classification includes both “mild” and “moderate” dehydration,
which are descriptive terms used in most pediatric textbooks.

3. No dehydration - patients with diarrhea but with no signs of dehydration

usually have a fluid deficit of ≤ 5% of their body weight.
- should be given more fluid than usual to prevent dehydration from developing,
as specified in WHO Treatment Plan A.

Persistent Diarrhea is an episode of diarrhea, with or without blood, which begins

acutely and lasts at least 14 days.
- It is usually associated with weight loss and often presents with serious
non-intestinal infections.
 Children with severe persistent diarrhea who also have any degree of
dehydration require special treatment and should be referred immediately to
a hospital. As a rule, treatment of dehydration should be initiated first, unless
there is another severe classification
 Children with persistent diarrhea and no signs of dehydration can be safely
managed in the outpatient clinic, at least initially.
Proper feeding is the most important aspect of treatment for most children with
persistent diarrhea.
The goals of nutritional therapy are to:
 Temporarily reduce the amount of animal milk (or lactose) in the diet;
 Provide a sufficient intake of energy, protein, vitamins, and minerals to
facilitate the repair process in the damaged gut mucus and improve
nutritional status;
 Avoid giving foods or drinks that may aggravate the diarrhea; and
 Ensure adequate food intake during convalescent to correct any malnutrition.

Routine treatment of persistent diarrhea with antimicrobial is not effective. Some

children, however have non-intestinal (or intestinal) infections that require
specific antimicrobial therapy. These should be properly diagnosed and treated
correctly.

Classification of Dysentery
 Ask the mother or caretaker of a child with diarrhea if there is blood in the
stools - if present, classified as Dysentery
 Although Dysentery is often described as a syndrome of bloody diarrhea with
fever, abdominal cramps, rectal pain, and mucoid stools, these features do
not always accompany bloody diarrhea, nor do they necessarily define its
etiology or determine appropriate treatment
 Bloody diarrhea in young children is usually a sign of invasive enteric infection
that carries a substantial risk of serious morbidity and death.
 Dysentery is especially severe in infants and in children who are
undernourished, those who develop clinically-evident dehydration during
their illness, or those who are not breastfeed.
 Dysentery occurs with increased frequency and severity in children who have
measles or had measles in the preceding month, and diarrheal episodes that
begin with dysentery are more likely to become persistent than those start
without blood in the stools.
 All children with dysentery should be treated promptly with an antibiotic
effective against Shigella because of the following:
1. Bloody diarrhea in children under 5 is caused much more frequently by
Shigella than by any other pathogen;
2. Shigellosis is more likely to result in complications and death if not
treated promptly.
 3. Early treatment of Shigellosis substantially reduces the risk of severe
morbidity or death.

Fever
 All sick children should be checked for fever.
 It may be caused by minor infections, but may also be the most obvious sign
of a life-threatening illness, particularly malaria, or other severe infections,
including meningitis, typhoid fever, or measles.

Clinical Assessment:

 Children are considered to have fever if their body temperature is above

37.5°C (axillary) or 38°C (rectal).
 In the absence of a thermometer, children are considered to have fever if they
feel hot.
 Fever also may be recognized based on a history of fever.
 A child presenting with fever should be assessed for:
a. Stiff neck
 A stiff neck may be a sign of meningitis, cerebral malaria, or another very
severe febrile disease.
 If the child is conscious and alert, check stiffness by tickling the feet, asking
the child to bend his/her neck (or to look down), or by very gently bending
the child’s head forward. It should move freely.
b. Risk of malaria and other endemic infections.
 In situations where routine microscopy is not available or the results may
be delayed, the risk of malaria transmission must be defined.
 The World Health Organization (WHO) has proposed definitions of malaria
risk settings for countries and areas with risk of malaria caused by:
Plasmodium falcifarum
1. High malaria risk setting - situation in which >5% of cases of febrile
disease in children aged 2-59 months are malarial disease.
2. Low malarial risk setting - situation in which < 5% of cases of febrile
disease in children aged 2-59 months are malarial disease, but in which
the risk is not eligible.
3. No malaria risk setting - malaria transmission does not normally occur
in the area, and imported malaria is uncommon.
c. Runny nose
 When malaria risk is low, a child with fever and a runny nose does not
need an antimalarial drug. This child’s fever is probably due to common
cold.
d. Duration of fever
 Fever due to viral illnesses are self-limiting.
 Fever for more than five days can mean that the child has a more severe
disease such as typhoid fever. In this instance, check if the fever has been
present every day.
e. Measles
 Children with fever should be assessed for signs of current or previous
measles (within the last three months).
 Measles deaths occur from complications such as pneumonia and
laryngotracheitis (67%), diarrhea (25%), measles alone, and a few from
encephalitis.
 Non- fatal complications include conjunctivitis, otitis media, and mouth
ulcers.
 Disabilities such as blindness, severe malnutrition, chronic lung disease
(bronchiectasis and recurrent infection) and neurologic dysfunction may
also result from measles.
 Detection of acute or current measles is based on fever with generalized
rash, plus at least one of the following:
- red eyes
- runny nose, or
- cough
 The mother should be asked about occurrence of measles within the last
three months (recent measles).
 Measles damages the epithelial surfaces and the immune system, and
lowers Vitamin A levels. This results in increased susceptibility to
infections caused by pneumococcus, gram-negative bacteria and
adenovirus.
 Recrudescence of herpes virus, Candida, and malaria can also occur during
measles infection.
 If the child has measles currently or within the last three months, assess
for possible mouth or eye complications and other possible complications
such as pneumonia, stridor in a calm child, diarrhea, malnutrition and ear
infection.
 Dengue Hemorrhagic Fever
  Before classifying fever, check for obvious causes of fever (ear pain, burn,
abscess)

Classification of Fever
 All children with fever and any general danger sign or stiff neck are classified
as having very severe febrile disease and should be urgently referred to a
hospital after pre-referral treatment with antibiotics (the same as for severe
pneumonia or very severe disease).
Note: in areas where P. falcifarum malaria is present, children should also receive
a pre-referral dose of an antimalarial (intramuscular quinine).
Further classification will depend on the level of malaria risk in the area.
 In a high-malarial-risk area or season- children with fever but no general
danger sign or stiff neck should be classified as having malaria.
 In a low-malarial-risk area or season - children with fever (or history of fever)
but no general danger sign or stiff neck are classified as having malaria and
given an antimalarial only if they have no runny nose ( asign of ARI), no
measles, and no other obvious cause of fever (pneumonia, sore throat, etc)
Evidence of another infections lowers the probability that the child’s illness is
due to malaria. Therefore, children in a low malaria risk area or season, who
have evidence of another infections, should NOT be given an antimalarial
drug.
 In a low-malarial-risk area or season, children with runny nose, measles or
clinical signs of other possible causes of fever are classified as having fever,
malaria unlikely. These children need follow-up. If their fever lasts more than
five days, they should be referred for further assessment to determine causes
of prolonged pyrexia. In low malaria-risk settings, a simple malaria laboratory
test is highly advisable.
 In a no-malaria-risk or season, an attempt should be made to distinguish case
of possible bacterial infection, which require antibiotic treatment, from cases
of non-complicated viral infection. If obvious causes of fever, such as
pneumonia, ear infection, or sore throat, are present children could be
classified as having possible bacterial infection and treated accordingly.
 In a no malaria risk area or season, if no clinical signs of obvious infection are
found, the working classification becomes uncomplicated fever. Such children
should be followed up in two days and assessed further. As in other situations,
all children with fever lasting more than five days should be referred for
further assessment.
Note: children with a high fever, defined as an axillary temperature > 39.5°C or a
rectal temperature > 39°C, should be given a single dose of paracetamol to
combat hyperthermia.

Classification of Measles
All children with fever should be checked for signs of current or recent measles
(within the last three months) and measles complications.
 Severe, complicated measles -when a child, with measles displays any general
danger sign, or has severe stomatitis with deep and extensive mouth ulcers or
severe eye complications, such as clouding of the cornea. Urgent referral to a
hospital is needed.
 Measles with eye or mouth complications - children with less severe measles
complications such as pus draining from the eye ( a sign of conjunctivitis) or
non-deep and non-extensive mouth ulcers are classified as such.Treatment at
the outpatient facility includes oral vitamin A, tetracycline ointment for
children with pus draining from the eye, and gentian violet for children with
mouth ulcers. Children classified with pneumonia, diarrhea, or ear infection
and measles with eye or mouth complication should be treated for other
classification(s) and given vitamin A treatment regimen. Because measles
depresses the immune system, these children may be also referred to the
hospital for treatment
 Measles - if no signs of measles complications have been found after a
complete examination, effective and safe management at home with vitamin
A treatment is recommended.

Ear Problems
 A child presenting with an ear problem should first be assessed for general
danger signs, cough or difficult breathing, diarrhea, and fever.
 A child with an ear problem may have an ear infection.
 Although ear infections rarely cause death, these are the main cause of
deafness in low-income areas which, in turn, may lead to learning problems

Clinical assessment - when otoscopy is not available, look for the following simple
clinical signs:
 Tender swelling behind the ear - the most serious complication of an ear
infection is a deep infection in the mastoid bone. It usually manifest with
tender swelling behind one of the child’s ear. In infants, this tender swelling
 also may be above the ear. When both tenderness and swelling are present,
the sign is considered positive and should not be mistaken for swollen lymph
nodes
 Ear pain - in the early stages of acute otitis, a child may have ear pain, which
usually causes the child to become irritable and rub the ear frequently.
 Ear discharge or pus

Classification of ear problems

 Mastoiditis - child with tenderness and swelling of the mastoid bone should
be referred to the hospital for treatment. Before referral, the child should first
receive a dose of antibiotic and a single dose of paracetamol for pain.
 Acute ear infection - child with ear pain or ear discharge (or pus) for less than
14 days should be treated for five days with the same first-line antibiotics as
for pneumonia.
 Chronic ear infection - if there is ear discharge (or pus) for >14 days, the ear
should be dried by wicking. Generally, antibiotics are not recommended.
 No ear infections - if no signs of ear infection are found, no specific treatment
is required.

Dengue Hemorrhagic Fever (DHF)

 DHF is caused by a virus that is spread by Aedes mosquitoes. Like malaria, it
occurs particularly in certain places and seasons
 Children with DHF have fever which may last for 2-7 days.
 The disease causes damage to the blood and blood vessels which may lead to
bleeding.
 This bleeding may occur in the skin, where petechiae are seen, or inside the
body
 Children may bleed from the mouth or nose, may vomit black fluid or may
pass black stools. Showing that they are bleeding from the stomach or
intestines.
 In a small proportion of cases, the child may become severely and rapidly
shocked, and may die unless he/she receives urgent care.
 The most severe signs of DHF often occur in the 2 days after the fever has
disappeared.
 The management of DHF depends on looking for signs that a child is bleeding
and that he/she is may become shocked.
 Shock must be treated with intravenous fluids and urgent referral.
 For safety, all cases of DHF should be referred.
 The rainy season favors increased transmission of the disease from man to
mosquito and mosquito to man.
 Rainwater in neglected containers and trash makes very favorable breeding
places for Aedes mosquitoes.
 During dry season, domestic water storage containers and decorative
containers inside houses are usual breeding places.
 All regions of the country are endemic for dengue and children are at risk
every day of the year.
 National Capital Region is highly endemic all year round, usually with a peak
two months after the rainfall.

Assess for Dengue Hemorrhagic Fever:

 Bleeding from the nose or gums - sign of bleeding from the stomach or
intestines
 Black stools - sign that the child is bleeding from the stomach or upper
intestines
 Abdominal pain
 Persistent vomiting
 Look and feel for signs of bleeding and shock
- Skin petechiae - small hemorrhages in the skin. They look small, dark, red
spots or patches in the skin. They are not raised and they are not tender.
Mostly seen on the abdomen or chest and extremities.
 Look and feel for signs suggesting SHOCK - is a condition where the blood
circulation fails (need urgent attention, including referral)
- the child looks pale and abnormally restless or abnormally sleepy or difficult to
awaken.
- cold clammy extremities
- slow capillary refill
- Tourniquet test

Classification of Dengue Fever

Severe Dengue Hemorrhagic Fever – if the child has any of the following signs:
bleeding from the nose or gums or in the vomitus or stool, skin petechiae,
shock-cold clammy extremities with or without slow capillary refill,
persistent abdominal pain and vomiting, or a positive tourniquet test.
Fever: Dengue Hemorrhagic Fever unlikely - used if the child has none of the
signs needed for classification of severe DHF

D. Checking Nutritional Status - Malnutrition and Anemia

Clinical Assessment
 Visible severe wasting – occurs when the child is very thin, has no fat, and
looks like the skin and bones
- Look for severe wasting on the muscles of the shoulders, arms, buttocks,
and legs.
- Look if the outline of the ribs is easily seen, if the hips are smaller
compared with the chest and the abdomen, if there are many folds of skin
on the buttocks and thighs as if the child is wearing baggy pants.
 Edema of both feet – done to determine kwashiorkor
- Use your thumb to press gently for a few seconds the top side of each foot.
- A child who has edema has a dent remaining in the child’s foot when you
lift your thumb
 Weight for age
 Palmar pallor – occurs when the child has unusual paleness of the skin.
Some palmar pallor - If the skin of the palm is pale
Severe palmar pallor - If the skin is very pale or so pale that it looks like
white

Note: for children aged 6 months or more, determine if the mid-upper arm
circumference (MUAC) is less than 115 mm. - severe malnutrition

Classification of Nutritional Status

Severe malnutrition or severe anemia – when the child has visible severe wasting,
severe palmar pallor, or edema on both feet
Very low weight or Anemia – if the child has some palmar pallor or very low
weight for age
Not very low-weight or No anemia - no signs of malnutrition

E. Assessing the Child’s feeding

 All children less than 2 years old and all children classified as having anemia or
low (or very low) weight need to be assessed for feeding:
Feeding assessment includes questioning the mother or caretaker about:
1. Breastfeeding frequency and night feeds;
2. Types of complimentary foods or fluids; frequency of feeding, and whether
feedings is active; and
3. Feeding patterns during the current illness

F. Check the Child’s Vitamin A Status

- Check the Vitamin A status of all sick children
- Vitamin A plays a role in the growth and development of children.
- It helps prevent invasion by infectious organisms and maintains tissues in
the skin , respiratory tract, intestinal tract, and the cornea of the eyes.
- Use the recommended Vitamin A schedule:
 First dose to six months above (100,000 iu)
 Subsequent doses every six months (200,000 iu) up to the age of 59
months

G. Checking Immunization Status

Four Common Situations contraindicated in Immunizing Sick Children
 Children being referred urgently to the hospital should not be immunized.
 Live vaccines (BCG, measles, polio, yellow fever) should not be given to
children with immunodeficiency diseases, or to children who are
immunosuppressed due to malignant disease, therapy with
immunosuppressive agents or irradiation

 DPT2/DPT3 should not be given to children who have had convulsions or

shock within three days of previous dose of DPT. DT can be administered
instead of DPT.
 DPT should not be given to children with recurrent convulsions or another
active neurological disease of the central nervous system. DT can be
administered instead of DPT.