THE STATE OF CHILD HEALTH TODAY

1992 IMCI was developed WHO-UNICEF to • 5.9 million children under age five
all developing countries died in 2015, nearly 16,000 every
1995 IMCI was introduced to the Philippines day 83% of deaths in children under
thru the DOH age five are caused by infectious,
1997 IMCI implementation in the neonatal or nutritional conditions
Philippines with approximately 4,000 the large majority of these deaths
trained workers. are from preventable causes.
2001 integration of IMCI to Nursing and
Midwifery Curriculum (attended by the
academe from different Nursing &
Midwifery school

EDUCATIONAL INSTITUTION: PILOT

SCHOOLS (Initial)
1. Nursing Education
• MINDANAO- San Pedro College,
Davao City
• VISAYAS- St. Paul College, Iloilo City
• NCR- University of Sto. Tomas,
Manila Baliuag University
WHY IMCI?
IMCI • Children present with multiple
potentially deadly conditions at once
• IMCI is an integrated approach to
- Lack of diagnostic tools (labs or
child health that focuses on the well-
radiology)
being of the whole child.
- Provides rely on patient history<
• A strategy for reducing mortality and
signs, and symptoms for diagnosis
morbidity associated with major
- Need to refer to a higher level of
causes of childhood illness
care for serious illness
• A joint WHO/UNICEF initiatives since
• In 1995 WHO and UNICEF developed
1992
a strategy known as Integrated
• Currently focused on first-level
Management of Childhood illness
health facilities
(IMCI). IMCI integrates case
• Comes as a generic guidelines for
management of the most common
management which have been
childhood problems, especially the
adapted to each country.
most important causes of death.
• IMCI has already been introduced in
more than 75 countries around the REASONS FOR DEVELOPING IMCI
world.
• Curative care
• Aspect of Nutrition
• Immunization
• Disease prevention
• Health Promotion
 IMCI CASE MANAGEMENT PROCESS
OBJECTIVES OF IMCI • Assess the child or young infant
• To reduce significantly global • Classify the illness
morbidity and mortality • Identify Treatment
• To contribute to a healthy growth • Treat the child/refer
and development of children • Counsel the mother
• Follow-up

ASSESSMENT USING IMCI STRATEGY

IMPORTANT ELEMENTS FOR IMPROVING • Assessment checklist divided into
CHILD HEALTH four parts
• Improve case management of sick • 1st Part: History Taking
children • 2nd Part: General Danger Signs
• Improve nutrition • 3rd Part: Main Symptoms
• Ensure immunization • 4th Part: Nutritional Status,
• Prevent injuries Immunization Status, and OTHER
• Prevent other disease Problems
• Improve psychosocial support and
stimulation THE INTREGATED CASE MANAGEMENT
PROCESS

MAJOR COMPONENTS OF IMCI Check for Assess Assess

• Improving case management skills of Danger Signs main
health worker and health facilities. symptoms
• Improving the health system to Convulsions Cough/ Nutrition
deliver IMCI difficulty in
- Ensuring the availability of essential breathing
drugs and other supplies Lethargy/ Diarrhoea Immunizati
- Improving the organization of work Unconscious on status
at the health facility level ness and
- Improving and monitoring and Inability to Fever Potential
supervision drink/breastf feeding
- Training of health workers in ETAT eed problems
(Emergency Triage Assessment and Vomiting Ear
Treatment) Problems
• Improving family and community
health practices
 CHECK FOR OTHER PROBLEMS IMCI CASE MANAGEMENT

Classify the condition of the child and assign FOCUSED ASSESSMENT

to one of the three color codes and Identify
the treatment actions as per the actions
• Danger signs Main Symptoms
Nutritional status Immunization
status other problems

URGENT
REFERRAL CLASSIFICATION
1. Pre-referral
treatments
2. Advise • Need to Refer
parents • Specific treatment
3. REFER the • Home management
child

At the referral TREATMENT

facility

1. ETAT • Identify treatment Treat

2. Diagnosis,
treatment and
3. Monitoring COUNSEL & FOLLOW-UP
and follow up
TREAT AT THE
OPD • Counsel Caretakers Follow- up
1. Treat local
infection PRINCIPLES OF INTEGRATED CARE
2. Give oral drugs • All sick children must be examined
3. Advise and for General Danger Sign
teach mother
4. Follow- up
• All sick children must be routinely
assessed for major symptoms
HOME MANAGEMENT • Only a limited number of carefully
Counsel caretaker on selected clinical signs are used
how to: • A combination of individual signs
1. Give oral drugs lead to a child’s classification(s)
2. Treat local infections
at home rather than diagnosis
3. Continue feeding • IMCI guidelines address most but
4. Danger signs not all of the major reasons a sick
5. Follow- up child brought to a clinic.
• IMCI management procedures use a
limited number of essential drugs
and encourage active participation
 of caretakers in the treatment of • Listen carefully to what the mother
children. tells you.
• An essential component of the IMCI • Use words the mother understands
guideline is the counseling about • Give the mother time to answer the
feeding, fluids, and when to return questions
to a health facility. • Ask additional questions when the
mother is not sure about her
AGE BRACKET: answers.
• BIIRTH to 2 months (Sick young
infant)
• Age 2 months up to 5 years (Sick
child)

STEPS IN CASE MANAGEMENT PROCESS

• Screen for general danger signs,

which would indicate any life-
threatening condition
• Specific questions about the most
common conditions affecting a
1. ASSESS THE CHILD OR YOUNG INFANT child’s health (diarrhea, pneumonia,
- taking a history and doing a physical fever, etc) – if the answers are
examination. positive, focused physical exam to
identify life-threatening illness
• Evaluation of the child’s nutrition
and immunization status. The
assessment includes checking the
child for other health problems.

2. CLASSIFY THE ILLNESS

• Making a decision on the severity of
the illness
• Based on the results of the
assessment a health-care provider
classifies a child’s illnesses using a
• Good communication with mother specially developed colour coded
of child triage system. Because many
children have more than one
 condition, each condition is mother how to give oral drugs, how
classified according to whether it to feed and give fluids during illness,
requires and how to treat local infections at
home;
URGENT PRE-REFERRAL TREATMENT AND • Provides advice on the home;
REFERRAL, - PINK • If needed, ask the mother or other
caregiver to return with the child for
Specific medical treatment and advice, follow-up on a specific date.

Simple advice on home management 5. COUNSEL THE MOTHER

3. IDENTIFY TREATMENT • Includes assessing how the child is

- The charts recommend appropriate fed and telling her about the foods
treatment for each classification and fluids to give the child and when
to bring back to health center.
• If a child requires urgent referral
(pink classification), essential 6. GIVE FOLLOW-UP CARE
treatment to be given before
referral is identified. • Describe what to do when a child
• If a child needs specific treatment returns to the health center by
(yellow classification), a treatment arrangement for a follow-up visit.
plan is developed, and the drugs to
be administered at the clinic are ASSESS THE CHILD
identified. The content of the
advice to be given to the mother is • Check for danger signs (or possible
decided on. bacterial infection)
• If no serious conditions have been • Ask about Main Symptoms
found (green classification), the • If the Main Symptoms is reported,
mother should be correctly advised assess further. Check nutrition and
on the appropriate actions to be immunization status.
taken for care of the child at home. • Check for OTHER problems.

4. TREAT THE CHILD ASSESSMENT

• Giving treatment In health center,
prescribing drugs or other 1. Determine which age group the child
treatments to be given at home, and belongs:
also teaching the mother how to • Birth up to 2 months
carry out the treatments. • 2 months up to 5 years
• Gives pre-referral treatment for sick •
children being referred; 2. Record the client’s data: Name, Age in
• Gives the first dose of relevant drugs months, Weight in kg, Temperature, etc.
to the children who are in need of
specific treatment< and teaches the
3. Ask the mother what the child’s • stare blankly and appear not to
problems are: notice what is going on around him
• Listen carefully to what the mother • does not respond when touched,
tells you shaken or spoken to
• Use words the mother understands
• Give the mother time to answer the EXERCISE
questions
• Ask additional questions when the Which of the following signs are “general
mother is not sure about her answer danger signs” in a sick child age 11 months
4. Determine if this is an initial visit or old? (identify all the correct options)
follow- up visit: a. Axillary temperature ≥ 39.0°C
- Initial Visit- 1st visit for this episode
of an illness or problem b. Lethargy
- Follow-up visit- the child has been c. History of convulsions related
seen a few days ago for the same to this illness
illness. d. Blood in the stool
e. Axillary temperature ≥ 37.5 °C
GENERAL DANGER SIGNS for more than 7 days

• Not able to drink or breastfeed Which of the following signs are “general
• Vomits everything danger signs” that you should always
• Convulsions check for in every sick child age 2 months
• Abnormally sleepy or difficulty to up to 5 years, according to the IMCI
awaken guidelines?

CHECK FOR GENERAL DANGER SIGNS a. Child is lethargic or unconscious

b. Child is restless or irritable
c. Child is not able to drink or
Not able to drink or breastfeed
breastfeed
• Too weak to drink and is not able to d. Child vomits frequently
suck or swallow when offered a e. Child has cyanosis
drink or Breast-feed
MAIN SYMPTOMS
Vomits everything
• A child Is not able to hold anything • Cough or Difficulty in breathing
down at all • Diarrhea
• If in doubt, offer the child water • Fever
• Ear Problem
Convulsion (during this illness)
• “fits” or “spasms” or “jerky
movements”
abnormally sleepy or difficult to awaken
• drowsy and does not show interest
in what is happening around him
 ASSESS AND CLASSIFY COUGH OR Ø NO
DIFFICULT BREATHING Ø YES

2 Common Causes of Pneumonia • FOR HOW LONG?

1. Stretococcus pnemoniae • COUNT THE BREATHS IN ONE
2. Hemophilus influenzae MINUTE

2 Causes of Death CUT-OFF for FAST BREATHING

1. Hypoxia- too little oxygen 2 months up to 12 months
2. Sepsis- generalized infection 50 breaths per minute or more
12 months up to 5 years:
PNEUMONIA 40 breaths per minute or more
• Is inflammation of the airspaces in
the lungs, most commonly due to an The child who is exactly 12 months old has
infection. fast breathing if you count 40 minute or
• Pneumonia may be caused by more
viruses, bacteria, or fungi; less
frequently by other causes. • LOOK FOR CHEST INDRAWING
• Signs and symptoms; fever, chills, - The lower ribs on both sides of the
cough, shortness of breath, and chest is pulled in when the child
fatigue. breathes in.
- Lower chest wall goes IN when the
ASSESS COUGH OR DIFFICULT BREATHING child breathes IN
- It must be clearly visible and present
Assessed for: all the time.
• How long the child has had cough or
difficult breathing
• Fast breathing
• Chest indrawing
• Stridor in calm child

Note:
1. If the child is asleep and has a cough or
difficult breathing, count the number of
breaths first before you try to wake the
child.
2. If there is any general danger sign,
complete the assessment and any pre- AND LISTEN FOR STRIDOR
referral treatment immediately so referral is • A harsh noise made when the child
not delayed. breathes IN
• Put your ear near the child’s mouth
• DOES THE CHILD HAVE COUGH OR because stridor can be difficult to
DIFFICULT BREATHING? hear
 • Wheezing- harsh noise while severe refer for
breathing OUT; not stridor disease. assessment.
• Look and listen for stridor when the = Soothe
child is calm. the throat
and relieve
YOUTUBE: the cough
with a safe
remedy
= Advise
mother
CLASSIFY THE CHILD ILLNESS when to
return
• Use a color-coded triage system to immediately
classify the child’s main symptoms = Follow-up
and his or her nutrition or feeding in 5 days if
status. not
improving
IDENTIFY
TREATMEN
T DIARRHEA
SIGNS CLASSIFY AS (Urgent pre- • Defines as 3 or more loose or watery
referral stool in a 24-hour period. More
treatments water than normal
are in bold Types:
print.) Ø ACUTE DIARRHEA- diarrhea lasts
= Any SEVERE = Give first less than 14 days
general PNEUMONIA dose of an Ø PERSISTENT DIARRHEA- diarrhea
danger OR VERY appropriate lasts 14 days or more
sign or SEVERE antibiotic. Ø DYSENTERY- Diarrhea with blood in
= Stridor in DISEASE = Refer the stool, with or without mucus.
calm child. URGENTLY Shigella bacteria.
to hospital.
= Fast PNEUMONIA = Give an Assessed for:
breathing appropriate • How long the child has had diarrhea
= Chest oral • Blood in the stool to determine if
indrawing antibiotic the child has Dysentery
for 5 days. • Signs of Dehydration
= Soothe
the throat • ASK: DOES THE CHILD HAVE
= No signs NO = if DIARRHEA?
of PNEUMONIA coughing • ASK: FOR HOW LONG?
pneumoni : COUCH OR more than • ASK: IS THERE BLOOD IN THE
a or very COLD 30 days, STOOL?
 • LOOK AT THE CHILD’S GENERAL
CONDITION
- If the child is lethargic or
unconscious
- A child has the sign restless and
irritable
• LOOK FOR SUNKEN EYES

• PINCH THE SKIN OF THE ABDOMEN

- Locate the area on the child’s
abdomen halfway between the
umbilicus and the side of the
abdomen
• VERY SLOWLY (longer than 2
seconds)
• SLOWLY (skin stays up even for a
brief instant)
• IMMEDIATELY

OFFER THE CHILD FLUID

• Not able to drink- if he is not able to
take fluid in his mouth and swallow
it
• Drinking poorly- if the child is weak
and cannot drink without help.
• Drinking eagerly, thirsty- reaches out
for the cup or spoon when you offer
water. Wants to drink more
 EXERCISES Which of the following respiratory rates
are “fast breathing if the child is 16 months
What is needed to count the respiratory old?
rate correctly in an 11-month-old child
with cough? (identify the correct answers) a. 21 breaths per minute
b. 32 breaths per minute
a. Child should be calm c. 41 breaths per minute
b. Child should be alert d. 53 breaths per minute
c. A special timer is indispensable e. 60 breaths per minute
d. The count should always be
repeated CLASSIFY THE CHILD ILLNESS
e. The count should be for a full • Use a color-coded triage system to
minute classify the child’s main symptoms
and his or her nutrition or feeding
What is the cut-off rate for “fast status.
breathing” in a child who is exactly 12
months old? THE CLASSIFICATION TABLE
• The classification table on the assess
a. 60 breaths per minute and classify have 3 rows
b. 50 breaths per minute • COLORS of the ROWS helps to
c. 40 breaths per minute IDENTIFY RAPIDLY whether the child
d. 30 breaths per minute has a SERIOUS DISEASE requiring
URGENT ATTENTION
IDENTIFY IF FAST BREATHING OR NORMAL
COLOR CODING
• 13-month in baby Ira with RR of 42 Ø PINK – urgent pre-referral treatment
– FAST BREATHING and referral (means the child has a
• 36 months baby Joey with RR of 55 severe classification and needs
– FAST BREATHING urgent attention and referral or
• 6 months baby Ruel with RR of 48 – admission for inpatient care.)
NORMAL Ø YELLOW – Specific medical
• 11 months Jera with RR of 52 – treatment and advice (means the
FAST BREATHING child needs a specific medical txt
• 4 months baby Raul with RR 42 – such as an appropriate antibiotic,
NORMAL oral antimalarial, or other treatment
• 2 months baby Leni with RR 40 – and how to give the treatment,
NORMAL Teaches how to care for the child at
home and when should return
Ø GREEN – Simple advice on home
management (not given a specific
medical treatment such as
antibiotics or other treatments, The
health worker teaches the mother
how to care for her child at home.) YELLOW
Treatment at Outpatient Health Facility
OUTPATIENT
OUTPATIENT HEALTH FACILITY HEALTH FACILITY
- Treat Local Infection
-
CHECK FOR DANGER SIGNS
Convulsions
- Give Oral Drugs
- Lethargy/Unconsciousness - Advise and Teach Caretaker
- Inability to Drink/Breastfeed
- Vomiting
- Follow-up

ASSESS MAIN SYMPTOMS

- Cough/Difficulty Breathing
-
-
Diarrhoea
Fever
GREEN
- Ear Problems Home Management

Assess NUTRITION and

HOME
IMMUNIZATION STATUS and Caretaker is counseled on how to:
POTENTIAL FEEDING
PROBLEMS - Give oral drugs
- Treat local infections at home
Check for OTHER PROBLEMS - Continue feeding
- When to return immediately
CLASSIFY CONDITIONS and - Follow-up
IDENTIFY TREATMENT
ACTIONS
According to Colour-Coded
Treatment Charts

REFER THE CHILD

PINK
Urgent Referral • Explain to the Child’s caretaker the
need for referral
OUTPATIENT • Calm the caretaker’s fears and help
HEALTH FACILITY resolve any problems. Write a
- Pre-referral Treatments referral note
- Advise Parents • Give instructions and supplies
- Refer Child needed to care for the child on the
way to the hospital.

PINK IDENTIFY
Urgent Referral TREATMENT
REFERRAL SIGNS CLASSIFY (Urgent pre-
FACILITY AS referral
- Emergency Triage and Treatment treatments are in
(ETAT) bold print).
- Diagnosis = Any general SEVERE Ø Give first dose of
- Treatment danger sign or PNEUMONIA an appropriate
- Monitoring and Follow-up = Chest OR VERY antibiotic.
indrawing or
= Strindor in SEVERE Ø Refer URGENTLY
calm child. DISEASE to hospital.

= Fast PNEUMONIA Ø Give an

breathing appropriate oral
antibiotic for 5
days.
Ø Soothe the
throat and
relieve the
cough with a
safe remedy.
Ø Advise mother
when to return
immediately.
Ø Follow-up in 2
days.
No signs of NO Ø If coughing more
pneumonia or PNEUMONIA than 30 days,
very severe : refer for Two of the Ø Give fluid
disease COUCH OR assessment. following and food
COLD Ø Soothe the signs: for some
throat and • Restless, dehydratio
relieve the irritable n (Plan B).
cough with a • Sunken Eyes SOME
safe remedy. • Drinks eagerly, DEHYDRATI Ø If child also
Ø Advise mother thirsty ON has a
when to return • Skin pinch sever
immediately. goes classificati
Ø Follow-up in 5 back on:
days if not slowly Ø Refer
improving. URGENTL
Two of the Ø If child has no Y to
following other severe hospital
signs: classification: with
• Lethargic or - Give fluid for mother
unconscious severe giving
• Sunken eyes SEVERE dehydration frequent
• Not able to DEHYDRATI (Plan C) sips of
drink or ON OR ORS on
drinking If child also has the way.
poorly another severe = advise the
• Skin pinch classification: mother to
goes back - Refer continue
very slowly URGENTLY to breastfeeding
hospital with Ø Advise
mother giving Ø Follow-up
frequent sips of
ORS on the Not enough NO Ø Give fluid and
way. signs to classify DEHYDRATI food to treat
= advise the as some or ON diarrhea at
mother to severe home (Plan A)
continue dehydration. Ø Advise mother
breastfeeding when to return
Ø If child is 2 years immediately.
or older and Ø Follow-up in 5
there is cholera days if not
in your area, improving.
give antibiotic for
cholera.
 FEVER

IDENTIFY MALARIA
TREATMENT - Malaria is an infectious disease caused
SIGNS CLASSIFY (Urgent pre- by a parasite, Plasmodium (causative
AS referral agent)
reatments - Mosquito borne infectious disease:
are in bold Anopheles mosquitoes
print.) - Four species of plasmodia: Plasmodium
Dehydratio SEVERE = Treat falciparum
n present PERSISTEN dehydration P. Vivax
T before P. Ovale
DIARRHOE referral P. Malariae
A unless the • Fever is the main symptom of malaria
child has
another
severe
classification.
= Refer to
hospital
No PERSISTEN = Advise the DECIDING MALARIA RISK
dehydratio T mother on • Child lives in malarious area or
n DIARRHOE feeding a • Has been in a malaria risk area in the
A child who has past 4 weeks.
PERSISTENT PD ORDER 129-S 2002 all the provinces in
DIARRHOEA. the country are categorized according to
= Follow-up malaria situation
in 5 days. • CATEGORY A provinces with no
Blood in DYSENTER = Treat for 5 significant improvement in malaria
the stool Y days with an situation in the last 10 years or
oral situation worsened in the last 5
antibiotic years, average number of cases of
recommende more than 1,000 in the last 10 years.
d for Shigella • Davao del Sur, Davao del Norte,
in your area. Davao Oriental, Agusan del Norte,
= Follow-up Sulu, Palawan, Bukidnon, Cagayan,
in 2 days. Zamboanga Del Sur, Agusan del Sur,
Tawi-Tawi, Misamis Oriental,
ASSESS AND CLASSIFY FEVER Saranggani, Basilan
Possible classification of child with fever
• Malaria MEASLES
• Measles • Rubeola
• Dengue Hemorrhagic Fever • Measles is a highly contagious viral
disease that can be fatal
 • Is an infection of the respiratory • The most severe signs of DHF often
system caused by a virus occur in the 2 days after the fever
“PARAMYXOVIRUS” has disappeared
• Fever and a generalized rash are the • There is no specific treatment for
main signs of measles dengue/severe dengue, but early
(maculopapular rash) detection and access to proper
• Most cases occur in children medical care lowers fatality rates
between 6 months and 2 years of below 1%.
age. • Dengue prevention and control
• Complications of measles occur in solely depends on effective vector
about 30% of all cases. The most control measures.
important are:
- Diarrhea (including dysentery and ASSESS FEVER
persistent diarrhea) • ASK: DOES THE CHILD HAVE FEVER?
- Pneumonia - check to see if the child has a
- Stridor history of fever, feels, hot or has a
- Mouth ulcers temperature of 37.5 °C or above
- Ear infection and
- Severe eye infection (which may • DECIDE THE MALARIA RISK
lead to corneal ulceration and - To classify and treat children with
blindness). fever, you must know the malaria
• 4D’s Fever risk in your area
• 3 C’s: Cough, CORYZA, Conjunctivitis
• ASK: FOR HOW LONG? IF MORE
DENGUE HEMORRHAGIC FEVER THAN 7 DAYS, HAS FEVER BEEN
PRESENT EVERY DAY?
• Dengue is a mosquito borne disease - Fever present every day for more
• The Aedes aegypti mosquito is the than 7 days may indicate severe
primary vector of dengue disease such as Typhoid
• The infection causes flu-like illness,
and occasionally develops into a • ASK: HAS THE CHILD HAD MEASLES
potentially lethal complication called WITHIN THE LAST 3 MONTHS?
severe dengue - May have an infection due to
• Children may have fever which may complications of measles such as an
last for 2 to 7 days. eye infection.
• Symptoms include headache, muscle
and joint pains, and Petechiae (small
res spots that do not disappear
when the skin is pressed, which are
caused by broken capillaries)
• Children may bleed from the mouth
• LOOK OR FEEL FOR STIFF NECK
or nose or may vomit black fluid or
- a child with fever and stiff neck
may pass black stools.
may have meningitis
 • LOOK FOR RUNNY NOSE • HAS THE CHILD HAD PERSISTENT
- A runny nose in a child with fever VOMITING?
may mean that the child has a • LOOK AND FEEL FOR SIGNS OF
common cold. BLEEDING
- Bleeding manifestations (bleeding
from nose and gums. Dried blood in
the nostrils)
- SKIN PETECHIAE (small hemorrhages
in the skin, small, dark, red spots or
patches in the skin. Not raised and
not tender. Mostly seen on the
abdomen or chest and extremities.)

• LOOK FOR SIGNS SUGGESTING

MEASLES
- Assess a child with fever to see if
there are signs suggesting measles.
Look for a generalized rash and for
one of the following signs: cough,
runny, nose, or red eyes.

• LOOK and FEEL for Signs Suggesting

• LOOK FOR MOUTH ULCERS. ARE
Shocks
THEY DEEP AND EXTENSIVE?
• Condition where the blood
• LOOK FOR PUS DRAINING FROM
circulation is failing
THE EYE
• Cold clammy Extremities
• LOOK FOR CLOUDING OF THE
• Slow Capillary Refill
CORNEA

ASSESS DENGUE
- Has the child had any bleeding from
the nose or gums, in the vomitus or
in the stools since the present illness
started?
- Has the child had black vomitus in
this illness
- Has the child had black stools?
• HAS THE CHILD HAD PERSISTENT
ABDOMINAL PAIN?
IMCI CASE MANAGEMENT PROCESS
ASSESS AND CLASSIFY DIARRHEA
1. Ask the mother what is the • How long the child had diarrhea
problem of the child • Types of diarrhea ( Acute, Persistent,
2. Check for GENERAL DANGER Dysentery)
SIGNS (GDS) • Signs of DEHYDRATION
- GDS + 2s/s of DHN – SEVER
• C- onvulsions DEHYDRATION
• U- nable to feed, drink or - NO GDS + 2s/s of DHN – SOME
DEHYDRATION
breastfeed - NO GDS + NO s/s of DHN- NO
• V- omits everything DEHYDRATION
• A- bnormally sleepy/difficult to • More than 14 days Diarrhea (Persistent
Diarrhea)
awaken (lethargic or Ø 14 days + DHN – SEVERE PERSISTENT
unconscious) DIARRHEA
Ø 14 days + NO DHN – PERSISTENT
DIARRHEA
REMEMBER: 1 DANGER SIGN – • BLOOD IN THE STOOL
SEVERE CLASSIFICATION - DYSENTERY

3. Assess MAIN SYMPTOMS ASSESS AND CLASSIFY FEVER

• COUGH • Does the child have FEVER? (By History, Feels, hot,
Temp of 37.5 or more)
• DIARRHEA • MALARIA (with Malaria Risk)
- GDS or STIFF NECK – VERY SEVERE FEBRILE
• FEVER DISEASE
-
• EAR PROBLEM -
(+) Bld. Smear – MALARIA
(-) BLOOD Smear – FEVER: NO MALARIA
Other cause of fever
NO MALARIA RISK
ASSESS AND CLASSIFY: COUGH OR - GDS + Stiff Neck – VERY SEVERE FEBRILE
DIFFICULTY OF BREATHING DISEASE
- NO GDS, NO Stiff Neck – FEVER

•ASSESS AND CLASSIFY: MEASLES

PNEUMONIA E- xtensive mouth ulcers
1. G- General Danger Signs ( C- louding of cornea
CUVA ) G- DS
S- Stridor ( harsh noise during = SEVERE COMPLICATED MEASLES
inspiration
= SEVERE PNEUMONIA • PUS (draining from eyes)
VERY SEVERE DISEASE
• MOUTH Ulcers
= MEASLES with eye or mouth
2. Fast Breathing
complications
- 2 months to 12 months - 50
breaths per minute or more
MEASLES now or within the last
•
- 12 months to 5 years old – 40
3 months
breaths per minute or more
= MEASLES
CHEST INDRAWING
= PNEUMONIA

3. NO signs/symptoms
= COUGH & COLDS
 IDENTIFY PROCEDURE:
TREATMENT
(Urgent pre-
referral
SIGNS CLASSIFY
treatments
AS
are in bold
print).

• Pump up a blood pressure cuff on

one of the arm to more than
venous pressure (70 mm Hg)
• Keep it for 5 minutes and then
ease the pressure
• Examine the extremity of the
pressure for petechiae.
• If there are more than 20
petechiae, the test is positive.

EAR PROBLEMS
• Clinical Assessment
TOURNIQUET TEST - Tender swelling behind the ear
• This gives a good indication for - Ear pain
assessing the blood vessels and - Ear discharge or pus
whether it will lead to Dengue
Shock Syndrome (DSS) or CLASSIFICATION MASTOIDITIS
Dengue Hemorrhagic Fever - Is usually caused by a middle ear
(DHF). This test involves infection (acute otitis media). The
checking what are known as infection may spread from the ear
petechiae. to the mastoid bone of the skull.

CRITERIA • Acute Ear Infection

• Child is not in shock - Pus draining from the ear and
• Has no signs of bleeding discharge has been present for
• Has no abdominal pain less than 2 weeks
• And 6 months older and has a
fever for more than 3 days • Chronic Ear Infection
- Pus draining from the ear and
discharge has been present for
more than 2 weks or more

• NO Ear Infection
 - No anemia and not (very) low
weight
• ASSESSING THE CHILD’S
FEEDING
- (1) breastfeeding frequency and
night feeds
- (2) types of complimentary foods
or fluids, frequency of feeding
and whether feeding is active;
and
- (3) feeding patterns during the
current illness.
IDENTIFY
TREATMENT
TYPES
• KWASHIORKOR- (protein
(Urgent pre-
malnutrition predominant)
referral
SIGNS CLASSIFY • MARASMUS – (deficiency in both
treatments
AS calorie and protein nutrition)
are in bold
• MARASMIC KWASHIORKOR –
print). (marked protein deficiency and
marked calorie insufficiency to as
the most severe form of
malnutrition)

DRY MALNUTRITION – OR
MARASMUS

NUTRITIONAL STATUS
• Clinical Assessment • This child is just skin and bones.
- Visible severe wasting This child needs more food –
- Edema of both feet especially energy foods.
- Weight for age
- Palmar pallor
• Classification of Nutritional status and
Anemia
- Severe malnutrition or severe
anemia
- Anemia or (very) low weight
 WET MALNUTRITION – OR • Unusual paleness of the skin
KWASHIORKOR • Some Palmar Pallor- if the skin of
the child’s palm is pale
• Palmar Pallor- if the skin of the
palm is very pale or so pale that it
looks white

LOOKS AND FEEL FOR EDEMA OF BOTH FEET

- A child with edema of both feet
may have kwashiorkor. Other
common signs of kwashiorkor
include thin, sparse and pale hair
that easily falls out; dry, scaly
skin especially on the arms and
legs; and a puffy or “moon” face
• This child skin, bones and water. - Use your thumb to press gently
• This child needs more food more for a few seconds on the top side
often – a lot of foods rich in of each foot. The child has
energy, and some foods rich in edema if a dent remains in the
protein child’s foot when you lift your
thumb.
ASSESSMENT FOR MALNUTRITION
AND ANEMIA CHECK FOR ACUTE MALNUTRITION

Look and Feel

• Look for signs of acute
malnutrition
• Look for edema of both feet
• Determine WFH/L ___ z-score
• Measure MUAC ____ mm in a
child 6 months or older
• LOOK FOR VISIBLE SEVERE MUAC TAPE
WASTING
- Severe wasting of the muscles of
the shoulders, arms, buttocks and
legs.
- Look to see if the outline of the
child’s ribs is easily seen
- Look at the child’s hips
- Look at the child from the side to
see if the fat of the buttocks is
missing. It looks as if the child is
wearing baggy pants
-

• LOOK FOR PALMAR PALLOR

 • DETERMINE WEIGHT FOR AGE
Look at the weight for age chart in the
IMCI chart booklet. To determine weight Immunization Schedule
for age:
AGE VACCINE
1. Calculate the child’s age in Birth BCG
months. /HepB0
2. Weigh the child if he has not 6 Penta 1 OPV RTV PCV
already been weighed today. weeks 1 1 1
10 Penta 2 OPV RTV PCV
3. Use the weight for age chart to
weeks 2 2 2
determine weight for age.
14 Penta 3 OPV RTV PCV
4. Decide if the point is above, on, weeks 3 3 3
or below the bottom curve. 9 Measles
- If the point is below the bottom months
curve, the child is very low weight 12 MMR
for age. months
- If the point is above or on the
bottom curve, the child is not very
low weight for age. Vaccine Minim Numb Dose Interval
um er of Betwee
Age at Dose n
st
1 s Doses
Check the Immunization, Vitamin A, Dose
Deworming status, and Oral Health Bacillus Birth or 1 0.05
Calmett anytim mL -----
Vitamin A Supplementation e-Guérin e after
• Give every child a dose of birth
Diphther 6 3 0.5m 4 weeks
Vitamin a every six months from ia- weeks L
the age of 6 months. Record the Pertussi
dose on the child’s chart s-
Tetanus
Routine Deworming Vaccine
Oral 6 3 2-3 4 weeks
• Give every child Mebendazole or Polio weeks drops
Albendazole every months from Vaccine
the age of one year. Hepatitis At birth 3 0.5m 6 wks
st
B L from 1
ORAL Health Vaccine dose,
nd
2
• Advise mother to bring the child dose, 8
to a dentist every 6 months for wks
dental check up from the age from 2
nd

dose.
Measles 9 1 0.5m
Vaccine month L -----
(not s
MMR)
 GOLDEN RULE
Route Site Reason
Bacillus
Calmette-
ID Right
deltoid
Protect the
possibility of
• There are no contraindications to
Guérin region of TB immunization of a sick child if the
the arm meningitis
and other TB
child is well enough to go home.
infections in • If a child is going to be referred,
which infants
are prone
do not immunize the child before
Diphtheria- IM Vastus An early start referral. The hospital staff at the
Pertussis- Lateralis with DPT referral site should make the
Tetanus reduces the
Vaccine chance of decision about immunizing the
severe child when the child is admitted.
pertussis.
Oral Polio ORAL Mouth The extent of This will avoid delaying referral
Vaccine protection
against polio
is increased CONTRAINDICATIONS TO
the earlier IMMUNIZATION
the OPV is
given.
Hepatitis B IM Vastus An early start • Do not give BCG to a child known
Vaccine lateralis of Hepatitis
B vaccine to have AIDS.
reduces the • Do not give DPT 2 or DPT 3 to a
chance of
being child who has had convulsions or
infected and shock within 3 days of the most
becoming a
carrier. recent dose.
Prevents • Do not give DPT to a child with
liver cirrhosis
and liver recurrent convulsions or another
cancer which active neurological disease of the
are more
likely to central nervous system.
develop if
infected with
• Children with diarrhea who are
Hepatitis B due for OPV should receive a
Measles SQ Upper
early in life
At least 85%
dose of OPV (oral polio vaccine)
Vaccine outer of measles during this visit. However, do not
(not MMR) portion of
the arms
can be
prevented by
count the dose. The child should
immunization return when the next dose of
at this age. OPV is due for an extra dose of
OPV.
Picture ( para hindi kayo mailto )
 a sign of pneumonia and is
SICK YOUNG INFANT (Birth to 2 serious in a young infant.
Months)
LOOK AT THE UMBILICUS – IS IT
RED OR DRAINING PUS? DOES THE
REDNESS EXTEND TO THE SKIN?

Assess and Classify • There may be some redness of

• Check for signs of Possible the end of the umbilicus or the
Bacterial Infections umbilicus may be draining pus.
• Classify Jaundice • If the redness extends to the skin
• Ask about the Diarrhea ( of the abdominal wall, it is a
dehydration and persistent serious infection.
diarrhea )
• Check for feeding problems or FEEL: MEASURE TEMPERATURE (OR
low weight FEEL FOR FEVER OR LOW BODY
• Check the young infant’s TEMPERATURE)
immunization status and Vitamin • Fever (axillary temperature more
A status than 37.5 °C or rectal
• Assess any other problems temperature more than 38°C) is
uncommon in the first two months
POSSIBLE BACTERIAL INFECTION of life.
• ASK: is the infant having difficulty • If a young infant has fever, this
in feeding? HAS THE INFANT may mean the infant has a
HAD CONVULSIONS? serious bacterial infection
• LOOK: COUNT THE BREATHS • If you do not have a thermometer,
IN ONE MINUTE. REPEAT THE feel the infant’s stomach or axilla
COUNT IF ELEVATED (underarm) and determine if it
- 60 breaths per minute or more is feels hot or unusually cool.
the cutoff used to identify fast
LOOK FOR SKIN PUSTULES. ARE THERE
breathing in a young infant.
MANY OR SEVERE PUSTULES?
• LOOK FOR SEVERE CHEST • Are red spots or blisters that
INDRAWING contain pus.
- Mild chest indrawing is normal in
a young infant because the chest
wall is soft. Severe chest
indrawing is very deep and easy
to see. Severe chest indrawing is
 ASSESS BREASTFEEDING
LOOK AT THE YOUNG INFANT’S
MOVEMENT. ARE THEY LESS THAN Assess breastfeeding:
NORMAL - If the infant is exclusively BF
- Does the infant move on his/her without difficulty and is not low
own? weight for age
- Does the infant not move at all - If the infant is not breastfeed at all
- If the infant has a serious
JAUNDICE problem requiring urgent referral
to a hospital

• Is the infant able to attach?

- Not well attached
- Good attachment

SIGNS OF GOOD ATTACHMENT

• Chin touching breast
• Is a yellow discoloration in a • Mouth wide open
newborn baby’s skin and eyes. • Lower lip turned outward
Infant jaundice oocurs because
• More areola visible above than
the baby’s blood contains an
below the mouth
excess of bilirubin
• Is the infant sucking effectively?
Classification
(that is slow deep sucks, sometimes
• Physiologic jaundice occurs
pausing)
more than 24 hours after birth
- Not sucking effectively
- Suckling effectively
• Pathologic jaundice occurs less
than 24 hours after birth
• Clear a blocked nose it it
interferes with BF
FEEDING PROBLEM OR LOW
WEIGHT

2 parts Assessment:
Ø Determine difficulty feeding
infant, what the young infant is
fed and how often
Ø Any problems with breastfeeding
or is low weight for age
• Look for ulcers or white patches in
• Is the infant breastfeed? If yes? How
the mouth
many times in 24 hours?
- THRUSH milk curds on the side of
• Does the infant usually receive any
the check or thick white coating of
other foods or drinks? If yes, how often?
the tongue
• What do you use to feed the infant?
 INFANT’S IMMUNIZATION STATUS

BIRTH: BCG HEP B1

6 PENTAVALENT OPV RTV PCV
WEEKS 1 1 1 1

Vitamin A:
- Give 200,000 IU to the mother
- Within 6 weeks of delivery
 IDENTIFY TREATMENT • Very Severe Febrile Disease/
• Determining if urgent referral is Malaria
needed • Very Severe Febrile Disease
• Identifying treatments needed • Severe Complicated Measles
• For patients who need urgent • Mastoiditis
referral: • Acute Ear Infection
- Identifying the urgent pre-referral • Sick Young Infant: Local Bacterial
treatments Infection
- Explaining the need for referral to
the mother
- Writing the referral note

REFERRAL NOTE
Ø Date and time of referral
Ø Name and age of the child
Ø Descriptions of child’s problems
Ø Reason for referral
Ø Treatments that was given
Ø Name, name of the health center
and address

FEBRUARY 14, 2019 @ 7:30AM

• Urgent Referral to SPMC

• Cesar Montano, 18 months
• Referred for: Sever Dehydration
Severe Malnutrition
Also has a cough- NO fast
Breathing and no Chest Indrawing
• Treatment given: Vitamin A
200,000 IU ORS- mother to give
sips on way to the hospital.
• Needs measles Immunization-
not given “Claudette S.
Advincula” “Piapi Health Center”

TREAT

1. Give an Appropriate Oral Antibiotic

• General Danger Sign
• Severe Pneumonia or Very
Severe Disease
• Pneumonia
• Severe Dehydration
• Dysentery