Session 4

Main Symptoms
- cough or difficult breathing - diarrhea - fever - ear problems
1

Learning Objectives
By the end of this session, the students will be able to:
(1) recall the anatomy and pathophysiology; (2) recognize the symptoms and signs; (3) assess and classify symptoms and signs; (4) identify the correct treatment and when to refer; (5) provide counseling; and (6) specify necessary follow-up care

2

Session 4-a

Cough or Difficult Breathing

3

Parts of the Respiratory System
•Nasal passages •Windpipe or trachea •Lungs

4

Inside the alveolus

5

Cough or Difficult Breathing
ASK: Does the child have cough or difficult breathing?
If NO IF YES, ASK: •For how long? If YES LOOK, LISTEN, FEEL: •Count the breaths in one minute •Look for chest indrawing •Look and listen for stridor Child must be calm

6

Ask about next main symptoms: diarrhea, fever, ear problems

If the child is: Fast breathing is: 2 mos – 12 mos. 50 breaths/min or more 12 mos – 5 yrs 40 breaths/min or more

Classify child’s illness using the color-coded classification table for cough or difficult breathing

Video of child with chest indrawing

7

Video of child with stridor

8

Cough or Difficult Breathing
SIG N •Any general danger S CLASSIF Y A S
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

sign or •Chest indrawing or •Stridor in a calm child

ID EN TIF Y Give TR EA TM ENT first dose of an

appropriate antibiotic Refer URGENTLY to hospital

•Fast breathing

PNEUMONIA

Give an appropriate oral antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 2 days If coughing > 30 days, refer for assessment Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

No signs of pneumonia or very severe disease

NO PNEUMONIA: COUGH OR COLD

9

Treatment
Soothe the Throat, Relieve the Cough with a Safe Remedy
Safe

infant

remedies to recommend: Breastmilk for exclusively breastfed tamarind, calamansi, ginger

Harmful

10

remedies to discourage: Codeine cough syrup Other cough syrups Oral and nasal decongestants

Treatment for Pneumonia or Very Severe Disease
Age or Weight Cotrimoxazole Give 2 times daily for 5 days Adult Syrup tab. 40 mg 80mg TMP TMP 200 mg 400 mg SMX SMX 1/2 1 5.0 ml. 7.5 ml Amoxycillin Give 3 times daily for 5 days Tablet Syrup 250 mg 125 mg/ 5 ml

2 -12 mos 12mos-5yrs

1/2 1

5.0 ml 10 ml.

11

Vitamin A Supplementation for Severe Pneumonia or Very Severe Disease
Age Vitamin A Capsule 100,000 I U
6 to 12 mos. 12 mos-5 yrs

200,000 I U ½ capsule 1 capsule

1 capsule 2 capsules

12

Session 4-b

DIARRHEA

13

Anatomy of the Gastrointestinal System

14

Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing and then ASK: DOES THE CHILD HAVE DIARRHOEA?

If NO

If YES

Does the child have diarrhoea?
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 (longer than 2 seconds)? Slowly? Classify DIARRHOEA

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhoea.

15

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.

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?

16

Video of a child with sunken eyes

17

Video of Skin Pinching

18

CLASSIFICATION TABLE FOR DEHYDRATION
SIGNS Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) If child has no other severe classification: — Give fluid for severe dehydration (Plan C). OR If child also has another severe classification: — Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Give fluid and food for some dehydration (Plan B). If child also has a severe classification: — Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding Advise mother when to return immediately. Follow-up in 5 days if not improving. Give fluid and food to treat diarrhoea at home (Plan A). Advise mother when to return immediately. Follow-up in 5 days if not improving.

SEVERE DEHYDRATION

Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly Not enough signs to classify as some or severe dehydration.

SOME DEHYDRATION

NO DEHYDRATION

19

No Dehydration

20

Some Dehydration

21

Severe Dehydration

22

No Dehydration
Tell the Mother: (a) Breastfeed frequently and longer for each feed. (b) If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk. (c) If the child is NOT exclusively breastfed, give 1 or more of the following: ORS Food-based fluids Clean Water

23

No Dehydration
Treatment Plan A
< 2 yrs 2-10 yrs

Age Amount of Fluid of Fluid(¼-½ cup) after each loose stool 50-100 ml

Type

ORS, rice water, 100-200 ml (½-1 cup) after each loose yogurt, soup with stool salt

• Give frequent small sips from a cup. • If the child vomits, wait 10 minutes. Then continue, but more slowly.

24

• Continue giving extra fluids until the diarrhea stops.

Some Dehydration
 Give

frequent small sips from a cup.  If the child vomits, wait 10 minutes. Then continue, but more slowly.  Continue giving extra fluids until the diarrhea stops.  Reassess after 4 hours and classify the child for dehydration.
25

Some Dehydration
If the mother must leave before completing treatment: show her how to prepare the ORS solution at home. show her how much to give to finish the 4 hour treatment at home give her enough ORS packets to complete rehydration.
26

Some Dehydration
Treatment Plan B
(Determine amount of ORS to be given in 4 hours)
Age Up to 4 mos WEIGHT In ml 4mos - 12mos 12mos – 2years

2 years – 5

< 6kg 200-400

6 - < 10kg 400-700

10 - <12kg 700-900

12-19kg 900-1400

27

• The approximate amount of ORS can also be calculated by multiplying the child’s weight (in kg) by 75.

Severe Dehydration

Can you give Intravenous fluids (IV) immediately?

28

Severe Dehydration
Treatment Plan C
To treat severe dehydration (IV fluid: pLRS) Age Initial Phase Subsequent Phase (30 ml/kg) (70 ml/kg)
Infants (<12 mos) 1 hour 5 hours Older children 30 minutes* hours * 2½

29

*Repeat once if radial pulse is still very weak or imperceptible.

Severe Dehydration
 Reassess

the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. give ORS (5ml/kg/hr) as soon as the child can drink. the infant after 6 hours & a child after 3 hours. Classify dehydration.

 Also

 Reassess

30

Severe Dehydration

If trained to use a nasogastric tube for rehydration?
31

Severe Dehydration
 Start

hydration by tube (or mouth) with ORS solution. Give (20ml/kg/hr) for 6 hours. (Total of 120ml/kg)  Reassess the child every 2 hours.
– –

If there is repeated vomiting or increasing abdominal distention, give the fluid more slowly. If hydration status is not improving after 3 hours, send the child for IV therapy.

 After

32

6 hours, reassess the child. Classify dehydration.

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA
IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)
Treat Dehydration

SIGNS

CLASSIFY AS

present

SEVERE PERSISTENT DIARRHOEA

dehydration before referral unless the child has another severe classification. Refer to hospital.

Advise No

dehydration

PERSISTENT DIARRHOEA

the mother on feeding a child who has PERSISTENT DIARRHOEA. Follow-up in 5 days.

33

Persistent Diarrhea
 After

5 days:

Ask:
 If

the diarrhoea has NOT stopped (3 or more stools) do a full reassessment, give the treatment, then refer to hospital. the diarrhoea has stopped (< 3 stools per day) Tell the mother to follow the usual feeding recommendations for the child’s age.

 If

34

CLASSIFICATION TABLE FOR DYSENTERY

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

Treat Blood

in the stool DYSENTERY

for 5 days with an oral antibiotic recommended for Shigella in your area. Follow-up in 2 days.

35

Dysentery
 After

2 days:

Ask:
 if  if

the child is dehydrated, treat hydration.

the number of stools, amount of stools, fever, abdominal pain or eating is same or worse: Change to 2nd line antibiotics & give for 5 days. Advise to return in 2 days.

36

Dysentery
 EXCEPTIONS:

If the child is less than 12 months old or was dehydrated on the 1st visit or had measles within the last 3 months. REFER TO HOSPITAL. If fewer stools, less blood in stools, less fever, less abdominal pain & eating better, continue antibiotics.
37

Session 4-c

Fever
38

Assess FEVER
A – – –

child has the main symptom of fever if: the child has history of fever the child feels hot the child has an axillary temperature of 37.5 or above

39

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above) Decide Malaria Risk Ask:  Does the child live in a malaria area?
 

Has the child visited malaria area in the past 4 weeks? If yes to either, obtain a blood smear. Look and Feel:  Look and feel for stiff neck.  Look for runny nose Look for signs of Measles: • Generalized rash. • One of these: cough, runny nose or red eyes

Then Ask:  For how long does the child has fever?

If >7 days, has the fever been present everyday? Has the child had measles within the last 3 months?

40

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

If the child has measles now or within the last three months:
 Look –

for mouth ulcers. Are they deep and extensive? for pus draining from the eye. for clouding of the cornea.

 Look  Look

41

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Dengue Risk: Yes or No
If Dengue Risk: Then Ask:  Has the child had any bleeding from the nose or gums or in the vomitus or stools?

Look and Feel:  Look for bleeding from nose or gums.
 

Has the child had black vomitus or stools? Has the child had abdominal pain? Has the child been vomiting?

Look for skin petechiae Feel for cold clammy extremities.

If none of the above ASK or LOOK and FEEL signs are present and the child is 6 months or older and fever present for more than 3 days. Perform Torniquet Test.

42

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk:
If

Classify FEVER

Malaria Risk
(including travel to malaria area)

the child has measles now or within the last three months:

Decide Dengue Risk: Yes or No

No Malaria Risk

43 If Dengue Risk:

Deciding Malaria Risk
 Malaria

is caused by parasites in the blood called “plasmodia” – “Plasmodium falciparum” by Anopheles mosquito

 Transmitted  Know

the malaria risk in your areas.

44

Malaria Risk Areas
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Palawan Davao Oriental Davao del Norte Compostela Valley Tawi-tawi Sulu Agusan del Sur Mindoro Occidental Kalinga Apayao Agusan del Norte

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Isabela Cagayan Quezon Ifugao Zamboanga del Sur Bukidnon Misamis Oriental Quirino Mountain Province Basilan

45

Classify FEVER
Malaria Risk
Malaria Risk
(including travel to malaria area) Any general danger sign or  Stiff Neck
 Blood

VERY SEVERE FEBRILE DISEASE/MALARIA

Classify FEVER

smear (+) If blood smear not done: NO runny nose and, NO measles, and NO other causes of fever
Blood

MALARIA

smear (-), or Runny nose, or Measles or Other causes of fever.

FEVER: MALARIA UNLIKELY

No Malaria Risk
VERY SEVERE FEBRILE DISEASE FEVER: NO MALARIA No sign of very severe febrile disease

No Malaria Risk

Any general danger sign or  Stiff Neck

46

Malaria Risk
Any general danger sign or  Stiff Neck
 Give

VERY SEVERE FEBRILE DISEASE /MALARIA

first dose of Quinine (under medical supervision or if a hospital is not accessible withing 4 hours) Give first dose of appropriate antibiotics. Treat the child to prevent low blood sugar. Give one dose of Paracetamol in health center for high fever (38.5C or above.) Send a blood smear with the patient.
Refer

URGENTLY to a hospital.

Blood

47

smear (+) If blood smear not done: NO runny nose and, NO measles, and NO other causes of fever

Treat

MALARIA

the child with an oral antimalarial. Give one dose of Paracetamol in health center for high fever (38.5C or above.) Advise mother when to return immediately. Follow up in 2 days if fever persists. If the fever is present every day for more than 7 days, refer for assessment.

Malaria Risk
Blood smear (-), or FEVER:  Runny nose, MALARIA UNLIKELY or  Measles or  Other causes of fever.

Give one dose of Paracetamol in health center for high fever (38.5C or above.)  Advise mother when to return immediately.  Follow up in 2 days if fever persists.  If the fever is present every day for more than 7 days, refer for assessment. Treat other causes of fever.

48

TREAT THE CHILD: Antimalarial Agents

Give an Oral Antimalarial 1st line Antibiotics: Chloroquine and Primaquine 2nd line Antibiotics: Sulfadoxine and Pyrimethamine If Chloroquine: The child should be watched closely for 30 minutes. If the child vomits, give another dose. Itching is a possible side effect of the drug.

49

If Sulfadoxine and Pyrimethamine: Give single dose in health center.

Antimalarial Agents
CHLOROQUINE Give for 3 days PRIMAQUINE Single dose for P. falciparum PRIMAQUINE Daily for 14 days for P. vivax SULFADOXINE + PYRIMETHAMINE Single dose

AGE

Tablet
(150mg base)

Tablet
(15mg base)
Day 1 Day 2 Day 3

Tablet
(15mg base)

Tablet
(500mg Sulfadoxine 25mg Pyrimethamine)

2 months up to 5 months (4 <7kg)

½

½

½

1/4

5 months up to 12 months (7 <10kg)

½

½

½

1/2

12 months up to 3 years (10 <14kg)

1

1

½

1/2

1/4

3/4

50

3 years up to 5 years (14 – 19kg)

1

3/4

1/2

1

TREAT THE CHILD: Antimalarial Agents
 Chloroquine  Explain

is given for 3 days.

to the mother that itching is a possible side effect. It is NOT dangerous. The mother should continue to give the drug.

51

TREAT THE CHILD: Antimalarial Agents

If the species of malaria is identified through blood smear, give the following:

P. falciparum – single dose Primaquine with the first dose of Chloroquine P. vivax – first dose of Primaquine with Chloroquine and give mother enough for one dose each day for the next 13 days.

52

TREAT THE CHILD: Antimalarial Agents
 If

you do not have the blood smear or you do not know which species of malaria is present, treat as P. falciparum. not give Primaquine to children under 12 months of age.

 Do

53

TECHNICAL UPDATES: Antimalarial Agents
TECHNICAL BASIS: Artemisinin Based Combination Therapies Based on available safety and efficacy data, the following therapeutic options are available and have potential for deployment (in prioritized order) if costs are not an issue:  Arthemether – lumefantrine (Coarthem TM)  Artesunate (3 days) + amodiaquine  Artesunate (3 days) + SP in areas where SP remains high  SP + Amodiaquine in areas where both SP and Amodiaquine remain high. This mainly limited to West Africa. 54

TECHNICAL UPDATES: Antimalarial Agents
 Administer

intramuscular antibiotic if the child cannot take an oral antibiotic for severe malaria or sugar to prevent low blood sugar.

 Quinine

 Breastmilk

55

Give an Intramuscular Antibiotic
A child may need an antibiotic before he leaves for the hospital, if he/she: – is not able to drink or breastfeed – vomits everything – has convulsions – is abnormally sleepy or difficult to awaken

56

Give an Intramuscular Antibiotic
Age or Weight
2 – 4 months (4 - <6kg) 4 – 9 months (6 - <8kg) 9 – 12 months (8 -10 kg) 1 – 3 years (10 - <14kg) 3 – 5 years (14 – 19 kg)

CHLORAMPHENICOL
Dose: 40 mg/kg Add 5 ml sterile water to vial containing 1000mg = 5.6 ml at 180mg/ml

1 ml = 180 mg 1.5 ml = 270 mg 2 ml = 360 mg 2.5 ml = 450 mg 3.5 ml = 630 mg

57

Give Quinine for Severe Malaria
 Quinine

is the preferred because it is rapidly effective.  Quinine is more safe and effective than intramuscular Chloroquine.  Possible side effects of Quinine injections are: sudden drop in blood pressure, dizziness, ringing in the ears and a sterile abscess.
58

Give Quinine for Severe Malaria

For children being referred with very severe febrile disease/Malaria:

Give the 1st dose of IM Quinine and refer the child urgently to the hospital Give the 1st dose of IM Quinine The child should remain lying down for 1 hour Repeat the Quinine injection 4 to 8 hours later, and then every 12 hours until the child is able to take an oral antimalarial. Do not continue Quinine injection for more than 1 week. DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE.

If referral is not possible:
– – –

– –

59

Give Quinine for Severe Malaria
INTRAMUSCULAR QUININE 300 mg/ml (In 2 ml ampules) 0.3 ml 0.4 ml 0.5 ml 0.6 ml

Age or Weight
4 months – 12 months (6 - <10kg) 12 months – 2 years (10 - <12kg) 2 – 3 years (12 - <14kg) 3 – 5 years (14 – 19kg)

60

TREAT THE CHILD: To Prevent Low Blood Sugar
 If

the child is able to breastfeed: – Ask the mother to breastfeed the child.  If the child is not able to breastfeed but is able to swallow: – Give expressed breastmilk or breastmilk substitute. If neither is available, give sugar water. Give 30 – 50 ml of milk or sugar water before departure.
61

TREAT THE CHILD: To Prevent Low Blood Sugar
To make Sugar Water:
Dissolve

4 level teaspoons of sugar (20 grams) in a 200 ml cup of clean water. the child is not able to swallow:
Give 50 ml of sugar water by nasogastric tube.

If

62

TREAT THE CHILD: Paracetamol for High Fever
PARACETAMOL
Age or Weight Tablet (500mg) Syrup (120mg/5ml)

2 months up to 3 years (4 - <14kg)

1/4

5ml (1 tsp)

3 years up to 5 years (14 – 19 kg)

1/2

10 ml (2 tsp)

63

No Malaria Risk
Any general danger sign or  Stiff Neck

VERY SEVERE FEBRILE DISEASE

Give

first dose of appropriate antibiotics. Treat the child to prevent low blood sugar. Give one dose of Paracetamol in health center for high fever (38.5C or above.) Refer URGENTLY to a hospital.

No sign of very severe febrile disease

FEVER: NO MALARIA

Give

one dose of Paracetamol in health center for high fever (38.5C or above.) Advise mother when to return immediately. Follow up in 2 days if fever persists. If the fever is present every day for more than 7 days, refer for assessment.

64

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk: If the child has measles now or within the last three months: Decide Dengue Risk: Yes or No

Severe Complicated Measles

Classify FEVER

Measles with Eye or Mouth Complications

Measles If dengue Risk, classify page 77 of the module Assess and Classify the Sick Child Age 2 months up to 5 years

65

If Dengue Risk:

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

If the child has measles now or within the last three months:

Look for mouth ulcers: are they deep and extensive Look for pus draining from the eye Look for clouding of the cornea

66

If measles now or within last three months, classify

Measles
 Fever

and generalized rash are the main signs of measles.  Highly infectious.  Over crowding and poor housing increases the risk of developing measles.  Caused by a virus that infects the layers of cells that line the lung, gut, eye, mouth and throat.
67

Measles

68

Complications of measles occur in about 30% of all cases – diarrhea (including dysentery and persistent diarrhea) – pneumonia and stridor – mouth ulcers – ear infection – severe eye infection (which may lead to corneal ulceration and blindness) Encephalitis occurs in about 1/1000 cases. (look for danger signs such as convulsions, abnormally sleepy or difficult to awaken)

Classify MEASLES
Clouding

of the

cornea Deep extensive mouth ulcers

SEVERE COMPLICATED MEASLES

Give

Vitamin A Give first dose of an appropriate antibiotics If clouding of the cornea or pus draining from the eye, apply Tetracycline eye ointment Refer URGENTLY to the hospital
Give

Pus

draining from the

eye Mouth ulcers

MEASLES WITH EYE OR MOUTH COMPLICATIONS

Vitamin A Give first dose of an appropriate antibiotics If pus draining from the eye, apply Tetracycline eye ointment If mouth ulcers, teach the mother to treat with gentian violet Follow up in two days
Give

Measles

69

now or within the last 3 months

MEASLES

Vitamin A

Children with Measles

70

71

Koplik’s spots

TREAT THE CHILD: Give Vitamin A
TREATMENT  Give one dose of Vitamin A in the Health Center SUPPLEMENTATION  Give one dose of Vitamin A in the Health Center if: – Child is 6 months of age or older – Child has not received a dose of Vitamin A in the past 6 months

72

TREAT THE CHILD: Give Vitamin A
AGE 2 – 6 months 6 – 12 months 1 – 5 years
 

Vitamin A Capsule 100,000 IU 50,000 IU 1 cap 2 caps 1/2 cap 1 cap 200,000 IU

200,000 IU = 6 drops 100,000 IU = 3 drops

73

Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk: If the child has measles now or within the last three months:

Severe DHF

Decide Dengue Risk: Yes or No If Dengue Risk:

Classify FEVER

Fever; DHF Unlikely

Torniquet Test 1.3gp

74

Torniquet Test 2.3gp

Tourniquet Test

Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes Positive test: 20 or more petechiae per 1 inch² (6.25 cm²)

75

Classify DENGUE HEMORRHAGIC FEVER
bleeding

from the nose

or gums Bleeding in the vomitus or stools Skin petechiae Cold clammy extremities Capillary refill more than 3 seconds abdominal pain or Vomiting or Positive torniquet test
No

SEVERE DENGUE HEMORRHAGIC FEVER

If

skin petechiae or abdominal pain or vomiting or positive torniquet test are the only positive signs, give ORS If any other signs of bleeding are present, give fluids rapidly as in Plan C Treat the child to prevent low blood sugar Refer all chioldren URGENTLY to the hospital DO NOT GIVE ASPIRIN

signs of severe dengue hemorrhagic fever

FEVER; DENGUE HEMORRHAIC FEVER UNLIKELY

Advise

76

mother when to return immediately Follow up in 2 days if fever persists or child shows signs of bleeding. DO NOT GIVE ASPIRIN

Dengue Hemorrhagic Fever
A child with dengue hemorrhagic fever or dengue shock syndrome may present severely hypotensive with disseminated intravascular coagulation (DIC), as this severely ill PICU patient did. Crystalloid fluid resuscitation and standard DIC treatment are critical to the child's survival.
77

Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well beyond a normal duration of 2 seconds.

78

Session 4-d

Ear Problem

79

Assess EAR PROBLEM
A – –

child with ear problem is assessed for: Ear pain Ear discharge If present, how long has the child has had ear discharge Tender swelling behind the ear, a sign of mastoiditis

80

Assess EAR PROBLEM
Then Ask: 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 for pus draining from the ear.  Feel for tender swelling behind the ear. Ask about ear problem in ALL sick children.

81

Classify EAR PROBLEM
Tender

swelling behind

MASTOIDITIS

Give

the ear

the first dose of an appropriate antibiotics Give first dose of Paracetamol for pain Refer URGENTLY to hospital
Give

Pus

is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain
Pus

ACUTE EAR INFECTION

an antibiotic for 5 days. (Amoxicillin)* Give Paracetamol for pain. Dry the ear by wicking. Follow up in 5 days.
topical

is seen draining from the ear and discharge is reported for 14 days or more.

CHRONIC EAR INFECTION

quinolone ear drops for at least two weeks Dry the ear by wicking. Follow up in 5 days.
No

No

82

ear pain and no pus is seen draining from the ear.

NO EAR INFECTION

additional treatment.

*Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high.

TECHNICAL UPDATES: Chronic Suppurative Otitis Media
TECHNICAL BASIS:  aural toilet combined with antimicrobial treatment is more effective than aural toilet alone  topical antibiotics were found to be better than systemic antibiotics in resolving otorrhea and eradicating middle ear bacteria  topical quinolones were found to be better than topical non-quinolones – topical ofloxacin or ciprofloxacin vs intramuscular gentamicin, topical gentamicin, tobramycin or neomycin-polymyxin

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TECHNICAL UPDATES: Acute Otitis Media
TECHNICAL BASIS:  oral amoxicillin as the better choice for the management of acute ear infection in countries where antimicrobial resistance to cotrimoxazole is high.

reduces the risk of mastoiditis in populations where it is more common

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TREAT THE CHILD: Dry the Ear by Wicking
 Dry

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the ear at least 3 times daily. – Roll a clean absorbent cotton or soft tissue paper into a wick. – Place the wick in the child’s ear. – Remove the wick when wet. – Replace the wick with a clean one and repeat these steps until the ear is dry.  Do not use a cotton-tipped applicator, a stick or a flimsy paper that will fall apart in the ear.

TREAT THE CHILD: Dry the Ear by Wicking
 Wick

the ear 3 times daily.  Use this treatment for as many days as it takes until the wick no longer gets wet when put in the ear and no pus drains from the ear.  Do not place anything (oil, foil or other substances) in the ear between wicking treatments.  Do not allow the child to go into swimming.
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