Integrated Management of Childhood Illness

IMCI Lecture (1)

General Danger Signs

ALL SICK Children

General Danger Signs
Checking for General danger signs: 1- Unable to drink or breastfeed 2-Vomits every thing 3- Has the child had convulsions? 4- Unconscious, lethargic 5- Is the child convulsing now

assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK and check · Is the child able to drink or breastfeed? · Does the child vomit every thing? · Has he had convulsions? (during present illness) LOOK · See if the child is lethargic or unconscious · See if the child is convulsing now .ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE?  Determine if this is an Initial or Follow Up visit for this problem  If Follow Up visit. use the follow up instruction on TREAT THE CHILD CHART  If Initial visit.

Unable to Drink or Breastfeed? The child is unable (too weak) to suck or swallow when he is offered a drink or breast milk • Ask the mother to describe exactly what happens when she offers the child something to drink • Ask the mother to offer her child a drink of clean water or breast milk and look to see if the child is swallowing . .

• ALL what goes down comes back up • A child who vomits several times but can hold down some fluids does not have this general danger sign. . fluids or oral drugs.Vomits Everything ? Not able to hold anything down AT ALL • Not able to hold down food.

• Use words the mother understands.Has the child had convulsions? • Ask the mother if the child developed convulsions during the current illness. .

The child may loose consciousness or may not be able to respond to spoken directions. • In a convulsing child the arms and legs stiffen. .Convulsions (cont…) • Explain what do you mean exactly by “convulsions”.

• The child does NOT respond when he is : •Touched •Shaken. or •Spoken to .Unconscious ? • An unconscious child is a child who cannot be awakened.

Lethargic ? Difficulty in maintaining the aroused state • A lethargic child is NOT awake and alert when he should be. • He is drowsy and does not show interest in what is happening around him. .

Lethargic (cont…) • Often a lethargic child does not look to his mother or watch examiner face when talks. • A lethargic child may stare blankly and appears not to notice what is going around. .

Cough OR Difficult Breathing Then ASK About: COUGH OR DIFFICULT BREATHING .

“Cough OR Difficult Breathing.” NOT “Cough AND Difficult Breathing”  Fewer than 25 percent of children with cough also have difficult breathing  Many causes of difficult breathing are not related to cough  Using both can cause false positives .

.Acute Respiratory Infections ( ARI ) Global & National Health Problem • Common cause of mortality. • Common cause of morbidity. • Commonest reason for irrational drug prescription.

Role of IMCI in ARI Insure Adequate Case Management • Identify those who need URGENT REFERRAL • Identify cases of PNEUMONIA. • Rationalize the use of DRUGS • Breast feeding and optimal nutrition • Vaccination and Vitamin A supplementation .

ASK · For how long? LOOK and LISTEN · Count the breaths in one minute · Look for chest indrawing · Look and listen for stridor · Look and listen for wheeze Child must be calm .Assessment THEN ASK ABOUT MAIN SYMPTOMS Does the child have Cough or Difficult breathing? IF YES.

Pneumonia: Severity • Recognition is based on: • Lower chest wall indrawing • Stridor • Fast breathing .

.LOWER CHEST WALL INDRAWING Index of : Severe Pneumonia or very severe disease Reasonable sensitivity & specificity " 89%".

present all the time in a calm child. admission or further assessment. • Must be definite. .Lower Chest Wall Indrawing • Studies found that lower chest wall indrawing best identified children who required referral.

• Look & Listen to Stridor: Listen to the harsh voice (in a calm child) Look at the chest wall (phase of breathing) . Severe Disease.STRIDOR • Is Another Indicator for Severe Pneumonia or V. • It is a harsh Inspiratory Voice.

WHY FAST BREATHING ? Good Predictor of PNEUMONIA In the sick child 2 months – 5 years * * 80%” “Sensitivity & specificity around Sensitivity= proportion of those with the disease who are correctly identified by sign Specificity= proportion of those without the disease who are correctly called free of the disease by using the sign. • Simplicity • Ease in training • Reliability .

• Auscultation is less sensitive indicator • and needs skills .FAST BREATHING ! Why not other signs of pneumonia? • Fever is poor predictor of pneumonia.

but do not wait for fever to subside .CUT-OFF POINTS for FAST BREATHING If the child is: •2 months up to 12 months FAST BREATHING IS: 50 40 breaths per minute or more breaths per minute or more •12 months up to 5 years •Best to count rate in a quiet and alert child •Fever can affect respiratory rates.

Cut-offs of Fast Breathing 60 50 40 .

Bronchiolitis • Older children plus those with recurrent attacks of wheeze .Wheezing: Causes • Under age of 2 years .bronchial asthma or reactive airways disease – Transient wheezers – Persistent wheezers • Other respiratory infections • Inhaled foreign body • Tuberculosis node compressing bronchus .

Wheezing: Why Added ?? • Morbidity from asthma is a problem in Sudan • Will reduce unnecessary referral to hospital • Rapid-acting bronchodilators are available at first-level facilities • Health workers are trained to recognize audible wheeze and use bronchodilators • Health worker can recognize when a child with recurrent wheeze is not responsive in the firstlevel health facility .



Severe Pneumonia OR Very Severe Disease Recognition: Urgently Refer Children with Cough OR Difficult Breathing AND –Any general danger sign OR –Lower chest wall indrawing OR –Stridor in a calm child .


Cough or Cold Antibiotics .No signs of Pneumonia or Very Severe Disease No Pneumonia.

Video session .

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