FEU Prayer Direct O God, we beseech You All our actions by your Holy inspiration And Help them

on by your gracious assistance So that every prayer and work of ours May begin with You And by You be happily ended AMEN

IMCI: Integrated Management of Childhood Illness

The IMCI is a broad strategy developed by WHO in collaboration with UNICEF. It aims at reducing childhood deaths, illness, and disability, and improving growth and development. It combines improved management of childhood illness with aspects of nutrition and immunization in children below the age of five years.

IMCI Case Management

Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Classification

Need to Refer
Specific treatment

Home management
Treatment Identify treatment Treat

Counsel & Follow-up Counsel caretakers Follow-up

COLOR CODING

PINK: Urgent Referral

YELLOW: Treatment at Outpatient Health Facility

GREEN: Home Management

At the start of a sick child (2 months to 5 years) consultation

Ask the mother what the childs problems are. Determine if this is an initial or followup visit for this problem.

Check for general danger signs

Ask: Not able to drink or breastfeed, Vomits everything, Convulsions, or Look: Abnormally sleepy or difficult to awaken
Need to Refer (except in severe dehydration)

IMCI Case Management

Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Classification

Need to Refer
Specific treatment

Home management
Treatment Identify treatment Treat

Counsel & Follow-up Counsel caretakers Follow-up

Ask about the main symptoms

Cough or difficulty in breathing Diarrhea Fever Ear problem

Cough or difficulty in breathing

Ask: For how long? Look: Count RR Chest indrawing Stridor

The child must be calm.

 Any general danger sign or Chest indrawing or Stridor

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

1st dose of antibiotic Vitamin A Breastfeeding/sugar water URGENT REFERRAL

 Fast breathing 2 12 months old: 50/minute 1 year or older: 40/minute

PNEUMONIA

Antibiotic for 5 days Relieve cough with safe remedy Advise mother on danger signs Follow up in 2 days

No signs of pneumonia or a very severe disease

NO PNEUMONIA: COUGH OR COLD

If cough 30 days refer to hospital for assessment Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement

Diarrhea: Classify For dehydration

Persistent diarrhea Blood in the stool

Classify for dehydration

2 or more of the following:
Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly

SEVERE DEHYDRATION

Plan C

Plan C: To treat dehydration quickly

IV fluid: LRS 100 ml/kg body weight (in 6 hrs for infants; 3 hrs for children)

NO
IV treatment within 30 minutes

NO
Oresol/NGT

Plan C: To treat dehydration quickly

Oresol/NGT

NO
Oresol p.o.

NO
URGENT REFERRAL

Classify for dehydration

2 of the following:
Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly

SOME DEHYDRATION

Plan B

Plan B: Treat some dehydration with ORS

Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Age < 4 mos 4-12 mos

Amount

200-400

400-700

Plan B: Treat some dehydration with ORS

Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Age 12 mos-2 yrs 2-5 yrs

Amount

700-900

900-1400

Plan B: Treat some dehydration with ORS

Show the mother how to give Oresol to the child: frequent sips from a cup If the child vomits, wait for 10 minutes. Then continue, but more slowly. Continue breastfeeding if the child wants to breastfeed. If the child develops puffy eyelids, stop ORS.

Plan B: Treat some dehydration with ORS

After 4 hours: Reassess the child & classify for dehydration. Select appropriate plan. Begin feeding the child in the health center.

Classify for dehydration

Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION

NO DEHYDRATION

Plan A

Plan A: Treat diarrhea at home

Give extra fluid.

Up to 2 yrs 50 100 ml after each LBM

2 -4 yrs

100 200 ml after each LBM

Continue feeding. Know when to return.

Persistent diarrhea: 14 days or more

+ Dehydration=severe persistent diarrhea

Treat dehydration Give Vitamin A Refer to hospital

Persistent diarrhea: 14 days or more

No dehydration=persistent diarrhea

Advise regarding feeding Give Vitamin A Follow up in 5 days

Blood in the stool = dysentery

Oral antibiotic for shigella for 5 days Follow up in 2 days

Fever: (history/temperature 37.5C or above)

Malaria risk?

Measles now or w/in last 3 mos Dengue risk?

Fever: Ask about malaria risk

Residing in endemic area? OR: Travel & overnight w/in past stay in endemic area, or 6 mos Blood transfusion

Malaria risk +

Blood smear Ask: Duration of fever? Present everyday? Look: Stiff neck Runny nose Other signs of measles

Malaria risk + any general danger sign or stiff neck

Very severe febrile disease/malaria

Quinine (under med. supervision) 1st dose of antibiotic, Paracetamol Urgent referral

Malaria risk +, blood smear + No runny nose, no measles

Malaria

Oral antimalarial Paracetamol Follow up in 2 days > 7 days fever hospital for assessment

Malaria Risk +, blood smear or runny nose or measles or other causes of fever

Fever: Malaria Unlikely

Give Paracetamol Follow up in two days

> 7 days fever hospital for assessment

Treat other causes of fever

No malaria risk Any general danger sign or stiff neck

Very severe febrile disease

1st dose of antibiotic, Paracetamol Urgent referral

Malaria Risk +, blood smear or runny nose or measles or other causes of fever

Fever: No Malaria

Give Paracetamol Follow up in two days

> 7 days fever hospital for assessment

Treat other causes of fever

Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers

Severe complicated measles

1st dose of antibiotic, Vitamin A Urgent referral

Measles now or w/in last 3 mos Pus draining from the eye or Mouth ulcers

Measles with eye or Mouth complications

Vitamin A Tetracycline eye ointment Gentian violet Follow up in 2 days

Measles now or w/in last 3 mos No other signs

Measles

Vitamin A

If there is Dengue risk

Bleeding gums, nose, in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs, but fever > 3 days Tourniquet test

Slow capillary refill

Indicates poor skin perfusion Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

Any of the danger signs or + tourniquet test

Severe Dengue hemorrhagic fever

If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS Any other signs of bleeding Plan C Urgent referral Do not give aspirin

No signs of severe dengue hemorrhagic fever

Fever: Dengue Hemorrhagic Fever Unlikely

Follow up in 2 days if fever persists or shows signs of bleeding Do not give Aspirin

Ear problem: tender swelling behind ear

Mastoiditis

1st dose of antibiotic Paracetamol for pain Urgent referral

Ear discharge < 14 days or Ear pain

Acute ear infection

Antibiotic for 5 days Paracetamol for pain Wicking Follow up in 5 days

Ear discharge for 14 days or more

Chronic ear infection

Wicking Follow up in 5 days

No ear pain, and no pus seen draining from ear

No Ear Infection

No additional treatment

IMCI Case Management

Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Classification

Need to Refer
Specific treatment

Home management
Treatment Identify treatment Treat

Counsel & Follow-up Counsel caretakers Follow-up

Visible severe wasting or Edema on both feet or Severe palmar pallor

Severe malnutrition or severe anemia

Vitamin A Urgent referral

Some palmar pallor or Very low weight for age

Anemia or very low weight for age

Assess for feeding problem Pallor: iron & Mebendazole Wt for age very low: Vitamin A

Not very low weight for age and no other signs of malnutrition

No Anemia and Not Very Low Weight

Assess for feeding problem ( if < 2 years old), and counsel the mother on feeding If feeding is problem: follow up in 5 days

IMCI Case Management

Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Classification

Need to Refer
Specific treatment

Home management
Treatment Identify treatment Treat

Counsel & Follow-up Counsel caretakers Follow-up

Immunization Status

Immunization Schedule:
BCG Hepatitis B DPT OPV Measles

At the start of a sick infant (1 week to 2 months) consultation

Ask the mother what the childs problems are. Determine if this is an initial or followup visit for this problem.

Convulsion or Fast breathing (60/minute or more) or Severe chest indrawing or nasal flaring or grunting or bulging fontanel or pus draining from ear or umbilical redness extending to the skin or Fever (37.5oC or higher), or low temp (< 35.5oC) or many or severe skin pustules or abnormally sleepy or difficult to awaken or less than normal movement

Possible Serious Bacterial Infection

Possible Serious Bacterial Infection

IM antibiotics Breastfeeding Refer immediately

Red umbilicus or draining pus or skin pustules

Local Bacterial Infection

Give oral antibiotic Treat local infection at center Teach mother how to treat local infections at home Follow up in 2 days

Diarrhea: Classify For dehydration

Severe persistent diarrhea Blood in the stool

Classify for dehydration

2 or more of the following:

Abnormally sleepy/difficult to wake Sunken eyes Skin pinch goes back very slowly

SEVERE DEHYDRATION

Plan C

SEVERE DEHYDRATION

If infant also has a Possible Serious Bacterial Infection Or Dysentery: Refer urgently to hospital Advise mother to continue breastfeeding Advise mother to keep infant warm

Classify for dehydration

2 of the following:
Restless, irritable Sunken eyes Skin pinch goes back slowly

SOME DEHYDRATION

Plan B

SOME DEHYDRATION

If infant also has a Possible Serious Bacterial Infection Or Dysentery:

Refer urgently to hospital Advise mother to continue breastfeeding

Diarrhea lasting for 14 days or more

severe persistent diarrhea

Treat dehydration first before referral Refer to hospital

Classify for dehydration

Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION

NO DEHYDRATION

Plan A

Blood on stool

Dysentery

Refer to hospital with mother giving frequent sips of ORS on the way

Not able to feed No attachment at all Not sucking at all

Not Able to Feed Possible Serious Bacterial Infection

Give Antibiotics Urgent referral

Not well attached Not sucking effectively Less than 8 breastfeeds in 24 hours Receive other foods or drinks Low weight for age Thrush (white patches in mouth)

Feeding Problem or Low Weight

Feeding Problem or Low Weight

Advise the mother to breastfeed for as long the infant wants If not sucking effectively: teach proper positioning and attachment If not breastfeeding at all: Refer to breastfeeding counseling

Feeding Problem or Low Weight

If not breastfeeding at all: Advise about correct preparing of milk substitutes If w/ thrush: teach mother how to treat at home Follow up any feeding problem or thrush in 2 days Low weight for age: in 14 days

 Not low weight for age no other signs of inadequate feeding

NO FEEDING PROBLEM

Advise mother to give home care for the young infant

Immunization Status

Immunization Schedule:
BCG Hepatitis B DPT OPV

Integrated Management of Childhood Illness WHO Regional Office for the Western Pacific/ Child Health

Integrated Management of Childhood Illness WHO Regional Office for the Western Pacific/ Child Health

CASE SAMPLE
Emilio: 37 months old, weighs 13.4 kg. . Temp is 36.8oC. Her mother says he had fever for the past 3 days and that since that morning, he has bleeding from nose and mouth. Abnormally sleepy, no cough or difficulty of breathing, no diarrhea, no malaria risk in their place but there are cases of Dengue Hemorrhagic Fever. The family has not traveled anywhere in the past month. He had measles over a year ago. His neck is stiff, does not have runny nose. Stool has not been black and has not vomited. No abdominal pain. Has dried blood in nostrils, few petechiae on his trunk. He is cold and clammy and capillary refill time is four seconds. No ear problems. No severe wasting, no palmar pallor, no edema on both feet.

Record and Classify on the form provided

Benedict is 3 years old and weighs 9.4 kg. His temperature is 37oC. His mother says he fees hot and he also has a cough. The health worker checks for general danger signs. Willy is unable to drink and has not vomited, does not have convulsions, and is not abnormally sleepy or difficult to awaken. Willy has been coughing for three days and his breathing is counted at 51 breaths/minute. He has no chest indrawing and does not have any stridor. Willy has no diarrhea. Their family took a trip to Palawan a month ago because his father comes from the place. He has felt hot for five days. He has had not measles within the last 3 months. He does not have a stiff neck, runny nose, and generalized rash. It is not possible to take a blood smear. There is no risk of Dengue.

 Feliza is 18 months old. She weighs 7 kg. Her temperature is 38.5oC. Her mother brings her today because the child feels hot and has a rash. The health worker sees that Feliza looks like skin and bones. The health worker checks for general danger signs. Feliza is able to drink, has not vomited, has not had convulsions, and is not abnormally sleepy or difficult to awaken . No cough or difficulty of breathing. No diarrhea. Feliza lives in an area where there is a malaria risk. She has had fever for 5 days. Her rash is generalized and she has red eyes. She has measles. She does not have stiff neck and runny nose. Her blood smear is positive to P. vivax. The health care worker asseses for measles complication. Feliza does not have mouth ulcers and she has no pus draining from eyes. No ear problem, no dengue risk With visible severe wasting, no palmar pallor, no edema on both feet. Her weight is very low for age.

 Nomai is 5 weeks old. Her weight is 4 kg. Her axillary temperature is 38.5oC. Her mother brought her to the health center because she has a rash. The health care worker assesses for signs of possible serious bacterial infection. Nomais mother says that there have been no convulsions. Omais breathing rate is 55/min. she has no chest indrawing, no nasal flaring, and no grunting. Her fontanel is bulging. There is no pus in her ears. And her umbilicus is normal. The health worker examines her entire body and finds a red rash with just a few skin pustules on her buttocks. She is awake, not abnormally sleepy. Her movements are normal. She does not have diarrhea.

THANK YOU VERY MUCH!!!

Lecturer: Luzviminda C. Reyes, RN, MSN