‡ IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

‡ IMCI is a strategy for reducing mortality and morbidity associated with major causes of childhood illness. ‡ IMCI was initiated jointly in 1992 by DOH, WHO and UNICEF. ‡ IMCI has already been introduced in more than 75 countries around the world.

‡ Primarily, there are two objectives of IMCI: 1. To significantly reduce global mortality and morbidity associated with the major causes of disease in children 2. To contribute a healthy growth and development of children.

‡Three major components of IMCI:

1. Improving case management skills of health workers

2. Improving the health system to deliver IMCI

3. Improving family and community health practices

I. II. III. IV. V. VI.

Assess the child or young infant Classify the illness Identify the treatment Treat the child/Refer Counsel the mother Give follow-up care

I. Assess the child or young infant ‡ Assess the child means taking a history and doing physical examination.

II. Classify the illness ‡ Classify the Illness means taking a decision on the severity of the illness ‡ Classifications are not specific disease diagnoses. Instead, they are categories that are used to determine treatment ‡ For effectively manage childhood illness, a colorcoded system has been utilized which represents: green yellow pink

II. Classify the illness
Color Presentation Green Yellow Pink Classification of Disease Mild Moderate Severe Level of Management Home Care Management at the RHU Urgent Referral

III. Identify Treatment ‡ The chart recommends appropriate treatment for each classification ‡ When using this process, selecting a classification on the chart is sufficient to allow you to identify treatment

IV. Treat the child ‡ Treat the child means giving treatment in the health center ‡ prescribing drugs or other treatments to be given at home ‡ teaching the mother how to carry out the treatments.

V. Counsel the mother ‡ Counsel the mother includes assessing how the child is fed ‡ telling the mother about the foods and fluids to give the child ‡ Telling the mother when to bring the child back to the health center.

VI. Give follow-up care ‡ Specific instructions for conducting each follow-up visit

OUT-PATIENT HEALTH FACILITY Check for GENERAL DANGER SIGNS ‡Convulsions (during this illness) ‡Lethargy/unconsciousness ‡Inability to drink or breastfeed ‡Vomiting Assess MAIN SYMPTOMS ‡Coughing/difficulty of breathing ‡Diarrhea ‡Fever ‡Ear Problems Urgent Referral OUT-PATIENT HEALTH FACILITY Pre-referral treatment Advise parents Refer child Assess NUTRITION AND IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS Home Management Check for OTHER PROBLEMS CLASSIFY CONDITION AND IDENTIFY TREATMENT ACTIONS According to color-coded treatment HOME Caretaker is counseled on: ‡Refer child ‡Home treatments ‡Feeding and fluids ‡When to return immediately ‡Follow-up

REFERRAL FACILITY ‡Emergency Triage and treatment (ETAT) ‡Diagnosis ‡Treatment ‡Monitoring and Follow-up

Treatment at Out-Patient OUT-PATIENT HEALTH FACILITY ‡Treat local infection ‡Give oral drugs ‡Advise and teach caretakers ‡Follow-up

Steps: 1. ASK THE MOTHER WHAT S THE CHILD PROBLEMS ARE a. Greet the mother appropriately and ask her to sit with her child b. Using good communication skills, ask the mother what the child s problems are and record them on the Recording Form c. Determine if this is an initial visit or follow up visit.

2. CHECK FOR GENERAL DANGER SIGNS

a. The child is not able to drink or breastfeed

b. The child vomits everything

c. The child has had convulsion (during this illness)

d. The child is abnormally sleepy or difficult to awaken

Exercises: Case 1 Mutya is 15 months old. She weighs 8.5 kg. Her temperature is 35.5°C. The health worker asked, What are the child s problems? The mother said, Mutya has been coughing for 4 days, and she is not eating well. This is Mutya s initial visit for this problem. The health worker checked Mutya for general danger signs. He asked, Is Mutya able to drink or Breastfeed? The mother said No. Mutya does not want to breastfeed. The health worker gave Mutya some water. She was too weak to lift her head. She was not able to drink from a cup. Next, he asked the mother, Is she vomiting? The mother said No. Then he asked, Has she had convulsions? The mother said No. The health worker looked to see if Mutya was abnormally sleepy or difficult to awaken . When the health worker and the mother were talking, Mutya watched them and looked around the room. She was not abnormally sleepy or difficult to awaken.

Answer the following: a. Write Mutya s name, age, weight, and temperature in the spaces provided on top of the line form. b. Write Mutya s problem on the line after the question Ask: What are the child s problems? c. Tick ( ) whether this is the initial or follow-up visit. d. Does Mutya have general danger signs? If yes, circle the signs on the Recording Form. Then tick( ) yes or no after the question, General danger signs present?

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify
CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO___

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify
CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES_ __NO___

Case 2: Nilo is 4 years old. He weighs 10 kg. His temperature is 38 °C. The health worker asked about the child s problems. Nilo s parents said, he is coughing and has ear pain. This is the initial visit for this problem. The health worker asked, Is your child able to drink? The parents answered, Yes. Does Nilo vomit everything? he asked. The parent said No. The health worker asked, Has he had convulsions? they said No. The health worker looked at Nilo, the child was not abnormally sleepy or difficult to awaken.

Answer the following: a. Write Nilo s name, age, weight, and temperature in the spaces provided on top of the line form. b. Write Nilo s problem on the line after the question Ask: What are the child s problems? c. Tick whether this is the initial or follow-up visit. d. Does Nilo have general danger signs? If yes, circle the signs on the Recording Form. Then tick yes or no after the question, General danger signs present?

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify
CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__ _

3. ASSESS AND CLASSIFY COUGH OR DIFFICULT BREATHING ‡ A child with cough or difficult breathing may have pneumonia or another severe respiratory infection ‡ Pneumonia is an infection of the lungs. Both bacteria and viruses can cause pneumonia ‡ In developing countries, pneumonia is often due to bacteria. The most common is Streptococcus pnuemoniae.

3.1 Assess cough and difficult breathing A child with cough or difficult breathing is assessed for: a. How long the child has had cough or difficult breathing b. Fast breathing-consider fast breathing if: 2mos-12mos. - 50 breaths/min. or more 12mos.-5yrs. - 40 breaths/min. or more c. Chest indrawing d. Stridor in calm child

3.2 Classify Cough or difficult breathing
‡Any general danger signs or ‡Chest indrawing or ‡Stridor in calm child ‡ Fast breathing ‡No sign of pneumonia or very severe disease
SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA NO PNEUMONIA COUGH OR COLD

Exercises: Case 1 Lupita is 8 months old. She weighs 6kg. Her temperature is 39°C. Her father told the worker, Lupita has had cough for 3 days. She is having trouble breathing. She is very weak. The health worker said, You have done the right thing to bring your child today. I will examine her now. The health worker checked for general danger signs. The mother said, Lupita will not breastfeed. She will not take any other drinks I offer her. Lupita does not vomit everything and not had convulsions. Lupita is abnormally sleepy. She did not look at the health worker or her parents when they talked. The health worker counted 55 breaths/min. He saw chest indrawing. He decided Lupita had stridor because he heard a harsh noise when she breathed in.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO___

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ______days

YES____ NO____

Count the breaths in one minute ____breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES_ __NO___

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ____3__days

YES__ __ NO____

Count the breaths in one minute __55__breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor

Severe Pneumonia or Very Severe Disease

Case 2 Bayani is 6months old. He weighs 5.5kg. His temperature is 38°C. His mother said he has had cough for 2 days. The health worker checked for general danger signs. The mother said that Bayani is able to breastfeed . He has not vomited during this illness. He has not had convulsions. Bayani is not abnormally sleepy or difficult to awaken. The health worker said to the mother, I want to check Bayani s cough. You said he has had cough for 2 days now. I am going to count his breathes. He will need to remain calm while I do this. The health worker counted 58 breathes/min. He did not see chest indrawing. He did not hear stridor.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__ _

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ___2___days

YES_ ___ NO____

Count the breaths in one minute __58__breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor

Pneumonia

4. ASSESS AND CLASSIFY DIARRHEA ‡ Diarrhea occurs when stools contain more water than normal. ‡ Defined as 3 or more loose or watery stools in a 24-hour period ‡ It is common in babies under 6months who are drinking cow s milk or infant feeding formulas

4.1 Assess Diarrhea A child with diarrhea is assessed for a. How long the child has diarrhea b. Blood in the stool to determine if the child has dysentery c. Signs of dehydration

ASK: For how long? To determine the type of diarrhea ‡ Acute Diarrhea- diarrhea lasts for less than 14 days ‡ Persistent Diarrhea- diarrhea last for 14 days or more

ASK: Is there blood in the stool? ‡ Diarrhea with blood in the stool, with or without mucus is called dysentery ‡ The most common cause of dysentery is Shigella bacteria

Check for signs of dehydration ‡ Restless and irritable ‡ Abnormally sleepy or difficult to awaken ‡ Sunken eyes ‡ Child is not able to drink or drinking poorly or drinking eagerly , thirsty ‡ Pinch the skin of the abdomen. Does it goes back: Very slowly(longer than 2 seconds); Slowly

4.2 Classify Diarrhea ‡ There are three classification tables for classifying diarrhea:  All children with diarrhea are classified for dehydration  If the child has had diarrhea for 14 days or more, classify the child for persistent diarrhea  If the child has blood in the stool, classify the child for dysentery.

4.2 Classify Diarrhea 4.2.1 Classify Dehydration
Two of the following signs: ‡Abnormally sleepy or difficult to awaken ‡Sunken eyes ‡Not able to drink or drinking poorly ‡Skin pinch goes back very slowly

SEVERE DEHYDRATION

Two of the following signs ‡Restless, irritable ‡Sunken eyes ‡Drinks eagerly, thirsty ‡Skin pinch goes back slowly

SOME DEHYDRATION

‡Not enough signs to classify as some or severe dehydration

NO DEHYDRATION

Case 1: Joel Joel has had diarrhea for five days. He has no blood in the stool. He is irritable. His eyes is sunken. His father and mother also think that Joel s eyes are sunken. The health worker offers Joel some water, and the child drinks eagerly. When the health worker pinches the skin on the child s abdomen, it goes back slowly.

‡ Record Joel s signs of dehydration and classify
DOES THE CHILD HAVE DIARRHEA ‡For how long?______days ‡Is there blood in the stool? YES____ NO____ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?

‡ Record Joel s signs of dehydration and classify
DOES THE CHILD HAVE DIARRHEA ‡For how long?___5___days ‡Is there blood in the stool? YES__ _ NO____ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?

Some Dehydration

4.2 Classify Diarrhea 4.2.2 Classify Persistent Diarrhea
‡ Dehydration present
SEVERE PERSISTENT DIARRHEA PERSISTENT DIARRHEA

‡No dehydration

Case 2: Farida Farida is 14 months old. She weighs 12 kg. Her temperature is 37.5°C. Farida s mother said the child has had diarrhea for 3 weeks. Farida does not have any general danger signs. She does not have cough or difficult breathing. The health worker assessed her diarrhea. He noted she has had diarrhea for 21 days. He asked if there had been blood in the stool. The mother said, No. The health worker checked Farida for signs of dehydration. The child is irritable throughout the visit. Her eyes are not sunken. The skin pinch goes back immediately.

‡ Record Farida s signs of and classify Persistent Diarrhea
DOES THE CHILD HAVE DIARRHEA ‡For how long?___21___days ‡Is there blood in the stool? YES__ __ NO____ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?

Persistent Diarrhea

4.2 Classify Diarrhea 4.2.3 Classify Dysentery
‡ Blood in the stool
DYSENTERY

Case 3: Carlo Carlo is 10 months old He weighs 8 kg. Her temperature is 38.5 °C. He is here today because he has had diarrhea for 3 days. Carlo does not have any general danger signs. He does not have cough or difficult breathing. The health worker assesses the child for diarrhea. You said Carlo has had blood in the stool. I will checked for signs of dehydration. The child is not abnormally sleepy or difficult to awaken. He is not restless nor irritable. He does not have a sunken eyes. The child drank normally when offered some water and does not seem thirsty. The skin pinch goes back immediately.

‡ Record Carlo s signs and classify
DOES THE CHILD HAVE DIARRHEA ‡For how long?____3__days ‡Is there blood in the stool? YES__ __ NO____ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?

Dysentery

‡ A child with fever may have malaria, measles, Dengue Hemorrhagic Fever(DHF) or another severe disease. Or a child with fever may have a simple cough or cold or another viral infection.

A. Malaria ‡ Malaria is caused by parasites in the blood called plasmodia ‡ They are transmitted through the bite of anopheles mosquitoes. ‡ Four species of plasmodia can cause malaria, but the only dangerous one is Plasmodium Falciparum

‡ Fever is the main symptom of malaria ‡ Other signs of falciparum malaria are shivering, sweating, and vomiting. ‡ In most areas in the Philippines where there is malaria transmission, malaria is a significant cause of death of children.

‡ Deciding Malaria Risk (Category of Provinces) Category A- Provinces with no significant improvement in malaria situation in the last 10 years or situatione worsened in the last 5 years, average number of cases of more than 1,000 in the last 10 years.

Category A Kalinga Davao del Sur Ifugao Compostela Valley Quirino Agusan del Norte Palawan Sulu

Davao del Norte Mt. Province Bukidnon Cagayan Zamboanga del Sur Agusan del Sur Tawi-tawi Misamis Oriental

Apayao Davao Oriental Isabela Saranggani Zambales Mindoro Occidental Quezon Basilan

Category B- Provinces where situation has improved in the last 5 years or average number of cases of 1001,000 per year.

Category B Abra Camarines Norte Nueva Ecija North Cotabato Mindoro Oriental Zamboanga del Norte

Laguna Ilocos Norte Sultan Kudarat Bataan Maguindanao Tarlac

Pangasinan Camarines Sur Bulacan Lanao del Sur Rizal Romblon

Category C-Provinces with significant reduction in cases in the last 5 years Albay Batanes Benguet Antique Ilocos Sur Sorsogon La Union Negros Oriental Pampanga Negros Occidental Batangas Eastern Samar Cavite Western Samar Marinduque Misamis Occidental Masbate Surigao del Norte

Category D- Provinces that are malaria free although are still potentially malarious due to presence of vector. Cebu Bohol Catanduanes Aklan Capiz Guimaras Siquijor Biliran Leyte Northern Samar Camiguin

B. Measles ‡ Measles is highly infectious caused by virus ‡ It infects the skin and the layer of cells that line the lungs, eyes, mouth and throat. ‡ Fever and generalized rash are the main signs of measles ‡ Most cases occur in children between 6 months and 2 years.

C. Dengue Hemorrhagic Fever(DHF) ‡ DHF is caused by virus that is spread by Aedes mosquitoes ‡ Children with DHF have fever which may last for 2 to 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 petechiea are seen, or inside the body. ‡ The most severe signs of DHF often occur in the 2 days after the fever has disappeared

5.1 ASSESS FEVER ‡ Ask: Does the child have fever?(by history, or feels hot or Temperature is 37°C or above) a. Decide Malaria Risk Ask:  Does the child live in a malaria area  Has the child visited or stayed overnight in a malaria area in the past 4 weeks. If Yes to either, obtain a blood smear

THEN ASK: ‡ For how long has the child had fever? ‡ If more than 7 days, has the fever been present everyday? ‡ Has the child had measles within the last 3 months

LOOK AND FEEL Look or feel stiff neck Look for runny nose

Look for signs of MEASLES: - Generalized rash and -One of these: cough, runny nose, or red eyes

If the child has measles Now or within last 3 months

Look for mouth ulcers -Are they deep and extensive Look for pus draining from the eyes Look for clouding of the cornea

Assess Dengue Hemorrhagic Fever ASK: ‡ Has the child had any bleeding from the nose or gums, or in the vomitus or stools? ‡ Has the child has black vomitus? ‡ Has the child had black stools? ‡ Has the child has persistent abdominal pain? ‡ Has the child has persistent vomiting?

LOOK AND FEEL Look for bleeding from the nose or gums Look for skin petechiae Feel for cold and clammy extremities Check for slow capillary refill Perform for the torniquet test

5.2 CLASSIFY FEVER ‡ There are 2 classification tables on the ASSESS AND CLASSIFY CHART: 1. Malaria Risk 2. No Malaria Risk ‡ To classify fever, you must know if there is malaria risk or not. Then select the appropriate classification table.

‡ Malaria Risk
‡Any general danger sign or ‡Stiff neck ‡Blood smear (+) If blood smear not done: ‡NO runny nose and ‡NO measles and ‡NO other cause of fever ‡Blood smear( ) OR ‡Runny nose OR ‡Measles OR ‡Other causes of fever
VERY SEVERE FEBRILE DISEASE/ MALARIA MALARIA

FEVER: MALARIA UNLIKELY

Example: A 2 year old-boy is brought to the health center because he has felt hot for 2 days. There is Malaria risk. He does not have general danger signs. He does not have cough or difficult breathing or diarrhea. A blood smear was done with negative result. The child observed to have runny nose. When the health worker assessed the child s fever, he recorded this signs.

‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.37.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk, obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days. Generalized rash and ‡If more than 7 days, has fever been present everyday? One of these: cough, runny nose ‡Has the child had measles with the last 3 months? Or red eyes.

Fever: Malaria Unlikely

‡ No Malaria Risk
‡Any general danger sign or ‡Stiff neck ‡No signs of severe febrile disease
VERY SEVERE FEBRILE DISEASE FEVER: NO MALARIA

‡

‡ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Very Febrile Disease: -presence of Danger Signs/Stiff neck -Needs URGENT REFERRAL Fever: No Malaria Severe Pneumonia or Very Severe Disease Pneumonia No Pnuemonia: Cough or cold Dysentery Severe complicated Measles Measles Severe DHF Abscess Typhoid Fever Infected wounds

5.3 CLASSIFY MEASLES
‡Any general danger sign or ‡Clouding of the cornea or ‡Deep or extensive mouth ulcers ‡Pus draining from the eye or ‡Mouth ulcers ‡Measles now or within the last 3 months
SEVERE COMPLICATED MEASLES

MEASLES WITH EYE AND MOUTH COMPLICATIONS MEASLES

5.4 Classify Dengue Hemorrhagic Fever
‡Bleeding from nose or gums ‡Bleeding in stools or vomitus ‡Skin petechiae ‡Cold and clammy extremities ‡Capillary refill more than 3 seconds ‡Persistent abdominal pain ‡Persistent vomiting ‡Torniquet test positive
SEVERE DENGUE HEMORRHAGIC FEVER

‡No signs of severe dengue hemorrhagic fever

FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

Example: Case of Fidel Fidel is 10 months old. He weighs 8.2 kg. His temperature is 37.5°C. His mother says he has a rash and cough. The health worker checked Fidel for general danger signs. Fidel was able to drink. Was not vomiting, and was not abnormally sleepy or difficult to awaken. The health worker asked about Fidel s cough. The mother said Fidel had been coughing for 5 days. He counted 43 breaths per minute. He did not see chest indrawing. He did not hear stridor when Fidel was calm. Fidel did not have diarrhea. Next, The health worker asked about Fidel s fever. There is Malaria risk. The mother said Fidel has felt hot for 2 days. Fidel did not have a stiff neck. He had a runny nose with this illness. The health worker did not have the facilities for examination of a blood smear. Fidel has rash covering his whole body. Fidel s eyes were red. The health worker checked the child for complications of measles. There were no pus draining from the eye and no clouding of the cornea. There have been no cases of dengue in their area.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__ _

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long?__5_days

YES__ __ NO____

Count the breaths in one minute __43__breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor

‡No Pneumonia ‡Cough or cold

DOES THE CHILD HAVE DIARRHEA ‡For how long?______days ‡Is there blood in the stool?

YES____ NO__ __ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?

‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.37.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk, obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days. Generalized rash and ‡If more than 7 days, has fever been present everyday? One of these: cough, runny nose ‡Has the child had measles with the last 3 months? Or red eyes.

Fever: Malaria Unlikely

If the child has measles now or within last 3months

Look for mouth ulcers If yes, are they deep and extensive? Look for pus draining from the eye Look for clouding of the cornea

Measles

Assess Dengue Hemorrhagic Fever ASK: ‡Has the child had any bleeding from the nose or gums or in the vomitus or stool? ‡Has the child has black vomitus or black stool? ‡Has the child had persistent abdominal pain? ‡Has the child had persistent vomiting?

LOOK AND FEEL Look for bleeding from nose or gums Look for skin petechiea Feels for cold and clammy extremities Check for capillary refill Perform torniquet test

Exercises: Case of Nestor Nestor is 5 months old. He weighs 5.2 kg. His axillary temperature is 37.5°C. His mother said he is not eating well. She said he feels hot, and she want a health worker to help him. Nestor is able to drink, has not vomited, does not have convulsions, and is not abnormally sleepy or difficult to awaken. Nestor does not have cough and diarrhea. Because Nestor s temperature is 37.5°C and feels hot, the health worker assessed Nestor further for signs related to fever. It is rainy season, and there is a risk of malaria. There is no dengue risk. The mother said Nestor s fever began 2 days ago. He has not had measles within the last 3 months. He does not have stiff neck, his nose is Not runny, and there are no signs suggesting measles. The blood smear for malaria was positive. ‡ Record s Nestor sign s and classify them in the recording form.

‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.37.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk, obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days. Generalized rash and ‡If more than 7 days, has fever been present everyday? One of these: cough, runny nose ‡Has the child had measles with the last 3 months? Or red eyes.

Malaria

6. ASSESS AND CLASSIFY EAR PROBLEM ‡ A child with ear problem may have ear infection ‡ Sometimes the infection can spread from the ear to the bone behind the ear (the mastoid) causing mastoiditis. ‡ Infection can also spread from the ear to the brain causing meningitis

6.1 ASSESS EAR INFECTION A child with ear problem is assessed for:  Ear pain  Ear dischearge-if yes, how long? - present for more than 2 weeks is treated as chronic ear infection -present for less than 2 weeks is treated as an acute ear infection  Tender swelling behind the ear, a sign of mastoiditis

6.2 CLASSIFY EAR PROBLEM
‡Tender swelling behind the ear ‡Ear pain ‡Pus is seen draining from the ear, and discharge is reported for less than 14 days ‡Pus is seen draining from the ear, and discharge is reported for 14 days or more ‡No ear pain and ‡No pus is seen draining from the ear
MASTOIDITIS ACUTE EAR INFECTION

CHRONIC EAR INFECTION

NO EAR INFECTION

Case I:Sally Sally is 3 years old. She weighs 13 kg. Her temperature is 37.4°C. Her mother came to the health center today because Sally is sick for the last 2 days. She was crying last night and complained that her ear is hurting. The health worker checked and found no general danger signs. Sally does not have cough or difficult breathing. She does not have diarrhea and fever. Next the health worker asked about Sally s ear problem. The mother said she is sure Sally has ear pain. The child cried most of the night because her ear hurts. There has been discharge coming from Sally s ear on and off for about a year, said the mother. The health worker did not see any pus draining from the child s ear. He felt behind the child s ears and felt tender swelling behind one ear.

‡ Record Sally s sign of ear problem and classify them on the Recording form.
DOES THE CHILD HAVE AN EAR PROBLEM? YES__ NO__ ‡Is there ear pain? ‡Is there ear discharge? If yes, for how long____days Look for pus draining from the ear Feel for tender swelling behind the ear

‡ Record Sally s sign of ear problem and classify them on the Recording form.
DOES THE CHILD HAVE AN EAR PROBLEM? YES__ __ NO____ ‡Is there ear pain? ‡Is there ear discharge? If yes, for how long? On and off about a year Look for pus draining from the ear Feel for tender swelling behind the ear

Mastoiditis

Case 2: Susan Susan is 18 months old. She weighs 9 kg. Her temperature is 37°C. Her mother said Susan had discharge coming from ear for the last 3 days. Susan does not have any general danger signs. She does not have cough or difficult breathing. She does not have diarrhea and fever. The health worker asked about Susan s ear problem. The mother said that Susan does not have ear pain, but the discharge has been coming from the ear for 3 or 4 days. The health worker saw pus draining from the child s right ear. He did not feel any tender swelling behind the ear.

‡ Record Susan s sign of ear problem and classify them on the Recording form.
DOES THE CHILD HAVE AN EAR PROBLEM? YES__ __ NO____ ‡Is there ear pain? ‡Is there ear discharge? If yes, for how long? _3 or 4 days Look for pus draining from the ear Feel for tender swelling behind the ear

ACUTE EAR INFECTION

7.0 CHECK FOR MALNUTRITION AND ANEMIA ‡ One type of malnutrition is protein-energy malnutrition. When the child has PEM: -The child may become severely wasted, a sign of marasmus -The child may develop edema, a sign of kwashiorkor -The child may not grow well and become stunted(too short) ‡ A child whose diet lacks recommended amounts of essential vitamins and minerals can develop malnutrition. ‡ Anemia is reduced number of red cells or a reduced amount of hemoglobin in each red cell.

7.1 Assess Malnutrition and Anemia ‡ Look for visible wasting -A child with visible wasting has Marasmus, a form of severe malnutrition. -The child is very thin, has no fat, and looks like skin and bones -The face of the child with visible severe wasting may still look normal. The child s abdomen may be large or distended

‡ Look and feel for edema of both feet -A child with edema of both feet may have Kwashiorkor, another form of severe malnutrition -Signs of kwashiorkor include thin, sparse and pale hair which easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or moon face.

‡ Look for palmar pallor -Pallor is unusual paleness of the skin. It is a sign of anemia ‡ Determine Weight for Age -Weight for age compares the child s weight with the weight of other children who are of the same age

7.2 Classify Nutritional Status
‡Visible severe wasting or ‡Edema of both feet or ‡Severe palmar pallor ‡Some palmar pallor or ‡Very low weight for age ‡Not very low weight for age and no other signs of malnutrition
SEVERE MALNUTRITION OR SEVERE ANEMIA

ANEMIA OR VERY LOW WEIGHT NO ANEMIA AND NOT VERY LOW WEIGHT

Case 1: Ana Ana is 18 months old. She weighs 7kg.Her temperature is 38.5°C. Her mother brought her today because the child has felt hot and has a rash. The health worker saw that Ana looks like skin and bones. The health worker checked for general danger signs. Ana is able to drink, has not vomited, has not had convulsions, and is not abnormally sleepy or difficult to awaken. She does not have cough or difficult breathing. She does not have diarrhea. Because Ana s mother said the child felt hot, and because her temperature is 38.5°C, the health worker assessed her for fever. Ana lives where there is a malaria risk. She has had fever for 5 days. Her rash is generalized rash, and she has red eyes. She has measles. She does not have a stiff neck. She does not have a runny nose. Her blood smear was positive for Plasmodium vivax. There is no dengue risk in the area. The health worker assessed her for signs of measles complications. Ana does not have mouth ulcers. There is no pus draining from the eye and no clouding of the cornea. Ana does not have an ear problem. The health worker next checked her for malnutrition and anemia. Ana has visible wasting. There is no palmar pallor. She does not have edema on both feet. The health worker determined her weight for age.

‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.37.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk, obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__5__days. Generalized rash and ‡If more than 7 days, has fever been present everyday? One of these: cough, runny nose ‡Has the child had measles with the last 3 months? Or red eyes.

MALARIA

If the child has measles now or within last 3months

Look for mouth ulcers If yes, are they deep and extensive? Look for pus draining from the eye Look for clouding of the cornea

Measles

CHECK FOR MALNUTRITION AND ANEMIA Look for visible severe wasting Look for edema of both feet Look for palmar pallor Severe palmar pallor? Some palmar pallor? Determine weight for age Very low? SEVERE MALNUTRITION OR SEVERE ANEMIA

Case 2: David David is 11 months old. He weighs 8kg. His temperature is 36.5°C. His mother says he has had a dry cough for the last 3 weeks. David does not have any general danger signs. The health worker assessed his cough. It has been present for 21 days. He counted 41 breathes/min. The health worker does not see chest indrawing. There is no stridor when the child is calm. David does not have diarrhea. He has not had a fever during this illness. He does not have an ear problem. The health worker checked David for malnutrition and anemia. David does not have visible severe wasting. His palms are very pale and appear almost white. There is no edema of both feet. The health worker determined David weight for age.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__ _

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long?__21 days

YES__ __ NO____

Count the breaths in one minute __41__breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor

‡No Pneumonia ‡Cough or cold

CHECK FOR MALNUTRITION AND ANEMIA Look for visible severe wasting Look for edema of both feet Look for palmar pallor Severe palmar pallor? Some palmar pallor? Determine weight for age Very low? SEVERE MALNUTRITION OR SEVERE ANEMIA

8.0 Check the Child s Immunization status Age Vaccine Birth BCG Hepa B-1 6 weeks DPT-1 OPV-1 Hepa B-2 10 weeks DPT-2 OPV-2 14 weeks DPT-3 OPV-3 Hepa B-3 9 months Measles

CHECK IMMUNIZATION STATUS OF THE FOLLOWING CHILDREN: 1. Metro, 6 months old. No general danger signs. Classified as No Pneumonia: Cough or Cold and No Anemia and Not Very Low Weight for Age. Immunization history: BCG, HEP B1 at birth; OPV1, DPT1,HEPB2; OPV2 and DPT2 given 6 weeks ago. 2. Victor, 3 months old. No general danger signs. Classified as Diarrhea with no Dehydration and also Anemia. Immunization history: BCG, OPV1, DPT1, and HEP B1 given 5 weeks ago. Victor has diarrhea. 3. Mark, 9 months old. No general danger signs. Classified as Pneumonia, Malaria. No Anemia and No Very Low Weight Immunization history: BCG, OPV1, DPT1 and HEP B1. When Mark was 7 months old, he received OPV2, DPT2 and HEP B2.

QUESTIONS 1. Is the child up to date with his immunization? 2. What immunizations, if any, does the child need today? 3. When should he return for his next immunization

Metro

Victor

Mark

9.0 Check the Child s Vitamin A Status
AGE 6 months Above 6 months to 59 months 100,000 IU 1 200,000 IU

1

Use recommended Vitamin A schedule -All children at 6 months of age should receive 100,000IU of Vitamin A. They should then receive 200,000 IU of vitamin A every 6 months up to the age of 59 months ‡ Observe precautions in Vitamin A administration -To avoid over dosage of vitamin A supplementation, always ask two questions:  Is the child 6 months of age or older?  If yes, has the child had a dose of Vitamin A supplementation in the past 6 months? ‡ If the child is 6 months of age or older and has not had a dose of vitamin A supplementation in the past 6 months, then give a single dose. ‡ The child may develop vomiting, headaches, or nausea after taking vitamin A. Reassure the mother that should this symptoms develop, they will disappear within 24 hours. ‡

In this exercise you will determine whether the child needs Vitamin A supplementation or not. Make a check on the appropriate column. You will give Vitamin A to a child: 1. Who is 36 months old, has no illness classification , not a very low weight and no anemia. The last dose of Vitamin A was 4 months ago 2. Who is 7 months old, has no pneumonia, and is up-todate with immunization 3. Who is 10 months old, has had measles vaccination but no Vitamin A. YES NO

‡ The last box on the ASSESS side of the chart reminds you to assess other problems that the child may have. ‡ Since the ASSESS AND CLASSIFY chart does not address of a sick child s problems, you will now assess other problems that the mother told you. ‡ For example, she may have said the child has a skin infection, itching, swollen neck glands. ‡ Identify and treat other problems according to your training, experience and health center policy. ‡ Refer the child for any problem you cannot manage in the health center.

NO 1.0 Determine if urgent referral is needed

2.0 Identify patient who do not need urgent referral

YES 3.0 Identify urgent prereferral treatment needed

4.0 Give pre-referral treatment

5.0 Refer the child

1.0 DETERMINE IF URGENT REFERRAL IS NEEDED a. Referral for severe classification ‡ Look at the severe classifications on the ASSESS AND CLASSIFY chart. These are colored pink and include: SEVERE PNEUMONIA OR VERY SEVERE DISEASE SEVERE DEHYDRATION SEVERE PERSISTENT DFIARRHEA VERY SEVERE FEBRILE DISEASE/MALARIA SEVERE COMPLICATED MEASLES SEVERE DHF MASTOIDITIS SEVERE MALNUTRITION OR SEVERE ANEMIA

b. Referral for the General Danger Signs ‡ Most of children who have a general danger sign also have a severe classification ‡ They will be referred for their severe classification c. Referral for Other Severe Problems ‡ The ASSESS AND CLASSIFY chart does not include all problems that children may have ‡ For any other severe problem that cannot be treated at the health center, you will need to refer the child.

2.0 IDENTIFY TREATMENTS WHO DO NOT NEED URGENT REFERRAL ‡ Look at the ASSESS AND CLASSIFY chart to find the treatments needed for each of the classification. ‡ List each treatment needed on the back of the Sick Child Recording Form.

3.0 IDENTIFY URGENT PRE-REFERRAL TREATMENT NEEDED ‡ When a child needs urgent referral, you must quickly identify and begin the most urgent treatments for the child. ‡ The following are urgent treatments. They are in bold print on the ASSESS AND CLASSIFY chart. You will give just the first dose of drugs before referral:

‡ Give an appropriate antibiotic: Give Quinine for SEVERE MALARIA Give Vitamin A Treat the child to prevent low blood sugar(This involves giving breastmilk, milk, or sugar water as described on the TREAT the child chart). Start IV fluids according to Plan C for the child for severe DHF with bleeding or cold clammy skin or capillary refill more than 3 seconds Give ORS according to Plan B for a child with SEVERE DHF severe with petechiae or a positive torniquet test or abdominal pain or vomiting but without cold clammy skin and with normal capillary refill. Give an oral antimalarial Give paracetamol for high fever(38.5°C or above) or pain from MASTOIDITIS Apply tetracycline eye ointment if there is clouding of the cornea and pus draining from eye. Provide ORS solution so that the mother can give frequent sips on the way yo the hospital

4.0 GIVE URGENT PRE-REFERRAL TREATMENTS ‡ How-to-do treatments are presented on the TREAT chart. ‡ When referring a child, do the treatment quickly. 5.0 REFER THE CHILD ‡ Do the 4 steps to refer a child to the hospital: 1. Explain to the mother the need for referral 2. Calm the mother s fear s and help her resolve any problems 3. Write a referral note for the mother to take with her to the hospital 4. Give the mother any supplies and instructions needed to care for her child on the way to the hospital

‡ Give an Appropriate Oral Antibiotic  For Pneumonia First Line Antibiotic: Amoxicillin Second-Line Antibiotic: Cotrimoxazole  For Diarrheal Diseases Ciprofloxacin is the most appropriate drug in place of Nalidixic Acid Giving Zinc supplements in the management of diarrhea

For Antimalarial: First-Line Antibiotics: ArtemeterLumefantrine ‡ Chronic ear infection should be treated with optical quinolone ear drops for at least 2 weeks in Addition to dry the ear by wicking ‡ Acute ear infection Oral amoxicillin is a better choice for the management of suppurative otitis 

‡ Treat Eye Infection with Tetracycline Eye Ointment ‡ Treat Mouth Ulcers with Gentian Violet  Give paracetamol for high fever or Ear Pain Home Management: -teach the mother how to give oral drugs at home -teach the mother how to treat local infections at home(eye infection with tetracycline ointment; mouth ulcers with gentian violet)

Treatment in the Health Center -IM antibiotics -Quinine for severe malaria -Immunization

‡ Counsel the mother includes assessing how the child is fed and telling her about the foods and fluids to give the child and when to bring the child back to the health center.

‡ Advise the mother to return immediately if the child has any of these signs:
Any sick child

‡Not able to drink or breastfeed ‡Becomes sicker ‡Develops a fever ‡Fast breathing ‡Difficult breathing ‡Blood in stool ‡Drinking poorly

If the child has no PNEUMONIA: COUGH OR COLD, also return if: If the child has diarrhea, also return if:

If the child has FEVER: ‡Any sign of bleeding DENGUE HEMORRHAGIC ‡Persistent abdominal pain FEVER UNLIKELY, also return if: ‡Persistent vomoting ‡Skin petechiae,skin rash

If the child has: Pneumonia Dysentery Malaria, if fever persist Fever: Malaria unlikely, if fever persisit Fever: No Malaria if fever persist Measles with eye or mouth complications DHF Unlikely, if fever persist Persistent Diarrhea Acute Ear Infection Chronic Ear Infection Feeding Problems Any Other Illness if not improving Anemia Very Low Weight For Age

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