Integrated Management of Childhood Illness

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

Causes of 10.5 million deaths among children < 5 in developing countries, 1999
Pneumonia 19%
One in every two child deaths in developing countries are due to just five infectious diseases and malnutrition

perinatal 20% Malnutrition 54%
Others 28%

Diarrhoea 15%

Measles 8% HIV/AIDS Malaria 7% 3%

Source: EIP/WHO, 1999 data

Important Elements for Improving Child Health
Improve case management of sick children Improve nutrition Ensure immunization Prevent injuries Prevent other diseases Improve psychosocial support and stimulation

Too many different pieces
Case management Drug Use Malaria Appropriate Care seeking Anemia HIV/AIDS New born care Home care


Child rights


Health system

Mothers health

Safe and Supportive Communication Environment


IMCI brings it all together Improving health workers¶ skills Strengthening health system Improving family and community practices .

.At the start of a sick child (2 months to 5 years) consultation Ask the mother what the child s problems are. Determine if this is an initial or followup visit for this problem.

IMCI Approach Classification Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Need to Refer Specific treatment Home management Treatment Identify treatment Treat Counsel & Follow-up Counsel caretakers Follow-up .

Convulsions. or Look: Abnormally sleepy or difficult to awaken Need to Refer (except in severe dehydration) .Check for general danger signs Ask: Not able to drink or breastfeed. Vomits everything.

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 .

o.Plan C: To treat dehydration quickly Oresol/NGT NO Oresol p. NO URGENT REFERRAL .

Classify for dehydration 2 of the following:  Restless. irritable  Sunken eyes  Skin pinch goes back slowly SOME DEHYDRATION Plan B .

use this chart. or if weight is unknown. Age Amount 12< 4 mos mos-2 yrs 200-400 700-900 4-12 yrs 2-5 mos 900-1400 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.

If the child develops puffy eyelids.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. Continue breastfeeding if the child wants to breastfeed. Then continue. wait for 10 minutes. but more slowly. . stop ORS.

Begin feeding the child in the health center. Select appropriate plan. .Plan B: Treat some dehydration with ORS After 4 hours: Reassess the child & classify for dehydration.

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 2 -4 yrs 50 100 100 ml after each LBM 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 37.5°C or above) Malaria risk? Measles now or w/in last 3 mos Dengue risk? .

or 6 mos Blood transfusion .Fever: Ask about malaria risk Residing in endemic area? OR: Travel & overnight w/in past stay in endemic area.

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

Paracetamol Urgent referral .Malaria risk + any general danger sign or stiff neck Very severe febrile disease/malaria Quinine (under med. supervision) 1st dose of antibiotic.

Malaria risk +. blood smear + No runny nose. no measles Malaria Oral antimalarial Paracetamol Follow up in 2 days > 7 days fever hospital for assessment .

No malaria risk Any general danger sign or stiff neck Very severe febrile disease 1st dose of antibiotic. Paracetamol Urgent referral .

Vitamin A Urgent referral .Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers Severe complicated measles 1st dose of antibiotic.

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 .

but fever > 3 days Tourniquet test . nose.If there is Dengue risk Bleeding gums. in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs.

persistent abdominal pain or vomiting. or + tourniquet test only signs.Any of the danger signs or + tourniquet test Severe Dengue hemorrhagic fever If skin petechiae. give ORS Any other signs of bleeding Plan C Urgent referral 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 .

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 & Albendazole Wt for age very low: Vitamin A .

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