The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Suzanne Y. Cañete

What is IMCI?
A strategy for reducing mortality and morbidity associated with major causes of childhood illness A joint WHO/UNICEF initiative since 1992

DOH Essential Package of Child Survival Interventions  

    

Skilled attendance during pregnancy, childbirth and the immediate postpartum Care of the newborn Breastfeeding and complementary feeding Micronutrient supplementation Immunization of children and mothers Integrated management of sick children Use of insecticide treated bed nets (in malarious areas)

What is IMCI?

According to the World Bank, the IMCI likely to have the greatest impact in reducing the global burden of disease

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Designed to teach integrated management of sick infants and children to first level HWs in primary care settings that have NO laboratory support and only a limited number of essential drugs .

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Action-oriented CLASSIFICATIONS. rather than EXACT DIAGNOSES. are used .

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Using few CLINICAL SIGNS as possible which health workers of diverse background can be trained to recognize .

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Case Management Process .

IMCI Case Management 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 .

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Assess and Classify the Sick Child age 2 months up to 5 years Management of the Sick Young Infant Age 1 week up to 2 months .

yellow.The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Classifying the Illness Most have three rows Each row is colored either pink. or green .

needs urgent attention and referral or admission for inpatient care .a severe classification .The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Classifying the Illness PINK .

an oral antimalarial. or other treatment .includes home teaching to mother .The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Classifying the Illness YELLOW .child needs an appropriate antibiotic.

includes home teaching to mother .child does not need specific medical treatment .The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Classifying the Illness GREEN .

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS Classifying the Illness Always start with the top row A child receives only one classification Always select the more serious classification .

up in two days If coughing more than 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 COLDS .Classifying the Illness Cough or difficult breathing SIGNS Any general danger sign or Chest Indrawing or Stridor in calm child Fast breathing CLASSIFY AS SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA TREATMENT Give first dose of an appropriate antibiotic Give Vitamin A Treat the child to prevent low blood sugar Refer URGENTLY to hospital Give an appropriate antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advise the mother when to return immediately Follow.

The INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ***Decide which age group the child is in How to select the appropriate case .

Assess And Classify The Sick Child Aged 2 Months Up To 5 Years .

Ask the mother what the child¶s problems are ‡ Determine child¶s age ‡ Determine if this is an initial or followfollow-up visit for this problem .

Check for General Danger Signs ‡ Ask ± Is the child not able to drink or breastfeed? ± Does the child vomit everything? ± Has the child had convulsions? ‡ Look ± Child is abnormally sleepy or difficult to awaken? .

complete the rest of the assessment IMMEDIATELY. ‡ There must be no delay in the treatment .Check for General Danger Signs ‡ If the child has a general danger sign.

Ask about Main Symptoms ‡ Does the child breathing? ‡ Does the child ‡ Does the child ‡ Does the child have cough or difficult have diarrhea? have fever? have an ear problem? .

no fat ± Outline of ribs easily seen ± Hips small when compared to chest and abdomen ± Fat of the buttocks is missing ± Abdomen large or distended .Assess for Malnutrition and Anemia ‡ Visible and severe wasting ± Thin.

Visible. severe wasting .

severe wasting .Visible.

Assess for Malnutrition and Anemia ‡ Look for edema of both feet .

Assess for Malnutrition and Anemia ‡ Look for palmar pallor .some palmar pallor (pale) .severe palmar pallor (very pale that the palm looks white) .

Palmar pallor

Palmar pallor

Palmar pallor

‡ Determine weight for age

. follow. If feeding problem. Advise mother when to return immediately Not very low weight for age and no other signs of malnutrition NO ANEMIA AND NOT VERY LOW WEIGHT If the child is less than 2 years old. -Follow-up in 30 days. follow. assess the child¶s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. If some pallor: -Give iron. If very low weight for age: -Give Vitamin A.up in 5 days.Classify Nutritional Status SIGNS Visible severe wasting or Edema of both feet or Severe palmar pallor CLASSIFY AS SEVERE MALNUTRITION OR SEVERE ANEMIA ANEMIA OR VERY LOW WEIGHT TREATMENT Give Vitamin A Refer URGENTLY to hospital Some palmar pallor or Very low weight for age Assess the child¶s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. -Follow. -If feeding problem.up in 14 days.up in 5 days. -Give Mebendazole if child is 2 years or older and has not had a dose in the previous 6 months. Advise mother when to return immediately.

Check the Child¶s Immunization Status Birth 6 weeks 10 weeks 14 weeks 9 months BCG. Hep B-2 DPT-2. OPV-1. OPV-2 DPT-3. OPV-3. Hep B-3 Measles . Hep B-1 DPT-1.

Check the Child¶s Immunization Status Three contraindications: -BCG to a child known to have AIDS -DPT 2 or 3 to a child who has had convulsions or shock within 3 days of most recent dose -DPT to a child with recurrent convulsions or another active neurological disease of the central nervous system .

.Check the Child¶s Immunization Status There are no contraindications to immunization of a sick child if the child is well enough to go home.

.Check the Child¶s Vitamin A Status VITAMIN A SUPPLEMENTATION SCHEDULE: First dose at 6 months or above Subsequent doses every 6 months.

000 IU of Vitamin A every six months up to the age of 59 months .000 IU of Vitamin A Subsequent doses: 200.Check the Child¶s Vitamin A Status Initial dose: 100.

Assess child¶s feeding (has ANEMIA OR VERY LOW WEIGHT OR < 2 YEARS OLD) ‡ Ask ± Do you breastfeed your child? ‡ How many times during the day? ‡ Do you also breastfeed during the night? .

Assess child¶s feeding ‡ Ask ± Does the child take any other food or fluids? ‡ What foods or fluids? ‡ How many times during the day? ‡ What do you use to feed the child? ‡ If low weight for age: How large are the servings? ‡ Does the child receive his own serving? Who feeds the child and how? .

has the child¶s feeding changed? If yes. how? .Assess child¶s feeding ‡ Ask ± During this illness.

Compare the mother¶s answers to the Recommendations for Care and Development for child¶s age .Assess care for development ‡ Ask questions about how mother cares for her child.

Assess care for development ‡ Ask ± How do you play with your child? ± How do you communicate with your child? .

Assess other problems. .

IDENTIFY TREATMENT .

Outline ‡ Determine if urgent referral is needed ‡ Identify treatments needed ‡ For patients who need urgent referral: ² Identify the urgent pre-referral treatments ² Explain the need for referral to the mother ² Writing the referral note .

0 Identify urgent prereferral treatment needed 4.0 Determine if urgent referral is needed Yes 3.0 Give prereferral treatment 5.0 Identify treatment for patient who do not need urgent referral No 1.Flow chart of Identifying Treatment 2.0 Refer the child .

DETERMINE IF URGENT REFERRAL IS NEEDED .

DETERMINE IF URGENT REFERRAL IS NEEDED Referral for Severe Classifications ‡ Severe Pneumonia or very severe disease ‡ Severe Dehydration ‡ Severe Persistent Diarrhea ‡ Very Severe Febrile Disease/ Malaria ‡ Very Severe Febrile Disease .

DETERMINE IF URGENT REFERRAL IS NEEDED Referral for Severe Classifications ‡ Severe Complicated Measles ‡ Severe Dengue Hemorrhagic Fever ‡ Mastoiditis ‡ Severe Malnutrition or Severe Anemia .

refer the child .Exceptions ‡ Severe Persistent Diarrhea ‡ Severe Dehydration If the child·s only classification is SEVERE DEHYDRATION. use Plan C to decide whether to refer the child If the child has another classification in addition to Severe Dehydration.

Referral for General Danger Signs ‡ Make sure child with any general danger sign is referred after first dose of an appropriate antibiotic and other urgent treatments .

severe classifications. or other severe problems MEANS (-) urgent referral to a hospital .Remember (-) general danger signs.

IDENTIFY TREATMENTS FOR PATIENTS WHO DO NOT NEED URGENT REFERRAL .

Identify Treatment ‡ List only the treatments that apply to the specific child being treated ‡ Include items for follow-up ‡ If several different times are specified for follow-up. you will look for the earliest definite time .

CHECKPOINT!!! 1 follow up in 2 days 2 follow up in 5 days 5 follow up in 5 days if not improving 3 follow up in 30 days 4 follow up in 2 days if fever persists .

IDENTIFY and GIVE URGENT PREPREREFERRAL TREATMENT NEEDED .

PrePre-referral Treatment ‡ ‡ ‡ ‡ Give an appropriate antibiotic Give Quinine for SEVERE MALARIA Give Vitamin A Treat the child to prevent low blood sugar .

PrePre-referral Treatment ‡ Start IV fluids according to Plan C for child with severe dengue hemorrhagic fever with bleeding or cold clammy skin or capillary refill more than 3 seconds .

PrePre-referral Treatment ‡ Give ORS according to Plan B for a child with SEVERE DENGUE HEMORRHAGIC FEVER severe with only petechiae or a positive tourniquet test or abdominal pain or vomiting but without cold clammy skin and with a normal capillary refill time .

PrePre-referral Treatment ‡ Give an oral antimalarial ‡ Give paracetamol for high fever (38.5°C or above) or pain from MASTOIDITIS ‡ Apply Tetracycline eye ointment if clouding of the cornea and pus draining from eye ‡ Provide ORS solution so that the mother can give frequent sips on the way to the hospital .

REFER THE CHILD .

Refer the child ‡ Explain to the mother the need for the referral. and get her to agree ‡ Calm the mother·s fears and help her resolve any problems .

TREAT THE CHILD .

V. III. .Outline I. Select the appropriate oral drug and determine dose and schedule Use good communication skills Teach the mother to give oral drugs at home Local Treatments Health Center Treatments II. IV.

COUNSEL THE MOTHER .

OUTLINE ‡ FEEDING RECOMMENDATIONS ‡ CARE FOR DEVELOPMENT ‡ WHEN TO RETURN ‡ MOTHER¶S OWN HEALTH .

FEEDING RECOMMENDATIONS ‡ Exclusive breastfeeding ‡ Complementary foods .

Sick child: FEEDING PROBLEMS Difficulty breastfeeding Using of feeding bottle Lack of active feeding Not feeding well during illness Not giving protein source of food in lugaw or rice Improper handling and use of breastmilk substitute .

Sick child: FEEDING PROBLEMS Teaching Correct Positioning and Attachment for Breastfeeding SIGNS OF GOOD ATTACHMENT: chin touching breast mouth wide open lower lip turned outward more areola visible above than below the mouth .

Good attachment? A B .

Good attachment? A B .

SIGNS OF GOOD POSITIONING: Infant¶s neck is straight or bent slightly back Infant¶s body is turned towards the mother Infant¶s body is close to the mother Infant¶s whole body is supported .Sick child: FEEDING PROBLEMS Poor ATTACHMENT can be influenced by proper POSITIONING of the young infant during breastfeeding.

Good position? A B .

Good position? A B .

CARE FOR DEVELOPMENT Common Problems: ‡ Mother cannot breastfeed ‡ Mother does not know what her child does to play or communicate ‡ Mother feels she does not have enough time to provide care for development .

Common Problems Mother has no toys for her child to play with Child is not responding. or seems ³slow´ Child is being raised by someone other than the mother .

When to return Follow-up visit in a specific number of days Immediately. if signs appear that suggest the illness is worsening For the child¶s next immunization .

When to return immediately ‡ Any sick child: ² Not able to drink or breastfeed ² becomes sicker ² Develops a fever .

When to return immediately ‡ If child has NO PNEUMONIA: COUGH OR COLD. also return if: ² Fast breathing ² Difficult breathing .

When to return immediately ‡ If child has diarrhea. also return if: ² Blood in the stool ² Drinking poorly .

When to return immediately ‡ If child has FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY. also return if: ² ² ² ² ² Any sign of bleeding Persistent abdominal pain Persistent vomiting Skin rashes Skin petechiae .

Give Follow up Care .

THANK YOU! .

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