INTEGRATED MANAGEMENT OF

CHILDHOOD ILLNESSES
Part 3
March 6, 2007
San Juan, Batangas
Teri Laude, MD
 1. ask
ASSESS 2. look

Home

CLASSIFY HEALTH CENTER/CLINIC

HOSPITAL/EMERGENCY ROOM

IDENTIFY
TREATMENT
 MALARIA
 Caused by parasites in the blood or plasmodia
carried by anophiline mosquitoes
 Most dangerous P. falciparum
 Symptoms:
 Fever*
 Shivering
 Sweating
 Vomiting
 Signs of malaria can overlap with signs of other
illnesses
 Uncomplicated malaria--> complicated malaria
(cerebral malaria or severe anemia) in 24 hours
fever
 Batangas belongs to Category C of provinces
 MALARIA
Category A: Category D:
• Kalinga Apayao •Cebu
• •Bohol
Mt Province
•Catanduanes
• Ifugao
•Aklan
• Isabela •Capiz
• Cagayan •Guimaras
• Quirino •Siquijor
• Zambales •Biliran
• Mindoro Occidental •Leyte Norte/Sur
• Palawan •Nothern Samar
• Quezon •Camiguin
• Misamis Oriental
• Davao del Norte/Sur/Oriental Risk for MALARIA:
• Bukidnon  fever in a no malaria area who have
• Compostela Valley
• Sarranggani traveled
• Zamboanga del Sur to and stayed overnight in a malaria area in
• Agusan del Sur/Norte the past 4 weeks or who had blood
• Surigao del Sur
• Tawi-tawi
transfusion during the past 6 months
• Sulu * Ask ALL CHILDREN with fever in no malaria
• Basilan risk area
 MEASLES
 Viral and highly infectious
 Risk factors: overcrowding and poor housing, affects
children 6mon-2 years old
 Infects the skin & layers of cells that line the lung, gut, eye,
mouth, and throat
 Damages the immune system for many weeks after the
onset of illness, leaving the child prone to other infections
 Complications:
 Diarrhea (including dysentery, persistent diarrhea
 Pneumonia
 Stridor
 Mouth ulcers
 Ear infection
 Sever eye infection (worsen to corneal ulceration/blindness)
 Encephalitis
 Contributes to malnutrition--> severe complications
 DENGUE HEMORRHAGIC FEVER
 Viral spread by Aedes mosquitoes
 Causes damage to blood & blood vessels--> bleeding
 Like malaria it occurs in particular places/seasons
 All regions of the country are ENDEMIC for dengue and childrewn
are at risk everyday of the year
 Signs and symptoms:
 duration of fever- 2-7 days
 Petechiae (skin)
 Internal hemorrhage (inside the body)
 Bleeding MOUTH, NOSE
 Vomit BLACK FLUID
 Passs BLACK STOOLS
 Most sever signs occur 2 days fever has disappeared
 Management depends on:
 (+)/(-) signs of BLEEDING
 (+)/(-) SHOCK
 May Lagnat ba ang bata?
1. History
2. Mainit ang pakiramdam
3. T ≥ 37.5C
Risk sa Malaria (1/2) => blood smear:
1. Nakatira ba ang bata sa lugar na may malaria?
2. Naglagi ba ang bata magadamag sa lugar na may
malaria sa loob ng 4 na linggo.

Tingnan at suriin:
Itanong:
1. Matigas ang leeg
1. Sipon
2. Gaano katagal na nilalagnat ang bata?
2. Senyales
3. Kung ≥ 7ng araw, araw-araw bang nilalagnat?
tigdas
3. a.
Nagkaroon
Pamamantalna bangng tigdas/measles
buong katawan ang
bata
b. sa sipon,
Ubo, loob ngnamumulang
3 buwan? mga mata
 May Lagnat ba ang bata?
Kung ang bata ay may tigdas/nagkatigdas sa loob ng 3 buwan
Tingnan ang mga sumusunod:
1. may mga singaw sa bibig (malalim/marami)
2. may nanang nagmumula sa mga mata
3. May panlalabo ng cornea ng mata

Suriin kung may dengue hemorrhagic fever ang bata

Tingnan at pakiramdaman:
Itanong kung ang bata ay may mga sumusunod na senyales:
1. Pagduduo ng ilong o gilagid
1. Pagdudugo ng ilong o gilagid o sa suka o sa dumi
2. Petechiae/ pamumula ng balat
2. Itim na isinuka
3. Cold clammy/ panlalamig ng mga kamay at binti
3. Itim na dumi
4. slow capillary refill
4. Tuloy-tuloy na pananakit ng tiyan
5. Tourniquet test
5. Tuloy-tuloy na pagsusuka
 CLASSIFICATION OF FEVER
A. Malaria Risk
SIGNS CLASSIFY AS TREATMENT
Any general  give first dose of QUININE *
danger sign  give first dose of an appropriate antibiotic
OR  treat the child to prevent low blood sugar
Stiff neck
Very severe
 give one dose of paracetamol in LHC for
febrile disease/ high fever (T≥38.5C)
malaria Send a blood smear with the patient
Refer URGENTLY to hospital
Blood smear (+) Treat the child with oral antimalarial
NO runny nose; and Give one dose of paracetamol in LHC for high fever
Malaria ≥ 38.5C
NO measles; and Advise mother when to return immediately
NO other causes of Follow-up in 2 days if fever persists
fever If fever is present dailiy ≥7 days refer for assessment

Blood smear (-) or Give one dose of paracetamol in LHC for high fever
Advise mother when to return immediately
Runny nose or Fever: Follow-up in 2 days if fever persists
Measles or Malaria If fever present daily ≥7days refer for assessment
Treat for other causes of fever
Other causes of fever unlikely
 Teach the mother to give oral drugs at home
Give an oral antimalarial
First-line antibiotic: chloroquine, primaquine, sulfadoxine and pyrimethamine
Second-line antibiotic: arthemether-lumefrantine
age Chloroquine Primaquine Primaquine Sulfadoxine+
(150mgbase/tab) (15mg base /tab) (15mg base /tab) pyremethamine
*give for 3 days * Give single •Give daily for 14 (500mg+ 25mg/tab)
dose in LHC for days for *give single dose in
P falciparum P vivax LHC
2 -5 mons (4- D1 1/2; D2 1/2; D3 1/2 1/4
<7 kgs)

5-12mons D1 1/2; D2 1/2; D3 1/2 1/2

(7-<10
kgs)

12mon- 3 yrs D1 1; D2 1; D3 1/2 1/2 1/4 3/4

(10-<14
kgs)

3-5 years D1 1 1/2; D2 1 1/2; D3 1 3/4 1/2 1

(14-19
kgs)
 IMCI: The Sick Child age 2 months-5 years
Give an appropriate oral antibiotic for severe disease:
First line antibiotic: Cotrimoxazole
Second line antibiotic: Amoxycillin

COTRIMOXAZOLE AMOXYCILLIN
Give 2 times daily for 5 days Give 3 times daily for 5 days
AGE OR ADULT TABLET SYRUP TABLET SYRUP
WEIGHT 80 mg trimethoprim + 40 mg trimethoprim + 250 mg 125 mg per 5 ml
400 mg 200 mg
sulfamethoxazole sulfamethoxazole

2 – 12 months 1/2 5.0 ml 1/2 5 ml

(4-10 kg)

12 months – 5 1 10.0 ml 1 10 ml
years (10-19 kg)
 Teach the mother to give oral drugs at home
Give paracetamol for HIGH fever (≥38C)

Age or weight Paracetamol Paracetamol

500mg/tab syrup
120mg/5ml
2 mon- 3 years 1/4 5ml
(4-<14kgs) (1 tsp)

3 -5 years 1/2 10ml

(14-<19kgs) (2 tsp)
 IMCI: The Sick Child age 2 months-5 years

Treat the child to prevent low blood sugar:

 If the child is able to breastfeed: Ask the mother to

breastfeed the child
 If the child is not able to breastfeed but is able to swallow
Give expressed breastmilk or a milk formula
If neither is available, give sugar water
Give 30-50 ml of milk or sugar water before departure.

To make sugar water: Dissolve 4 level teaspoon of sugar

in a 200 ml cup of clean water
 CLASSIFICATION OF FEVER
B. No Malaria Risk
SIGNS CLASSIFY AS TREATMENT
Any general give one dose of an appropriate antibiotic
danger sign  treat the child to prevent low blood sugar
Very severe
OR  give one dose of paracetamol in LHC for
Stiff neck febrile disease high fever (T≥38.5C)
Refer URGENTLY to hospital
No signs of very Give one dose of paracetamol in LHC for high fever
severe febrile disease Advise mother when to return immediately
Fever: Follow-up in 2 days if fever persists
No Malaria If fever present daily ≥7days refer for assessment
Treat for other causes of fever
 CLASSIFICATION OF FEVER
If the child has Measles now or within the last 3 months
SIGNS CLASSIFY AS TREATMENT
Clouding of  give vitamin A
cornea or Severe  give first dose of an appropriate antibiotic
Deep extensive Complicated  if clouding of the cornea or pus draining
mouth ulcers
Measles *** from the eye, apply tetracycline eye ointment
Any danger sign Refer URGENTLY to hospital
Pus draining from the Give vitamin A
eye or Measles witheye If pus draining from the eye, apply tetracycline eye
or mouth ointment
Mouth ulcers
If mouth ulcers, teach the mother to treat with gentian
Complications** violet
* Follow-up in 2 days
Advise mother when to return immediately
Measles now or within Give vitamin A
the last 3 months Advise the mother when to return immediately
Measles
 Teach the mother to give oral drugs at home
Give Vitamin A

Age Vitamin A caps Vitamin A caps

(100,000 IU) (200,000 IU)
6 -12 mons 1 1/2

12 mons-5 years - 1

Treatment: give one dose in the LHC

Supplementation: give one dose in the LHC if

a) child is 6 mons of age or older
b) child has not received a dose of Vitamin A in the past 6 mon
 CLASSIFICATION OF FEVER
Assess for Dengue Hemorrhagic Fever
SIGNS CLASSIFY AS TREATMENT
Bleeding from nose or If persistent vomiting or persistent abdominal
gums, or pain, or skin petechiae, or positive Tourniquet
Bleeding in stools or test are the only POSITIVE signs; give ORS
vomitus, or (PLAN B)
Black stools or Severe If any other signs of bleeding are positive,
vomitus, or
Skin petechiae, or
Dengue give fluids rapidly as in PLAN C
Cold clammy Hemorrhagic treat the child to prevent low blood sugar
extremities, or Refer all children URGENTLY to hospital
Capillary refill time ≥ Fever DO NOT GIVE ASPIRIN
3secs, or
Persistent abdominal
pain, or
Persistent vomiting, or
Tourniquet test (+)

Fever: Advise mother when to return immediately

No signs of severe Follow-up in 2 days if fever persists or
dengue hemorrhagic Dengue
child shows signs of bleeding
fever Hemorrhagic DO NOT GIVE ASPIRIN
Fever unlikely
 Plan C: Treat Severe Dehydration Quickly
•START IV FLUID IMMEDIATELY
AGE First give Then give
30ml/kg in 70ml/kg in
Can you give IV fluid
YES Infants under 1 hour* 5 hours
immediately?
12months
12months - 30 min 2 ½ hours
5 years

*Repeat once if radial pulse is stil very weak or not detectable

•Reassess the child every 1-2 hrs. If hydration
NO status is not improving, give the IV drip more
rapidly.
•Also give ORS (about 5 ml/kg/hr as soon as the
child can drink usually after 3-4 hours (infants) or
1-2 hours (children)/
•Reassess an infant after 6 hours and a child
after 3 hours. Classify dehydration then choose
the appropriate plan (A, B or C) to continue
treatment.
 Plan C
•Refer URGENTLY to hospital for IV treatment
Is IV treatment
available nearby (within YES •If the child can drink, provide the mother with
ORS solution and show her how to give frequent
30 minutes)?
sips during the trip;.

NO •Start rehydration by tube (or mouth) with ORS

solution Give 20 ml/kg/hr for 6 hours (total of 120
mg/kg)

Are you trained to use
NGT for rehydration?
YES
NO
Can the child drink?
•Reassess the child every 1-2 hours
•If there is repeated vomiting or increasing
abdominal distension, give fluid more slowly
•If hydration status is not improving after 3
hours, send the child for IV therapy.
•After 5 hours, reassess the child. Classify
dehydration then choose the appropriate plan
(A,B,C) to continue treatment.

Refer URGENTLY to hospital for IV

NO or NG treatment
 Plan B: Treat Some Dehydration with ORS
Give in the health center recommended amount of ORS over 4-hour
period:

 DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS:

AGE Up to 4 4 -12 12 months 2 – 5 years

months months to 2 years

WEIGHT < 6kg 6 to <10 kg 10 to <12kg 12-19 kg

ORS to give 200-400 400-700 700-900 900-1400

(in ml)

Use the child’s age only when you do not know the weight. The approximate
amount of ORS required (in ml) can also be calculated by multiplying the child’s
weight (in kg) by 75.
 Plan B
 DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4
HOURS
 If the child wants more ORS than show, give more
 For infants under 6 months who are not breastfed, also give 100-
200 ml clean water during this period.

 SHOW THE MOTHER HOW TO GIVE ORS.

 Give frequent small sips from a cup.
 If the child vomits, wait 10 minutes, then continue, but more
slowly
 Continue breastfeeding whenever the child wants.

 AFTER 4 HOURS
 Reassess the child and classify the child for dehydration.
 Select the appropriate plan to continue treatment.
 Begin feeding the child in the health center.
 Plan B
 DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4
HOURS
 SHOW THE MOTHER HOW TO GIVE ORS.
 REASSESS AFTER 4 HOURS
 IF THE MOTHER MUST LEAVE BEFORE COMPLETING
TREATMENT:
 Show her how to prepare ORS solution at home
 Show her how much ORS to give to finish the 4-hour treatment at
home.
 Give her enough ORS packets to complete rehydration. Also give
her 2 packets as recommended in Plan A.
 Explain the 4 rules of Home Treatment
 GIVE EXTRA FLUIDS
 GIVE ZINC SUPPLEMENTS
 CONTINUE FEEDING
 WHEN TO RETURN
 Give follow-up care MALARIA
care for the child who returns for follow-up using all the boxes that
match the child’s previous classification
If the child has any new problem, assess, classify and treat the new
problem as in ASSESS & CLASSIFY chart
If fever persists after 2 days, or returns within 14 days:
Do a full assessment of the child

Treatment:
1) If the child has any general danger sign or stiff neck, treat as very
severe febrile disease/malaria
2) If the child has any cause of fever other than malaria, provide
treatment
3) If malaria is the only apparent cause of fever
 Take a blood smear
 Give 2nd-line antimalarial w/o waiting for result of blood smear
 Advise mother to return if fever persists
 If fever persists after 2 day treatment with 2nd-line oral antimalarial, refer with
blood smear for reassessment
 If fever has been present for 7 days, refer for assessment
 Give follow-up care
Fever-Malaria Unlikely
If fever persists after 2 days
Do a full assessment of the child

Treatment:
1) If the child has any general danger sign or stiff neck, treat as very
severe febrile disease/malaria
2) If malaria is the only apparent cause of fever
 Take a blood smear
 Treat with the 1st-line oral antimalarial,
 Advise mother to returnin 2 days if fever persists
 If fever has been present for 7 days, refer for assessment
 Give follow-up care
Fever (no Malaria)

If fever persists after 2 days

Do a full assessment of the child
Make sure that there has been no travel to malarious area & overnight
stay in malaria area
If there has been travel and overnight stay take blood smear, if possible

Treatment:
1) If there has been travel & overnight stay malaria area- blood smear
(+) or there is no blood smear-> classify accdg to FEVER WITH
MALARIA RISK and treat accordingly
2) If there has been no travel or blood smear (-):
 if the child has any general danger sign or stiff neck, treat as very severe
febrile disease
 If the child has any apparent cause of fever, provide treatment
 If no apparent cause of fever, advise the mother to return again in 2 days if
fever persists
 If fever has been present for 7 days, refer for assessment
 Give follow-up care
Measles with eye or mouth complications

After 2 days:
Look for red eyes and pus draining from the eyes
Look at the mouth ulcers
Smell the mouth

Treatment for eye infection:

1) If pus draining from the eye, ask the mother previous treatment. If treatment
correct, refer to hospital. If treatment incorrect, teach mother correct
treatment
2) If pus gone but redness remains, continue the treatment
3) If no pus or redness, stop the treatment

Treatment for mouth ulcers:

1) If mouth ulcers are worse, or there is a very foul smell from the mouth, refer
to hospital
2) If mouth ulcers are the same or better, continue using half-strength gentian
violet for a total of 5 days
 Give follow-up care
Fever: Dengue Hemorrhagic Fever unlikely

if fever persists after 2 days:

Do a full assessment of the child
Do a tourniquet test
Assess for the other causes of fever

Treatment:
1) If the child has any general danger signs of bleeding, including skin petechiae
or a positive tourniquet test, or signs of shock, or persistent abdominal pain
or persistent vomiting, refer to HOSPITAL
2) If the child has any other apparent cause for fever, provide treatment
3) If fever has been present for 7 days, refer for assessment
4) If no apparent cause of fever, advise the mother to return daily until the child
has had no fever for at least 48 hours
5) Advise mother to make sure child is given more fluids and is eating
 CASE 2: Darwin
Darwin is 3 years old. He weighs 9.4 kg. His temperature is 37C. His
mother says he feels hot. He has a cough, she says.
The health worker checked for general danger signs. Darwin was able
to drink, had not vomited, did not have convulsions, and was not
abnormally sleepy or difficult to awaken.
The mother said Darwin had been coughing for 3 days. The health
worker counted 51 breaths per minute. He did not see chest
indrawing. There was no stridor when Darwin was calm.
Darwin does not have diarrhea.
The health worker also thought that Darwin felt hot. He assessed the
child for further signs of fever. There is risk of malaria. He has felt
hot for 5 days, the mother said. He has not had measles within the
last 3 months. He did not have a stiff neck, there was no runny
nose, and no generalized rash. It was not possible to take a blood
smear. There is no sign suggesting DHF.
Record the child’s signs and classify them on the Recording Form
 Case 3: Letty
Letty is 5 months old. She weighs 5 kg. Her temperature is 36.5C. Her family
brought her to the health center because she feels hot and has a cough for
2 days. She is able to drink. She has not vomited or had convulsions, and
is not abnormally sleepy or difficult to awaken
The health worker said,”I’m going to check her cough now.” The health worker
counted 43 breaths per minute. There was no chest indrawing and no
stridor when Letty was calm.
Letty did not have diarrhea.
“Now , I will check her fever,” said the health worker. Her mother said, “Letty
has felt hot off and on for 2 days.” She had not measles within the last 3
months. She does not have stiff neck or runny nose.
Letty has generalized rash. Her eyes are red. She has mouth ulcers. They are
deep and extensive. She does not have pus draining from the eye. She
does not have clouding of the cornea.
Record the child’s signs and classify them on the Recording Form
 Case 5:Nemia
Nemia is 3 yo. She weighs 10 kg. Her axillary temperature is 38C.
She was brought to the LHC due to cough. She also has a rash.
The BHW checked Nemia for danger signs. She was able to drink, she had not
been vomiting, everything, and she did not have convulsions. She was not
abnormally sleepy or difficult to awaken
The BHW assessed Nemia’s cough. The mother told the health worker Nemia
had been coughing for 2 days. Nemia’s breathing rate wass counted 30
breahts per minute. There was no chest indrawing. No stridor was heard
when Nemia was calm
Nemia did nto have diarrhea.
The BHW assessed Nemia’s fever. It was the wet season. There is no risk for
malaria with no cases reported for the past 10 years. The mother said,
“Nemia felt hot for the past 3 days”. She did not have stiff neck. She does
not have a runny nose. Blood smear (-)
Nemia was noted to have generalized rashes. Her eyes are red. She does not
have mouth ulcers. No pus was draining from her eyes nor any clouding of
the cornea.
She ws noted to have gumbleeding and abdominal pain. She has no bleeding
from nose, no vomiting of bllod, no bloody stools.
Record the child’s signs and classify them on the Record Form.
What questions would you like to ask in history/examiination