Integrated healt

Alexandria University IMCI Lecture 1 EMRO- WHO

IMCI Lecture 1

Integrated Management of Childhood

Illness

IMCI Lecture 1 Alexandria University EMRO- WHO

The IMCI process relies on:

• Case detection using simple clinical signs based on expert clinical opinion and results of research.

• Empirical treatment developed according to action-oriented classifications rather than exact diagnosis and covering the most likely diseases covered by each classification.


Age Groups Covered By IMCI

IMCI process can be used by health providers (doctors and nurses) who see sick infants and children aged up to 5 years:

– Children aged 2 months up to 5 years– Infants from birth up to 2 months


Where Care for Children Is Provided?

Home 1st level health facility Specialized hospital

I M C ICommunityComponent REFERRAL CARE


Where should IMCI be applied?

At 1st level health facilities:– Clinics– Rural and urban health centers– MCH centers– Outpatient departments of hospitals

Since children with potentially fatal illnesses are brought to these 1st level facilities.


Diseases Covered By IMCI

• Cough or difficult breathing

• Diarrhea• Throat problems• Ear Problems• Fever & Measles

3/4of Episodes of

Childhood illness

MALNUTRITION


Diseases NOT covered by IMCI

• The IMCI guidelines address the most important but NOT ALL of the major reasons a sick child is brought to the clinic

• The IMCI encourages the health provider to assess problems not included in IMCI charts. These are considered under the box :

ASSESS OTHER PROBLEMS


The IMCI Wall Charts

• For sick children aged 2 months – 5 years:•Assess and Classify the sick child•Treat the child•Counsel the mother

• For sick infants from birth to 2 months:•Assess, Classify and Treat the sick young infant


Assess & Classify

the Sick Child, Age 2 months up

to 5 years

22

ASSESS AND CLASSIFY THE SICK CHILDAGE 2 MONTHS UP TO 5 YEARS

CLASSIFY IDENTIFYTREATMENTASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE

• Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

ASK:

• Is the child able to drink or breastfeed?• Does the child vomit everything?• Has the child had convulsions?

THEN ASK ABOUT MAIN SYMPTOMS:Does the child have cough or difficult breathing?

ASSESS

LOOK:

• See if the child is lethargic or unconscious.• See if the child is convulsing now.

SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.)

• Any general danger sign.

VERYSEVERE DISEASE

Treat convulsions if present now.Complete assessment immediately.Give first dose of an appropriate antibiotic.Treat the child to prevent low blood sugar.Refer URGENTLY to hospital*.

If the child is: Fast breathing is:2 months up 50 breaths perto 12 months minute or more

12 months up 40 breaths per

IF YES,ASK:

• For how long? CHILD MUST

BE CALM

LOOK AND LISTEN:

• Count the breaths in oneminute.

• Look for chest indrawing.• Look and listen for stridor.• Look and listen for wheeze

ClassifyCOUGH orDIFFICULT

BREATHING

• Any general danger sign OR• Stridor in calm child OR • Chest indrawing (If chest indrawing and

wheeze go directly to”Treat Wheezing” then reassess after treatment .

SEVEREPNEUMONIA

OR VERY SEVERE DISEASE

Give first dose of an appropriate antibiotic.Treat wheezing if present.Treat the child to prevent low blood sugar.Refer URGENTLY to hospital.*

• Fast breathing (If wheeze, go directly to “Treat

Wheezing” then reasess after treatment.

PNEUMONIA

Give an appropriate antibiotic for 5 days.Treat wheezing if present.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 2 days.

• No signs of pneumonia or very severe disease

(If wheeze, go directly to “Treat

Wheezing”

NO PNEUMONIA:COUGH OR COLD

Treat wheezing if present.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 2 days if wheezing.Follow-up in 5 days if not improving


Step by Step through the IMCI charts:ASSESS & CLASSIFY THE SICK CHILD AGE 2

MONTHS UP TO 5 YEARS,

TREAT THE CHILD, and COUNSEL THE MOTHER:• General Danger Signs

• Cough or Difficult breathing

• Diarrhea

• Throat Problems

• Ear Problems

• Fever & Measles

• Malnutrition and/or Anemia

• Check for child immunization

• Assess Other problems

• Treat the Child

• Give follow-up care

• Counsel the Mother


General Danger Signs

CHECK for

GENERAL DANGER SIGNS

in ALL Children


General Danger Signs

• Checking for General danger signs

• Unable to drink or breastfeed

• Vomits every thing

• Has the child had convulsions?

• Unconscious, lethargic

• Classification of general danger signs

22





ASK:



ASSESS

LOOK:




VERYSEVERE DISEASE




IF YES,ASK:


BE CALM

LOOK AND LISTEN:




BREATHING



SEVEREPNEUMONIA





PNEUMONIA





Wheezing”





ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE

• Determine if this is an Initial or Follow Up visit for this problem If Follow Up visit, use the follow up instruction on the TREAT THE CHILD CHART If Initial visit, assess the child as follows:


ASK LOOK

• Is the child able to drink or breast-feed?• Does the child vomit every thing?• Has he had had convulsions? (during present illness)

• See if the child is lethargic or unconscious• See if the child is convulsing now


Unable to Drink or Breastfeed?

• Ask the mother to describe exactly what happens when she offers the child something to drink

• If you are not sure, ask the mother to offer her child a drink of clean water or breast milk and look to see if the child is swallowing it .

The child is unable to suck or swallow when he is offered a drink or breast milk


Vomits Everything ?

• Not able to hold down food, fluids or oral drugs.

• ALL what goes down comes back up• A child who vomits several times but can

hold down some fluids does not have this general danger sign.

Not able to hold anything down AT ALL


Has the child had convulsions?

• Ask the mother if the child has had convulsions during the current illness.

• Use words the mother understands.


Convulsions (cont…)

• Explain what do you mean exactly by “convulsions”.

• In a convulsing child the arms and legs stiffen. The child may loose consciousness or may not be able to respond to spoken directions.


Unconscious ?

• An unconscious child is a child who cannot be awakened.

• The child does NOT respond when he is :•Touched•Shaken, or•Spoken to


UNCONSCIOUS CHILD


Lethargic ?

• A lethargic child is NOT awake and alert when he should be.

• He is drowsy and does not show interest in what is happening around him.

Difficulty in maintaining the aroused state


Lethargic (cont…)

• Often a lethargic child does not look to his mother or watch your face when you talk

• A lethargic child may stare blankly and appears not to notice what is going around him.


LETHARGIC CHILD


ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE

• Determine if this is an Initial or Follow Up visit for this problem If Follow Up visit, use the follow up instruction on the TREAT THE CHILD CHART If Initial visit, assess the child as follows:


ASK LOOK

• Is the child able to drink or breast-feed?• Does the child vomit every thing?• Has he had had convulsions? (during present illness)

• See if the child is lethargic or unconscious• See if the child is convulsing now

22





ASK:



ASSESS

LOOK:




VERYSEVERE DISEASE




IF YES,ASK:


BE CALM

LOOK AND LISTEN:




BREATHING



SEVEREPNEUMONIA





PNEUMONIA





Wheezing”





CLASSIFY GENERAL DANGER SIGNS:

SIGNS CLASSIFY AS TREAT

• Any Danger Sign

VERYSEVEREDISEASE

Treat convulsions IF present now Complete assessment immediately Give 1st dose of appropriate antibiotic Treat child to prevent low blood sugar Refer URGENTLY to hospital

22





ASK:



ASSESS

LOOK:




VERYSEVERE DISEASE




IF YES,ASK:


BE CALM

LOOK AND LISTEN:




BREATHING



SEVEREPNEUMONIA





PNEUMONIA





Wheezing”





Cough OR Difficult Breathing

Then ASK About:COUGH ORDIFFICULTBREATHING


Acute Respiratory Infections (ARI)•Importance

DefinitionRole of IMCI

•PneumoniaRecognition • Fast breathing • Chest indrawing

•WheezingCauses • Why Added ?

•How to classify Cough or Difficult breathing?

Severe pneumonia or very severe disease Pneumonia Nopneumonia, Cough or cold


“Cough OR Difficult Breathing,” NOT “Cough AND Difficult Breathing”

Fewer than 25 percent of children with cough also have difficult breathing

Many causes of difficult breathing are not related to cough

Using both can cause false positives


Acute Respiratory Infections ( ARI )

•Common cause of mortality.

•Common cause of morbidity.

•Commonest reason for irrational drug prescription.

Global & National Health Problem


Insure Adequate Case Management

• Identify those who need URGENT REFERRAL

• Identify cases of PNEUMONIA.

• Rationalize the use of DRUGS

• Breast feeding and optimal nutrition

• Vaccination and Vitamin A supplementation

Role of IMCI in ARI


Pneumonia: Severity

Recognition is based on:

• Fast breathing, and

• Lower chest wall indrawing


WHY FAST BREATHING ?

•Simplicity•Ease in training•Reliability

Good Predictor of PNEUMONIAIn the sick child 2 months – 5 years

**

““Sensitivity & specificity around 80%”Sensitivity & specificity around 80%”

Sensitivity= proportion of those with the disease who are correctly identified by sign

Specificity= proportion of those without the disease who are correctly called free of the disease by using the sign.


FAST BREATHING !FAST BREATHING !Why not other signs of pneumonia?Why not other signs of pneumonia?

•Fever is poor predictor of pneumonia.

•Auscultation is less sensitive indicator

and needs skill


CUT-OFF POINTS for FAST BREATHING

If the child is: FAST BREATHING IS:

•2 months up to 12 months

•12 months up to 5 years

50 breaths per minute

or more

40 breaths per minute

or more

•Best to count rate in a quiet and alert child•Fever can affect respiratory rates, but do not wait for fever to subside


60

50

40

Cut-offs of Fast Breathing


LOWER CHEST WALL LOWER CHEST WALL INDRAWINGINDRAWING

Index of :

Severe Pneumoniaor very severe disease

Reasonable sensitivity & specificity " 89%".


Lower Chest Wall Indrawing

• Studies found that lower chest wall indrawing best identified children who required referral, admission or further assessment.

• Must be definite, present all the time


Wheezing: Causes• Under age 2 - Bronchiolitis• Older children plus those with recurrent

attacks of wheeze - bronchial asthma or reactive airways disease

–Transient wheezers

–Persistent wheezers

• Other respiratory infections

• Inhaled foreign body

• Tuberculous node compressing bronchus


Wheezing: Why Added ??

• Morbidity from asthma is a problem in Egypt

• Will reduce unnecessary referral to hospital

• Rapid-acting bronchodilators are available at first-level facilities

• Health workers are trained to recognize audible wheeze and use bronchodilators

• Health worker can recognize when a child with recurrent wheeze is not responsive in the first-level health facility

22





ASK:



ASSESS

LOOK:




VERYSEVERE DISEASE




IF YES,ASK:


BE CALM

LOOK AND LISTEN:




BREATHING



SEVEREPNEUMONIA





PNEUMONIA





Wheezing”





THEN ASK ABOUT MAIN SYMPTOMS

Does the child have Cough or Difficult breathing?

IF YES, ASK LOOK and LISTEN

• For how long • Count the breaths in one minute• Look for chest indrawing• Look and listen for stridor• Look and listen for wheeze

Child must be calm

22





ASK:



ASSESS

LOOK:




VERYSEVERE DISEASE




IF YES,ASK:


BE CALM

LOOK AND LISTEN:




BREATHING



SEVEREPNEUMONIA





PNEUMONIA





Wheezing”





CLASSIFFY COUGH OR DIFFICULT BREATHING:• Any danger sign, OR• Stridor in calm child, OR• Chest indrawing( If Wheeze, go directly to treat wheeze, then reassess)

SEVERE

PNEUMONIA OR

VERY SEVERE DISEASE

Give 1st dose of appropriate antibiotic Treat wheezing, if present Treat child to prevent low blood sugar Refer URGENTLY to hospital

• Fast breathing (If Wheeze, go directly to treat wheeze, then reassess)

PNEUMONIA

Give appropriate antibiotic for 5 days Treat wheezing, if present If coughing more than 30 days ,refer for assessment Relieve cough with a safe remedy Advise mother when to return immediately Follow up in 2 days• No signs of pneumonia

or very severe disease (If Wheeze, go directly to treat wheeze)

NO

PNEUMONIA:COUGH OR

COLD

Treat wheezing, if present If coughing more than 30 days ,refer for assessment Relieve cough with a safe remedy Advise mother when to return immediately Follow up in 2 days, if wheezing Follow up in 5 days if not improving


CHEST INDRAWING

FAST BREATHING

SEVERE PNEUMONIAOR VERY SEVERE DISEASE

±±


Severe Pneumonia OR Very Severe Disease

Urgently Refer Children with Cough OR Difficult Breathing AND

–Lower chest wall indrawing OR

–Stridor when calm OR

–Any general danger sign

Recognition:


FAST BREATHINGFAST BREATHING

• No General Danger Sign. • No Lower Chest Wall indrawing.• No Stridor while calm.

• No General Danger Sign. • No Lower Chest Wall indrawing.• No Stridor while calm.

PNEUMONIAPNEUMONIA

+


No Pneumonia,

Cough or Cold

Antibiotics

No signs of Pneumonia or Very Severe Disease


Diarrhea

Then ASK About :

DIARRHEA


DiarrheaDiarrhea

Assessment

DehydrationAssessment • Classification

Home FluidsSelection • Fluids to avoid

Persistent Diarrhea Definition • Causes

Classification

Dysentery Classification

Antibiotics


Assessment of Diarrhea

D E H Y D R A T I O N

F o r A l lP E R S I S T E N T

D I A R R H E AC o n d i t i o n a l

D Y S E N T E R YC o n d i t i o n a l

D I A R R H E A



Does the child have diarrhea?

IF YES ASK:

•For how long?

•Is there blood in

the stools

LOOK AND FEEL:•Look at the child’s general condition, Is he:

–Lethargic or unconscious?–Restless or irritable?

•Look for sunken eyes•Offer the child fluid. Is the child:

–Not able to drink or drinking poorly?–Drinking eagerly, thirsty?

•Pinch the skin on the abdomen. Does it go back :

–Very slowly (longer than 2 seconds)?–Slowly?



Dehydration

• Sensorium (lethargic,unconscious OR restless, irritable)

• Sunken Eyes (ask caretaker as well)

• Drinking (poorly OR eagerly)

• Skin Pinch (very slowly OR slowly OR immediately)

– Pinched in longitudinal manner

– Pinched between the thumb and the bent fore-finger

Assessment is based on 4 signs:


Assessment for dehydration Simplified to only 2 out of 4 possible signs

• Term "Floppy" is eliminated – variability of interpretation; adds little to "lethargic" or "unconscious".

• Tears & dryness of tongue are excluded – have been excluded: add little in sensitivity or specificity.

• Characterization of the eyes: modified – were reduced: differentiation between "very sunken" and "sunken" eyes

is often problematic and arbitrary.

• Skin pinch: more qualified – was further qualified: measured in the abdomen and given a time

parameter.


Unconscious child


Lethargic child


Sunken Eyes


Skin Pinch returns Very Slowly (> 2 seconds


Dehydration

• Mistakes in taking a skin pinch:– Pinching either too close to the midline or too far laterally

– Pinching the skin in an horizontal direction

– Not pinching the skin long enough

– Releasing the skin so that the finger and thumb remain in a

closed position

• Classification of skin pinches:– Normal — it goes back immediately

– Slowly — the fold is visible for less than 2 second

– Very slowly — the fold is visible for more than 2 seconds.

Assessment


1- CLASSIFY FOR DEGREE OF DEHYDRATIONTwo of the following signs:• Lethargic or unconscious• Sunken eyes• Drinks poorly or unable to drink• Skin pinch goes back very slowly

SEVEREDEHYDRATION

If child has no other severe classification: Give fluids for severe dehydration (Plan C) OR If child has also another severe classification: Refer URGENTLY to hospital while giving ORS sips-Advise to continue breastfeeding

Two of the following signs:• Restless, irritable• Sunken eyes• Thirsty, drinks eagerly• Skin pinch goes back slowly

SOMEDEHYDRATION

Give fluids and food for some dehydration (Plan B) If child has also a severe classification: - Refer URGENTLY to hospital while giving frequent ORS sips -Advise to continue breastfeeding Advise when to return immediately Follow up in 5 days IF not improving

• NO enough signs to classify as some or severe dehydration

NO

DEHYDRATION

Give fluids and food to treat diarrhea at home (Plan A) Advise when to return immediately Follow up in 5 days IF not improving


Home Fluids For Oral Rehydration

• Home Fluids for Diarrhea Must Be:

–Safe when given in large volumes

–Easy to prepare

–Acceptable color and palatability

–Effective in preventing dehydration

Selection:


• Ideal home fluids contain:– salts and nutrients (sodium, potassium, chloride, and

bicarbonate)– calories to replenish diet

• Examples of home fluids:– ORS solution– salted soup– salted drinks

Home Fluids For Oral Rehydration

Selection:


• Other acceptable home fluids that do not contain salt:– plain clean water

– water in which a cereal has been cooked (unsalted)

– soup (unsalted)

– yoghurt-based drinks (unsalted)

– green coconut water

– weak tea (unsweetened)

– fresh fruit juice (unsweetened)

Home Fluids For Oral Rehydration Selection:


• Fluids causing hypernatremia– most soft and carbonated drinks– sweetened fruit drinks– sweetened tea(s)

• Fluids with stimulant, diuretic or purgative effects– coffee– some medicinal teas or infusions

Home Fluids For Oral Rehydration Fluids to avoid:



Persistent Diarrhea

• Diarrhea that occurs for 14 or more days

• Less than 10 percent of all diarrhea

• Associated with 30 to 50 percent of diarrhea deaths

• Malnutrition greatly increases the risk of death

Definition:


•Proximate Causes• Secondary disaccharidase deficiency• Salmonella sp.• Shigella sp.• Enteroadherent E. coli• Cryptosporidium

•Contributing Factors• Protein energy malnutrition• Micronutrient deficiencies• Immunodeficiency

Persistent DiarrheaCauses:


2-CLASSIFY FOR PERSISTENT DIARRHEA

• Dehydration present SEVERE

PERSISTENTDIARRHEA

Treat dehydration before referral unless the child has another severe classification Refer to hospital

• No dehydration

PERSISTENT

DIARRHEA

Advise mother on feeding child with Persistent Diarrhea Give multivitamin / mineral supplement Advise mother when to return immediately Follow up in 5 days


3. CLASSIFY FOR DYSENTERY

•Blood in the

stools

DYSENTERY

•Treat for 5 days with an oral

antibiotic recommended for

Shigella

•Advise mother when to return

immediately

•Follow-up in 2 days


Antibiotics for Dysentery

• Effective for Shigella species and for Salmonella in infants under one year of age

• Early Treatment with Antibiotics:

– shortens the duration of the illness– reduces risk of serious complications & death

Antibiotics:


Antimicrobials against Shigella

EFFECTIVE• Co-Trimoxazole • Nalidixic acid• Pivmecillinam• Ceftriaxone • Ciprofloxacin• Other

quinolones

INEFFECTIVE• Metronidazole• Streptomycin• Chloramphenicol• Sulfonamide• Cepholosporins• Aminoglycosides• Nitrofurans


SUMMARY:HOW TO CLASSIFY DIARRHEA?

There are 3 Classification for diarrhea:

• Classify for the DEHYDRATION (for ALL Children)

• Classify for PERSISTENT DIARRHEA (Conditioned)

• Classify for DYSENTERY (Conditioned)


THROAT PROBLEM

CHECK for THROAT PROBLEM in ALL CHILDREN


Throat Problems•Sore Throat & Pharyngitis

• Overview• Management Issue• Sensitivity & Specificity of signs

•Role of IMCI

•Classification of Throat Problem

•Treatment


is more than just

a sore throat. ?

Pharyngitis


• Main reason to treat streptococcal sore throat is prevention of rheumatic fever and rheumatic heart disease

• Ideal prevention of rheumatic fever entails treatment of streptococcal pharyngitis with penicillin

• Streptococcal sore throat and rheumatic fever are still important issues in children older than 5 years in Egypt

• Cases of rheumatic fever have been reported in children less than 5 years in Egypt

Sore Throat: Overview


Not all,Sore throatsare streptococcal !

However


Should We Treat All Sore All Sore Throats Throats With Antibiotics ?Antibiotics ?

• Cost• Side effects• Resistance• Super - infection


• Only 15-20% sore throats are Group A Streptococcus (GAS)

• Lack of reliable clinical signs leads to over-treatment of sore throats

• Children under 3 often have non-specific signs such as fever and crusts around nose

• GAS infections generally rare in children under 2 years

Sore Throat: Management Issues


• Sensitivity and specificity tend to move in opposite directions

• Clinical diagnosis of GAS infection is difficult without rapid diagnostic test or routine cultureClinical feature Sensitivity % Specificity %History of fever 92.3 14.4Temp >38ºC 37.4 66.0Exudate 31.0 31.0Enlarged node 81.3 45.1Tender node 33.6 82.2Exudate or large node 84.1 40.1Exudate/large node & tender node 12.1 93.9

Sore Throat: Management Issues


For Accurate Diagnosis:

• Throat culture

• Ag detection

• ASO Titre

Expensive, Not available at PHC level


THEN, HOW WILL IMCI HELP ?

•Select few definite signs.

•In countries with HIGH prevalence RF or RHD, Better rely on high sensitivity of sign, not to miss any case.

•In countries with Low prevalence, rely on high specificity of sign to avoid over-treatment



IN ALL CHILDREN:

Check for throat problem

ASK: LOOK AND FEEL

• Does the child have sore throat?

• Feel for enlarged tender lymph nodes on the front of the neck• Look for red (congested) throat• Look for white or yellow exudate on the throat and tonsils.





CLASSIFY THROAT PROBLEM:

• TWO of the following:• Red (congested) throat• White or yellow exudate on the throat and tonsils• Enlarged tender lymph nodes on the front of neck

STREPTOCOCCALSORE THROAT

Give benzathine penicillin Soothe the throat with a safe remedy Give paracetamol for pain Advise when to returm immediately Follow up in 5 days IF not improving

• Insufficient criteria to classify as streptococcal sore throat

NONSTREPTOCOCCAL

SORE THROAT

Soothe the throat with a safe remedy Give paracetamol for pain Advise when to returm immediately Follow up in 5 days IF not improving

• No throat signs or symptoms (with or without fever)

NO THROATPROBLEM

Continue assessment of the child


• Treatment to prevent RHF and RHD, but also reduces duration of symptoms and signs, and anorexia

• Single dose of IM Benzathine penicillin remains best treatment – levels of penicillin remain elevated for up to 10 days– can prevent a sore throat developing for up to 21 days later– administration can be very painful and incorrect administration

can cause sterile abscesses, sciatic nerve injury

• Penicillin V or amoxicillin are alternatives but more expensive and 10-day compliance is poor

Sore Throat: Treatment


EAR PROBLEM

ASK about :

EAR PROBLEM


EAR PROBLEM•Types of ear infection

•External otitis• Ask• Look

•Otitis media• Ask • Look

•Symptoms & Signs Used in IMCI

•Classification of ear problem

•Treatment



Ear Infection ?

• External ear :

Otitis Externa

• Middle ear :

Otitis Media


Diagnosis of External Otitis

• Agonizing Ear Pain– Out of proportion of inflammation– Triggered by manipulating the tragus– Itching is a precursor of inflammation

• Discharge: Serous or Purulent

• Conduction Hearing loss: difficult to test in young children (NOT INCLUDED IN IMCI)

ASK


Diagnosis of External Otitis

• Discharge: Serous or Purulent

• Ear Canal: **•Erythema•Edema•Otoscopy: very painful

**SUBJECTIVE SIGNS, NOT INCLUDED IN IMCI

LOOK


Diagnosis of Otitis Media

• Agonizing Ear Pain• Discharge (Otorrhea): Purulent• Other NON SPECIFIC Symptoms:

•Fever•Irritability OR Lethargy•Anorexia, Nausea, Vomiting, Diarrhea

•Headache ?

ASK


Diagnosis of Otitis Media

• Discharge: Purulent• Pneumatic Otoscopy:**

•Calm cooperative child•Good positioning•Clean empty ear canal•Experienced physician++

**DIFFICULT TO ACHIEVE, NOT INCLUDED IN IMCI

LOOK


We are left with:ASK

•Agonizing ear Pain•Ear Discharge

LOOK•Pus Draining from the ears

FEEL:•Tender swelling behind ear

(Mastoid)

These are used in IMCI


MASTOIDITIS



ASSESS EAR PROBLEM:

Does the child have an ear problem?

IF YES ASK: LOOK AND FEEL

• Is there agonising ear pain?• If there ear discharge? If YES, for how long?

• Look at pus draining from the ear• Feel for tender swelling behind the ear.



CLASSIFY EAR PROBLEM:

• Tender swelling behind the ear

MASTOIDITIS

Give 1st dose of appropr. antibiotic Give 1st dose of paracetamol for pain Treat child to prevent low blood sugar Refer URGENTLY to hospital

• Pus seen draining from ear and Discharge reported for less than 14 days OR• Agonising ear pain

ACUTE EARINFECTION

Give antibiotic for 10 days Give paracetamol for pain Dry the ear by wicking Advise when to return immediately Follow up in 5 days

• Pus seen draining from ear and Discharge reported for 14 days or more

CHRONIC EAR

INFECTION

Dry the ear by wicking Refer to ENT Specialist

• No ear pain and• No pus seen draining from the ear

NO EAR

INFECTION

Advise mother to go to ENT specialist for assessment


Stepwise Antibiotics in Otitis Media(Nelson Textbook of Pediatrics)

AMOXICILLIN (high dose)First line antibiotic recommended in IMCI

If it fails

AMOXICILLIN-CLAVULANATE

If it fails

CEFTRIAXONE



FEVER

ASK

about

FEVER


FeverFebrile Illness

Causes

Fever After Five DaysReferral

Classification of Fever Overvie

Stiff neck

Classification of fever


• Fever as a secondary cause – management of the condition results in

management of the fever– pneumonia, measles, dysentery, ear infections,

runny nose

• Fever associated with severe illnesses which use danger signs for classification and treatment– meningitis, septicemia, sepsis

Febrile IllnessCauses:


• Non-localizing signs do not allow for distinction at a first-level health facility

• Danger signs identify a seriously ill child who needs to be referred

• Meningitis, septicemia

• Severe pneumonia or Very serere disease

• Mastoiditis

• Severe complicated Measles, etc

Febrile Illness


• Conditions do not have any obvious simple clinical sign but have fever in common

• Prevalence too low to include specific signs and symptoms for each condition

Fever after Five Days

Referral


• Differentiates between simple viral fevers and other diseases where the only presenting symptom is fever

• Detects conditions needing diagnostic and therapeutic intervention – Tuberculosis

– Urinary tract infection

– Typhoid, Brucellosis, Osteomyelitis, etc.

Fever after Five Days

Referral in Order To:



Does the child have fever?

(by history or feels hot or temperature 37.5oC or more)

IF YES, ASK LOOK AND FEEL

• For how long?• If more than 5 days, has fever been present every day?• Has the child had measles within the last 3 months?

• Look or feel for stiff neck Look for signs of Measles:• Generalised rash and • One of these: cough, runny nose, or red eyes.

If the child has measles now or within the last 3 months:

• Look for mouth ulcers Are they deep and extensive?• Look for pus draining from the eye• Look for clouding of the cornea


Looking andFeeling forSTIFF NECK



CLASSIFY FEVER:• Any generalised danger sign OR • Stiff neck

VERY SEVEREFEBRILEDISEASE

Give 1st dose of appropiate antibiotic (I.M) Treat child to prevent low blood sugar Give one dose of paracetamol in clinic for fever 38oC or above Refer URGENTLY to hospital

• Apparent bacterial cause of fever, e.g− Pneumonia− Dysentery− Acute ear infection− Strept. sore throat− Abscess, cellulitis,etc.

FEVER-POSSIBLE

BACTERIALINFECTION

Give paracetamol for fever (38oC or more) Treat apparent cause of fever . Advise mother when to return immediately Follow Up in 2 days IF fever persists If fever is present every day for more than 5 days, refer for assessment.

• No apparent bacterial cause of fever

FEVER-BACTERIAL INFECTIONUNLIKELY

Give paracetamol for fever (38oC or more) Advise mother when to return immediately Follow Up in 2 days IF fever persists If fever is present every day for more than 5 days, refer for assessment



MALNUTRITION & ANEMIA

CHECK ForMALNUTRITION andANEMIAin ALL CHILDREN


MALNUTRITION & ANEMIA•Anemia

Clinical signs for classificationSensitivity and specificity of signs

•Nutritional statusIceberg of malnutritionWeight for age as indicatorOther indicatorsGrowth Monitoring

•Checking for Malnutrition and AnemiaWasting Edematous feet Weight for age curve Pallor

•Classification of nutritional statusof anemia


• Severe anemia: classified using severe palmar &/Or mucous membrane pallor

• Anemia: classified using some palmar &/Or mucous membrane pallor

• Study in Alexandria (2000-01) proved that:

AnemiaClinical Signs for Identification:

Clinical Sign Sensitivity Specificity

Severe Palmar Pallor 60.6% 96.4%Some Palmar Pallor 87.3% 47.7%Severe Conjunctival Pallor 52.7% 98.1%Some Conjunctival Pallor 49.9% 64.0%Severe Lip Pallor 42.9% 97.8%Some Lip Pallor 53.1% 57.1%


Studies in Alexandria, Gambia, Bangladesh,Kenya & Uganda

concluded that:• Best sensitivity obtained for “Some

palmar pallor”• Best specificity obtained for severe

conjunc. pallor• Sensitivity of severe palmar pallor similar

to or better than that of conjunctival pallor

• Specificity about the same for both severe palmar and conjunctival pallor.

• Using both signs together decreased sensitivity but increased the specificity in both severe and some pallor.


• All children should be assessed for nutritional status

• Low weight requiring home management or nutritional counseling

• Severe malnutrition needing referral

– Marasmus indicated by severe visible wasting

– Edematous malnutrition (kwashiorkor) indicated by edema of both feet

Nutritional Status


Mild & Moderate forms

severe forms

The Iceberg of Malnutrition


• Weight for height assessments most accurate but not routinely performed

• Weight for age Z-score can be viewed as a proxy estimate for weight for height

Weight for Age as Indicator


• Low WFA (<-2 Z-score)– Population-based nutritional surveys only– For comparison of different areas and time– Not for patient-based disease

• Mid upper arm circumference (MUAC)– Not as effective as WFH gold standard– Prone to errors: even half a centimeter could

result in wrong classification– Useful for screening an emergency situation

Other Indicators


• Could provide valuable information about a child’s current growth -- potential powerful tool

• No consensus on quantitative definition of growth faltering– Weight loss between 2 monthly measurements

– Weight gain over 3 monthly measurements

– Falling off the curve

• Efficacy difficult to demonstrate– No effect on nutritional status

– Health workers have difficulty recognizing “faltering”

Growth MonitoringLimitations:



THEN CHECK FOR MALNUTRITION AND ANEMIA

LOOK AND FEEL Classify

• Look for visible severe wasting• Look for edema of both feet• Determine weight for age

NUTRITIONALSTATUS

LOOK Classify ANEMIA

• Look for palmar and/or mucous membrane pallor. Is it:− Severe palmar and / or m. m. pallor?− Some palmar and / or m. m. pallor?




LOW WEIGHT FOR AGE



CLASSIFY NUTRITIONAL STATUS

• Visible severe wasting OR• Edema of both feet

SEVEREMALNU-TRITION

Give vitamin A Treat the child to prevent low blood sugar Refer URGENTLY to hospital

• Low weight for age

LOW

WEIGHT

Assess the child’s feeding & counsel mother according to FOOD box on the COUNSEL THE MOTHER chart If there is feeding problem: Follow up in 5 days Advise when to return immediately

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

NOT LOW

WEIGHT

If child is less than 2 years old, assess feeding & counsel mother according to FOOD box on the COUNSEL THE MOTHER chart If there is feeding problem: Follow up in 5 days


CLASSIFY ANEMIA

• Severe palmar and /or mucous membrane pallor

SEVERE ANEMIA

Treat the child to prevent low blood sugar Refer URGENTLY to hospital

• Some palmar and /or mucous membrane pallor

ANEMIA

Give iron Advise when to return immediately Follow up in 14 days

• No palmar or mucous membrane pallor

NOANEMIA

If child is aged from 6 – 30 months, give ONE dose of iron weekly (supplementation)


CHECK THE CHILD IMMUNIZATION STATUS

CHECK

IMMUNIZATIONand VITAMIN ASupplementationstatus In ALL CHILDREN


CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A SUPPLEMENTATION STATUS

AGE VACCINE VITAMIN A

Before 3 months2 months4 months6 months9 months18-24 months

BCGOPV-1OPV-2OPV-3OPV-4OPV

(Booster)

DPT-1DPT-2DPT-3

MeaslesDPT

(Booster)

HBV-1HBV-2HBV-3

MMR

100,000 U200,000 U

ASSESS OTHER PROBLEMS


TREAT THE CHILD

Give an Appropriate Oral Antibiotic…..

Teach the Mother to Give Oral Drugs at Home…

Teach Mother to Treat Local Infections at Home…

Treatments Given in Clinic Only….

Give Extra Fluid for Diarrhea

Continue Feeding…

Immunize Every Child, as Needed…


GIVE FOLLOW-UP CARE

Pneumonia, No pneumonia-Wheeze

Dysentery, Persistent Diarrhea

Sore throat, Ear Infection, Fever, Measles

Feeding Problems, Low weight

Pallor


COUNSEL THE MOTHER FOOD:

•Assess Child’s Feeding•Feeding Recommendations during Illness & Health•Counsel the Mother about Feeding Problems

FLUID

•Advise the Mother to Increase Fluid During Illness

Counsel the Mother About Her Own Health

Advise the Mother when to Return to Health Worker


Integrated healt

Healthcare