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Transcript of Imci Strategy
SICK CHILDREN AGED 2 MONTHS TO 59 MONTHS
Main Symptom 1- Cough or Difficult Breathing
(Three days antibiotic treatment of non-severe and severe pneumonia.
Oral antibiotic for non-severe pneumonia should be given for three (3) days instead of 5 days to sick children 2 -59 months old. Shorter courses of antibiotic were found to be equally effective as the five-day duration, reduces cost of treatment in addition to improving compliance and reduces the antimicrobial resistance in the community
Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol of severe pneumonia in children 2-59 months old of age. A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used.
Children with wheeze and fast breathing and/or lower chest indrawing should be given a trial of rapid-acting inhaled bronchodilator (up to three cycles for up to 15-20 minutes apart) before they are classified as pneumonia and prescribed antibiotics.
Use of Amoxicillin and first line antibiotic and Cotrimoxazole as second line antibiotic in the treatment of pneumonia, very severe disease, ear problem is recommended. Main Symptom 2 - Diarrhea
Use of Reformulated Oral Rehydration Salts which should contain 75mEq/L, 75mmol/L glucose concentration and has a total osmolarity of 245 mOsm/L.
Use of Zinc supplements for 10-14 days in the management of diarrhea. Zinc supplementation during the episodes of acute diarrhea reduced the duration and severity of the episode. In addition, studies showed that zinc supplementation given for 10-14 days lowered the incidence of diarrhea in the following 2-3 months. Inclusion of zinc in the management of diarrhea could prevent 300,000 children from dying every year.
In the treatment of bloody diarrhea (Dysentery) Ciprofloxacin is the most appropriate drug in place of Nalidixic acid which leads to rapid development of resistance. Ciprofloxacin is given in a dose of 15 mg/kg two times per day for three (3) days.
Giving of multivitamins and minerals (including Zinc) for 14 days is added in the treatment protocol of PERSISTENT DIARRHEA in addition to continue feeding and follow-up.
Main Syptom 3- Fever
First Line Antibiotic for Malaria Chloroquine,Primaquine, Sulfadoxine and Pyrimethamine. Second line Antibiotic Artemeter-Lumefantrine
Note: New Malaria treatment guidelines will be changed this year making Arthemeter-Lumefantrine as first-line antibiotic.
Main Symptom 4- Ear Problem
Chronic ear infection to be treated with topical quinolone ear drops for at least two weeks in addition to dry ear by wicking
Oral Amoxicillin is first-line antibiotic for the management of acute ear infection and is given two times a day for three (3) days. Even though antibiotics may provide a small benefit for acute ear infection in children, oral amoxicillin plays an important role in reducing the risk of mastoiditis.
Malnutrition and Anemia
Where available, MUAC (Mid-upper arm circumference) less than 110mm is now considered an indicator for Severe Malnutrition. If MUAC is not available, look for visible severe wasting.
Malnutrition and anemia are presented in two separate algorithms
Use of WHO Growth standards instead of the International Reference Standard. (explanation of the WHO GPRS).
Management of severe malnutrition where referral is not possible, manage the child at the health center. If the child has no appetite, a modified milk diet is given. This is made by dried skimmed milk (DSM) sugar and oil.
Mix: 25 g dried skimmed milk
70 g sugar
35 g rice flour
27 g oil and some water
Boil: 5-7 minutes
Allow to cool and then add 20 ml WHO vitamin mineral mix for severe malnutrition and mix again
Make up the volume to 1,000 ml by adding previously boiled water
Feed for a few days 11 ml/kg every 2 hours
Once appetite is restored, a diet with 80 g dried skimmed milk, 50 g sugar and 60 g of oil is prepared. Add water up to 1000 ml and 20 ml WHO mineral and vitamin solution. Increase progressively the feeds up to 200 ml/kg given in 6 feeds (30 ml/kg every 4 hours adjusted to the childs appetite).
VITAMIN A Capsule distribution schedule:
Give first dose at age 6 months or above; give subsequent dose every 6 months.
TREATMENT : for nightblindness, bitots spot, xeropthalmia, corneal xerosis
Give 1 capsule today
Give 1 capsule tomorrow
Give 1 capsule 2 weeks after; subsequent dose after 6 months, then
follow the every six months dose.
Routine Worm Treatment
Give every child Mebendazole/Albendazole every 6 months from the age of one (1) year.
SICK YOUNG INFANT AGED UP TO 2 MONTHS
The first symptom to manage among sick young infants, Check for Possible Bacterial Infection was changed to Check for very severe disease and local bacterial infection and the signs to look for in the assessment of this symptom was reduced from 12 to 7 signs.
The seven signs include: not feeding well, or convulsion, or fast breathing (60 bpm or more), or severe chest indrawing, or fever (37.5 C or above), or low body temperature (less than 35.5 C), or movement only when stimulated, or no movement at all .
The new classifications include: Very severe disease (pink), Severe disease (yellow), Severe disease or local bacterial infection unlikely (green)
Checking for JAUNDICE is added in the protocol for Sick Young Infant aged up to 2 months. Classifications include SEVERE JAUNDICE ( pink row),
JAUNDICE (yellow row) and NO JAUNDICE (green row).
UPDATES ON INFANT FEEDING
HIV and Infant Feeding
In areas where HIV is public health problem all women should be encouraged to receive HIV testing and counseling. If a woman is HIV-infected and replacement feeding is acceptable, feasible, affordable, sustainable and safe for her and her infant, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during the first 6 months of life.
Infant and Young Child Feeding Policy
Early initiation of breastfeeding within the first hour of life;Exclusive breastfeeding up to six months;Addition of safe, adequate complementary foods at age 6 completed months while;
Continuing breastfeeding up to 2 years and beyond.
UST College of Nursing Note: New Malaria treatment guidelines will be changed this year making Arthemeter-Lumefantrine as first-line antibiotic.
Ask about the main symptoms
Cough or difficulty in breathingDiarrheaFeverEar problem
NO PNEUMONIA: COUGH OR COLD
If cough 30 days refer to hospital for assessmentsafe throat remedyFollow-up in 5 days.
If No signs of pneumoniaor a very severe disease
If wheezing, give inhaled bronchodilator for 5 days
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 (2 sec)
Classify for dehydration
If with no other severe classification: Plan C- IVF in RHU
If less than 2 yrs & there is choleraIn the area, give TETRACYCLINE
Not enough signs to classify as SEVERE DEHYDRATION orSOME DEHYDRATION
Classify for dehydration
Plan A: Extra Fluids Give Zinc supplementFollow-up in 5 days
Then CHECK CHILDS IMMUNIZATION STATUS
BirthBCGHepB1 6 weeksOPV1HepB2DPT1 Hib1 10 weeksOPV2 DPT2 Hib 2 14 weeksOPV3HepB3DPT3 Hib 3 9 monthsMeasles 15 months MMR
New Vaccination Schedule
BirthBCGHepB0 6 weeksPentavalent1 OPV1 RTV1* PCV1* 10 weeksPentavalent2 OPV2 RTV2* PCV2* Pentavalent3 OPV3 RTV3* PCV3* 9 monthsMeasles 12 months MMR
RTV*PCV* - in selected areas only due to limited suppliesPentavalent vaccine includes DPT, HIB, HepB
Bleeding gums, nose, in vomitus or stools ,orPersistent vomiting & abdominal pain, Skin petechiae, orCold clammy extremities, orSlow capillary refill (more than 3 secs) + Tourniquet test
If with blood in the stool - dysentery
Oral antibiotic- CIPROFLOXACIN for 3 days Follow-up in 2 days
2 of the following:- Restless, irritable- Sunken eyes- Drinks eagerly, thirsty- Skin pinch goes back slowly (2 sec)