IMCI TECHnical Updates.revised

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Why Update?

New knowledge on clinical management of childhood diseases are available

Implementation of IMCI has identified problems and questions which were addressed by operational research Epidemiology of diseases has evolved thus a revised version has to accommodate and reflect these changes

Technical updates adapted in Philippine IMCI

Antibiotic treatment of non-severe and severe pneumonia Low osmolarity ORS and antibiotic treatment for bloody diarrhea Treatment of fever/malaria Treatment of ear infections Infant feeding Treatment of helminthiasis Management of sick young infant aged up to 2 months

I. Acute respiratory infection

First-line/second line antibiotic for non-severe pneumonia

previous First line Cotrimoxazole Second line Amoxicillin

updated Amoxicillin Cotrimoxazole

Duration of antibiotic treatment from 5 days to 3 days Frequency of administration of antibiotics from 3x to 2x a day


Management for non-severe pneumonia therefore:First line: Oral amoxicillin to be given in 25mg/kg dose twice daily in children 2-59 months of age for 3 days Second line: Oral Cotrimoxazole to be given 2x daily for 3 days


Technical basis: 3 days treatment is equally effective as the 5 day treatment Reduces cost of treatment Improves compliance Reduces antimicrobial resistance in the community

Acute Respiratory Infections

Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia

Where referral is difficult and injection is not available, oral Amoxicillin in 45 mg/kg/dose 2x daily should be given to children with severe pneumonia for 5 days

Technical basis:

Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia

Acute Respiratory Infections

Gentamicin plus ampicillin vs chloramphenicol for very severe pneumonia

Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol for very severe pneumonia in children 2-59 months of age. A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used

Acute Respiratory Infections Inclusion of Wheeze For children with wheeze and fast breathing and/or lower chest wall indrawing

Give a trial of rapid-acting inhaled bronchodilator (up to 3 cycles) before they are classified as pneumonia and prescribed antibiotics. 0.5 ml salbutamol diluted in 2.0 ml of sterile water per dose nebulization should be used


Use of low osmolarity oral rehydration salts

Technical basis: Efficacy of ORS solution for tx of acute non-cholera in children is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245mOsm/l.

The need for unscheduled supplemental IV is reduced by 33%, stool output is reduced by about 20% and the incidence of vomiting by about 30%

Diarrheal Diseases

Use of antibiotics in the management of bloody diarrhea (shigella dysentery) Ciprofloxacin is the most appropriate drug in place of nalidixic acid which leads to rapid development of resistance Dose: 15 mg/kg body weight 2x a day for 3 days

Diarrheal diseasesTechnical basis: - Ciprofloxacin is several thousand-fold greater than that of nalidixic acid - Ciprofloxacin is 100 to 1000-fold less prone to selection of single-step spontaneous highly resistant organisms - Simplified tx regimens (2 doses /day x 3 days instead of 4 doses/day x 5 days with nalidixic acid) - Considered for its safety, efficacy and reduced cost


Giving of Zinc supplements in the management of diarrhea Dose: 2 mos. up to 6 mos. - tab daily for 10-14 days 6 mos. or more 1 tab daily for 10-14 days

Giving of multivitamins and minerals (with zinc) for 14 days is added in the treatment of persistent diarrhea

Technical basis: reduced duration and severity of diarrhea episode lowered incidence of diarrhea in the ff. 2-3 months



First line antibiotic for Malaria (Artemetherlumefantrine) For children 1-3 yrs Day 1 after 8 hrs Day 2 Day 3 old 1 tablet 1 tablet 1 tablet 2x a day 1/2 tablet 2x a day


For children 4-8 yrs old Day 1 2 tablets after 8 hrs 2 tablets Day 2 2 tablets 2x a day Day 3 2 tablets 2x a day Day 4 Primaquine, -3/4 tablets for 14 days


Treatment schedule for uncomplicated P. falcifarum malariaday 1-3 day 4 Artemether-Lumefantrine (Coartem) Primaquine, single dose only on day 4

Note: Primaquine is contraindicated in children < 1y.o.


Treatment schedule for confirmed P. vivax casesChloroquine for 3 days Primaquine for 14 days

Day 1-3 Day 4-17

Mixed P.falciparum and P. vivaxArtemether + lumefantrine Primaquine

Day 1-3 Day 4-17


Treatment of drug-resistant malaria

In case of parasitological or clinical failure to a given drug, refer patient to the next level with proper documentation (blood smear result incl. parasite count on day7, 14, 21, & 28

Quinine sulfate(300 or 600 mg/tab) 10 mg/kg/dose every 8 hours for 7 days + Clindamycin 10 mg/kg 2x a day for 3 days


Pre-referral treatment: Artesumate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow.


Antimalarials for treatment of Malaria The following therapeutic options are available and have potential for deployment (in prioritized order) if costs are not an issue: Artemether-lumefantrine (Coartem TM) Artesunate (3 days) plus amodiaquine Artesunate (3 days) plus SP in areas where SP efficacy remains high SP plus amodiaquine in areas where efficacy of both amodiaquine and SP remain high (limited in west African countries)

Technical basis: Artemisin-based combination therapy (ACT) result in rapid substantial reduction of the parasite biomass and rapid resolution of clinical symptoms In combination, allows reduction of artemisin tx, while enhancing efficacy and reduce likelihood of resistance development to the partner drug

EAR INFECTIONSChronic ear infection Chronic ear infection should be treated with optical quinolone ear drops for at least 2 weeks in addition to dry ear by wicking Acute ear infection Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimixazole is high


Technical basis: Cochrane review of randomized controlled trials published in the Cochrane Library

Aural toilet combined with antimicrobial treatment is more effective than aural toilet alone; oral antibiotics were found to be better than aural toilet alone


antibiotics were found to be better than aural toilet alone; the addition ot topical; antibiotics to aural toilet was associated with a 57% rate of otorrhea resolution compared to 27% with aural toilet alone

Topical antibiotics were found to be better than systemic antibiotics in resolving otorrhea and eradicating middle ear bacteria; in general topical quinolones were found to be better than topical non-quinolones; finally combined topical and systemic antibiotics are no better than topical antibiotics alone


safety of topical quinolones in children has been well documented without good evidence of a risk of ototoxicity

Malnutrition and anemia

MUAC (mid-upper arm circumference) less than 10 mm is now considered an indicator for severe malnutrition Use of the new WHO Growth Standards Inclusion of management of severely malnourished children where referral is not possible

Immunization ScheduleAge Birth 6 weeks 10 weeks 14 weeks 9 months Vaccine BCG, HepB1 DPT1, OPV1, HepB2 DPT2, OPV2 DPT3, OPV3, HepB3 Anti-measles

INFANT FEEDINGExclusive breastfeeding up to 6 mos.

Breastfeed as often as the child wants, day and night at least 8 times in 24 hours Breastfeed when the child shows signs of hunger, beginning to fuss, sucking fingers, or moving the lips

Do not give other foods or fluids Only if the child is older than 4 mos. and appears hungry after breastfeeding and is not gaining weight adequately, add complementary foods. Give 1-2 tablespoons, 1-2 times per day after breastfeeding

Infant Feeding . . .Complementary feeding 6 mos. up to 23 mos.

Breastfeed as often as the child wants Give adequate serving of complementary foods: 3 times per day if breastfed, with 1-2 nutritious snacks as desired from 9-23 mos.

Give foods 5 times per day if not breastfed with 1 or 2 cups of milk Give small chewable items to eat with fingers. Let the child try to feed itself, but provide help

Do not give other foods or fluids Only if the child is older than 4 mos. and appears hungry after breastfeeding and not gaining weight adequately, add complementary foods. Give 1-2 tablespoons, 1-2 times per day after breastfeeding

Infant Feeding . . .

Management of severe malnutrition where referral is not possible

Where a child is classified as having severe malnutrition and referral is not possible, the IMCI guidelines should be adapted to include management at first-level facilities modified milk diet is given

Infant Feeding . . .

HIV and Infant Feeding

In areas where HIV is a public health problem all women should be encouraged to receive HIV testing and counseling Avoid breastfeeding If a mother is HIV-infected and replacement feeding is acceptable, feasible, affordab