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

Acute respiratory infection

• First-line/second line antibiotic for non-severe pneumonia previous updated– First line Cotrimoxazole Amoxicillin – Second line Amoxicillin Cotrimoxazole

• Duration of antibiotic treatment from 5 days to 3 days

• Frequency of administration of antibiotics from 3x to 2x a day

ACUTE RESPIRATORY INFECTION

• 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

ACUTE RESPIRATORY INFECTION

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 InfectionsInclusion 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

DIARRHEAL DISEASES

• 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 DISEASES• Giving of Zinc supplements in the management of diarrhea

Dose: 2 mos. up to 6 mos. - ½ 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

Fever• First line antibiotic for Malaria (Artemether-

lumefantrine)

For children 1-3 yrs old

Day 1 1 tablet

after 8 hrs 1 tablet

Day 2 1 tablet 2x a day

Day 3 1/2 tablet 2x a day

Fever• 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, ½-3/4

tablets for 14 days

Fever• Treatment schedule for uncomplicated

P. falcifarum malaria

day 1-3 Artemether-Lumefantrine (Coartem)

day 4 Primaquine, single dose only on day 4

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

Fever• Treatment schedule for confirmed P.

vivax cases Day 1-3 Chloroquine for 3 days Day 4-17 Primaquine for 14 days

• Mixed P.falciparum and P. vivax

Day 1-3 Artemether + lumefantrine Day 4-17 Primaquine

Fever

• 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

Fever

• Pre-referral treatment:

Artesumate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow.

EAR INFECTIONS

Chronic 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

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 Vaccine

Birth BCG, HepB1

6 weeks DPT1, OPV1, HepB2

10 weeks DPT2, OPV2

14 weeks DPT3, OPV3, HepB3

9 months Anti-measles

INFANT FEEDING

• Exclusive 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

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

– If a mother 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 months of life

– The child of HIV-infected mother who is not breastfed should receive complementary foods

HELMINTH INFESTATIONS

• Helminth infestations in children below 24 months– Albendazole and mebendazole can be safely used in

children 12 months or older– Give 500 mg Mebendazole or 400 mg Albendazole in

single dose

Technical basis:– Tanzania study: Mebendazole had a

positive effect on motor and language development and compared with placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhea, dysentery and ARI) one week after intervention

Sick young infant aged up to 2 months

Previous UpdatedAge: 1 week up to Birth up to 2

2 months months

Main symptom:Previous: Possible serious bacterial infection

Updated: Very severe disease and local bacterial infection

Sick young infant – cont’d

• Signs to look for in assessment:

Previous: 12 signs

Updated: 7 signs

Sick young infant – cont’d• Classification: Previous: Updated: Very severe disease (pink) Very severe

disease Local bacterial infection (yellow) Severe disease Severe disease or local Severe disease or bacterial infection unlikely local bacterial (green) infection unlikely

Sick young infant – cont’d

• Checking for jaundice is added in the protocol

• Classification: Severe jaundice (pink)

Jaundice (yellow)

No jaundice (green)

Acute Respiratory InfectionsTechnical basis:• Multicentre randomized clinical study in 8 sites in 7

countries (N=958)– 12.7% failed treatment by day 6 – higher in

Chloramphenicol group (RR of 1.5); common reasons were deaths (n=44), development of septic shock (n=29), or persistence of very severe pneumonia (n=21)

– Tx failure at 48 hours (8.6%), constituting 51% of all tx failure.

– Overall more deaths occurred at the chloramphenicol group than the ampicillin-gentamicin group by day 30.

– Based on these results the use of gentamicin plus ampocillin for the management of very severe pneumonia is warranted

Acute Respiratory InfectionsTechnical basis:• WHO supported studies on “The assessment &

management of wheeze in children 1-59 months of age presenting with cough and /or difficult breathing” in several countries

Pakistan (n=1622)595 (36.7% w/ audible wheeze)

Thailand (n=521) 48 (9.2% w/ audible wheeze)

number Response Subsequent deterioration

number Response Subsequent deterioration

Non-severepneumonia

1004(61.8%)

621 (61.8%)

93(14.9%)

256(49.1%)

217(84.8%)

14(6.4%)

Severepneumonia

618(38.2%)

166(26.8%)

63(37.9%)

265(50.9%)

189(71.3%)

24(12.7%)

-These data show a large no. of children w/ wheeze are being classified as pneumonia and are being prescribed antibiotics unnecessarily.

- Bronchodilators are being underutilized in children with wheeze.

-Majority of children with wheeze who respond to a trial of inhaled bronchodilators continue to do well when sent home without an antibiotic.

Acute Respiratory Infections

Diarrheal diseases

Technical 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

DIARRHEAL DISEASES

EAR INFECTIONSTechnical basis:

– Cochrane review of randomized controlled trials published in the Cochrane Library• Aural toilet cobined with antimicrobial tx is more effective

than aural toilet alone; oral antibiotics were found to be better than aural toilet alone

• Topical 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

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

FEVER/MALARIA• 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