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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.
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Where Care for Children Is Provided?
Home 1st level health facility Specialized hospital
I M C ICommunityComponent REFERRAL CARE
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
Diseases Covered By IMCI
• Cough or difficult breathing
• Diarrhea• Throat problems• Ear Problems• Fever & Measles
3/4of Episodes of
Childhood illness
MALNUTRITION
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
Alexandria University IMCI Lecture 1 EMRO- WHO
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
Alexandria University IMCI Lecture 1 EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
General Danger Signs
CHECK for
GENERAL DANGER SIGNS
in ALL Children
Alexandria University IMCI Lecture 1 EMRO- WHO
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
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
CHECK FOR GENERAL DANGER SIGNS
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Has the child had convulsions?
• Ask the mother if the child has had convulsions during the current illness.
• Use words the mother understands.
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
Unconscious ?
• An unconscious child is a child who cannot be awakened.
• The child does NOT respond when he is :•Touched•Shaken, or•Spoken to
IMCI Lecture 1 Alexandria University EMRO- WHO
UNCONSCIOUS CHILD
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
LETHARGIC CHILD
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
CHECK FOR GENERAL DANGER SIGNS
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
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Cough OR Difficult Breathing
Then ASK About:COUGH ORDIFFICULTBREATHING
Alexandria University IMCI Lecture 1 EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
“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
IMCI Lecture 1 Alexandria University EMRO- WHO
Acute Respiratory Infections ( ARI )
•Common cause of mortality.
•Common cause of morbidity.
•Commonest reason for irrational drug prescription.
Global & National Health Problem
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Pneumonia: Severity
Recognition is based on:
• Fast breathing, and
• Lower chest wall indrawing
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
60
50
40
Cut-offs of Fast Breathing
IMCI Lecture 1 Alexandria University EMRO- WHO
LOWER CHEST WALL LOWER CHEST WALL INDRAWINGINDRAWING
Index of :
Severe Pneumoniaor very severe disease
Reasonable sensitivity & specificity " 89%".
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
CHEST INDRAWING
FAST BREATHING
SEVERE PNEUMONIAOR VERY SEVERE DISEASE
±±
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
IMCI Lecture 1 Alexandria University EMRO- WHO
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
+
IMCI Lecture 1 Alexandria University EMRO- WHO
No Pneumonia,
Cough or Cold
Antibiotics
No signs of Pneumonia or Very Severe Disease
IMCI Lecture 1 Alexandria University EMRO- WHO
Diarrhea
Then ASK About :
DIARRHEA
Alexandria University IMCI Lecture 1 EMRO- WHO
DiarrheaDiarrhea
Assessment
DehydrationAssessment • Classification
Home FluidsSelection • Fluids to avoid
Persistent Diarrhea Definition • Causes
Classification
Dysentery Classification
Antibiotics
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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?
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
Unconscious child
IMCI Lecture 1 Alexandria University EMRO- WHO
Lethargic child
IMCI Lecture 1 Alexandria University EMRO- WHO
Sunken Eyes
IMCI Lecture 1 Alexandria University EMRO- WHO
Skin Pinch returns Very Slowly (> 2 seconds
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
IMCI Lecture 1 Alexandria University EMRO- WHO
•Proximate Causes• Secondary disaccharidase deficiency• Salmonella sp.• Shigella sp.• Enteroadherent E. coli• Cryptosporidium
•Contributing Factors• Protein energy malnutrition• Micronutrient deficiencies• Immunodeficiency
Persistent DiarrheaCauses:
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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:
IMCI Lecture 1 Alexandria University EMRO- WHO
Antimicrobials against Shigella
EFFECTIVE• Co-Trimoxazole • Nalidixic acid• Pivmecillinam• Ceftriaxone • Ciprofloxacin• Other
quinolones
INEFFECTIVE• Metronidazole• Streptomycin• Chloramphenicol• Sulfonamide• Cepholosporins• Aminoglycosides• Nitrofurans
IMCI Lecture 1 Alexandria University EMRO- WHO
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)
IMCI Lecture 1 Alexandria University EMRO- WHO
THROAT PROBLEM
CHECK for THROAT PROBLEM in ALL CHILDREN
Alexandria University IMCI Lecture 1 EMRO- WHO
Throat Problems•Sore Throat & Pharyngitis
• Overview• Management Issue• Sensitivity & Specificity of signs
•Role of IMCI
•Classification of Throat Problem
•Treatment
IMCI Lecture 1 Alexandria University EMRO- WHO
is more than just
a sore throat. ?
Pharyngitis
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
Not all,Sore throatsare streptococcal !
However
IMCI Lecture 1 Alexandria University EMRO- WHO
Should We Treat All Sore All Sore Throats Throats With Antibiotics ?Antibiotics ?
• Cost• Side effects• Resistance• Super - infection
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
For Accurate Diagnosis:
• Throat culture
• Ag detection
• ASO Titre
Expensive, Not available at PHC level
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
EAR PROBLEM
ASK about :
EAR PROBLEM
Alexandria University IMCI Lecture 1 EMRO- WHO
EAR PROBLEM•Types of ear infection
•External otitis• Ask• Look
•Otitis media• Ask • Look
•Symptoms & Signs Used in IMCI
•Classification of ear problem
•Treatment
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
Ear Infection ?
• External ear :
Otitis Externa
• Middle ear :
Otitis Media
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Diagnosis of External Otitis
• Discharge: Serous or Purulent
• Ear Canal: **•Erythema•Edema•Otoscopy: very painful
**SUBJECTIVE SIGNS, NOT INCLUDED IN IMCI
LOOK
IMCI Lecture 1 Alexandria University EMRO- WHO
Diagnosis of Otitis Media
• Agonizing Ear Pain• Discharge (Otorrhea): Purulent• Other NON SPECIFIC Symptoms:
•Fever•Irritability OR Lethargy•Anorexia, Nausea, Vomiting, Diarrhea
•Headache ?
ASK
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
MASTOIDITIS
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
FEVER
ASK
about
FEVER
Alexandria University IMCI Lecture 1 EMRO- WHO
FeverFebrile Illness
Causes
Fever After Five DaysReferral
Classification of Fever Overvie
Stiff neck
Classification of fever
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
Looking andFeeling forSTIFF NECK
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
MALNUTRITION & ANEMIA
CHECK ForMALNUTRITION andANEMIAin ALL CHILDREN
Alexandria University IMCI Lecture 1 EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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%
IMCI Lecture 1 Alexandria University EMRO- WHO
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.
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
Mild & Moderate forms
severe forms
The Iceberg of Malnutrition
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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
IMCI Lecture 1 Alexandria University EMRO- WHO
• 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:
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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?
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
LOW WEIGHT FOR AGE
IMCI Lecture 1 Alexandria University EMRO- WHO
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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)
IMCI Lecture 1 Alexandria University EMRO- WHO
CHECK THE CHILD IMMUNIZATION STATUS
CHECK
IMMUNIZATIONand VITAMIN ASupplementationstatus In ALL CHILDREN
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO
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…
IMCI Lecture 1 Alexandria University EMRO- WHO
GIVE FOLLOW-UP CARE
Pneumonia, No pneumonia-Wheeze
Dysentery, Persistent Diarrhea
Sore throat, Ear Infection, Fever, Measles
Feeding Problems, Low weight
Pallor
IMCI Lecture 1 Alexandria University EMRO- WHO
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
IMCI Lecture 1 Alexandria University EMRO- WHO