Integrated Management of Childhood Illnesses (IMCI)

8/8/2019 Integrated Management of Childhood Illnesses (IMCI)

1/109

Integrated Management ofIntegrated Management of

Childhood Illnesses (IMCI)Childhood Illnesses (IMCI)

Prof. Priscila L. LonganillaProf. Priscila L. Longanilla


2/109

OverviewOverview


3/109

IMCIIMCI

WHAT IS IMCI?WHAT IS IMCI?

a strategy for reducing mortality anda strategy for reducing mortality and

morbidity associated with major causes ofmorbidity associated with major causes ofchildhood illnesschildhood illness

A joint WHO/UNICEF initiative since 1992A joint WHO/UNICEF initiative since 1992


4/109

Essential Package for Child SurvivalEssential Package for Child Survival

Skilled attendance during pregnancy, deliverySkilled attendance during pregnancy, deliveryand immediate postpartumand immediate postpartum

Care of the newbornCare of the newborn Breastfeeding and complementary feedingBreastfeeding and complementary feeding Micronutrient supplementationMicronutrient supplementation Immunization of childrenImmunization of children

and mothersand mothers Integrated management ofIntegrated management of

sick children (IMCI)sick children (IMCI)

Use of insecticideUse of insecticide--treated bedtreated bed--netsnets


5/109

IMCIIMCI

OBJECTIVESOBJECTIVES

To reduce SIGNIFICANTLY globalTo reduce SIGNIFICANTLY globalmortality and morbidity assoc. with themortality and morbidity assoc. with themajor causes of disease in childrenmajor causes of disease in children

To contribute to healthy growth andTo contribute to healthy growth anddevelopment of childrendevelopment of children


6/109

Major causes of death under five, 2002Major causes of death under five, 2002ARI18%

Diarrhea 15%

Malaria 10%

Measles 5%HIV/

AIDS

4%

Perinatal

23%

Other

25%

Deaths assoc. with

malnutrition

54%


7/109

IMCIIMCI

THE PROBLEM:THE PROBLEM:

1.1. The under five population is the mostThe under five population is the most

vulnerable groupvulnerable group2.2. Child mortality remains UNACCEPTABLYChild mortality remains UNACCEPTABLY

HIGHHIGH

3.3. Many of these deaths had no medicalMany of these deaths had no medicalattendance or being seen by firstattendance or being seen by first levellevelhealth facilitieshealth facilities


8/109

IMCIIMCI

THE PROBLEMTHE PROBLEM

4. First4. First--level facilities:level facilities:

-- undermanned/underpaidundermanned/underpaid-- HWs are not appropriately TRAINEDHWs are not appropriately TRAINED

-- drug supply inadequate/not properlydrug supply inadequate/not properly

managedmanaged

-- inaccessibleinaccessible

-- poor laboratory supportpoor laboratory support


9/109

IMCIIMCI

THE PROBLEMTHE PROBLEM

5. Family and community profile/ practices5. Family and community profile/ practices

-- late help seeking behaviorlate help seeking behavior

-- poor utilization of health facilitiespoor utilization of health facilities-- literacyliteracy

-- traditional beliefs/traditionstraditional beliefs/traditions

-- economiceconomic

-- large familieslarge families-- crowded, dense, polluted environmentcrowded, dense, polluted environment


10/109

Main symptoms of 450 sick childrenMain symptoms of 450 sick children

0

10

20

30

40

50

60

70

80

90

100

82.5%

45%

92.5 %

8.4%

Cough Diarrhea Fever Ear problems


11/109

IMCIIMCIFrequency of presenting complaints of 450Frequency of presenting complaints of 450

children (as volunteered by mothers)children (as volunteered by mothers)

-10 10 30 50 70

Fever

CoughDiarrhea

Ear problemsSkin lesions

Abdominal pain

Eye discharge

Dental problemsNeck swelling

Gen. swellingAnorexia

Rectal prolapse

HeadachesNot recorded

Not covered by IMCI

(13%)

Covered by

IMCI

(87 %)


12/109


13/109

FREQUENCYOF 4 MAIN SYMPTOMS IN EACH PATIENTFREQUENCYOF 4 MAIN SYMPTOMS IN EACH PATIENTVSMMCVSMMC

0 20 40 60

ONE SYMPTOM62%

2 SYMPTOMS 31%

3 SYMPTOMS 4%

4 SYMPTOMS 3%


14/109

The IMCI training was designed to teach The IMCI training was designed to teachintegrated management of sick youngintegrated management of sick younginfants and children to first level HWs ininfants and children to first level HWs inprimary care settings that have NOprimary care settings that have NOlaboratory support and only a limitedlaboratory support and only a limitednumber of essential drugs.number of essential drugs.


15/109

Action oriented CLASSIFICATIONS , Action oriented CLASSIFICATIONS ,rather than EXACT DIAGNOSES, arerather than EXACT DIAGNOSES, areused.used.


16/109

A careful balance has been struck A careful balance has been struck

between SENSITIVITY and SPECIFICITYbetween SENSITIVITY and SPECIFICITY


17/109

Using FEW CLINICAL SIGNS as

possible which health workers of diverse

background can be trained to recognize


18/109

The IMCI guidelines rely on detection of The IMCI guidelines rely on detection ofcases based on SIMPLE CLINICAL SIGNS,cases based on SIMPLE CLINICAL SIGNS,without laboratory tests, and offerwithout laboratory tests, and offerEMPIRIC TX EMPIRIC TX


19/109

IMCIIMCI

COMPONENTSCOMPONENTS

Improving case management skills ofImproving case management skills of

health workershealth workersa. standard guidelinesa. standard guidelines

b. training (preb. training (pre-- service and inservice and in-- service)service)

c. followc. follow--up after trainingup after training


20/109

IMCIIMCI


Improving the health system to deliverImproving the health system to deliver

IMCIIMCIa. essential drug supplya. essential drug supply

b. organization of health facilitiesb. organization of health facilities

c. management of supervisionc. management of supervision


21/109

IMCIIMCI


Improving family and community practicesImproving family and community practices


22/109

IMCIIMCI

CASE MX PROCESSCASE MX PROCESS

1.1. HWHW assessesassesses the sick childthe sick child

-- IDENTIFYIDENTIFY any danger sign presentany danger sign present-- ASKASK about the four(4) main symptomsabout the four(4) main symptoms

cough, diarrhea, fever, and earcough, diarrhea, fever, and ear

problemproblem-- REVIEWREVIEW nutrition, Vit A ,immunizationnutrition, Vit A ,immunization


23/109

IMCIIMCI


2. HW2. HW CLASSIFIESCLASSIFIES childs illness using achilds illness using a

colorcolor--coded triage:coded triage:PINK= urgent referralPINK= urgent referral

YELLOW= specific medical tx, and adviceYELLOW= specific medical tx, and advice

GREEN= simple advice on home careGREEN= simple advice on home care


24/109

IMCIIMCI


3. HW then3. HW then identifies SPECIFIC TXidentifies SPECIFIC TX

-- anan INTEGRATED TREATMENT PLANINTEGRATED TREATMENT PLAN isisdevelopeddeveloped

-- decides referral (hospital) or homedecides referral (hospital) or home


25/109

IMCIIMCI

CASE MX PROCESSCASE MX PROCESS4.4. TREATMENT INSTRUCTIONSTREATMENT INSTRUCTIONS are carried out:are carried out:

referral: prereferral: pre--referral treatment, convincingreferral treatment, convincing

mothers to go to hospital, arranging formothers to go to hospital, arranging fortransporttransporthome care: continue feeding, fluids, others;home care: continue feeding, fluids, others;oral drugs, ORS, treat local infections,oral drugs, ORS, treat local infections,signs to come back immediately, when to returnsigns to come back immediately, when to returnfor routine followfor routine follow--upup

5.5. COUNSELINGCOUNSELING mothersmothers6.6. FFFF--UPUP instructions when the child returns toinstructions when the child returns to

clinicclinic


26/109

IMCIIMCI

Management

of sick

children

Nutrition Immunization Other disease

Prevention

Promotion of

growth and

development

Integrated Management

of Childhood Illness (IMCI)


27/109

IMCIIMCI

CHILD HEALTH INTERVETIONS IN IMCICHILD HEALTH INTERVETIONS IN IMCI

Case Mx interventions:Case Mx interventions:

Pneumonia MalariaPneumonia Malaria

Diarrhea MalnutritionDiarrhea Malnutrition-- dehydration Anemiadehydration Anemia

-- persistent diarrhea Measlespersistent diarrhea Measles

-- dysentery Ear infectiondysentery Ear infectionMeningitisMeningitis

SepsisSepsis


28/109

IMCIIMCI

Preventive interventions:Preventive interventions:

Immunization during sick child visitsImmunization during sick child visits

Nutrition counselingNutrition counseling

BreastfeedingBreastfeeding


29/109

WHYWHYTHEN SHOULD IMCI BETHEN SHOULD IMCI BE

TAUGHT TOTAUGHT TO

MEDICAL/NU

RSIN

GMEDICAL/NU

RSIN

GSTUDENTS?STUDENTS?


30/109

Why is IMCI needed in medical /Why is IMCI needed in medical /

nursing education?nursing education? Gives priority and emphasis to theGives priority and emphasis to the mostmost

frequent and serious healthfrequent and serious health

problemsproblemsof childrenof children Provides aProvides a link to reallink to real--lifelife situationssituationswhere diagnostic tools and drugs may bewhere diagnostic tools and drugs may bescarcescarce

Promotes rapidPromotes rapid recognitionrecognitionof theof theseverity of a childs illness andseverity of a childs illness and actionaction,,including rapid referral for severely illincluding rapid referral for severely illchildrenchildren


31/109

Why is IMCI needed in medical /Why is IMCI needed in medical /

nursing education?nursing education?LinksLinks preventivepreventive andand curativecurative

carecare ProvidesProvides additional skillsadditional skillsin importantin important

areas such as nutrition counsellingareas such as nutrition counselling EmphasizesEmphasizes actionaction--orientedorientedandand

affordableaffordable interventionsinterventions Links different levelsLinks different levelsof healthof health

professionals and different levels of aprofessionals and different levels of ahealth systemhealth system


32/109

PrePre--Service educationService education

The initial undergraduate education ofhealthThe initial undergraduate education ofhealthcare professionals before they enter serviccare professionals before they enter servic

Objectives for incorporating IMCI into academicObjectives for incorporating IMCI into academicprogrammes:programmes:

-- Improve student theoretical and practical knowledImprove student theoretical and practical knowled

-- Improve student skills in standard caseImprove student skills in standard case

managementmanagement

-- Prepare students to support and follow nationalPrepare students to support and follow nationalguidelines and to work within the nationalhealthguidelinesandto work withinthe nationalhealthsystemsystem


33/109

IMCIIMCI

Preventive and promotive elementsPreventive and promotive elements

Reducing missed opportunities forReducing missed opportunities forimmunizationimmunization

Breastfeeding and other nutritionalBreastfeeding and other nutritionalcounselingcounseling

Vitamin A and Iron supplementationVitamin A and Iron supplementation Treatment of helminth infestationsTreatment of helminth infestations


34/109

We are guilty of many errors and manyWe are guilty of many errors and manyfaults, but our worst crime is abandoningfaults, but our worst crime is abandoningchildren, neglecting the fountain of life.children, neglecting the fountain of life.Many of the things we need can waitMany of the things we need can wait

thethe CHILDCHILD can notcan not


35/109

Right now is the time his bones areRight now is the time his bones areformed, his blood being made, andformed, his blood being made, andhis senses arehis senses are

being developedbeing developed


36/109

To him we cannot answerTo him we cannot answer

TOMORROW,TOMORROW,

his name is TODAYhis name is TODAY

--Gabriela MistalGabriela Mistal


37/109


38/109

Integrated Case ManagementIntegrated Case Management

ProcessProcess


39/109

Assess the child or young infantAssess the child or young infant Classify the illnessClassify the illness Identify treatmentIdentify treatment

Treat the childTreat the child Counsel the motherCounsel the mother Give followGive follow up careup care


40/109

How to select the appropriate case?How to select the appropriate case?

Decide which age group the child is in:Decide which age group the child is in:

Age 1 week up to 2 monthsAge 1 week up to 2 months

Age 2 months up to 5 yearsAge 2 months up to 5 years


41/109

The ProcessThe Process


42/109

A. AssessmentA. Assessment Greet the mother appropriately and askGreet the mother appropriately and ask

her to sit with her childher to sit with her child

AgeAge

TemperatureTemperatureWeightWeight

Ask the what the childs problems are.Ask the what the childs problems are.

Record what the mother tells you about theRecord what the mother tells you about thechilds problemschilds problems


43/109

Use good communication skills:Use good communication skills:

Listen carefully to what the mother tells youListen carefully to what the mother tells you

Use words the mother understandsUse words the mother understands

Give the mother time to answer the questionsGive the mother time to answer the questions

Ask additional questions when the mother isAsk additional questions when the mother isnot sure about her answernot sure about her answer


44/109

Determine if the visit is:Determine if the visit is:

InitialInitial

FollowFollow upup


45/109

Check for General Danger SignsCheck for General Danger Signs

ASK:ASK: Is the child is not able to drink or breastIs the child is not able to drink or breast

feed?feed?

Does the child vomit everything?Does the child vomit everything? Has the child has convulsions? (during theHas the child has convulsions? (during the

present illness)present illness)


46/109

LOOK:LOOK:

See if the child is abnormally sleepySee if the child is abnormally sleepyor difficult to awakenor difficult to awaken

ASKABOUTTHE MAINASKABOUTTHE MAINSYMPTOMS:SYMPTOMS:

Cough or Difficulty of BreathingCough or Difficulty of Breathing

Ask for how longAsk for how long childchildCount the breaths in one minuteCount the breaths in one minute must bemust be

Look for chest indrawingeLook for chest indrawinge calmcalm

Listen for stridorListen for stridor


47/109

REMEMBER:REMEMBER:

If the child is:If the child is: Fast breathing is:Fast breathing is:

1 week up to 2 mos1 week up to 2 mos 60 Bpm and60 Bpm and

2 mos up to 12 mos2 mos up to 12 mos 50 Bpm and50 Bpm and 12 mos up to 5 years12 mos up to 5 years 40 Bpm and40 Bpm and


48/109

Classify Cough or Difficulty ofClassify Cough or Difficulty ofBreathingBreathing

A lA l SEVERSEVER Give first dose of an appropriateGive first dose of an appropriate


49/109

Any generalAny generaldanger signs ordanger signs or

Chest indrawingChest indrawing

Stridor in calmStridor in calmchildchild

SEVERSEVERPNEUMONIAPNEUMONIA

OR VERYOR VERYS

EVERES

EVEREDISEASEDISEASE

Give first dose of an appropriateGive first dose of an appropriateantibioticantibiotic

Give Vit. AGive Vit. ATreat the child to prevent low bloodTreat the child to prevent low blood

sugarsugarRefer URGENTLY to hospitalRefer URGENTLY to hospital

Fast breathingFast breathing PNEUMONIAPNEUMONIA

Give an appropriate antibiotic for 5Give an appropriate antibiotic for 5daysdays

Soothe the throat and relieve theSoothe the throat and relieve thecough with a safe remedycough with a safe remedy

Advise mother when to returnAdvise mother when to returnimmediatelyimmediately

FollowFollow up in 2 daysup in 2 days

No signs ofNo signs ofpneumonia orpneumonia orvery severevery severediseasedisease

NONOPNEUMONIAPNEUMONIACOUGH ORCOUGH OR

COLDCOLD

if coughing more than 30 days, referif coughing more than 30 days, referfor assessmentfor assessment

Soothe the throat and relieve theSoothe the throat and relieve thecough with safe remedycough with safe remedy


FollowFollow up in 5 days if not improvingup in 5 days if not improving


50/109

Does the child have diarrhea?Does the child have diarrhea?

If yes, ASK:If yes, ASK:

For how long?For how long?

Is there a blood in the stoolIs there a blood in the stool


51/109


52/109

LOOKAND FEEL:LOOKAND FEEL:

Offer the child fluid. Is the child:Offer the child fluid. Is the child:Not able to drink or drinking poorly?Not able to drink or drinking poorly?

Drinking eagerly, thirsty?Drinking eagerly, thirsty?

Pinch the skin of the abdomen.Pinch the skin of the abdomen.Does it goes back:Does it goes back:

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


53/109

Classify DiarrheaClassify Diarrhea

For DehydrationFor Dehydration

If the child has no otherIf the child has no other


54/109

Two of the followingTwo of the followingsigns:signs:

AbnormallyAbnormallysleepy or difficultsleepy or difficultto awakento awaken

Sunken eyesSunken eyesNot able toNot able todrink or drinkingdrink or drinkingpoorlypoorly

Skin pinch goesSkin pinch goesback very slowlyback very slowly

SevereSevereDehydrationDehydration

If the child has no otherIf the child has no othersevere classification:severe classification:

-- give fluid for severegive fluid for severe

dehydration (Plan C).dehydration (Plan C). ORORIf child also has anotherIf child also has anothersevere classification:severe classification:

-- referrefer URGENTLYURGENTLY totothe hospital with motherthe hospital with mothergiving frequent sips ofORSgiving frequent sips ofORSon the way.on the way.

-- advise mother toadvise mother tocontinue breastfeeding.continue breastfeeding.

If child is 2 years or olderIf child is 2 years or olderand there is cholera in yourand there is cholera in yourarea, give antibiotic forarea, give antibiotic forcholeracholera


55/109

Two of theTwo of thefollowing signs:following signs:

RestlessnessRestlessness

Sunken eyesSunken eyesDrinks eagerlyDrinks eagerlySkin pinchSkin pinchgoes backgoes backslowlyslowly

SomeSomeDehydrationDehydration

Give ORS, ZincGive ORS, Zincsupplementation and foodsupplementation and foodfor some dehydrationfor some dehydration

(Plan B)(Plan B)

If the child has anotherIf the child has anothersevere classification:severe classification:

-- refer URGENTLY torefer URGENTLY to

hospital with motherhospital with mothergiving frequent sips ofgiving frequent sips ofORS on the way.ORS on the way.

-- advise mother toadvise mother to

continue breast feedingcontinue breast feedingAdvise mother when toAdvise mother when toreturn immediatelyreturn immediately

FollowFollow up in 5 days ifup in 5 days ifnot improvingnot improving


56/109

Not enough signsNot enough signs

to classify as someto classify as someor severeor severedehydrationdehydration

NoNoDehydrationDehydration

Give ORS, ZincGive ORS, Zincsupplementation andsupplementation andfood to treatfood to treatdiarrhea at homediarrhea at home

Advise motherAdvise motherwhen to returnwhen to returnimmediatelyimmediately

FollowFollow up in 5up in 5days if not improvingdays if not improving


57/109

and if diarrhea 14 days or moreand if diarrhea 14 days or more

treat dehydration beforetreat dehydration before


58/109

DehydrationDehydrationpresentpresent

SEVERESEVEREPERSISTENTPERSISTENTDIARRHEADIARRHEA

treat dehydration beforetreat dehydration beforereferral unless the childreferral unless the childhas another severehas another severeclassificationclassification

Give Vit.AGive Vit.ARefer to hospitalRefer to hospital

No dehydrationNo dehydration PERSISTENTPERSISTENTDIARRHEADIARRHEA

Advise the mother onAdvise the mother onfeeding a child who hasfeeding a child who hasPERSISTENT DIARRHEAPERSISTENT DIARRHEA

Give Vit.AGive Vit.AFollowFollow up in 5 daysup in 5 daysAdvise mother when toAdvise mother when toreturn immediatelyreturn immediately


59/109

and if blood in the stooland if blood in the stool

Blood in theBlood in thestoolstool

DYSENTERYDYSENTERY

Treat for 5 daysTreat for 5 dayswith an oralwith an oral

antibioticantibioticrecommended forrecommended forShigella in your areaShigella in your area

FollowFollow up in 2up in 2

daysdaysAdvise motherAdvise motherwhen to returnwhen to returnimmediatelyimmediately


60/109


61/109

ASK:ASK:

For how long hasFor how long hasthe child had fever?the child had fever?If more than 7 days,If more than 7 days,has fever beenhas fever been

present everyday?present everyday?Has the child hadHas the child hadmeasles within themeasles within thelast 3 months?last 3 months?

LOOK& FEEL:LOOK& FEEL:

Look and feel for stiffLook and feel for stiffneckneck

Look for runny noseLook for runny nose

LOOKFOR SIGNSLOOKFOR SIGNS

OF MEASLESOF MEASLESGeneralized rash, andGeneralized rash, andOne of these: cough,One of these: cough,

runny nose or red eyesrunny nose or red eyes


62/109


63/109


64/109

Blood smear (+)Blood smear (+)If blood smear notIf blood smear notdone:done:

No runny noseNo runny noseNo measlesNo measlesNo other causes ofNo other causes offeverfever

MALARIAMALARIA

Treat the child with oral antiTreat the child with oral anti

malarialmalarialGive one dose ofGive one dose ofparacetamol in health centerparacetamol in health centerfor high fever (38.5 C orfor high fever (38.5 C orabove)above)

Advise mother when toAdvise mother when toreturn immediatelyreturn immediately

FollowFollow up in 2 days if feverup in 2 days if feverpersistpersist

If fever is present every dayIf fever is present every dayfor more than 7 days refer forfor more than 7 days refer forassessmentassessment


65/109

Blood smear (Blood smear (--))

Runny nose orRunny nose or

Measles orMeasles or

Other causes ofOther causes offeverfever

FEVER MALARIAFEVER MALARIAUNLIKELYUNLIKELY

Give one dose ofGive one dose ofparacetamol inparacetamol inhealth center forhealth center for

high fever (38.5 C orhigh fever (38.5 C orabove)above)

Advise motherAdvise motherwhen to returnwhen to return

immediatelyimmediatelyFollowFollow up in 2up in 2days if fever persistdays if fever persist

If fever is presentIf fever is present

every day for moreevery day for morethan 7 days refer forthan 7 days refer forassessmentassessment

Treat other causesTreat other causesof feverof fever


66/109


67/109

Any dangerAny dangersigns orsigns or

Stiff neckStiff neck

VERY SEVEREVERY SEVEREFEBRILEFEBRILEDISEASEDISEASE

Give one dose ofGive one dose ofappropriate antibioticappropriate antibiotic

Treat the child to preventTreat the child to preventlow blood sugarlow blood sugar

Give one dose ofGive one dose ofparacetamol in health centerparacetamol in health centerfor high fever (38.5 C orfor high fever (38.5 C orabove)above)

ReferU

RGEN

TLY to hospitalReferU

RGEN

TLY to hospital

Give one dose ofGive one dose of


68/109

No signs ofNo signs of

severe febrilesevere febrilediseasedisease

FEVER: NO MALARIAFEVER: NO MALARIA

Give one dose ofGive one dose ofparacetamol inparacetamol inhealth center forhealth center for

high fever (38.5 C orhigh fever (38.5 C orabove)above)


FollowFollow up in 2up in 2days if fever persistdays if fever persist

If fever is presentIf fever is presentevery day for moreevery day for more

than 7 days refer forthan 7 days refer forassessmentassessment

Treat other causesTreat other causesof feverof fever


69/109

If the child has measles now orIf the child has measles now or

within the last three months:within the last three months: Look for mouth ulcersLook for mouth ulcers

Are they deep or extensive?Are they deep or extensive?

Look for pus draining from the eyesLook for pus draining from the eyes

Look for clouding of the cornea.Look for clouding of the cornea.


70/109

If MEASLES now or within last 3If MEASLES now or within last 3months, Classifymonths, Classify


71/109

Clouding ofClouding ofcorneacornea

Deep extensiveDeep extensivemouth ulcersmouth ulcers

Any dangerAny dangersignssigns

SEVERESEVERECOMPLICATEDCOMPLICATEDMEASLES***MEASLES***

Give Vit.AGive Vit.A

Give first dose ofGive first dose ofan appropriatean appropriateantibioticsantibiotics

If clouding of theIf clouding of the

cornea or puscornea or pusdraining from thedraining from theeye, applyeye, applytetracyclin eyetetracyclin eye

ointmentointmentRefer URGENTLYRefer URGENTLYto hospitalto hospital


72/109


73/109

Assess Dengue Hemorrhagic FeverAssess Dengue Hemorrhagic Fever

ASK:ASK:Has the child had anyHas the child had anybleeding from the nose orbleeding from the nose orgums or in the vomitus orgums or in the vomitus or

stool?stool?Has the child had blackHas the child had blackvomitus?vomitus?

Has the child had blackHas the child had black

stools?stools?Has the child hadHas the child hadpersistent abdominal pain?persistent abdominal pain?

Has the child hadHas the child hadpersistentvomiting?persistentvomiting?

LOOK& FEELLOOK& FEEL

Look for bleeding from noseLook for bleeding from noseor gumsor gums

Look for skin petechiaeLook for skin petechiae

Feel for cold clammyFeel for cold clammyextremitiesextremities

Check for slow capillary refill.Check for slow capillary refill.-- if none of the above ASKorif none of the above ASKor

LOOK& FEEL signs are presentLOOK& FEEL signs are present& the child is 6 months and& the child is 6 months andolder & fever present for moreolder & fever present for morethan 3 daysthan 3 days

Perform tourniquet testPerform tourniquet test


74/109


75/109


76/109

Does the child have an earDoes the child have an ear

problem?problem?IF YES:IF YES:

Is there ear pain?Is there ear pain?

Is there ear discharge?Is there ear discharge?if yes, for how long?if yes, for how long?

LOOK, LISTEN:LOOK, LISTEN:

Look for the pusLook for the pus

draining from the ear.draining from the ear.

Feel for tender swellingFeel for tender swellingbehind the earbehind the ear


77/109

Tender swellingTender swellingbehind the earbehind the earMASTODITISMASTODITIS

give first doseof angive first doseof anappropriate antibioticappropriate antibiotic

give first dose ofgive first dose ofparacetamol for painparacetamol for pain

Refer URGENTLY toRefer URGENTLY tohospitalhospital

Ear painEar painPus is seenPus is seendraining from thedraining from theear and dischargeear and dischargeis reported foris reported forless than 14 daysless than 14 days

ACUTE EARACUTE EARINFECTIONINFECTION

Give an antibioticGive an antibioticfor 5 daysfor 5 days

Give paracetamolGive paracetamol

for painfor painDry the ear byDry the ear bywickingwicking

FollowFollow up in 5up in 5

daysdays

h bh b


78/109

Pus is seenPus is seendraining from thedraining from the

ear and dischargeear and dischargeis reported foris reported forless than or 14less than or 14days moredays more

CHRONIC EARCHRONIC EARINFECTIONINFECTION

Dry the ear byDry the ear bywickingwicking

FollowFollow up in 5up in 5daysdays


No ear pain, andNo ear pain, and

No pus seenNo pus seendraining from thedraining from theearear

NO EARNO EARINFECTIONINFECTION

No additionalNo additionaltreatmenttreatment



79/109

Check for malnutrition and AnemiaCheck for malnutrition and Anemia

LOOK, LISTEN:LOOK, LISTEN:

Look for visible severe wastingLook for visible severe wasting

Look for edema of both feetLook for edema of both feet Look for palmar pallor. Is it:Look for palmar pallor. Is it:-- severe palmar pallor?severe palmar pallor?

-- some palmar pallor?some palmar pallor?

Determine weight for ageDetermine weight for age


80/109

Classify nutritional statusClassify nutritional status

Visible severeVisible severewasting orwasting or

Edema of bothEdema of bothfeet orfeet or

Severe palmarSevere palmarpallorpallor

SEVERESEVEREMALNUTRITIONMALNUTRITIONOR SEVEREOR SEVERE

ANEMIAANEMIA

Give Vit. AGive Vit. AReferReferURGENTLY toURGENTLY to

hospitalhospital

Assess the childs feeding andAssess the childs feeding andl h h f dil h h f di


81/109

Some palmarSome palmar

pallor orpallor orVery lowVery lowweight for ageweight for age

ANEMIAANEMIA

OR VERYOR VERYLOWLOW

WEIGHTWEIGHT

counsel the mother on feedingcounsel the mother on feedingaccording to the FOOD box on theaccording to the FOOD box on theCOUNSEL THE MOTHER chartCOUNSEL THE MOTHER chart

-- if feeding problem, followif feeding problem, follow upupin 5 daysin 5 days

If some pallorIf some pallor-- give irongive iron

-- give mebendazole/albendazole ifgive mebendazole/albendazole ifchild is 12 months or older and haschild is 12 months or older and hasnot had a dose in previous 6 mos.not had a dose in previous 6 mos.

-- followfollow up in 14 daysup in 14 days

Ifvery low weight for ageIfvery low weight for age-- give Vit. Agive Vit. A

-- followfollow up in 30 daysup in 30 days


If th hild i lIf th hild i l


82/109

Notvery lowNotvery lowweight for ageweight for ageand no otherand no othersigns ofsigns ofmalnutritionmalnutrition

NO ANEMIANO ANEMIAAND NOT VERYAND NOT VERY

LOW WEIGHTLOW WEIGHT

If the child is lessIf the child is lessthan 2 years old,than 2 years old,

assess the childsassess the childsfeeding and counselfeeding and counselthe mother on feedingthe mother on feedingaccording to the foodaccording to the food

box on the COUNSELbox on the COUNSELTHE MOTHER chartTHE MOTHER chart

-- if feeding is aif feeding is aproblem, followproblem, follow up inup in

5 days5 daysAdvise the motherAdvise the motherwhen to returnwhen to returnimmediatelyimmediately


83/109

Then check the childsThen check the childs

immunization statusimmunization statusImmunization Schedule:Immunization Schedule:

Age Age VaccineVaccine

BirthBirth BCGBCG Hep BHep B 11

6 weeks6 weeks DPTDPT 11 OPVOPV -- 11 HEP BHEP B 22

10 weeks10 weeks DPTDPT -- 22 OPVOPV -- 22 HEP BHEP B 33

14 weeks14 weeks DPTDPT -- 33 OPVOPV -- 33

9 months9 months MeaslesMeasles


84/109

Then check the vitamin A statusThen check the vitamin A status

Vitamin A supplementation schedule:Vitamin A supplementation schedule:

11ststdose at 6 months or abovedose at 6 months or above

Subsequent dose every 6 monthsSubsequent dose every 6 months

Assess Other ProblemsAssess Other Problems


85/109

ASSESS, CLASSIFY AND TREATASSESS, CLASSIFY AND TREATTHE SICK INFANT AGE 1 WEEKTHE SICK INFANT AGE 1 WEEK

UP TO 2 MONTHSUP TO 2 MONTHS


86/109

CHECK FOR POSSIBLE BACTERIALCHECK FOR POSSIBLE BACTERIAL


87/109

CHECKFOR POSSIBLE BACTERIALCHECKFOR POSSIBLE BACTERIAL

IN

FECTION

IN

FECTION

ASK:ASK:Has the infant had convulsions?Has the infant had convulsions?


88/109

Look, ListenLook, Listen

Count the breaths in oneCount the breaths in oneminute. Repeat the count ifminute. Repeat the count if

elevated.elevated. Look for chest indrawingLook for chest indrawing Look for nasal flaringLook for nasal flaring

Look and listen for gruntingLook and listen for grunting

Childmust be

calm


89/109

Look, ListenLook, Listen

Look and feel for bulging fontanelsLook and feel for bulging fontanels Look for pus draining from the earLook for pus draining from the ear Look at the umbilicus. Is it red or draining pus? DoesLook at the umbilicus. Is it red or draining pus? Does

the redness extend to the skin?the redness extend to the skin? Measure the temperature (or feel for fever or lowMeasure the temperature (or feel for fever or lowbody temperature)body temperature)

Look for skin pustules. Are there many or severeLook for skin pustules. Are there many or severe

pustules?pustules? See if the young infant is abnormally sleepy or difficultSee if the young infant is abnormally sleepy or difficultto awaken.to awaken.

Look at the young infants movements. Are they lessLook at the young infants movements. Are they less

than normal?than normal?


90/109

Classify ALL YOUNG INFANTSClassify ALL YOUNG INFANTS

Convulsions orConvulsions or GiveGive thethe first firstdd ff


91/109

Fast breathing (60 BPM orFast breathing (60 BPM ormore)more)

Severe chest indrawingSevere chest indrawingNasal flaringNasal flaringGruntingGruntingBulging fontanelBulging fontanel

Pus drainiing from the earPus drainiing from the earUmbilical redness extendingUmbilical redness extendingto the skinto the skin

Fever (37.5 or above, or lowFever (37.5 or above, or low

body tempbody tempMany or severe postulesMany or severe postulesAbnormally sleepy or difficultAbnormally sleepy or difficultto awakento awaken

Less than normal movementsLess than normal movements

POSSIBLEPOSSIBLE

SERIOUSSERIOUSBACTERIALBACTERIALINFECTIONINFECTION

dosedose ofofintramuscularintramuscular

antibioticsantibioticsTreatTreat thethe childchildtoto preventprevent lowlowbloodblood sugarsugar

AdviseAdvise thethemothermother howhow totokeepkeep thethe infantinfantwarmwarm onon thethe

wayway toto thethehospitalhospital

ReferReferURGENTLYURGENTLY toto

thethe hospital**hospital**


92/109

Red umbilicus orRed umbilicus ordraining pusdraining pus

Skin pustulesSkin pustules

LOCALLOCALBACTERIALBACTERIALINFECTIONINFECTION

givegive anan appropriateappropriate

oraloral antibioticantibioticTreatTreat locallocal infectioninfection ininthethe healthhealth centercenter andandteachteach thethe mothermother toto

treattreat locallocal infectionsinfections atathomehome

AdviseAdvise thethe mothermother

howhow toto givegive homehome carecareforfor thethe youngyoung infantinfant

FollowFollow upup inin 22 daysdays

THEN ASK:THEN ASK:


93/109

THEN ASKTHEN ASKDoes the young infant haveDoes the young infant have

diarrhea?diarrhea?IF YES, ASK:IF YES, ASK:

For how long?For how long?Is there bloodIs there bloodin the stool?in the stool?


Look at the young infants general condition.Look at the young infants general condition.Is the young infant:Is the young infant:

-- Abnormally sleepy or difficult to awaken?Abnormally sleepy or difficult to awaken?

-- Restless or irritableRestless or irritable

Look for sunken eyesLook for sunken eyes

Pinch the skin of the abdomen.Pinch the skin of the abdomen.Does it goes back:Does it goes back:-- Very slowly (longer than 2 seconds)Very slowly (longer than 2 seconds)

-- Slowly?Slowly?


94/109

CLASSIFY DIARRHEACLASSIFY DIARRHEAFOR DEHYDRATIONFOR DEHYDRATION


95/109


96/109

Two of theTwo of thefollowingfollowingsigns:signs:

Restless,Restless,irritableirritable

Sunken eyesSunken eyesSkin pinchSkin pinch

goes backgoes backslowlyslowly

SOMESOMEDEHYDRATIONDEHYDRATION

Give fluid for someGive fluid for somedehydrationdehydration

IfinfantalsohasIfinfantalsohasPOSSIBLE SERIOUSPOSSIBLE SERIOUSBACTERIALBACTERIALINFECTION orINFECTION or

DYSENTERY:DYSENTERY:

-- Refer URGENTLY toRefer URGENTLY tohospital with motherhospital with mothergiving frequent sips ofgiving frequent sips ofORS on the wayORS on the way

-- Advise mother toAdvise mother tocontinue breastfeedingcontinue breastfeeding


97/109

Not enoughNot enoughsigns to classifysigns to classify

as some oras some orsevereseveredehydrationdehydration

NONODEHYDRATIONDEHYDRATION

Give fluid toGive fluid totreat diarrhea attreat diarrhea athomehome


98/109

and if diarrhea 14 days or moreand if diarrhea 14 days or more

Diarrhea lastingDiarrhea lasting14 days or more14 days or more

SEVERESEVEREPERSISTENTPERSISTENT

DIARRHEADIARRHEA

If the young infantIf the young infanthas dehydration,has dehydration,

treat dehydrationtreat dehydrationbefore referralbefore referralunless the infant hasunless the infant hasalso POSSIBLEalso POSSIBLE

SERIOUSSERIOUSBACTERIALBACTERIALINFECTIONINFECTION

Refer to hospitalRefer to hospital


99/109

THEN CHECK FOR FEEDINGTHEN CHECK FOR FEEDING


100/109

THEN CHECKFOR FEEDINGTHEN CHECKFOR FEEDINGPROBLEM OR LOW WEIGHT:PROBLEM OR LOW WEIGHT:

IF YES, ASK:IF YES, ASK:

Is there any difficulty feeding?Is there any difficulty feeding?

Is the infant breastfeed? IfIs the infant breastfeed? Ifyes, how many times in 24yes, how many times in 24hours?hours?

Does the infant usually receiveDoes the infant usually receive

any other foods or drinks? Ifany other foods or drinks? Ifyes, how often?yes, how often?

What do you use to feed theWhat do you use to feed theinfant?infant?


Determine weight forDetermine weight for

age.age.


101/109

IF AN INFANT:IF AN INFANT:

Has any difficult feeding.Has any difficult feeding. Is breast feeding less than 8 times in 24Is breast feeding less than 8 times in 24

hourshours Is taking any other foods or drinks, orIs taking any other foods or drinks, or Is low weight for age, andIs low weight for age, and

Has no indication to refer urgently to theHas no indication to refer urgently to thehospital:hospital:


102/109


103/109

Is the infant able to attach?Is the infant able to attach?

No attachment atNo attachment atallall

Not well attachedNot well attached Good attachmentGood attachment

TO CHECKATTACHMENT, LOOKFOR:TO CHECKATTACHMENT, LOOKFOR:

Chin touching breastChin touching breastMouth wide openMouth wide openLower lip turned outwardLower lip turned outward

More areola visible above than below the mouthMore areola visible above than below the mouth(all of these signs should be present if the(all of these signs should be present if theattachment is good)attachment is good)

Is the infant sucking effectivelyIs the infant sucking effectively


104/109

Is the infant sucking effectivelyIs the infant sucking effectively(that is, slow deep suck, something pausing)(that is, slow deep suck, something pausing)

Look for ulcers or white patches inLook for ulcers or white patches inthe mouth (thrush)the mouth (thrush)

Not sucking at allNot sucking at all Not suckingNot suckingeffectivelyeffectively

SuckingSuckingeffectivelyeffectively

Clear a blocked nose if it interferes withbreastfeeding


105/109

Classify FEEDINGClassify FEEDING

Not able to feedNot able to feedNo attachmentNo attachmentat allat all

Not sucking atNot sucking atallall

NOT ABLE TONOT ABLE TOFEED POSSIBLEFEED POSSIBLE

SERIOUSSERIOUSBACTERIALBACTERIAL

INFECTIONINFECTION

Give the first doseGive the first doseof intramuscularof intramuscularantibioticsantibiotics

Treat to preventTreat to preventlow blood sugarlow blood sugar

Advise the motherAdvise the motherhow to keep thehow to keep theyoung infant warmyoung infant warmon the way to theon the way to thehospitalhospital

Refer URGENTLYRefer URGENTLYto hospitalto hospital

Not wellNot wellattached toattached to

Advise the motherAdvise the motherto breastfeed as oftento breastfeed as often


106/109

attached toattached tobreastbreast

Not suckingNot suckingeffectivelyeffectively

Less than 8Less than 8breastfeeds in 24breastfeeds in 24

hourshours

Receives otherReceives otherfoods or drinksfoods or drinks

Low weight forLow weight forageageThrush (ulcersThrush (ulcersor white patchesor white patches

in mouth)in mouth)

FEEDINGFEEDINGPROBLEM ORPROBLEM ORLOW WEIGHTLOW WEIGHT

to breastfeed as oftento breastfeed as oftenand for as long as theand for as long as the

infant wants, day andinfant wants, day andnightnight

--if not well attachedif not well attachedor not suckingor not sucking

effectively, teach theeffectively, teach thecorrect positioningcorrect positioningand attachmentand attachment

--if breastfeedingif breastfeedingless than 8 times inless than 8 times in24 hours, advise to24 hours, advise toincrease frequency ofincrease frequency offeedingfeeding


107/109

Not wellNot wellattached toattached to


108/109

attached toattached tobreastbreast

Not suckingNot suckingeffectivelyeffectively

Less than 8Less than 8breastfeeds in 24breastfeeds in 24

hourshours

Receives otherReceives otherfoods or drinksfoods or drinks

Low weight forLow weight forageageThrush (ulcersThrush (ulcersor white patchesor white patches

in mouth)in mouth)

FEEDINGFEEDINGPROBLEM ORPROBLEM ORLOW WEIGHTLOW WEIGHT

If thrush, teach theIf thrush, teach the

mother to treatmother to treatthrush at homethrush at home

Advise the motherAdvise the motherto give home care forto give home care forthe young infantthe young infant

FollowFollow up anyup anyfeeding problem orfeeding problem or

thrush in 2 days.thrush in 2 days.FollowFollow up weightup weightfor age in 14 days.for age in 14 days.


109/109

Not low weightNot low weightfor age and nofor age and no

other signs ofother signs ofinadequateinadequatefeedingfeeding

NO FEEDINGNO FEEDINGPROBLEMPROBLEM

Advise theAdvise themother to givemother to givehome care for thehome care for the

young infantyoung infantPraise thePraise themother formother forfeeding the infantfeeding the infant

wellwell

Integrated Management of Childhood Illnesses (IMCI)

Documents

Transcript of Integrated Management of Childhood Illnesses (IMCI)