Download - IMCI Lecture

GOOD MORNINGGOOD MORNING

“We are guilty of many errors and many faults, but our worst crime is abandoning children, neglecting the fountain of life. Many of the things we need can wait…

the CHILD can not………”

“Right now is the time his bones are formed, his blood being made, and his senses are being developed…”

To him we cannot answer “TOMORROW”

his name is “TODAY.”

~ Gabriela Mistal

Integrated Management of Childhood Illness (IMCI)

Christian T. Caligagan, M.D., DPPS

IMCI

WHAT IS IMCI?

• A strategy for reducing mortality and morbidity associated with major causes of childhood illness.

• A joint WHO/UNICEF initiative since 1992

IMCI

OBJECTIVES

• To reduce SIGNIFICANTLY global mortality and morbidity associated with the major causes of diseases in children.

• To contribute to healthy growth and development of children.

IMCI

According to the World Bank:

“The IMCI is likely to have the greatest impact in reducing the global burden of disease.”

Major causes of death under five, 2002ARI 18%

Diarrhea 15%

Malaria 10%

Measles 5%HIV/AIDS4%

Perinatal23%

Other25%

Deaths assoc. withmalnutrition

54%

IMCI

The IMCI training was designed to teach integrated management of sick infants and children to first level health workers in primary care settings that have NO laboratory support and only a limited number of essential drugs.

IMCI

Action-oriented CLASSIFICATIONS , rather than EXACT DIAGNOSES are used.

IMCI

A careful balance has been struck

between SENSITIVITY and

SPECIFICITY.

IMCI

Using FEW CLINICAL SIGNS as

possible which health workers of diverse

background can be trained to recognize.

IMCI

The IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS without laboratory tests and offer EMPIRIC TREATMENT.

Main 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

IMCIFrequency of presenting complaints of 450

children (as volunteered by mothers)

-10 10 30 50 70

FeverCough

DiarrheaEar problemsSkin lesions

Abdominal painEye discharge

Dental problemsNeck swelling

Gen. swellingAnorexia

Rectal prolapse

HeadachesNot recorded

Not covered by IMCI (13%)

Covered by IMCI (87 %)

Main symptoms of 478 children VSMMC

0

10

20

30

40

50

60

70

COUGH FEVER DIARRHEA EAR PROBLEM

FREQUENCY OF 4 MAIN SYMPTOMS IN EACH PATIENT VSMMC

0 20 40 60

ONE SYMPTOM62%

2 SYMPTOMS 31%

3 SYMPTOMS 4%

4 SYMPTOMS 3%

IMCI

COMPONENTS

1. Improving case management skills of health workers.

a. standard guidelines

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

c. follow-up after training

IMCI

2. Improving the health system to deliver

IMCI.

a. essential drug supply

b. organization of health facilities

c. management of supervision

IMCI

3. Improving family and community practices

IMCI

CASE MANAGEMENT PROCESS

1. Health worker assesses the sick child.

- IDENTIFY any danger sign present (unable to feed and drink, vomits everything, convulsion, difficult to awaken or abnormally sleepy)

- ASK about the four(4) main symptoms

cough, diarrhea, fever, and ear problem

- REVIEW nutrition, Vitamin A and immunization

IMCI

2. Health worker CLASSIFIES child’s illness using a color-coded triage:

PINK = urgent referral

YELLOW = specific medical treatment and advice

GREEN = simple advice on home care

IMCI

3. Heath worker then identifies SPECIFIC TREATMENT.

- an INTEGRATED TREATMENT PLAN is

developed

IMCI

4. TREATMENT INSTRUCTIONS are carried out: oral drugs, ORS, treat local infections, signs to come back immediately, when to return for routine follow-up.

5. COUNSELING mothers.

6. FF-UP instructions when the child returns to clinic.

IMCI

Management of sick children

Nutrition Immunization Other diseasePrevention Promotion of growth and development

Integrated Management of Childhood Illness (IMCI)

IMCI

CHILD HEALTH INTERVENTIONS IN IMCICase Management Interventions: Pneumonia Malaria Diarrhea Malnutrition - dehydration Anemia - persistent diarrhea Measles - dysentery Ear infection

Meningitis Dengue Sepsis

IMCI

Preventive interventions:

Immunization during sick child visits

Nutrition counseling

Breastfeeding

Why is IMCI needed in medical education?

• Gives priority and emphasis to the most frequent and serious health problems of children

• Provides a link to real-life situations where diagnostic tools and drugs may be scarce

• Promotes rapid recognition of the severity of a child’s illness and action, including rapid referral for severely ill children

• Links preventive and curative care• Provides additional skills in important areas such as

nutrition counselling • Emphasizes action-oriented and affordable

interventions• Links different levels of health professionals and

different levels of a health system

IMCI

• currently focused on first level facilities

out-patient facility - initially

in-patient facility - later

• comes as a generic guidelines for management which have been adapted to each country.

IMCI

Identification and provision of treatment

• Rehydration (diarrhea, DHF)

• Antibiotics ( e.g. pneumonias)

• Antimalarial

• Vitamin A

IMCI

Preventive and Promotive elements:

• Reducing missed opportunities for immunization

• Breastfeeding and other nutritional counseling

• Vitamin A and iron supplementation

• Treatment of helminthic infestations

IMCI

THE PROBLEMS:

1. The under five population is the most vulnerable group.

2. Child mortality remains UNACCEPTABLY HIGH.

3. Many of these deaths had no medical attendance or being seen by first –level health facilities.

IMCI

4. First-level facilities: - undermanned/underpaid - health workers are not appropriately TRAINED - drug supply inadequate/not properly

managed - inaccessible - poor laboratory support

IMCI

5. Family and community profile/ practices - late “help seeking” behavior - poor utilization of health facilities - literacy - traditional beliefs/traditions - economic - large families - crowded, dense, polluted environment

IMCI

TECHNICAL BASIS

ARI and DIARRHEA

IMCI-ARI

ASSESSMENT SIGNS:

1. BREATH RATE (FAST BREATHING)

2. DURATION OF COUGH

3. CHEST INDRAWING

4. STRIDOR when CALM

IMCI-ARI

Children who have been coughing for 30 days or more are referred for FURTHER ASSESSMENT, to consider the possibility of tuberculosis and other conditions.

IMCI-ARI

STRIDOR

> harsh noise when the child is breathing IN.

> can be reliably assessed when the child is CALM.

IMCI-ARI

Why Wheezing was not included:1. Mortality from asthma is relatively

uncommon.2. Children with severe bronchospasm will

be referred on the basis of chest indrawing.

(Training is simplified, concentrate on conditions contributing SUBSTANTIALLY to mortality)

IMCI-ARI

If wheezing is included in the guidelines:

1. Improves health worker credibility in managing difficult breathing.

2. Relieves suffering in child with significant wheezing.

3. Reduced referral.

4. More complex training (in-service).

IMCI-ARI

Wheezing was NOT included in IMCI so that:

1. Training less COMPLEX

2. Special supplies not needed

3. Training FOCUSED on pneumonia

4. Needless referral

IMCI-ARI

Objectives of the guidelines are to divide sick children with cough or difficult breathing into THREE categories:

1. Those who require admission for severe pneumonia

2. Those who require ANTIBIOTICS because they are LIKELY to have pneumonia

3. Those who simply have cough or cold and do not require antibiotics.

IMCI-ARI

Detecting Pneumonia by 2 key clinical signs:

1. Fast breathing

2. Lower chest wall indrawing

IMCI-ARI

Use of auscultation for predicting pneumonia in children

Place Sensitivity

1. Baltimore, Maryland 43%

2. New Haven, Connecticut 33%

3. Nairobi, Kenya 66%

4. Boston, Massachusetts 57%

Note: Diagnosis of pneumonia is confirmed by x-ray.

IMCI-ARI

Comparison of methods for detection of pneumonia in children ( 2mos up to 59mos)

METHOD SENSITIVITY SPECIFICITY

Stethoscope 53% 59%(crepitations)

Simple clinical signs 77% 58%(fast breathing or chest indrawing)

Note: Diagnosis of pneumonia is confirmed by X-ray.

IMCI-ARI

*Expert auscultation (crepitations) is less sensitive as a single sign, although when combined with FAST BREATHING, the two signs together will be more sensitive than either sign alone.

*But if both SIGNS are required to be present, the two signs together will be more SPECIFIC but will lose SENSITIVITY.

IMCI-ARI

TECHNICAL BACKBROUND

1. Initial recommendation: 50/min or more

(60% to 75% sensitive)

2. Lowered to 40/min for 12 mos. up to 59 mos.

(62% to 79%) BUT at the same time SPECIFICITY fell from 92% to 77% and 80%

IMCI-ARI

Sensitivity of the RR for Predicting Pneumonia in Young Children

Place RR≥50/min RR≥40/min 2-11 months 12-59 monthsGoroka, PNG 80 74Vellore, India 89 71Bsse, the Gambia 85 87Manila, Phil. 77 78Maseru, Lesotho 79 54

IMCI-ARI

FAST BREATHING (as defined by WHO):

2 months - 11 months = 50 breaths/min

11 months - 59 months = 40 breaths/min

IMCI-ARI

“ Fast breathing as defined by WHO, detects about 80% of children with pneumonia who need antibiotic treatment, and using fast breathing to detect pneumonia has been shown to reduce mortality.”

- Sazawal S., Black R.E.

Meta analysis of Intervention Trials

on Case Management of Pneumonia in

community settings; Lancet, 1992

IMCI-ARI

“ There is no uniform agreement about how to define the group of children with ARI who actually need antibiotics. The difficulty is how to distinguish those with potentially life-threatening disease from the rest by using SIMPLE SIGNS.”

“Radiology is helpful, but many children with relatively minor disease have MARKED radiological signs, while many who die have MINIMAL radiological signs.”

- Campbell H., et al. Assessment of Clinical

Criteria for Identification of Severe ARI

IMCI-ARI

LOWER CHEST WALL INDRAWING1. def: inward movement of the bony structures of

the chest wall with inspiration.2. Due: to increased tension on the anterior

insertion of the diaphragm on the xiphoid process and the internal surfaces of the cartilages and adjacent parts of the lower SIX ribs, in overcoming respiratory obstruction

3. Mild chest indrawing is NORMAL in young infants below 2 mos. The abnormal sign is called SEVERE LOWER CHEST WALL INDRAWINGSEVERE LOWER CHEST WALL INDRAWING

IMCI-ARILOWER CHEST WALL INDRAWING ISSUES:

1. Why not include intercostal indrawing?

> Ninety two percent (92%) of children with chest indrawing has intercostal indrawing requiring both signs did not change sensitivity, with small decrease in specificity and positive predictive value .

> Chest indrawing was found more specific than intercostal indrawing for a pediatrician’s diagnosis of severe pneumonia requiring admission.

> Chest indrawing therefore will REFER more children than would be admitted by a pediatric expert , as severe pneumonia, because it is also present in bronchiolitis, and asthma.

IMCI-ARI

Duration of illness before death is often short, thus early maternal recognition of signs of pneumonia and prompt care seeking are essential to prevent deaths.

Children often die quickly from pneumonia if treated too late or not treated at all.

IMCI-ARI

Use of antibiotics by doctors for ARI

Place Antibiotic given

1. Algeria 76%

2. Mexico 49%

3. Christchurch, 62%

New Zealand

IMCI - DIARRHEA

ASSESSMENT SIGNS:

1. Duration

2. Blood in the stool

3. Signs of dehydration– general condition => abnormally sleepy, difficult to

awaken, restless or irritable– sunken eyes

_ not able to drink, drinking poorly, thirsty, drinks eagerly (if you offer a drink)

– skin pinch => goes back slowly or very slowly

IMCI - DIARRHEA

Duration of diarrhea

1. Acute diarrhea2. Persistent diarrhea

(could also be severe persistent)

Blood in the stool or dysentery

IMCI - DIARRHEAAssessment and classification of DHN

Changes in the assessment of DHN:1. “Tears” and “dryness of mouth” have been excluded,

the signs add little in sensitivity or specificity to the classification.

2. Categories in the characterizations of “sunken eyes” difficulties in the field in differentiating “very sunken” and “sunken.”

3. The *stars* which marked essential items for a child’s classification have been excluded.

4. The requirement for any two signs to classify as severe or some dehydration remains, ensuring that the previous criteria of at least one *sign* still exists.

IMCI - DIARRHEA

TREATMENT PLAN A

1. FLUIDS

2. FOOD RECOMMENDED FOR AGE

IMCI - DIARRHEATREATMENT PLAN A

3. reFERRAL

Previous SIX signs (CDD) > many watery stools not able to drink > repeated vomiting becomes sicker > marked thirst in IMCI > develops fever > blood in the stool > drinking poorly

4. ZINC

IMCI - DIARRHEA

TREATMENT PLAN AHome fluid should be:1. Safe when given in large volumes. Avoid: 1. very sweet tea 2. soft drinks 3. sweetened fruit drinks Hyperosmolar solution Hyperosmolar solution above 300mOsm/L can cause worsening dehydration, osmotic

diarrhea and hypernatremia. DO NOT GIVE PURGATIVES & STIMULANTS.

IMCI - DIARRHEA

TREATMENT PLAN A

2. Easy to prepare

3. Acceptable

4. Effective

Home fluids for Philippines:

Breastmilk, water, food-based fluid such as rice water, buko juice, ORS

IMCI - DIARRHEA

TREATMENT PLAN B

** No change**

TREATMENT PLAN C

**No change**

Exception: Emphasis on giving anti-cholera antibiotic if child is 2 yrs. and above and there is cholera in the area

IMCI - DIARRHEA

PERSISTENT DIARRHEA** No change**Except for re-emphasis on:1. No routine use of antibiotic2. Dietary management = breast milk, low lactose

or lactose free, food recommendation for age3. Vitamins and minerals = at least 2 RDAs of

*folate, *iron, *zinc, *magnesium, *copper and *Vit A

4. Vitamin A (Philippines) as single dose.

IMCI - DIARRHEA

Key ingredients: 1 RDA 2RDA

1. Vit A (gRE) 400 800

2. Folic acid(g) 50 100

3. Mg(mg) 80 160

4. Zinc(mg) 10 20

5. Copper(mg) 1 2

IMCI - DIARRHEA

DYSENTERY Antibiotic is given for Shigella (which causes 50% of all bloody

diarrheas) on the basis of presence of blood in the stools. Why? > Dysentery is 10% of all diarrheas but causes 15% of all deaths.

> Stool culture in many settings is not feasible.

> Stool microscopy to detect protozoa may be unavailable or unreliable.

> Shigella is associated with severe complications especially when associated with measles.

IMCI

FEVER, EAR PROBLEM

MALNUTRITION ANEMIA

IMCI - FEVER

FEVER

A. 1. temperature of 37.5 C and above

2. history of fever by the mother

3. warm to touch

B. Determine if malaria risk or no malaria risk

-> if no malaria risk: ask if there was travel to malaria risk in 30 days

-> if malaria risk: take a blood smear

IMCI-FEVERASSESSMENT SIGNS1. Duration more than 7 days, present everyday2. Stiff neck3. Runny nose4. Signs of measles Now: generalized rash AND any of the ff: cough, runny nose, red eyes Measles for the past 3 months5. Signs of complications of measles Eyes: clouding of the cornea pus draining Mouth: ulcers = deep or extensive

IMCI-FEVER

MALARIA CLASSIFICATION1. MALARIA IS CONSIDERED: > (+) positive blood smear > and IF BLOOD SMEAR is NOT DONE with NO OTHER CAUSES OF FEVER

2. MALARIA UNLIKELY > Blood smear negative > There is the presence of other possible CAUSES of fever.

IMCI-FEVER

Signs of DHF: > abdominal pain > vomiting > signs of shock >> cold clammy extremities >> slow capillary refill > positive (+) tourniquet test > bleeding = History and PE

IMCI-FEVER

TREATMENT

1. Limiting antipyretic treatment to high fever(38.5C and above) not just any fever

>moderate rise in temperature MAY improve immune defense against infection

> high fever should be treated because it increases O2 consumption

Antipyretic: Paracetamol

IMCI-FEVER

MEASLESComplications1. Stomatitis > caused by: herpes virus, candida, or by the

measles virus > treated by: half strength gentian violet (0.25%) *if you use full strength = may cause mouth ulcers 2. Eye complications – corneal ulceration

IMCI - EAR PROBLEM

Assessment Signs:1. Ear pain2. Ear discharge

OTOSCOPY VS. IMCI GUIDELINESSensitivity - 30% to 77%Specificity - 2% to 99%PPV = 63%

Pneumatic otoscope is more accurate than simple otoscopy because the simple otoscope does not have the ability to determine whether the eardrum is RED and IMMOBILE.

IMCI-EAR PROBLEM

TREATMENT

Various treatment regimens using different antibiotics showed varied results.

5 days vs. 10 days

Cotrimoxazole vs. Amoxicillin

Major rationale for treating ear infections is NOT TO RESOLVE THE SYMPTOMS BUT TO PREVENT MASTOIDITIS.

IMCI-EAR PROBLEM

EAR WICKING to dry the ear.

1. Strong tissue paper

2. Cotton cloth

3. If available: periodic suctioning using an ear bulb

IMCI-MALNUTRITION

ACUTE VS CHRONIC

1. Chronic also called stunting > begins in infancy > develops in the first 2 years

2. Acute malnutrition is a medical emergency.

IMCI-NUTRITION1. Detecting Marasmus = visible severe wasting2. Detecting Kwasiorkor = edema of both feet3. Moderate malnutrition Indicators: Weight for Height Height for age

IMCI: “ Very Low Weight for Age”

The very low weight for age is used as a PROXY to the more reliable weight for height.

weight for age = < -3 SD

IMCI-MALNUTRITION

IF LENGTH/HEIGHT IS AVAILABLE:

1. Most sensitive and specific indicator for acute changes in nutritional status.

2. The best method to identify a child who needs MOST from nutrition interventions.

3. Weight for height scores of < -3SD SHOULD BE ADDED TO VISIBLE WASTING AND EDEMA OF BOTH FEET AS INDICATORS FOR SEVERE MALNUTRITION.

IMCI - ANEMIA

PALMAR PALLOR

1. Shown in studies to have good performance as a SINGLE SIGN to detect anemia clinically.

2. Detecting anemia based on clinical guideline detects MODERATE and SEVERE ANEMIA but NOT MILD ANEMIA.

IMCI Technical Updates

May, 2005

Dr Carolyn Maclennan

WHO-WPRO

IMCI technical updates : Why?

• New research knowledge available on clinical management of childhood diseases.

• IMCI adaptation and implementation process provide experiences & lessons.

• IMCI implementation identified problems & questions, addressed through operational research in Regions and countries.

• Impact of some diseases has evolved (HIV/AIDS) : specific aspects require updating in the context of IMCI.

6 Areas Updated

1. Antibiotic treatment of severe and non-severe pneumonia.

2. Low osmolarity ORS and antibiotic treatment for bloody diarrhoea.

3. Treatment of fever/malaria

4. Treatment of ear infections

5. Infant feeding

6. Treatment of helminthiasis

ANTIBIOTIC TREATMENT OF PNEUMONIA

Frequency of administration of amoxicillin treatment of non-severe

pneumonia

• Study compared the pharmacokinetics & levels of oral amoxicillin (15 mg/kg of body weight/dose) thrice daily with the 25 mg/kg/dose twice-daily regimen in 66 children ages 3 to 59 months with pneumonia

• Conclusion: Amoxicillin twice-daily is a feasible alternative to thrice-daily dosing.

Frequency of administration of amoxicillin treatment of non-severe

pneumonia

• A randomized, controlled, double blind trial compared the clinical efficacy of twice daily oral Cotrimoxazole with twice daily oral Amoxicillin for treatment of childhood pneumonia in OPD of 7 hospitals & 1 community health service in Pakistan

• Conclusion: Both Amoxicillin and Cotrimoxazole provided equally effective therapy for non-severe pneumonia.

Conclusion

• Oral amoxicillin should be used twice daily for the treatment of non-severe pneumonia.

Duration of amoxicillin treatment of non-severe pneumonia

• Two (2) double-blind randomized controlled trials in Pakistan & India compared treatment outcome with 3-day oral Amoxicillin with that of currently recommended 5-day therapy in children

2-59 months.


• Pakistan study: 2000 children with pneumonia diagnosed in the OPD of 7 hospitals enrolled.

• Patients were randomly assigned to three days or five days of treatment with oral Amoxicillin.

• Primary outcome was treatment failure & analyses were by intention to treat.


• Treatment failed in 209 (21%) patients in the 3-day group, & 202 (20%) in the 5-day group (difference 0.7%; 95% CI – 1.8 to 3.2).

• 12 (1%) children in the 3-day group & 13 (1%) in the 5-day group the disease relapsed (difference 0.1%; - 0.6 to 0.8).


• Treatment more likely to fail in children who did not adhere to treatment (p < 0.0001), younger than 12 months (p < 0.0001),

illness lasted for 3 days or longer (p = 0.004), respiratory rate was more than 10 breaths per min above the age-specific cut-off (p = 0.004) & with vomiting (p = 0.009).


• Non-adherence was also associated with failure of treatment in the 5-day group (p<0.0001).

• India study: conducted in ambulatory care settings in 7 referral hospitals.

• Children received oral amoxicillin, 30–45 mg/kg/day, in 3 divided doses for the first 3 days & then either continued on an active drug or placebo for the next 2 days. Primary outcome was clinical cure.


• 2,188 cases were randomized, 1,095 to 3-day and 1,093 to 5-day treatment with amoxicillin

• Clinical cure was achieved in 980 (89.5%). • 983 (89.9%) patients on 3-day & 5-day

treatment respectively (difference 0.4, 95% CI: -2.1 to 3.0).


• Adherence assessed on day 3 and day 5 follow-up was 94% and 85.2%, respectively.

• Loss to follow-up was 5.4% by day 5.

• There were no deaths, 41 hospitalizations and 36 minor adverse reactions.

• 225 (10.28%) clinical failures and 106 relapses (5.3 %) & these rates were similar in both groups.

Conclusion

• Oral amoxicillin should be given for 3 days for non-severe pneumonia in children 2-59 months of age.

Duration of oral cotrimoxazole therapy for non-severe pneumonia

• Double-blind, randomized, placebo-controlled multicentre equivalence trial at 2 sites in Indonesia and Bangladesh.

• Studied 3-day versus 5-day oral cotrimoxazole for the treatment of non-severe pneumonia & effect on antimicrobial resistance in nasopharyngeal S. pneumoniae and H. influenzae isolates. Children were followed up for 15 days.

Duration of oral Cotrimoxazole therapy for non-severe pneumonia

• 84.3% (735/872) children in the 5-day group & 83.8% (737/879) in the 3-day group were cured 15 days after enrolment.

• at enrolment, cotrimoxazole non-susceptible S. pneumoniae were 54.7% (359/656) & 51.3% (329/641) in the 5-day and 3-day groups.

Duration of oral Cotrimoxazole therapy for non-severe pneumonia

• This became 64.1% (409/262) & 61.5% (266/432) on day 15, in the 5-day and 3-day groups (p = 0.50).

• For H. influenzae prevalence of non-susceptible strains on 0 and 15 day were 44.6% vs. 61.9% and 41.7% vs. 53.7% in the 5-day and 3-day groups respectively (P= 0.06).

Conclusion

• Oral Cotrimoxazole should be given for 3 days for non-severe pneumonia in children 2-59 months of age.

Use of oral amoxicillin versus injectable penicillin in children with severe

pneumonia

• Data from Amoxicillin Penicillin Pneumonia International Study, multinational, multicentre trial conducted in 8 countries compared injectable Penicillin (n = 857) with oral Amoxicillin (n = 845).

• Treatment failed in 187 (21.8%) patients in the injectable Penicillin group & 185 (21.8%) in the oral Amoxicillin group.

Use of oral amoxicillin versus injectable penicillin in children with severe

pneumonia

• 26 (3.0%) children in the injectable Penicillin group & in 39 (4.6%) in the oral Amoxicillin group the disease relapsed.

• The results showed that the clinical outcome with oral Amoxicillin was comparable to injectable Penicillin in hospitalized children with severe pneumonia.

Conclusion

• Where referral is difficult and injection is not available, oral Amoxicillin should be given to children with severe pneumonia.

Gentamicin plus Ampicillin versus Chloramphenicol for Very Severe

Pneumonia• Multicenter randomized clinical study

conducted in 8 countries to compare the efficacy of Chloramphenicol with that of Ampicillin & Gentamicin in children aged 2 to 59 months with very severe pneumonia.

• 958 children were randomized, 122 (12.7%) patients failed treatment by day 6 (primary outcome).


Pneumonia

• Treatment failure was higher in the Chloramphenicol group, the relative risk being 1.5 ( 1.1 to 2.1).

• Common reasons for treatment failure by day 6 were: death (n = 44), development of septic shock (n = 29), persistence of very severe pneumonia (n = 21).


Pneumonia

• Treatment failure at 48 hours, 10 and 30 days as secondary outcomes & 82 (8.6 %) patients had treatment failure by 48 hours; constituting about 51% of all treatment failure.

• Cumulative treatment failures on days 10 & 30 remained higher in the Chloramphenicol group & distribution of treatment failure categories remained the same as seen on day 6, 44 death were recorded as the reason for treatment failure.


Pneumonia

• 21 deaths occurred after change of antibiotics & after the patients were categorized as treatment failure.

• More deaths occurred in the Chloramphenicol group than the Ampicillin & Gentamicin group by day 30 (RR = 1.6; 95%CI 0.99-2.6).

• Most deaths (74%) occurred within 48 hours.

Conclusion

• Injectable Ampillicin plus Gentamicin is a better choice than injectable Chloramphenicol for very severe pneumonia in children 2 - 59 months of age.

Trial of rapid acting bronchodilators in children

with wheeze & signs of pneumonia

• Multicentre prospective study, children 1-59 months of age with auscultatory/audible wheeze with fast breathing &/or lower chest indrawing screened.

• Response to up to 3 cycles of inhaled salbutamol recorded.

• Responders were enrolled & sent home on inhaled bronchodilators and followed up on days 3 & 5.

Trial of rapid acting bronchodilators in children

with wheeze & signs of pneumonia

• In Pakistan, 1622 children with wheeze were screened, of which 1004 (61.8%) had WHO defined non-severe & 618 (38.2%) severe pneumonia. Wheeze was audible in only 595 (36.7%) of children.

• Of 1004 non-severe pneumonia children, 621 (61.8%) responded to up to three cycles of bronchodilator.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia

• Of 618 severe pneumonia children only 166 (26.8%) responded.

• Among those, 93 (14.9%) children in non-severe & 63 (37.9%) in the severe pneumonia group showed subsequent deterioration on follow-ups.

• No family history of wheeze, temperature >100oF & severe pneumonia at the time of screening were identified as independent predictors of subsequent deterioration.


• In Thailand, 521 children with wheeze screened, 256 (49.1%) had WHO defined non-severe & 265 (50.9%) severe pneumonia.

• Wheeze audible in 48 (9.2%) children.

• Of 256 non-severe pneumonia children, 217 (84.8%) responded to up to 3 cycles of bronchodilator.


• Of 265 severe pneumonia children 189 (71.3%) responded.

• Among responders, 14 (6.4%) children in non-severe & 24 (12.7%) in the severe pneumonia group showed subsequent deterioration on follow-ups.

• Body temperature >100oF & severe pneumonia identified as independent predictors of subsequent deterioration.

Conclusion

• Children with wheeze and fast breathing and/or lower chest indrawing should be given a trial of rapid acting inhaled bronchodilator (up to 3 cycles), before they are classified as pneumonia and prescribed antibiotics.

DIARRHEAL DISEASES

Use of Low Osmolarity ORS

• Studies have shown that the efficacy of ORS solution for treatment of children with acute non-cholera diarrhea is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, & its total osmolarity to 245 mOsm/l.

• Results show the need for unscheduled supplemental IV therapy in children given this solution is reduced by 33%, stool output is reduced by about 20% & the incidence of vomiting by about 30%.

Use of Low Osmolarity ORS

• For children with cholera, reduced osmolarity ORS solutions were at least as effective as standard ORS & safety data to date while limited are reassuring.

Conclusion

• Countries should now use and manufacture the low sodium ORS for all children with diarrhea but keep the same label to avoid confusion.

Antibiotics in the management of bloody

diarrhea (Shigella dysentery) Ciprofloxacin has been shown to have

some significant advantages over Nalidixic acid:

1. Its activity against Enterobacteriacae is several thousand fold greater than that of Nalidixic acid.

2. Ciprofloxacin is 100 to 1000-fold less prone than Nalidixic acid to selection of single step spontaneous highly resistant organisms.

Antibiotics in the management of bloody

diarrhea (Shigella dysentery)

3. Ciprofloxacin given twice daily for 3 days instead of 4 times daily for 5 days with Nalidixic acid has been shown to be very effective against all species of Shigella.

Antibiotics in the management of bloody diarrhea (Shigella dysentery)

• Strains of Shigella resistant to Nalidixic acid, show some degree of cross resistance to Ciprofloxacin & other newer Quinolones.

• Minimum Inhibitory Concentration (MIC) of Ciprofloxacin is increased in strains already resistant to Nalidixic acid.

Antibiotics in the management of bloody diarrhea (Shigella dysentery)

• Appearance of full resistance to Ciprofloxacin is likely hastened when this antibiotic is used as 2nd line treatment of strains already resistant to Nalidixic acid.

Cost & Safety of Ciprofloxacin

• Safety: No reports of arthropathy in children as a result of Nalidixic acid use in developed or developing countries.

• Extensive use of the newer Quinolones in children during the last few years has confirmed the safety of these antibiotics, including the lack of reported arthropathies.

Cost & Safety of Ciprofloxacin

• Cost: The cost of treatment with Ciprofloxacin is now about 1/3 that of treatment with Nalidixic acid. For example, a 5-day course of treatment with Nalidixic acid for a 15 kg child costs about US

$ 0.34, while treatment of the same child for 3 days with Ciprofloxacin costs about

US $ 0.10.

Conclusion

• Ciprofloxacin is the most appropriate drug in place of Nalidixic acid which leads to rapid development of resistance.

Zinc in the Management of Diarrhea • Meta-analysis of studies evaluating the impact

of Zinc supplementation to prevent diarrhea concluded that Zinc supplementation given for 10-14 days lowered the incidence of diarrhea in the following 2-3 months.

• Cost effectiveness study of Zinc as adjunct therapy for the acute diarrhoea in children in Tanzania showed:

Cost Effectiveness Ratio to be reduced by > 1/3 when ORS was combined with Zinc for the treatment in children with diarrhoea, from US $ 113 to US $ 73 per day averted.

Zinc in the Management of Diarrhea

• Preliminary results of pilot studies in a Brazil, Egypt, Ethiopia, India, Mali, Pakistan & Philippines showed ORS use rates increased, antidiarrheals and antimicrobial use rates significantly decreased when Zinc is prescribed with ORS solution.

Conclusion

• Along with increased fluids and continued feeding, all children with diarrhoea should be given zinc supplementation for 10-14 days

DOSE: 20mg per day in children > 6 months

10mg per day in infants < 6 months

FEVER / MALARIA

Antimalarials for treatment of malaria

• Artemisinin-based combination therapies have been shown to improve treatment efficacy.

• Advantages of Artemisinin-based combination therapy (ACT) relate to the unique properties and mode of action of the Artemisinin.


• Component which include rapid substantial reduction of the parasite biomass and rapid resolution of clinical symptoms.

• Due to the very short half-life of Artemisinin derivatives, their use as monotherapy requires a multiple dose regimen of 7 days duration.


• Combination of one of these drugs with a longer half-life “partner” antimalarial drug allows a reduction in the duration of artemisinin treatment, while at the same time enhancing efficacy & reducing the likelihood of resistance development to the partner drug.


• Artesunate used in combination therapy have been shown to delay the development of resistance to its partner drug (Mefloquine) in low malaria transmission areas in Southeast Asia.

Conclusion

• In malarious areas, treatment of falciparum malaria in most countries is with Artemisinin-based combination therapies due to high multi-drug resistance.

• Due to high cost, it is important that there is a laboratory-based diagnosis with microscopy or rapid diagnostic tests.

Conclusion

• Vivax malaria also can cause severe morbidity and should also be diagnosed and treated.

• Treatment of both falciparum and vivax malaria should follow national guidelines.

EAR INFECTIONS

Management of acute ear infection

1. Ear discharge less than 14 days duration only (not ear pain), should be used in the classification of acute ear infection.

2. Oral Amoxicillin is a better choice for the management of acute ear infection in countries where antimicrobial resistance to Cotrimoxazole is high.

Management of chronic ear infection

• Daily installation of topical antiseptics or topical antibiotics after meticulous aural toilet for at least 2 weeks is the most cost-effective treatment for the short-term resolution of otorrhoea.

• Topical Quinolones are particularly effective in resolving otorrhoea without the risk of ototoxicity.

• There is no evidence that the addition of oral antibiotics confers increased benefit.

INFANT FEEDING

Exclusive Breastfeeding

• A systematic review of current scientific evidence on the optimal duration of exclusive breastfeeding identified & summarized studies comparing exclusive breastfeeding for 4 to 6 months, versus 6 months, in terms of growth, infant iron status, morbidity, atopic disease, motor development, post-partum weight loss & amenorrhoea.

Exclusive Breastfeeding

• Evidence did not suggest an adverse effect of exclusive breastfeeding for six (6) months on infant growth on an overall population basis.

Exclusive Breast feeding

• Available data suggested that exclusive breastfeeding for six months has a protective effect against gastrointestinal infection in developing & developed countries, & confers an advantage to the mother in prolonging the duration of lactational amenorrhoea.

Conclusion

• Exclusive breastfeeding for 6 months should be strongly promoted.

Complementary feeding

• Current IMCI guidelines for complementary feeding remain valid in developing countries.

• Updated standards for developing locally appropriate feeding recommendations are summarized in Guiding Principles for Complementary feeding the Breastfed Child & may be used to guide the generic IMCI guidelines for complementary feeding after 6 months of age.

HIV and infant feeding

• In areas where HIV is a significant public health problem all women should be encouraged to receive HIV counselling and testing.

• If a mother is HIV-infected and when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended.

• Otherwise, exclusive breastfeeding is recommended during the first months of life.

HELMINTHIC INFESTATIONS

Management of helminthic infestations in

children below 24 months • Data from studies in Africa, Asia & Latin

America, that included children below the age of 2 years, showed the drug of treatment choice to be albendazole in 8 studies & mebendazole in 2 studies.

• A recent study in Tanzania with children aged 6 to 59 months (212 were less than 24 months), mebendazole was the drug of treatment & parasitological, nutritional & cognitive variables were assessed.

Management of helminthic infestations in

children below 24 months

• Mebendazole had a positive effect on motor & language development & comparison between the treated and placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhoea, dysentery & acute respiratory illness) one week after intervention.

Management of helminthic infestations in children below 24 months

• A recent consultation addressing the use of Albendazole/Mebendazole in children under 24 months states that there is paucity of safety data regarding the use of these drugs in infants under 12 months.

• Due to the great distribution of parasites, safety & low cost of the treatment (< $ 0.017 for one dose of Mebendazole or Albendazole) & the relative high cost of diagnosis (need of microscope, lab material and training).

Management of helminthic infestations in children below 24 months

• In endemic areas, children that have not been dewormed in the previous 6 months should be offered deworming irrespective to the possibility to confirm their infectious status.

Conclusion

• Albendazole and Mebendazole can be safely used in children 12 months or older.

Dengue

• New evidence is emerging but cannot be recommended currently until results of further field testing becomes available.

THANK YOU