Integrated healt

Alexandria University IMCI Lecture 1 EMRO- WHO
IMCI Lecture 1
Integrated
Management
of Childhood
Illness

IMCI Lecture 1Alexandria 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.

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

Where Care for Children Is Provided?
Home 1st
level health facility Specialized hospital
I M C ICommunity
Component REFERRAL CARE

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.

Diseases Covered By IMCI
• Cough or difficult
breathing
• Diarrhea
• Throat problems
• Ear Problems
• Fever & Measles
3/4
of Episodes of
Childhood illness
MALNUTRITION

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

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

Assess & Classify
the Sick Child,
Age 2 months up
to 5 years

22
ASSESS AND CLASSIFY THE SICK CHILD
AGE 2 MONTHS UP TO 5 YEARS
CLASSIFY IDENTIFY
TREATMENTASK 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.
VERY
SEVERE
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 per
to 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 one
minute.
• Look for chest indrawing.
• Look and listen for stridor.
• Look and listen for wheeze
Classify
COUGH or
DIFFICULT
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 .
SEVERE
PNEUMONIA
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.
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
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

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

General Danger Signs
CHECK
for
GENERAL DANGER
SIGNS
in
ALL Children

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

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

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

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

Has the child had convulsions?
• Ask the mother if the child has had
convulsions during the current illness.
• Use words the mother understands.

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.

Unconscious ?
• An unconscious child is a child who cannot
be awakened.
• The child does NOT respond when he is :
•Touched
•Shaken, or
•Spoken to

UNCONSCIOUS CHILD

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

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.


LETHARGIC CHILD

CLASSIFY GENERAL DANGER SIGNS:
SIGNS CLASSIFY AS TREAT
•       Any
Danger
Sign VERY
SEVERE
DISEASE
    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

Cough OR Difficult
Breathing
Then
ASK
About:
COUGH OR
DIFFICULT
BREATHING

Acute Respiratory Infections
(ARI)•Importance
Definition
Role of IMCI
•Pneumonia
Recognition • Fast breathing • Chest indrawing
•Wheezing
Causes •
Why Added ?
•How to classify Cough or
Difficult breathing?
Severe pneumonia or very severe disease
Pneumonia
Nopneumonia, Cough or cold

“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

Acute Respiratory Infections
( ARI )
• Common cause of mortality.
• Common cause of morbidity.
• Commonest reason for
irrational drug prescription.
Global & National Health Problem

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

Pneumonia: Severity
Recognition is based on:
• Fast breathing, and
• Lower chest wall indrawing

WHY FAST BREATHING ?
• Simplicity
• Ease in training
• Reliability
Good Predictor of PNEUMONIA
In 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.

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

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

60
50
40
Cut-offs of Fast Breathing

LOWER CHEST WALLLOWER CHEST WALL
INDRAWINGINDRAWING
Index of :
Severe Pneumonia
or very severe disease
Reasonable sensitivity
& specificity " 89%".

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

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

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

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

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
sugar
•       Fast breathing
(If Wheeze, go directly to
treat wheeze, then
reassess)
PNEUMONIA
    Give appropriate antibiotic for 5
days
    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
    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

CHEST INDRAWING
FAST BREATHING
SEVERE PNEUMONIA
OR VERY SEVERE DISEASE
±±

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:

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
+

No Pneumonia,
Cough or Cold
Antibiotics
No signs of
Pneumonia
or Very
Severe
Disease

Diarrhea
Then
ASK
About :
DIARRHEA

Diarrhea
Diarrhea
Assessment
Dehydration
Assessment • Classification
Home Fluids
Selection • Fluids to avoid
Persistent Diarrhea
Definition • Causes
Classification
Dysentery
Classification
Antibiotics

Assessment of Diarrhea
D E H Y D R A T I O N
F o r A ll
P E R S I S T E N T
D I A R R H E A
C o n d i t i o n a l
D Y S E N T E R Y
C o n d i t i o n a l
D I A R R H E A

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?

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:

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.

Unconscious child

Lethargic child

Sunken
Eyes

Skin Pinch returns Very Slowly (> 2 seconds

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

1-         CLASSIFY FOR DEGREE OF DEHYDRATION
Two of the following signs:
•       Lethargic or unconscious
•       Sunken eyes
•       Drinks poorly or unable
to drink
•       Skin pinch goes back
very slowly
SEVERE
DEHYDRATION
    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
SOME
DEHYDRATION
    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)

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
Selectio
n:

• 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
Selection:

• 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)
Selection:

• 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
Fluids to avoid:

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:

•Proximate Causes
• Secondary disaccharidase deficiency
• Salmonella sp.
• Shigella sp.
• Enteroadherent E. coli
• Cryptosporidium
•Contributing Factors
• Protein energy malnutrition
• Micronutrient deficiencies
• Immunodeficiency
Persistent Diarrhea
Causes:

2-CLASSIFY FOR PERSISTENT DIARRHEA
•       Dehydration present SEVERE
PERSISTENT
DIARRHEA
    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

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

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:

Antimicrobials against
Shigella
EFFECTIVE
• Co-Trimoxazole
• Nalidixic acid
• Pivmecillinam
• Ceftriaxone
• Ciprofloxacin
• Other
quinolones
INEFFECTIVE
• Metronidazole
• Streptomycin
• Chloramphenicol
• Sulfonamide
• Cepholosporins
• Aminoglycosides
• Nitrofurans

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)

THROAT PROBLEM
CHECK
for
THROAT PROBLEM
in
ALL
CHILDREN

Throat Problems
•Sore Throat & Pharyngitis
• Overview
• Management Issue
• Sensitivity & Specificity of signs
•Role of IMCI
•Classification of Throat Problem
•Treatment

is more than
just
a sore throat. ?
Pharyngit
is

• 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

Not all,
Sore throats
are
streptococcal !
However

Should We Treat All SoreAll Sore
ThroatsThroats With
Antibiotics ?Antibiotics ?
• Cost
• Side effects
• Resistance
• Super - infection

• 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

• Sensitivity and specificity tend to
move in opposite directions
• Clinical diagnosis of GAS infection
is difficult without rapid diagnostic
test or routine culture
Clinical feature Sensitivity % Specificity %
History of fever 92.3 14.4
Temp >38ºC 37.4
66.0
Exudate 31.0 31.0
Enlarged node 81.3
45.1
Tender node 33.6 82.2
Exudate or large node 84.1
40.1
Exudate/large node & tender node 12.1
93.9
Sore Throat: Management Issues

For Accurate Diagnosis:
• Throat culture
• Ag detection
• ASO Titre
Expensive, Not available at PHC level

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

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.

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
STREPTOCOCCAL
SORE THROAT
   Give benzathine penicillin
    Soothe the throat with a safe
remedy
    Give paracetamol for pain
    Advise when to returm immediately
•       Insufficient criteria to
classify as streptococcal
sore throat
NON
STREPTOCOCCAL
SORE THROAT
    Soothe the throat with a safe
remedy
    Advise when to returm immediately
•       No throat signs or
symptoms
(with or without fever)
NO THROAT
PROBLEM
    Continue assessment of the child

• 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

EAR PROBLEM
ASK
about :
EAR
PROBLEM

EAR PROBLEM
•Types of ear infection
•External otitis
• Ask
• Look
•Otitis media
• Ask
• Look
•Symptoms & Signs Used in IMCI
•Classification of ear problem
•Treatment

Ear Infection ?
• External ear :
Otitis Externa
• Middle ear :
Otitis Media

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

Diagnosis of External Otitis
• Discharge:
Serous or Purulent
• Ear Canal: **
•Erythema
•Edema
•Otoscopy: very painful
**SUBJECTIVE SIGNS, NOT INCLUDED IN
IMCI
LOOK

Diagnosis of Otitis Media
• Agonizing Ear Pain
• Discharge (Otorrhea): Purulent
• Other NON SPECIFIC Symptoms:
•Fever
•Irritability OR Lethargy
•Anorexia, Nausea, Vomiting,
Diarrhea
•Headache ?
ASK

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

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

MASTOIDITIS

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.

CLASSIFY EAR PROBLEM:
•       Tender swelling behind
the ear MASTOIDITIS
   Give 1st
dose of appropr. antibiotic
   Give 1st
dose of paracetamol for pain
sugar
•       Pus seen draining from
ear
and Discharge reported
for
less than 14 days OR
•       Agonising ear pain
ACUTE EAR
INFECTION
   Give antibiotic for 10 days
    Dry the ear by wicking
•       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

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

FEVER
ASK
about
FEVER

Fever
Febrile Illness
Causes
Fever After Five
Days
Referral
Classification of
Fever
Overvie
Stiff neck
Classification of fever

• 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 Illness
Causes:

• 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

• 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

• 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:


Does the child have fever?
(by history or feels hot or temperature 37.5o
C 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

Looking
and
Feeling
for
STIFF
NECK

CLASSIFY FEVER:
•       Any generalised
    danger sign
OR
•       Stiff neck
VERY
SEVERE
FEBRILE
DISEASE
   Give 1st
dose of appropiate antibiotic (I.M)
   Treat child to prevent low blood sugar
   Give one dose of paracetamol in clinic for
fever 38o
C or above
•       Apparent bacterial
cause of fever, e.g
−      Pneumonia
−      Dysentery
−      Acute ear infection
−      Strept. sore throat
−      Abscess,
cellulitis,etc.
FEVER-
POSSIBLE
BACTERIAL
INFECTION
    Give paracetamol for fever (38o
C or more)
    Treat apparent cause of fever .
    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
INFECTION
UNLIKELY
    Give paracetamol for fever (38o
C or more)
    Follow Up in 2 days IF fever persists
    If fever is present every day for more than
    5 days, refer for assessment

MALNUTRITION & ANEMIA
CHECK
For
MALNUTRITION
and
ANEMIA
in ALL CHILDREN

MALNUTRITION & ANEMIA
•Anemia
Clinical signs for classification
Sensitivity and specificity of signs
•Nutritional status
Iceberg of malnutrition
Weight for age as indicator
Other indicators
Growth Monitoring
•Checking for Malnutrition and Anemia
Wasting Edematous feet Weight for age curve Pallor
•Classification
of nutritional status
of anemia

• 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:
Anemia
Clinical 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%

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.

• 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

Mild & Moderate forms
severe forms
The Iceberg of Malnutrition

• 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

• 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

• 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 Monitoring
Limitations:

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
NUTRITIONAL
STATUS

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?

LOW WEIGHT FOR AGE

CLASSIFY NUTRITIONAL STATUS
•       Visible severe wasting
   OR
•       Edema of both feet
SEVERE
MALNU-
TRITION
   Give vitamin A
   Treat the child to prevent low blood
sugar

•       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

•       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

CLASSIFY ANEMIA
•       Severe palmar and /or
    mucous membrane
pallor
SEVERE
ANEMIA
   Treat the child to prevent low blood
sugar
•       Some palmar and /or
    mucous membrane
pallor
ANEMIA
    Give iron
•       No palmar or mucous
    membrane pallor
NO
ANEMIA
    If child is aged from  6 – 30 months,
give
   ONE dose of iron weekly
(supplementation)

CHECK THE CHILD
IMMUNIZATION STATUS
CHECK
IMMUNIZATION
and
VITAMIN A
Supplementation
status
In ALL CHILDREN

CHECK THE CHILD’S IMMUNIZATION AND
VITAMIN A SUPPLEMENTATION STATUS
AGE VACCINE VITAMIN A
Before 3
months
2 months
4 months
6 months
9 months
18-24 months
BCG
OPV-1
OPV-2
OPV-3
OPV-4
OPV
(Booster)
DPT-1
DPT-2
DPT-3
Measles
DPT
(Booster)
HBV-1
HBV-2
HBV-3
MMR 100,000 U
200,000 U

ASSESS OTHER PROBLEMS

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…

GIVE FOLLOW-UP CARE
Pneumonia, No pneumonia-Wheeze
Dysentery, Persistent Diarrhea
Sore throat, Ear Infection, Fever, Measles
Feeding Problems, Low weight
Pallor

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

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