INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES

- started by WHO/UNICEF---in the Phil, (1992)

GOAL: to reduce global mortality
To contribute to health growth
7weeks-5 years old
PRINCIPLES
1. Classify and DO NOT diagnose
2. Limited use of essential drugs
3. Addresses the common but NOT all disease

COMPONENTS
1. Improve Case Management Skills of health workers
- standard guidelines, training (pre-service, in-service), follow-up after training
2. Improve Health System to deliver IMCI
- essential drug supply and management, organization of work in health facilities
3. Improve Family and Community practices
- health education, community action group/nework
MANAGEMENT
Assess the child classify the illness identify treatment treat the child council mother follow-up care

NOTE: ALWAYS GIVE THE FIRST DOSE OF APPROPRIATE TREATMENT BEFORE REFERRAL (including testing for blood sugar)
ASSESS CLASSIFY identify treatment treat the child council mother follow-up care

MAIN SYMTPOMS PINK-urgent referral DEPENDS ON THE CHILD PROBLEM

COUGH PNEUMONIA
DIARRHEA Yellow- no urgent DEHYDRATION/DIARRHEA
FEVER referral needed MALARIA
EAR PROBLEM MEASLES
Green- home care EAR PROBLEM
4 DANGER SIGNS MALNUTRITION
(CUVA)
Convulsions
Unable to breastfeed/drink
Vomiting
Abnormally sleepy/difficulty to be awaken

1. DOES THE CHILD HAVE COUGH OR IS DIFFICULTY BREATIHNG? NO! next symptom
YES! count bpm, look for chest indrawing and stridor

ASSESS classify the illness identify treatment treat the child council mother follow-up care
4 DANGER SIGNS (any) SEVERE PNEUMONIA give first dose of antibiotic REFER
STRIDOR
CHEST INDRAWING PNEUMONIA Amoxicillin 2x a day for 3 days (1st line drug of choice) FOLLOW-UP IN 3 DAYS
FAST BREATHING Cotrimoxazole 1tab for 7 days (2nd line drug of choice)
2mos-12mos (50bpm or up) IF cough is >14days or recurrent wheeze refer for possible TB or asthma assessment
12mos 5 yrs (40bpm or up)
NO DANGER SIGN NO PNEUMONIA: COLD OR COUGH SLK (Sampaloc, Luya, Kalamansi)
(Reminder: only cough is present) BreasTfeeding
If wheezing give bronchodilator for 5 days
2. DOES THE CHILD HAVE DIARRHEA? NO! next symptom
YES! for how long? any blood in the stool?

For how Assess the child classify the illness identify treatment treat
the child council mother follow-up care
Assess the child classify the illness identify
treatment treat the child council mother follow-up
long? 14 DAYS OR LESS care

14 DAYS OR MORE
PINK LETHARGIC MGT: give vit. A
SUNKEN EYES SEVERE DEHYDRATION SEVERE PERSISTENT
ABNORMALLY SLEEPY DIARRHEA
UNABLE TO DRINK
skin pinch-VERY slowly
PINK: PLAN C IV, NGT REFER!
Give sips of ORS on the way; breastfeed
Give antibiotic for cholera, if indicated

YELLOW SUNKEN EYES PERSISTENT DIARRHEA

RESTLESS, IRRITABLE SOME DEHYDRATION
DRINKS EAGERLY without dehydration
THIRSTY
Skin pinch-slowly MGT: give vit. A; Zinc Suppl
YELLOW: PLAN B
Breastfeed
ORS and Zinc supplements Any blood in stool?
Home-made DYSENTERY
MGT: Naledexic Acid
Sugar 8 tsp, salt 1 tsp, water 1L Ciprofloxacin for 3 days drug of choice

GREEN NOT ENOUGH SIGN

NO DEHYDRATION GREEN: PLAN A 4 RULES
ORS
Sugar 4tsp Zinc supplements
Salt 1pinch Breastfeeding
Water 1cup When to Return

**CHOLERA > GIVE ERYTHROMYCIN

**ZINC 2-6 months (½ tab daily for 14 days)
OR TETRACYCLINE
6 months up (1 daily for 14 days)

** teach mother to give additional fluid

2 years below (50-100ml after each loose stool)
2 years above (100-300ml after each loose stool)

any blood in the stool? Ciprofloxacin x 3 days

DYSENTERY
3. DOES THE CHILD HAVE FEVER? NO! next symptom
YES! DECIDE IF MALARIA RISK OR NOT; ASSESS FOR MEASLES; ASSESS FOR BLEEDING (DHF)
DECIDE: MALARIA RISK OR NO MALARIA RISK???
Child living in a malaria area?
Visited/traveled or stayed overnight in a malaria area over the past 4 weeks?
(ex. Palawan)
MALARIA RISK (high/low) NO MALARIA RISK
YES! OBTAIN A BLOOD SMEAR!!! ASSESS:
STIFF NECK; RUNNY NOSE
GENERALIZED RASH; RED EYES, COUGH
ANY GENERAL DANGER SIGN; OR ANY DANGER SIGN
STIFF NECK FIRST DOSE OF QUININE STIFF NECK PARACETAMOL (38.5)
VERY SEVERE FEBRILE PARACETAMOL (38.5) TREAT CHILD TO
DISEASE/MALARIA IV VERY SEVERE FEBRILE PREVENT LOW BLOOD
REFER (SEND WITH THE DISEASE SUGAR
BLOOD SMEAR RESULT)
(+) BLOOD SMEAR (BSMP) -give first line of oral antimalarial
NO OTHER CAUSE OF FEVER MALARIA - paracetamol; antibiotic CO-ARTEM OR
COARTEMETHER
If fever is present every day for more than 7 days, refer for assessmet

BLOOD SMEAR (-); NO SIGNS OF VERY SEVERE FEBRILE DISEASE

RUNNY NOSE FEVER: MALARIA UNLIKELY
FEVER: NO MALARIA PARACETAMOL
MEASLES PARACETAMOL
OTHER CAUSE OF FEVER TREAT OTHER CAUSE

** ANTIMALARIAL DRUG
- ARTEMETHER-LUMFANTINE 2X A DAY FRO 2 DAYS
- ARTESUNATE AMODIAQUINE

Treat the Child to Prevent Low Blood (DONE AT THE CLINIC ONLY)
If able Breastfeed
If the child is not able to breastfeed but is able to swallow: Give 30 - 50
ml of milk or sugar water* before departure.
If the child is not able to swallow: Give 50 ml of milk or sugar water* by
nasogastric tube.
If no nasogastric tube available, give 1 teaspoon of sugar moistened
with 1-2 drops of water sublingually and repeat doses every 20
minutes to prevent relapse.

* TO MAKE SUGAR WATER: Dissolve 4 level teaspoons of sugar (20

grams) in a 200-ml cup of clean water.
IF THE CHILD HAS MEASLES NOW OR WITHIN THE LAST THREE MONTHS
ASSESS:
DEEP OR EXTENSIVE MOUTH ULCERS
PUS DRAINING FROM THE EYES
CLOUDING OF THE CORNEA

ANY DANGER SIGN; OR PUS DRAINING FROM THE EYE MEASLES NOW OR WITHIN THE PAST 3
CLOUDING CORNEA; OR MOUTH ULCERS MONTHS
RED
DEEP OR EXTENSIVE MOUTH ULCERS YELLOW: MEASLES WITH EYE GREEN: MEASLES
OR MOUTH COMPLICATIONS
PINK: SEVERE COMPLICATED MGT:
MEASLES MGT: VITAMIN A
VIT. A
MGT: TETRACYCLINE OINTMENT FOR TEACH MOTHER ABOUT
VIT. A EYE GENTIAN VIOLET
TETRACYCLINE OINTMENT FOR TEACH MOTHER ABOUT ADVISE WHEN TO RETURN
EYE GENTIAN VIOLET
REFER! NYSTATIN

ASSESS FOR SIGNS OF BLEEDING (DENGUE H-FEVER):

BLEEDING FROM GUMS, NOSE, VOMITUS OR STOOL (BLACK)
ABDOMINAL PAIN
PERSISTENT VOMITING
All signs above; NO SIGNS OF SEVERE DENGUE H-FEVER
Capillary refill >3sec PINK: SEVERE DENGUE H-FEVER
GREEN: DENGUE H-FEVER UNLIKELY

MGT:
If NO signs of bleeding Plan B MGT:
ORS GIVE PARACETAMOL
If WITH signs of bleeding Plan C DO NOT GIVE ASPIRIN
ORS
DO NOT GIVE ASPIRIN

** GENTIAN VIOLET FOR MOUTH ULCER

VITAMIN A
**NYSTATIN FOR THRUSH
6-12 MOS 100, 000 IU
** TETRACYLCINE FOR EYE INFECTION
1YR ABOVE 200, 000 IU

Give first dose any time after 6 months of age

to ALL CHILDREN; THEN every 6 months after

4. DOES THE CHILD HAVE EAR PROBLEM?

YES!
ASSESS:
- ANY EAR PAIN? EAR DISCHARGES (PUS) & HOW LONG?
- TENDER SWELLING BEHIND THE EAR

TENDER SWELLING PINK: MASTOIDITIS First dose of Antibiotic (Amoxicillin)

Paracetamol for pain
-->REFER!
-PUS/DISCHARGES YELLOW : ACUTE EAR INFECTION Antibiotic, Paracetamol, DRY EAR
FOR LESS THAN 14 BY WICKING
DAYS
-EAR PAIN
PUS/DISCHARGES YELLOW : CHRONIC EAR INFECTION DRY EAR BY WICKING,
FOR MORE THAN 14 QUINOLONE OTIC DROPS FOR 2 WEEKS
DAYS
NO EAR PAIN GREEN: NO EAR INFECTION NO ADDITIONAL TREATMENT, FOLLOW-
NO DISCHARGES UP CHECK UP ONLY
5. CHECK FOR ANY MALNUTRITION AND ANEMIA
DETERMINE WEIGHT AND AGE
LOOK FOR EDEMA OF BOTH FEET
VISIBLE SEVERE WASTING
FOR >6MOS, ASSESS IF MUAC IS <115mm
CHECK FOR ANY MALNUTRITION AND ANEMIA SEVERE PALMAR PALLOR
DETERMINE WEIGHT AND AGE
LOOK FOR EDEMA OF BOTH FEET PINK
VISIBLE SEVERE WASTING SEVERE ANEMIA
FOR >6MOS, ASSESS IF MUAC IS <115mm
Not able to finish RUTF

MARASMUS LACKS CARBOHYDRATES

GGY PANTS

KWASHIORKOR LACKS PROTEIN MGT:

EDEMATOUS, MOON-SHAPED FACE TREAT PREVENT LOW BLOOD SUGAR
COMPLICATED SEVERE VIT. A
ACUTE KEEP THE CHILD WARM
MALNUTRITION

VERY LOW WEIGHT FOR AGE SOME PALLOR

MUAC < 115; able to finish RUTF YELLOW
GIVE IRON ANEMIA
UNCOMPLICATED MGT:
VIT. A GIVE ALBENDAZOLE/MEBENDAZOLE if >1 yr old and has not
SEVERE ACUTE
FEEDING PROBLEM FOLLOW-UP received in previous 6mos
MALNUTRITION
IN 5-7 DAYS FOLLOW-UP IN 14 DAYS

NOT VERY LOW WEIGHT FOR AGE NO PALMAR PALLOR

NO OTHER SIGNS OF MALNUTRITION GREEN
NO ANEMIA
GREEN
NOT VERY LOW WEIGHT

** VIT. A
- 6-12 MONTHS 100 000 U
- 1 YEAR ABOVE 200 000 U

5. CHECK FOR HIV INFECTION

ASK HAS THE MOTHER OR CHILD HAD HIV TEST?
IF YES, DECIDE HIV STATUS
IF MOTHER IS POSITIVE, AND CHILD IS NEGATIVE OR UNKNOWN
- ASK BREASTFEEDING WITHIN 6 MONTHS BEFORE TEST UNTIL NOW?
- IS MOTHER TAKING PROPHLAXIS
IF NOT, THEN TEST
POSITIVE VIROLOGICAL/SEROLOGICAL TEST INITIATE ART TREATMENT
GIVE COTRIMOXAZOLE PROPHYLAXIS
CONFIRMED HIV
INFECTION

MOTHER POSITIVE AND CHILD IS NEGATIVE OR NOT INITIATE ART TREATMENT

TESTED HIV EXPOSED
GIVE COTRIMOXAZOLE PROPHYLAXIS

NEGATIVE TEST IN MOTHER AND CHILD TREAT, COUNSEL AND FOLLOW-UP EXISTING INFECTIONS
HIV INFECTION
UNLIKELY

SEROLOGICAL TESTS (Including rapid tests) - These tests detect

antibodies made by immune cells in response to HIV. They do not detect
the HIV virus itself.

VIROLOGICAL TESTS (Including DNA or RNA PCR) - These tests

directly detect the presence of the HIV virus or products of the virus in the
blood.
WHEN TO RETURN

WHEN TO RETURN IMMEDIATELY