imci nov 2009
TRANSCRIPT
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Integrated Managementof Childhood Illness
LESTER A. DENIEGA M.D.LESTER A. DENIEGA M.D.
DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS
USTFMSUSTFMS
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1. Skilled attendance during pregnancy, childbirth and
the immediate postpartum
2. Care of the newborn
3. Breastfeeding and complementary feeding4. Micronutrient supplementation
5. Immunization of children and mothers
6. Integrated management of sick children
7. Use of insecticide treated bed nets (in malarious areas)
Essential Package of Child Survival
Interventions
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Distribution of deaths of children
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Immediate Causes of Death in
Underfive Children, WPR
Source: Child Health Epidemiologist and research group (CHERG) estimates of under-five
deaths, 2000-03
Under-
nutrition
53%
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Immediate Causes
deaths in perinatal and neonatal periodsdominate the U5MR; the perinatal period is also
associated with the highest number of
disabilities; highest risk is in the first day of birth;
40 - 80% of neonatal deaths are associated with
low birth weight;
malnutrition remains the highest attributable
causal factor of all childhood deaths in childrenunder 5;
most important immediate causes of death from
communicable diseases remain diarrhoea and
ARI
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What is the IMCI ?
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Objectives of the Global Child
Health Programme
To reduce significantly global mortality and
morbidity associated with the major causes ofdisease in children
To contribute to healthy growth and
development of children
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Overall Case Management
ProcessOutpatient
1 - assessment
2 - classification and identification of treatment3 - referral, treatment or counseling of the childs
caretaker (depending on the classification identified
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of patient
progress
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The Integrated Case Management Process
Treatment
treat local infection
give oral drugs
advise and teach
caretaker
follow up
Outpatient Health
Facility
Home
Caretaker iscounselled on:
home treatment
feeding &fluids
when to return
immediately
follow-up
check for danger signsassess main symptoms
assess nutrition and Immunization status
and potential feeding problems
Check for other problems
classify conditions and
identify treatment actions
Outpatient Health Facility
Urgent referral
pre-referral treatment
advise parents
refer child
Outpatient Health Facility
emergency triage &
treatment
Diagnosis & treatmentmonitoring & ff-up
Referral facility
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IMCI CASE MANAGEMENT
PROCESS Assess by checking for danger signs
(or possible bacterial infection in a
young infant) asking questions aboutcommon conditions, examining the
child, and checking nutrition and
immunization status. Ask other healthproblems
Classify using a color-coded triage
system
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IMCI CASE MANAGEMENT
PROCESS Identify specific treatments
Provide practical treatment
instructions including teaching how togive oral drugs, how to feed and give
fluids and how to treat local infections at
home
Counsel to solve any feeding problemsafter assessing feeding
Give follow-up care when a child is
brought back as requested
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Target Groups
Sick young infant
1 week up to 2 months
Sick young children
2 months up to 5 years
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SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS
FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic
ASK THE CHILDS AGE
IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years
USE THE CHART:
ASSESS, CLASSIFY AND TREAT
THE SICK YOUNG INFANT
USE THE CHART:
ASSESS AND CLASSIFYTHE SICK CHILD
TREATTHE CHILD
COUNSEL THE MOTHER
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THE SICK CHILD AGE 2
MONTHS TO 5 YEARS:
ASSESS AND
CLASSIFY
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Ask the mother or caretaker about the childs problem.
If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for theproblem, give follow-up care according to PART VII)
.
Check for signs of malnutrition and anaemia and classify the childs nutritional status
Check the childs immunization status and decide if the child needs any immunizations today.
Assess any other problems.
Then: Identify Treatment (PART IV), Treat the Child(PART V), and Counsel the Mother (PART VI)
SUMMARY OF ASSESS AND CLASSIFY
Check for General Danger Signs
Check for signs of malnutrition and anaemia and classify the childs nutritional status
Check the childs immunization status and decide if the child needs any immunizations today.
Ask mother/caretaker about 4 main symptoms:
1. cough or difficult breathing2. Diarrhea
3. Fever
4. Ear problem
When a main symptom is present:Assess the child further for signs related to the main sx,
and
Classify the illness acc. to the signs (present or absent)
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FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC
GREET the mother appropriately and
ask about her child.
LOOK to see if the childs weight and
temperature have been recorded
ASK the mother what the childs problems are
DETERMINE if this is an initial visit or a follow-up visit for this problem
IF this is an INITIAL VISIT for theproblem
ASSESS and CLASSIFY the child followingthe guidelines in this part of the handbook (PART II)
GIVE FOLLOW-UP CARE according to theguidelines in PART VII of this handbook
When a child is brought to the clinic
IF this is a FOLLOW-UP VISIT for the problem
Use Good Communication skills:
(see also Chapter 25) Listen carefully to what the mother tells you. Use words the mother understands
Give the mother time to answer the questions.---Ask additional questions when the mother is
not sure about her answer.
*Record Important Information
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GENERAL DANGER SIGNS
ForALL sick children ask the mother about the childs problem, then
CHECK FOR GENERAL DANGER SIGNS
CHECK FOR GENERAL DANGER SIGNS
A child with any general danger sign needs URGENTattention; complete the
assessment and any pre-referral treatment immediately so referral is not delayed
ASK: LOOK:
Is the child able to drink or breastfeed? See if the child is lethargic orunconscious
Does the child vomit everything?
Is the child had convulsions?
Make surethat a
child with
anydangersign is
referredafter
receivingurgent
pre-referral
treatment.
Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear
problems.CHECK for malnutrition and anaemia, immunization status and for other problems.
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DANGER SIG
NSConvulsions: associated with meningitis, cerebral
malaria or other life-threatening conditions
Unconscious or lethargic: A lethargic child who isawake but does not take any notice of his or hersurroundings or does not respond normally tosounds or movements
Unable to drink: s/he is too weak or because s/hecannot swallow
Vomits everythingIf a child has one or more of these signs, s/he must
be considered seriously ill and will almost alwaysneed referral
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Checking theMain Symptoms:
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Checking the Main Symptoms
1. Cough or difficult breathing
3 clinical signs
Respiratory rate
Lower chest wall indrawing Stridor
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Nasal
passages
Windpipe
or trachea
Lungs
Parts of the Respiratory System
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Inside the alveolus
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ASK: Does the child have cough or difficult breathing?
IfYES
IFYES, ASK:
F
or how long?
LOOK, LISTEN, FEEL:
Count the breaths in one minuteLook for chest indrawing
Look and listen for stridor
Child
mustbe
calm
If the child is: Fast breathing is:
2 mos 12 mos. 50 breaths/min or more12 mos 5 yrs 40 breaths/min or more
Classify childs illness using the color-coded
classification table for cough or difficult breathing
IfNO
Ask aboutnext main
symptoms:
diarrhea,
fever, ear
problems
Cough or Difficult Breathing
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Treatment
Soothe the Throat, Relieve the Cough witha Safe RemedySafe remedies to recommend:
Breastmilk for exclusively breastfed infanttamarind, calamansi, ginger
Harmful remedies to discourage:
Codeine cough syrup
Other cough syrups
Oral and nasal decongestants
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Treatment for Pneumonia or
Very Severe DiseaseCotrimoxazoleGive 2 times daily
for 5 days
AmoxycillinGive 3 tim es daily
for 5 days
Age orWeight
Adult
tab.80mgTMP
400 mgSMX
Syrup
40 m gTMP
200 mg
SMX
Tablet
250 m g
Syrup
125mg/5 m l
2 -12 mos 1/2 5 .0 ml. 1/2 5 .0 ml
12mos-5yrs 1 7.5 ml 1 10 ml.
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Pathogen Antimicrobial
ARI PathogensARI Pathogens
Streptococcus pneumoniaeStreptococcus pneumoniae
Hemophilus influenzaeHemophilus influenzae
Gram (+) cocciGram (+) cocci
Staphylococcus aureusStaphylococcus aureus
Staphylococcus epidermidisStaphylococcus epidermidis
Chloramphenicol
Cotrimoxazole
Penicillin
Chloramphenicol
Cotrimoxazole
Ampicillin
Oxacillin
Cotrimoxazole
Ciprofloxacin
Vancomycin
Oxacillin
Cotrimoxazole
Vancomycin
7.0
11.8
18.4
4.0
11
3.0
24.2
20.9
13.1
3.0
3
9
6
5
11
5
18
8
6
0.7
47
42
0.3
3
9
9
3
18
13
18
8
7
0
51
50
0
5
15
5
5
36
10
17
6
8
0
39
37
0
% Resistance
2000 2002 2003 2004
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Vitamin A
Supplementation
for Severe Pneumonia or Very SevereDiseaseV itam in A CapsuleAge
100,000 IU 200,000 IU
6 to 12 m os. 1 capsule capsule
12 mo s-5 yrs 2 capsules 1 capsule
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DIARRHEA
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Anatomy of the GastrointestinalSystem
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DiarrheaForALL sick children ask the mother about the childs problem, check for general danger signs,
ask about cough or difficult breathing and then
ASK: DOES THE CHILD HAVE DIARRHOEA?
If NO If YES
Does the child have diarrhoea?
IF YES, ASK: LOOK, LISTEN, FEEL:
F
or how long?
Look at the childs general condition.Is the child:
Is there blood in the
stool 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 of the abdomen.
Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
CLASSIFY the childs illness using the colour-coded classification tables for diarrhoea.
Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and
anaemia, immunization status and for other problems.
Classify DIARRHOEA
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Checking the Main Symptoms
2. Diarrhea
Dehydration General condition
Sunken eyes
Thirst Skin elasticity
Persistent diarrhea
Dysentery
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Clinical Types of Diarrhea and
its major dangers Acute watery diarrhea (includes cholera): lasts several
hours or days; main danger is dehydration
Acute bloody diarrhea: dysentery causing major
damage to intestinal mucosa, sepsis and malnutrition
Persistent diarrhea: lasts 14 days or longer that resultsin malnutrition and serious non-intestinal infection
Diarrhea with severe undernutrition: major dangers
are:severe systemic infection, dehydration, heart failure,vitamin and mineral deficiency
The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
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4 Key Elements for effective
clinical management of acute diarrhea Replacement of fluids, usually by ORT to
prevent dehydration in the home and to treatdehydration
Continued feeding, especially breastfeeding,during diarrhea episodes and inconvalescence
No use of antidiarrheal drugs and selective
use of antibiotics Effective instruction of the childs mother on
how to take care of the sick child at home
the indications for follow-up
methods of preventing future episodes of diarrhea
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Four Rules for
Home Treatment of Diarrhea
(Treatment Plan A)
Rule 1: Give more fluids than usual
Rule 2: Zinc supplementation at 20mg/day for 10-14 days
(10 mg for infants < 6 months)
Rule 3: Continue to feed the child Rule 4: When to return to the clinic
Diarrhea Treatment Guidelines for Clinic-Based Health Care Workers
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Tell the Mother:
(a) Breastfeed frequently and longer for each feed.
(b) If the child is exclusively breastfed, give ORS or
clean water in addition to breastmilk.
(c) If the child is NOT exclusively breastfed, give 1 or
more of the following:
ORS
Food-based fluids
Clean Water
No Dehydration
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Fluids that normally contain
salt
ORS solution
Salted drinks (salted rice
water, salted yoghurt drink)
Vegetable or chicken soup
with salt
Fluids that do not contain
salt
Plain water
Water in which a cereal has
been cooked
Unsalted soup
Yoghurt drinks without salt
Green coconut water
Weak tea
Unsweetened fresh fruit
juice
The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
FLUIDS TO GIVE
Wherever possible, these should include at least one
fluid that normally contains salt
Plain clean water should also be given
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XX XX FLUIDS NOT TO BE GIVENFLUIDS NOT TO BE GIVEN XXXX
Drinks sweetened with sugar
Commercial carbonated beverages
Commercial fruit juices Sweetened tea
Other fluids to avoid
Those with stimulant, diuretic and purgative effect
Coffee Some medicinal teas or infusions
The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
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Treatment Plan AAge Amount of Fluid Type of Fluid
< 2 yrs 50-100 ml (- cup) after each loose stool2-10 yrs 100-200 ml (-1 cup) after each loose stool
ORS, rice water, yogurt,soup with salt
No Dehydration
Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, butmore slowly.
Continue giving extra fluids until the diarrhea stops.
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Treatment Plan B(Determine amount of ORS to be given in 4 hours)
Age Up to 4 mos 4mos - 12mos 12mos 2years 2 years 5years
Some Dehydration
< 6kg 6 - < 10kg 10 -
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Approximate amount ofORS
solution to
give in the first 4 hoursAge Less
than 4
mos.
4-11
months
12-23
months
2 4
years
5 14
years
15 years
older
Weight Lessthan 5
kg.
5-7.9kgs.
8 10.9kgs.
11-15.9kgs.
16-29.9kgs.
30 kgs.or more
In ml 200 -
400
400 -
600
600 -
800
800 -
1200
1200 -
2200
2200 -
4000
In local
measure
TPB
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Give frequent small sips from a cup.
If the child vomits, wait 10 minutes.
Then continue, but more slowly.
Continue giving extra fluids until the
diarrhea stops.
Reassess after 4 hours and classify
the child for dehydration.
Some Dehydration
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If the mother must leave before completing
treatment:
show her how to prepare the ORS solution
at home.
show her how much to give to finish the 4
hour treatment at home
give her enough ORS packets to completerehydration.
Some Dehydration
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Severe Dehydration
Can you give Intravenousfluids (IV) immediately?
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Severe Dehydration
Treatment Plan C
To treat severe dehydration (IV fluid: pLRS)
Age Initial Phase Subsequent Phase
(30 ml/kg) (70 ml/kg)
Infants (
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If trained to use anasogastric tube for
rehydration?
Severe Dehydration
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Start hydration by tube (or mouth)with ORS solution. Give (20ml/kg/hr)
for 6 hours. (Total of 120ml/kg)
Reassess the child every 2 hours. If there is repeated vomiting or increasing
abdominal distention, give the fluid more
slowly.
If hydration status is not improving after 3hours, send the child for IV therapy.
After 6 hours, reassess the child.
Classify dehydration.
Severe Dehydration
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Etiologic Agents for most cases of diarrheaOrganism Proportion of cases Effectiveness of
antibiotics in TxRotavirus
ETEC
No agent found
Shigella
Campylobacter spp
Vibrio Cholera
Nontyphoid salmonella
Up to 50% in health
facilities; 5-10% in
community
Up to 25% in all ages
25% or more5 10%
5-15%
5 10% in endemic areas
Up to 10% of cases
Not effective
Not effective
Not effective
Effective
Effective only if given
early in course of
disease
Effective
Not effective in usual
uncomplicated diarrhea
WHO
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4 conditions where antimicrobials
are indicated
Cholera - Tetracycline
Shigella dysentery - Nalidixic acid
Giardiasis - Metronidazole
Amoebiasis - Metronidazole
A ti i bi l % i t f E t i
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Antimicrobial % resistance of Enteric
pathogensPathogenS. typhi
AntimicrobialChloramphenicol
Cotrimoxazole
Ampicillin
20020
3
2
20031
0
0
20040
1
1
Nontyphoidal
Salmonella
Chloramphenicol
Cotrimoxazole
Ampicillin
Ciprofloxacin
16
15
24
4
21
31
47
8
18
20
2
0
Shigella Chloramphenicol
Ampicillin
Cotrimoxazole
Nalidixic acid
Ciprofloxacin
78
73
0
43
50
78
0
12
60
50
67
0
0
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CLASSIFICATION TABLE FOR DEHYDRATION
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Two of the following signs:
Lethargic or unconsciousSunken eyes
Not able to drink or drinking
poorly
Skin pinch goes back very
slowly
SEVERE
DEHYDRATION
If child has no other severe classification:
Give fluid for severe dehydration (Plan C).OR
If child also has another severe classification:
Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera.
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
SOME
DEHYDRATION
Give fluid and food for some dehydration (Plan B).
If child also has a severe classification:
Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
Advise mother when to return immediately.Follow-up in 5 days if not improving.
Not enough signs to
classify as some or
severe dehydration. NO
DEHYDRATION
Give fluid and food to treat diarrhoea at home
(Plan A).
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
CLASSIFICATION TABLE FOR DEHYDRATION
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
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No Dehydration
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Some Dehydration
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Severe Dehydration
CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA
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Dehydration present SEVERE
PERSISTENT
DIARRHOEA
Treat dehydration before referral unless
the child has another severe
classification.
Refer to hospital.
No dehydration PERSISTENT
DIARRHOEA
Advise the mother on feeding a child who
has PERSISTENTDIARRHOEA.
Follow-up in 5 days.
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA
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After 5 days:Ask:
If the diarrhoea has NOT stopped (3 or
more stools) do a full reassessment, givethe treatment, then refer to hospital.
If the diarrhoea has stopped (< 3 stools
per day) Tell the mother to follow the usualfeeding recommendations for the childsage.
Persistent Diarrhea
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Blood in thestool DYSENTERY
Treat for 5 days with
an oral antibioticrecommended for
Shigella in your area.
Follow-up in 2 days.
CLASSIFICATION TABLE FOR DYSENTERY
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
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After 2 days:Ask:
if the child is dehydrated, treathydration.
if the number of stools, amount ofstools, fever, abdominal pain or eating
is same or worse: Change to 2nd lineantibiotics & give for 5 days. Advise toreturn in 2 days.
Dysentery
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EXCEPTIONS:
If the child is less than 12 months old or
was dehydrated on the 1st
visit or hadmeasles within the last 3 months. REFER
TO HOSPITAL.
If fewer stools, less blood in stools, less
fever, less abdominal pain & eating better,
continue antibiotics.
Dysentery
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Session 4-c
Fever
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Checking the Main Symptoms
3. Fever
Stiff neck Risk of malaria and other endemic
infections, e.g. dengue hemorrhagic fever
Runny nose
Measles Duration of fever (e.g. typhoid fever)
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Assess FEVER
A child has the main symptom of fever
if:
the child has history of fever
the child feels hot
the child has an axillary temperature of
37.5 or above
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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
Decide Malaria Risk
Ask:
Does the child live in a malaria area?
Has the child visited malaria area in the past 4 weeks?
If yes to either, obtain a blood smear.
Then Ask:
For how long does the child hasfever?
If >7 days, has the fever beenpresent everyday?
Has the child had measles withinthe last 3 months?
Look and Feel:
Look and feel for stiff neck. Look for runny nose
Look for signs of Measles:
Generalized rash.
One of these: cough, runny nose or
red eyes
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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
If the child has measles now or within thelast three months:
Look for mouth ulcers.
Are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
Then Ask:
Has the child had anybleeding from the nose or
gums or in the vomitus orstools?
Has the child had blackvomitus or stools?
Has the child had abdominalpain?
Has the child been vomiting?
Look and Feel:
Look for bleeding from nose orgums.
Look for skin petechiae Feel for cold clammy
extremities.
If none of the above ASK or LOOK
and FEEL signs are present and
thechild is 6 months or older and
fever
present for more than 3 days.
Perform Torniquet Test.
Decide Dengue Risk: Yes or NoIf Dengue Risk:
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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
Decide Malaria Risk:
If the child has
measles now or within
the last three months:
Decide Dengue Risk: Yes
or No
If Dengue Risk:
Classify
FEVER
Malaria Risk(including travel to
malaria area)
No Malaria
Risk
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Deciding Malaria Risk
Malaria is caused by parasites in the
blood called plasmodia Plasmodium falciparum
Transmitted by Anopheles mosquito
Know the malaria risk in your areas.
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Malaria Risk Areas
1. Palawan
2. Davao Oriental
3. Davao del Norte
4. Compostela Valley5. Tawi-tawi
6. Sulu
7. Agusan del Sur
8. Mindoro Occidental9. Kalinga Apayao
10. Agusan del Norte
11.Isabela
12.Cagayan
13.Quezon
14.Ifugao15.Zamboanga del Sur
16.Bukidnon
17.Misamis Oriental
18.Quirino19.Mountain Province
20.Basilan
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Classify FEVER
Classify
FEVER
Malaria Risk(including travel to
malaria area)
No Malaria
Risk
Malaria Risk Any general danger sign
or
Stiff Neck
VERY SEVERE
FEBRILE
DISEASE/MALARIABlood smear (+)
If blood smear not done:
NO runny nose and,
NO measles, and NO
other
causes of fever
MALARIA
Blood smear (-), or
Runny nose, or
Measles or
Other causes of fever.
FEVER:
MALARIA UNLIKELY
No Malaria Risk Any general danger sign
or
Stiff Neck
VERY SEVERE
FEBRILE DISEASE
No sign of very severe FEVER:
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Malaria Risk
Any generaldanger
sign or
Stiff Neck
VERY SEVERE
FEBRILE
DISEASE
/MALARIA
Give first dose of Quinine (under medicalsupervision or if a hospital is not accessible
withing 4 hours)
Give first dose of appropriate antibiotics.
Treat the child to prevent low blood sugar.
Give one dose of Paracetamol in health center
for
high fever (38.5C or above.)
Send a blood smear with the patient.
ReferURGENTLY to a hospital.
Blood smear (+)
If blood smear notdone:
NO runny nose
and,
NO measles, and
NO other causes
of fever
MALARIA
Treat the child with an oral antimalarial.
Give one dose of Paracetamol in health centerfor
high fever (38.5C or above.)
Advise mother when to return immediately.
Follow up in 2 days if fever persists.
If the fever is present every day for more than
7 days, refer for assessment.
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Malaria Risk
Blood smear(-), or
Runny nose,
or
Measles or
Other causes
of fever.
FEVER:
MALARIA
UNLIKELY
Give one dose of Paracetamol inhealth center for high fever (38.5C
or above.)
Advise mother when to return
immediately.
Follow up in 2 days if fever persists.
If the fever is present every day for
more than 7 days, refer for
assessment.
Treat other causes of fever.
TREAT THE CHILD:
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TREATTHE CHILD:
Antimalarial Agents Give an Oral Antimalarial
1st line Antibiotics: Chloroquine and Primaquine
2nd line Antibiotics: Sulfadoxine andPyrimethamine
If Chloroquine:
The child should be watched closely for 30 minutes. If thechild vomits, give another dose.
Itching is a possible side effect of the drug.
If Sulfadoxine and Pyrimethamine:
Give single dose in health center.
Antimalarial Agents
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Antimalarial AgentsCHLOROQUINE
Give for 3 days
PRIMAQUINE
Single dose
for P.falciparum
PRIMAQUINE
Daily for 14
days for P.vivax
SULFADOXINE +
PYRIMETHAMINE
Single dose
AGE Tablet
(150mg base)Tablet
(15mg base)
Tablet
(15mg base)
Tablet
(500mg Sulfadoxine
25mg Pyrimethamine)Day 1 Day 2 Day 3
2 months up
to 5 months
(4 -
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TREATTHE CHILD:
Antimalarial Agents
Chloroquine is given for 3 days.
Explain to the mother that itching is a
possible side effect. It is NOT
dangerous. The mother should continueto give the drug.
TREAT THE CHILD:
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TREATTHE CHILD:
Antimalarial Agents
If the species of malaria is identified
through blood smear, give the following:
P. falciparum single dose Primaquine with
the first dose of Chloroquine
P. vivax first dose of Primaquine with
Chloroquine and give mother enough for
one dose each day for the next 13 days.
TREAT THE CHILD:
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TREATTHE CHILD:
Antimalarial Agents
If you do not have the blood smear or
you do not know which species ofmalaria is present, treat as P. falciparum.
Do not give Primaquine to children under12 months of age.
TECHNICAL UPDATES:
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TECHNICAL UPDATES:
Antimalarial AgentsTECHNICAL BASIS: Artemisinin BasedCombination TherapiesBased on available safety and efficacy data, the followingtherapeutic options are available and have potential for
deployment (in prioritized order) if costs are not an issue: Arthemether lumefantrine (Coarthem TM)
Artesunate (3 days) + amodiaquine
Artesunate (3 days) + SP in areas where SP remains high
SP + Amodiaquine in areas where both SP andAmodiaquine remain high. This mainly limited to West
Africa.
TECHNICAL UPDATES:
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TECHNICAL UPDATES:
Antimalarial Agents
Administer intramuscular antibiotic if the
child cannot take an oral antibiotic
Quinine for severe malaria
Breastmilk or sugar to prevent low blood
sugar.
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Give an Intramuscular Antibiotic
A child may need an antibiotic before
he leaves for the hospital, if he/she:
is not able to drink or breastfeed
vomits everything
has convulsions
is abnormally sleepy or difficult toawaken
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Give an Intramuscular Antibiotic
Age orWeight
CHLORAMPHENICOLDose: 40 mg/kg
Add 5 ml sterile water to vial containing 1000mg
= 5.6 ml at 180mg/ml
2 4 months (4 -
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Give Quinine for Severe Malaria
Quinine is the preferred agent because it
is rapidly effective.
Quinine is more safe and effective than
intramuscular Chloroquine.
Possible side effects of Quinine injections
are:sudden drop in blood pressure,
dizziness, ringing in the ears and a sterileabscess.
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Give Quinine for Severe Malaria
For children being referred with very severe febriledisease/Malaria:
Give the 1st dose of IM Quinine and refer the childurgently to the hospital
If referral is not possible:
Give the 1st dose of IM Quinine
The child should remain lying down for 1 hour
Repeat the Quinine injection 4 to 8 hours later, andthen every 12 hours until the child is able to take an
oral antimalarial. Do not continue Quinine injection for more than 1
week.
DO NOT GIVE QUININE TO A CHILD LESS THAN 4MONTHS OF AGE.
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Give Quinine for Severe Malaria
Age orWeightINTRAMUSCULAR QUININE
300 mg/ml (In 2 ml ampules)
4 months 12 months
(6 -
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TREAT THE CHILD:
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TREATTHE CHILD:
To Prevent Low Blood Sugar
To make Sugar Water:
Dissolve 4 level teaspoons of sugar (20grams)
in a 200 ml cup of clean water.
If the child is not able to swallow:
Give 50 ml of sugar water by nasogastric
tube.
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No Malaria RiskAny general
danger sign or
Stiff Neck
VERY
SEVERE
FEBRILE
DISEASE
Give first dose of appropriate antibiotics.
Treat the child to prevent low blood sugar.
Give one dose of Paracetamol in healthcenter for high fever (38.5C or above.)
Refer URGENTLY to a hospital.
No sign of
very severe
febrile disease
FEVER:
NO MALARIA
Give one dose of Paracetamol in health
center for high fever (38.5C or above.)
Advise mother when to return
immediately.
Follow up in 2 days if fever persists.
If the fever is present every day for more
than 7 days, refer for assessment.
Does the child have fever?
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(by history, or feels hot or temperature 37.5C
and above)
Decide MalariaRisk:
If the child hasmeasles now orwithin the last
threemonths:
Decide DengueRisk: Yes or No
If Dengue Risk:
Classify
FEVER
Severe
Complicated
Measles
Measles with
Eye or Mouth
Complications
Measles
If dengue Risk, classify page 77 of the module Assess
and Classify the Sick Child Age 2 months up to 5 years
Does the child have fever?
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If the child has
measles now
or within the
last three
months:
Look for mouth
ulcers: are they
deep and
extensive
Look for pus
draining from the
eyeLook for clouding
of the cornea
Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
If
measles
nowor within
last
three
months,
classify
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Measles
Fever and generalized rash are the mainsigns of measles.
Highly infectious.
Over crowding and poor housingincreases the risk of developing
measles. Caused by a virus that infects the layers
of cells that line the lung, gut, eye,mouth and throat.
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Measles
Complications of measles occur in about 30% ofall cases
diarrhea (including dysentery and persistentdiarrhea)
pneumonia and stridor mouth ulcers
ear infection
severe eye infection (which may lead to
corneal ulceration and blindness) Encephalitis occurs in about 1/1000 cases. (look
for danger signs such as convulsions, abnormallysleepy or difficult to awaken)
Classify MEASLES
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Classify MEASLESClouding of the
cornea
Deep extensive
mouth ulcers
SEVERE
COMPLICATED
MEASLES
Give Vitamin A
Give first dose of an appropriate
antibiotics
If clouding of the cornea or pus
draining
from the eye, apply Tetracycline eye
ointment
Refer URGENTLY to the hospitalPus draining from
the eye
Mouth ulcers
MEASLES WITH EYE
OR MOUTH
COMPLICATIONS
Give Vitamin A
Give first dose of an appropriate
antibiotics
If pus draining from the eye, apply
Tetracycline eye ointment
If mouth ulcers, teach the mother totreat
with gentian violet
Follow up in two days
Measles now or
within the last 3
months
MEASLES Give Vitamin A
Children with Measles
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Kopliks spots
TREAT THE CHILD:
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TREATTHE CHILD:
Give Vitamin ATREATMENT
Give one dose of Vitamin A in the Health
Center
SUPPLEMENTATION
Give one dose of Vitamin A in the Health
Center if:
Child is 6 months of age or older
Child has not received a dose of
Vitamin A in the past 6 months
TREAT THE CHILD:
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TREATTHE CHILD:
Give Vitamin A
AGEVitamin A Capsule
100,000 IU 200,000 IU
2 6 months 50,000 IU
6 12 months 1 cap 1/2 cap
1 5 years 2 caps 1 cap
200,000 IU = 6 drops
100,000 IU = 3 drops
Does the child have fever?
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Does the child have fever?(by history, or feels hot or temperature 37.5C and above)
Decide Malaria Risk:
If the child has measles
now or within the last three
months:
ClassifyFEVER
Severe DHF
Fever; DHFUnlikely
Torniquet Test 1.3gp
Torniquet Test 2.3gp
Decide Dengue Risk:
Yes or No
If Dengue Risk:
T i t T t
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Tourniquet Test
Inflate blood
pressure cuff to a
point midway
between systolicand diastolic
pressure for 5
minutes
Positive test: 20 ormore petechiae per
1 inch (6.25 cm )
Classify DENGUE
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HEMORRHAGIC FEVERbleeding from the nose
or gums
Bleeding in the
vomitus or stools
Skin petechiae
Cold clammy
extremities
Capillary refill morethan 3 seconds
abdominal pain or
Vomiting or
Positive torniquet test
SEVERE DENGUE
HEMORRHAGIC
FEVER
If skin petechiae or abdominal pain
or vomiting or positive torniquet test
are the only positive signs, give ORS
If any other signs of bleeding are
present, give fluids rapidly as in Plan
C
Treat the child to prevent low blood
sugarRefer all chioldren URGENTLY to the
hospital
DO NOT GIVE ASPIRIN
No signs of severe
dengue hemorrhagic
fever
FEVER; DENGUE
HEMORRHAIC
FEVER UNLIKELY
Advise mother when to return
immediately
Follow up in 2 days if fever persists
or child shows signs of bleeding.
DO NOT GIVE ASPIRIN
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Delayed capillary refill may be the first sign of intravascular
volume depletion. Hypotension usually is a late sign in
children. This child's capillary refill at 6 seconds was delayedwell beyond a normal duration of 2 seconds.
S i 4 d
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Session 4-d
Ear Problem
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Checking the Main Symptoms
4. Ear problems
Tender swelling behind the ear Ear pain
Ear discharge or pus (acute or
chronic)
A EAR PROBLEM
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Assess EAR PROBLEM
A child with ear problem is assessed for:
Ear pain
Ear discharge If present, how long has the child has
had ear discharge
Tender swelling behind the ear, a signof mastoiditis
A EAR PROBLEM
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Assess EAR PROBLEM
Then Ask: Does the child have an ear problem?IfYES, ASK:
Is there ear pain?
Is there ear discharge? If yes, for how long?
LOOK and FEEL:
Look for pus draining from the ear.
Feel for tender swelling behind the ear.
Ask about ear problem in ALL sick children.
Classif EAR PROBLEM
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Classify EAR PROBLEMTender swelling behind
the ear
MASTOIDITIS Give the first dose of an appropriate
antibiotics
Give first dose of Paracetamol for pain
Refer URGENTLY to hospital
Pus is seen draining
from the ear and
discharge is reported
for less than 14 days, or
Ear pain
ACUTE EAR
INFECTION
Give an antibiotic for 5 days.
(Amoxicillin)*
Give Paracetamol for pain.Dry the ear by wicking.
Follow up in 5 days.
Pus is seen draining
from the ear and
discharge is reported
for 14 days or more.
CHRONIC EAR
INFECTION
topical quinolone ear drops for at least
two weeks
Dry the ear by wicking.
Follow up in 5 days.
No ear pain and no pus
is seen draining from
the ear.
NO EAR INFECTION No additional treatment.
*Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high.
TECHNICAL UPDATES:
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Chronic Suppurative Otitis Media
TECHNICAL BASIS: aural toilet combined with antimicrobial
treatment is more effective than aural toiletalone
topical antibiotics were found to be better thansystemic antibiotics in resolving otorrhea anderadicating middle ear bacteria
topical quinolones were found to be better thantopical non-quinolones
topical ofloxacin or ciprofloxacin vsintramuscular gentamicin, topical gentamicin,tobramycin or neomycin-polymyxin
TECHNICAL UPDATES:
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Acute Otitis Media
TECHNICAL BASIS:
oral amoxicillin as the better choice for
the management of acute ear infectionin countries where antimicrobial
resistance to cotrimoxazole is high.
reduces the risk of mastoiditis in
populations where it is more common
TREATTHE CHILD:
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Dry the Ear by Wicking Dry the ear at least 3 times daily.
Roll a clean absorbent cotton or soft tissue paper
into a wick.
Place the wick in the childs ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat
these steps until the ear is dry.
Do not use a cotton-tipped applicator, a stick or a
flimsy paper that will fall apart in the ear.
TREATTHE CHILD:
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Dry the Ear by Wicking
Wick the ear 3 times daily.
Use this treatment for as many days as it
takes until the wick no longer gets wet when
put in the ear and no pus drains from the ear. Do not place anything (oil, foil or other
substances) in the ear between wicking
treatments.
Do not allow the child to go into swimming.
Malnutrition and Anemia
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ForALL sick children ask the mother about the childs difficult breathing, diarrhoea,
fever, ear problem and then
CHECK FOR MALNUTRITION AND ANAEMIA.
THEN CHECK FOR MALNUTRITION AND ANAEMIA
CLASSIFY the childs illness using the colour-coded-classification table for malnutrition
and anemia
Then CHECK immunization status and for other problems.
LOOK AND FEEL:
Look for visible severe wasting.
Look for palmar pallor. Is it: Severe palmar
pallor?
Some palmar pallor?
Look for oedema of both feet.
Determine weight for age.
Classify
NUTRITIONAL
STATUS
Checking Nutritional Status,
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Feeding, Immunization Status Malnutrition
visible severe wasting
edema of both feet
weight for age
Anemia
palmar pallor
Feeding and breastfeeding
Immunization status
IDENTIFY TREATMENT
CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA
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Visible severe wasting
orSevere palmar pallor or
Oedema of both feet.
SEVEREMALNUTRITION OR
SEVERE ANAEMIA
Give Vitamin A.
Refer URGENTLY to hospital.
Some palmar pallor or
Very low weight for age.
ANAEMIA OR VERY
LOWWEIGHT
Assess the
feeding according to the FOOD box on the COUNSEL
THE MOTHERchart. If feeding problem, follow-up in 5 days.
If pallor:
Give iron.
Give oral antimalarial if high malaria risk.
Give mebendazole if child is 2 years or older and
has not had a dose in the previous 6 months.
Advise mother when to return immediately.
If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
Not very low weight for
age and no other signs NO ANAEMIA AND
If child is less than 2 years old, assess the
feeding and counsel the mother on feeding
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
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Immunization Status
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THEN CHECK THE CHILDS IMMUNIZATION STATUS
ForALL sick children ask the mother about the childs about cough or difficult
breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia
andCHECK IMMUNIZATION STATUS.
IMMUNIZATION
SCHEDULE:
AGE
Birth
6 weeks
10 weeks
14 weeks
9 months
VACCINE
BCG
DPT-1
DPT-2
DPT-3
Measles
OPV-0
OPV-1
OPV-2
OPV-3
DECIDE if the child needs an immunization today, or if the mother should be
told to come back with the child at a later date for an immunization.
Note: Remember there are no contraindications to immunization of a sick child
if the child is well enough to go home.
Then CHECK for other problems.
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Common Contraindications toCommon Contraindications to
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Common Contraindications toCommon Contraindications to
ImmunizationsImmunizations1. Children who are being referred urgently to the
hospital should not be immunized
2. Live vaccines should not be given to sick children with
immunodeficiency or immunosuppressed due tomalignant disease, treatment with immunosuppressive
agents or irradiation
3. DPT2 / DPT3 should not be given to children who
have had convulsions or shock within 3 days of a
previous dose of DPT
4. DPT should not be given to children with recurrent
convulsions or another active neurological disease of
the CNS.
Common Contraindications toCommon Contraindications to
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Common Contraindications toCommon Contraindications to
ImmunizationImmunization
OPV:
If the child had diarrhea, give a dose ofOPV but do
not count the dose. Ask the mother to return in 4
weeks for the missing dose ofOPV
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OTHER PROBLEMS
For all sick children ask the mother about the child\s problem,
check for general danger signs, ask about cough or difficult breathing
diarrhea, fever, ear problem, and then check for malnutrition
and anemia, immunization status AND
ASSESS OTHER PROBLEMS
TREAT any other problems according to your training,
experience and clinic policy.
REFER the child for any other problem that you cannot manage
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Assessing Other Problems
Meningitis
Sepsis
Tuberculosis
Conjunctivitis Others:also mothers (caretakers) own
health
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Ask the mother or caretaker about the young
SUMMARY OF ASSESS AND CLASSIFY
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If this is an INITIAL VISIT for the problem, follow the steps below.
(If this is a follow-up visit for the problem, give follow-up care according toPART VII)
Check forPOSSIBLE BACTERIAL INFECTION and classify the illness.
Ask the mother or caretaker about
DIARRHOEA:
If diarrhoea is present:
assess the infant further for signs related todiarrhoea, and
classify the illness according to the signs
which are present or absent.
Check forFEEDING PROBLEM OR LOWWEIGHT and classify the
Check the infants immunization status and decide if the infant needs anyimmunization today.
Assess any other problems.
Then: Identify Treatment (PART IV), Treat the Infant (PART V),
and Counsel the Mother (PART VI)
ForALL sick young infants check for signs ofPOSSIBLE BACTERIAL INFECTION
How to check a young infant for possible bacterial infection
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CHECK FOR POSSIBLE BACTERIAL INFECTIONASK:
Has the infant had
convulsions?
LOOK, LISTEN, FEEL:Count the breaths in one minute.
Repeat the count if elevated.
Look for severe chest indrawing.
Look for nasal flaring
Look and listen for grunting.
Look and feel for bulging fontanelle.
Look for pus draining from the ear.
Look at the umbilicus. Is it red or draining pus?
Does the redness extend to the skin?
Measure temperature (or feel for fever or low body temperature)
Look for skin pustules. Are there many or severe pustules?
See if the young infant is lethargic or unconscious.
Look at the young infantss movements. Are they less than normal?
YOUNGINFANT
MUST BE
CALM
CLASSIFY the infants illness using the COLOUR-CODED-CLASSIFICATIONTABLE FOR POSSIBLE BACTERIALINFECTION.
Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other
problems.
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(U t f l t t t i b ld i t )
CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
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Convulsions or
Fast breathing (60 breaths per
minute or more) orSevere chest indrawing or
Nasal flaring or
Grunting or
Bulging fontanelle or
Pus draining from ear or
Umbilical redness extending tothe skin or
Fever (37.5 C* or above orfeels hot) or low bodytemperature (less than 35.5 C*
or feels cold) or
Many or severe skin pustules or
Lethargic or unconscious or
Less than normal movement.
POSSIBLE
SERIOUS
BACTERIALINFECTION
Give first dose of intramuscular antibiotics.
Treat to prevent low blood sugar.Advise mother how to keep the infant warm
on the way to hospital.
Refer URGENTLY to hospital
Red umbilicus ordraining pus or
Skin pustules.
LOCAL
BACTERIAL
INFECTION
Give an appropriate oral antibiotic.Teach the mother to treat local infections at
home.
Advise mother to give home care for the young
infant.
Follow-up in 2 days
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 C higher.
How to assess and classify a young infant for diarrhea?
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ForALL sick young infants check for signs of possible bacterial infection andthen
ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?
IF YES: ASSESS AND CLASSIFY the young infants diarrhoea using theDIARRHOEA box in the YOUNG INFANTchart. The
process is very similar to the one used for the sick child (see Chapter 8).
Then CHECK for feeding problem or low weight, immunization status and otherproblems.
ForALL sick young infants check for signs of possible bacterial infection, ask aboutdiarrhoea and then CHECK FOR FEEDING PROBLEM OR LOWWEIGHT.
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
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THEN CHECK FOR FEEDING PROBLEM OR LOWWEIGHT
LOOK, LISTEN, FEEL:
g? Determine weight for age.
s,how many times in 24 hours?
ive any other foods or drinks?
e infant?
Has any difficulty feeding,
Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age,
AND
Has no indications to refer urgently to hospital:
If the infant has not fed in the previous hour, ask the mother to put her
infant to the breast.O
bserve the breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother if she can wait
and tell you when the infant is willing to feed again.)
Is the infant able to attach?
no attachment at all not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outward
More areola visible above then below the mouth
(All these signs should be present if the attachment is good.)Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
no suckling at all not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding. Look for ulcers or white patches in the mouth (thrush).
CLASSIFY the infants nutritional status using the colour-coded classification table for feeding problem or low weight.
Then CHECK immunization status and for other problems.
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOWWEIGHT
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Not able to feed or
No attachment at all or
Not suckling at all.
NOT ABLE TO FEED
POSSIBLE
SERIOUS BACTERIALINFECTION
Give first dose of intramuscular antibiotics.
Treat to prevent low blood sugar.
Advise the mother how to keep the young infantwarm on the way to hospital.
Refer URGENTLY to hospital.
Not well attached to breast
or
Not suckling effectively or
Less than 8 breastfeeds in
24 hours or
Receives other foods or
drinks or
Low weight for age or
Thrush (ulcers or white
patches in mouth).
FEEDING PROBLEM
OR LOWWEIGHT
Advise the mother to breastfeed as often and for as long as theinfant wants, day and night.
-If not well attached or not suckling effectively, teach
correct positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise toincrease frequency of feeding.
If receiving other foods or drinks, counsel mother aboutbreastfeeding more, reducing other foods or drinks, and using acup.
If not breastfeeding at all:
Refer for breastfeeding counselling andpossible relactation.
Advise about correctly prepared breastmilksubstitutes and using a cup.
If thrush, teach the mother to treat thrush at home.
Advise mother to give home care for the young infant.
Follow-up any feeding problem or thrush in 2 days. Follow-uplow weight for age in 14 days.
Not low weight for age and
no other signs of inadequate
feeding.
NO FEEDING
PROBLEM
Advise mother to give home care for the young infant.
Praise the mother for feeding the infant well
(Urgent pre referral treatments are in bold print.)
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TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outward
More areola visible above then below
the mouth
(All these signs should be present if the attachment is good)
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Communicate and Counsel
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GIVEFO
LLO
W-UPCARE
Follow-up care for the sick young
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Follow up care for the sick young
infant When to return immediately Signs of any of the following:
Breastfeeding or drinking poorlyBecomes sicker
Develops a fever
Fast breathingDifficult breathing
Blood in the stool
Follow-up care for the sick young
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Follow up care for the sick young
infant
Follow-up in 2 days on antibiotics
for local bacterial infection or
dysentery
Follow-up in 2 days - with a feeding
problem or oral thrush
Follow-up in 14 days with low
weight for age
If th hild h R t f f ll i
FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART
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If the child has: Return for follow-up in:
PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVERMALARIA UNLIKELY, if fever
persists
MEASLES WITH EYE OR MOUTHCOMPLICATIONS
2 days
PERSISTENTDIARRHOEA ACUTE EAR
INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEMANYOTHER ILLNESS, if not improving
5 days
PALOR VERY 14 days
LOW WEIGHTFOR AGE 30 days
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THANK YOU!!THANK YOU!!