imci technical updates.revised
TRANSCRIPT
IMCI TECHNICAL UPDATES
Why Update?
New knowledge on clinical management of childhood diseases are available
Implementation of IMCI has identified problems and questions which were addressed by operational research
Epidemiology of diseases has evolved thus a revised version has to accommodate and reflect these changes
Technical updates adapted in Philippine IMCI
Antibiotic treatment of non-severe and severe pneumonia
Low osmolarity ORS and antibiotic treatment for bloody diarrhea
Treatment of fever/malaria Treatment of ear infections Infant feeding Treatment of helminthiasis Management of sick young infant aged up to 2
months
I. Acute respiratory infection
First-line/second line antibiotic for non-severe pneumonia previous updated First line Cotrimoxazole Amoxicillin Second line Amoxicillin Cotrimoxazole
Duration of antibiotic treatment from 5 days to 3 days
Frequency of administration of antibiotics from 3x to 2x a day
ACUTE RESPIRATORY INFECTION
Management for non-severe pneumonia therefore:
First line: Oral amoxicillin to be given in 25mg/kg
dose twice daily in children 2-59 months of age for 3 days
Second line: Oral Cotrimoxazole to be given 2x daily
for 3 days
ACUTE RESPIRATORY INFECTION
Technical basis:
3 days treatment is equally effective as the 5 day treatment
Reduces cost of treatment Improves complianceReduces antimicrobial resistance in the
community
Acute Respiratory Infections
Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia
Where referral is difficult and injection is not available, oral Amoxicillin in 45 mg/kg/dose 2x daily should be given to children with severe pneumonia for 5 days
Technical basis:
Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia
Acute Respiratory Infections
Gentamicin plus ampicillin vs chloramphenicol for very severe pneumonia
Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol for very severe pneumonia in children 2-59 months of age.
A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used
Acute Respiratory Infections
Inclusion of Wheeze For children with wheeze and fast breathing
and/or lower chest wall indrawing
Give a trial of rapid-acting inhaled bronchodilator (up to 3 cycles) before they are classified as pneumonia and prescribed antibiotics.
0.5 ml salbutamol diluted in 2.0 ml of sterile water per dose nebulization should be used
DIARRHEAL DISEASES
Use of low osmolarity oral rehydration salts
Technical basis: Efficacy of ORS solution for tx of acute non-cholera in
children is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245mOsm/l.
The need for unscheduled supplemental IV is reduced by 33%, stool output is reduced by about 20% and the incidence of vomiting by about 30%
Diarrheal Diseases
Use of antibiotics in the management of bloody diarrhea (shigella dysentery) Ciprofloxacin is the most appropriate
drug in place of nalidixic acid which leads to rapid development of resistance
Dose: 15 mg/kg body weight 2x a day for 3 days
Diarrheal diseases
Technical basis:- Ciprofloxacin is several thousand-fold greater
than that of nalidixic acid- Ciprofloxacin is 100 to 1000-fold less prone to
selection of single-step spontaneous highly resistant organisms
- Simplified tx regimens (2 doses /day x 3 days instead of 4 doses/day x 5 days with nalidixic acid)
- Considered for its safety, efficacy and reduced cost
DIARRHEAL DISEASES
Giving of Zinc supplements in the management of diarrhea
Dose: 2 mos. up to 6 mos. - ½ tab daily for 10-14 days 6 mos. or more – 1 tab daily for 10-14 days
Giving of multivitamins and minerals (with zinc) for 14 days is added in the treatment of persistent diarrhea
Technical basis: reduced duration and severity of diarrhea episode lowered incidence of diarrhea in the ff. 2-3
months
DIARRHEAL DISEASES
Fever
First line antibiotic for Malaria (Artemether-lumefantrine)
For children 1-3 yrs old
Day 1 1 tablet
after 8 hrs 1 tablet
Day 2 1 tablet 2x a day
Day 3 1/2 tablet 2x a day
Fever
For children 4-8 yrs old
Day 1 2 tablets
after 8 hrs 2 tablets
Day 2 2 tablets 2x a day
Day 3 2 tablets 2x a day
Day 4 Primaquine, ½-3/4
tablets for 14 days
Fever
Treatment schedule for uncomplicated P. falcifarum malaria
day 1-3 Artemether-Lumefantrine (Coartem)
day 4 Primaquine, single dose only on day 4
Note: Primaquine is contraindicated in children < 1y.o.
Fever
Treatment schedule for confirmed P. vivax cases
Day 1-3 Chloroquine for 3 days
Day 4-17 Primaquine for 14 days
Mixed P.falciparum and P. vivax Day 1-3 Artemether + lumefantrine
Day 4-17 Primaquine
Fever
Treatment of drug-resistant malaria In case of parasitological or clinical failure to a
given drug, refer patient to the next level with proper documentation (blood smear result incl. parasite count on day7, 14, 21, & 28
Quinine sulfate(300 or 600 mg/tab)
10 mg/kg/dose every 8 hours for 7 days
+ Clindamycin 10 mg/kg 2x a day for 3 days
Fever
Pre-referral treatment:
Artesumate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow.
FEVER/MALARIA
Antimalarials for treatment of Malaria
The following therapeutic options are available and have potential for deployment (in prioritized order) if costs are not an issue: Artemether-lumefantrine (Coartem TM) Artesunate (3 days) plus amodiaquine Artesunate (3 days) plus SP in areas where SP
efficacy remains high SP plus amodiaquine in areas where efficacy of
both amodiaquine and SP remain high (limited in west African countries)
Technical basis: Artemisin-based combination therapy
(ACT) result in rapid substantial reduction of the parasite biomass and rapid resolution of clinical symptoms
In combination, allows reduction of artemisin tx, while enhancing efficacy and reduce likelihood of resistance development to the partner drug
EAR INFECTIONS
Chronic ear infection Chronic ear infection
should be treated with optical quinolone ear drops for at least 2 weeks in addition to dry ear by wicking
Acute ear infection Oral amoxicillin is a
better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimixazole is high
EAR INFECTIONS
Technical basis: Cochrane review of randomized
controlled trials published in the Cochrane Library
Aural toilet combined with antimicrobial treatment is more effective than aural toilet alone; oral antibiotics were found to be better than aural toilet alone
Topical antibiotics were found to be better than aural toilet alone; the addition ot topical; antibiotics to aural toilet was associated with a 57% rate of otorrhea resolution compared to 27% with aural toilet alone
Topical antibiotics were found to be better than systemic antibiotics in resolving otorrhea and eradicating middle ear bacteria; in general topical quinolones were found to be better than topical non-quinolones; finally combined topical and systemic antibiotics are no better than topical antibiotics alone
The safety of topical quinolones in children has been well documented without good evidence of a risk of ototoxicity
Malnutrition and anemia
MUAC (mid-upper arm circumference) less than 10 mm is now considered an indicator for severe malnutrition
Use of the new WHO Growth Standards Inclusion of management of severely
malnourished children where referral is not possible
Immunization Schedule
Age Vaccine
Birth BCG, HepB1
6 weeks DPT1, OPV1, HepB2
10 weeks DPT2, OPV2
14 weeks DPT3, OPV3, HepB3
9 months Anti-measles
INFANT FEEDING
Exclusive breastfeeding up to 6 mos.
Breastfeed as often as the child wants, day and night at least 8 times in 24 hours
Breastfeed when the child shows signs of hunger, beginning to fuss, sucking fingers, or moving the lips
Do not give other foods or fluids Only if the child is older than 4 mos. and appears
hungry after breastfeeding and is not gaining weight adequately, add complementary foods. Give 1-2 tablespoons, 1-2 times per day after breastfeeding
Infant Feeding . . .
Complementary feeding 6 mos. up to 23 mos. Breastfeed as often as the child wants Give adequate serving of complementary foods: 3
times per day if breastfed, with 1-2 nutritious snacks as desired from 9-23 mos.
Give foods 5 times per day if not breastfed with 1 or 2 cups of milk
Give small chewable items to eat with fingers. Let the child try to feed itself, but provide help
Do not give other foods or fluids Only if the child is older than 4 mos. and appears
hungry after breastfeeding and not gaining weight adequately, add complementary foods.
Give 1-2 tablespoons, 1-2 times per day after breastfeeding
Infant Feeding . . .
Management of severe malnutrition where referral is not possible Where a child is classified as having severe
malnutrition and referral is not possible, the IMCI guidelines should be adapted to include management at first-level facilities
modified milk diet is given
Infant Feeding . . .
HIV and Infant Feeding In areas where HIV is a public health problem all
women should be encouraged to receive HIV testing and counseling
Avoid breastfeeding If a mother is HIV-infected and replacement feeding is acceptable, feasible, affordable, sustainable and safe for her and her infant.
The child of HIV-infected mother who is not breastfed should receive complementary foods
HELMINTH INFESTATIONS Helminth infestations in children below 24 months
Albendazole and mebendazole can be safely used in children 12 months or older
Give 500 mg Mebendazole or 400 mg Albendazole in single dose
Technical basis:
Tanzania study: Mebendazole had a positive effect on motor and language development and compared with placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhea, dysentery and ARI) one week after intervention
Sick young infant aged up to 2 months
Previous UpdatedAge: 1 week up to Birth up to 2
2 months months
Main symptom:Previous: Possible serious bacterial infection
Updated: Very severe disease and local bacterial infection
Sick young infant – cont’d
Signs to look for in assessment:
Previous: 12 signs
Updated: 7 signs
Any one of the following signs • Not feeding well or • Convulsions or • Fast breathing (60 breaths per minute or more) or
• Severe chest indrawing or • Fever (37.5°C* or above) or • Low body temperature (less than 35.5°C*) or • Movement only when stimulated or no
movement at all
Sick young infant – cont’d
Classification:
Previous: Updated:
Very severe disease (pink) Very severe disease
Local bacterial infection (yellow) Severe disease
Severe disease or local Severe disease or
bacterial infection unlikely local bacterial
(green) infection unlikely
Sick young infant – cont’d
Checking for jaundice is added in the protocol
Classification: Severe jaundice (pink)
Jaundice (yellow)
No jaundice (green)
Acute Respiratory Infections
Technical basis: Multicentre randomized clinical study in 8 sites in 7
countries (N=958) 12.7% failed treatment by day 6 – higher in
Chloramphenicol group (RR of 1.5); common reasons were deaths (n=44), development of septic shock (n=29), or persistence of very severe pneumonia (n=21)
Tx failure at 48 hours (8.6%), constituting 51% of all tx failure.
Overall more deaths occurred at the chloramphenicol group than the ampicillin-gentamicin group by day 30.
Based on these results the use of gentamicin plus ampocillin for the management of very severe pneumonia is warranted
Acute Respiratory Infections
Technical basis: WHO supported studies on “The assessment & management
of wheeze in children 1-59 months of age presenting with cough and /or difficult breathing” in several countries
Pakistan (n=1622)595 (36.7% w/ audible wheeze)
Thailand (n=521) 48 (9.2% w/ audible wheeze)
number Response Subsequent deterioration
number Response Subsequent deterioration
Non-severe
pneumonia1004(61.8%)
621 (61.8%)
93(14.9%)
256(49.1%)
217(84.8%)
14
(6.4%)
Severe
pneumonia618(38.2%)
166(26.8%)
63(37.9%)
265(50.9%)
189(71.3%)
24(12.7%)
-These data show a large no. of children w/ wheeze are being classified as pneumonia and are being prescribed antibiotics unnecessarily.
- Bronchodilators are being underutilized in children with wheeze.
-Majority of children with wheeze who respond to a trial of inhaled bronchodilators continue to do well when sent home without an antibiotic.
Acute Respiratory Infections