INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Jocelyn F. Villanueva, Ed.D., R.N.

INTRODUCTION:
Integrated Management of Childhood Illnesses has been established as an approach to strengthen the provision of comprehensive and essential health package to the children. Newborns usually refer to infants during the first month of life. Infants are those that are still below one year old.

The top cause of death among newborns is Pneumonia, followed by bacterial sepsis. Other causes of mortality in newborn are related to pregnancy.
Among children 0-4 years of age, the number one cause of death is pneumonia. Accidents are identified as the top cause of mortality among older children 5-9 years old followed by pneumonia and malignant neoplasm.

Methods in Managing Childhood Illnesses

Assess the Patient Taking the history of the patient is one way of getting information about the disease condition. This can be done by asking and observing the patients condition to explore the possible causes.
Classify the Diseases A thorough assessment supported with laboratory results is necessary for classification of illnesses and confirmation of the disease. Classification of the disease are: 1.) mild, 2.) moderate, 3.) severe

Treat the Patient Treatment is a curative method of treating diseases. This vary on the condition of the patient. Counsel the patient Providing health education to clients promotes health and avoid risk of infection. These are important for parents/ caregivers especially who lack knowledge on health practices and risk factors that contribute to disease ailments.

Color-coded system:
Color Presentation Green Classification of Diseases Mild Level of Management Home Care

Yellow

Moderate

Manage at the RHU Urgent Referral in Hospital

Pink

Severe

THE INTEGRATED CASE MANAGEMENT PROCESS

OUTPATIENT HEALTH FACILITY
Check for DANGER SIGNS Convulsions Abnormality sleepy or difficult to awaken Unable to drink/breastfeed Vomits everything Assess MAIN SYMPTOMS Cough/difficulty breathing Fever Diarrhea Ear problem

Assess NUTRITION, IMMUNIZATION and VITAMIN A SUPPLEMENTATION STATUS and POTENTIAL FEEDING PROBLEMS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to color-coded treatment

Treatment in outpatient facility

Urgent referral

OUTPATIENT HEALTH FACILITY

Pre-referral treatments Advise parents Refer child REFERRAL FACILITY Pre-referral treatments Advise parents Refer child

OUTPATIENT HEALTH FACILITY Treat local infection Give oral drugs Advise and teach caretaker Follow-up Home Management

HOME Caretaker counseled on: Home treatment (s) When to return immediately Follow-up

IMCI is categorized according to age as:

sick child aged 2 months to 5 years; and sick young infant aged 1week to 2 months.

ASSESS AND CLASSIFY THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

ASSESS
ASK THE MOTHER WHAT THE CHILDS 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 the TREAT THECHILD chart. - if initial visit, assess the child as follows: CHECK FOR DANGER SIGNS
LOOK: ASK: See if the child is abnormally Is the child not able to drink or breastfeed? sleepy or difficult to awaken. Does the child vomit everything? Has the child had convulsions? (during the present illness)

If YES

A child with any danger signs needs URGENT attention, complete the assessment and any pre-referral treatment so referral is not delayed.

MAKE SURE THE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after the First dose of an appropriate antibiotic and other urgent treatments. Exception: Rehydration of the child according to plan C may resolve the danger signs so that referral is no longer needed.

THEN ASK ABOUT THE MAIN SYMPTOMS: Does the child have cough or difficult breathing?
If YES, ASK: For how long? LOOK, LISTEN: Count the breaths in one minute. Look for chest indrawing. Look and listen for stridor. If the child is: 2 months up to 12 months old 12 months up Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more Classify COUGH or DIFFICULT BREATHING

CHILD MUST BE CALM.

SIGNS
Any general danger sign or Chest indrawing or Stridor in calm child Fast breathing

CLASSIFY AS
SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA -

TREATMENT
Give first dose of an appropriate antibiotic. Give vitamin A Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.

- Give an appropriate antibiotic 5 days. - Soothe the throat and relieve the cough with a safe remedy. - Advise mother when to return immediately. - Follow up in 2 days. - If coughing for 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 5 days if not improving.

No signs of pneumonia or very severe disease.

NO PNEUMONIA COUGH OR COLD

ASK: Does the child have diarrhea?

If YES, ASK: For how long? Is there blood in the stool?

LOOK, FEEL: Look at the childs general condition: Is the child abnormally sleepy or difficult to awaken? Restless and irritable? Look for sunken eyes. Offer the child fluids. 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? Does it go back slowly?

Classify DIARRHEA

For DEHYDRATION
Two of the following sign: Abnormally sleepy or difficult to awaken. Sunken eyes. Not able to drink or drinking poorly. Skin pinch goes back slowly Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back very slowly

SEVERE DEHYDRATION

- If the child has no other severe classification: Give fluid for severe dehydration. OR. - If the child has another severe classification: Refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. Advice mother to continue breastfeeding. - If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. - Give fluid and food for some dehydration - If the child has another severe classification: Refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. Advice mother to continue breastfeeding. - Advise mother when to return immediately. - Follow up in 5 days if not improving Give fluid and food to treat diarrhea at home. Give zinc supplements. Advise mother when to return immediately. Follow up in 5 days if not improving.

SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration

NO DEHYDRATION

and if diarrhea for 14 days or more

SEVERE PERSISTENT DIARRHEA - Treat dehydration before referral unless the child has another severe classification. - Give vitamin A. - Refer to hospital. - Advise the mother on feeding a child who has persistent diarrhea. -Give vitamin A. - Follow up in 5 days. - Advise mother when to return immediately.

Dehydration present

No dehydration

PERSISTENT DIARRHEA

and if blood in stool

Blood in the stool DYSENTERY

- Treat for 5 days with an oral antibiotic recommended for Shigella in your area. - Follow up in 2 days. - Advise mother when to return immediately.

ASK: Does the child have fever?

Decide Malaria Risk

Ask: Does the child live in a malaria area? Has the child visited/travelled or stayed overnight in a malaria area in the past 4 weeks. If YES to either, obtain a blood smear.
ASK: For how long has the child had fever? If more than 7 day, has the fever been present everyday? Has the child had measles within the last 3 months? LOOK AND FEEL: Look or feel for stiff neck. Look for runny nose. Look for signs of measles: - general rashes and - one of these: cough, runny nose or red eyes.. Classify FEVER

MALARIA RISK
Any general danger sign or Stiff neck VERY SEVERE FEBRILE DISEASE/ MALARIA - Give first dose of quinine( under medical supervision or if a hospital is not accessible within 4 hours). - Give first dose of an appropriate antibiotic. - Treat the child to prevent blood sugar. - Give 1 dose of paracetamol in health center for high fever 38.5 or above. - Refer urgently to the hospital. - Treat the child when an oral anti malaria - Give 1 dose of paracetamol and health center for high fever 38.5 or above. -Advise mother when to return immediately. - Follow up in 2 days if fever persists. - If fever is present everyday for more than seven days, refer for assessment. - Give one dose of paracetamol in health center for high fever 38.5 or above. -Advise mother when to return immediately. - Follow up in 2 days if fever persists. - If fever is present everyday for more than seven days, refer for assessment.

Blood 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

- Give one dose of an appropriate antibiotic. - Treat the child to prevent blood sugar. - Give 1 dose of paracetamol in health center for high fever 38.5 or above. - Refer urgently to the hospital.

No signs of a very severe febrile disease

FEVER: NO MALARIA

- Give one dose of paracetamol in health center for high fever 38.5 or above. -Advise mother when to return immediately. - Follow up in 2 days if fever persists. - If fever is present everyday for more than seven days, refer for assessment.

ASK: Does the child have fever?

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 eyes. Look for clouding of the cornea.

If MEASLES Now or within Last 3 months, classify

If MEASLES now or within last 3 months, classify

Clouding of the cornea or Deep or extensive mouth ulcers Any danger sign - Give vitamin A. - Give first dose of an appropriate antibiotic - If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment. - Refer URGENTLY to hospital.

SEVERE COMPLICATED MEASLES

Pus draining from the eye or Mouth ulcers

MEASLES WITH - Give Vitamin A. EYE OR MOUTH - If pus draining from the eye, apply COMPLICATIONS tetracycline eye ointment. - If mouth ulcers, teach the mother to treat gentian violet. - Follow up in 2 days. - Advise mother when to return immediately. MEASLES - Give vitamin A. - Advise mother when to return immediatley

Measles now or within the last 3 months

ASK: Does the child have fever?

Assess Dengue Hemorrhagic Fever
ASK: LOOK AND FEEL:

Has the child had any bleeding from the nose or gums, or in the vomitus or stools? Has the child had black vomitus? Has the child had black stools? Has the child had persistent abdominal pain? Has the child had persistent vomiting?

Look for bleeding from nose or gums. Look for skin petechiae. Feel for cold and clammy extremities. Check for slow capillary refill. If none of Assess DENGUE the above ASK, LOOK, and Feel signs are Hemorrhagic Fever present and the child is 6 months or older and fever present for more than 3 days. Perform the tourniquet test.

Assess Dengue Hemorrhagic fever

Bleeding from nose or gums SEVERE Bleeding in stools or vomitus DENGUE Black stools or vomitus or HEMORRHAGIC Skin petechiae or FEVER Cold and clammy extremities Or capillary refill more than 3 seconds or Persistent abdominal pain or Persistent vomiting or Tourniquet test positive - If persistent vomiting or persistent abdominal pain or skin petechiae or positive tourniquet test are the only positive signs, give ORS. - If any other signs of bleeding is positive, give fluids rapidly. - Treat the child to prevent low blood sugar. - Refer all children URGENTLY to hospital. - Do not give ASPIRIN.

No signs of severe dengue hemorrhagic fever.

FEVER: DENGUE HEMORRHAGIC 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

ASK: Does the child have an ear problem?

LOOK, FEEL: IF YES: Is there ear pain? Is there ear discharge? If yes, for how long? Look for the pus draining from the ear Feel for tender swelling behind the ear. Classify EAR PROBLEM

Classify Ear Problem

Tender swelling behind the ear MASTOIDITIS - Give first dose of an appropriate antibiotic. - Give first dose of paracetamol for pain. - Refer URGENTLY to hospital.

Ear pain Pus is seen draining from the ear, and discharge is reported for less than 14 days. Pus is seen draining from the ear, and discharge is reported for less than 14 days.

ACUTE EAR INFECTION

CHRONIC EAR INFECTION

- Give an antibiotic for 5 days. - Give paracetamol for pain. - Dry the ear by wicking - Follow up in 5 days. -Advise the mother when to return immediately - Dry the ear by wicking - Follow up in 5 days. - Advise the mother when to return immediately. - No additional treatment - Advise the mother when to return immediately.

No ear pain, and No pus is seen draining from the ear

NO EAR INFECTION

CHECK FOR MALNUTRITION AND ANEMIA

LOOK, LISTEN: Look for visible severe wasting Look for edema of both feet. Look for palmar pallor. Is it Severe palmar pallor? Some palmar pallor? Determine weight for age.

Classify NUTRITIONAL STATUS

Classify NUTRITIONAL STATUS

Visible severe wasting or Edema of both feet or Severe palmar pallor Some palmar pallor or Very low weight for age - Give vitamin A. - Refer URGENTLY to hospital

SEVERE MALNUTRITION OR SEVERE ANEMIA

ANEMIA OR VERY LOW WEIGHT

- Assess the childs feeding and counsel the the mother on feeding according to the FOOD box on the counsel the mother chart. If feeding problem, follow up in 5 days. -If some pallor: give iron give mebendazole if the child is 12 months or older, and has not had a dose in the previous six months. follow up in 14 days. - If child less than 2 years old , assess feeding and counsel the mother on feeding. if feeding problem, follow up in 5 days..

Not very low weight for age, and no other signs of malnutrition

NO ANEMIA AND NOT VERY LOW WEIGHT

TEACHING THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Also, follow the instructions listed in each drugs dosage table. Determine the appropriate drugs and dosage for the childs age or weight. Tell the mother the reason for giving the drugs to the child. Demonstrate how to measure a dose. Watch the mother practice measuring a dose by herself. Ask the mother to give the first dose to her child. Explain carefully how to give the drug, then label and package the drug. If more than one drug will be given, collect, count, and package each drug separately. Explain that all the oral drug tablets or syrup must be used to finish the course of treatment, even if the child gets better. Check the mothers understanding before she leaves the health center.

Give an Appropriate Oral Antibiotics FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS: First-line antibiotic : Second-line ANTIBIOTIC :

CONTRIMOXAZOLE AMOXYCILIN

FOR DYSENTERY:
Give an antibiotic recommended for Shigella in your area for 5 days. First-line antibiotic for Shigella : CONTRIMOXAZOLE Second-line antibiotic for Shigella: NALIDIXIC ACID FOR CHOLERA: Give an antibiotic recommended for Cholera in your area for 3 days. First-line antibiotic for Cholera : TETRACYCLINE Second-line antibiotic for Cholera: COTRIMOXAZOLE

TEACHING THE MOTHER TO GIVE ORAL DRUGS AT HOME

Give an Oral Antimalarial First-line Antimalarial
CHLOROQUINE, PRIMAQUINE, SULFADOXINE AND PYRIMETHAMINE. Second-line Antimalarial ARTEMETER-LUMEFRANTINE

IF CHLOROQUINE: - Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the health center for additional tablets. - Explain that itching is a possible side effect of the drug, but is not dangerous. IF SULFADOXINE + PYRIMETHAMINE: Give a single dose in the health center 2 hours before intake of Choroquine. IF PRIMAQUINE: Give single dose on Day 4 for P. falcipanum. IF ARTEMETER-LUMEFRANTINE: combination give for 3 days.

Give Paracetamol for High Fever (38.5 or above) or Ear Pain

 Give Vitamin A TREATMENT Give one dose in the health center. SUPPLEMENTATION Give one dose in the health center if : - child is six months of age or older, - child has not received a dose of vitamin A in the past six months. Give Iron Give one dose daily for 14 days.

Give Mebendazole/Albendazole Give 500 mg Mebendazole/400 mg Albendazole as a single dose in the health center if the child is 12 months up to 59 months and has not had a dose in the previous 6 months, with the following dose.

TEACHING THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given. Describe the treatment steps listed in the appropriate box. Watch the mother as she does the first treatment in the health center (except the remedy for cough or sore throat). Tell her how often the treatment should be done at home. If needed for treatment at home, give mother the tube of tetracycline ointment or a small bottle of gentian violet. Check the mothers understanding before she leaves the health center.

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 3 times daily. Wash hands. Ask child to close eyes. Use clean cloth and water to gently wipe away pus. Then apply tetracycline eye ointment in both eyes 3 times daily. Ask the child to look up. Squirt a small amount of ointment on the inside of the lower lid. Wash hands again. Treat until redness is gone. Do not use other eye ointment or drops, or put anything else in the eye.

Dry the Ear by Wicking

Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, strong 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 ear is dry.

Treat Mouth Ulcers with Gentian Violet

Treat the mouth ulcers twice daily. Wash hands. Wash childs mouth clean using soft cloth wrapped around the finger and wet with salt water. Paint the mouth with half-strength gentian violet, using cotton bud. Wash hands again.

Soothe the Throat and Relieve Cough with a Safe Remedy

Safe remedies to recommend: Breastmilk for exclusively breastfed infant. Tamarind, Calamansi and Ginger. Harmful remedies to discourage : Codeine cough syrup. Other cough syrups. Oral and nasal decongestants.

GIVE THESE TREATMENTS IN HEALTH CENTER ONLY

Explain to the mother why the drug is given. Determine the dose appropriate for the childs weight or age. Use a sterile needle and sterile syringe. Measure the dose accurately. Give the drug as an intramuscular injection.

If children cannot be referred, follow the instructions provided.

Give an Intramuscular Antibiotic

FOR CHILDREN BEING REFERRED WHO CANNOT TAKE ORAL ANTIBIOTIC

Give the first dose of intramuscular chloramphenicol and refer child urgently to hospital.

IF REFERRAL IS NOT POSSIBLE: Repeat the chloramphenicol injection every 12 hours for 5 days. Then change to an appropriate oral antibiotic to complete 10 days of treatment .

Give Quinine for Severe Malaria

FOR CHILDREN BEING REFERRED WITH A VERY SEVERE FEBRILE DISEASE/ MALARIA:

Give the first dose of intramuscular QUININE and refer urgently to hospital.

IF REFERRAL IS NOT POSSIBLE: Give first of intramuscular QUININE. The child should remain lying down for one hour. Repeat the QUININE injection at 4 and 8 hours later and then every 12 hrs. until the child is able to take an oral antimalarial. Do not continue QUININE injections for more than 1 week. DO NOT GIVE QUININE TO CHILD LESS THAN 4 MONTHS of AGE.

Treat the Child to Prevent Low Blood Sugar Level

If the child is able to breastfeed: Ask the mother to breastfeed the child.

If the child is not able to breastfeed but is able to swallow: Give expressed breastmilk or a breastmilk substitute. If neither of these is available, give sugar water. Give 30-50 ml of milk or sugar water before departure. To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in 200-ml cup of clean water.

If the child is not able to swallow: Give 50 ml of milk or sugar water by nasogastric tube.

If the child is difficult to awaken or unconscious, start IV infusion: Give 5 ml/kg of 10% of dextrose solution (D10) over a few minutes, Or give 1 ml/kg 0f 50% (D50) by slow push.

GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING

Plan A: Treat Diarrhea at Home Counsel the mother on the 4 Rules of Home Treatment: Give Extra Fluid, Give Zinc Supplements, Continue Feeding, When to Return. 1. GIVE EXTRA FLUID (as much as the child will take) Tell the Mother: - Breastfeed frequently and longer at each feeding. - If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk. - If the child is not exclusively breastfed, give one or more of the ff: ORS solution, food-based fluids (such as soup, rice water, or buko juice), or clean water. It is especially important to give ORS at home when: - the child has been treated with Plan B or Plan C during the visit, or - the child cannot return to a health center if the diarrhea gets worse.

Teach the Mother how to mix and give ORS. Give the Mother 2 packets of ORS to use at home. Show the Mother how much fluid to give in addition to the usual fluid intake:

Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother: Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue giving extra fluid until the diarrhea stops. 2. GIVE ZINC SUPPLEMENTS 10 mg per day in infants - < 6 months fo 10 14 days 20 mg per day in children 6 months 5 years old for 10 14 days

3. CONTINUE FEEDING 4. WHEN TO RETURN

 Plan B: Treat Some Dehydration with ORS Give in health center recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS.

Up to 4 months < 6 kg 4 mos. up to 12 months 6 to - < 10 kg 12 mos. up to 2 years 10 to - < 12 kg 2 years up to 5 years 12 to - < 19 kg

AGE
WEIGHT

AMOUNT (ml)

200 - 400

400 - 700

700 - 900

900 - 1400

If the child wants more ORS than shown, give more. For infants under 6 months of age who are not breastfed, also give 100 200 ml clean water during this period.

FOUR RULES OF HOME TREATMENT

1. 2. 3. 4. Give Extra Fluid Give Zinc Supplements Continue Feeding Know When to Return

Plan C: Treat Severe Dehydration Quickly Start IV fluid immediately. If the child can drink, give ors by mouth while the drip is being set up. Give 100ml/kg Ringers Lactate Solution (or, if not available, normal saline), divided as follows:
AGE Infants (under 12 months) First give 30 ml/kg in: 1 hour* 30 minutes* Then give 70 ml/kg in: 5 hours 2 hours

FOLLOW THE ARROWS. IF THE ANSWER IS YES, GO ACROSS. IF NO, GO DOWN.

Can you give intravenous (IV) YES fluid immediately?

NO

Children (12 months to 5 years)

* Repeat once if the radial pulse is still very weak or is not detectable.

Reassess the child every 1-2 hours. If the childs hydration status does not improve, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hr) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify the dehydration. Then choose the appropriate plan (A, B, or C) to continue the treatment.

Refer the child URGENTLY to a hospital for IV treatment.

Is IV treatment YES available nearby (within 30 minutes)?

If the child can drink, provide the mother with ORS solution and show her how to give the child frequent sips of it during the trip.

Are you trained to use a nasogastric (NG) tube for rehydration?

Start the rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hr for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours: if there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. if the childs hydration status has not improved after 3 hours, send the child for IV therapy.

Can the child drink?

After 6 hours, reassess the child. Classify the dehydration. Then choose the appropriated plan (A,B, or C) to continue the treatment.
NOTE:

Refer urgently to a hospital for IV or NG treatment.

If possible, observe the child at least 6 hours after rehydration to be sure that the mother can maintain the hydration, giving the child ORS solution by mouth.