INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ASSES AND CLASSIFY THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS METHODS IN MANAGING

CHILDHOOD ILLNESS
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 DISEASE a thorough assessment supported with laboratory result is necessary for qualification of illness and conformation of the disease. Classification of the dse. are 1.) mild 2.)moderate 3.)severe TREAT THE PATIENT is a curative method of treating dse. COUNSEL THE PATIENT health education to clients promotes health and avoid risk of infection. To effectively manage childhood illnesses a color-coded system has been utilized which represents: COLOR PRESENTATION Green Yellow Pink CLASSIFICATION OF DISEASE Mild Moderate Severe LEVEL OF MANAGEMENT Home care Manage at the RHU Urgent referral in Hospital

ASSESS, CLASSIFY, AND IDENTIFY THE TREATMENT ASSESS ASK THE MOTHER WHAT THE CHILDS PROBLEM ARE Determine if this is an initial or follow-up visit for this problem - If follow-up, use the follow up instructions on the TREAT THE CHILD chart. - If initial visit, asses the child CLASSIFY USE ALL BOXES THAT MATCH THE CHILDS SYMPTOMSS AND PROBLEMS TO CLASSIFY THE ILLNES IDENTY TREATMENT CHECK FOR GENERAL DANGER SIGNS

ASK: Is the child not be able to drink or breastfeed

LOOK: See if the child is abnormally sleepy or difficult to awaken.

Does the child vomit everything? Has the child had convulsion? (during the present illness) IF YES MAKE SURE THE CHILD WITH ANY GENERAL DANGER SIGN IS REFFERED after the first dose of 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: Look, Listen: For how long? Count the breaths in one minute Look for chest indrawing Look and listen for stridor If the child is: 2 mos. Up to 12 mos. Old 12 mos. Up Classify COUGH or DIFFICULT BREATHING SIGNS CLASSIFY AS

CHILD MUST BE CALM.

Fast breathing is: 50 bmp 40 bmp TREATMENT(urgent pre-referral treatment are in bold print.) Give first dose of an appropriate antibiotic Give Vitamin A Treat the child to prevent low blood sugar Refer URGENTLY to hospital

Any general danger sign or Chest in drawing or Stridor in calm child

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Fast breathing PNEUMONIA

No signs of pneumonia or very severe disease.

NO PNEUMONIA COUGH OR COLD

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

ASK: Does the child have diarrhea? IF YES, ASK: For how long? Is there blood in the stool?

LOOK AND FEEL: Look at the childs general condition. Is the child: -Abnormally sleep or difficult to awaken? -Restless and 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 slow (longer than 2 seconds)? -Slowly?

CLASSIFY DIARRHEA For DEHYDRATION Two of the following signs: Abnornally sleepy or difficult to awaken

If the child has no other severe classification, give

SEVERE DEHYDARTION

fluid for severe dehydration (PLAN C) OR If the child another severe classification: Refer Urgently to hospital, with mother giving frequent sips or ORS on the way.

Sunken eyes Not able to drink or drinking poorly Skin pinch goes back slowly Two of the following signs: Restless, irritable Sunken eyes Drink eagerly, thirsty Skin pinch goes back very slowly Not enough signs to classify as some or severe dehydration

Advise mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for cholera.

SOME DEHYDRATION

Give fluid and food for some dehydration If the child another severe classification: Refer Urgently to hospital, with mother giving frequent sips or ORS on the way. Advise mother to continue breastfeeding Advise the mother when to return immediately. Follow up in 5 days if not improving. Give fluid to treat diarrhea at home (PLAN A) Give vitamin Zinc supplements. Advise mother when to return immediately Follow up in 5 days if not improving

NO DEHYDRATION

And if diarrhea for 14 days or more Dehydration SEVERE PERSISTANT present DIARRHEA No dehydration PERSISTANT DIARRHEA

Treatment dehydration before referral unless the child has another severe classification Give Vitamin A Refer to hospital Advise mother on feeding a child who has PERSISTANT Diarrhea Give Vitamin A Follow up in 5 days Advise mother when to return immediately 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

And if blood in stool Blood in the stool

DYSENTERY

Then Ask: Does the child have fever? (by history, or feels or if temperature is 37.5 C or above) Decide malaria risk Ask Does the child live in a malaria area? Has the child visited/traveled or stayed overnight in a malaria area in the past 4 weeks If yes to either, obtain a blood smear. Then ask: Look and Feel For how long has the child had fever? Look or feel for stiff neck If more than 7 days, has the fever been present Look for runny nose Every day? Has the child had measles within the last 3 months? Look for for the sign of MEASLES General rashes and One of these: cough, runny nose or red eyes Classify Fever Malaria Risk VERY SEVERE Any general Give first dose of quinine FEBRILE danger sign or Give first dose of an appropriate antibiotic DISEASE/MALARIA Stiff neck Treat the child to prevent blood sugar Give 1 dose of paracetamol in health center for high fever Send a blood smear with the patient Refer URGENTLY to hospital MALARIA Blood smear (+) Treat the child with an oral antimalarial No runny nose, no Advise mother when to return immediately measles, and no Follow up in 2 days if fever persist other cause of If fever is present everyday for more than 7 days fever refer for assessment FEVER MALARIA Blood smear (+) Give 1 dose of paracetamol in health center for high UNLIKELY fever Runny nose or Advise mother when to return immediately Measles Follow up in 2 days if fever persist Other causes of fever If fever is present everyday for more than 7 days refer for assessment.

No Malaria Risk Any general danger sign or Stiff neck

VERY SEVERE FEBRILE DISEASE

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 Refer URGENTLY to hospital Give 1 dose of paracetamol in health center for high fever Advise mother when to return immediately Follow up in 2 days if fever persist If fever is present everyday for more than 7 days refer for assessment.

No sign of a very severe febrile disease

FEVER NO MALARIA

Ask: Does the child have an ear problem? If yes: Is there ear pain? Is there ear discharges? If yes, for how long? Look, Feel: Look for the pus draining from the ear. Feel for tender swelling behind the ear. Classify Ear Problem Tender swelling behind the ear MASTOIDITIS
Give 1st dose of an

appropriate antibiotic
Give 1st dose of paracetamol

Ear pain Pus is seen draining from

ACUTE EAR INFECTION

for pain Refer URGENTLY to Hospital Give an antibiotic for 5 days Give paracetamol for pain

the ear and discharge is reported to less than 14 days Pus is seen draining from the ear and discharge is reported to less than 14 days CHRONIC EAR INFECTION

No ear pain, and No pus is seen draining from the ear THEN CHECK FOR MALNUTRITION: Look, Listen Look for visible severe wasting Look for edema of both feet Look for palmar pallor Determine weight for age Classify NUTRITIONAL STATUS Visible severe wasting Edema of both feet Severe palmar pallor Some palmar pallor Very low weight for age

NO EAR INFECTION

Dry the ear by wicking Follow up in 5 days Advise mother when to return immediately Dry the ear by wicking Follow up in 5 days Advise mother when to return immediately No additional treatment Advise mother when to return immediately.

SEVERE MALNUTRITION OR ANEMIA ANEMIA OR VERY LOW WEIGHT

Give Vitamin A Refer URGENTLY to Hospital Assess the childs feeding and counsel the mother If some pallor -give iron -give mebenadazole if the child is 12 months or older, and has not had a dose in previous 6 months -follow up in 14 days If very low weight for age -Give Vit. A

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

NO ANEMIA AND NOT VERY LOW WEIGHT

-Follow up in 30 days Advise mother when to return immediately If the child than 2 y/o assess the childs feeding and counsel the mother on feeding -If feeding is problem, follow up in 5 days Advise mother when to return immediately

IMMUNIZATION SCHEDULE:

CHECK THE CHILDS IMMUNIZATION STATUS AGE VACCINE Birth BCG 6 weeks DPT-1 OPV-1 HEP B-1 10 weeks DPT -2 OPV-2 HEP B-2 14 weeks DPT 3 OPV 3 HEP B-3 9 Months Measles CHECK THE CHILDS VITAMIN A STATUS Vitamin A Supplementation Schedule: The 1st dose at 6 mos. Or above Subsequent doses every 6 mos.

TREAT THE CHILD Teach the mother how to give oral drugs at home: Oral antibiotics -1st line cotrimoxazole -2nd line - amoxycillin

 Oral antimalarial -1st line choloroquine,primaquine,sulfadoxine and pyrimethamine -2nd line artemeter-lumefrentine Paracetamol Vitamin A Iron Mebendazole Teach the mother how to treat local infections at home Treat eye infection with tetracycline eye ointment Dry the ear by wicking Treat mouth ulcers with gentian violet Soothe the throat and relieve cough with a safe remedy. Give these treatment in health center only Intramuscular antibiotic Quinine for severe malaria Prevent low blood sugar Give extra fluid for diarrhea and continue feeding Plan A: Treat Diarrhea at home Plan B: Treat some Dehydration with ORS Plan C: Treat severe dehydration QUICKLY Immunize every sick child, as needed. Give every sick child vitamin A, as needed Give Follow-up Care COUNSEL THE MOTHER Food Assess the childs feeding Assess the Childs Feeding

 Assess the Childs Feeding Ask questions about the childs usual feeding and feeding during this illness. Compare the mothers answers to the Feeding Recommendations for the childs age in the box below. ASK Do you breastfeed your child? - How many times during the day? - Do you also breastfeed during the night? Does the child take any other food or fluids? - What food or fluids? - How many times per day? - What do you use to feed the child? - If very low weight for age: How large are servings? Does the child receive his own serving? Who feeds the child and how? During this illness, has the childs feeding changed? If yes, how? Feeding recommendations Feeding Recommendations During Sickness and Health Up to 4 Months of Age 4 Months up to 6 Months 6 Months up to 12 Months 12 Months up to 2 Years 2 Years and Older

Breastfeed as often Breastfeed as often Breastfeed as often as the Breastfeed as often as the

Give family foods at 3 meals

as the child wants, day and night, at least 8 times in 24 hours. Do not give other foods or fluids.

as the child wants, day and night, at least 8 times in 24 hours. Only if the child: - shows interest in semisolid foods, or - appears hungry after breastfeeding, or - is not gaining weight adequately, add complementary foods (listed under 6 months up to 12 months). Give these foods 1 or 2 times per day after breastfeeding

child wants.

each day. Also, twice daily, give nutritious food between meals, Give adequate servings of: Give adequate servings of: such as: ______________________ ______________________ ______________________ _____________________* - 3 times per day if breastfed; - 5 times per day if not breastfed. ______________________ ______________________ ______________________ _____________________* or family foods 5 times per day. ______________________ ______________________ ______________________ ______________________ ______________________

child wants.

Counsel about feeding problems Counsel the Mother About Feeding Problems If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

 If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.) As needed, show the mother correct positioning and attachment for breastfeeding. If the child is less than 4 months old and is taking other milk or foods: - Build mothers confidence that she can produce all the breastmilk that the child needs. - Suggest giving more frequent, longer breastfeeds, day and night, and gradually reducing other milk or foods. If other milk needs to be continued, counsel the mother to: - Breastfeed as much as possible, including at night. - Make sure that other milk is a locally appropriate breastmilk substitute. - Make sure other milk is correctly and hygienically prepared and given in adequate amounts. - Finish prepared milk within an hour. If the mother is using a bottle to feed the child: - Recommend substituting a cup for bottle. - Show the mother how to feed the child with a cup. If the child is not being fed actively, counsel the mother to: - Sit with the child and encourage eating. - Give the child an adequate serving in a separate plate or bowl. If the child is not feeding well during illness, counsel the mother to: - Breastfeed more frequently and for longer if possible. - Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feedings. - Clear a blocked nose if it interferes with feeding. - Expect that appetite will improve as child gets better.

 Follow-up any feeding problem in 5 days.

Fluid Increase fluid during Illness Advise the Mother to Increase Fluid During Illness FOR ANY SICK CHILD: Breastfeed more frequently and for longer at each feed. Increase fluid. For example, give soup, rice water, yoghurt drinks or clean water. FOR CHILD WITH DIARRHOEA: Giving extra fluid can be lifesaving. When to return Advise the mother when to return to the health worker Counsel the mother about her own health THE INTEGATED ASE MANAGEMENT PROCESS OUT PATIENT HEALTH FECILITY Check for danger signs Convulsions Abnormality sleepy or difficult to awaken Unable to drink/breastfeed Vomits everything Assess main symptoms Cough/DOB Diarrhea

Fever Ear problems Assess nutrition, immunization and Vitamin A supplementation status and Potential feeding problems Check for other problems Classify condition and identify treatment action Urgent referral According to color-coded treatment Outpatient health facility
Pre-referral treatments Advice parents Refer child Referral facility Emergency Triage treatment (ETAT) Diagnosis Treatment Monitoring and follow-up

Treatment in outpatient facility Outpatient health facility Treat local infection Give oral drugs Advise and teach caretaker Follow-up

Home Management Home Caretaker counseled on: Home treatment(s) Feeding and fluids When to return immediately Follow-up