Integrated Management of Childhood Illness

IMCI Lecture (1)

General Danger Signs

CHECK
for GENERAL DANGER SIGNS in

ALL SICK Children

General Danger Signs

Checking for General danger signs: 1- Unable to drink or breastfeed 2-Vomits every thing 3- Has the child had convulsions? 4- Unconscious, lethargic 5- Is the child convulsing now

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 instruction on

TREAT THE CHILD CHART If Initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

ASK and check
Is the child able to drink or breastfeed? Does the child vomit every thing? Has he had convulsions? (during present illness)

LOOK
See if the child is lethargic or unconscious See if the child is convulsing now

Unable to Drink or Breastfeed?

The child is unable (too weak) to suck or swallow when he is offered a drink or breast milk

Ask the mother to describe exactly what happens when she offers the child something to drink Ask the mother to offer her child a drink of clean water or breast milk and look to see if the child is swallowing .

Vomits Everything ?
Not able to hold anything down AT ALL Not able to hold down food, fluids or oral drugs. ALL what goes down comes back up A child who vomits several times but can hold down some fluids does not have this general danger sign.

Has the child had convulsions?

Ask the mother if the child developed convulsions during the current illness.

Use words the mother understands.

Convulsions (cont)
Explain what do you mean exactly by convulsions. In a convulsing child the arms and legs stiffen. The child may loose consciousness or may not be able to respond to spoken directions.

Unconscious ?
An unconscious child is a child who cannot be awakened. The child does NOT respond when he is :
Touched Shaken, or Spoken to

Lethargic ?
Difficulty in maintaining the aroused state

A lethargic child is NOT awake and alert when he should be. He is drowsy and does not show interest in what is happening around him.

Lethargic (cont)
Often a lethargic child does not look to his mother or watch examiner face when talks. A lethargic child may stare blankly and appears not to notice what is going around.

Cough OR Difficult Breathing

Then

ASK
About: COUGH OR DIFFICULT BREATHING

Cough OR Difficult Breathing, NOT Cough AND Difficult Breathing

Fewer than 25 percent of children with cough also have difficult breathing

Many causes of difficult breathing are not related to cough Using both can cause false positives

Acute Respiratory Infections ( ARI )

Global & National Health Problem

Common cause of mortality.

Common cause of morbidity.

Commonest reason for irrational drug prescription.

Role of IMCI in ARI

Insure Adequate Case Management
Identify those who need URGENT REFERRAL Identify cases of PNEUMONIA. Rationalize the use of DRUGS Breast feeding and optimal nutrition Vaccination and Vitamin A supplementation

Assessment
THEN ASK ABOUT MAIN SYMPTOMS
Does the child have Cough or Difficult breathing?
IF YES, ASK
For how long?

LOOK and LISTEN

Count the breaths in one minute Look for chest indrawing Look and listen for stridor Look and listen for wheeze

Child must be calm

Pneumonia: Severity
Recognition is based on:

Lower chest wall indrawing Stridor Fast breathing

LOWER CHEST WALL INDRAWING

Index of : Severe Pneumonia or very severe disease

Reasonable sensitivity & specificity " 89%".

Lower Chest Wall Indrawing

Studies found that lower chest wall indrawing best identified children who required referral, admission or further assessment. Must be definite, present all the time in a calm child.

STRIDOR
Is Another Indicator for Severe Pneumonia or V. Severe Disease. It is a harsh Inspiratory Voice. Look & Listen to Stridor: Listen to the harsh voice (in a calm child) Look at the chest wall (phase of breathing)

WHY FAST BREATHING ?

Good Predictor of PNEUMONIA In the sick child 2 months 5 years

* * 80% Sensitivity & specificity around

Sensitivity= proportion of those with the disease who are correctly identified by sign Specificity= proportion of those without the disease who are correctly called free of the disease by using the sign.

Simplicity Ease in training Reliability

FAST BREATHING !
Why not other signs of pneumonia? Fever is poor predictor of pneumonia. Auscultation is less sensitive indicator

and needs skills

CUT-OFF POINTS for FAST BREATHING

If the child is: 2 months up to 12 months FAST BREATHING IS:

50 40

breaths per minute or more breaths per minute or more

12 months up to 5 years

Best to count rate in a quiet and alert child Fever can affect respiratory rates, but do not wait for fever to subside

Cut-offs of Fast Breathing

60 50

40

Wheezing: Causes
Under age of 2 years - Bronchiolitis Older children plus those with recurrent attacks of wheeze - bronchial asthma or reactive airways disease
Transient wheezers Persistent wheezers

Other respiratory infections

Inhaled foreign body

Tuberculosis node compressing bronchus

Wheezing: Why Added ??

Morbidity from asthma is a problem in Sudan Will reduce unnecessary referral to hospital Rapid-acting bronchodilators are available at first-level facilities Health workers are trained to recognize audible wheeze and use bronchodilators

Health worker can recognize when a child with recurrent wheeze is not responsive in the firstlevel health facility

CLASSIFFY COUGH OR DIFFICULT BREATHING

Any General D.Sign or CHEST INDRAWING or

STRIDOR

SEVERE PNEUMONIA
OR VERY SEVERE DISEASE

Severe Pneumonia OR Very Severe Disease

Recognition:
Urgently Refer Children with Cough

OR Difficult Breathing AND

Any general danger sign OR Lower chest wall indrawing OR Stridor in a calm child

FAST BREATHING

PNEUMONIA

No signs of Pneumonia or Very Severe Disease

No Pneumonia, Cough or Cold

Antibiotics

Video session