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5 years of age
GOALS
To reduce the Infant and under-five mortality rate by at least one third in 2010 To reduce the Infant and under-5 mortality rate by at least two thirds in 2015
onditions Overlap (other prob.) elies on history and signs & symptoms quipment & Drugs are scarce
bility of Health workers to practice complicated clinical procedures are few inimal or non-existent Diagnostic nontools
COMPONENTS OF IMCI
upgrading the case management and counseling skills of health care providers
strengthening the health care system for effective management of childhood illnesses improving the family and community
health practices related to childhood and nutrition
Other Benefits:
Promotes accurate identification of childhood illness in outpatient settings Ensure appropriate combined treatment for all major illness Strengthens the counseling of caretakers and provision of preventive services Speed up referral of severely ill children Promotion of appropriate care-seeking behavior in the home setting, improved nutrition and preventive care, and the correct implementation of prescribed care
E L E M E N T S O F I M C I
E L E M E N T S O F I M C I
Elements of IMCI
Assess feeding, including breastfeeding practices. COUNSEL to solve any feeding problem found. Then counsel the mother about her own health When a child is brought back to the clinic as requested, GIVE FOLLOW UP CARE and if necessary, reassess the child for new problems
A child with ANY of the Danger Signs has a serious problem and needs URGENT referral to the hospital
y ASK: Has the child had convulsions? y Use the term for convulsions like fits , spasm , or jerky
movements which the mother understands
awaken
y An abnormally sleepy child is drowsy and does not show interest in what is happening around him/her y He does not look at his mother or watch your face when you talk y He may stare blankly and does not notice what is going on around him y He does not respond when she is touched, shaken or spoken to
Clinical Assessment
Three key clinical signs are used to assess a sick child with cough or difficult breathing:
1. Respiratory rate, which distinguishes children who have
2. Lower chest wall indrawing, which indicates severe 3. Stridor, which indicates those with severe pneumonia who
Fast Breathing is :
60 or more per minute 50 or more per minute 40 or more per minute
THE INTEGRATED CASE MANAGEMENT PROCESS OUT PATIENT HEALTH FACILITY Check for DANGER SIGN
Convulsions Abnormality sleepy or difficult to awaken Unable to drink / breastfeed Vomits everything
Asses NUTRITION,ANEMIA, IMMUNIZATION, and VITAMIN A SUPPLEMENTATION STATUS and POTENTIAL FEEDING PROBLEM Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTION
According to color-coded treatment
Urgent Referral
OUTPATIENT HEALTH FACILITY Pre-referral treatment Advise parents Refer child REFERRAL FACILITY Emergency Triage and Treatment (ETAT) Diagnosis Treatment Monitoring and follow-up
Home Management
HOME Caretaker counseled on: Home treatments Feeding and Fluids When to return immediately Follow-up
SIGN
CLASSIFY
TREATMENT Give the 1st dose of an appropriate antibiotic Give Vitamin A If chest indrawing and wheeze,go directly to treat wheezing Treat child to prevent the lowering of his or her blood sugar level Refer the child URGENTLY to a hospital
Give an appropriate antibiotic for 3 days If wheezing (even if it disappeared after rapid-acting
Fast Breathing
PNEUMONIA
bronchodilator), give an inhaled bronchodilator for 5 days. Soothe the throat and relieve the cough with a safe remedy If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for Tb or asthma Advise the mother regarding when the return to the health centre Follow-up in 2 days
hospital for assessment Soothe the throat and relieve the cough with a safe remedy Advise the mother regarding when to return to the health center Follow-up in 5 days if no improvement is observed
DIARRHEA
SIGN
Two of the following signs : Abnormally sleepy or difficult to awaken Sunken eyes Not able to drink or drinking poorly Pinched skin goes back to its original state very slowly
CLASSIFY
TREATMENT
If the child has no other severe classification : Give fluid for severe dehydration (PLAN C)
SEVERE DEHYDRATION
If the child has another severe classification : Refer the child URGENTLY to a hospital, with the mother giving the child frequent sips of ORS on the way. Advise to the mother to continue breastfeeding the child If the child 2 years old and older, and there is a cholera in your area : Give the child an antibiotic for cholera
Give ORS, zinc supplements and food for some
Two of the following signs : Restless, irritable Sunken eyes Drinks eagerly, thirsty Pinched skin goes back to its original state very slowly
SOME DEHYDRATION
dehydration (PLAN B) If the child has another classification : Refer the child URGENTLY to a hospital, with the mother giving the child frequent sips or ORS on the way. Advise the mother to continue breastfeeding the child Advise the mother regarding when to return to the health center immediately Follow-up in 5 days if no improvement is observed
NO DEHYDRATION
diarrhea at home (PLAN A) Advise the mother regarding when to return to the health center immediately Follow-up in 5 days if no improvement is observed
e.
2. Continue Feeding The Child 3. Return To The Health Center 4. Give Zinc Supplementation
1. Determine The amount of ORS to give during the 1st 4 hours 2. Show the mother how to give
ORS SOLUTION REASSESS and CLASSIFY
After 4 Hours
AGE
Below 4 months 4 to 12 months 12 months to 2 years 2 to 5 years old
Use the child s age only when You do not know his or her weight. The approximate amount of ORS required (in mL) can also be calculated by multiplying the child s weight (in kg) by 75
Is IV treatment available nearby (within 30 minutes)? Are you trained to use NGT for rehydration? Can the child drink
Y e s Y e s
Persistent Diarrhea
SIGN Dehydration present CLASSIFY SEVERE, PERSISTENT DIARRHEA TREATMENT
Treat the dehydration before referral unless
the child another severe classification. Give vitamin A Refer the child to a hospital
No Dehydration
PERSISTENT DIARRHEA
has PERSISTENT DIARRHEA Give Vitamin A Give multivitamins and minerals ( including zinc) for 14 days. Follow-up in 5 days Advise the mother when to return immediately.
DYSENTERY
Give ciprofloxacin for 3 days. Follow up in 2 days. Advise the mother when to return
immediately.
C. Provinces with a significant reduction in cases in the last five years ( Albay, Batanes, Batangas ,Marinduque etc) D. Provinces that are malaria-free, although some are potentially malarious due to vectors ( Aklan, Bohol, Capiz, Cebu etc)
MALARIA RISK
( Including travel to a malaria-risk area)
Stiff neck
MALARIA
If the blood smear test is not done : NO runny nose, and NO measles NO other causes fever
CLASSIFY FEVER
Any general
danger sign
NO MALARIA RISK
Stiff neck
febrile disease
FEVER : NO MALARIA
MALARIA RISK
SIGN
CLASSIFY
TREATMENT
Give the 1st dose of quinine (under medical supervisor or
if a hospital is not assessable within 4 hours) Give the 1st dose of an appropriate antibiotic Threat the child to prevent the lowering of his/her blood sugar level Give one dose of paracetamol in the health center for high fever (38.5C or above) Send a blood smear with the patient Refer the child URGENTLY to a hospital
If the blood smear test is not done : NO runny nose, and NO measles NO other causes fever
MALARIA
Treat the child with an oral antimalarial Give one dose of paracetamol in the health center for high fever (38.5C or above) Advise the mother regarding when to return to the
health center immediately Follow-up in 2 days if the fever persist If fever has been present everyday for more than 7 days, refer the child to a hospital assessment
Give one dose of paracetamol in the health center for high fever (38.5C or above) Advise the mother regarding when to return to
the health center immediately Follow-up in 2 days if the fever persist If fever has been present everyday for more than 7 days, refer the child to a hospital assessment Treat other causes of fever
SIGN
CLASSIFY
TREATMENT
Any general
antibiotic Threat the child to prevent the lowering of his/her blood sugar level Give one dose of paracetamol in the health center for high fever (38.5C or above) Refer the child URGENTLY to a hospital
Give one dose of paracetamol in the
No sign of a
FEVER NO MALARIA
health center for high fever (38.5C or above) Advise the mother regarding when to return to the health center immediately Follow-up in 2 days if the fever persist If fever has been present everyday for more than 7 days, refer the child to a hospital assessment
Oral Antimalarial
First Line Second Line : CHLOROQUINE and PRIMAQUINE : SULFADOXINE and PYRIMETHAMINE
If CHLOROQUINE and PRIMAQUINE Explain the mother that she should watch he child carefully for 30 minutes after giving him or her a dose of chloroquine. If the child vomits within 30 minute, 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, and that it is not dangerous IF SULFADOXINE + PYRIMETHAMINE Give a single dose in the health center
MEASLES
SIGN
CLASSIFY
TREATMENT
Give Vitamin A Give the 1st dose of an appropriate antibiotic If there is clouding of the cornea or pus
Clouding of the
draining from the eye, apply tetracycline eye ointment Refer the child URGENTLY to a hospital
Give Vitamin A If there is pus draining from the eye, apply
MEASLES WITH tetracycline eye ointment EYE OR If there are mouth ulcers, teach the mother how to treat them with Gentian MOUTH Violet COMPL Follow-up 2 days ICATIONS
Advise the mother when to return
immediately.
Measles now or
MEASLES
immediately.
SIGN
Bleeding from the nose
CLASSIFY
TREATMENT
or gums Blood in the stool or vomits Black stool or vomitus Skin petechiae SEVERE, DENGUE Cold and clammy extremities HEMORRHAGIC Slow capillary refill, < 3 FEVER seconds. Persistent abdominal pain Persistent vomiting Tourniquet test positive
abdominal pain, persistent vomiting, or positive tourniquet tests are the only positive signs, give ORS If any other sign or bleeding is positive, give fluids rapidly , as in Plan C Treat the child to prevent the lowering of his or her blood sugar level Refer the child URGENTLY to a hospital DO NOT GIVE ASPIRIN
Advise the mother regarding when to
return to the health center immediately Follow-up in 2 days if the fever persists or if the child shown sign of bleeding DO NOT GIVE ASPIRIN
EAR PROBLEM
SIGN
Tender swelling behind
CLASSIFY
MASTOIDITIS
TREATMENT
Give the 1st dose of an appropriate
the ear
antibiotic Give the 1st dose of paracetamol for pain Refer the child URGENTLY to a hospital
and discharge that has been present for less than 14 days, or Ear pain
Pus draining from the
Give antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Follow-up 5 days Advise the mother when to return immediately.
ear, and discharge that has been present for 14 days or more
Dry the ear by wicking Instill quinolone otic drops for 2 weeks. Follow-up in 5 days Advise the mother when to return immediately.
NO EAR INFECTION
immediately.
Asses Malnutrition :
1. Determine weight for age. 2. Look for edema of both feet. 3. Look for visible severe wasting. 4. For children aged 6 months or more, determine if MUAC* is less than 115 mm.
SIGN
If age up to 6 months and
CLASSIFY
SEVERE MALNUTRITION
TREATMENT
Treat the child to prevent low blood sugar Give Vitamin A Refer the child URGENTLY to a hospital
-visible severe wasting -edema of both feet If age 6 months and above and -MUAC is less than 115 mm -visible severe wasting -edema of both feet
age
mother on feeding according to the feeding recommendations and care for development. Give Vitamin A. Advise the mother to return immediately Follow up in 30 days.
If the child is less than 2 years old, assess
Not very low weight for age and no other sign of malnutrition
the child s feeding and counsel the mother on feeding recommendations and care foe development. If feeding is a problem, follow-up in 5 days Advise the mother regarding when to return to the health center immediately
ANEMIA
SIGN
Severe palmar pallor
CLASSIFY
SEVERE ANEMIA
TREATMENT
Refer the child URGENTLY to a hospital Asses the child s feeding and counsel the mother
Some palmar
pallor
ANEMIA
on feeding according to the feeding recommendations and care for development. Give IRON. Give ALBENDAZOLE/MEBENDAZOLE if child is 1 yr or older and has not had a dose in the previous 6 months. Advise the mother to return immediately Follow up in 14 days.
No palmar pallor
NO ANEMIA
child s feeding and counsel the mother on feeding recommendations and care foe development. If feeding is a problem, follow-up in 5 days Advise the mother regarding when to return to the health center immediately
IRON SYRUP Ferrous Sulfate 150 mg per 5 ml (6 mg elemental iron per ml) 2.5 ml (1/2 Tsp)
IRON DROPS Ferrous Sulfate 25 mg (25 mg elemental iron per ml) 0.6 ml
4 ml (3/4 tsp)
1.0 ml
tablet
5 ml (1 tsp)
1.5 ml
1 tablet
10 ml (2 tsp)
2.0 ml
Albendazole
Albendazole treats hookworm and whipworm infection. These infections contribute to anemia because of iron loss through intestinal bleeding
FIRST LINE
Cotrimoxazole Cotrimoxazole Cotrimoxazole Cifrofloxacin Tetracycline
SECOND LINE
Amoxycillin Amoxycillin Amoxycillin Nalidixic Acid Cotrimoxazole
SIGN
CLASSIFY
TREATMENT
Any one of the following signs: Not feeding well or Convulsion or Fast breathing (60 or more breaths/minute) Severe chest in drawing Fever (37.5C , or feels hot) or low body temperature (less than 35.5C, or feels cold) Movement only when stimulated or no movement at all.
intramuscular antibiotic Treat the young infant to prevent the lowering of his / her blood sugar level Advise the mother regarding hoe to keep the infant warm on the way to the hospital Refer the infant URGENTLY to a hospital
Give the young infant an appropriate antibiotic. Treat the local infection in the health center, and teach the mother to treat local infection at home Advise the mother to give home care for the young infant. Asses and counsel the mother on care for development. Follow-up in 2 days
young infant. Asses and counsel the mother on care for the development.
SIGN
Not able to breastfeed No attachment at all No sucking at all
CLASSIFY
POSSIBLE SERIOUS BACTERIAL INFECTION
TREATMENT
Give the 1st dose of IM antibiotics Treat the infant to prevent the lowering of his or
her blood sugar level Advise the mother about how to keep the young infant warm on the way to the hospital Refer the infant URGENTLY to the hospital
Advise the mother to breastfeed the infant as often
the breast Not sucking effectively Less than 8 breastfeeding in 24 FEEDING PROBLEM OR LOW WEIGHT hours FOR AGE Receives other foods or drinks Low weight for age Thrush (ulcers or white patches in the mouth)
as possible and for as long as the infant wants to be breastfeed, day or night If the infant is receiving other foods and drinks, counsel the mother about breastfeeding the infant more and reducing his/her intake the other foods and drinks, and about using a cup for feeding the infant If there is thrush, teach the mother hoe to treat it at home Advise the mother regarding how to give home care to the young infant Follow-up any feeding problem or thrush in 2 days Follow-up low weight for age in 14 days
Not low weight for age and no either signs of inadequate feeding
home care to the young infant Praise the mother for feeding the infant well
Jaundice
SIGN
Any jaundice if age is
TREATMENT
Treat the infant to prevent the lowering of his
or her blood sugar level Advise the mother about how to keep the young infant warm on the way to the hospital Refer the infant URGENTLY to the hospital
Advise the mother to give home care for the
Jaundice appearing
JAUNDICE
infant. Advise the mother to return immediately if palms and soles are yellow. If the young infant is older than 14 days, refer to a hospital for assessment. Assess and counsel the mother on care for development. Follow-up in 1 day.
No jaundice
NO JAUNDICE
development. Advise mother to give home care for the young infant.
DEHYDRATION
SIGN
Two of the following
CLASSIFY
TREATMENT
If the infant does not have VERY SEVERE DISEASE.
signs: -movement only when stimulated or no movement at all -Sunken eyes -Skin pinch goes back very slow
SEVERE DEHYDRATION
SEVERE JAUNDICE nor DYSENTERY: - give fluid for severe dehydration ( Plan C ) OR IF INFANT also has a VERY SEVERE DISEASE, SEVERE JAUNDICE or DYSENTERY: -refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. -advise mother to continue breastfeeding. -advise the mother on how to keep the young warm on the way to the hospital.
Give fluid for some dehydration ( Plan B ).
Two of the following signs: -restless, irritable -sunken eyes. -skin pinch goes back slowly
SOME DEHYDRATION
IF INFANT also has a VERY SEVERE DISEASE, SEVERE JAUNDICE or DYSENTERY: -refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. -advise mother to continue breastfeeding. -assess and counsel the mother on care for development
NO DEHYDRATION
Give fluid to treat diarrhea at home. ( Plan A ) assess and counsel the mother on care for
development
Dehydration
SIGN CLASSIFY TREATMENT
If the young infant has dehydration, treat dehydration before referral unless the infant also has VERY SEVERE DISEASE. REFER TO HOSPITAL refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. -advise mother to continue breastfeeding.
Diarrhea
DYSENTERY
FEEDING PROBLEM
SIGN
Not well attached
CLASSIFY
TREATMENT
If not able to attach well or not suckling
to breast Not suckling effectively Less than 8 breastfeed in 24 hours Receives other food and drinks Low weight for age Thrush ( ulcers or white patches in the mouth )
effectively, teach correct positioning and treatment. -if unable to attach well immediately, teach the mother to express breast milk and feed using a cup. If breastfeeding is done less frequently 8 times every 24 hours, advise to increase frequency of breastfeeding. Advise the mother to breastfeed as often and as long as the infant wants, day and night. If the mother gives her infant other foods or drinks, counsel her about breastfeeding further and instruct her to reduce other foods and drinks, and to use a cup. -if not breastfeeding at all: *refer to breastfeeding counseling and possible relactation. *advise about the correct preparation of breastmilk substitutes and the use of a cup.
SI
LASSIF
T EAT E T
keep the low weight infant warm at home. If thrush, teach the mother to treat thrush at home. Advise the mother to give home care for the young infant Follow up any feeding problem or thrush in 2 days Follow-up low weight for age in 14 days. Assess and counsel the mother on care for development.
Assess and counsel the mother on
care
ot low-weight-
O FEEDI P OBLE
for development Advise mother to give home care for the young infant. Praise the mother for feeding the infant well.
6. Not feeding well during illness 7. Complementary food not enough in quantity/quality/variety 8. Child 6 months or older, but not yet given complementary foods 9. Infant not exclusively breastfed 10. Improper handling and use of breast milk substitute
2 DAYS
PERSISTENT DIARRHEA ACUTE EAR INFECTION CHRONIC EAR INFECTION KER FEEDING PROBLEMS ANY OTHER ILLNESS, if not improving
5 DAYS
ANEMIA
VERY LOW WEIGHT FOR AGE
14 DAYS 30 DAYS
NOT ABLE TO DRINK OR BREASTFED BECOMES SICKER DEVELOPS A FEVER FAST BREATHING DIFFICULT BREATHING
BLOOD IN THE STOOL IF THE CHILD HAS DIARRHEA, DRINKING POORLY also return if:
IF CHILD HAS FEVER :DENGUE HEMORRHAGIC FEVER UNLIKELY,also return if:
ANY SIGN OF BLEEDING PERSISTENT ABDOMINAL PAIN PERSISTENT VOMITING SKIN PETECHIAE SKIN RASH