Integrated Management of Childhood Illness (IMCI) Cristina Marie Manzano RN,RM,MAN

General Objective To ensure that before graduation, all students undergo the enhanced curriculum for Nursing where IMCI is integrated starting at Level II up to level IV

IMCI as a STRATEGY Management of common childhood illness is done in an integrated manner Includes preventive interventions Adjusts curative interventions to the capacity and functions of the health system (evidence based – syndromic approach) Involves the family members and the community in the health care process

Objectives of IMCI Reduce deaths and the frequency and severity of illness and disability Contribute to improved growth and development

Why IMCI? Overlap of conditions Diagnostic tools are minimal or non-existent Drugs and equipment are scarce Health workers have few opportunities to practice complicated clinical procedures Relies on history & signs & symptoms A global strategy with 1 purpose of improving the health of children up to age 5 and decrease their chances of death

Improving case management skills of health workers Components of the IMCI Improving case management skills of health workers Improving the health system to deliver IMCI Improving family and community health practices Providing guidelines for managing child health problems Imrpoving the health system to deliver IMCI Improving family & community health practices. To improve nutrition and child development thru breastfeeding support groups or child feeding centers. Promote or improve the existing health system.

Target age for the IMCI strategy Young infants - 1 week up to 2 months Older children – 2 months to five years old

Diseases covered in the IMCI Pneumonia Diarrhea Dengue hemorrhagic fever Malaria Measles Malnutrition

METHODS IN MANAGING CHILDHOOD ILLNESSES Color Presentation Classification of Diseases Level of Management Green Mild Home care Yellow Moderate Manage at the RHU Pink Severe Urgent referral in Hospital To effectively manage childhood illnesses a color- coded system has been utilized:

A. Danger Signs I. Focused Assessment Vomits everything Seizure/ convulsions  38.5C & above sleepiness Sucking/ drinking inability

Check for General Danger Signs Ask: - is the child not able to breastfeed or drink? - does the child vomit everything? - has the child had convulsions? Look: - see if the child is abnormally sleepy or difficult to awaken? If YES…

Cough or DOB Diarrhea Fever Ear Problem B. Main Symptoms

1. Cough or DOB

Pneumonia Age <2 mos. >2 mos. Danger signs No Pneumonia Cough/ colds (+) fast breathing >60 cpm Danger signs No Pneumonia Pneumonia Severe Pneumonia Home Mg’t Specific tx REFER Tx Cough > 30 days  Refer 2. Relieve cough w/ safe remedy 3. Advise mother on danger sign 4. Ff up in 5 days Tx Antibiotics for 5 days Relieve cough w/ safe remedy 3. Advise mother on danger sign 4. Ff up in 2days Tx 1.1st dose antibiotic 2. Vitamin A  100,000 IU 3. breast feeding/ water with sugar

Pneumonia Age >2 mos. No Pneumonia Pneumonia VSP VSD Home Mg’t Cough/ colds (+) fast breathing 2 – 11 mos.  50 1 – 5 y/o 40 (+) fast breathing chest indrawing Danger signs No Pneumonia Pneumonia VSP VSD Home Mg’t Specific tx REFER Tx Cough>30days  Refer 2. Relieve cough w/ safe remedy 3. Advise mother on danger sign 4. FF. up in 5 days Tx Antibiotics for 5 days Relieve cough w/ safe remedy 3. Advise mother on danger sign 4. Ff up in 2days Tx 1.1st dose antibiotic 2. Vitamin A  100,000 IU 3. breast feeding/ water with sugar

2. Diarrhea

Diarrhea How Long? <14 days >14 days. No change NO dehydration Thirsty Irritable Restless Eye sunken Skin pinch  back slowly Sunken eyeballs Skin pinch  back very slowly Abnormally Sleepy Doesn’t Drink NO dehydration Some Dehydration Severe Dehydration Home Mg’t Specific tx REFER Tx  Plan A Give extra fluid 2. cont. feeding 3. Ff up. In 5 days Tx  Plan B w/ ORS (good for 24 hrs) in 4 hours wt(kg)x75ml frequent sips from cup child vomits  wait 10 min., cont. slowly Stop ORS child has puffy eyelids after 4 hours re-assess & classify select tx plan Tx Plan C IVF along w/ ORS IVFLR(100ml/kg)

Severe Persistent diarrhea How Long? >14 days Persistent diarrhea Persistent diarrhea + dehydration Persistent diarrhea + NO dehydration Severe Persistent diarrhea REFER Specific Tx Tx Treat dehydration first Give vit. A Refer to hospital Tx Advise regarding feeding Give vit. A FF. up in 5 days

With blood (dysentery) NO blood( cholera) Diarrhea Stool With blood No Blood Tx Oral antibiotics follow up in 2 days With blood (dysentery) NO blood( cholera) Tx 1st linecotrimoxazole 2nd linenalidixic acid Tx 1st line tetracycline 2nd line  cotrimoxazole

3. Fever

a. Malaria

Malaria unlikely  fever Malaria Risk Area Non-Malaria Risk Area (+) malaria risk (-) blood smear no runny nose/measles (+) Malaria risk (+) blood smear no runny nose (+) Malaria risk any danger sign stiff neck Malaria unlikely  fever Malaria Malaria Home Mg’t Specific tx REFER Tx Paracetamol  fever >38C Ff. up in 2 days fever > 7 days REFER Tx antimalarial a. 1st line  chlorquine, primaquine b. 2nd line  sulfadoxin, pyrimethamine Paracetamol- >38.5C fever >7 days REFER Tx quinine  under medical Supervision,if a hosp. is not accessible 1st dose  antipyretic URGENT referral

Very Severe Febrile Dse. MALARIA Non-Malaria Risk Area Any danger sign stiff neck NO signs of very severe febrile disease NO Malaria NO Malaria Very Severe Febrile Dse. Fever (NO malaria) Tx 1st dose antibiotics paracetamol  >38.5C REFERRAL. Tx paracetamol  >38.5C follow up in 2 days  if fever persists fever is > 7 days present  REFER to hosp.

b. measles

MEASLES now or w/in last 3 mos pus draining from eye mouth ulcers Clouding of Cornea or Deep mouth ulcer  oral thrush, Koplik spots Home Mg’t Specific tx REFER Tx Vit. A admin. child100,000 IU adult200,000 IU Pregnant10,000 IU Tx Vit. A  100,000 IU tetracycline ointment  pus from the eye 3.half strength gentian violet  mouth ulcer or oral thrush 3. follow up in 2 days Tx 1st dose of antibiotics Vit. A Tetracycline ointment URGENT referral

c. Dengue

If There is Dengue Risk bleeding gums black vomitus or stool persistent abdominal pain persistent vomiting skin petechiae slow capillary refill if no sign  tourniquet test if fever is present > 3 days

dengue hemorrhagic fever + Danger risk Any Danger Signs or No sign of severe dengue hemorrhagic fever + Danger risk Any Danger Signs or + tourniquet test DHF UNLIKELY SEVERE DHF Home Mg’t REFER Tx Tx the cause fever > 7 days  REFER if NO apparent cause of fever  return daily to H. center until there is no fever Give more fluids Do not Give Aspirin Tx Plan C  if with other signs of bleeding Do NOT give Aspirin REFERRAL

4. Ear Problems

Tx antibiotics for 5 days paracetamol for pain dry ear by wicking EAR PROBLEM NO ear pain No pus Pus draining from ear < 14 days Ear pain Pus draining from ear >14 days Ear pain Tender swelling behind the ear NO ear infection Acute Ear Infection Chronic Ear Infection Mastoiditis No Mg’t Specific Tx Specific Tx REFER NO further assessment Tx antibiotics for 5 days paracetamol for pain dry ear by wicking Ff up in 5 days Tx dry ear by wicking Ff up in 5 days Tx 1st dose of antibiotic paracetamol REFER

C. Nutritional Status

1. Nutrition

Visible severe wasting (<13cm upper arm circ.) edema on both feet or severe palmar pallor Some palmar pallor or very low weight for age SEVERE MALNUTRITION/ SEVERE ANEMIA Anemia or Very low weight for age REFER Specific Tx Vitamin A Today, tomorrow & 2 weeks after tomorrow Wait for 30 min. before lifting the child Vitamin A Assess for feeding problem & counsel mother Pallor  iron Albendazole (> 12 mos. Or no doze in previous 6 mos.) Very low weight  vitamin A & ff. up after

2. Immunization 3. Vitamin A Supplementation

THEN CHECK THE CHILD’S IMMUNIZATION STATUS IMMUNIZATION SCHEDULE AGE VACCINE Birth BCG Hep B-1 6 weeks DPT-1 OPV-1 Hep B-2 10 weeks DPT-2 OPV-2 14 weeks DPT-3 OPV-3 Hep B-3 9 months Measles THEN CHECK THE VITAMIN A STATUS VITAMIN A SUPPLEMENTATION SCHEDULE: The first dose at 6 months or above. Subsequent doses every 6 months.

THEN CHECK THE CHILD’S IMMUNIZATION STATUS IMMUNIZATION SCHEDULE AGE VACCINE Birth BCG Hep B-1 6 weeks DPT-1 OPV-1 Hep B-2 10 weeks DPT-2 OPV-2 14 weeks DPT-3 OPV-3 Hep B-3 9 months Measles THEN CHECK THE VITAMIN A STATUS VITAMIN A SUPPLEMENTATION SCHEDULE: The first dose at 6 months or above. Subsequent doses every 6 months.

THAT’S ALL FOLKS!!!

Thank you!