1. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES Part 3 March 6, 2007 San Juan, Batangas Teri Laude, MD

2. ASSESS CLASSIFY IDENTIFY TREATMENT Home HEALTH CENTER/CLINIC HOSPITAL/EMERGENCY ROOM 1. ask 2. look

3. MALARIA  Caused by parasites in the blood or plasmodia carried by anophiline mosquitoes  Most dangerous P. falciparum  Symptoms:  Fever*  Shivering  Sweating  Vomiting  Signs of malaria can overlap with signs of other illnesses  Uncomplicated malaria--> complicated malaria (cerebral malaria or severe anemia) in 24 hours fever  Batangas belongs to Category C of provinces

4. MALARIA Category A: Kalinga Apayao Kalinga Apayao Mt Province Mt Province Ifugao Ifugao Isabela Isabela Cagayan Cagayan Quirino Quirino Zambales Zambales Mindoro Occidental Mindoro Occidental Palawan Palawan Quezon Quezon Misamis Oriental Misamis Oriental Davao del Norte/Sur/Oriental Davao del Norte/Sur/Oriental Bukidnon Bukidnon Compostela Valley Compostela Valley Sarranggani Sarranggani Zamboanga del Sur Zamboanga del Sur Agusan del Sur/Norte Agusan del Sur/Norte Surigao del Sur Surigao del Sur Tawi-tawi Tawi-tawi Sulu Sulu Basilan Basilan Category D: Cebu Bohol Catanduanes Aklan Capiz Guimaras Siquijor Biliran Leyte Norte/Sur Nothern Samar Camiguin Risk for MALARIA:  fever in a no malaria area who have traveled to and stayed overnight in a malaria area in the past 4 weeks or who had blood transfusion during the past 6 months * Ask ALL CHILDREN with fever in no malaria risk area

5. MEASLES  Viral and highly infectious  Risk factors: overcrowding and poor housing, affects children 6mon-2 years old  Infects the skin & layers of cells that line the lung, gut, eye, mouth, and throat  Damages the immune system for many weeks after the onset of illness, leaving the child prone to other infections  Complications:  Diarrhea (including dysentery, persistent diarrhea  Pneumonia  Stridor  Mouth ulcers  Ear infection  Sever eye infection (worsen to corneal ulceration/blindness)  Encephalitis  Contributes to malnutrition--> severe complications

6. DENGUE HEMORRHAGIC FEVER  Viral spread by Aedes mosquitoes  Causes damage to blood & blood vessels--> bleeding  Like malaria it occurs in particular places/seasons  All regions of the country are ENDEMIC for dengue and childrewn are at risk everyday of the year  Signs and symptoms:  duration of fever- 2-7 days  Petechiae (skin)  Internal hemorrhage (inside the body)  Bleeding MOUTH, NOSE  Vomit BLACK FLUID  Passs BLACK STOOLS  Most sever signs occur 2 days fever has disappeared  Management depends on:  (+)/(-) signs of BLEEDING  (+)/(-) SHOCK

7. May Lagnat ba ang bata? 1.History 2.Mainit ang pakiramdam 3.T ≥ 37.5C Risk sa Malaria (1/2) => blood smear: 1.Nakatira ba ang bata sa lugar na may malaria? 2.Naglagi ba ang bata magadamag sa lugar na may malaria sa loob ng 4 na linggo. Itanong: 1.Gaano katagal na nilalagnat ang bata? 2.Kung ≥ 7 araw, araw-araw bang nilalagnat? 3.Nagkaroon na ba ng tigdas/measles ang bata sa loob ng 3 buwan? Tingnan at suriin: 1.Matigas ang leeg 2.Sipon 3.Senyales ng tigdas a. Pamamantal ng buong katawan b. Ubo, sipon, namumulang mga mata

8. May Lagnat ba ang bata? Kung ang bata ay may tigdas/nagkatigdas sa loob ng 3 buwan Tingnan ang mga sumusunod: 1.may mga singaw sa bibig (malalim/marami) 2.may nanang nagmumula sa mga mata 3.May panlalabo ng cornea ng mata Suriin kung may dengue hemorrhagic fever ang bata Itanong kung ang bata ay may mga sumusunod na senyales: 1.Pagdudugo ng ilong o gilagid o sa suka o sa dumi 2.Itim na isinuka 3.Itim na dumi 4.Tuloy-tuloy na pananakit ng tiyan 5.Tuloy-tuloy na pagsusuka Tingnan at pakiramdaman: 1.Pagduduo ng ilong o gilagid 2.Petechiae/ pamumula ng balat 3.Cold clammy/ panlalamig ng mga kamay at binti 4. slow capillary refill 5.Tourniquet test

9. CLASSIFICATION OF FEVER A. Malaria Risk SIGNS CLASSIFY AS TREATMENT  Any general danger sign OR  Stiff neck  give first dose of QUININE *  give first dose of an appropriate antibiotic  treat the child to prevent low blood sugar  give one dose of paracetamol in LHC for high fever (T≥38.5C)  Send a blood smear with the patient  Refer URGENTLY to hospital Very severe febrile disease/ malaria  Treat the child with oral antimalarial  Give one dose of paracetamol in LHC for high fever ≥ 38.5C  Advise mother when to return immediately  Follow-up in 2 days if fever persists  If fever is present dailiy ≥7 days refer for assessment  Blood smear (+)  NO runny nose; and  NO measles; and  NO other causes of fever Malaria Fever: Malaria unlikely  Give one dose of paracetamol in LHC for high fever  Advise mother when to return immediately  Follow-up in 2 days if fever persists  If fever present daily ≥7days refer for assessment  Treat for other causes of fever  Blood smear (-) or  Runny nose or  Measles or  Other causes of fever

10. Teach the mother to give oral drugs at home Give an oral antimalarial First-line antibiotic: chloroquine, primaquine, sulfadoxine and pyrimethamine Second-line antibiotic: arthemether-lumefrantine ageChloroquine(150mgbase/tab) *give for 3 days Primaquine (15mg base /tab) * Give single dose in LHC for P falciparum Primaquine (15mg base /tab) Give daily for 14 days for Give daily for 14 days for P vivax Sulfadoxine+ pyremethamine (500mg+ 25mg/tab) *give single dose in LHC 2 -5 mons (4- <7 kgs) D1 1/2; D2 1/2; D3 1/2 1/4 5-12mons(7-<10 kgs) kgs) D1 1/2; D2 1/2; D3 1/2 1/2 12mon- 3 yrs (10-<14 kgs) kgs) D1 1; D2 1; D3 1/2 1/21/43/4 3-5 years (14-19 kgs) kgs) D1 1 1/2; D2 1 1/2; D3 1 3/41/21

11. IMCI: The Sick Child age 2 months-5 years Give an appropriate oral antibiotic for severe disease: First line antibiotic: Cotrimoxazole Second line antibiotic: Amoxycillin COTRIMOXAZOLE Give 2 times daily for 5 days AMOXYCILLIN Give 3 times daily for 5 days AGE OR WEIGHT ADULT TABLET 80 mg trimethoprim + 400 mg sulfamethoxazole SYRUP 40 mg trimethoprim + 200 mg sulfamethoxazole TABLET 250 mg SYRUP 125 mg per 5 ml 2 – 12 months (4-10 kg) 1/25.0 ml1/25 ml 12 months – 5 years (10-19 kg) 110.0 ml110 ml

12. Teach the mother to give oral drugs at home Give paracetamol for HIGH fever (≥38C) Age or weight Paracetamol 500mg/tab Paracetamol syrup 120mg/5ml 2 mon- 3 years (4-<14kgs)1/45ml (1 tsp) 3 -5 years (14-<19kgs)1/210ml (2 tsp)

13. IMCI: The Sick Child age 2 months-5 years Treat the child to prevent low blood sugar:  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 milk formula If neither is available, give sugar water Give 30-50 ml of milk or sugar water before departure. To make sugar water: Dissolve 4 level teaspoon of sugar in a 200 ml cup of clean water

14. CLASSIFICATION OF FEVER B. No Malaria Risk SIGNS CLASSIFY AS TREATMENT  Any general danger sign OR  Stiff neck  give one dose of an appropriate antibiotic  treat the child to prevent low blood sugar  give one dose of paracetamol in LHC for high fever (T≥38.5C)  Refer URGENTLY to hospital Very severe febrile disease Fever: No Malaria  Give one dose of paracetamol in LHC for high fever  Advise mother when to return immediately  Follow-up in 2 days if fever persists  If fever present daily ≥7days refer for assessment  Treat for other causes of fever  No signs of very severe febrile disease

15. CLASSIFICATION OF FEVER If the child has Measles now or within the last 3 months SIGNS CLASSIFY AS TREATMENT  Clouding of cornea or  Deep 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 ***  Give vitamin A  If pus draining from the eye, apply tetracycline eye ointment  If mouth ulcers, teach the mother to treat with gentian violet  Follow-up in 2 days  Advise mother when to return immediately  Pus draining from the eye or  Mouth ulcers Measles witheye or mouth Complications*** Measles  Give vitamin A  Advise the mother when to return immediately  Measles now or within the last 3 months

16. Teach the mother to give oral drugs at home Give Vitamin A Age Vitamin A caps (100,000 IU) Vitamin A caps (200,000 IU) 6 -12 mons 11/2 12 mons-5 years -1 Treatment: give one dose in the LHC Supplementation: give one dose in the LHC if a) child is 6 mons of age or older b) child has not received a dose of Vitamin A in the past 6 mon

17. CLASSIFICATION OF FEVER Assess for Dengue Hemorrhagic Fever SIGNS CLASSIFY AS TREATMENT  Bleeding from nose or gums, or  Bleeding in stools or vomitus, or  Black stools or vomitus, or  Skin petechiae, or  Cold clammy extremities, or  Capillary refill time  Capillary refill time ≥ 3secs, or  Persistent abdominal pain, or  Persistent vomiting, or  Tourniquet test (+)  If persistent vomiting or persistent abdominal pain, or skin petechiae, or positive Tourniquet test are the only POSITIVE signs; give ORS (PLAN B)  If any other signs of bleeding are positive, give fluids rapidly as in PLAN C  treat the child to prevent low blood sugar  Refer all children URGENTLY to hospital  DO NOT GIVE ASPIRIN 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  No signs of severe dengue hemorrhagic fever

18. Plan C: Treat Severe Dehydration Quickly Can you give IV fluid immediately? YES AGE First give 30ml/kg in Then give 70ml/kg in Infants under 12months 1 hour* 5 hours 12months - 5 years 30 min 2 ½ hours START IV FLUID IMMEDIATELY * Repeat once if radial pulse is stil very weak or not detectable Reassess the child every 1-2 hrs. If hydration status is not improving, 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 dehydration then choose the appropriate plan (A, B or C) to continue treatment. NO

19. Plan C Is IV treatment available nearby (within 30 minutes)? YES Refer URGENTLY to hospital for IV treatment If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip;. NO Are you trained to use NGT for rehydration? NO Can the child drink? YES Start rehydration by tube (or mouth) with ORS solution Give 20 ml/kg/hr for 6 hours (total of 120 mg/kg) Reassess the child every 1-2 hours If there is repeated vomiting or increasing abdominal distension, give fluid more slowly If hydration status is not improving after 3 hours, send the child for IV therapy. After 5 hours, reassess the child. Classify dehydration then choose the appropriate plan (A,B,C) to continue treatment. NO Refer URGENTLY to hospital for IV or NG treatment

20. Plan B: Treat Some Dehydration with ORS Give in the health center recommended amount of ORS over 4-hour period:  DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS: AGE Up to 4 months 4 -12 months 12 months to 2 years 2 – 5 years WEIGHT < 6kg 6 to <10 kg 10 to <12kg 12-19 kg ORS to give (in ml) 200-400400-700700-900900-1400 Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) by 75.

21. Plan B  DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS  If the child wants more ORS than show, give more  For infants under 6 months who are not breastfed, also give 100- 200 ml clean water during this period.  SHOW THE MOTHER HOW TO GIVE ORS.  Give frequent small sips from a cup.  If the child vomits, wait 10 minutes, then continue, but more slowly  Continue breastfeeding whenever the child wants.  AFTER 4 HOURS  Reassess the child and classify the child for dehydration.  Select the appropriate plan to continue treatment.  Begin feeding the child in the health center.

22. Plan B  DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS  SHOW THE MOTHER HOW TO GIVE ORS.  REASSESS AFTER 4 HOURS  IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:  Show her how to prepare ORS solution at home  Show her how much ORS to give to finish the 4-hour treatment at home.  Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A.  Explain the 4 rules of Home Treatment  GIVE EXTRA FLUIDS  GIVE ZINC SUPPLEMENTS  CONTINUE FEEDING  WHEN TO RETURN

23. Give follow-up care MALARIA If fever persists after 2 days, or returns within 14 days: Do a full assessment of the child Treatment: 1) If the child has any general danger sign or stiff neck, treat as very severe febrile disease/malaria 2) If the child has any cause of fever other than malaria, provide treatment 3) If malaria is the only apparent cause of fever  Take a blood smear  Give 2nd-line antimalarial w/o waiting for result of blood smear  Advise mother to return if fever persists  If fever persists after 2 day treatment with 2nd-line oral antimalarial, refer with blood smear for reassessment  If fever has been present for 7 days, refer for assessment  care for the child who returns for follow-up using all the boxes that match the child’s previous classification  If the child has any new problem, assess, classify and treat the new problem as in ASSESS & CLASSIFY chart

24. Give follow-up care If fever persists after 2 days Do a full assessment of the child Treatment: 1) If the child has any general danger sign or stiff neck, treat as very severe febrile disease/malaria 2) If malaria is the only apparent cause of fever  Take a blood smear  Treat with the 1st-line oral antimalarial,  Advise mother to returnin 2 days if fever persists  If fever has been present for 7 days, refer for assessment Fever-Malaria Unlikely

25. Give follow-up care If fever persists after 2 days Do a full assessment of the child Make sure that there has been no travel to malarious area & overnight stay in malaria area If there has been travel and overnight stay take blood smear, if possible Treatment: 1) If there has been travel & overnight stay malaria area- blood smear (+) or there is no blood smear-> classify accdg to FEVER WITH MALARIA RISK and treat accordingly 2) If there has been no travel or blood smear (-):  if the child has any general danger sign or stiff neck, treat as very severe febrile disease  If the child has any apparent cause of fever, provide treatment  If no apparent cause of fever, advise the mother to return again in 2 days if fever persists  If fever has been present for 7 days, refer for assessment Fever (no Malaria)

26. Give follow-up care After 2 days: Look for red eyes and pus draining from the eyes Look at the mouth ulcers Smell the mouth Treatment for eye infection: 1) If pus draining from the eye, ask the mother previous treatment. If treatment correct, refer to hospital. If treatment incorrect, teach mother correct treatment 2) If pus gone but redness remains, continue the treatment 3) If no pus or redness, stop the treatment Treatment for mouth ulcers: 1) If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital 2) If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days Measles with eye or mouth complications

27. Give follow-up care if fever persists after 2 days: if fever persists after 2 days: Do a full assessment of the child Do a tourniquet test Assess for the other causes of fever Treatment: 1) If the child has any general danger signs of bleeding, including skin petechiae or a positive tourniquet test, or signs of shock, or persistent abdominal pain or persistent vomiting, refer to HOSPITAL 2) If the child has any other apparent cause for fever, provide treatment 3) If fever has been present for 7 days, refer for assessment 4) If no apparent cause of fever, advise the mother to return daily until the child has had no fever for at least 48 hours 5) Advise mother to make sure child is given more fluids and is eating Fever: Dengue Hemorrhagic Fever unlikely

28. CASE 2: Darwin Darwin is 3 years old. He weighs 9.4 kg. His temperature is 37C. His mother says he feels hot. He has a cough, she says. The health worker checked for general danger signs. Darwin was able to drink, had not vomited, did not have convulsions, and was not abnormally sleepy or difficult to awaken. The mother said Darwin had been coughing for 3 days. The health worker counted 51 breaths per minute. He did not see chest indrawing. There was no stridor when Darwin was calm. Darwin does not have diarrhea. The health worker also thought that Darwin felt hot. He assessed the child for further signs of fever. There is risk of malaria. He has felt hot for 5 days, the mother said. He has not had measles within the last 3 months. He did not have a stiff neck, there was no runny nose, and no generalized rash. It was not possible to take a blood smear. There is no sign suggesting DHF. Record the child’s signs and classify them on the Recording Form

29. Case 3: Letty Letty is 5 months old. She weighs 5 kg. Her temperature is 36.5C. Her family brought her to the health center because she feels hot and has a cough for 2 days. She is able to drink. She has not vomited or had convulsions, and is not abnormally sleepy or difficult to awaken The health worker said,”I’m going to check her cough now.” The health worker counted 43 breaths per minute. There was no chest indrawing and no stridor when Letty was calm. Letty did not have diarrhea. “Now, I will check her fever,” said the health worker. Her mother said, “Letty has felt hot off and on for 2 days.” She had not measles within the last 3 months. She does not have stiff neck or runny nose. Letty has generalized rash. Her eyes are red. She has mouth ulcers. They are deep and extensive. She does not have pus draining from the eye. She does not have clouding of the cornea. Record the child’s signs and classify them on the Recording Form

30. Case 5:Nemia Nemia is 3 yo. She weighs 10 kg. Her axillary temperature is 38C. She was brought to the LHC due to cough. She also has a rash. The BHW checked Nemia for danger signs. She was able to drink, she had not been vomiting, everything, and she did not have convulsions. She was not abnormally sleepy or difficult to awaken The BHW assessed Nemia’s cough. The mother told the health worker Nemia had been coughing for 2 days. Nemia’s breathing rate wass counted 30 breahts per minute. There was no chest indrawing. No stridor was heard when Nemia was calm Nemia did nto have diarrhea. The BHW assessed Nemia’s fever. It was the wet season. There is no risk for malaria with no cases reported for the past 10 years. The mother said, “Nemia felt hot for the past 3 days”. She did not have stiff neck. She does not have a runny nose. Blood smear (-) Nemia was noted to have generalized rashes. Her eyes are red. She does not have mouth ulcers. No pus was draining from her eyes nor any clouding of the cornea. She ws noted to have gumbleeding and abdominal pain. She has no bleeding from nose, no vomiting of bllod, no bloody stools. Record the child’s signs and classify them on the Record Form. What questions would you like to ask in history/examiination