1. Acute Respiratory Infections ARI
Assistant Professor
Dr. Batool Ali Ghalib Yassin
Department of Family & Community Medicine
College of Medicine – University of Baghdad

2. Objectives By the end of this lecture you will be able to:
Appraise the important of ARI program on childhood morbidities & mortalities
Follow the guidelines of managing a child with ARI
Classify the ARI cases according to age, severity ,signs & symptoms.
List the steps of management according to ARI case management chart.

3. Acute Respiratory Infections (ARI)
ARIs
are a worldwide problem. In addition to diarrhoea & malnutrition, ARIs form a main cause of morbidity & mortality among children in developing countries.
Impact
Contribute to 30-60% of all children attending outpatient department of health facilities,
70% of which are upper ARIs.
Facts
Overall incidence of ARIs among children in developing & developed countries is within the same range, BUT
The annual incidence of pneumonia is 3-4 % in children <5 years of age in developed countries compared to 10-20% in developing countries.
In fact
The majority of these infections are mild & can be treated at home without the use of antibiotics.

4. Acute Respiratory Infections (ARI)
The objectives of ARI control program
To identify the few serious cases of ARI
To follow the standard case management guidelines for ARI cases
Primary offenders are usually viruses
Responsible for a high proportion of the primary infections
Bacteria may be primary or secondary offenders
Streptococcus pneumoniae & Haemophilus influenzae are the most frequent causes of pneumonia
Account to 2-4% of cases in developed countries and 20% of cases in developing countries
On average, a child living in an urban area gets 5-8 attacks of ARI/year, & each attack lasts for 7-9 days (35-72 days of illness/year)

5. The Standard Case Management of ARI Cases
Assessment
ASK
How old is the child?
Less than 2 months
Has the child stopped feeding well (1/2 amount)
2 months - 5 years
Is the child able to drink
Is the child coughing? For how long
< 30 days: acute
> 3o days: chronic
Does the child have fever
Did the child have convulsions during the current illness?

6. The Standard Case Management of ARI Cases
Assessment
Look & Listen
Chest indrawing
When the child breathes in, the lower chest wall goes in
Stridor
Is a harsh sound made when the child breathes in
Wheeze
Is a soft musical sound made when the child breathes out
Count
RR/min
* < 2 months 60+
* 2-12 m 50+
* 12m -5yrs 40+

7. The Standard Case Management of ARI Cases
Assessment
See
If the child is abnormally sleepy or difficult to wake
Feel
Fever
If the temperature is 38°C or more
low body temperature
< 35.5°C indicates hypothermia
Check
For severe under-nutrition
Marasmus or kwashiorkor

8. Classification Child Age Two months up to 5 years Very Severe Disease
Not able to drink*
Convulsions
Abnormally sleepy or difficult to wake
Stridor in a calm child
Severe under nutrition
Severe Pneumonia
chest indrawing
Pneumonia
No chest indrawing, BUT
the child has FAST BREATHING
No Pneumonia
(cough or cold)
No chest indrawing & no fast breathing

9. Classification Child Age Less than 2 months Very Severe Disease
Abnormally sleepy or difficult to wake
* Convulsions
* Stridor in a calm child
* Stopped feeding well**
* Wheeze**
* Fever or low body temperature**
* Grunting**, * Cyanosis**
Severe Pneumonia
chest indrawing OR
Fast Breathing
60+
No Pneumonia
(cough or cold)
No chest indrawing & no fast breathing
& no dander sign

10. Very Severe Disease No Pneumonia Management & Severe Pneumonia
1. Give the first (Pre-referral) dose of paranteral antibiotics.
2. Refer urgently to hospital.
3. Treat fever, if present.
Pneumonia
Only for
(children between 2 months and 5 years(
Treat child at home with antibiotics for five days:
Cotrimoxazole, amoxicillin (syrup or tablets) or
Procaine Penicillin (daily i.m. injections).
Teach the mother how to give the dose, how much, how many doses per day and for how many days.
Give the first dose in the health centre
Reassess in two days, or sooner if the child gets worse.
Advise on home care.
No Pneumonia
(cough or cold)
No antibiotics
Advise home care
Look for other problems
watch for danger signs, to return immediately

11. Standard Case Management of Ear Problems
Classification
Assessment
Antibiotics for 5 days
Dry the ear by wicking
Reassess in five days
Treat fever and pain with paracetamol
Acute Ear Infection
< 2 wks
Ask: a. Does the child have ear pain? Yes
b. Does the child have pus draining from the ear? If yes, for how long?
Dry ear by wicking
If case does not improve, refer
Chronic Ear Infection
> 2 wks
Yes
Look : for pus draining from the ear, and a red immobile ear drum.
Refer urgently to hospital
Give pre-referral antibiotic
Mastoiditis
Feel: for a tender swelling behind the ear.

12. Standard Case Management of Sore Throat
Classifi-cation
Assessment
Ask: a. Does the child have a sore throat?
Refer urgently to hospital
2. Give pre-referral antibiotic
3.Treat fever and pain with
paracetamol
Throat abscess No
b. Is the child able to drink?
Soft food and drink
Treat fever and pain with paracetamol
Viral Sore Throat
Yes, but with pain
Benzathin penicillin or amoxicillin
Give a safe soothing remedy
Treat fever and pain with paracetamol
Streptococcal Sore Throat
Yes
Look for exudates on the throat.
Feel the front of the neck for lymph nodes.

13. Accessibility to an Adequate Supply of Safe Water
Safe Water: Is water that does not contain chemical substances and micro-organisms in concentrations that could cause disease or illness in any form.
Adequate Water Supply: Is one that provides safe water in quantities sufficient for drinking and for domestic and other household purposes so as to make the personal hygiene of the members of that household possible.

14. Basic Sanitation
Sanitation: Refers to the means of collecting and disposing of excreta and community liquid wastes in a hygienic way so as not to endanger the health of individuals and the community as a whole.
Safe Excreta Disposal: Should aim to prevent excreta from coming into direct contact with man, contaminating ground or surface water, being accessible to animals or insects, coming into contact with food and creating public or private nuisance.
It is estimated that 1.2 billion people in the world today have no access to safe water and that 1.9 billion have no access to basic sanitation.

15. Food Supplementation
There are two specific forms of food supplementation :
I. Food Supplements: These are directed to two target groups:
1. Pregnant women at risk of delivering LBW infants: Extra food supplements are given during the third trimester which is the period of rapid foetal growth. The aim is to reduce the risk of LBW. The amount given is cal + 10 g protein/day. This will result in an additional average weight gain of 1.5 Kg, which will be reflected in an average increase of BW by 300g.
How to identify women at risk:
Women whose weight is 90% or less of the standards weight for height.
Women with mid-upper arm circumference of <22.5cm.
Women who fail to have a regular weight gain of 1.5Kg/month during the last 6 months of pregnancy.
Much of maternal malnutrition can be prevented through the training of elderly women & TBAs to provide nutrition information & to promote beliefs and customs favourable to pregnant and lactating women, as well as young children.

16. Food Supplementation
2. Children: High protein food supplements for malnourished children are a major component of many health care programs. These programs are of two types:
Take home distribution system: Where the rations are distributed at regular intervals with the expectation that the food will be eaten by the beneficiary at home. Problems are substitution of other foods and sharing by other members of the household.
Central feeding: where the beneficiaries are assembled at a single place & fed together. The problems which face these programs are travel cost and cross infections.
Maternal education is a critical component of most feeding programs aiming at the correction of inappropriate feeding habits.

17. Food Supplementation II. Food Fortification:
It is defined as the process whereby micronutrients are added to food to maintain or improve the quality of the diet of a population or a community.
The program aims at dealing with specific micronutrient deficiencies & is typically used in conjunction with staple foods.
The three major specific micronutrient deficiencies are: iodine, vitamin A and iron.
Vitamin A and iron deficiency, even in mild forms, may exacerbate the duration and severity of other diseases, sometimes causing death, which may have been otherwise avoidable.

18. Food Supplementation; 1) Iodine Deficiency:
Epidemiology
It is a prevalent nutritional deficiency in many parts of the world such as Africa, Latin America and Asia
where what is called the “Goitre Belt” exists
Iodine Deficiency
In these areas, the soil and therefore, the foods are deficient in Iodine
Burden
There are approximately 10,000,000 people in these areas affected by iodine deficiency disorders (IDD)
consequences of IDD ranging from a disfigured neck to severe mental and physical retardation

19. Food Supplementation 1) Iodine Deficiency:
-This problem is very easily prevented through fortifying salt with iodine.
For people living in remote areas and not consuming the fortified salt, long term release iodine injections are given, which release iodine slowly over years.
The amount added is 30g of iodine to one tonne of salt (iodine loss may take place due to humidity).

20. Food Supplementation 2) Iron Deficiency:
Population at risk
Women in the child bearing age
Pre-school children
Burden
230,000,000 have Hb concentrations below those specified as indicative of anaemia
2/3 of pregnant women in developing countries are anaemic.
Requirements
The daily requirements for iron are nearly 6 times in the last trimester of pregnancy than the non-pregnant state

21. Food Supplementation 2) Iron Deficiency:
This need is covered by iron from the diet and from iron stores, which if inadequate, anaemia will result.
In infants, iron stores are exhausted around the fourth month of life, especially when weaning is delayed or the weaning diet is mainly starchy.
Anaemia may not lead directly to death, but it has a profound effect on learning and problem solving capacities, psychological and physical behaviour, development of fatigue, reduction of work capacity and increased risk of maternal and foetal morbidity.

22. Food Supplementation 2) Iron Deficiency:
IDA is prevented by
Changing dietary habits (increase animal protein and vegetables rich in iron),
Iron supplementation to pregnant and lactating women, and
Fortifying foods with iron salts (flour, sugar, salt and spices).

23. Food Supplementation 3)Vitamin A Deficiency:
Annually, 5-10 million children develop mild xerophthalmia & nearly 250,000 are blinded by this condition. VAD is related to other health problems as well. Studies have shown that child death rates almost triple with each increase in the degree of VAD. These excessive deaths are due to diarrhoeal diseases and respiratory infections.
Children are supplemented with Vitamin A capsules or drops once every 6 months
In Iraq they receive 50,000 IU at 9 months of age and 100,000 IU at 18 months of age.
This had reduced deaths rates in children over 1 year of age by 1/3.
It also helps to add green leafy vegetables and yellow fruit and vegetables as well as fats and oils to the child’s weaning foods.

24. Food Supplementation 3)Vitamin A Deficiency:
Vitamin A deficiency also causes
- anaemia and impaired growth.
- Survival of children with measles can be increased by giving vitamin A supplementation.
Breast feeding is protective against vitamin A deficiency in infants if the mother’s vitamin A levels are adequate.
Postnatal lactating women are supplemented with 200,000 IU of vitamin A.
Vitamin A can also be added to milk and sugar.

25. Health Education
is the part of health care that is concerned with promoting healthy behaviour.
A person's behaviour may be the main cause of a health problem, but it can also be the main solution. (smoking, poorly nourished kid, Butcher’s habits)
Health education does not replace other health services, but it is needed to promote the proper use of these services. (immunization)

26. Health Education & PHC The truth is that ;
Individuals & families, not doctors & other health workers, make most of the important decisions that affect their health.
Mothers decide what food to give to their families & how to prepare it. Families decide when to go to a doctor, where to go & whether or not to follow the instructions they receive from a health worker.
people need to be equipped with the knowledge & skills necessary to exercise individual & community responsibility

27. Major objectives of education for health are to enable people:
To define their own problems & needs.
To understand what they can do about these problems with their own resources combined with outside support.
To decide on the most appropriate action to promote healthy living & community well-being.

28. Changes in Behaviour
Favourable behaviour must be encouraged, unfavourable ones must be stopped.
Natural change: in response to the change in the community around us. Example: we wear different clothes for different seasons.
Planned change: we change behaviour to improve our lives. Example: stop smoking, eat healthier diets.
Note: not all people are ready to change, some may change quickly, and others may change slowly.

29. Helping people to lead healthier lives
Using Force;
It gives a temporary change in behaviour
Giving Information;
it is needed but the success is not always there.
Discussing & Participating;
This is the most vital part to help through community full participation.

30. Health Education; Types
Health Education with Individuals; Counselling.
Health Education with groups
The advantages of group education:
Provides support & encouragement
Permits sharing of experience & skills
Makes it possible to pool the resources of all members
Health Education with Communities
get the support of influential people in the community.
Make sure that all people in the community are informed about the problem & that their information on plans & progress is updated. For this purpose, we need to use all available methods of communication.
Get the maximum number of people involved, in order to strengthen the capacities of the community to solve its problems.