THE IMCI STRATEGY Integrated Management of Childhood Illness An integrated approach to child health that focuses on the well-being

g of the whole child. Aims to reduce death, illness & disability, and to promote growth and development among under under 5 children. It combines improved management of childhood illness with aspects of Nutrition, VAC supplementation, deworming, immunization, and other factors influencing child and maternal health. A strategy for reducing mortality and morbidity associated with major causes of childhood illness. A joint WHO/UNICEF initiative since 1992 Currently focused on first level health facilities Comes as a generic guidelines for management which have been adapted to each country Diseases comprising 70% of deaths among under 5 children Pneumonia Diarrhea Dengue hemorrhagic fever Malaria Measles Malnutrition Objectives of IMCI To reduce significantly global mortality and morbidity associated with the major causes of disease in children. To contribute to healthy growth and development of children. Assess for General Danger Signs Routinely assess for major symptoms. Use limited number of carefully selected clinical signs. Address most, if not all of the major reasons a child is brought to the clinic. Use a limited number of essential drugs and encourage participation of caretakers in the treatment. Counseling of caretakers. Components of IMCI Improving case management skills of health workers. o Standard guidelines o Training (pre-service and in-service) o Follow-up after training Improving the health system to deliver IMCI: o Essential drug supply and management o Organization of work in health facilities o Management and supervision Improving family and community practices Benefits of IMCI Addresses major child health problems Responds to demand Promotes preventive as well as curative care Cost-effective Promotes cost saving

Improves equity The IMCI Case Management Process 1.Assess 2.Classify 3.Identify Treatment 4.Treat 5.Counsel the Mother 6.Follow-Up

Age groups Sick Child Aged 2 months up to 5 years Young Infants Aged Up to 2 months The IMCI Case Management Process ASSESS AND CLASSIFY Check for GENERAL DANGER SIGNS not able to drink or breastfeed vomits everything convulsions abnormally sleepy or difficult to awaken Not able to drink or breastfeed Not able to suck or swallow when offered a drink or breast milk because he/she is too weak or cannot swallow Ask: Is the child able to take fluid into his/her mouth and swallow it? Vomits everything Not able to hold anything down What goes down comes back up Check: offer the child fluid water or expressed breast milk Convulsion Arms and legs stiffen because the muscles are contracting The child may lose consciousness or not able to respond to spoken directions or handling, even if the eyes are open May be due to fever or associated with meningitis, cerebral malaria or other life threatening conditions Abnormally sleepy or difficult to awaken Drowsy and does not take notice of his/her surroundings Does not respond normally to sounds or movement Stares blankly and appear not to notice what is going on Cannot be wakened. Does not respond when touched, shaken, or spoken to Assess & Classify THE 4 MAIN SYMPTOMS Cough or difficult breathing Diarrhea Fever Ear problem Assess and classify cough or difficult breathing How long?

 Count the breaths in one minute. Decide if fast breathing is present Look for chest indrawing Look and listen for stridor Look and listen for wheeze o If wheezing and either fast breathing or chest indrawing: - Give a trial rapid acting inhaled bronchodilator for up to three times 1520 minutes apart. Count the breaths and look for chest indrawing again, then classify. - 0.5 ml salbutamol diluted in 2.0 ml of sterile water per dose nebulization should be used. Assess and Classify Cough or Difficult breathing If child is: Fast Breathing is: 2 months up to 12 50 breaths per minute or months more 12 months up to 5 40 breaths per minute or years more Chest Indrawing the lower chest wall goes IN as the child breaths IN Stridor a harsh noise as the child breaths IN Wheeze soft musical noise made when the child breaths OUT

Two of the following signs: Abnormally sleepy or difficult to awaken Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly Not enough signs to classify as some or severe dehydration

Severe Dehydration

Some Dehydration

No Dehydration

If diarrhea is 14 days or more Dehydration present. Severe persistent diarrhea No Dehydration. Persistent Diarrhea If there is blood in stool Blood in the stool

Dysentery

Classify the illness Urgent pre-referral treatment and referral Specific medical treatment and advice Simple advice on home management Classify cough or difficult breathing Any general danger sign Severe pneumonia Chest indrawing or Very Severe Stridor in calm child Disease Fast breathing Pneumonia (If wheezing go directly to treat wheezing) No signs of pneumonia or No Pneumonia: very severe disease Cough or Cold (If wheezing go directly to treat wheezing) Assess diarrhea For how long? Is there blood in the stool? Look at the childs gen. condition. Look for sunken eyes. Offer the child fluid drinking normally/poorly/eagerly? Not able to drink? Pinch the skin of the abdomen. o Look for sunken eyes o Skin Pinch that goes back Very Slowly Classify diarrhea for dehydration

Assess Fever Decide malaria risk If malaria risk, obtain a blood smear For how long? If more than 7 days, has fever been present every day? Has the child had measles within the last 3 months Look or feel for stiff neck. Look for runny nose. Look for signs of measles. If child has measles now or within the last 3 months: o Look for mouth ulcers o Look for pus draining from the eyes. o Look for clouding of the cornea Generalized Rash of Measles Measles Complications: Mouth Ulcer Pus Draining from Eye Clouding of the Cornea Classify fever (Malaria Risk) Any general danger sign Stiff neck Blood smear (+) If no blood smear: no runny nose and no measles and no other causes of fever Blood smear (-) or runny nose or measles or other causes of fever

Very Severe Febrile Disease/Malaria Malaria

Fever: Malaria Unlikely

Classify fever (No Malaria Risk) Any general danger sign Very Severe Febrile Stiff neck Disease No signs of very severe Fever: No Malaria febrile disease

Classify Measles Clouding of the cornea Deep or extensive mouth ulcers Any general danger sign Pus draining from the eye, or Mouth ulcers Measles now or within the last 3 months

Severe Complicated Measles Measles with Eye or Mouth Complications Measles

Check for malnutrition and anemia For all Children: Determine weight for age. Look for edema of both feet. Look for visible severe wasting. For children aged 6 months or more, determine if MUAC is less than 115 mm Signs of Severe Malnutrition Edema of Both Feet Visible Severe Wasting Classify Nutritional Status: If age up to 6 months - and visible severe wasting - and edema of both feet If age 6 months and above and: - MUAC less than 115mm or edema of both feet or visible severe wasting Very low weight for age Not very low weight for age and no other signs of malnutrition Check for Anemia LOOK AND FEEL: Look for palmar pallor. Is it Severe palmar pallor? Some palmar pallor Check for Signs of Anemia No palmar pallor Some palmar pallor Severe palmar pallor Classify for Anemia: Severe palmar pallor Some palmar pallor No palmar pallor SEVERE ANEMIA ANEMIA NO ANEMIA SEVERE MALNUTRITION

Assess/Classify Dengue Hemorrhagic Fever Bleeding from nose or gums Bleeding in stools/vomitus Black stools/vomitus Skin petechiae Cold and clammy extremities Capillary refill more than 3 seconds Persistent abdominal pain Persistent vomiting Tourniquet test positive Assess DHF Skin petechiae dark red spots or patches in the skin. When skin is streached, they do not disappear Persistent abdominal pain continuous, without relief Persistent vomiting not associated with food intake Positive tourniquet test 20 or more petechiae in one square inch Assess/Classify Dengue Hemorrhagic Fever Any one sign present: Severe Dengue Hemorrhagic Fever No sign present - Fever: Dengue Hemorrhagic Fever Unlikely Assess Ear Problem Is there ear pain? Is there ear discharge? For how long? Look for pus draining from the ear. Feel for tender swelling behind the ear. Classify ear problem Tender swelling behind the ear Ear Pain Pus is seen draining from the ear and discharge is reported for less than 14 days Pus is seen draining from the ear and discharge is reported for 14 days or more No ear pain No pus seen draining from the ear Mastoiditis Acute Ear Infection

VERY LOWWEIGHT NOT VERY LOW WEIGHT

Check for: Immunization Status Vitamin A Supplementation Status Deworming Status Assess for Other Problems Identify Treatment Determine if urgent referral is needed. Identify treatment for patient who do not need urgent referral. For patients who need urgent referral, identify urgent pre-referral treatment. Give pre-referral treatment. Refer the child with a referral note. Acute respiratory infection

Chronic Ear Infaction

No Ear Infection

First-line/second line antibiotic for non-severe pneumonia PREVIOUS UPDATED First line Cotrimaxazole Amoxicillin Second Amoxicillin Cotrimaxazole line Duration of antibiotic treatment from 5 days to 3 days Frequency of administration of antibiotics from 3x to 2x a day Management for non-severe pneumonia therefore: First line - Oral amoxicillin to be given in 25mg/kg dose twice daily in children 2-59 months of age for 3 days Second line - Oral Cotrimoxazole to be given 2x daily for 3 days Technical basis: 3 days treatment is equally effective as the 5 day treatment Reduces cost of treatment Improves compliance Reduces antimicrobial resistance in the community Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia o Where referral is difficult and injection is not available, oral Amoxicillin in 45 mg/kg/dose 2x daily should be given to children with severe pneumonia for 5 days Technical basis: Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia Gentamicin plus ampicillin vs chloramphenicol for very severe pneumonia o Injectable ampicillin plus injectable gentamicin is a better choice than injectable o chloramphenicol for very severe pneumonia in children 2-59 months of age. o A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia o Where referral is difficult and injection is not available, oral Amoxicillin in 45 mg/kg/dose 2x daily should be given to children with severe pneumonia for 5 days Technical basis: Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia Give Extra Fluid for Diarrhea and Continue Feeding Treatment Plan A for No Dehydration 1.Give Extra Fluid: a.Up to 2 yrs. : 50-100 ml after each loose stool b.2 yrs. Or more: 100-200 ml after each loose stool 2.Give Zinc Supplements (for 10-14 days): a.< 6 mos. : 10 mg/day b.6 mos. 5 yrs: 20 mg/day

3.Continue feeding 4.When to Return Diarrheal diseases Use or oral osmolarity oral rehydration salt Technical basis: Efficacy of ORS solution for tx of acute noncholera in children is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245mOsm/l. The need for unscheduled supplemental IV is reduced by 33%, stool output is reduced by about 20% and the incidence of vomiting by about 30%. Composition mmol/liter Sodium Chloride Glucose, anhydrous Potassium Citrate Total Osmolarity New 75 65 75 20 10 245 Old 90 80 111 20 10 311

Benefits of Zinc Supplementation Reduces the severity of diarrhea Shortens the duration of diarrhea Lowers the number of diarrhea episodes protects the child from diarrhea for the next 2 3 months.

Treatment Plan B for Some Dehydration Give recommended amount of Reformulated ORS: AGE Up to 4 months 12 2 years 4 up to 12 months up to 5 month months up to 2 years s years WEIGH Less 6 6 to less 10 to 12 to T kg than 10 less less kg than 12 than kg 20 kg Amou 200450-800 800-960 960nt of 450 1600 fluid (ml) over 4 hours The approximate amount of ORS required can also be calculated by multiplying childs weight by 75 If the child wants more ORS, give more For infants below 6 months who are not breastfed, also give 100-200 ml clean water during this period. Give frequent small sips from a cup. If child vomits, wait 10 minutes then continue more slowly

 Continue breastfeeding whenever the child wants After 4 hours: Reassess, classify, select appropriate treatment plan; begin feeding the child in the clinic. Treatment Plan C for Severe Dehydration Can you give IV fluid? If yes, give IV fluid immediately. If No: Is IV treatment available nearby (within 30 minutes)? If yes, refer immediately to hospital for IV treatment. If No: Are you trained to use NG tube for rehydration? If yes, start rehydration by NG If No: Can the child drink? If yes, give ORS by mouth If No, refer URGENTLY to hospital for IV or NG treatment. Diarrheal Diseases Use of antibiotics in the management of bloody diarrhea (shigella dysentery) Ciprofloxacin is the most appropriate drug in place of nalidixic acid which leads to rapid development of resistance Dose: 15 mg/kg body weight 2x a day for 3 days Treat the Child: Oral Antibiotics/Antimalarial For Cholera: First Line: Tetracycline Second Line: Erythromycin Oral Antimalarial: First Line: Artemether-Lumefantrine Second Line: Chloroquine, Primaquine, Sulfadoxine and Pyrimethamine Fever Treatment of drug-resistant malaria In case of parasitological or clinical failure to a given drug, refer patient to the next level with proper documentation (blood smear result incl. parasite count on day7, 14, 21, & 28 o Quinine sulfate(300 or 600 mg/tab) o 10 mg/kg/dose every 8 hours for 7 days + Clindamycin 10 mg/kg 2x a day for 3 days Pre-referral treatment: Artesunate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow. EAR INFECTIONS Chronic ear infection Chronic ear infection should be treated with otical quinolone ear drops for at least 2 weeks in addition to dry ear by wicking Acute ear infection Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high Dry the Ear by Wicking and Instill Quinolone Eardrops Dry the ear using wick of clean absorbent cloth or soft, strong tissue paper. Instill quinolone eardrops after wicking 3 times daily for 2 weeks

Quinolone eardrops may include: ciprofloxacin, norfloxacin, or ofloxacin Follow the Rule of Three : 3 drops, tilt head for 3 minutes, instill 3 times a day Other Treatments Vitamin A for sick children Iron for anemia Paracetamol for high fever (38.5 C or more) and for ear pain. Mebendazole/Albendazole for deworming. Multivitamins and minerals for Persistent Diarrhea (with at least 2 of Recommended Energy and Nutrient Intake: folate, Vitamin A, zinc, magnesium, copper) Tetracycline Eye Ointment for eye infection (TID) Quinolone Eardrops & Ear Wicking for ear discharge (TID). Half-strength Gentian Violet for mouth ulcers ( BID). Cough Remedies: breastmilk tamarind, calamansi, ginger (SKL) Given at Health Center Only: o IM Antibiotic for children being referred who cannot take oral antibiotic : - Give Gentamicin (7.5 mg/kg) AND Ampicillin 50 mg/kg Treat to Prevent Low Blood Sugar Breastfeed more frequently Give sugar 30-50 ml of milk or sugar water before departure (for referral) To make sugar water: Dissolve 4 level teaspoon (20 grams) of sugar in 200 ml cup of clean water If unconscious, give D10 5ml/kg over a few minutes or give D50 1ml/kg by slow push. Revised Immunization Schedule Age Vaccine Birth BCG, HepB1 6 weeks DPT1, OPV1, HepB2 10 weeks DPT2, OPV2 14 weeks DPT3, OPV3, HepB3 9 months Anti measles 12 15 MMR months Routinely Check for Deworming Status Give Mebendazole/Albendazole - Give 500 mg. Mebndazole/400mg Albendazole as a single dose in the health center if the child is 12 months up to 59 months and has not received a dose in the previous 6 months Mebendazole/Albendazole Dose: AGE OR WEIGHT Albendaz Mebendaz ole 400 ole 500 mg mg tab. tab. 12 months up to tablet 1 tablet 23 months 24 months up to 1 tablet 1 tablet 59 months Vitamin A Treatment/Supplementation

AGE 6 months up to 12 months 12 months up to 5 yrs

Vitamin A Capsules 100,000 200,000 IU IU 1 capsule capsule 1 capsule

Diarrhea Fever: DHF Unlikely

Blood in stool Drinking poorly Any sign of bleeding Persistent abdominal pain Persistent vomiting Skin petechiae/ Skin rash

Counsel the Mother on Infant Feeding 1.Exclusive breastfeeding up to 6 mos. Breastfeed as often as the child wants, day and night at least 8 times in 24 hours Breastfeed when the child shows signs of hunger, beginning to fuss, sucking fingers, or moving the lips Do not give other foods or fluids 2.Complementary feeding 6 mos. up to 23 mos. Breastfeed as often as the child wants Give adequate serving of complementary foods: 3 times per day if breastfed, with 1-2 nutritious snacks as desired from 923 mos. Give foods 5 times per day if not breastfed with 1 or 2 cups of milk Give small chewable items to eat with fingers. Let the child try to feed itself, but provide help 3.Management of severe malnutrition where referral is not possible Where a child is classified as having severe malnutrition and referral is not possible, the IMCI guidelines should be adapted to include management at firstlevel facilities modified milk diet is given 4.HIV and Infant Feeding In areas where HIV is a public health problem all women should be encouraged to receive HIV testing and counseling If a mother is HIV-infected and replacement feeding is acceptable, feasible, affordable, sustainable and safe for her and her infant, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life The child of HIV-infected mother who is not breastfed should receive complementary foods Care for Development communication and play Increase fluids during illness When to Return: o for follow-up o immediately o for immunization When to Return Immediately Any sick child Not able to drink or breastfeed Becomes sicker Develops fever No Pneumonia: Fast breathing Cough or cold Difficult breathing

Give Follow-Up Care: Persistent Diarrhea After 5 days: Ask: Has the diarrhea stopped? How many loose stools is the child having per day? Treatment If diarrhea has not stopped (3 or more/day), do a full reassessment. Give any treatment needed. Refer to hospital. If diarrhea has stopped, tell the mother to follow the feeding recommendation for childs age. Assess: Age up to 2 months Previous Age: 1 week up to 2 months Updated Birth up to 2 months

Main symptom: Previous: Possible serious bacterial infection Updated: Very severe disease and local bacterial infection Signs to look for in assessment: Previous: 12 signs Updated: 7 signs Classify: Aged Up to 2 months (Updated) Not feeding well, or Convulsions, or Fast breathing (60 bpm or more), or Severe chest indrawing, or Fever (37.5 C or above), or Low body temp. (less than 35.5 C), or Movement only when stimulated or no movement at all Classify, Identify Treatment Red Local Give an appropriate umbilic Bacteri oral antibiotic. us al Teach the mother to Skin Infectio treat local infections pustule n at home. s Advise mother how to give home care for the young infant. Follow-up in 2 days. Checking for jaundice is added in the protocol Classification: Severe jaundice (pink), Jaundice (yellow), No jaundice (green) SEVERE Any jaundice if age JAUNDICE less than 24 hrs, or Yellow palms and soles at any age JAUNDICE Jaundice appearing after 24 hrs of age, and

 Palms and soles not yellow No Jaundice NO JAUNDICE

Assess and Classify diarrhea For dehydration ( severe, some or no dehydration) If diarrhea is 14 days or more: Severe Persistent Diarrhea If blood in stool: Dysentery Check for feeding Problem or Low Weight Not well attached to Feeding breast Problem or Low Not suckling effectively Weight Less than 8 feeds in 24 hrs. Receives other foods or drinks Low weight for age Thrush Not low weight for age No feeding and no other signs of Problem inadequate feeding Assess: Age up to 2 months Check for the young infants immunization status Assess other problems Treat the Young Infant Give an appropriate oral antibiotic: First Line: Amoxycillin Second Line: Cotrimoxazole ( Not given in infants less than 1month of age who are premature or jaundiced). Injectable Antibiotic (for referred patients unable to take oral antibiotic or for cases where referral is not possible): Ampicillin and Gentamicin Treat Skin Pustules Wash hands. Gently wash off pus and crusts with soap and water. Dry the area. Paint with full-strength Gentian Violet. Wash hands. Treat Umbilical Infection Wash hands. Paint with full-strength Gentian Violet. Wash hands. Treat Oral Thrush Wash hands. Wash mouth with clean soft cloth wrapped around the finger and wet with salt water. Paint the mouth with half-strength Gentian Violet. Wash hands. Teach Correct Positioning and Attachment for Breastfeeding Show her how to help the infant to attach. She should: Touch her infants lips with her nipple. Wait until her infants mouth opening wide,

Move her infant quickly onto breast, aiming the infants lower lip well below the nipple. Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again. Signs of Good Attachment Chin touching the breast Mouth wide open. Lower lip turned outward. More areola visible above the top lip than below the lower lip. Advise Mother to Give Home Care for the Young Infant Food and Fluid: Breastfeed frequently, as often and for as long as the infant wants. When to Return: o For Follow-up Visit o Immediately o For Immunization Make sure the young infant stays warm at all times. When to Return Immediately Breastfeeding or drinking poorly. Becomes sicker. Develops fever. Fast breathing. Difficult breathing. Blood in stool. Follow-Up Care: Oral Thrush After 2 days: Look for ulcers or white patches in the mouth. Reassess feeding If thrush is worse, or if the infant has problems with attachment or suckling, refer to hospital. If thrush is the same or better, and the infant is feeding well, continue half-strength Gentian Violet for a total of 5 days. Technical updates adapted in Philippine IMCI Antibiotic treatment of non-severe and severe pneumonia Low osmolarity ORS and antibiotic treatment for bloody diarrhea Treatment of fever/malaria Treatment of ear infections Infant feeding Treatment of helminthiasis Management of sick young infant aged up to 2 months