Int egrate d

Manageme nt of
Ch ildhoo d Illne ss

Integrated Management of Childhood Illness

WHO Regional Office for the Western Pacific/ Child Health
 Cau se s of 10 .5 mi lli on de at hs amo ng
ch il dren < 5 in deve lo ping co untri es , 199 9

Pneum on ia
19%

One in
every two child
deaths in perinatal
developing 20% Maln utr iti on
countries
Dia rrh oe a
are due to just 54%
five infectious Others 28%
15%
diseases
and
malnutrition
Me asle s
8%
HIV /AID S Ma la ria
3% 7%
Source: EIP/WHO, 1999 data
 Import ant El ement s
for Improvi ng Chi ld Health

• Improve case management of sick children

• Improve nutrition
• Ensure immunization
• Prevent injuries
• Prevent other diseases
• Improve psychosocial support and stimulation
 Too many di ff erent
piec es…
Appropriate
Case Care seeking Anemia
management
Home
Nutrition HIV/AIDS care
Drug
Use
New born
Malaria care
Child Follow-up
rights
Health Safe and
system Mothers Supportive
Communication
health Environment
IM CI bri ngs t hem a ll toget he r

IMP RO VEMEN T OF HEA LTH

SYSTEM

IM PRO VEMEN T OF CA SE MA NAGEMENT

FA MIL Y AN D COM MUN IT Y PR AC TI CES

CH IL D RI GHT S
 IM CI bri ngs i t all toget he r

Improving health Strengthening

workers’ skills health system

Improving family
and community
practices
 At t he s ta rt of a si ck chi ld
(2 mo nths to 5 ye ars) co nsul tat ion

• Ask the mother what the child’s

problems are.
• Determine if this is an initial or follow-
up visit for this problem.
 IMCI Ca se Ma na gement

Cl as sifi ca tion
Focus ed
Ass essment Nee d to Refer
Dang er sig ns
Ma in Sym ptoms
Nutri tion al status Specif ic treat ment
Immu ni zati on status
Other prob lems Home
management

Coun sel & Fol low-up Treatme nt

Cou ns el careta kers Id enti fy trea tm ent

Fol low-up Trea t
 Chec k f or ge nera l da nger signs

Ask:
• Not able to dr ink or breas tfee d,
• Vomi ts eve rythi ng,
• Convuls ions , or
Lo ok:
• Abnorm all y sle epy or dif fi cult
to aw ake n

Need t o Re fe r
(e xce pt in s ev ere de hy drat ion)
 Ask abo ut t he ma in sym pt om s

• Cough or difficulty in breathing

• Diarrhea
• Fever
• Ear problem
 Cough or dif fic ult y in br eathi ng

Ask:
• For how long?
Look:
• Count RR
• Chest indrawing The child
must be calm.
• Stridor
 Any gen era l dange r sign or
 Che st ind raw ing or
 St ridor

SEVER E P NEUM ONIA O R

VERY SEVER E D ISEASE

 1 st dos e of ant ibiot ic

 Vita min A
 Brea st fe edi ng/s ugar w at er
 URG EN T REFE RRAL
 Fa st bre at hing
2 – 12 mont hs old: ≥ 50 /m inut e
1 y ear o r ol de r: ≥ 4 0/minut e

PNEUM ON IA

 Ant ibi otic fo r 5 day s

 Re lie ve co ugh with s afe re medy
 Adv ise mot he r on dange r signs
 Fo llow up in 2 da ys
 No s igns o f pn eumo ni a
or a very severe dise as e

NO P NEUM ON IA: COUG H OR CO LD

 If co ug h ≥ 30 day s
 re fer to h ospit al for ass ess me nt
 Re li eve co ugh wi th s afe re medy
 Adv ise mo the r o n da nge r s igns
 Fo llow up in 5 d ays i f no impro veme nt
Dia rr hea : C la ssif y

For de hydra tio n

Pers ist en t
di ar rhe a

Bloo d in the
stoo l
 Cla ss ify for de hydr at io n

2 o r m ore of the fo llow ing:

 Abnor mall y sleepy /di fficul t t o wak e
 Sunk en eyes
 Not able t o fe ed/drink ing poor ly
 Sk in pinch goe s bac k v er y slow ly

SEVER E D EHYD RA TION Plan C

 Plan C: To t rea t dehy dra tion q uick ly

IV f luid: LRS 1 00 ml/k g body w eight

(in 6 hrs for infant s; 3 hrs f or chil dre n)

NO

IV t rea tme nt within 3 0 minut es

NO

Ore sol/N GT
Plan C: To t rea t dehy dra tion q uick ly

Ore sol/N GT

NO

Ore sol p .o.

NO

URGE NT REFERRA L
 Cla ss ify for de hydr at io n

2 o f the fo ll ow ing:
 Re st les s, i rri tabl e
 Sunk en eyes
 Sk in pinch goe s bac k slowly

SOM E D EH YDRAT ION Plan B

 Plan B: Tre at s ome dehy dra tion with ORS

Determ ine t he a mount (in ml) of O res ol

to be giv en in 4 hours
= we ig ht of t he chil d ( in k g) X 7 5, or
if we ight i s unk now n, us e t his cha rt .

Age < 4 mos 4-1 2 mos

Amoun t 200-4 00 400- 70 0
 Plan B: Tre at s ome dehy dra tion with ORS

Determ ine t he a mount (in ml) of O res ol

to be giv en in 4 hours
= we ig ht of t he chil d ( in k g) X 7 5, or
if we ight i s unk now n, us e t his cha rt .

Age 12 mos-2 yrs 2-5 y rs

Amoun t 700-9 00 90 0-1 400
Plan B: Tre at s ome dehy dra tion with ORS

 Show th e mo th er how t o gi ve Or es ol t o
the chil d: fre quent s ips from a cup
 If t he chil d v omi ts, wait for 1 0 min ute s.
The n cont inue, but mo re s lowly .
 Co ntinue bre as tfe eding i f t he chi ld
wa nts t o bre as tfee d.
 If t he chil d dev elops puff y ey eli ds , s to p
ORS .
Plan B: Tre at s ome dehy dra tion with ORS

Aft er 4 ho urs :
 Re as se ss t he chi ld & clas sify f or
dehy dra tion.
 Se lect appropriat e pl an.
 Begin fee di ng t he child in t he he alt h
cen te r.
 Cla ss ify for de hydr at io n

Not enough signs to cla ssif y as

SEV ERE DE HYD RA TIO N o r
SOME DE HYDR ATIO N

NO D EH YDRAT ION Plan A

 Plan A: Tr ea t diarr hea a t home

 Giv e ext ra fl uid.

Up to 2 50 – 1 00 ml af ter each LB M
yr s
2 -4 yrs 100 – 200 ml aft er ea ch
LB M
 Co ntinue fee di ng.
 Kn ow whe n t o re turn.
 Persi st ent di ar rh ea: 1 4 da ys or mor e

+ Dehy dra tion= se ver e pe rsis te nt

di arrhe a

• Tr eat de hydra tio n

• Give Vit amin A
• Refer t o hos pit al
 Persi st ent di ar rh ea: 1 4 da ys or mor e

No dehydra ti on=pers is tent dia rr hea

• Advis e rega rdi ng feeding

• Give Vit amin A
• Fol lo w up in 5 da ys
Blo od in the sto ol = dysent ery

• Ora l ant ibi ot ic for shige lla fo r

5 days
• Foll ow up in 2 d ays
Fe ver: (hi st ory/t empera tu re 3 7.5 °C or
above)

Ma lari a ris k?

Meas les now or w/i n las t 3 m os

Dengu e ri sk ?
 Feve r: A sk ab out mal ari a ris k

• Residi ng in ende mic a rea?

OR:
• Tra ve l & ove rnight
stay in ende mic a rea, or w/in pa st
• Blood tra ns fus io n 6 mos
 Ma la ria ri sk +

• Blood smear
• Ask: Dura ti on of fever?
Pre sen t eve ryda y?
• Lo ok: St if f nec k
Run ny no se
Ot he r si gns of meas les
 Ma lar ia ri sk +
any g ene ral da nger s ign or sti ff nec k

Very s ever e fe bri le dise as e/ ma lari a

• Quinine (under med. supervis ion)

• 1 st do se of anti bio tic , Par ac eta mol
• Urgen t referr al
Ma la ri a ris k +, blo od sm ear +
No runny nos e, no meas les

Ma la ri a

• Or al ant ima lar ia l

• Para cet amol
• Foll ow up i n 2 da ys
• > 7 da ys feve r  hospi ta l for
ass essment
 No ma la ri a r is k
Any ge nera l da ng er sig n or st iff neck

Ve ry se vere febrile di seas e

• 1 st do se of ant ibio tic , Par ac et am ol

• Urgent referr al
 Measle s now or w/ in la st 3 mos
Cl ouding of cornea or
Dee p or ext ensi ve mouth ulc ers

Se vere compli ca ted me as les

• 1 st do se of ant ibio tic , Vi tam in A

• Urgent referr al
Mea sl es n ow or w /i n la st 3 mos
Pus dr ai ni ng fr om t he eye or
Mouth ul cers

Measles wi th eye or
Mout h compl ications

• Vi tamin A
• Tetr acycli ne eye oin tment
• Gent ia n viol et
• Foll ow up i n 2 da ys
Measle s now or w/ in la st 3 mos
No other signs

Meas les

• Vi tamin A
 If the re is Dengue ri sk

Bl eeding gums , no se , i n vomit us

or stools
Bl ack v omit us or s tools
Per sist ent abdominal pai n
Per sist ent v om iting
Sk in p etechi ae
Slow ca pi ll ary re fi ll
No signs, b ut fe ver > 3 da ys 
To urni que t t es t
 Any of th e da ng er s ig ns
or + t ourn iqu et t est

Se vere Dengue hemorrha gi c f ev er

• If ski n pet echia e, p ersi st ent

abdomina l p ain or vo mi ting , or +
tourni qu et t est onl y s ig ns, gi ve OR S
• An y oth er s igns of bl eedi ng  P la n C
• Urgent r efe rra l
• Do not g ive as pi ri n
 Ea r pr obl em:
tender swelling beh ind ear

Mas toid it is

• 1 st do se of anti bio tic

• Pa ra cetamo l fo r pa in
• Urgen t referr al
Ea r di scha rg e < 14 da ys or
Ea r pa in

Ac ut e ea r in fe ct ion

• Ant ibi otic for 5 d ays

• Para ceta mol f or pa in
• Wicking
• Foll ow up i n 5 da ys
Ea r di scha rg e for 14 d ays or more

Chr onic ea r in fec tion

• Wicking
• Foll ow up i n 5 da ys
Vis ible seve re wa sti ng or
Edema on both f eet or
Seve re pa lma r pa ll or

Sev ere malnut rit ion or

se vere a nem ia

• Vit amin A
• Urgent referr al
 Some p al ma r pa ll or or
Ver y low weig ht f or a ge

Ane mi a or very low w eigh t for

ag e

• Assess f or f eed ing p robl em

• Pall or: i ron & A lb end azole
• Wt for age very low: V it amin A