Integrated Management of Childhood Illness

1
Integrated Management of Childhood Illness

• Dr. Ridwan Omar
• Specialist Paediatrician
• The Crompton Hospital

2
W e l c o m e
3
WHY IMCI?

• 1990s unacceptable high mortality rate in the
  under 5-year age group
• Main causes
• Pneumonia
• Diarrhoea
• Measles
• Malaria
• Malnutrition
• Perinatal problems

4
Overlap

• Combination of diseases
• Single diagnosis inappropriate
• Multifaceted therapy
• Nutritional assessment of every child

5
The difference

• Accurate identification first contact
• Appropriate combined treatment of all major
  illnesses
• Speeds up referral of the severely ill child
• Improves the quality of care of sick children at
  the first referral level

6
Sick Child 2 months to 5 years

• Assess, classify and identify treatment
• General danger signs
• Cough or difficult breathing
• Wheezing
• Diarrhoea
• Fever
• Ear problem
• Malnutrition and anaemia
• HIV infection

7
The approach

• Ask mom what the problems are?
• Rapid appraisal of all waiting children
• Is this an initial or follow-up visit for this
  problem?
• Check for general danger signs

8
General Danger Signs

• Is the child able to drink or breastfeed?
• Does the child vomit everything?
• Has the child had convulsions during this
  illness?
• Is the child lethargic or unconscious?

9
How sick is this child?
10
Management of a child with general danger signs

• Requires urgent attention
• Complete the assessment
• Start pre-referral treatment
• If lethargy or unconsciousness -
• Give oxygen
• Test for low blood sugar then treat/prevent

11
Give oxygento all children with 1. severe
pneumonia (with or without wheeze)2. convulsions
or 3. loss of consciousness
Use nasal prongs at 2 litres per minute
Reproduced with kind permission of Ms. Thandiwe
Conjwa
12
Treat hypoglycaemia

• Is defined as lt 3 mmol/L in a child and
• lt2.5 mmol/L in a young infant
• Treat with 5 mls/kg of 10 dextrose solution by
  nasogastric tube or intravenous line
• Keep the child warm
• Refer immediately

13
Then ask about main symptoms

• Does the child have cough or difficulty
  breathing?
• Does the child have diarrhoea?
• Does the child have fever?
• Does the child have an ear problem?
• Then check for malnutrition and anaemia
• Consider HIV status and symptoms

14
Does the child have cough or difficulty breathing?
15
If the child has a cough

• ASK
• for how long?
• LOOK, LISTEN, FEEL
• Count the breaths in one minute
• Look for chest indrawing
• Look and listen for stridor or wheeze

16
Classify cough

• SEVERE PNEUMONIA/VERY SEVERE DISEASE
• Any general danger sign
• Chest indrawing
• Stridor in a calm child
• PNEUMONA
• Fast breathing
• COUGH OR COLD
• No signs of pneumonia or very severe disease

17
Treatment of severe pneumonia

• First dose Ceftriaxone IM
• First dose Co-trimoxazole
• Give oxygen
• If stridor give nebulised adrenalin
• Test for low blood sugar, then treat/prevent
• Keep child warm
• Refer URGENTLY

18
Treatment of pneumonia

• Give amoxycillin for 5 days
• If HIV-infected or exposed also give
• co-trimoxazole
• Soothe the throat and relieve the cough
• If coughing for more than 2 weeks, do a
  tuberculin test and refer for possible TB or
  asthma
• Advise mother when to return immediately
• Follow-up in 2 days

19
Treatment of cough or cold

• Soothe the throat and relieve the cough
• If coughing for more than 2 weeks, do a
  tuberculin test and refer for possible TB or
  asthma
• Advise mother when to return immediately
• Follow-up in 5 days if not improving

20
Soothe the throat,relieve the cough with a safe
remedy

• Safe remedies to encourage-
• Breast milk
• Warm water or weak tea add sugar or honey and
  lemon if available
• Harmful remedies to discourage-
• Herbal smoke inhalation
• Vicks drops by mouth
• Any mixture containing vinegar

21
Is the child wheezing?
22
If the child is wheezing

• ASK
• Has the child had a wheeze before this illness
• Does the child frequently cough at night?
• Has the child had a wheeze for more than 7 days?
• Is the child on treatment for asthma at present?

23
Classify wheeze

• RECURRENT WHEEZE
• Yes to any question
• WHEEZE (FIRST EPISODE)
• All other children with wheeze

24
Treat wheeze

• Recurrent wheeze-
• Give salbutamol via spacer for 5 days
• Give oral prednisone for 3 days
• Refer non-urgently for assessment
• First episode wheeze-
• Give salbutamol via spacer for 5 days
• Follow-up in 5 days if still wheezing

25
Give salbutamol for wheeze

• Give salbutamol with a spacer
• Teach mother how to use it
• Can use 500 ml plastic cold drink bottle
• MDI 100 ug per puff ? 4 to 8 puffs using a
  spacer , allow 4 breaths per puff, repeat 3 to 6
  times a day as required
• Nebulised salbutamol ? dilute 1 ml in 3 ml saline
  can repeat every 20 to 30 minutes in first hour

26
Does the child have diarrhoea?
27
If the child has diarrhoea

• ASK
• For how long?
• Is there blood in the stool?
• How much and what fluid is the mother giving?

28
The child with diarrhoea

• LOOK OR FEEL
• General condition
• Lethargic or unconscious?
• Restless and irritable?
• Look for sunken eyes?
• Offer the child fluid
• Able to drink? Drinking poorly? Eagerly?

29
The child with diarrhoea

• Pinch the skin of the abdomen
• Does it go back
• Slowly?
• Or very slowly? (more than 2 seconds)

30
Now classify diarrhoea

• SEVERE DEHYDRATION
• Lethargic/unconscious
• Sunken eyes
• Unable to drink/drinking poorly
• Skin pinch goes back very slowly
• SOME DEHYDRATION
• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
• NO VISIBLE DEHYDRATION
• Not enough signs

31
Treat severe dehydration quickly
32
Principles of management
33
Intravenous fluids

• Start IV fluid immediately
• Weigh the child or estimate the weight
• Give Ringers lactate solution (or normal saline)
• 20 mls/kg before referral
• Repeat this amount up to twice if the radial
  pulse is weak or not detectable

34
Nasogastric tube rehydration

• Start rehydration with ORS solution
• Give 20 mls/kg each hour for 6 hours
• Refer urgently for further management
• Re-assess the child every 1 2 hours while
  awaiting transfer
• If there is repeated vomiting give the fluid more
  slowly
• If there is abdominal distention STOP fluids and
  refer urgently

35
Treat child with some dehydration

• Give oral fluids
• Advise mother to continue breastfeeding and
  feeding
• Give zinc for two weeks
• Advise the mother when to return immediately

36
Treat child with some dehydration

• Oral rehydration solution
• 1 litre boiled water
• 8 level teaspoons sugar
• Half a level teaspoon salt
• 20 mls/kg/hour for four hours
• Give frequent small sips from a cup
• If child vomits, wait 10 minutes, then continue

37
If the diarrhoea is 14 days or more

• CLASSIFY -
• SEVERE PERSISTENT DIARRHOEA
• Dehydration present
• PERSISTENT DIARRHOEA
• No visible dehydration

38
Treat persistent diarrhoea

• Give additional dose vitamin A
• Give zinc for 2 weeks
• Follow-up in 5 days
• Advise the mother when to return immediately

39
And if theres blood in the stool

• CLASSIFY
• SEVERE DYSENTERY
• Dehydration present
• Age less than 12 months
• DYSENTERY
• No dehydration
• Age 12 months or more

40
Treat dysentery

• Treat for five days with CIPROFLOXACIN
• Give 12 hourly for 5 days and finish course
• 250mg/5 ml
• 7 - lt 15 kg 1 ml per dose
• 15 - lt 20 kg 3 mls per dose
• Advise when to return immediately
• Follow-up in 2 days

41
Does the child have fever?
42
Always classify fever
43
The child has fever

• Decide the childs malaria risk
• Lives in malaria zone
• Visited a malaria zone in the past 4 weeks
• Ask about the fever
• For how long?
• Look and feel for
• Stiff neck
• Bulging fontanelle

44
Classify the fever

• SUSPECTED MENINGITIS
• Any general danger sign
• Stiff neck or bulging fontanelle
• FEVER OTHER CAUSE
• None of the above signs

45
Treat suspected meningitis

• Give first dose ceftriaxone IM
• Test for low blood sugar, then treat or prevent
• Give one dose paracetamol for fever gt 38C
• Refer URGENTLY

46
Treat fever of other cause

• Give paracetamol for high fever
• Treat for other causes
• Advise mother when to return immediately
• If fever has been present daily for more that 7
  days, refer
• Follow-up in 2 days if fever persists

47
If MALARIA risk

• SEVERE SUSPECTED MALARIA
• General danger sign
• Stiff neck or bulging fontanelle
• Malaria test any result or not done
• MALARIA
• Malaria test positive
• SUSPECTED MALARIA
• Malaria test not done and
• Severe pneumonia or pneumonia
• No other adequate cause of fever found

48
Treat suspected severe malaria

• Treat for malaria
• Treat for suspected meningitis
• Test for low blood sugar, then treat or prevent
• Give one dose of paracetamol for high fever
• Refer URGENTLY

49
Treat Malaria

• In all provinces use combination therapy
• Record and notify
• In KwaZulu-Natal and Limpopo province use
• Artemether Lumefantrine (Co-Artemether)
• Give one tablet and repeat dose after 8 hours
• 10 15 kg ? 1 tablet bd on days 2 and 3
• 15 25 kg ? 2 tablets bd on days 2 and 3
• Give Co-artemether with food

50
Also consider measles
51
Does the child have an ear problem?

• MASTOIDITIS
• Tender swelling behind the ear
• ACUTE EAR INFECTION
• Ear pain
• Pus draining from the ear or discharge lt 14 days
• CHRONIC EAR INFECTION
• Pus draining from the ear and discharge gt 14 days
• NO EAR INFECTION
• No ear pain and no pus draining from the ear

52
Treat mastoiditis

• Give ceftriaxone IM
• Give first dose of paracetamol
• Refer URGENTLY

53
Treat acute ear infection

• Give amoxycillin for 5 days
• If ear discharge teach mom dry wicking
• Give paracetamol for pain
• Follow-up in 5 days if pain or discharge persists
• Follow-up in 14 days

54
Treat chronic ear infection

• Teach mom to clean by dry wicking
• Instil ofloxacin ear drops twice daily for
• 4 weeks
• Tell the mother to come back if she suspects
  hearing loss
• Follow-up in 14 days

55
Check for malnutrition
56
Classify nutritonal status

• SEVERE MALNUTRITION
• Very low weight
• Visible severe wasting
• Oedema of both feet
• NOT GROWING WELL
• Low weight
• Weight gain unsatisfactory
• GROWING WELL
• Not low weight and/or
• Weight gain satisfactory

57
Treat severe malnutrition

• Give additional dose vitamin A
• Test for low blood sugar, then treat or prevent
• Refer URGENTLY
• Keep the child warm

58
Treat the child not growing well

• Assess feeding and counsel
• Treat for worms if due
• Advise when to return immediately
• Follow vitamin A schedule
• If close TB contact, manage accordingly
• Follow up in 14 days

59
Check for anaemia
60
Classify all children for anaemia

• SEVERE ANAEMIA
• Severe palmar pallor or
• Hb lt 6.0 g/dl
• ANAEMIA
• Some palmar pallor
• Hb 6 up to 10.0 g/dl
• NO ANAEMIA
• No pallor

61
Treat anaemia

• Give iron and counsel on iron rich diet -
• Give 3 doses daily for 2 months
• 2 mg/kg/dose elemental iron
• Give with food
• Assess feeding and counsel
• Treat for worms if due
• Follow-up in 14 days

62
Consider HIV status
63
Classify for symptomatic HIV infection

• SUSPECTED SYMPTOMATIC HIV IF THREE OR MORE OF THE
  FOLLOWING
• Pneumonia now?
• Ear discharge, ever?
• Low weight for age?
• Unsatsifactory weight gain?
• Persistent diarrhoea?
• Enlarged lymph glands?
• Oral thrush?
• Parotid enlargement?
• Hepatomegaly?

64
Manage suspected symptomatic HIV

• Offer PCR testing for the child
• Start co-trimoxazole prophylaxis
• Also give amoxycillin if classified as pneumonia
• Treat for oral thrush
• Counsel the mother
• Refer for ART assessment where indicated
• Follow-up in 14 days

65
Treat for thrush with nystatin

• Clean the mouth
• Nystatin 1 ml qid for 7 days, after feeding
• If breastfed, check mothers breasts for thrush
• Advise mother to wash breasts after feeds
• If bottle fed, change to cup
• Give paracetamol if needed

66
Take home message

• General danger signs
• Cough or difficulty breathing
• Wheezing
• Diarrhoea
• Fever
• Ear problem
• Malnutrition
• Anaemia
• HIV infection

67
(No Transcript)