IMCI UPDATES

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Why Update? New knowledge on clinical management of childhood diseases are available Implementation of IMCI has identified problems and questions which were addressed by operational research Epidemiology of diseases has evolved thus a revised version has to accommodate and reflect these changes

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

Acute respiratory infection First-line/second line antibiotic for non-severe pneumoniaprevious First line Cotrimoxazole Second line Amoxicillin updated Amoxicillin Cotrimoxazole

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

ACUTE RESPIRATORY INFECTION

ACUTE RESPIRATORY INFECTIONTechnical basis: 3 days treatment is equally effective as the 5 day treatment Reduces cost of treatment Improves compliance Reduces antimicrobial resistance in the community

Acute Respiratory Infections Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia 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 daysTechnical basis:

Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia

Acute Respiratory Infections Gentamicin plus ampicillin vs chloramphenicol for very severe pneumonia Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol for very severe pneumonia in children 2-59 months of age. A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used

Acute Respiratory InfectionsInclusion of Wheeze For children with wheeze and fast breathing and/or lower chest wall indrawing Give a trial of rapid-acting inhaled bronchodilator (up to 3 cycles) before they are classified as pneumonia and prescribed antibiotics. 0.5 ml salbutamol diluted in 2.0 ml of sterile water per dose nebulization should be used

DIARRHEAL DISEASES Use of low osmolarity oral rehydration saltsTechnical basis: Efficacy of ORS solution for tx of acute non-cholera 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%

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

DIARRHEAL DISEASES Giving of Zinc supplements in the management of diarrhea Dose: 2 mos. up to 6 mos. - tab daily for 10-14 days6 mos. or more 1 tab daily for 10-14 days

Giving of multivitamins and minerals (with zinc) for 14 days is added in the treatment of persistent diarrhea

Technical basis: reduced duration and severity of diarrhea episode lowered incidence of diarrhea in the ff. 2-3 months

Fever First line antibiotic for Malaria (Artemetherlumefantrine) For children 1-3 yrs old Day 1 1 tablet after 8 hrs 1 tablet Day 2 1 tablet 2x a day Day 3 1/2 tablet 2x a day

Fever For children 4-8 yrs old Day 1 2 tablets after 8 hrs 2 tablets Day 2 2 tablets 2x a day Day 3 2 tablets 2x a day Day 4 Primaquine, -3/4 tablets for 14 days

Fever Treatment schedule for uncomplicated P. falcifarum malariaday 1-3 day 4 Artemether-Lumefantrine (Coartem) Primaquine, single dose only on day 4

Note: Primaquine is contraindicated in children < 1y.o.

Fever Treatment schedule for confirmed P. vivax casesDay 1-3 Day 4-17 Chloroquine for 3 days Primaquine for 14 days

Mixed P.falciparum and P. vivaxDay 1-3 Day 4-17 Artemether + lumefantrine Primaquine

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 Quinine sulfate(300 or 600 mg/tab) 10 mg/kg/dose every 8 hours for 7 days + Clindamycin 10 mg/kg 2x a day for 3 days

Fever Pre-referral treatment: Artesumate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow.

EAR INFECTIONSChronic ear infection Chronic ear infection should be treated with optical 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 cotrimixazole is high

Malnutrition and anemia MUAC (mid-upper arm circumference) less than 10 mm is now considered an indicator for severe malnutrition Use of the new WHO Growth Standards Inclusion of management of severely malnourished children where referral is not possible

Immunization ScheduleAge Birth 6 weeks 10 weeks 14 weeks 9 months Vaccine BCG, HepB1 DPT1, OPV1, HepB2 DPT2, OPV2 DPT3, OPV3, HepB3 Anti-measles

INFANT FEEDING

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 Only if the child is older than 4 mos. and appears hungry after breastfeeding and is not gaining weight adequately, add complementary foods. Give 1-2 tablespoons, 1-2 times per day after breastfeeding

Infant Feeding . . . 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 9-23 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

Infant Feeding . . . 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

Infant Feeding . . . 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

HELMINTH INFESTATIONS Helminth infestations in children below 24 months Albendazole and mebendazole can be safely used in children 12 months or older Give 500 mg Mebendazole or 400 mg Albendazole in single dose

Technical basis: Tanzania study: Mebendazole had a positive effect on motor and language development and compared with placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhea, dysentery and ARI) one week after intervention

Sick young infant aged up to 2 monthsPrevious 1 week up to Age: 2 months months Updated Birth up to 2

Main symptom: Previous: Possible serious bacterial infection Updated: Very severe disease and local bacterial infection

Sick young infant contd Signs to look for in assessment: Previous: 12 signs Updated: 7 signs

Sick young infant contd Classification: Previous:Very severe disease (pink) disease Local bacterial infection (yellow) Severe disease or local disease or bacterial infection unlikely (green)

Updated:Very severe Severe disease Severe local bacterial infection unlikely

Sick young infant contd Checking for jaundice is added in the protocol Classification: Severe jaundice (pink) Jaundice (yellow) No jaundice (green)

Acute Respiratory InfectionsTechnical basis: Multicentre randomized clinical study in 8 sites in 7 countries (N=958) 12.7% failed treatment by day 6 higher in Chloramphenicol group (RR of 1.5); common reasons were deaths (n=44), development of septic shock (n=29), or persistence of very severe pneumonia (n=21) Tx failure at 48 hours (8.6%), constituting 51% of all tx failure. Overall more deaths occurred at the chloramphenicol group than the ampicillin-gentamicin group by day 30. Based on these results the use of gentamicin plus ampocillin for the management of very severe pneumonia is warranted

Acute Respiratory InfectionsTechnical basis: WHO supported studies on The assessment & management of wheeze in children 1-59 months of age presenting with cough and /or difficult breathing in several countriesPakistan (n=1622)595 (36.7% w/ audible wheeze)

Thailand (n=521)48 (9.2% w/ audible wheeze)

number Non-severe pneumonia Severe pneumonia

Response

Subsequent deterioration

number

Response

Subsequent deterioration

1004(61.8%)

621(61.8%)

93(14.9%)

256(49.1%)

217(84