IMCI Workshop

• IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

• IMCI is a strategy for reducing mortality and morbidity associated with major causes of childhood illness.

• IMCI was initiated jointly in 1992 by DOH, WHO and UNICEF.

• IMCI has already been introduced in more than 75 countries around the world.

IMCI

IMCI

• Primarily, there are two objectives of IMCI:1. To significantly reduce global mortality and morbidity associated with the major causes of disease in children2. To contribute a healthy growth and development of children.

IMCI

•Three major components of IMCI:

1. Improving case managementskills of healthworkers

IMCI

2. Improving the health system to deliver IMCI

IMCI

3. Improving family and community health practices

Case Management Process

I. Assess the child or young infantII. Classify the illnessIII. Identify the treatmentIV. Treat the child/ReferV. Counsel the motherVI. Give follow-up care


I. Assess the child or young infant• “Assess the child” means

taking a history and doing physical examination.

Case Management Process II. Classify the illness• “Classify the Illness” means taking a decision on the

severity of the illness• Classifications are not specific disease diagnoses.

Instead, they are categories that are used to determine treatment

• For effectively manage childhood illness, a color-coded system has been utilized which represents:

green yellow pink


Color Presentation Classification of Disease Level of Management

Green Mild Home Care

Yellow Moderate Management at the RHU

Pink Severe Urgent Referral

II. Classify the illness


III. Identify Treatment• The chart recommends appropriate treatment

for each classification• When using this process, selecting a

classification on the chart is sufficient to allow you to “identify treatment”


IV. Treat the child• “Treat the child” means giving treatment in

the health center• prescribing drugs or other treatments to be

given at home• teaching the mother how to carry out the

treatments.


V. Counsel the mother• “Counsel the mother” includes assessing how

the child is fed • telling the mother about the foods and fluids

to give the child • Telling the mother when to bring the child

back to the health center.


VI. Give follow-up care• Specific instructions for

conducting each follow-up visit

THE INTEGRATED CASE MANAGEMENT PROCESS

OUT-PATIENT HEALTH FACILITY

Check for GENERAL DANGER SIGNS•Convulsions (during this illness)•Lethargy/unconsciousness•Inability to drink or breastfeed•Vomiting

Assess MAIN SYMPTOMS•Coughing/difficulty of breathing•Diarrhea•Fever•Ear Problems

Assess NUTRITION AND IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS

CLASSIFY CONDITION AND IDENTIFY TREATMENT ACTIONS According to color-coded treatment

Urgent Referral OUT-PATIENT HEALTH FACILITYPre-referral treatmentAdvise parentsRefer child

REFERRAL FACILITY•Emergency Triage and treatment (ETAT)•Diagnosis•Treatment•Monitoring and Follow-up

Treatment at Out-PatientOUT-PATIENT HEALTH FACILITY•Treat local infection•Give oral drugs•Advise and teach caretakers•Follow-up

Home Management

HOMECaretaker is counseled on:•Refer child•Home treatments•Feeding and fluids•When to return immediately•Follow-up

Case Management Process Assess and Classify

Steps:1. ASK THE MOTHER WHAT’S THE CHILD PROBLEMS

AREa. Greet the mother appropriately and ask her to sit with her childb. Using good communication skills, ask the mother what the child’s problems are and record them on the Recording Formc. Determine if this is an initial visit or follow up visit.


2. CHECK FOR GENERAL DANGER SIGNS

a. The child is not able to drink or breastfeed b. The child vomits everything

c. The child has had convulsion (during this illness)

d. The child is abnormally sleepy or difficult to awaken


Exercises: Case 1Mutya is 15 months old. She weighs 8.5 kg. Her temperature is 35.5°C.The health worker asked, “What are the child’s problems?” The mother

said, “Mutya has been coughing for 4 days, and she is not eating well.”This is Mutya’s initial visit for this problem.

The health worker checked Mutya for general danger signs. He asked, “Is Mutya able to drink or Breastfeed?” The mother said “No. Mutya does not want to breastfeed.” The health worker gave Mutya some water. She was too weak to lift her head. She was not able to drink from a cup.

Next, he asked the mother, “Is she vomiting?” The mother said “No.” Then he asked, “Has she had convulsions?” The mother said “No.”

The health worker looked to see if Mutya was abnormally sleepy or difficult to awaken . When the health worker and the mother were talking, Mutya watched them and looked around the room. She was not abnormally sleepy or difficult to awaken.


Answer the following:a. Write Mutya’s name, age, weight, and temperature

in the spaces provided on top of the line form.b. Write Mutya’s problem on the line after the

question “Ask: What are the child’s problems?”c. Tick (√) whether this is the initial or follow-up visit.d. Does Mutya have general danger signs? If yes,

circle the signs on the Recording Form. Then tick(√) “yes” or “no” after the question, “General danger signs present?”


MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARSChild’s Name:_____Age:_____ Weight______kg. Temperature_______ASK:What are the child’s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify

CHECK FOR DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKENVOMITS EVERYTHINGCONVULSIONS

General DangerSigns Present?YES___NO___





General DangerSigns Present?YES_√__NO___


Case 2:

Nilo is 4 years old. He weighs 10 kg. His temperature is 38 °C.The health worker asked about the child’s problems. Nilo’s parents

said, “he is coughing and has ear pain. This is the initial visit for this problem.

The health worker asked, “Is your child able to drink?” The parents answered, “Yes.’ Does Nilo vomit everything?” he asked. The parent said “No.” The health worker asked, “Has he had convulsions?” they said “No.” The health worker looked at Nilo, the child was not abnormally sleepy or difficult to awaken.


Answer the following:a. Write Nilo’s name, age, weight, and temperature in

the spaces provided on top of the line form.b. Write Nilo’s problem on the line after the question

“Ask: What are the child’s problems?”c. Tick whether this is the initial or follow-up visit.d. Does Nilo have general danger signs? If yes, circle

the signs on the Recording Form. Then tick “yes” or “no” after the question, “General danger signs present?”





General DangerSigns Present?YES___NO__√_


Cough or Difficult Breathing

3. ASSESS AND CLASSIFY COUGH OR DIFFICULT BREATHING

• A child with cough or difficult breathing may have pneumonia or another severe respiratory infection

• Pneumonia is an infection of the lungs. Both bacteria and viruses can cause pneumonia

• In developing countries, pneumonia is often due to bacteria. The most common is Streptococcus pnuemoniae.



3.1 Assess cough and difficult breathingA child with cough or difficult breathing is assessed for:a. How long the child has had cough or difficult breathingb. Fast breathing-consider fast breathing if:2mos-12mos. - 50 breaths/min. or more12mos.-5yrs. - 40 breaths/min. or morec. Chest indrawingd. Stridor in calm child



3.2 Classify Cough or difficult breathing•Any general danger signs or•Chest indrawing or•Stridor in calm child

SEVERE PNEUMONIA ORVERY SEVERE DISEASE

• Fast breathing PNEUMONIA

•No sign of pneumonia or very severe disease

NO PNEUMONIACOUGH OR COLD



Exercises: Case 1Lupita is 8 months old. She weighs 6kg. Her temperature is 39°C. Her

father told the worker, “Lupita has had cough for 3 days. She is having trouble breathing. She is very weak.” The health worker said, “You have done the right thing to bring your child today. I will examine her now.”

The health worker checked for general danger signs. The mother said, “Lupita will not breastfeed. She will not take any other drinks I offer her.” Lupita does not vomit everything and not had convulsions. Lupita is abnormally sleepy. She did not look at the health worker or her parents when they talked.

The health worker counted 55 breaths/min. He saw chest indrawing. He decided Lupita had stridor because he heard a harsh noise when she breathed in.



MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARSChild’s Name:________________Age:_____ Weight______kg. Temperature_______ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify



General DangerSigns Present?YES___NO___

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES____ NO____

•For how long? ______days •Count the breaths in one minute ____breaths per minute. Fast breathing?

•Look for chest indrawing•Look and listen for stridor






General DangerSigns Present?YES_√__NO___

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES__√__ NO____

•For how long? ____3__days •Count the breaths in one minute __55__breaths per minute. Fast breathing?

•Look for chest indrawing

•Look and listen for stridor

Severe Pneumonia or Very Severe Disease



Case 2Bayani is 6months old. He weighs 5.5kg. His temperature is 38°C. His

mother said he has had cough for 2 days. The health worker checked for general danger signs. The mother said that

Bayani is able to breastfeed . He has not vomited during this illness. He has not had convulsions. Bayani is not abnormally sleepy or difficult to awaken.

The health worker said to the mother, “I want to check Bayani’s cough. You said he has had cough for 2 days now. I am going to count his breathes. He will need to remain calm while I do this.”

The health worker counted 58 breathes/min. He did not see chest indrawing. He did not hear stridor.







DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES_√___ NO____

•For how long? ___2___days •Count the breaths in one minute __58__breaths per minute. Fast breathing?


Pneumonia


Diarrhea4. ASSESS AND CLASSIFY DIARRHEA• Diarrhea occurs when stools contain more

water than normal.• Defined as 3 or more loose or watery stools in

a 24-hour period• It is common in babies under 6months who

are drinking cow’s milk or infant feeding formulas


Diarrhea4.1 Assess DiarrheaA child with diarrhea is assessed fora. How long the child has diarrheab. Blood in the stool to determine if the child

has dysenteryc. Signs of dehydration


DiarrheaASK: For how long?To determine the type of diarrhea• Acute Diarrhea- diarrhea lasts for less than 14

days• Persistent Diarrhea- diarrhea last for 14 days

or more


DiarrheaASK: Is there blood in the stool?• Diarrhea with blood in the stool, with or

without mucus is called dysentery• The most common cause of dysentery is

Shigella bacteria


DiarrheaCheck for signs of dehydration• Restless and irritable• Abnormally sleepy or difficult to awaken• Sunken eyes• Child is not able to drink or drinking poorly or

drinking eagerly , thirsty• Pinch the skin of the abdomen. Does it goes

back: Very slowly(longer than 2 seconds); Slowly


Diarrhea4.2 Classify Diarrhea• There are three classification tables for

classifying diarrhea:All children with diarrhea are classified for

dehydrationIf the child has had diarrhea for 14 days or

more, classify the child for persistent diarrheaIf the child has blood in the stool, classify the

child for dysentery.


Diarrhea

4.2 Classify Diarrhea4.2.1 Classify Dehydration

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

SEVERE DEHYDRATION

Two of the following signs•Restless, irritable•Sunken eyes•Drinks eagerly, thirsty•Skin pinch goes back slowly

SOME DEHYDRATION

•Not enough signs to classify as some or severe dehydration

NO DEHYDRATION


Diarrhea Case 1: Joel

Joel has had diarrhea for five days. He has no blood in the stool. He is irritable. His eyes is sunken. His father and mother also think that Joel’s eyes are sunken. The health worker offers Joel some water, and the child drinks eagerly. When the health worker pinches the skin on the child’s abdomen, it goes back slowly.


Diarrhea • Record Joel’s signs of dehydration and classify

DOES THE CHILD HAVE DIARRHEA YES____ NO____•For how long?______days •Look at the child’s general condition. •Is there blood in the stool? Is the child:

Abnormally sleepy or difficult to awaken Restless and irritable? •Look for sunken eyes •Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? •Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly?


Diarrhea • Record Joel’s signs of dehydration and classify

DOES THE CHILD HAVE DIARRHEA YES__√_ NO____•For how long?___5___days •Look at the child’s general condition. •Is there blood in the stool? Is the child:


Some Dehydration


Diarrhea 4.2 Classify Diarrhea

4.2.2 Classify Persistent Diarrhea

• Dehydration present SEVERE PERSISTENT DIARRHEA

•No dehydration PERSISTENT DIARRHEA


Diarrhea Case 2: Farida

Farida is 14 months old. She weighs 12 kg. Her temperature is 37.5°C. Farida’s mother said the child has had diarrhea for 3 weeks.

Farida does not have any general danger signs. She does not have cough or difficult breathing.

The health worker assessed her diarrhea. He noted she has had diarrhea for 21 days. He asked if there had been blood in the stool. The mother said, “No.” The health worker checked Farida for signs of dehydration. The child is irritable throughout the visit. Her eyes are not sunken. The skin pinch goesback immediately.


Diarrhea • Record Farida’s signs of and classify Persistent Diarrhea

DOES THE CHILD HAVE DIARRHEA YES__√__ NO____•For how long?___21___days •Look at the child’s general condition. •Is there blood in the stool? Is the child:


Persistent Diarrhea


Diarrhea 4.2 Classify Diarrhea

4.2.3 Classify Dysentery

• Blood in the stool DYSENTERY


Diarrhea Case 3: Carlo

Carlo is 10 months old He weighs 8 kg. Her temperature is 38.5 °C. He is here today because he has had diarrhea for 3 days.

Carlo does not have any general danger signs. He does not have cough or difficult breathing.

The health worker assesses the child for diarrhea. “You said Carlo has had blood in the stool. I will checked for signs of dehydration.” The child is not abnormally sleepy or difficult to awaken. He is not restless nor irritable. He does not have a sunken eyes. The child drank normally when offered some water and does not seem thirsty. The skin pinch goes back immediately.


Diarrhea • Record Carlo’s signs and classify

DOES THE CHILD HAVE DIARRHEA YES__√__ NO____•For how long?____3__days

•Look at the child’s general condition. •Is there blood in the stool? Is the child:


Dysentery


Fever

• A child with fever may have malaria, measles, Dengue Hemorrhagic Fever(DHF) or another severe disease. Or a child with fever may have a simple cough or cold or another viral infection.


Fever

A. Malaria• Malaria is caused by parasites in the blood

called “plasmodia”• They are transmitted through the bite of

anopheles mosquitoes.• Four species of plasmodia can cause malaria,

but the only dangerous one is Plasmodium Falciparum


Fever

• Fever is the main symptom of malaria• Other signs of falciparum malaria are

shivering, sweating, and vomiting.• In most areas in the Philippines where there is

malaria transmission, malaria is a significant cause of death of children.


Fever

• Deciding Malaria Risk (Category of Provinces)Category A- Provinces with no significant

improvement in malaria situation in the last 10 years or situatione worsened in the last 5 years, average number of cases of more than 1,000 in the last 10 years.


FeverCategory A

Kalinga Davao del Norte ApayaoDavao del Sur Mt. Province Davao OrientalIfugao Bukidnon IsabelaCompostela Valley Cagayan SarangganiQuirino Zamboanga del Sur ZambalesAgusan del Norte Agusan del Sur Mindoro OccidentalPalawan Tawi-tawi QuezonSulu Misamis Oriental Basilan


Fever

Category B- Provinces where situation has improved in the last 5 years or average number of cases of 100-1,000 per year.


FeverCategory B

Abra Laguna PangasinanCamarines Norte Ilocos Norte Camarines SurNueva Ecija Sultan Kudarat BulacanNorth Cotabato Bataan Lanao del SurMindoro Oriental Maguindanao RizalZamboanga del Norte Tarlac Romblon


Fever

Category C-Provinces with significant reduction in cases in the last 5 yearsAlbay Batanes BenguetAntique Ilocos Sur SorsogonLa Union Negros Oriental PampangaNegros Occidental Batangas Eastern SamarCavite Western Samar MarinduqueMisamis Occidental Masbate Surigao del Norte


Fever

Category D- Provinces that are malaria free although are still potentially malarious due to presence of vector.Cebu Bohol CatanduanesAklan Capiz GuimarasSiquijor Biliran LeyteNorthern Samar Camiguin


Fever

B. Measles• Measles is highly infectious caused by virus• It infects the skin and the layer of cells that

line the lungs, eyes, mouth and throat.• Fever and generalized rash are the main signs

of measles• Most cases occur in children between 6

months and 2 years.


Fever

C. Dengue Hemorrhagic Fever(DHF)• DHF is caused by virus that is spread by Aedes mosquitoes• Children with DHF have fever which may last for 2 to 7

days• The disease causes damage to the blood and blood vessels

which may lead to bleeding. This bleeding may occur in the skin , where petechiea are seen, or inside the body.

• The most severe signs of DHF often occur in the 2 days after the fever has disappeared


Fever

5.1 ASSESS FEVER• Ask: Does the child have fever?(by history, or feels

hot or Temperature is 37°C or above)a. Decide Malaria RiskAsk: Does the child live in a malaria area Has the child visited or stayed overnight in a

malaria area in the past 4 weeks.If Yes to either, obtain a blood smear


FeverTHEN ASK: LOOK AND FEEL• For how long has the child had •Look or feel stiff neck fever? •Look for runny nose• If more than 7 days, has the fever been present everyday?• Has the child had measles within •Look for signs of MEASLES: the last 3 months - Generalized rash and

-One of these: cough, runny nose, or red eyes


Fever

If the child has measles •Look for mouth ulcersNow or within last -Are they deep and extensive3 months •Look for pus draining from the

eyes•Look for clouding of the cornea


FeverAssess Dengue Hemorrhagic FeverASK: LOOK AND FEEL• Has the child had any bleeding •Look for bleeding from the nose or gums

from the nose or gums, or in the •Look for skin petechiaevomitus or stools? •Feel for cold and clammy extremities

• Has the child has black vomitus? •Check for slow capillary refill• Has the child had black stools? •Perform for the torniquet test• Has the child has persistent

abdominal pain?• Has the child has persistent vomiting?


Fever

5.2 CLASSIFY FEVER• There are 2 classification tables on the ASSESS

AND CLASSIFY CHART:1. Malaria Risk2. No Malaria Risk• To classify fever, you must know if there is

malaria risk or not. Then select the appropriate classification table.


Fever(Malaria)• Malaria Risk

•Any general danger sign or•Stiff neck

VERY SEVERE FEBRILE DISEASE/ MALARIA

•Blood smear (+)If blood smear not done:•NO runny nose and•NO measles and•NO other cause of fever

MALARIA

•Blood smear(₋) OR•Runny nose OR•Measles OR•Other causes of fever

FEVER:MALARIA UNLIKELY


Fever(Malaria)

Example:A 2 year old-boy is brought to the health center because he has felt hot for 2 days. There is Malaria risk. He does not have general danger signs. He does not have cough or difficult breathing or diarrhea. A blood smear was done with negative result. The child observed to have runny nose. When the health worker assessed the child’s fever, he recorded this signs.


Fever(Malaria)

•DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.37.5°C or above YES_√_NO____

Decide MALARIA risk:•Does the child live in malaria area? LOOK AND FEEL:•Has the visited or stayed overnight •Look and feel for stiff neck in a malaria area for the past 4 weeks? •Look for runny noseIf Malaria risk, obtain a blood smear:(+) (Pf) (Pv) (-) NOT DONETHEN ASK: Look for signs of MEASLES•For how long has the child has fever?__2__days. •Generalized rash and•If more than 7 days, has fever been present everyday? •One of these: cough, runny nose•Has the child had measles with the last 3 months? Or red eyes.

Fever:MalariaUnlikely


Fever(Malaria)

• No Malaria Risk

•Any general danger sign or•Stiff neck

VERY SEVERE FEBRILE DISEASE

•No signs of severe febrile disease

FEVER:NO MALARIA


Fever(Malaria)

• Very Febrile Disease:-presence of Danger Signs/Stiff neck-Needs URGENT REFERRAL

• Fever: No Malaria1. Severe Pneumonia or Very Severe Disease2. Pneumonia3. No Pnuemonia: Cough or cold4. Dysentery5. Severe complicated Measles6. Measles7. Severe DHF8. Abscess9. Typhoid Fever10. Infected wounds


Measles

5.3 CLASSIFY MEASLES•Any general danger sign or•Clouding of the cornea or•Deep or extensive mouth ulcers

SEVERE COMPLICATED MEASLES

•Pus draining from the eye or•Mouth ulcers

MEASLES WITH EYE AND MOUTH COMPLICATIONS

•Measles now or within the last 3 months

MEASLES


Dengue Hemorrhagic Fever5.4 Classify Dengue Hemorrhagic Fever

•Bleeding from nose or gums •Bleeding in stools or vomitus •Skin petechiae•Cold and clammy extremities•Capillary refill more than 3 seconds•Persistent abdominal pain•Persistent vomiting•Torniquet test positive

SEVERE DENGUE HEMORRHAGIC FEVER

•No signs of severe dengue hemorrhagic fever

FEVER: DENGUE HEMORRHAGIC FEVER

UNLIKELY


FeverExample: Case of Fidel

Fidel is 10 months old. He weighs 8.2 kg. His temperature is 37.5°C. His mother says he has a rash and cough.

The health worker checked Fidel for general danger signs. Fidel was able to drink. Was not vomiting, and was not abnormally sleepy or difficult to awaken.

The health worker asked about Fidel’s cough. The mother said Fidel had been coughing for 5 days. He counted 43 breaths per minute. He did not see chest indrawing. He did not hear stridor when Fidel was calm.

Fidel did not have diarrhea.Next, The health worker asked about Fidel’s fever. There is Malaria risk. The mother said Fidel

has felt hot for 2 days. Fidel did not have a stiff neck. He had a runny nose with this illness. The health worker did not have the facilities for examination of a blood smear.

Fidel has rash covering his whole body. Fidel’s eyes were red. The health worker checked the child for complications of measles. There were no pus draining from the eye and no clouding of the cornea. There have been no cases of dengue in their area.


(Fidel’s Case)MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARSChild’s Name:________________Age:_____ Weight______kg. Temperature_______ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS




•For how long?__5_days •Count the breaths in one minute __43__breaths per minute. Fast breathing?


•No Pneumonia•Cough or cold


(Fidel’s Case)

DOES THE CHILD HAVE DIARRHEA YES____ NO__√__•For how long?______days •Look at the child’s general condition. •Is there blood in the stool? Is the child:



(Fidel’s Case)



Fever:MalariaUnlikely


(Fidel’s Case)

If the child has measles •Look for mouth ulcersnow or within last If yes, are they deep 3months and extensive?

•Look for pus draining from the eye •Look for clouding of

the cornea

Measles


(Fidel’s Case)

Assess Dengue Hemorrhagic FeverASK: LOOK AND FEEL•Has the child had any bleeding •Look for bleeding from from the nose or gums or in the nose or gums vomitus or stool? •Look for skin petechiea•Has the child has black vomitus •Feels for cold and clammy or black stool? extremities•Has the child had persistent •Check for capillary refill abdominal pain? •Perform torniquet test•Has the child had persistent vomiting?


Fever

Exercises: Case of NestorNestor is 5 months old. He weighs 5.2 kg. His axillary temperature is 37.5°C. His

mother said he is not eating well. She said he feels hot, and she want a health worker to help him.

Nestor is able to drink, has not vomited, does not have convulsions, and is not abnormally sleepy or difficult to awaken. Nestor does not have cough and diarrhea.

Because Nestor’s temperature is 37.5°C and feels hot, the health worker assessed Nestor further for signs related to fever. It is rainy season, and there is a risk of malaria. There is no dengue risk. The mother said Nestor’s fever began 2 days ago. He has not had measles within the last 3 months. He does not have stiff neck, his nose is Not runny, and there are no signs suggesting measles. The blood smear for malariawas positive.• Record’s Nestor sign’s and classify them in the recording form.


(Nestor’s Case)



Malaria


Ear Problem

6. ASSESS AND CLASSIFY EAR PROBLEM• A child with ear problem may have ear

infection• Sometimes the infection can spread from the

ear to the bone behind the ear (the mastoid) causing mastoiditis.

• Infection can also spread from the ear to the brain causing meningitis


Ear Problem

6.1 ASSESS EAR INFECTIONA child with ear problem is assessed for:

Ear painEar dischearge-if yes, how long?

- present for more than 2 weeks is treated as chronic ear infection-present for less than 2 weeks is treated as an acute ear infection

Tender swelling behind the ear, a sign of mastoiditis


Ear Problem 6.2 CLASSIFY EAR PROBLEM

•Tender swelling behind the ear

MASTOIDITIS

•Ear pain•Pus is seen draining from the ear, and discharge is reported for less than 14 days

ACUTE EAR INFECTION

•Pus is seen draining from the ear, and discharge is reported for 14 days or more

CHRONIC EAR INFECTION

•No ear pain and•No pus is seen draining from the ear

NO EAR INFECTION


Ear Problem

Case I:SallySally is 3 years old. She weighs 13 kg. Her temperature is 37.4°C. Her mother came to the health center today because Sally is sick for the last 2 days. She was crying last night and complained that her ear is hurting. The health worker checked and found no general danger signs. Sally does not have cough or difficult breathing. She does not have diarrhea and fever.Next the health worker asked about Sally’s ear problem. The mother said she is sure Sally has ear pain. The child cried most of the night because her ear hurts. There has been discharge coming from Sally’s ear on and off for about a year, said the mother. The health worker did not see any pus draining from the child’s ear. He felt behind the child’s ears and felt tender swelling behind one ear.


Ear Problem

• Record Sally’s sign of ear problem and classify them on the Recording form.

DOES THE CHILD HAVE AN EAR PROBLEM? YES__ NO__

•Is there ear pain? •Look for pus draining from the ear•Is there ear discharge? •Feel for tender swelling behind the earIf yes, for how long____days


Ear Problem

• Record Sally’s sign of ear problem and classify them on the Recording form.

DOES THE CHILD HAVE AN EAR PROBLEM? YES__√__ NO____

•Is there ear pain? •Look for pus draining from the ear •Feel for tender swelling behind the ear•Is there ear discharge? If yes, for how long? On and off about a year

Mastoiditis


Ear Problem

Case 2: SusanSusan is 18 months old. She weighs 9 kg. Her temperature is 37°C. Her

mother said Susan had discharge coming from ear for the last 3 days.Susan does not have any general danger signs. She does not have cough or

difficult breathing. She does not have diarrhea and fever.The health worker asked about Susan’s ear problem. The mother said that

Susan does not have ear pain, but the discharge has been coming from the ear for 3 or 4 days. The health worker saw pus draining from the child’s right ear. He did not feel any tender swelling behind the ear.


Ear Problem

• Record Susan’s sign of ear problem and classify them on the Recording form.

DOES THE CHILD HAVE AN EAR PROBLEM? YES__√__ NO____

•Is there ear pain? •Look for pus draining from the ear •Feel for tender swelling behind the ear•Is there ear discharge? If yes, for how long? _3 or 4 days

ACUTE EAR INFECTION


Malnutrition and Anemia7.0 CHECK FOR MALNUTRITION AND ANEMIA• One type of malnutrition is protein-energy malnutrition.

When the child has PEM:-The child may become severely wasted, a sign of marasmus-The child may develop edema, a sign of kwashiorkor-The child may not grow well and become stunted(too short)

• A child whose diet lacks recommended amounts of essential vitamins and minerals can develop malnutrition.

• Anemia is reduced number of red cells or a reduced amount of hemoglobin in each red cell.


Malnutrition and Anemia7.1 Assess Malnutrition and Anemia• Look for visible wasting

-A child with visible wasting has Marasmus, a form of severe malnutrition.-The child is very thin, has no fat, and looks like skin and bones-The face of the child with visible severe wasting may still look normal. The child’s abdomen may be large or distended


Malnutrition and Anemia


Malnutrition and Anemia• Look and feel for edema of both feet

-A child with edema of both feet may have Kwashiorkor, another form of severe malnutrition-Signs of kwashiorkor include thin, sparse and pale hair which easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or “moon” face.


Malnutrition and Anemia


Malnutrition and Anemia• Look for palmar pallor

-Pallor is unusual paleness of the skin. It is a sign of anemia

• Determine Weight for Age-Weight for age compares the child’s weight with the weight of other children who are of the same age


Malnutrition and Anemia7.2 Classify Nutritional Status

•Visible severe wasting or•Edema of both feet or•Severe palmar pallor

SEVERE MALNUTRITION OR SEVERE ANEMIA

•Some palmar pallor or•Very low weight for age

ANEMIA OR VERY LOW WEIGHT

•Not very low weight for age and no other signs of malnutrition

NO ANEMIA AND NOT VERY LOW WEIGHT


Malnutrition and Anemia Case 1: Ana

Ana is 18 months old. She weighs 7kg.Her temperature is 38.5°C. Her mother brought her today because the child has felt hot and has a rash. The health worker saw that Ana looks like skin and bones.

The health worker checked for general danger signs. Ana is able to drink, has not vomited, has not had convulsions, and is not abnormally sleepy or difficult to awaken.

She does not have cough or difficult breathing. She does not have diarrhea.Because Ana’s mother said the child felt hot, and because her temperature is

38.5°C, the health worker assessed her for fever. Ana lives where there is a malaria risk. She has had fever for 5 days. Her rash is generalized rash, and she has red eyes. She has measles. She does not have a stiff neck. She does not have a runny nose. Her blood smear was positive for Plasmodium vivax. There is no dengue risk in the area.

The health worker assessed her for signs of measles complications. Ana does not have mouth ulcers. There is no pus draining from the eye and no clouding of the cornea.

Ana does not have an ear problem. The health worker next checked her for malnutrition and anemia. Ana has visible wasting. There is no palmar pallor. She does not have edema on both feet. The health worker determined her weight for age.


Malnutrition and Anemia (Ana’s Case)



MALARIA


(Ana’s Case)

If the child has measles •Look for mouth ulcersnow or within last If yes, are they deep 3months and extensive?

•Look for pus draining from the eye •Look for clouding of

the cornea

Measles


(Ana’s Case)

CHECK FOR MALNUTRITION AND ANEMIA

•Look for visible severe wasting•Look for edema of both feet•Look for palmar pallor Severe palmar pallor? Some palmar pallor?•Determine weight for age Very low?

SEVERE MALNUTRITIONOR SEVERE ANEMIA


Malnutrition and AnemiaCase 2: David

David is 11 months old. He weighs 8kg. His temperature is 36.5°C. His mother says he has had a dry cough for the last 3 weeks.

David does not have any general danger signs. The health worker assessed his cough. It has been present for 21 days. He counted 41 breathes/min. The health worker does not see chest indrawing. There is no stridor when the child is calm.

David does not have diarrhea. He has not had a fever during this illness. He does not have an ear problem.

The health worker checked David for malnutrition and anemia. David does not have visible severe wasting. His palms are very pale and appear almost white. There is no edema of both feet. The health worker determined David weight for age.


(David’s Case)MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARSChild’s Name:________________Age:_____ Weight______kg. Temperature_______ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS




•For how long?__21 days •Count the breaths in one minute __41__breaths per minute. Fast breathing?


•No Pneumonia•Cough or cold


(Ana’s Case)

CHECK FOR MALNUTRITION AND ANEMIA

•Look for visible severe wasting•Look for edema of both feet•Look for palmar pallor Severe palmar pallor? Some palmar pallor?•Determine weight for age Very low?

SEVERE MALNUTRITIONOR SEVERE ANEMIA

Case Management Process Immunization Status

8.0 Check the Child’s Immunization status Age Vaccine

Birth BCG Hepa B-1 6 weeks DPT-1 OPV-1 Hepa B-2 10 weeks DPT-2 OPV-2 14 weeks DPT-3 OPV-3 Hepa B-3

9 months Measles


CHECK IMMUNIZATION STATUS OF THE FOLLOWING CHILDREN:1. Metro, 6 months old. No general danger signs. Classified as No Pneumonia: Cough or

Cold and No Anemia and Not Very Low Weight for Age.Immunization history: BCG, HEP B1 at birth; OPV1, DPT1,HEPB2; OPV2 and DPT2 given 6 weeks ago.

2. Victor, 3 months old. No general danger signs. Classified as Diarrhea with no Dehydration and also Anemia.Immunization history: BCG, OPV1, DPT1, and HEP B1 given 5 weeks ago. Victor has diarrhea.

3. Mark, 9 months old. No general danger signs. Classified as Pneumonia, Malaria. No Anemia and No Very Low WeightImmunization history: BCG, OPV1, DPT1 and HEP B1. When Mark was 7 months old, he received OPV2, DPT2 and HEP B2.


QUESTIONS Metro Victor Mark

1. Is the child up to date with his immunization?2. What immunizations, if any, does the child need today?

3. When should he return for his next immunization

Case Management Process Vitamin A Status

9.0 Check the Child’s Vitamin A Status

AGE 100,000 IU 200,000 IU6 months

Above 6 months to 59 months

1

1


• Use recommended Vitamin A schedule-All children at 6 months of age should receive 100,000IU of Vitamin A. They should then receive 200,000 IU of vitamin A every 6 months up to the age of 59 months

• Observe precautions in Vitamin A administration-To avoid over dosage of vitamin A supplementation, always ask two questions:

Is the child 6 months of age or older? If yes, has the child had a dose of Vitamin A supplementation in the past 6

months?• If the child is 6 months of age or older and has not had a dose of vitamin A

supplementation in the past 6 months, then give a single dose.• The child may develop vomiting, headaches, or nausea after taking vitamin

A. Reassure the mother that should this symptoms develop, they will disappear within 24 hours.


In this exercise you will determine whether the child needs Vitamin A supplementation or not. Make a check on the appropriate column.

You will give Vitamin A to a child:

1. Who is 36 months old, has no illness classification , not a very low weight and no anemia. The last dose of Vitamin A was 4 months ago

2. Who is 7 months old, has no pneumonia, and is up-to-date with immunization

3. Who is 10 months old, has had measles vaccination but no Vitamin A.

YES NO

Case Management Process Assess Other Problems

• The last box on the ASSESS side of the chart reminds you to assess other problems that the child may have.

• Since the ASSESS AND CLASSIFY chart does not address of a sick child’s problems, you will now assess other problems that the mother told you.

• For example, she may have said the child has a skin infection, itching, swollen neck glands.

• Identify and treat other problems according to your training, experience and health center policy.

• Refer the child for any problem you cannot manage in the health center.

Case Management Process Identify Treatment

1.0

Determine if urgent referral is needed

2.0 Identify patient who do not need urgent referralNO

3.0 Identify urgent pre- referral treatment needed

YES4.0 Give pre-referral treatment

5.0 Refer the child


1.0 DETERMINE IF URGENT REFERRAL IS NEEDEDa. Referral for severe classification• Look at the severe classifications on the ASSESS AND CLASSIFY

chart. These are colored pink and include:SEVERE PNEUMONIA OR VERY SEVERE DISEASESEVERE DEHYDRATIONSEVERE PERSISTENT DFIARRHEAVERY SEVERE FEBRILE DISEASE/MALARIASEVERE COMPLICATED MEASLESSEVERE DHFMASTOIDITISSEVERE MALNUTRITION OR SEVERE ANEMIA


b. Referral for the General Danger Signs• Most of children who have a general danger sign also

have a severe classification • They will be referred for their severe classificationc. Referral for Other Severe Problems• The ASSESS AND CLASSIFY chart does not include all

problems that children may have• For any other severe problem that cannot be treated

at the health center, you will need to refer the child.


2.0 IDENTIFY TREATMENTS WHO DO NOT NEED URGENT REFERRAL

• Look at the ASSESS AND CLASSIFY chart to find the treatments needed for each of the classification.

• List each treatment needed on the back of the Sick Child Recording Form.


3.0 IDENTIFY URGENT PRE-REFERRAL TREATMENT NEEDED

• When a child needs urgent referral, you must quickly identify and begin the most urgent treatments for the child.

• The following are urgent treatments. They are in bold print on the ASSESS AND CLASSIFY chart. You will give just the first dose of drugs before referral:


• Give an appropriate antibiotic:Give Quinine for SEVERE MALARIAGive Vitamin ATreat the child to prevent low blood sugar(This involves giving breastmilk, milk, or sugar water as described on the TREAT the child chart).Start IV fluids according to Plan C for the child for severe DHF with bleeding or cold clammy skin or capillary refill more than 3 secondsGive ORS according to Plan B for a child with SEVERE DHF severe with petechiae or a positive torniquet test or abdominal pain or vomiting but without cold clammy skin and with normal capillary refill.Give an oral antimalarialGive paracetamol for high fever(38.5°C or above) or pain from MASTOIDITISApply tetracycline eye ointment if there is clouding of the cornea and pus draining from eye.Provide ORS solution so that the mother can give frequent sips on the way yo the hospital


4.0 GIVE URGENT PRE-REFERRAL TREATMENTS • “How-to-do” treatments are presented on the TREAT chart.• When referring a child, do the treatment quickly.5.0 REFER THE CHILD• Do the 4 steps to refer a child to the hospital:1. Explain to the mother the need for referral2. Calm the mother’s fear s and help her resolve any problems3. Write a referral note for the mother to take with her to the

hospital4. Give the mother any supplies and instructions needed to

care for her child on the way to the hospital

Case Management Process Treat The Child

• Give an Appropriate Oral AntibioticFor Pneumonia

First –Line Antibiotic: AmoxicillinSecond-Line Antibiotic: Cotrimoxazole

For Diarrheal Diseases•Ciprofloxacin is the most appropriate drug in place of Nalidixic Acid •Giving Zinc supplements in the management of diarrhea


For Antimalarial:•First-Line Antibiotics: Artemeter-Lumefantrine

• Chronic ear infection should be treated with optical quinolone ear drops for at least 2 weeks in Addition to dry the ear by wicking

• Acute ear infection –Oral amoxicillin is a better choice for the management of suppurative otitis


• Treat Eye Infection with Tetracycline Eye Ointment• Treat Mouth Ulcers with Gentian VioletGive paracetamol for high fever or Ear PainHome Management:

-teach the mother how to give oral drugs at home-teach the mother how to treat local infections at home(eye infection with tetracycline ointment; mouth ulcers with gentian violet)


Treatment in the Health Center-IM antibiotics-Quinine for severe malaria-Immunization

Counsel the Mother

• “Counsel the mother” includes assessing how the child is fed and telling her about the foods and fluids to give the child and when to bring the child back to the health center.

Counsel the Mother

• Advise the mother to return immediately if the child has any of these signs:

Any sick child •Not able to drink or breastfeed•Becomes sicker•Develops a fever

If the child has no PNEUMONIA:COUGH OR COLD, also return if:

•Fast breathing

•Difficult breathing

If the child has diarrhea, also return if:

•Blood in stool•Drinking poorly

If the child has FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY, also return if:

•Any sign of bleeding•Persistent abdominal pain•Persistent vomoting•Skin petechiae,skin rash

Follow-Up VisitIf the child has: Return for follow up

PneumoniaDysenteryMalaria, if fever persistFever: Malaria unlikely, if fever persisitFever: No Malaria if fever persistMeasles with eye or mouth complicationsDHF Unlikely, if fever persist

2 days

Persistent DiarrheaAcute Ear InfectionChronic Ear InfectionFeeding ProblemsAny Other Illness if not improving

5 days

Anemia 14 days

Very Low Weight For Age 30 days

THANK YOU FOR LISTENING!!!

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