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INTEGRATED MANNER

PREVENTIVE INTERVENTION
EVIDENCE BASED SYNDROMIC
APPROACH
FAMILY AND COMMUNITY
INVOLVEMENT
 REDUCE DEATHS AND THE FREQUENCY AND
SEVERITY OF ILLNESS AND DISABILITY
 CONTRIBUTE TO IMPROVED GROWTH AND
DEVELOPMENT
 IMPROVE CASE MANAGEMENT SKILLS OF
HEALTH WORKERS
 IMPROVE HEALTH SYSTEM TO DELIVER IMCI
 IMPROVE FAMILY AND COMMUNITY HEALTH
PRACTICES
 Allsick children must be examined for “general
danger signs” which indicate the need for
immediate referral or admission to a hospital.
 All sick children must be routinely assessed for
major symptoms (for children age 2 months up to 5
years: cough or difficult breathing, diarrhea, fever,
ear problems; for young infants age 1 week up to 2
months: bacterial infection and diarrhea). They
must also be routinely assessed for nutritional and
immunization status, feeding problems, and other
potential problems.
 Only a limited number of carefully-selected
clinical signs are used, based on evidence of
their sensitivity and specificity 7 to detect
disease.Careful and systematic assessment of
common symptoms and well-selected specific
clinical signs provide sufficient information to
guide rational and effective actions.
 These signs were selected considering the
conditions and realities of first-level health
facilities.
 A combination of individual signs leads to a
child’s classification(s) rather than a diagnosis.
Classification(s) indicate the severity of
condition(s). They call for specific actions based
on whether the child (a) should be urgently
referred to another level of care, (b) requires
specific treatments (such as antibiotics or
antimalarial treatment), or (c) may be safely
managed at home. The classifications are colour
coded: “pink” suggests hospital referral or
admission, “yellow” indicates initiation of
treatment, and “green” calls for home treatment.
 The IMCI guidelines address most, but not all, of the
major reasons a sick child is brought to a clinic. A
child returning with chronic problems or less common
illnesses may require special care. The guidelines do
not describe the management of trauma or other
acute emergencies due to accidents or injuries.
 IMCI management procedures use a limited number
of essential drugs and encourage active participation
of caretakers in the treatment of children.
 An essential component of the
IMCI guidelines is the counseling
of caretakers about home
management, including
counseling about feeding, fluids
and when to return to a health
facility
OUTPATIENT HEALTH FACILITY REFERRAL HEALTH FACILITY

 Assessment;  Emergency triage


assessment and
 Classification and treatment (ETAT);
identification of  Diagnosis, treatment and
monitoring of patient
treatment progress. Appropriate
 Referral, home management
treatment or  Teaching the mother
Counseling the mother
counseling of the 

child’s caretaker
 Follow-up care
 Few health workers
opportunities to practice
complicated cases
 Reliance on History and S/S

 Overlap of conditions

 Minimal diagnostic tools

 Scarce drugs and equipment


 YOUNG INFANT: 1 WK TO 2 MOS
 OLDER CHILDREN: 2 MOS TO 5
Y/O
 Vomiting
 Convulsions

 Drink unable

 Sleepiness ( look for)


 Cough
 Diarrhea

 Fever

 Ear Problem

 Anemia / Malnutrition
SIGNS CLASSIFY AS TREATMENT

GDS SEVERE 1ST DOSE OF AB


CHEST PNEUMONIA OR VIT A
INDRAWING VERY SEVERE PREVENT LOW BS
DSE
STRIDOR REFER
SIGNS CLASSIFY AS TREATMENT
FAST PNEUMONIA AB FOR 5 DAYS
BREATHING SOOTHE THROAT AND
RELIEVE COUGH
ADVISE WHEN TO RETURN
FOLLOW-UP 2 DAYS
SIGNS CLASSIFY AS TREATMENT
NO SIGNS OF NO PNUEMONIA: REFER IF COUGH>30DAYS
PNEUMONIA COUGH OR COLD SOOTHE THROAT AND
OR VSD RELIEVE COUGH
ADVISE WHEN TO RETURN
FU: 5 DAYS
SIGNS CLASSIFY AS TREATMENT

2 OF THE FF: SEVERE PLAN C


SLEEPY DEHYDRATION REFER (IF WITH OTHER
SUNKEN EYES SEVERE CLASSIFICATION)
UNABLE TO DRINK AB FOR CHOLERA (2Y/O,
WITH CHOLERA IN AREA)
SKIN TURGOR: VP
SIGNS CLASSIFY AS TREATMENT
2 OF THE FF: SOME PLAN B
SUNKEN EYES DEHYDRATION REFER (IF WITH OTHER
THIRSTY SEVERE CLASSIFICATION
S. TURGOR:POOR FU:5 DAYS
RESTLESS
SIGNS CLASSIFY AS TREATMENT

NOT ENOUGH NO PLAN A


SIGNS DEHYDRATION ZINC
SIGNS CLASSIFY AS TREATMENT
DEHYDRATION SEVERE TREAT DHN
PRESENT PERSISTENT VIT A
DIARRHEA REFER URGENTLY
NO DHN PERSISTENT ADVISE ON FEEDING
DIARRHEA VIT A
ADVISE WHEN 2
RETURN
FU: 5 DAYS
PLAN A
AT HOME

Continue feeding
ZINC (10-14 DAYS)
10mg/day: less than 6 months
20mg/day:6 months above

GIVE EXTRA FLUIDS


When to return
PLAN B
SOME DHN : ORESOL

ORS in ml: kg wt X 75
REASSESS AFTER 4
HRS

Plan A or Plan C
PLAN C IVF
TX SEVERE DHN QUICKLY
INFANT: 30ml/kg(1h)
70ml/kg (5h)
Children:30ml/kg(30 mins)
70ml/kg (2.5h)
Reassess and Give ORS
Reclassify: infants (6H)
children (3H)
NGT
SIGNS CLASSIFY AS TREATMENT
BLOOD IN DYSENTERY ANTIBIOTIC 4 5 DAYS
STOOL FOLLOW-UP IN 2
DAYS
ADVISE WHEN 2
RETURN
SIGNS CLASSIFY AS TREATMENT
GDS VERY SEVERE 1ST DOSE OF AM, QUININE
STIFF NECK FEBRILE DSE/ PREVENT LOW BS
MALARIA PARACETAMOL
REFER
SIGNS CLASSIFY AS TREATMENT
+ BLOOD MALARIA ORAL ANTI-MALARIAL
SMEAR PARACETAMOL
NO OTHER ADVISE WHEN 2 RETURN
CAUSES OF FOLLOW-UP 2 DAYS
FEVER
REFER IF FEVER OF 7 DAYS
SIGNS CLASSIFY AS TREATMENT
¯BLOOD FEVER: MALARIA PARACETAMOL
SMEAR UNLIKELY ADVISE WHEN 2 RETURN
-OTHER
FU: 2DAYS
CAUSES OF REFER IF FEVER OF 7 DAYS
FEVER
TREAT OTHER CAUSES
SIGNS CLASSIFY AS TREATMENT
GDS VERY SEVERE 1ST DOSE OF AB, PREVENT
STIFF NECK FEBRILE DSE LOW BS
PARACETAMOL
REFER
NO SIGNS FEVER: NO PARACETAMOL
OF VERY MALARIA ADVISE WHEN 2 RETURN
FEBRILE DSE FOLLOW-UP 2 DAYS
REFER IF FEVER OF 7 DAYS
TREAT OTHER CAUSES
SIGNS CLASSIFY AS TREATMENT
GDS SEVERE VIT A
CLOUDING OF COMPLICATED 1ST DOSE OF AB, PREVENT
CORNEA MEASLES LOW BS
DEEP OR PARACETAMOL
EXTENSIVE TETRACYLCINE OINTMENT
MOUTH REFER
ULCERS
SIGNS CLASSIFY AS TREATMENT
PUS DRAINING MEASLES WITH VIT A
FROM THE EYE EYE OR MOUTH TETRACYCLINE/GENTIAN VIOLET
OR MOUTH COMPLICATIONS PARACETAMOL
ULCERS ADVISE WHEN 2 RETURN
FOLLOW-UP 2 DAYS
SIGNS CLASSIFY AS TREATMENT
-MEASLES NOW MEASLES VIT A
OR WITHIN PARACETAMOL
THE LAST 3 ADVISE WHEN 2 RETURN
MONTHS
FU: 2DAYS
SIGNS CLASSIFY AS TREATMENT
BLEEDING SEVERE DENGUE PLAN B: VOMITING,
PETECHIAE HEMORRHAGIC ABDOMINAL
COLD CLAMMY SKIN FEVER PAIN,PETECHIAE
CAPILLARY PLAN C: SIGNS OF
REFILL>3 SEC BLEEDING
ABDOMINAL PAIN PREVENT LOW BS
VOMITING REFER URGENTLY
+ TOURNIQUET
TEST
SIGNS CLASSIFY AS TREATMENT

-NOSIGNS OF FEVER: DENGUE ADVISE WHEN 2 RETURN


SEVERE DENGUE H. FEVER FU: 2DAYS
UNLIKELY NO ASPIRIN
SIGNS CLASSIFY AS TREATMENT

TENDER SWELLING MASTOIDITIS 1ST DOSE ANTIBIOTIC


BEHIND EAR PARACETAMOL FOR PAIN
REFER URGENTLY
SIGNS CLASSIFY TREATMENT
AS
PUS DRAINING ACUTE EAR ANTIBIOTICS 4 5 DAYS
FROM EAR <14 INFECTION PARACETAMOL
DAYS OR EAR WICKING
PAIN CHRONIC EAR FU IN 5 DAYS
IF 14 DAYS OR INFECTION
MORE
SIGNS CLASSIFY ASTREATMENT

-NO EAR PAIN NO NO EAR NO ADDITIONAL TX


PUS INFECTION
SIGNS CLASSIFY AS TREATMENT
VISIBLE SEVERE SEVERE VITAMIN A
WASTING MALNUTRITION REFER URGENTLY
EDEMA OF BOTH AND ANEMIA
FEET
SEVERE PALMAR
PALLOR
SIGNS CLASSIFY AS TREATMENT

SOME PALMAR ANEMIA OR COUNSEL ON FEEDING


PALLOR OR VERY VERY LOW PALMAR PALLOR: FE,
LOW WEIGHT FOR WEIGHT MEBENDAZOLE, FU: 14
AGE IF LOW WT: VIT A FU: 30
DAYS
SIGNS CLASSIFY AS TREATMENT
-NOTVERY LOW NO ANEMIA AND COUNSEL MOTHER ON
WEIGHT FOR AGE NOT VERY LOW FEEDING
AND NO OTHER WEIGHT ADVISE WHEN TO
SIGNS OF RETURN
MALNUTRITION FU: 5 DAYS
SIGNS CLASSIFY AS TREATMENT

CONVULSIONS POSSIBLE 1ST IM AB


FAST BREATHING SERIOUS (BENZYLPENICILLIN
SEVERE CHEST INDRAWING BACTERIAL AND GENTAMYCIN)
NASAL FLARING INFECTION PREVENT LOW BS
GRUNTING
ADVISE MOTHER
BULGING FONTANNELS HOW TO KEEP
PUS FR EAR INFANT WARM
UMBILICAL REDNESS(SKIN)
REFER URGENTLY
37.5C>, <35.5C
MANY OR SEVERE SKIN
PUSTULES
ABNORMALLY SLEEPY
LESS THAN N MOVEMENT
SIGNS CLASSIFY AS TREATMENT
RED UMBILICUS OR LOCAL ORAL ANTIBIOTICS
DRAINING PUS OR BACTERIAL TREAT LOCAL
SKIN PUSTULES INFECTION INFECTION IN
HEALTH CENTER
ADVISE MOTHER
ABOUT HOME CARE
FU: 2 DAYS
SIGNS CLASSIFY AS TREATMENT
2 OF THE FF: SEVERE PLAN C
SLEEPY DEHYDRATION REFER IF WITH POSSIBLE
SUNKEN EYES SERIOUS BACTERIAL
INFECTION
SKIN TURGOR: VP
SIGNS CLASSIFY AS TREATMENT
2 OF THE FF: SOME PLAN B
SUNKEN EYES DEHYDRATION REFER IF WITH POSSIBLE
S. TURGOR:POOR SERIOUS BACTERIAL
INFECTION
RESTLESS
FU:2 DAYS
SIGNS CLASSIFY AS TREATMENT

NOT ENOUGH NO PLAN A


SIGNS DEHYDRATION
SIGNS CLASSIFY AS TREATMENT
DIARRHEA 14 SEVERE TREAT DHN FIRST
DAYS OR MORE PERSISTENT UNLESS THERE IS
DIARRHEA POSSIBLE SERIOUS
BACTERIAL INFECTION
REFER URGENTLY

BLOOD IN STOOL DYSENTERY REFER URGENTLY


WITH MOTHER GIVING
ORS ON THE WAY
SIGNS CLASSIFY AS TREATMENT

NOT ABLE TO: NOT ABLE TO 1ST DOSE IM AB


FEED FEED PREVENT LOW BS
POSSIBLE
ATTACH ADVISE HOW TO KEEP
SERIOUS
SUCK WARM
BACTERIAL
INFECTION REFER URGENTLY
SIGNS CLASSIFY AS TREATMENT
NOT WELL FEEDING BREASTFEED AS OFTEN AS
ATTACHED PROBLEMS OR POSSIBLE
NOT SUCKLING LOW WEIGHT TREAT THRUSH
EFFECTIVELY ADVISE ABOUT HOME
LESS THAN 8 CARE
BREASTFEED IN
FU: 2 DAYS FEEDING OR
24 HRS
THRUSH
RECEIVE OTHER
FOODS OR FU:14 DAYS LOW WEIGHT
DRINKS FOR AGE
LOW WEIGHT
FOR AGE
THRUSH
SIGNS CLASSIFY AS TREATMENT
-NOTLOW NO FEEDING COUNSEL MOTHER ON
WEIGHT FOR PROBLEM FEEDING
AGE AND NO
OTHER SIGNS OF
INADEQUATE
FEEDING
 Tellmother the reason for giving the drugs to the
child
 Demonstrate how to measure a dose
 Watch the mother practice measuring a dose by
herself
 Ask the mother to give the first dose to her child
 Explain carefully how to give the drug, label and
package the drug.
 Explain that all the oral drug tables or syrup must
be used to finish the course of treatment, even if
the child gets better.
 Check the mother’s understanding before she
leaves the health center
1ST LINE ANTIBIOTICS 2ND LINE ANTIBIOTICS

 CHLOROQUINE
 Artemeter-
 PRIMAQUINE
Lumefrantine
 SULFADOXINE

PYRIMETHAMINE
VITAMIN A IRON
 One dose daily for 14
days

 Give one dose in


health center if:
 Child is 6 months of
age or older
 Child has not
received a dose of
vitamin A in the past
6 months
PARACETAMOL
 For
Fever (38.5)
MEBENDAZOLE/ALBENDAZOLE
and Ear Pain
 Give500mg in the
health center if:
 Child is 12 months up to
59 months
 No dose received in the
previous 6 months
 Clean both eyes 3 times daily
 Apply tetracycline eye ointment in both
eyes 3 times daily
 Treat until redness is gone

 Do not use other eye ointments or drops


or put anything else in the eye
 Roll clean absorbent cloth into a wick
 Place in child’s ear

 Remove when wet

 Replace with a clean one and repeat


until ear is dry
 Wash hands
 Wash child’s mouth clean using cloth
wet with salt water
 Paint mouth with gentian violet using
cotton bud
 Wash hands again
SAFE REMEDIES: HARMFUL REMEDIES:

 Breast milk for  Codeine cough


exclusively syrup
breastfed infant  Other cough
 Tamarind, syrup
calamansi and  Oral and nasal
ginger decongestants
INTRAMUSCULAR ANTIMALARIAL

 CHLORAMPHENICOL  QUININE (FOR VERY


INTRAMUSCULAR ANTIBIOTIC
SEVERE FEBRILE
DISEASE/MALARIA)
 Breastfeed child
 Give expressed breast milk or breast
milk substitute
 Give sugar water (4tsp sugar in 200ml
water)
 Give 50ml milk or sugar water by NGT

 IV infusion
 Full assessment of
child
MALARIA  If child has other
cause of fever: treat.
 If malaria is the only
cause: blood smear,
2nd -line ant malarial,
follow-up in 2days
 Full assessment of child
 If with GDS or stiff neck, treat
as VERY SEVERE FEBRILE
FEVER- DISEASE/MALARIA
MALARIA
 If malaria is the only cause of
UNLIKELY
fever: blood smear, 1st -line ant
malarial, follow-up in 2 days
FEVER: NO  Full assessment of the child
MALARIA  If with GDS or stiff neck, treat as
VERY SEVERE FEBRILE DISEASE
 Follow-up in 2 days
MEASLES WITH  Look for red eyes and
EYE OR MOUTH
COMPLICATIONS pus draining from eyes
 Look at mouth ulcers

 Smell mouth ulcers


TREATMENT FOR EYE INFECTION TREATMENT FOR MOUTH ULCERS

 If pus is draining from eye:  Worse or foul-smelling:


ask mother to describe refer
how treatment was done
 If pus gone, but redness  Same or better:
remains: continue the continue treatment for a
treatment
total of 5 days
 If no pus or redness: stop
treatment
DHF UNLIKELY TREATMENT
 Full assessment  Signs of bleeding: IVF
 Tourniquet test and refer
 Assess for other causes  Other causes of fever,
treat
 Fever for 7 days: refer
for assessment
TREATMENT
 Reassess for ear
problem  If there is tender swelling
or high fever: treat as
 Measure child’s mastoiditis
temperature  Acute ear infection: ear
pain or discharge persists:
treat with 5 more days of
same antibiotic
 Chronic ear infection: check
wicking of mother
FEEDING PROBLEM ANEMIA
 Reassess feeding  Give iron
 Counsel mother  Continue giving iron
everyday for 2 months
 If very low weight for with follow-up every 14
age: return in 30 days days
after initial visit  If with palmar pallor
after 2 months: refer for
assessment
 Difficultyin breastfeeding
 Child less than 4 months taking other
milk/food
 Use of breast milk substitute/ cow’s milk/
evap milk
 Use of feeding bottles
 Lack of active feeding
 Not feeding well during illness
 Complementary food not enough
 Child 6 months above not yet given
complementary foods
 Infants not exclusively breastfed
Any sick  Not able to drink or
child breastfeed
 Becomes sicker

 Develops a fever
No  Fast breathing
pneumonia:cough or
 Difficult breathing
cold
Diarrhea  Blood in stool
 Drinking poorly
Fever: DHF  Signs of bleeding
unlikely
 Persistent abdominal
pain
 Skin petechiae

 Skin rash