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
pneumonia
previous updated
– First line Cotrimoxazole Amoxicillin
– Second line Amoxicillin Cotrimoxazole
• Duration of antibiotic treatment from 5 days to
3 days
• Frequency of administration of antibiotics
from 3x to 2x a day
 ACUTE RESPIRATORY
INFECTION
• 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

Technical 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 days

Technical 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 Infections
Inclusion 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 salts

Technical 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. - ½ tab daily for 10-14 days

6 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 (Artemether-
lumefantrine)

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, ½-3/4
tablets for 14 days
 Fever
• Treatment schedule for uncomplicated
P. falcifarum malaria

day 1-3 Artemether-Lumefantrine

(Coartem)
day 4 Primaquine, single dose only on
day 4

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

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

• Mixed P.falciparum and P. vivax

Day 1-3 Artemether + lumefantrine
Day 4-17 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 INFECTIONS
Chronic ear infection Acute ear infection
• Chronic ear infection • Oral amoxicillin is a
should be treated with better choice for the
optical quinolone ear management of
drops for at least 2 suppurative otitis
weeks in addition to media in countries
dry ear by wicking 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 Schedule
Age Vaccine
Birth BCG, HepB1
6 weeks DPT1, OPV1, HepB2
10 weeks DPT2, OPV2
14 weeks DPT3, OPV3, HepB3
9 months 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 first-
level 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
months
Previous Updated
Age: 1 week up to Birth up to 2
2 months months

Main symptom:
Previous: Possible serious bacterial infection

Updated: Very severe disease and local

bacterial infection
 Sick young infant – cont’d
• Signs to look for in assessment:

Previous: 12 signs

Updated: 7 signs
 Sick young infant – cont’d
• Classification:
Previous: Updated:
Very severe disease (pink) Very severe
disease
Local bacterial infection (yellow) Severe disease
Severe disease or local Severe
disease or
bacterial infection unlikely local bacterial

(green) infection unlikely

 Sick young infant – cont’d
• Checking for jaundice is added in the
protocol
• Classification: Severe jaundice (pink)
Jaundice (yellow)
No jaundice (green)
 Acute Respiratory Infections
Technical 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 Infections
Technical 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 countries
Pakistan (n=1622) Thailand (n=521)
595 (36.7% w/ audible wheeze) 48 (9.2% w/ audible wheeze)
number Response Subsequent number Response Subsequent
deterioration deterioration

Non-severe 1004 621 93 256 217 14

pneumonia (61.8%) (61.8%) (14.9%) (49.1%) (84.8%) (6.4%)
Severe 618 166 63 265 189 24
pneumonia (38.2%) (26.8%) (37.9%) (50.9%) (71.3%) (12.7%)

-These data show a large no. of children w/ wheeze are being classified as
pneumonia and are being prescribed antibiotics unnecessarily.
- Bronchodilators are being underutilized in children with wheeze.
-Majority of children with wheeze who respond to a trial of inhaled bronchodilators
continue to do well when sent home without an antibiotic.
Acute Respiratory Infections
 Diarrheal diseases
Technical basis:
- Ciprofloxacin is several thousand-fold greater than that
of nalidixic acid
- Ciprofloxacin is 100 to 1000-fold less prone to selection
of single-step spontaneous highly resistant organisms
- Simplified tx regimens (2 doses /day x 3 days instead of
4 doses/day x 5 days with nalidixic acid)
- Considered for its safety, efficacy and reduced cost
DIARRHEAL DISEASES
 EAR INFECTIONS
Technical basis:
– Cochrane review of randomized controlled trials published in the
Cochrane Library
• Aural toilet cobined with antimicrobial tx is more effective than aural
toilet alone; oral antibiotics were found to be better than aural toilet
alone
• Topical antibiotics were found to be better than aural toilet alone; the
addition ot topical; antibiotics to aural toilet was associated with a
57% rate of otorrhea resolution compared to 27% with aural toilet
alone
• Topical antibiotics were found to be better than systemic antibiotics in
resolving otorrhea and eradicating middle ear bacteria; in general
topical quinolones were found to be better than topical non-quinolones;
finally combined topical and systemic antibiotics are no better than
topical antibiotics alone
• The safety of topical quinolones in children has been well documented
without good evidence of a risk of ototoxicity
 FEVER/MALARIA
• Antimalarials for treatment of Malaria
The following therapeutic options are available and have potential for
deployment (in prioritized order) if costs are not an issue:
– Artemether-lumefantrine (Coartem TM)
– Artesunate (3 days) plus amodiaquine
– Artesunate (3 days) plus SP in areas where SP efficacy remains high
– SP plus amodiaquine in areas where efficacy of both amodiaquine and SP
remain high (limited in west African countries)

Technical basis:
– Artemisin-based combination therapy (ACT) result in rapid
substantial reduction of the parasite biomass and rapid resolution of
clinical symptoms
– In combination, allows reduction of artemisin tx, while enhancing
efficacy and reduce likelihood of resistance development to the
partner drug