INTEGRATED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)
Steps in the IMCI Case Management Process: 1. Asse Assess ss and and Cla Class ssif ify y 2. Iden Identi tify fy Treat reatme ment nt 3. Treat 4. Coun Counse sell the the Moth Mother er 5. Follow-Up A. Assess and Classify Sick Children 2 months up to 5 Years
1. Determine which age group the child belongs: 1 week up to 2 months 2 months up to 5 years mon ths, Weight Weight in kg., temperature, etc. 2. Record the child’s data : Name, : Name, Age in months, 3. Ask 3. Ask the mother what the child’s child’s problems are. 4. Determine if this is an initial or follow – up visit: Initial visit – 1st visit for this episode of an illness or problem Follow-up visit- the child has been seen a few days ago for the same illness - if the chil child’ d’ss conditi condition on improv improved, ed, still still the the same same or is gettin getting g better better 4. Check for general danger signs: a. not not able able to to drin drink k or bre breas astf tfeed eed too weak to drink and is not able to suck or swallow when offered a drink or • Breast-feed if not sure: ask mother to offer child a drink of clean water or breast milk • A child may have difficulty sucking when his nose is blocked. If the nose is • blocked, clean it. b. b. vomi vomits ts eve every ryth thin ing g a child is not able to hold anything down at all • if in doubt, offer the child water • c. convul convulsio sions ns (dur (during ing this this illn illness ess)) arms and legs stiffen because muscles are contracting • the child may lose consciousness or not be able to respond to spoken directions or • handling, even if eyes are open “fits” or “spasms” or “jerky movements” • Note: Shiver is not convulsion. There is no loss of consciousness. d. abnorm abnormall ally y sleepy sleepy or diff difficul icultt to awaken awaken drowsy and does not show interest in what is happening around him • stare blankly and appear no to notice what is going on around him • does not respond when touched, shaken or spoken to • Note: 1. If the child is asleep and an d has cough or difficult breathing, count the number of breaths first before you try to wake the ch ild. 2. If there is any general danger dange r sign, complete the assessment and any pre-referral treatment immediately so referral is not delayed.
5. Assess 5. Assess and classify cough or difficult breathing • 2 Common Causes of Pneumonia 1. Stretococcus pnemoniae 2. Hemophilus influenzae • 2 Causes of Death 1. hypox hypoxia ia – too too lit littl tlee oxyge oxygen n 2. sepsis sepsis – gene general ralize ized d infe infecti ction on •
Health workers can identify almost all causes of pneumonia by checking for 2 clinical signs: 1. fast breathing – body’s response to stiff lungs and hypoxia 2. chest indrawing
Assess cough or difficult breathing: Does the child have cough cou gh or difficult breathing? “fast” or “noisy” or “interrupted”?
* If the answer is NO, look back bac k to see if you think the child has cough or difficult breathing. how long? • chronic cough – more than 30 days - may be sign of tuberculosis, asthma, whooping cough or another problem fast breathing • a. count count the the brea breath thss in one minut minutee 1. chil child d mus mustt be quie quiett and and calm calm 2. no fee feedi ding, ng, cryin crying g or angry angry child’s shirt. If you are not sure about the number of ∗ Ask the mother to lift the child’s breaths you counted, repeat the count. b. cut-of cut-offf for for fast fast breathi breathing: ng: if the child is: 2 months up to 12 months 12 months up to 5 years
fast breathing is: 50 breaths/ minute or more 40 breaths/ minute or more
Determine if the child is breathing IN or breathing OUT chest indrawing – the lower chest wall goes IN when the child breaths b reaths IN • NORMAL: the whole chest wall and abdomen move OUT when the child breaths IN Best Best posi positi tion on : lyi lying ng dow down n Cond onditions : cl clearly vi visible Note: intercostals indrawing or intercostals retractions and subcostal indrawing are not chest indrawing. ∗
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Look or listen for stridor. stridor. Stridor – harsh noise made when the child breaths IN - happens when there is swelling of the larynx, trachea, or epiglottis ∗Put your ear near the child’s mouth and look at the movement of the abdomen to determine if child is breathing IN or OUT wet noise - blocked nose wheezing - harsh noise while breathing OUT; not stridor
CLASSIFY COUGH OR DIFFICULT BREATHING 6. Assess 6. Assess and classify diarrhea diarrhea – loose or watery stool - defined defined as 3 or or more more loose loose or water watery y stool stoolss in a 24 24 – hour hour period period
Assess: how long? • blood in stool • signs of dehydration • If YES, asses for: dehydration • persistent diarrhea – 14 days or more • Dysentery • Asses for dehydration: Abnormally sleepy or difficult to awaken • Restless and irritable: (all the time) • Sunken eyes: If not sure, ask the mother if the child’s eyes look unusual. • Offer the child fluid : • Not able to drink - if he is not able to take fluid in his mouth and swallow it Drinking poorly – if the child is weak and cannot drink without help. Drinking eagerly, eagerly, thirsty – reaches out for the cup or spoon when you offer water. water. Pinch the skin of the abdomen: • Goes back very slowly – longer than 2 seconds Goes back slowly – the skin stays up for even ev en a brief time after release. CLASSIFY DIARRHEA FOR ;: DEHYDRATION
PERSISTENT DIARRHEA DYSENTERY 7. Assess 7. Assess Fever : A child has the main symptom fever if: - the child child has has histo history ry of fever fever – no no fever fever now but but had had fever fever withi within n 72 hours hours or - the ch child fe feels hot hot or - the child child has an axilla axillary ry temper temperatur aturee of of 37.5 C or or above above Decide malaria risk: -
chil child d liv lives es in mala malari riou ouss are areaa or has been in a malari malariaa risk risk area area in the past past 4 weeks. weeks.
Look or feel for stiff neck: - look look to see see if the the child child moves moves and and bends bends his neck neck easi easily ly as he he looks looks around around or or - draw draw the the chi child ld’’s att attent entio ion n to his his toe toess or - gently gently supp support ort his his back back and and bend bend the the head head forwar forward d toward toward hid ches chest. t. Look for runny nose ( not history of runny nose) Look for signs of Measles: generalized rash and any one of the following: cough, runny runny nose, nose, or red eyes. eyes. Measle Measless rash: begins begins behind behind the ears ears and on the neck, spreads to the face, and to the rest of the body; does not have vesicles or pustules; does not itch. If the child has measles now or within the last 3 months, assess for: - mouth mouth ulcer ulcerss – painfu painfull open open sore sore on the insi inside de of the the mouth mouth and and lips lips or tongue tongue - pus pus dra draiining ning from from the eye eye - clou cloudi ding ng of of the the corn cornea ea – hazy hazy area area in in the the corn cornea ea Assess for Dengue Hemorrhagic Fever all children two months of age or older.Look and feel for signs of bleeding and shock: - blee bleedi ding ng from from the the nos nosee and and gums gums - skin skin petechi petechiae ae – small small hemorr hemorrhag hages es in the the skin; skin; look look like like small small dark dark red red spots spots or patches in the skin; not raised, not tender; if you stretch the skin they do not lose their color. color. - Cold Cold and and cla clamm mmy y extr extrem emit itie iess - If with with cold cold and clammy clammy extr extremi emitie ties, s, check check for slow slow capil capillar lary y refill refill ( longe longer r than 3 seconds - Perf Perform orm the the tourn tourniq iquet uet test test if: if: there there are no signs signs in in the ASK ASK or LOOK LOOK and FEEL, the child is 6 months or older, and the fever is present for more than 3 days. CLASSIFY FEVER 8. Assess 8. Assess Ear Problem Assess the child for : - Ear pain - Ear disc dischar harge ge ; Pres Present ent less less than than 2 weeks weeks – Acute Acute ear ear infect infection ion Present 2 weeks or more – Chronic Ear Infection - Tende enderr swe swell llin ing g behi behind nd the the ear ear CLASSIFY EAR PROBLEM 9. Check for malnutrition and anemia: Look for visible severe wasting – a child with visible severe wasting has marasmus, a form of severe malnutrition.. A child has this sign sign if he is thin, has no fat, and looks like skin and bones. Look for palmar pallor – a sign of anemia Some palmar pallor – the skin on the child’s palm is pale Severe palmar pallor – the palm is very pale or so pale that it looks white
Look and feel for edema of both feet – the child may have kwashiorkor, a form of severe malnutrition. Determine weight for age: Very low weight for age – child’s weight is below the bottom curve o f a weight for age chart. CLASSIFY NUTRITION NU TRITIONAL AL STATUS STATUS 10. Check the child’s child’s immunization status. 11. Check the child’s Vitamin A status.
12. Assess other other Problems Problems..
B. Management Management of the Sick Young Infant Infant Age Age 1 Week Week Up to 2 Months Months 1. Assess the sick young infant
Check the young infant for possible bacterial infection.
1. Ask if if the child child had had convulsio convulsion n at any any time time after after birth. birth. 2. Count Count the the number number of breat breaths hs in one minut minute. e. Fast Fast brea breath thin ing g is 60 breath breathss per minute or more. 3. Look for for sever severee chest chest indrawi indrawing. ng. Mild Mild chest chest indrawi indrawing ng is norma normall in a young young infant or young child. Severe chest indrawing is very deep and easy to see. 4. Look for nasal nasal flaring flaring – widening widening of the the nostrils nostrils when when the young young infant breath breathss in. 5. Look and liste listen n for grunting grunting – soft, soft, short short sounds sounds when breathin breathing g out. 6. ‘Look and and feel for bulging bulging fontanelle. fontanelle. Fontanelle Fontanelle is is the soft spot on on the top top of the the young infant’s head, where the bones of the head have not formed completely. 7. Look at at the umbi umbilic licus us – is it it red or or draini draining ng pus? pus? 8. Measur Measuree temperat temperature ure or feel feel for fever fever or low body temper temperatu ature. re. Fever Fever (axilla (axillary ry temperature temperature 37.5 37.5 C or more; more; rectal rectal temperat temperature ure 38 C or more). more). Hypothermia Hypothermia ( axillary temperature below 35.5 C; rectal temperature b elow 36 C). 9. Look for skin skin pustules pustules – red spots or blister blisterss which contain contain pus. A severe severe pustule pustule is large of has redness extending beyond the pustule. 10. LOOK: See if the child is abnormally sleepy or difficult to awaken. 11. LOOK at the young infant’s infant’s movement. Are they less less that normal? CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION Assess Diarrhea -
For how long? Is ther theree blo blood od in the the sto stool ol?? Look Look at the the young young infan infant’ t’ss gener general al condit conditio ion. n. Is it “Abnor “Abnorma mall lly y sleepy sleepy or difficult to awaken” or “Restless and irritable”? Look fo for su sunken ey eyes. Pinch Pinch the skin skin of the abdom abdomen. en. Does Does it it go back back very slowly slowly?? Or slow slowly? ly?
CLASSIFY DIARRHEA Check for feeding problem or low weight. Assess Breastfeeding. 4 Signs of Good Positioning; - with with inf infan ant’ t’ss head head and body body stra straig ight ht - facing facing her her breas breast, t, with with infa infant’ nt’ss nose nose oppos opposite ite her her nippl nipples es - with with infa infant nt’’s body body clos closee to to her her body body - suppor supportin ting g infant infant’’s whole whole body body, not just just neck neck and and should shoulders ers
4 Sign of Good Attachment: - Chin to touch uching breast - Mouth wide open - Lowe Lowerr lip lip turne urned d out outwa warrd - More More are areola ola vis visib ible le abo above ve than than belo below w the the mout mouth. h. Suckling effectively – the infant suckles with slow, slow, deep sucks and sometimes pauses. You may see or hear the infant swallowing. Not Not suckli suckling ng effectiv effectively ely – he is taking taking only rapid, rapid, shallow shallow sucks. You may see indrawing of the cheeks. You do not see or hear swallowing. swallowing. Not suckling at all – not able to suck breastmilk into his mouth and swallow. swallow. Look for ulcers or white patches in the mouth (thrush). Thrush looks like milk cuds on the inside of the cheek, or thick thick white coating of the tongue. tongue. Try to wipe wipe it off. Milk curds will be removed but thrush will remain. Check the Young Infant’s Infant’s Immunization Status Assess Other Problems
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