4 - Imci - Orpeza - Afssst

LECTURE 4: INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)
MRS. BERNADETTE ORPEZA, RN `
Why IMCI?
INTEGRATED MANAGEMENT OF CHILDHOOD • 10M children die each year in developing
ILLNESS countries before they reach their 5th birthday
(1998).
Link:
• 7 in 10 deaths are due to acute respiratory
https://drive.google.com/file/d/19M7EWHQaWSWu5jq infections (mostly pneumonia), diarrhea,
9kKm6FOMlfMcLW6O4/view?usp=sharing measles, malaria, or malnutrition-often in
combine.
INTRODUCTION • Many are not properly assessed and treated and
• According to WHO, based on statistics, children that their parents are poorly advised.
5 years old and below have been poorly advised
particularly the parents of these children are
poorly advised when it comes to their health and
diseases that can be easily prevented. These
factors may provide quality care to children and
global community.
INTEGRATED MANAGEMENT OF CHILDHOOD

ILLNESS (IMCI)
• An integrated approach to child health that
focuses on the well-being of the whole child.
• It aims to reduce death, illness and disability, and
to promote improved growth and development
among children under five years of age.
• It includes both preventive and curative elements
that are implemented by families and
communities as well as by health facilities.
Who are the children covered by the IMCI protocol?

1. Sick children from birth up to 2 months (Sick
young infant)
2. Sick children 2 months up to 5 years (Sick child)
What does IMCI offers?

• It offers simple and effective methods to prevent
and manage the leading causes of serious illness
and mortality in young children.
• The guidelines promote evidence-based
assessment and treatment, using a syndromic
approach that supports the rational, effective, and
affordable use of drugs.
So basically, an mga sakit na mga nakikitan ha children 5
years old and below are mostly preventable and studies All of these diseases can be readily preventable in the
show that because of poorly advised parents, they are outpatient settings. The purpose of the development of
unable to treat the child thus increasing the mortality of the IMCI is to provide a strategy where infants and
these children. children can be attended to in an efficient manner.
Where is it intended to be used? Rationale for the integrated approach in the

management of sick children:
• The approach is designed for use in outpatient
clinical settings with limited diagnostic tools, • Majority of deaths are caused by 5 preventable
limited medications, and limited opportunities to and treatable conditions namely:
practice complicated procedures. - Pneumonia
Those areas where facilities and resources are scarce. - Diarrhea
This is where IMCI is intended. The management may - Measles
differ in hospital settings and in areas with easy access to - Malaria
diagnostic and treatment modalities. - Malnutrition
• 3 out of 4 episodes of childhood illnesse are
COMPONENTS OF IMCI STRATEGY caused by this condition.
1. Improvements in the case management skills of • Most children have more than one illness at one
health worker. time.
2. Improvements in the health system required to • Single diagnosis may not be possible or
deliver child health interventions effectively. appropriate.
3. Improvements in family and community practices.
WESTERN PACIFIC REGION
• 527,000 children die before their 5th birthday.
• 97% occurred in six countries, namely,
Cambodia, China, the Lao People's Democratic
© albesa, floria, saldaña, silvano, soyosa, tezon NCA 1 ┃ NURSING COURSE APPRAISAL 1
Republic, Papua New Guinea, the Philippines,

and Vietnam.
Classify
• Using a colour-coded triage system.
Urgent pre-referral treatment and referral (RED)

*If the institution where the infant or the child went to
IMCI IN THE PHILIPPINES for consultation needs immediate attention and the
• Started as a pilot basis in 1996 current set-up of the facility will not be able to cater to
the needs of the child or infant then he/she will be
• Intended for health workers and hospital staff
needed to be referred to a higher center.
were capacitated to implement the strategy at the Specific medical treatment It and advice
frontline level. (YELLOW)
Simple Management (GREEN)
ACCELERATING IMPLEMENTATION OF IMCI IN THE *Note: Kan sir Mark ngan ha HANDBOOK mismo, PINK
PHILIPPINES 2015-2025 daw pero han kan Ma’am Orpeza ppt RED.
General objective:
• To accelerate IMCI implementation all over the 2. TREAT THE CHILD
country. • Identify specific treatments for the child
- If requires urgent referral, give essential
Specific objectives: By 2025 treatment before transfer.
• To establish IMCI-ICATT training, units and core You need to render first aid that is available
trainers in all regions of the country. in the facility.
• To implement IMCI in at least 80% of primary - If needs treatment at home, develop an
health care facilities (barangay health centers integrated treatment plan and give the first
and BHSs). dose of drugs in the clinic
• To integrate IMCI in all medical, nursing and - If should be immunized, give immunizations
midwifery schools. • Provide practical treatment options
• To establish IMCI referral hospitals in all - Teach caretaker how to give oral drugs
provinces and cities. Patients usually die because of poor advices
• To establish core IMCI activities in the barangays. given to them.
(to be identified). - How to feed and give fluids
- How to treat local infections
INTEGRATED CASE MANAGEMENT PROCESS (4
COMPONENTS) 3. COUNSEL
1. Assess and Classify the sick child • Assess feeding, including assessment of
2. Treat the child breastfeeding practices, and counsel to solve any
3. Counsel feeding problems.
4. Follow-up • Then counsel the mother about her own health.
4. FOLLOW-UP
• Give follow-up care and if necessary, reassess
the child for new problem.
1. ASSESS
• Check for danger sings (or possible bacterial
infection in a young infant).
• Ask questions about common conditions.
• Examining the child.
• Check nutrition and immunization status.
• Check other health problems.
SUMMARY OF THE INTEGRATED CASE For all sick children age 2 months p to 5 years who
MANAGEMENT PROCESS are brought to the clinic:
If waray na problema, you are just going to enforce the

teachings that you have initially given. If it’s for follow-up
care already, you need to assess if there are other
problems that needs to be assessed or new problems of
the patient.
SELECTING THE APPROPRIATE CASE GENERAL DANGER SIGNS

MANAGEMENT CHARTS • Check for General Danger Signs
• If the child is a young infant aged up to 2 months Ask:
• If the child is aged up to 2 months to 5 years • Is the child able to drink or breastfeed?
• For all sick children aged 1 week to 5 years who • Does the child vomit everything?
are brought to the clinic, ask for the child’s age. • Has the child had convulsions?
• If it’s a young infant up to 2 months, use the chart
Look:
using the ASSESS, CLASSIFY and TREAT THE
• See if the child is lethargic or unconscious.
YOUNG INFANT.
• Is the child convulsing now?
• If the child is 2 months up to 5 years of age, you’re URGENT Attention
going to ASSESS and CLASSIFY, TREAT THE
CHILD and at the same time, you are going to Any general Pink: •
Give
counsel the mother. danger sign VERY diazepam if
SEVERE convulsing
THE SICK CHILD (2 MONTHS TO 5 YEARS) DISEASE now
• Cough or difficult breathing • Quickly
• Diarrhea complete the
• Fever assessment
• Ear problem • Give any
• Malnutrition and feeding pre-referral
treatment
• Immunization status
immediately
• Treat to
prevent low
blood sugar
• Keep the
child warm
• Refer
URGENTLY.
• A child with any general danger sign needs
URGENT attention; complete the assessment
and any pre-referral treatment immediately so
referral is not delayed.
• CONVULSION is a danger sign only when:
- Occurs in less than 6 months
- More than one episode
- Occurring for more than 15 minutes
• This definition EXCLUDES SIMPLE FEBRILE
CONVULSIONS
COUGH OR DIFFICULTY BREATHING wheeze, refer for

possible TB or
ASK ABOUT MAIN SYMPTOMS: asthma
Does the child have cough or difficult breathing? assessment
• Advise mother
when to return
If yes, ask: Look, listen, feel*: immediately
For how long? *CHILD MUST BE CALM* • Follow-up in 3
days
• Count the breaths in one
• No signs COUGH OR • If wheezing (or
minute. COLD
of disappeared
• Look for chest indrawing. pneumoni after rapidly
• Look and listen for stridor. a or very acting
• Look and listen for severe bronchodilator)
disease. give an inhaled
wheezing.
bronchodilator
for 5 days
If wheezing with either fast • Soothe the
breathing or chest throat and
indrawing: relieve the
• Give a trial of rapid acting cough with a
safe remedy
inhaled bronchodilator for • If coughing for
up to three times 15-20 more than 14
minutes apart. Count the days or recurrent
breaths and look for chest wheezing, refer
indrawing again, and then for possible TB
or asthma
classify.
assessment
• Advise mother
when to return
If the child is: Fast breathing is: immediately
2 months up to 12 months 50 breaths per minute or • Follow-up in 5
more days if not
12 months up to 5 years 40 breaths per minute or improving
more
CLASSIFY: • If pulse oximeter is available, determine oxygen
COUGH OR DIFFICULT BREATHING saturation and refer if < 90%.
• If referral is not possible, manage the child as
• Any Pink: • Give first dose of described in the pneumonia section of the national
general SEVERE an appropriate referral guidelines or as in WHO Pocket Book for
danger PNEUMONI antibiotic hospital care for children.
signs A • Refer • Oral Amoxicillin for 3 days could be used in
or OR URGENTLY to patients with fast breathing but no chest indrawing
• Stridor in VERY hospital in low HIV settings.
calm child SEVERE • In settings where inhaled bronchodilator is not
DISEASE available, oral salbutamol may be tried but not
• Chest PNEUMONI • Give oral recommended for treatment of severe acute
indrawing A Amoxicillin for wheeze.
or 5 days
• Fast • If wheezing (or Rationale for management of children with wheeze
breathing. disappeared
after rapidly • Wheeze can cause fast breathing and or chest
acting indrawing.
bronchodilator) • Good response to inhaled bronchodilator may
give an inhaled cause fast breathing or chest indrawing to
bronchodilator disappear.
for 5 days**** • Only children with wheeze and signs of
• If chest pneumonia (fast breathing and/or chest
indrawing in HIV indrawing) need antimicrobials.
exposed/infecte
• Wheezing without signs of pneumonia only
d child, give first
bronchodilator treatment.
dose of
amoxicillin and
refer. ANTIBIOTIC treatment for Pneumonia (first line drug)
• Soothe the • Children aged 2-59 months pneumonia (chest
throat and indrawing and or high RR) should be treated with oral
relieve the amoxicillin of at least 40mg/kg/dose twice a day for
cough with a five days.
safe remedy
• If coughing for PRACTICE QUESTION:
more than 14 What color is Pneumonia: Cough or Cold classified as?
days or recurrent
a. Green older and

b. Pink there is
c. Yellow cholera in
d. Red your area,
For TB patients who experience hemoptysis, the color give
is PINK or RED. antibiotic
for cholera
PRACTICE QUESTION:
Two of the SOME • Give fluid,
following DEHYDRATIO zinc
If the child has wheezing and either fast breathing or chest
signs: N supplement
indrawing is present, the nurse should: • Restless, s, and food
a. Refer urgently to hospital irritable for some
b. Give a trial acting inhaled bronchodilator • Sunken dehydration
c. Assess vital signs eyes (Plan B)
d. Give vitamin A • Drinks
eagerly, If child also has
DIARRHEA thirsty a severe
• Does the child have diarrhea? • Skin pinch classification:
goes back • Refer
slowly. URGENTLY
If yes, ask: Look and feel: to hospital
For how long? • Look at the child's general with mother
Is there blood condition. Is the child: giving
in the stool? - Lethargic or frequent sips
of ORS on
unconscious?
the way
- Restless and irritable? • Advise the
• Look for sunken eyes (sign mother to
of dehydration). continue
• Offer the child fluid. Is the breastfeedin
g
child:
- Not able to drink or • Advise
drinking poorly? mother
- Drinking eagerly, when to
thirsty? return
immediately
• Pinch the skin of the
• Follow-up in
abdomen. Does it go back: 5 days if not
- Very slowly (longer than improving
2 seconds)? Not enough NO • Give fluid,
- Slowly? signs to classify DEHYDRATIO zinc
CLASSIFY: as some or N supplements,
DIARRHEA FOR DEHYDRATION severe and food to
dehydration. treat diarrhea
Two of the Pink: If child has no at home
following SEVERE other severe (Plan A)
signs: DEHYDRATIO classification: • Advise
• Lethargic N • Give fluid for mother when
or severe to return
unconsciou dehydration immediately
s (Plan C) • Follow-up in
• Sunken OR 5 days if not
eyes If child also has improving
• Not able to another severe In the clinical trial pediatric patients with moderate to
drink or classification: severe infection were initiated on 6-0 mg/kg of IV every 8
drinking • Refer hours and allowed to switch to oral therapy after that to
poorly URGENTLY correct the signs of dehydration.
• Skin pinch to hospital
goes back with mother IF DIARRHEA 14 DAYS OR MORE
very slowly. giving Dehydration Pink: • Treat
frequent sips present. SEVERE dehydration
of ORS on PERSISTENT before referral
the way DIARRHEA unless the
• Advise the child has
mother to another
continue severe
breastfeedin classification
g • Refer to
hospital
• If child is 2 No dehydration PERSISTENT • Advise the
years or DIARRHEA mother on
feeding a child also experiences persistent diarrhea for 3 days. What is

who has the specific classification of the child?
PERSISTENT ANSWER: Some dehydration
DIARRHEA
• Give FEVER
multivitamins • Fever is defined by history or feels hot or
and minerals temperature 37.5°C or above (based on axillary
(including
T°, rectal T° is 0.5°C higher)
zinc) for 14
days • Decide if the area is Malaria Risk
• Follow-up in 5 • Look for any bacterial cause of fever
days • Local tenderness, oral sores, refusal to use limb,
IF THERE IS BLOOD IN STOOL hot tender swelling, red tender skin or boils, lower
Blood in stool. DYSENTERY • Give abdominal pain or pain in passing urine in older
ciprofloxacin children.
for 3 days
• Follow-up in 3 Malaria Diagnosis
days • Prompt parasitological confirmation by
• Advise microscopy alternatively by Rapid Diagnostic
mother when
Tests (RDIS) is recommended in ALL patients
to return
immediately. suspected of malaria before treatment is started.
Treatment for Diarrhea: FEVER: MALARIA RISK

• Does the child have fever? (By history or feels hot
• Use of low/ reduced osmolarity Oral Rehydration
or temperature of 37.5°C or above)
Salts (ORS)
• Providing children with zinc for 14 days:
- Children >6 months 20 mg zinc If yes: Look and feel:
- Children <6 months 10 mg of zinc • Decide • Look or feel for stiff neck.
• Ciprofloxacin as first line drug for bloody Malaria Risk: • Look for runny nose.
diarrhea (dysentery) high or low • Look for any bacterial
• Then ask: cause of fever**.
Compositions of the Old and Reformulated ORS
- For how • Look for signs of
long? MEASLES:
OLD WHO- REFORMULATED - If more - Generalized rash
ORS (meq or ORS (meq or than 7 - One of these: cough,
mmol/l) mmol/l) days, has runny nose, or red
fever eyes
Glucose 111 75
been
Sodium 90 75 present
Chloride 80 65 every
Potassium 20 20 day?
- Has the
Citrate 10 10
child had
Osmolarity 311 245 measles
within the
PRACTICE QUESTION: last 3
What color is classification is “No Dehydration” if months?
diarrhea is 14 days or more.
a. Green
b. Pink
c. Yellow
d. Red Do a malaria test: If NO severe classification
• In all fever cases if High malaria risk.
PRACTICE QUESTION: • In Low malaria risk if no obvious cause of fever
If a child has not enough signs to classify as some or present.
severe dehydration, the child will be classified as: CLASSIFY:
a. Severe Dehydration FEVER
b. Mild Dehydration
c. Some Dehydration HIGH OR LOW MALARIA RISK
d. No Dehydration • Any general Pink: • Give first dose
danger signs VERY of artesunate or
or SEVERE quinine for
PRACTICE QUESTION:
• Stiff neck. FEBRILE severe malaria
Baby Cathy, a 12-month-old infant was rushed by her DISEASE • Give first dose
mother in the nearest health center because of sunken of an
eyes and irritability. Upon further assessment, the infant appropriate
antibiotic
•
Treat the child • Give one dose
to prevent low of paracetamol
blood sugar in clinic for high
• Give one dose fever (38.5C or
of paracetamol above)
in clinic for high • Refer
fever (38.5C or URGENTLY to
above) hospital.
• Refer • No general FEVER • Give one dose of
URGENTLY to danger paracetamol in
hospital signs. clinic for high
Malaria test MALARIA • Give • No stiff fever (38.5C or
POSITIVE recommended neck. above).
first line oral • Give appropriate
antimalarial. antibiotic
• Give one dose treatment for
of paracetamol any identified
in clinic for high bacterial cause
fever (38.5C or of fever.
above). • Advise mother
• Give when to return
appropriate immediately.
antibiotic • Follow-up in 2
treatment for an days if fever
identified persists.
bacterial cause • If fever is
of fever present every
• Advise mother day for more
when to return than 7 days,
immediately. refer for
• Follow-up in 3 assessment.
days if fever
persists FEVER: MEASLES
• If fever is
present every
day for more
than 7 days, If the child • Look for mouth ulcers.
refer for has measles Are they deep and
assessment. now or within extensive?
• Malaria test FEVER: • Give one dose the last 3 • Look for pus draining
NEGATIVE NO of paracetamol months: from the eye.
• Other cause MALARIA in clinic for high
of fever fever (38.5C or • Look for clouding of the
PRESENT above) cornea.
• Give
appropriate IF MEASLES NOW OR WITHIN LAST 3
antibiotic MONTHS, CLASSIFY
treatment for an Check for signs of MEASLES now or within the last 3
identified months.
bacterial cause
• Any Pink: • Give
of fever
general SEVERE Vitamin A
• Advise mother COMPLICATED
danger treatment
when to return sign MEASLES • Give first
immediately
or dose of an
• Follow-up in 3 • Clouding appropriate
days if fever of cornea antibiotic
persists
or • If clouding
• If fever is • Deep or of the
present every extensive cornea or
day for more
mouth pus draining
than 7 days,
ulcers from the
refer for
eye, apply
assessment tetracycline
NO MALARIA RISK AND NO TRAVEL TO eye
MALARIA RISK AREA ointment
• Any general Pink: • Give first dose • Refer
danger VERY of an URGENTLY
signs. SEVERE appropriate to hospital
• Stiff neck. FEBRILE antibiotic.
• Pus MEASLES WITH • Give
DISEASE • Treat the child
draining EYE OR Vitamin A
to prevent low from the MOUTH treatment
blood sugar. eye COMPLICATIONS
or • If pus • Persistent • Treat the

• Mouth draining vomiting child to
ulcers from the • Positive prevent the
eye, treat tourniquet lowering of
eye test his or her
infection blood sugar
with level.
tetracycline • Refer the
eye child
ointment URGENTL
• If mouth Y to the
ulcers, treat hospital.
with gentian • DO NOT
violet GIVE
• Follow-up in ASPIRIN!
3 days • No signs of FEVER: • Advise the
• Measles MEASLES • Give severe DENGUE mother
now or Vitamin A dengue HEMORRHAGI regarding
within the treatment. hemorrhagi C FEVER when to
last 3 c fever. UNLIKELY return
months. immediately
• These temperatures are based on axillary to the health
temperature. Rectal temperatures are center.
apporximately 0.5C higher. • Follow-up in
• Look for tenderness: Oral sores, refusal to use the 2 days if
limb, hot tender swelling, red tender skin or boils, fever still
lower abdominal pain or pain on passing urine in persists or if
older children. the child
• If no malaria test available: High malaria risk shows signs
(Classify as MALARIA), Low malaria risk or NO of bleeding.
obvious cause of fever (Classify as MALARIA) • DO NOT
• Other important complications of mealses: GIVE
Pneumonia, stridor, diarrhea, ear infection and ASPIRIN!
acute malnutrition.
PRACTICE QUESTION:
Treatment of Very Severe Disease in Malaria risk area: A 3-year old child living in Coron, Palawan with her
• Pre-referral treatment includes rectal Artesunate mother and father. One afternoon, she was rushed by her
suppository or oral Quinine and IM Ampicillin and mother to the nearest health center for consultation. Upon
Gentamicin assessment, she has increased body temperature of 38C
but tested NEGATIVE for Malaria test. What is the
Treatment of Uncomplicated Falciparum Malaria: specific classification of the child?
ANSWER: Green
• Artemisinin-based combination therapies (ACTs)
should be used in the treatment of uncomplicated
PRACTICE QUESTION:
P. falciparum malaria
A 1-year old child living in Palo, Leyte with her mother.
• ACTs should include at least 3 days of treatment Evelyn was rushed to the nearest health center for
with an artemisinin derivative. consultation. Upon assessment, the patient has
increased temperature of 38C but tested NEGATIVE for
FEVER: DENGUE HEMORRHAGIC FEVER Malaria test. What is her specific classification?
ANSWER: Green (Fever, No Malaria)
• Bleeding Pink: • If skin
from the SEVERE petechiae, PRACTICE QUESTION:
nose or DENGUE persistent Which of the following is the treatment if a child has the
gums HEMORRHAGI abdominal
classification of GREEN and HAS MEASLES at the time
• Bleeding in C FEVER pain,
persistent of consultation?
the stool or
vomitus vomiting o ANSWER: Give Vitamin A only.
• Black stool positive
or vomitus tourniquet EAR PROBLEM
• Skin test are the • Does the child have an ear problem?
petechiae only
• Cold, positive
clammy signs, give
extremities ORS.
• Slow • If any other
capillary sign of
refill (more bleeding is
than 3 positive,
seconds) give fluids
• Persistent rapidly
abdominal (Plan C).
pain
If yes: Look and feel:

• Is there • Look for pus draining
ear pain? from the ear.
• Is there • Feel for tender swelling
ear behind the ear.
discharge?
• If yes, for
how long?
CLASSIFY:
EAR PROBLEM
• Tender Pink: • Give first
swelling MASTOIDITIS dose of an
behind the appropriate
ear. antibiotic
• Give first
dose of
paracetamol
for pain
• Refer
URGENTLY
to hospital
• Pus is seen ACUTE EAR • Give an
draining INFECTION antibiotic for
from the ear 5 days
and • Give
discharge is paracetamol
reported for for pain
less than 14 • Dry the ear
days by wicking
or • Follow-up in
• Ear pain. 5 days
• Pus is seen CHRONIC EAR • Dry the ear
draining INFECTION by wicking
from the ear • Treat with
and topical
discharge is quinolone
reported for eardrops for
14 days or 14 days
more. • Follow-up in
5 days
• No ear pain NO EAR • No
and No pus INFECTION treatment
seen
draining
from the ear
ACUTE MALNUTRITION
• Look for edema of both feet.
• Determine WFH/L z-score using the WHO growth
standard charts.
• Measure the Mid-Upper Arm Circumference
using MUAC tape in all children 6 months or
older.
• Offer Ready To Use Therapeutic Food (RUFT)
for appetite test.
CHECK FOR ACUTE MALNUTRITION

Look and Feel:
• Look for signs of acute malnutrition
• Look for edema of both feet.
• Determine WFH/L* ___ z-score.
• Measure MUAC**____ mm in a child 6 months or
older.
If WFH/L less than -3 z-scores or MUAC less than

115mm, then:
• Check for any medical complication present:
- Any general danger signs
- Any severe classification
- Pneumonia with chest indrawing
• If no medical complications present:
- Child is 6 months or older, offer RUTF*** to
eat. Is the child:
✓ Not able to finish RUTF portion?
✓ Able to finish RUTF portion?
• Child is less than 6 months, assess breastfeeding:
- Does the child have a breastfeeding problem?
CLASSIFY:
NUTRITIONAL STATUS
• Edema of both Pink: • Give first
feet COMPLICATED dose
OR SEVERE ACUTE appropria
• WFH/L less than MALNUTRITION te
-3 z-scores OR antibiotic
MUAC less than • Treat the
115 mm AND child to
any one of the prevent
following: low blood
APPETITE TEST
Medical sugar
• Offer appropriate amount of RUTF to the child to complication • Keep the
eat. present or Not child
• After 30 minutes check if the child was able to able to finish warm
finish or not able to finish the amount of RUTF RUTF or • Refer
given and decide. Breastfeeding URGENT
• Child ABLE to finish at least one-third of a packet problem. LY to
of RUTF portion (92 g) or 3 teaspoons from a pot hospital
within 30 minutes.
• Child NOT ABLE to eat one-third of a packet of
RUTF portion (92 g) or 3 teaspoons from a pot • WFH/L less than UNCOMPLICATE • Give oral
within 30 minutes. -3 z-scores D SEVERE antibiotic
OR ACUTE s for 5
• MUAC less than MALNUTRITION days
115 mm • Give
AND ready-to-
• Able to finish use
RUTF therapeut
ic food for
a child
aged 6
months or
more
• Counsel
the
mother
on how to
feed the
child.
• Assess
for
possible
TB
infection
• Advise
mother
when to - Max MNP into complementary food

return preferably soft or semi-sold before feeding it
immediat to the child.
ely - Do not add MNP to food before or during
• Follow up cooking.
in 7 days - For 6-11months infant, give a total of 60
• WFH/L between MODERATE • Assess sachets over period of 6 months.
-3 and -2 z- ACUTE the child's - For 12-23 months children, give 60 sachets
scores MALNUTRITION feeding every 6 months for a total of 120 sachets in a
OR and
year.
• MUAC 115 up to counsel
125 mm the
mother ANEMIA
on the
feeding Check for anemia:
recomme • Look for palmar pallor. Is it:
ndations - Severe palmar pallor?
• If feeding - Some palmar pallor?
problem,
follow up CLASSIFY:
in 7 days ANEMIA
• Assess Severe Pink: Refer URGENTLY to
for palmar SEVERE hospital
possible pallor ANEMIA
TB Some pallor ANEMIA • Give iron
infection. • Give mebendazole
• Advise if child is 1 year or
mother older and has not
when to had a dose in the
return previous 6 months
immediat • Advise mother
ely when to return
• Follow-up immediately
in 30 • Follow-up in 14
days days
• WFH/L - 2 z- NO ACUTE • If child is No palmar NO ANEMIA • If child is less than 2
scores or more MALNUTRITION less than pallor years old, assess
OR 2 years the child's feeding
• MUAC 125 mm old, and counsel the
or more. assess mother according to
the child's the feeding
feeding recommendations.
and • If feeding problem,
counsel follow-up in 5 days.
the • Assess for sickle cell anemia if common in your
mother area.
on • If child has severe acute malnutrition and is
feeding receiving RUTF, DO NOT give iron because there
according is already adequate amount of iron in RUTF.
to the
feeding
recomme
ndations
• If feeding
problem,
follow-up
in 7 days
• WFH/L is Weight-for-Height or Weight-for-Length
determined by using the WHO growth standards
charts.
• MUAC is Mid-Upper Arm Circumference measured
using MUAC tape in all children 6 months or older.
• RUTF is Ready-to-Use Therapeutic Food for
conducting the appetite test and feeding children with
severe acute malnutrition.
Give Micronutrient Powder

• Give Micronutrient Powder Supplement an MNP)
daily to children 6-23 months old:
- Use this at 6 months of age during the
introduction of complementary feeding.
• Positive •Give
serological cotrimoxazole
test in a child prophylaxis
18 months or • Assess the
older child’s
feeding and
provide
appropriate
counselling to
the mother
• Advise the
mother on
home care
• Assess or
refer for TB
assessment
and INH
preventive
therapy
• Follow-up
regularly as
per national
guidelines
• Mother HIV- HIV • Give
positive AND EXPOSED cotrimoxazole
negative prophylaxis
virological • Start or
test in a continue ARV
breastfeeding prophylaxis as
child or only recommended
stopped less • Do virological
than 6 weeks test to confirm
ago HIV status
OR • Assess the
• Mother HIV- child’s feeding
positive, child and provide
not yet tested appropriate
HIV INFECTION OR counselling to
What we need to know about HIV: • Positive the mother
• We need to ask if the mother had an HIV test
serological • Advise the
test in a child mother on
• Learn how to decide the HIV status of the mother less than 18 home care
• Ask about the breastfeeding status of the child months old • Follow-up
• If no test has been done, to request for the test regularly as
CHECK FOR HIV INFECTION per national
Ask: guidelines
• Has the mother or child had an HIV test? Negative HIV test HIV Treat, counsel
in mother or child. INFECTION and follow-up
IF YES: UNLIKELY existing
Decide HIV status: infections.
• Mother: POSITIVE or NEGATIVE • Give cotrimoxazole prophylaxis to all HIV infected
• Child: and HIV exposed children until confirmed negative
- Virological test POSITIVE or NEGATIVE after cessation of breastfeeding.
- Serological test POSITIVE or NEGATIVE • If virological test is negative, repeat test 6 weeks
after the breastfeeding has stopped; if serological
If mother is HIV positive and child is negative or test is positive, do a virological test as soon as
unknown, ASK: possible.
• Was the child breastfeeding at the time or 6 weeks
before the test? COUNSEL AND FOLLOW-UP CARE
• Is the child breastfeeding now? Advise the Mother When to Return to Health Worker
follow-up visit:
If breastfeeding ASK: Is the mother and child on
ARV prophylaxis? • Advise the mother to come for follow-up at the
IF NO, THEN TEST: earliest time listed for the child's problems.
• Mother and child status unknown: TEST mother. If the child has: Return for follow-up
• Mother HIV positive and child status unknown: in:
TEST child. ✓ PNEUMONIA 3 days
CLASSIFY HIV STATUS ✓ DYSENTERY
• Positive CONFIRMED • Initiate ART ✓ MALARIA, if fever
virological HIV treatment and persists
test in child INFECTION HIV care ✓ FEVER: NO
OR MALARIA, if fever
persists
✓ MEASLES WITH
EYE OR MOUTH
✓ COMPLICATIONS
✓ MOUTH OR GUM
ULCERS OR
THRUSH
✓ PERSISTENT 5 days
DIARRHOEA
✓ ACUTE EAR
INFECTION
✓ CHRONIC EAR
INFECTION
✓ COUGH OR COLD, if
not improving
✓ UNCOMPLICATED 14 days
SEVERE ACUTE
✓ MALNUTRITION SICK YOUNG INFANT AGE UP TO 2 MONTHS
✓ FEEDING Check for the following:
PROBLEM
✓ ANEMIA 14 days • Very severe disease and local bacterial infection
✓ MODERATE ACUTE 30 days • Jaundice
MALNUTRITION • Diarrhea
✓ CONFIRMED HIV According to national • HIV infection
INFECTION recommendations. • Feeding problem or- low weight for age
✓ HIV EXPOSED
* NEXT WELL-CHILD VISIT: Advise the mother to
return for next immunization according to immunization
schedule.
WHEN TO RETURN IMMDIATELY
Advise 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 child has COUGH OR ✓ Fast breathing
COLD, also return if: ✓ Difficult breathing
If child has diarrhea, also ✓ Blood in stool
return if: ✓ Drinking poorly
VERY SEVERE DISEASE AND LOCAL BACTERIAL • Advise mother

INFECTION to give home
care for the
young infant
• Follow up in 2
ASK: LOOK, LISTEN, FEEL:
days
• Is the * YOUNG INFANT MUST BE None of the signs SEVERE Advise mother to
infant CALM* of very severe DISEASE give home care.
having • Count the breaths in one disease or local OR LOCAL
difficulty minute. Repeat the count if bacterial INFECTION
infection. UNLIKELY
in more than 60 breaths per
• These thresholds are based on axillary
feeding? minute. temperature. The thresholds for rectal temperature
• Has the • Look for severe chest reading are approximately 0.5C higher.
infant indrawing. • If referral is not possible, management the sick
had • Measure axillary young infant as described in the national referral
convulsio temperature. care guidelines or WHO Pocket Book for hospital
care for children.
ns (fits)? • Look at the umbilicus. Is it
red or draining pus? Treatment of Sever Disease and Local Bacterial
• Look for skin pustules. Infection
• Look at the young infant's • Give first dose of Intramuscular Antibiotics
movements. - Give first dose of both ampicillin and
gentamicin intramuscularly.
If infant is sleeping, ask the WEIGHT AMPICILLIN GENTAMICIN
mother to wake him/her. Dose: 50 mg
- Does the infant move on per kg
To a vial of
his/her own? 250 mg
Add 1.3 ml Undiluted 2 ml vial
If the young infant is not sterile water = containing 20 mg = 2
moving, gently stimulate 250 mg/1.5ml ml at 10 mg/ml OR Add
him/her. 6 ml sterile water to 2
ml vial containing 80
- Does the infant not move
mg* = 8 ml at 10 mg/ml
at all? AGE <7 AGE >= 7
days days
Dose: 5 Dose: 7.5
CLASSIFY ALL YOUNG INFANTS mg per kg mg per kg
Any one of the Pink: • Give first dose 1 - <1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
following signs: VERY of 1.5 - <2 kg 0.5 ml 0.9 ml* 1.3 ml*
• Not feeding SEVERE intramuscular 2 - <2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
well DISEASE antibiotics 2.5 - <3 kg 0.8 ml 1.4 ml* 2.0 ml*
• Convulsions • Treat to 3 - <3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
• Fast prevent low 3.5 - <4 kg 1.1 ml 1.9 ml* 2.8 ml*
breathing (60 blood sugar 4 - <4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
breaths per • Refer
minute or URGENTLY to • Avoid using undiluted 40 mg/ml gentamicin.
more) hospital • Referral is the best option for a young infant
• Severe chest • Advise mother classified with VERY SEVERE DISEASE. If referral
indrawing how to keep is not possible, continue to give ampicillin and
• Fever (37.5C the infant gentamicin for at least 5 days. Give ampicillin two
or above) warm on the times daily to infants less than one week of age and
• Low body way to the 3 times daily to infants one week or older. Give
temperature hospital. gentamicin once daily.
(less than
35.5C) TREAT THE YOUNG INFANT TO AVOID LOW BLOOD
• Movement SUGAR
only when
stimulated or
• If the young infant is able to breastfeed:
no
- Ask the mother to breastfeed the young infant.
movement at
all. • If the young infant is not able to breastfeed but
is able to swallow:
• Umbilicus LOCAL • Give an
- Give 20-50 ml (10 ml/kg) expressed breast milk
red or BACTERIA appropriate
before departure. If not possible to give
draining pus INFECTION oral antibiotic
expressed breast milk, give 20-50 ml (10
• Skin • Teach the ml/kg) sugar water (To make sugar water:
pustules mother to treat
Dissolve 4 level teaspoons of sugar (20 grams)
local infections in a 200-ml cup of clean water).
at home
• If the young infant is not able to swallow:
- Give 20-50 ml (10 ml/kg) of expressed breast than 24 •Refer

milk or sugar water by nasogastric tube. hours URGENTLY
• Yellow to hospital
TEACH THE MOTHER HOW TO KEEP THE YOUNG palms and • Advise
INFANT WARM ON THE WAY TO THE HOSPITAL soles at any mother how
age to keep the
• Provide skin to skin contact
infant warm
• Keep the young infant clothed or covered as much as on the way to
possible all the time. Dress the young infant with extra the hospital
clothing including hat, gloves, socks and wrap the • Jaundice JAUNDICE • Advise the
infant in a soft dry cloth and cover with a blanket. appearing mother to
after 24 give home
GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR hours of age care for the
LOCAL BACTERIAL INFECTION • Palms and young infant.
First-line antibiotic: __________________ soles not • Advise
Second-line antibiotic: ________________ yellow mother to
AGE OR WEIGHT AMOXICILLIN return
Give 2 times daily for 5 immediately
days if palms and
soles appear
Tablet Syrup
yellow.
250mg 125 mg in
5 ml • If the young
Birth up to 1 month (<4 ¼ 2.5 ml infant is older
kg) than 14 days,
refer to a
1 month up to 2 months ½ 5 ml
hospital for
(4-<6 kg)
assessment
• Follow-up in
TEACH THE MOTHER TO TREAT LOCAL
1 day
INFECTIONS AT HOME
No jaundice NO JAUNDICE Advice the
• Explain how the treatment is given. mother to give
• Watch her as she does the first treatment in the home care to the
clinic. young infant.
• Tell her to return to the clinic if the infection
worsens. DIARRHEA
What is diarrhea in a young infant?
To Treat Skin Pustules To Treat Thrush (ulcers • A young infant has diarrhea if the stools have
or Umbilical Infection or white patches in change from usual pattern and are many and
• The mother should mouth) watery (more water than fecal matter)
do the treatment The mother should do the • The normally frequent or semi-solid stools of a
twice daily for 5 days: treatment four times daily breastfed baby are not diarrhea.
- Wash hands for 7 days:
- Gently wash off - Wash hands
- Paint the mouth Ask: Does the young infant have diarrhea?
pus and crusts
with half-strength IF YES, LOOK AND FEEL:
with soap and
water gentian violet • Look at the young infant's general condition:
- Dry the area (0.25%) using a Infant's movements
- Paint the skin or soft cloth - Does the infant move on his/her own?
umbilicus/cord wrapped around - Does the infant not move even when
with full strength the finger stimulated but then stops?
gentian violet - Wash hands - Does the infant not move at all?
(0.5%) - Is the infant restless and irritable?
- Wash hands • Look for sunken eyes.
* To Treat Diarrhea, See TREAT THE CHILD Chart* • Pinch the skin of the abdomen. Does it go back:
- Very slowly (longer than 2 seconds)? OR
slowly?
JAUNDICE
CLASSIFY DIARRHEA FOR DEHYDRATION
Two of the Pink: If infant has no
following SEVERE other severe
If jaundice LOOK AND FEEL: signs: DEHYDRATION classification:
present, • Look for jaundice (yellow • Movement • Give fluid for
only when severe
ASK: eyes or skin)
stimulated dehydration
When did the • Look at the young infant's or no (Plan C)
jaundice palms and soles. Are they movement
appear first? yellow? at all If infant also has
• Sunken another severe
eyes classification:
CLASSIFY JAUNDICE • Skin pinch • Refer
• Any Pink: • Treat to goes back URGENTLY
jaundice if SEVERE prevent low very to hospital
age less JAUNDICE blood sugar slowly. with mother
giving • Perform HIV test for the mother; if positive, perform

frequent sips virological test for the young infant.
of ORS on CLASSIFY HIV STATUS
the way • Positive CONFIRME • Give
• Advise the virological D HIV cotrimoxazole
mother to test in young INFECTION prophylaxis
continue infant from age 4-6
breastfeeding weeks
Two of the SOME • Give fluid and • Give HIV ART
following DEHYDRATION breast milk for and care
signs: some • Advise the
• Restless dehydration mother on home
and (Plan B) care
irritable • Follow-up
• Sunken If infant has any regularly as per
eyes severe national
• Skin pinch classification: guidelines
goes back • Refer • Mother HIV- HIV • Give
slowly. URGENTLY to positive EXPOSED cotrimoxazole
hospital with AND prophylaxis
mother giving negative from age 4-6
frequent sips virological weeks
of ORS on the test in a • Start or continue
way breastfeedi PMTCT ARV
• Advise the ng young prophylaxis as
mother to infant or per national
continue only recommendatio
breastfeeding stopped ns (PMTCT –
less than 6 Prevention of
• Advise mother weeks ago Maternal to
when to return OR Child
immediately • Mother HIV- Transmission)
• Follow-up in 2 positive, • Do virological
days if not young infant test at age 4-6
improving not yet weeks or repeat
Not enough NO • Give fluids to tested 6 weeks after
signs to DEHYDRATION treat diarrhea OR the child stops
classify as at home and • Positive breastfeeding
some or continue serological • Advise the
severe breastfeeding test in a mother on home
dehydration. (Plan A) young infant care
• Advise mother • Follow-up
when to return regularly as per
immediately national
• Follow-up in 2 guidelines
days if not Negative HIV HIV Treat, counsel and
improving. test in mother or INFECTION follow-up existing
child. UNLIKELY infections.
HIV INFECTION • Prevention of Maternal-To-Child-Transmission
(PMTCT) ART prophylaxis.
CHECK FOR HIV INFECTION • Initiate triple ART for all pregnant and lactating
Ask: women with HIV infection, and put their infants on
• Has the mother and/or young infant had an HIV ART prophylaxis from birth for 6 weeks if
test? breastfeeding or 4-6 weeks if on replacement
feeding.
IF YES:
• What is the mother's HIV status? FEEDING PROBLEM OR LOW WEIGHT FOR AGE
- Serological test POSITIVE or NEGATIVE *(except HIV-exposed young infants not breastfed)
• What is the young infant's HIV status?
- Virological test POSITIVE or NEGATIVE • Not well FEEDING • If not well attached
- Serological test POSITIVE or NEGATIVE attached to PROBLEM or sucking
breast OR LOW effectively, teach
If mother is HIV positive and NO positive virological • Not WEIGHT correct positioning
test in child ASK: suckling and attachment.
• Is the young infant breastfeeding now? effectively - If not able to
• Was the young infant breastfeeding at the time of • Less than 8 attach well
test or before it? breastfeeds immediately,
• Is the mother and young infant on PMTCT ARV in 24 hours teach mother
prophylaxis? • Receives to express
other foods breast milk
IF NO test: Mother and young infant status or drinks and feed by a
unknown cup.
• Low weight - If FEEDING PROBLEM OR LOW WEIGHT FOR AGE

for age breastfeeding *(for HIV-exposed young infants not breastfed)
• Thrush less than 8
(Ulcers or times in 24 • Milk FEEDING • Counsel the
white hours, advise incorrectly or PROBLEM OR mother
patches in to increase LOW WEIGHT
unhygienically about
mouth) frequency in
prepared feeding
feeding.
Advise • Giving • Explain the
mother to inappropriate guidelines
breastfeed as replacement for safe
often and as feeds replacement
long as the • Giving feeding
infants wants, insufficient • Identify
day and replacement concerns of
night. feeds mother and
• If receiving other • An HIV family about
foods or drinks, feeding
positive
counsel mother
mother mixing • If mother is
about
breastfeeding breast and using a
more, reducing other feeds bottle, teach
other foods or before 6 cup feeding
drinks, and using months • Advise the
a cup. If not • Using a mother how
breastfeeding at feeding bottle to feed and
all • Low weight for keep the low
- Refer for age weight infant
breastfeeding • Thrush (ulcers warm at
counselling home
or white
and possible
patches in • If thrush,
relactation.
- Advise about mouth teach the
correctly mother to
prepared treat thrush
breastmilk at home
substitutes • Advise
and using a mother to
cup. give home
- Advise care for the
mother how young infant
to feed and • Follow up
keep the low
any feeding
weight infant
warm at problem or
home thrush in 2
• If thrush, teach days
the mother to treat • Follow up
thrush at home. low weight
• Advise mother to for age in 14
give home care days
for the young Not low weight NO FEEDING • Advise
infant. for age and no PROBLEM mother to
• Follow-up any other signs of give home
feeding problem inadequate care for the
or thrush in 2 feeding. young infant.
days.
• Praise the
• Follow-up low
weight for age in mother for
14 days. feeding the
Not low weight NO • Advise mother to infant well.
for age and no FEEDING give home care
other signs of PROBLEM for the young
inadequate infant.
feeding. • Praise the mother
for feeding the
infant well.
COUNSEL THE MOTHER

Advise the mother to give home care for the young
infant
1. EXCLUSIVELY BREASTFEED THE YOUNG
INFANT
- Give only breastfeeds to the young infant. COMMUNICATE AND COUNSEL
Breastfeed frequently, as often and for as
long as the infant wants. GOOD CHECKING POOR QUESTIONS
2. MAKE SURE THAT THE YOUNG INFANT IS QUESTIONS
KEPT WARM AT ALL TIMES. How will you prepare the Do you remember how to
- In cool weather cover the infant's head and ORS solution? mix the ORS?
feet and dress the infant with extra clothing. How often should you Should you breastfeed
3. WHEN TO RETURN: breastfeed your child? your child?
FOLLOW-UP VISIT On what part of the eye do Have you used ointment
If the infant has: Return for first follow- you apply the ointment? on your child before?
up in: How much extra fluid will Do you know how to give
✓ Jaundice 1 day you give after each loose extra fluids?
stool?
✓ Local Bacterial 2 days
Infection Why is it important to Will you remember to
✓ Feeding Problem wash your hands? wash your hands?
✓ Thrush
✓ Diarrhea ASSESS BREASTFEEDING
✓ Low weight for age 14 days
✓ Confirmed HIV According to national Has the infant breastfed in the previous hours?
Infection recommendations • If the infant has not fed in the previous hour,
✓ HIV Exposed ask the mother to put her infant to the breast.
Observe the breastfeed for 4 minutes.
WHEN TO RETURN IMMEDIATELY: • If the infant was fed during the last hour, ask
the mother if she can wait and tell you when
the infant is willing to feed again.
Advise the mother to return immediately if the
• Is the infant well-attached?
young infant has any of these signs:
- Not well-attached
✓ Breastfeeding poorly
- Good attachment
✓ Reduced activity
To check attachment, look for:
✓ Becomes sicker
• Chin touching breast
✓ Develops a fever
✓ Feels unusually cold • Mouth wide open
✓ Fast breathing • Lower lip turned outwards
✓ Difficult breathing • More areola visible above than below the
✓ Palms and soles appear yellow mouth
(All of these signs should be present if the attachment

is good.)
Is the infant suckling effectively (That is, slow deep
sucks, sometimes pausing)?
• Not suckling effectively
• Suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
*Unless not breastfeeding, because the mother is HIV
positive*

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LECTURE 4: INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

MRS. BERNADETTE ORPEZA, RN `

INTEGRATED MANAGEMENT OF CHILDHOOD

Who are the children covered by the IMCI protocol?

What does IMCI offers?

Where is it intended to be used? Rationale for the integrated approach in the

Republic, Papua New Guinea, the Philippines,

Urgent pre-referral treatment and referral (RED)

If waray na problema, you are just going to enforce the

SELECTING THE APPROPRIATE CASE GENERAL DANGER SIGNS

COUGH OR DIFFICULTY BREATHING wheeze, refer for

a. Green older and

feeding a child also experiences persistent diarrhea for 3 days. What is

Treatment for Diarrhea: FEVER: MALARIA RISK

or • If pus • Persistent • Treat the

If yes: Look and feel:

CHECK FOR ACUTE MALNUTRITION

If WFH/L less than -3 z-scores or MUAC less than

when to - Max MNP into complementary food

Give Micronutrient Powder

WHEN TO RETURN IMMDIATELY

Advise mother to return immediately if the child

VERY SEVERE DISEASE AND LOCAL BACTERIAL • Advise mother

- Give 20-50 ml (10 ml/kg) of expressed breast than 24 •Refer

giving • Perform HIV test for the mother; if positive, perform

• Low weight - If FEEDING PROBLEM OR LOW WEIGHT FOR AGE

COUNSEL THE MOTHER

(All of these signs should be present if the attachment

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