INTERGRATED MANAGEMENT OF

CHILDHOOD ILLNESS ( IMCI)

BY IRERI IMMACULATE
 Introduction
• Children are not just little adults!!
• An adult gives you the history directly – a child
needs his parents to relay the history
• Adult somatic growth is complete – a child’s growth
is constantly changing in predictable ways
• An adult has completed all stages of development –
a child’s development and age are integrally
related and impact all aspects of her physical and
emotional states
 DIFFERENCES BETWEEN PAEDIATRIC HISTORY
AND ADULT HISTORY
• Content Differences
– Prenatal and birth history
– Developmental history
– Social history of family - environmental risks
– Immunization history
• Parent as Historian
– Parent’s interpretation of signs, symptoms
• Children above the age of 4 may be able to provide
some of their own history
• Reliability of parents’ observations varies
• Adjust wording of questions - “When did you first
notice Johnny was limping”? instead of “When did
Johnny’s hip pain start”?
– Observation of parent-child interactions
• Distractions to parents may interfere with
history taking
• Quality of relationship
– Parental behaviors/emotions are important
• Parental guilt -nonjudgmental/reassurance
 Outline of the Pediatric History
• Chief Complaint
– Brief statement of primary problem (including duration)
that caused family to seek medical attention
• History of Present Illness
– Initial statement identifying the historian, that person’s
relationship to patient and their reliability
– Age, sex, race, and other important identifying
information about patient
– Concise chronological account of the illness, including
any previous treatment with full description of
symptoms.
• Past Medical History
– Major medical illnesses
– Major surgical illnesses-list operations and dates
– Trauma-fractures, lacerations
– Previous hospital admissions with dates and diagnoses
– Current medications
– Known allergies (not just drugs)
• Immunization status - be specific, not just up
to date
•  Pregnancy and Birth History
– Maternal health during pregnancy: bleeding, trauma,
hypertension, fevers, infectious illnesses, medications,
drugs, alcohol, smoking, rupture of membranes
– Gestational age at delivery
– Labor and delivery - length of labor, fetal distress, type of
delivery (vaginal, cesarean section), use of forceps,
anesthesia, breech delivery
– Neonatal period - Apgar scores, breathing problems, use
of oxygen, need for intensive care, hyperbilirubinemia,
birth injuries, feeding problems, length of stay, birth
weight
• Developmental History
– Ages at which milestones were achieved and current
developmental abilities - smiling, rolling, sitting alone,
crawling, walking, running, 1st word, toilet training,
riding tricycle, etc (see developmental charts)
– School-present grade, specific problems, interaction with
peers
– Behavior - enuresis, temper tantrums, thumb sucking,
pica, nightmares etc.
• Feeding History
– Breast or bottle fed, types of formula, frequency and
amount, reasons for any changes in formula
– Solids - when introduced, problems created by
specific types
– Fluoride use
• Family History
– Illnesses - cardiac disease, hypertension, stroke,
diabetes, cancer, abnormal bleeding, allergy and asthma,
epilepsy
– Mental retardation, congenital anomalies, chromosomal
problems, growth problems, consanguinity, ethnic
background
• Social
– Living situation and conditions - daycare, safety issues
– Composition of family
– Occupation of parents
 Review of Systems:
• Weight - recent changes, weight at birth
• Skin and Lymph - rashes, adenopathy, lumps, bruising
and bleeding, pigmentation changes
• Headaches, concussions, unusual head shape,
strabismus, conjunctivitis, visual problems, hearing,
ear infections, draining ears, cold and sore throats,
tonsillitis, mouth breathing, snoring, apnea, oral
thrush, epistaxis, caries
• Cardiac - cyanosis and dyspnea, heart murmurs,
exercise tolerance, squatting, chest pain, palpitations
• Respiratory - pneumonia, bronchiolitis, wheezing,
chronic cough, sputum, hemoptysis, TB
• GI - stool color and character, diarrhea,
constipation, vomiting, hematemesis, jaundice,
abdominal pain, colic, appetite
• GU - frequency, dysuria, hematuria, discharge,
abdominal pains, quality of urinary stream,
polyuria, previous infections, facial edema
• Musculoskeletal - joint pains or swelling, fevers,
scoliosis, myalgia or weakness, injuries, gait changes
• Pubertal - secondary sexual characteristics, menses
and menstrual problems, pregnancies, sexual
activity
• Allergy - urticaria, hay fever, allergic rhinitis, asthma,
eczema, drug reactions
IMCI
• Integrated Management of
Childhood illness (IMCI)
18
 definition
• Is the integrated strategy that
combines and links together existing
child health programs
• Is an evidenced based, syndrome
approach to case management that
supports the rational, effective and
affordable use of drugs and diagnostic
tools.
• A joint WHO/UNICEF initiative since
1992.Currently focused on first level
health facilities
 OBJECTIVES OF IMCI
• To reduce significantly mortality and morbidity
associated with the major cause of diseases in
children
• To promote improved growth and development of
children under 5 years of age.
 PRINCIPLES OF IMCI CASE MANAGEMENT

• All sick children aged up to 5 years are examined for general

danger signs and all sick young infants are examined for very
severe disease. These signs indicate immediate referral or
admission to hospital
• The children and infants are then assessed for main symptoms.
For older children, the main symptoms include: cough or
difficulty breathing, diarrhea, fever and ear infection. For young
children, local bacterial infection, diarrhea and jaundice. All
sick children are routinely assessed for nutritional and
immunization and deworming status and other problems
• Only a limited number of clinical signs are used
• A combination of individual signs leads to a child’s classification
within one or more symptom groups rather than a diagnosis.
• IMCI management procedures use limited
number of essential drugs and encourage active
participation of  caretakers in the treatment of
children
• Counseling of caretakers on home care, correct
feeding and giving of fluids, and when to return to
clinic is an essential component of IMCI
 Essential IMCI Drugs at Health Facilities

• Oresol
• Oral antibiotics
• (1st line – Cotrimoxazole
• Oral anti malarial
• 1st LINE_ Artemether Lumefantine
• 2nd line – Oral and parenteral Quinine
• Tetracycline tablets
• Iron
• Vitamin A
• Paracetamol
• Vaccines
• Mebendazole /Albendazole
• Tetracycline eye ointment
• Gentian violet
• Chloramphenicol IM (optional)
• Gentamicin IM (optional)
• Benzyl Penicillin IM (Optional)
 INTRODUCTION
- 70% of children under five years die from
pneumonia, diarrhea, malaria, measles and
malnutrition.
- There are feasible and effective ways health workers
can care for children with these illness and prevent
most of the deaths.
- WHO and UNICEF uses updated technical findings to
describe management of these illness in a set of
combined guidelines instead of using separate
guidelines for each illness.
• IMCI helps a health worker to quickly consider all
of child’s symptoms and not overlook any
problem.
• There is also counseling to mothers and other
care givers on importance of seeking care for a
sick child before a child becomes extremely sick
and follow up visits.
 CASE MANAGEMENT PROCESS
1. Assess the child or Young infant
2. Classify the illness
3. Identify Treatment
4. Treat the child
5. Counsel the mother
6. Give follow-up care
 PURPOSE OF IMCI
1. Assess signs and symptoms of illness, nutrition,
immunization and Vitamin A supplementation
status
2. Classify the illness
3. Identifying Treatment for the child’s classification
of illness and deciding on referral
4. Giving important pre-referral medication
5. Providing Treatments in the clinic.
eg.Vit.A,ORS,DRUGS.
6.Teaching mothers to give specific treatment at
home.eg.oral antibiotics
7. Counselling the mother on feeding and return
dates
8.Reassessing during follow up and providing
appropriate care.
• NB: Most classification tables have 3 rows
colored pink, yellow or Green depending on
the seriousness of the childs illness.
THE LEGEND .
 SEVERE CLASSIFICATION.A CLASSIFICATION
THAT NEEDS URGENT REFERRAL AFTER FIRST
DOSE OF APPROPRIATE ANTIBIOTIC AND
ADMISSION IN A HOSPITAL

 LESS SEVERE CLASSIFICATION.THE CHILD NEEDS

AN APPROPRIATE ANTIBIOTIC OR OTHER ORAL
TREATMENT.A CLASSIFICATION THAT NEEDS
TREAMENT AT HOME AND HEALTH EDUCATION

 CHILD DOESN’T NEED SPECIFIC MEDICAL

TREATMENT.A CLASSIFICATION THAT NEEDS
HEALTH EDUCATION TO THE MOTHER.

32
• Assess and Classify the
Sick Child Aged 2 months
up to 5 years
• This describes how to assess and classify sick
children so that signs of diseases are not
overlooked.
• According to the chart, the mother is asked
about the childs’ problems and he/she is
examined for general danger signs.
• Four main symptoms are considered
- Cough and Difficult in breathing
- Diarrhea
- Fever
- Ear Problem
A child with one or more of the main symptoms could
have a serious illness.
Children with HIV may be ill more often and illness
may be more severe.
 Skills to be learnt include:
• Asking the mother what the child’s problem is
• Checking for General danger signs.
• Asking the mother about the four main symptom
• When a main symptom is present,assess the child
further for signs related to the main symptoms,
classifying illness according to signs present
• Checking for signs of malnutrition and anemia and
classifying a childs nutrition status.
• Checking the child for symptomatic HIV infection.
• Checking the childs’ immunisation status and
Vit.A implementation status.
• Asking any other problem.
1.ASK THE MOTHER WHAT THE CHILDS PROBLEM ARE:
- A child may be brought to the clinic because it is
sick, well child visits, immunizations and treatment
of injuries
- IMCI Charts are not to be used on a well child
brought for immunization or for a child with any
injury or burn.
• When you see a mother and the sick child
- Greet the mother appropriately
-Ask the mother what the childs problem are-
ensure you have good communication skills.
-Determine if it is an initial visit or follow up
visit for the problem.
CHECK FOR GENERAL DANGER SIGN
A danger sign is present if:
-A child is not able to feed /breastfeed
- The child vomits everything
- The child has had convulsions or is convulsing now.
-The child is lethargic or unconsciousness.
NB: Most children with a General danger sign needs
urgent referral to the hospital.
3.ASSESS AND CLASSIFY COUGH OR DIFFICULT IN
BREATHING
A child with cough and difficult in breathing may have
pneumonia or another severe respiratory infection.
Two clinical signs suggesting pneumonia are:- fast
breathing and chest in drawing.
• A child with difficult breathing is assessed for:
- How long the child has had cough or difficult in
breathing
-Fast beathing;2/12-1 year-more than 50 breaths
per min,1yr-5 yr-More than 40 breaths per min.
-Chest in drawing
-Stridor in a calm child
-Wheeze
 CLASSIFY COUGH AND DIFFICULT IN
BREATHING
• The three possible classification for this are:-
- Severe pneumonia or Very severe Disease
-Pneumonia
-No pneumonia
 SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)

* Any general SEVERE  Give first dose of an appropriate

danger sign PNEUMONIA
or
antibiotics.( penicillin)
OR
* Chest VERY
 Give Vitamin A.
indrawing or SEVERE  Treat the child to prevent low blood
* Stridor in DISEASE
sugar.
calm child.
 Refer URGENTLY to hospital.

 Give an appropriate antibiotic

* Fast breathing PNEUMONIA
( amoxicillin) for 5 days.
 Soothe throat and relieve the cough with a
safe remedy.
 Advise mother when to return immediately
 Follow-up in 2 days.
 If coughing more than 30 days, refer for
No signs of NO PNEUMONIA assessment.
COUGH OR
pneumonia COLD  Soothe the throat and relievee the cough
or every with a safe remedy.
severe  Advise mother when to return immediately.
disease  Follow-up in 5 days if not improving.
44
 MANAGEMENT
• SEVERE PNEUMONIA OR VERY SEVERE DISEASE
- A child with chest in drawing usually has severe
pneumonia or it may have another serious acute
lower respiratory infection. eg.bronchiolitis,
pertusis or wheezing problem.
- Chest in drawing develops when lungs become stiff
and the child needs more effort to breath and the
breathing may become slowed.
- It may be the only sign of severe pneumonia
- Chest in drawing is also an entry sign for suspected
symptomatic HIV infection.
• The child need urgent referral to a hospital for
teatment.eg.Oxygen and I.V. antibiotics.
• Before referral, administer appropriate antibiotic
to prevent pneumonia from worsening.
• Also treat other serious bacteria infection .eg.
sepsis and meningitis
• Treat the child to prevent low blood sugar.
• Incase of convulsions, manage airway and give
diazepam.
• Check the child for suspected symptomatic HIV
infection.
 PNEUMONIA
• A child with fast breathing and no danger sign
is classified as having pneumonia
TREATMENT
- Give an appropriate antibiotic
- Give vitamin A
- Teach the mother to give antibiotics at home
- Advice her on when to return.
 No pneumonia,cough or cold
• There is no need for an antibiotic
• Advice the mother on good home care of the child
using the home remedy.eg. warm beverages
• Incase of a chronic cough, refer the child to hospital
for further assessment.
ASSESS AND CLASSIFY DIARRHOEA
• Diarrhoea is the passing of 3 or more watery
stools in a 24 hour period.
• Common in babies under 6 months on
formula feeds or cows’ milk.
• TYPES OF DIARRHOEA
a) Acute Diarrhea
-lasts less than 14 days
-Causes dehydration
- Leads to malnutrition
b) Persistent diarrhea
-Lasts more than 14 days
- Causes nutritional problems
-Contributes to death in children
-Found mainly in HIV infections
• Child with diarrhea is assessed for:
- Duration of diarrhea
-Presence of blood in stool
-Signs of dehydration
 ASSESS DIARRHEA
- General condition
- Abnormally sleepy-Lethargic/unconsciousness
- Restless or irritable
- Sunken eyes
- Assess for blood in stools
• Observe the child as he drinks
• Assess if the child drinks
-Normally
- eagerly/Thirsty
- Weakly
Pinch the skin of the abdomen;
- Does it go back very slowly
- Goes back slowly
- Goes back normally.
 CLASSIFY DIARRHOEA
CLASSIFY DEHYDRATION IN ACUTE DIARRHOEA
1. Severe dehydration
2. Some dehydration
3. No dehydration
CLASSIFY PERSISTENT DIARRHEA AS:
1.Severe persistent diarrhea
2.Persistent diarrhea
• Presence of blood in stool is classified as
dysentry.
TWO OF THE  If child has no other severe classification:
FOLLOWING SIGNS: -Give fluid to severe dehydration (Plan C.)
SEVERE OR
* ABNORMALLY
If child also has another severe
SLEEPY OR DEHYDR classification:
DIFFICULT TO
AWAKEN ATION -Refer URGENTLY to hospital with mother
* SUNKEN EYES giving frequent slps of ORS on the way.
* NOT ABLE TO
DRINK OR
Advise the mother to continue breastfeeding.
DRINKING  If child is 2 years or older and there is cholera
POORLY in your area, give antibiotic for cholera.
* SKIN PINCH GOES
BACK VERY
SLOWLY

TWO OF THE  Give fluid and food for some dehydration (Plan B).
FOLLOWING SIGNS:
 If child also has a severe classification:
* RESTLESS,
SOME -Refer URGENTLY to hospital with mother giving
IRRITABLE DEHYDRATIO frequent sips of ORS on the way.
* SUNKEN EYES N Advise mother to continue breastfeeding.
* DRINKS EAGERLY,  Advise mother when to return immediately.
THIRSTY  Follow-up in 5 days if not improving.
* SKIN PINCH GOES
BACK
SLOWLY.

NO
 Give fluid and food to treat diarrhea at
NOT ENOUGH
SIGNS DEHYDRATION home (Plan A).
TO CLASSIFY AS  Advise mother when to return immediately.
SOME OR  Follow-up in 5 days if not improving .
SEVERE 57
DEHYDRATION.
 THEN ASK: Duration of diarrhoea≥ 14 days
DEHYDRATIO  Treat dehydration before referral unless
N SEVERE
the child has another severe
PRESENT PERSISTEN classification.
T  Give Vitamins A.
DIARRH
EA
 Refer to hospital

PERSISTENT
 ADVISE THE MOTHER ON FEEDING A
* No CHILD WHO HAS PERSISTENT DIARRHEA.
DIARRHEA
Dehydration  GIVE VITAMIN A.
 FOLLOW-UP IN 5 DAYS.

 Treat for 5 days with an oral antibiotic

* Blood in the DYSENTERY recommended for Shigella in your area.
stool  Follow-up in 2 days.

58
 MANAGEMENT OF DIARRHOE/GE
• Antibiotics are NOT indicated unless there is
dysentry or persistent diarrhea and proven
amoebiasis or girdiasis.
• All cases should receive zinc sulphate
• Manage nutrition of the child
• Pharmacological management-antibiotics used
only when the diseases associated with diarrhea
are confirmed.
Management of dehydration
 Management of severe dehydration
PLAN C:TREAT SEVERE DEHYDRATION IN THE CLINIC
-Give Ringers lactate in divided doses as follows
- Give 30mls/Kg in 1 hour if child is below 1 year and
over ½ hour if above 1 year.
- Another alternative is 70 ml/kg of Ringers lactate in
5 hours for under 1 year and over 21/2 hours for
above one year
- Reassess at least hourly,after every 3-6
hours,reclassify as severe,some or no dehydration.
• Another alternative is use of NGT where
100mls/Kg of ORS is given over 6 hours.
PLAN B;TREAT SOME DEHYDRATION WITH ORS
-It includes an initial treatment period of 4 hours in
the clinic
Give ORS 75mls/Kg over a period of 4 hours
- After four hours, reassess and classify the child for
dehydration and choose appropriate plan to
continue with.
PLAN A:TREAT DIARRHEA AT HOME
- This is for treatment of a child who has diarrhea
but no dehydration.
- Three rules apply in home treatment.
- Give extra fluid
- Continue breast feeding
- Give ORS 10mls/Kg after every loose stool
- Return for follow up
 SEVERE PERSISTENT DIARRHOEA
• Treat dehydration using appropriate fluid
plan.ie.plan C
• Advice mother to feed the child frequently
• Give vitamins and minerals
• Identify and treat infections
• Monitor the child
• JOEL , 11 MONTHS OLD, WEIGH S 8 KG .HE COMES
TO THE CLINIC TODAY BECAUSE HE HAD
DIARRHOEA. HE HAS NO BLOOD IN THE STOOL . HE
IS IRRITABLE. HIS EYES ARE SUNKEN.THE HEALTH
WORKER OFFERS THE CHILD FLUID , AND THE CHILD
DRINKS EAGERLY . WHEN THE HEALTH WORKER
PINCHES THE SKIN OF THE ABDOMEN , IT GOES
BACK SLOWLY. ASSESS AND CLASSIFY JOELS ILLNESS.
 ASSESS AND CLASSIFY FEVER
• A child with fever may have malaria,measles,or a
simple cough,cold,viral infections or a very severe
disease.
• MALARIA
- It’s a protozoa infection caused by plasmodium
species especially P.falciparum.
- It’s a major public health problem in Kenya
- It has two epidemiological situations
a) Stable Malaria
-Occurs in high rainfall areas within lake basins or
coastal strips.
-These are also known as High malaria risk areas.
-Nearly all populations have the parasite in most
parts of the year especially children and pregnant
women
b) Unstable Malaria
-Is seasonal and follows rainfall pattern.
- Becomes epidemic with prolonged rainfall
-All ages are affected and can develop severe
disease
-Areas affected are Low Malaria Risk areas.
 ASSESS FOR FEVER
• Does the child feel hot or temperature of 37.5◦c
• Then ask:
- For how long,
-If more than 7 days,has fever been present
everyday?
-Has the child had measles within the last 3
months
• Look and feel for stiff neck
• Look for runny nose
• Look for signs of Measles
- Generalised rash and
- One of these:cough,runny nose or red eyes.
• If the child has measles now or within the last
three months
-Look for mouth ulcers
- Look for pus draining from the eye
-Look for clouding of the cornea.
  Give first dose of quinine (under medical
* Any VERY supervision or if a hospital is not
general SEVERE accessible within 4 hours.
danger FEBRILE  Give first dose of an appropriate
sign or DISEAS antibiotic.
* Stiff neck. E/  Treat the child to prevent low blood
MALARIA sugar.
 Give one dose of paracetamol in health
center for high fever (37.5 0C or above).
 Send a blood smear with the patient.
 Refer URGENTLY to hospital.
  Treat the child with an oral antimalarial.

* Blood  Give one dose of paracetamol in health center

smear (+) MALARIA
for high fever (37.5 0C or above).
If blood  Advise mother when to return immediately.
smear  Follow-up in 2 days if fever persists.
not
 If fever is present every day for more than 7
done:
* NO runny days, refer for assessment.
nose,
and
* NO
measles,
and
* NO other
causes of
fever
 THEN ASK: Does the Child have Fever?

 Give first dose of quinine (under medical

VERY SEVERE supervision or if a hospital is not accessible
FEBRILE DISEASE/
within 4 hours.
* Any general MALARIA
 Give first dose of an appropriate antibiotic.
danger sign
or
 Treat the child to prevent low blood sugar.
* Stiff neck.
 Give one dose of paracetamol in health center
for high fever (37.5 0C or above).
 Send a blood smear with the patient.
 Refer URGENTLY to hospital.
 Treat the child with an oral antimalarial.
* Blood smear (+)  Give one dose of paracetamol in health center
If blood smear MALARIA
not done:
for high fever (37.5 0C or above).
* NO runny nose,  Advise mother when to return immediately.
and  Follow-up in 2 days if fever persists.
* NO measles, and
* NO other causes
 If fever is present every day for more than 7
of fever days, refer for assessment.

FEVER:
 Give one dose of paracetamol in health
* Blood smear
(-), or MALARIA center for high fever (37.5 0C or above).
* Runny nose, or UNLIKELY  Advise mother when to return immediately.
* Measles, or  Follow-up in 2 days if fever persists.
* Other causes  If fever is present every day for more than 7
of fever
days, refer for assessment.
75
 THEN ASK: Does the Child have Fever?

 Give vitamin A.
* Clouding of SEVERE  Give first dose of an appropriate
cornea or COMPLICATED antibiotic.
* Deep or MEASLES ***
 If clouding of the cornea or pus draining
extensive from the eye, apply tetracycline eye
Mouth ulcers ointment.
 Refer URGENTLY to hospital.

MEASLES WITH  Give Vitamin A.

*Pus draining EYE OR MOUTH
from COMPLICATIONS
 If pus draining from the eye, apply
the eye or *** tetracycline eye ointment.
* Mouth ulcers
 If mouth ulcers, teach the mother to
treat with gentian violet.
 Follow-up in 2 days

MEASLES
 Give Vitamin A.
*Measles now
or
within the last 3
months

76
 THEN ASK: Does the Child have Fever?

* *Bleeding from
 If skin petechiae or positive
nose or gums or SEVERE tourniquet tests are the only positive
HEMORRHAGIC
*Bleeding in
stools or FEVER
signs give ORS.
vomitus or  If any other signs are positive, give
*Black stools or
vomitus or
fluids rapidly as in Plan C.
*Skin petechiae  Treat the child to prevent low blood
or
*Cold and sugar.
clammy
extremities or
 Refer all children URGENTLY to
*Capillary refill hospital.
more
than 3 seconds
 DO NOT GIVE ASPIRIN.
or
*Abdominal pain
and
vomiting
* Tourniquet test
positive.

*No signs of
FEVER: DENGUE  Advise mother when to return
severe
HEMORRHAGIC
FEVER
immediately.
hemorrhagic fever
UNLIKELY  Follow up in 2 days if fever persists
or child shows signs of bleeding.
 DO NOT GIVE ASPIRIN.
77
NB: To classify and treat fever, one must know the
malaria risk in the area.
There is high malaria risk if most of the fever cases
are due to malaria
There is low malaria risk if less than 5% of fever cases
are due to malaria.
• MEASLES
- The main signs of measles are fever and generalized
rash.
- It is highly infectious especially in overcrowded
areas.
- Etiology- caused by a virus
- It infects the skin and layers of the cells lining the
lungs,gut,eye,mouth and throat. There is also
damage to the immune system.
• Complications include
-Diarrhea
-Pneumonia
-Mouth ulcers
-Ear infections
-Severe eye infection and blindness.
Leads to malnutrition secondary to diarrhoea and
mouth ulcers.
• Grace is 4 months old. She weighs 5.5kg. Her
temperature is 38.0C. She is in the health
center today because she has diarrhea. She
does not have any General Danger Signs. She
is not coughing and does not have difficult
breathing. Assess and classify Grace illness.
 ASSESS AND CLASSIFY EAR PROBLEM

• Assess for:
- Ear pain
- Ear discharge and duration
- Tender swelling behind the ear-Mastoiditis
TENDER MASTOIDITIS UURGENT REFERRAL
SWELLING ADMINISTER FIRST DOSE OF APPROPRIATE
BEHIND THE
EAR
CLASSIFICATION ANTIBIOTICS
ADMINISTER PARACETAMOL FOR PAIN
SURGERY

PUS DRAINS ACUTE EAR INFECTION ADMINISTER ORAL ANTIBIOTICS

FROM THE Acute PARACETAMOL FOR PAIN
EAR< 14 DAYS WICKING TO DRY THE EAR
EAR PAIN

PUS DRAINS CHRONIC EAR INFECTION WICKING TO DRY THE EAR

FROM THE EAR DON’T GIVE REPEATED COURSES OF
FOR MORE ANTIBIOTIC
THAN 14 DAYS  
 
OR
NO EAR NO EAR INFECTION NO TREATMENT NEEDED
INFECTION
 ASSESS FOR MALNUTRITION AND
ANAEMIA
Visible severe wasting SEVERE Urgent referral
Severe pal mar pallor MALNUTRITION/SEVERE Special feeding
Edema of both feet ANEMIA Antibiotic Treatment
Weight below very low Vitamin A
weight curve Treat to prevent low blood
sugar
Some pal mar pallor ANEMIA/VERY LOW WEIGHT -Administer Iron
Very low weight for age -Administer Ant malarias in
high risk areas
-Mebendazole for
Hookworms/Whip worms
-Advice follow up in 2/52 for
palmar pallor and 1/12 for
very low weight
No pallor NO ANEMIA/NOT VERY LOW -Assess childs feeding and
No signs of malnutrition WEIGHT. advice on proper feeding
-Administer Mebendazole if
child is >2 years
NB: Growth faltering and very low weight is an
entry sign for suspected HIV infection.
 ASSESS FOR SUSPECTED SYMPTOMATIC HIV
INFECTION
• Assess for Symptomatic HIV Infection.
• 3 or more of he following:
-Enlargement of lymph nodes
-Oral thrush
-Growth faltering
-Fast breathing/chest in drawing
-TB in any of the parents in the last 5 years
-2 or more episodes of diarrhea lasting more than
14 days.
Any 3 of the following SUSPECTED SYMPTOMATIC HIV
-Enlargement of lymph nodes of INFECTION
neck,axilla or groin
-Oral thrush
-Growth faltering
-Fast breathing/chest in drawing
-TB in any of the parents in the last 5
years
-2 or more episodes of diarrhea
lasting more than 14 days.

Less than three of the above NO SUSPECTED SYMPTOMATIC HIV

INFECTION
 CHECK FOR IMMUNISATION STATUS
AND VIT A SUPPLEMENTATION STATUS
• Use recommended immunization schedule
• Give recommended vaccine if the child is due.
• NB:CONTRAINDICATIONS TO IMMUNISATIONS
1. Do not give BCG and Yellow fever vaccine to a child
known to have Symptomatic HIV infection
2. Do not give Pentavalent 2 and 3 to a child who has
had convulsion or shock within 3 days of the recent
dose.
3. Do not give Pentavalent to a child with recurrent
convulsion or another neurological disease.
• Children with diarrhea due for OPV should
receive it but should return in 4 weeks for an
extra OPV dose
• If a child is going to be refered,do not immunize
the child before referal.The hospital staff should
make the decision about immunizing the child
once admitted.
 WHO/UNICEF Recommendations for HIV Infected Children

Vaccine Asymptomatic Symptomatic Optimal timing of

HIV HIV immunization
BCG Yes No Birth

DPT Yes Yes 6, 10, 14 wks

PCV 10 Yes Yes 6, 10, 14 wks

OPV* Yes Yes 0, 6, 10, 14 wks

Measles Yes Yes 6 and 9 months

Hepatitis B & HiB Yes Yes 6, 10, 14 wks

Yellow fever Yes No** 9 months

* IPV an alternative for children with symptomatic HIV

** Pending further studies
90
 ASSESS ANY OTHER PROBLEM THE CHILD
HAS.
• Since ASSESS and CLASSIFY does not address all
of the sick Childs' problems, you will now assess
other problems the mother told you about. She
may have said the child has skin infection, itching
or swollen lymph nodes.
• Identify and treat any other problems according
to your training, experience and clinic policy.
Assess, Classify and Treat the
Sick Young Infant Age 1 week
up to 2 months
• To assess the young infant, Ask if the infant has had
convulsions.
• look and feel for:
-Number of breaths in 1 minute
- Look for severe chest in drawing
- Look for nasal flaring
- Look for grunting and wheezing
- Look and feel for bulging Fontanelle.
- Look for pus draining from eyes and ears
- Look for pus draining from OR redness of the
umbilicus
- Measure the Temperature
- Look for skin pustules
- Assess if infant is lethargic or unconscious.
- Look for movements.
 CHECK FOR POSSIBLE BACTERIAL INFECTION
SIGNS CLASSIFY AS TREATMENT
* Convulsion or POSSIBLE * Give first dose of an
* Fast breathing (60 breaths per SERIOUS appropriate
minute or more) or BACTERIAL antibiotics.
* Severe chest in drawing or INFECTION/ * Give Vitamin A.
* Nasal flaring or
NEONATAL * Treat the child to
* Grunting or
SEPSIS prevent low blood
* Bulging fontanelle or
sugar.
* Pus draining from ear or
* Umbilical redness extending to * Refer URGENTLY to
the skin or hospital.
* Fever (37.5ºC* or above or feels
hot) or low body temperature
(less than (35.5ºC* or feels cold)
or
* Many or severe skin pustules or
* Abnormally sleepy or difficulty to
awaken or
* Less than normal movement

95
 LOCAL * Give an appropriate
* Red umbilicus or draining pus BACTER oral antibiotic
or IAL
* Skin pustules * Treat local
INFECTI
ON infection in the
health centre and
teach the mother to
treat local
infections at home
* Advise mother to
give home care for
the young infant
* Follow up in 2
days
 ASSESS FOR DIARRHEA
• Diarrhoea
• Blood in the stool
• Restless and irritable
• Sunken eyes
• Very slow skin pinch
 THEN ASK: Does the young infant have diarrheal

* If infant does not have POSSIBLE SERIOUS

Two of the following
BACTERIAL INFECTION nor DYSENTERY
Abnormally sleepy SEVERE
or difficult to awaken - Give fluid for severe dehydration (Plan C) OR
DEHYDRATION
* Sunken eyes
* Not able to drink or * If infant also has POSSIBLE SERIOUS BACTERIAL
drinking poorly
INFECTION or DYSENTERY
* Skin pinch goes
back very slowly - Refer URGENTLY to hospital with mother giving
frequent sips or ORS on the way.
Advise mother to continue breastfeeding

Two of the following

* Give fluid and food for some dehydration (Plan B).
signs:
SOME
* If infant also has POSSIBLE SERIOUS
* Restless, irritable DEHYDRATION BACTERIAL INFECTION or DYSENTERY
* Sunken eyes - Refer URGENTLY to hospital with mother
* Drinks eagerly, giving frequent sips or ORS on the way.
thirsty
* Skin pinch goes
Advise mother to continue breastfeeding
back slowly.

NO
 Give fluid and food to treat diarrhoea at home
Not enough
DEHYDRATION
(Plan A).
signs to
classify as some
or
severe
dehydration 98
.
 THEN ASK: Does the young infant have diarrhoea

SEVERE * If young infant is dehydrated, treat

* Dehydration PERSISTENT dehydration before referral unless the infant
lasting 14 DIARRHEA has also POSSIBLE SERIOUS BACTERIAL
days or INFECTION
more
* Refer to hospital.

* Refer URGENTLY to hospital with mother

* Blood in DYSENTERY giving frequent sips or ORS on the way.
the Advise mother to continue breastfeeding
stool

99
 ASSESS FOR FEEDING PROBLEMS
CHECK IF AN INFANT HAS:

• Any difficulty feeding

• Is infant breastfeeding
• Breastfeeding less than 8 times in 24 hours
• Taking other foods or fluids
• Low weight for age
 THEN CHECK FOR FEEDING PROBLEM OR
LOW WEIGHT:
* Not able to feed
or
* No attachment at
all or
* Not sucking at all
* Not well attached to
breast .
* Not suckling effectively
or
* Less than 8 breast
feedings in 24 hours or
* Receives other foods or
drinks or
* Low weight for age or
* Thrush (ulcers or white
patches in mouth)
* Not low weight for age and
no other signs of
inadequate feeding
NOT AB LE TO FEED _ * Give first dose of intramuscular antibiotics
POSSIBLE SERIOUS
* Treat to prevent low blood sugar
BACTERIAL INFECTION
* Advise the mother how to keep the young infant warm on the
way to the hospital
* Refer URGENTLY to hospital
* Advise the mother to breastfeed as often and for as long as the infant wants,
day and night
FEEDING PROBLEM
- If not well attached or not suckling effectively, teach correct positioning and
OR LOW WEIGHT attachment.
- If breastfeeding less than 8 times in 24 hours, advise to increase frequency of
feeding
* If receiving other foods or drinks, counsel mother about breastfeeding more,
reducing other foods or drinks, using a cup
- If not breastfeeding at all:
1. Refer for breastfeeding counselling and possible relaxation
2. Advise about correctly preparing breast milk substitutes and using a cup
* If thrush, teach the mother to treat thrush at home
* Advise mother to give home care for the young infant
* Follow-up any feeding problem or thrush in 2 days
Follow-up low weight for age in 14 days
* Advise mother to give home care for the young infant
NO FEEDING PROBLEM * Praise the mother for feeding the infant well
101
 THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT:

* Not able NOT ABLE * Give first dose of

to feed or TO FEED intramuscular antibiotics
* No POSSIBLE
attachmen SERIOUS * Treat to prevent low blood
t at all or BACTERIA sugar
* Not L * Advise the mother how to
sucking at INFECTIO
N
keep the young infant warm on
all
the way to the hospital
* Refer URGENTLY to hospital

102
 * Advise the mother to breastfeed as often and for
* Not well as long as the infant wants, day and night
attached to FEEDING - If not well attached or not suckling effectively,
breast . PROBLEM OR teach correct positioning and attachment.
LOW WEIGHT - If breastfeeding less than 8 times in 24 hours,
* Not suckling
effectively or advise to increase frequency of feeding
* Less than 8 * If receiving other foods or drinks, counsel mother
breast about breastfeeding more, reducing other foods or
feedings in drinks, using a cup
24 hours or - If not breastfeeding at all:
* Receives 1. Refer for breast feeding counselling.
other foods 2. Advise about correctly preparing breast
or drinks or milk substitutes and using a cup and spoon.
* Low weight * If thrush, teach the mother to treat thrush at
for age or home
* Thrush * Advise mother to give home care for the young
(ulcers or infant
white * Follow-up any feeding problem or thrush in 2 days
patches in Follow-up low weight for age in 14 days
mouth)

* Advise mother to give home care for

* Not low weight
for age and no the young infant
NO FEEDING
other signs of
inadequate PROBLEM * Praise the mother for feeding the infant
feeding well
103
• CHECK IMMUNISATION STATUS OF THE
INFANT

• ASSESS ANY OTHER PROBLEM THE CHID HAS.

 BREASTFEEDING PROBLEMS AND SOLUTIONS

1. Difficult Breastfeeding
-Assess breastfeeding and breast problems
-Show mother on correct positioning and
attachment
2. Use of feeding bottle
- Recommend reinstating breastfeeding if possible
-Recommend substituting bottle with cup and
spoon.
 -Show the mother how to feed the child with a
cup.
-Re emphasize hand washing.
3.Lack of Active feeding
-Counsel the mother feed the infant on demand
4. Child has Symptomatic HIV infection.
-Treat mouth sores quickly if present
-Ensure extra feeding when recovering from illness.
-Counsel on breastfeeding.
5.NOT FEEDING WELL DURING ILLNESS
Counsel mother to :
• Clear blocked nostrils if they interferes with feeding
• Breast feeding more frequently and longer
• Encourage the child to eat as much as possible
• Give varied,soft,appetising enriched foods.
• Offer small frequent foods
• Check regularly for oral thrush.
• Follow up for feeding problems in 5/7 days.
 REFERRAL OF A CHILD
• Cases when urgent referral is needed;
1. Severe pneumonia /Very severe disease
2. Severe Dehydration(if clinic can’t offer I.V. fluids)
3. Severe persistent diarrhea
4. Very severe febrile disease
5. Severe complicated measles
6. Mastoiditis
7. Severe malnutrition/Severe anemia
 TREATMENT IN IMCI
1.PNEUMONIA
a) Give antibiotic treatment
i) Mild chest in drawing and no respiratory
distress, administer oral Amoxycillin.See the child
daily and if no improvement give I.M.
Chloramphenicol.
SEVERE PNEUMONIA/VERY SEVERE DISEASE

• A child with general danger signs with very

severe disease, give I.M.XPEN.If not available,
give oral amoxycillin.Treatment should be
given 10 days in total.
b)Give a bronchodilator
If wheezing, give a bronchodilator if available
c) Treat fever-give paracetamol 6 hourly.
d)Manage fluids carefully
-Give fluids with caution to avoid overloading
-Encourage child to drink
-Avoid NGT if child is in respiratory distress
e) Manage Airway
-Clear blocked nostrils
-Help a child to cough up secretions
f)Keep the infant warm
 COTRIMOXAZOLE AMOXYCILLIN
AGE/WT 480 mg tabs 120mg tabs syrup 250mg Syrup
capsule 125mg/5ml
2/12-12/12 ½ tab 2 5mls 1/2 5 mls
4-10kg

1year-5 yrs 1tab 3tabs 7.5 mls 1 10mls

10-19kgs
 SEVERE FEBRILE DISEASE
• Give antibiotic and ant malaria treatment
- Treat for meningitis and Malaria
- Meningitis-I.M CAF and benzyl penicillin QID.Give
high doses. Treat for 10 days
-Malaria-Give quinine, if not available, oral
antimalarials.
-Manage fluids carefully
NB:Very severe febrile disease with stiff neck and
bulging fontanelle,restrict fluids.
• Treat fever using paracetamol
• Paediatric paracetamol doses

AGE WEIGHT 500mg tablet 120mg/5mlsyrup

2/12-1yr 6-9 ¼ 2.5-5ml

1-3 years 10-14 ¼ 5-10ml

3-5 years 15-19 1/2 10ml

NB: Fever alone is not a reason to give antibiotic
except in young infant aged less than 2
months.
 TREATMENT OF UNCOMPLICATED MALARIA

1ST Line-Artemether Lumefantrine

Dosing Schedule for AL
BODY WEIGHT NO.OF TABLETS(20mgA and 120mg L)

5-14 Kg(<3 YR) 1 BD FOR 3 DAYS

15-24kg(4-8 yr) 2

25-34Kg(9-14yr) 3

>34 Kg(>14 yr) 4

 TREATMENT OF SEVERE MALARIA
• IV or IM QUININE
• Loading dose,20 mg/Kg.Over three hours
• Maintainance dose 10mg/Kg
• Switch to oral quinine after the child improves
at 10mg/kg/day.
 ANTIBIOTICS
MENINGITIS
Give penicillin and Chloramphenicol
-Benzyl Penicillin 100 000i.u/Kg in 4 divided doses
-Chloramphenicol 40mg/kg 12 hrly
 Severe pneumonia
• 1ST LINE:Benzyl penicillin 50 000iu/Kg QID
• 2ND Line:Ceftazidime 90-150mg/kg/day or
• Ceftriaxone 50-75 mg/kg/day OD.
VERY SEVERE PNEUMONIA
• Benzyl penicillin and Gentamicin 7.5mg/Kg I.M
 MASTOIDITIS
• Give IM benzyl penicillin
• Treatment for 10 days
• Switch to oral CAF 25mg/kg QID after 3-5 days.
 VITAMIN A
• Given to a child with severe malnutrition,
measles, persistent diarrhea and severe
pneumonia
• Given in 2 doses for measles
• One dose given for other disease conditions if
he had not received one in the past one
month.
• One dose given as per KEPI schedule.
 MULTI VITAMIN/MINERAL SUPPLEMENT

• Given to children with persistent diarrhea

• Given daily for two weeks
AGE/WEIGHT MULTIVITAMIN/MINERAL SUPPLEMENT
SYRUP

2/12-6/12 2.5 mls

4-8Kg

6/12-2 years 5.0 mls

8-12Kg

2yrs-5yrs 7.5mls
12-19Kg
 DIAZEPAM FOR CONVULSIONS
Main treatment for recurrent convulsions
• Give 0.5mg/Kg diazepam injection solution per
rectal
• Check blood sugar levels and manage
appropriately.5mls/Kg of 10% Dextrose
• Repeat diazepam in 10 minutes
• Give Oxygen if available and refer
• Check ABC after the fit
• Check airway and clear
 TREAT CHILD FOR HYPOGLYCAEMIA
• Ask the mother to breastfeed if the child can
breastfeed
• Give EBM if the child can swallow but unable to
breastfeed
• If unable to swallow, give Dextrose 10%(10mls/Kg)
I.V. slowly
• Keep the child warm
• Refer urgently
 TREAT WHEEZING
• Use a bronchodilator to treat wheezing
• Assess the child after 30 minutes
• CLASSIFICATION OF WHEEZING
ASSESS TREAT CHILD<1 YR
Chest in drawing +other -Nebulise using rapid acting
danger sign bronchodilator
-First dose of Antibiotic
-Refer immediately
Fast breathing + wheeze -Oral bronchodilators
-Oral antibiotics
-Send home on treatment
-Follow up in 2/7
No fast -Oral bronchodilators
breathing;wheeze only -Send home on treatment
TREAT CHILD>1YR
-Nebulise using rapid acting
bronchodilator
-Assess after 30 minutes
-Give oral prednisolone
-Give first dose of antibiotic
and refer immediately
-Oral bronchodilators
-Oral antibiotics
-Send home on treatment
-Follow up in 2/7
Oral bronchodilators
-Send home on treatment
 ORAL BRONCHODILATORS
• Salbutamol inhaler in spacer 2 puffs in 10
minutes.
• Subcutaneous epinephrine 0.01ml/Kg
• Nebulizer salbutamol :<1 yr0.5ml in 2.0ml of
sterile water>1 yr1.0mls in 2.0 mls of sterile
water
• If not improved, IV Aminophylline 5mg/kg given
slowly over 20 minutes
• Monitor vital signs.
 ORAL SALBUTAMOL TDS FOR 5 DAYS
AGE 2MG TABS 4MG TABS SYRUP

2/12-12/12 ½ ¼ 2.5mls

1yr-5yr 1 ½ 5.0mls
 ETAT:TRIAGE OF SICK CHILDREN
• Emergency signs
1. Airway and Breathing:
 obstructed breathing,
 central cyanosis,
 severe respiratory distress,
 weak/absent breathing
2. Circulation
 Cold hands with;
 capillary refill> 3 seconds,
 weak and fast pulse,
 Slow( <60bpm) or absent pulse
3. Coma /convulsions/confusion in a
child:AVPU=P’ or U’
4. Diarrhoea with sunken eyes= assessement
and treatment for severe dehydration
 PRIORITY SIGNS IN A CHILD
• Tiny-sick infant aged less than 2 months
• Temperature very high > 39.5
• Trauma-major trauma
• Poisoning-mother reports poisoining
• Pallor-severe palmar pallor
• Restless/irritable/Floppy
• Respiratory distress
• Referral-has an urgent referral letter
• Malnutrition-visible severe wasting
• Oedema of both feet
• Burns-severe burns
• Children having the above priority signs should
be given priority in the queue, weigh the baby,
take baseline observations.
END

MWISHO