Approach to Sick Child Under 5 Years Old (IMCI)

PRE-CONFERENCE WORKSHOP 1

Assessment and Management of Children with Cough and Difficult Breathing

IMCI Case Management Process

Includes no of important elements; Assessment

Classification
Identification of treatment, referral, treatment, counselling Follow-up care

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Introduction
A child with cough or difficult breathing may have pneumonia or another severe respiratory infection. Both bacteria and viruses can cause pneumonia In developing countries, pneumonia is often due to bacteria. The most common are Streptococcus pneumoniae and Hemophilus influenzae. Children with bacterial pneumonia may die from hypoxia or sepsis .
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Introduction..
There are many children who come to the clinic with less serious respiratory infections. Most children with cough or difficult breathing have only a mild infection. For example, a child who has a cold may cough because nasal discharge drips down the back of the throat or bronchitis. These children are not seriously ill. They do not need treatment with antibiotics. Their families can treat them at home.
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Introduction
Health workers need to identify the few, very sick children with cough or difficult breathing who need treatment with antibiotics. Fortunately, health workers can identify almost all cases of pneumonia by checking for these two clinical signs: fast breathing and chest indrawing.

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Presenting complaint or sign can be associated with a number of conditions;

Presenting compliant Cough and/or Fast breathing Drowsy or Unconsciousness Possible cause/ associated condition Pneumonia Severe anaemia P. falciparum malaria Cerebral malaria Meningitis Severe dehydration Very severe pneumonia Pneumonia Diarrhoea Ear infection Pneumonia Meningitis Sepsis

Measles rash

Very sick young infant

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IMCI Case Management Process

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IMCI Case Management Process

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IMCI Case Management Process

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IMCI Case Management Process

THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?

IF YES, ASK: LOOK, LISTEN, FEEL: For how long . Count the breaths in one minute Look for chest indrawing Look and listen for stridor Look and listen for wheeze if wheezing and either fast breathing or chest indrawing: Give a trial of inhaled Salbutamol for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again and then classify If the child is: 2 months up to 12 months 12 months up to 5 years fast breathing is: 50 breaths per minute or more 40 breaths per minute or more

Child must be calm

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LOOK for chest indrawing

When the child breathes IN (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. Chest indrawing is lower chest wall indrawing. It does not include "intercostal indrawing.(soft tissue between the rib goes in)

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LOOK for chest indrawing

For chest indrawing to be present, it must be clearly visible and present all the time. If chest indrawing only present when the child is crying or feeding, the child does not have chest indrawing.

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LOOK for chest indrawing

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LOOK and LISTEN for stridor

Is a harsh noise made when the child breathes IN, happens when there is a swelling of the larynx, trachea or epiglottis. This swelling interferes with air entering the lungs. It can be life-threatening when the swelling causes the child's airway to be blocked. A child who has stridor when calm has a dangerous condition.
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LOOK and LISTEN for wheeze

Is a musical noise heard when the child breathes OUT. Occurs when the air flow from the lungs is obstructed due to narrowing of the small airways. If the child is wheezing and has either fast breathing or chest indrawing, give a trial of inhaled Salbutamol for three times; every 15 -20 minutes apart. 15 minutes after completing the 3rd dose of inhaled Salbutamol, count the breaths and look for chest indrawing again and re-classifying.
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CLASSIFY cough or difficult breathing

There are four possible classifications for a child with cough or difficult breathing; SEVERE PNEUMONIA OR VERY SEVERE DISEASE or PNEUMONIA or WHEEZE or COUGH OR COLD

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IMCI Case Management Process

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Classification table for cough or difficult breathing

SIGNS Any general danger sign or Chest indrawing or Stridor in calm child CLASSIFY AS TREATMENT (Urgent pre-referral treatment are in bold print) Give first dose of an appropriate antibiotic Refer URGENTLY to hospital* Give oxygen if available Treat wheeze if present with inhaled Salbutamol SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Fast breathing

PNEUMONIA

Give oral antibiotic for 5 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe the throat and relieve cough with safe remedy If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma Advise mother when to return immediately Follow up in 2 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe throat and relieve cough with safe remedy Advise mother when to return immediately Follow up in 5 days

Wheeze WHEEZE

No signs of pneumonia or very severe disease

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If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma COUGH OR COLD Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

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TREAT THE CHILD

Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION, MASTOIDITIS OR VERY SEVERE DISEASE: FIRST-LINE ANTIBIOTIC: AMOXCYCILLIN (25 mg/kg/dose) SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE (4mg/kg/dose)
AMOXYCILLIN Give TWO times daily for 5 days COTRIMOXAZOLE (Trimethoprime + Sulphamethoxazole) Give TWO times daily for 5 days Syrup 40 mg Trimethoprim + 200 mg Suphamethoxazole/5 ml 2.5 ml

AGE or WEIGHT 2 months up to 4 months (4 - <6 kg)

Syrup 125 mg/5 ml 5 ml

4 months up to 12 months (6- <10 kg)

12 months up to 5 years (10- <19 kg)

7.5 ml
10 15 ml

5 ml
7.5 10 ml

FOR SEVERE PNEUMONIA OR VERY SEVERE DISEASE/ MASTOIDITIS: If the child can take orally give 04/07/2013 20 double the dose of Amoxycillin before urgent referral. Do not use Cotrimoxazole.

GIVE THESE TREATMENT IN CLINIC ONLY

Treat Wheeze in the Child 1. Use of Nebuliser
Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a nebulizer chamber. Place the mask to cover the childs nose and mouth. Give the oxygen flow of 6-8 liters/min. Nebulise until the liquid is used up or for at least 15 minutes.

2. Use of Spacer or Aerochamber

Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler into spacer or Aerochamber. Depress the canister down to actuate the spray once. Gently place the mask of the spacer to cover the mouth and nose. Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child). Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff. 04/07/2013 Replace inhaler cap.

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Classification table for cough or difficult breathing

Any general danger sign or Chest indrawing or Stridor in calm child SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic Refer URGENTLY to hospital* Give oxygen if available Treat wheeze if present with inhaled Salbutamol Fast breathing Give oral antibiotic for 5 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe the throat and relieve cough with safe remedy If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma Advise mother when to return immediately Follow up in 2 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe throat and relieve cough with safe remedy Advise mother when to return immediately Follow up in 5 days

PNEUMONIA

Wheeze WHEEZE

No signs of pneumonia or very severe disease

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If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma COUGH OR COLD Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

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TREAT THE CHILD

Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION, MASTOIDITIS OR VERY SEVERE DISEASE: FIRST-LINE ANTIBIOTIC: AMOXCYCILLIN (25 mg/kg/dose) SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE (4mg/kg/dose)
AMOXYCILLIN Give TWO times daily for 5 days COTRIMOXAZOLE (Trimethoprime + Sulphamethoxazole) Give TWO times daily for 5 days Syrup 40 mg Trimethoprim + 200 mg Suphamethoxazole/5 ml 2.5 ml

AGE or WEIGHT 2 months up to 4 months (4 - <6 kg)

Syrup 125 mg/5 ml 5 ml

4 months up to 12 months (6- <10 kg)

12 months up to 5 years (10- <19 kg)

7.5 ml
10 15 ml

5 ml
7.5 10 ml

FOR SEVERE PNEUMONIA OR VERY SEVERE DISEASE/ MASTOIDITIS: If the child can take orally give 04/07/2013 23 double the dose of Amoxycillin before urgent referral. Do not use Cotrimoxazole.

GIVE THESE TREATMENT IN CLINIC ONLY

Treat Wheeze in the Child 1. Use of Nebuliser
Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a nebulizer chamber. Place the mask to cover the childs nose and mouth. Give the oxygen flow of 6-8 liters/min. Nebulise until the liquid is used up or for at least 15 minutes.

2. Use of Spacer or Aerochamber

Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler into spacer or Aerochamber. Depress the canister down to actuate the spray once. Gently place the mask of the spacer to cover the mouth and nose. Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child). Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff. 04/07/2013 Replace inhaler cap.

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TREAT THE CHILD

GIVE ORAL SALBUTAMOL
ORAL SALBUTAMOL Give three times daily for 5 days AGE or WEIGHT
2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6- <10 kg) 12 months up to 3 years (10- <14 kg) 3 years up to 5 years (14 - <19 kg) 2mg/5 ml syrup 1 ml 2 ml 3.5 ml 5 ml

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TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Soothe the Throat, Relieve the Cough with a Safe Remedy Safe remedies to recommend: - Breastmilk for breastfed infant. - Warm water if not breastfed. Harmful remedies to discourage: - Cough syrup. - Nasal decongestants.
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WHEN TO RETURN IMMEDIATELY

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 Fast breathing Difficult breathing Blood in stool Drinking poorly

If child has COUGH OR COLD, also return if: If child has Diarrhoea, also return if:

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Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT
If the child has: PNEUMONIA DYSENTRY MALARIA, if fever persists FEVER-MALARIA UNLIKELY, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS WHEEZE PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEM ANY OTHER ILLNESS, if not improving ANAEMIA VERY LOW WEIGHT FOR AGE
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Return for first follow-up visit in:

2 days

5 days

14 days
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Classification table for cough or difficult breathing

Any general danger sign or Chest indrawing or Stridor in calm child SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic Refer URGENTLY to hospital* Give oxygen if available Treat wheeze if present with inhaled Salbutamol Fast breathing Give oral antibiotic for 5 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe the throat and relieve cough with safe remedy If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma Advise mother when to return immediately Follow up in 2 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe throat and relieve cough with safe remedy Advise mother when to return immediately Follow up in 5 days

PNEUMONIA

Wheeze WHEEZE

No signs of pneumonia or very severe disease

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If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma COUGH OR COLD Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

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GIVE THESE TREATMENT IN CLINIC ONLY

Treat Wheeze in the Child 1. Use of Nebuliser
Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a nebulizer chamber. Place the mask to cover the childs nose and mouth. Give the oxygen flow of 6-8 liters/min. Nebulise until the liquid is used up or for at least 15 minutes.

2. Use of Spacer or Aerochamber

Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler into spacer or Aerochamber. Depress the canister down to actuate the spray once. Gently place the mask of the spacer to cover the mouth and nose. Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child). Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff. 04/07/2013 Replace inhaler cap.

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TREAT THE CHILD

GIVE ORAL SALBUTAMOL
ORAL SALBUTAMOL Give three times daily for 5 days AGE or WEIGHT
2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6- <10 kg) 12 months up to 3 years (10- <14 kg) 3 years up to 5 years (14 - <19 kg) 2mg/5 ml syrup 1 ml 2 ml 3.5 ml 5 ml

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TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Soothe the Throat, Relieve the Cough with a Safe Remedy Safe remedies to recommend: - Breastmilk for breastfed infant. - Warm water if not breastfed. Harmful remedies to discourage: - Cough syrup. - Nasal decongestants.
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WHEN TO RETURN IMMEDIATELY

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 Fast breathing Difficult breathing Blood in stool Drinking poorly

If child has COUGH OR COLD, also return if: If child has Diarrhoea, also return if:

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Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT
If the child has: PNEUMONIA DYSENTRY MALARIA, if fever persists FEVER-MALARIA UNLIKELY, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS WHEEZE PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEM ANY OTHER ILLNESS, if not improving ANAEMIA VERY LOW WEIGHT FOR AGE
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Return for first follow-up visit in:

2 days

5 days

14 days
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Classification table for cough or difficult breathing

Any general danger sign or Chest indrawing or Stridor in calm child SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic Refer URGENTLY to hospital* Give oxygen if available Treat wheeze if present with inhaled Salbutamol Fast breathing Give oral antibiotic for 5 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe the throat and relieve cough with safe remedy If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma Advise mother when to return immediately Follow up in 2 days Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days Soothe throat and relieve cough with safe remedy Advise mother when to return immediately Follow up in 5 days

PNEUMONIA

Wheeze WHEEZE

No signs of pneumonia or very severe disease

04/07/2013

If coughing more than 14 days or if having recurrent wheezing, refer for assessment for TB or Asthma COUGH OR COLD Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 5 days if not improving

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Thank you
Dr Yusnita Binti Yatim Pakar Perubatan Keluarga UD54 Klinik Kesihatan Peramu Jaya