GOOD

MORNING

We are guilty of many errors and many faults, but our worst crime is abandoning children, neglecting the fountain of life. Many of the things we need can wait the CHILD can not

Right now is the time his bones are formed, his blood being made, and his senses are being developed

To him we cannot answer TOMORROW his name is TODAY. ~ Gabriela Mistal

Integrated Management of Childhood Illness (IMCI)

Christian T. Caligagan, M.D., DPPS

IMCI
WHAT IS IMCI? A strategy for reducing mortality and morbidity associated with major causes of childhood illness. A joint WHO/UNICEF initiative since 1992

IMCI
OBJECTIVES To reduce SIGNIFICANTLY global mortality and morbidity associated with the major causes of diseases in children. To contribute to healthy growth and development of children.

IMCI
According to the World Bank: The IMCI is likely to have the greatest impact in reducing the global burden of disease.

Major causes of death under five, 2002

Other 25% ARI 18%

Deaths assoc. with malnutrition 54%

Diarrhea 15%

Perinatal 23% HIV/ AIDS 4%

Malaria 10% Measles 5%

IMCI
The IMCI training was designed to teach integrated management of sick infants and children to first level health workers in primary care settings that have NO laboratory support and only a limited number of essential drugs.

IMCI

Action-oriented CLASSIFICATIONS , rather than EXACT DIAGNOSES are used.

IMCI
A careful balance has been struck between SENSITIVITY and SPECIFICITY.

IMCI
Using FEW CLINICAL SIGNS as possible which health workers of diverse background can be trained to recognize.

IMCI
The IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS without laboratory tests and offer EMPIRIC TREATMENT.

100 Main symptoms of 450 sick children 92.5 % 90 82.5% 80 70 60 50 45% 40 30 20 8.4% 10 0
Cough Diarrhea Fever Ear problems

IMCI
Frequency of presenting complaints of 450 children (as volunteered by mothers)
Fever Cough Diarrhea Ear problems Skin lesions Abdominal pain Eye discharge Dental problems Neck swelling Gen. swelling Anorexia Rectal prolapse Headaches Not recorded Covered by IMCI (87 %)

Not covered by IMCI (13%)

-10

10

30

50

70

Main symptoms of 478 children VSMMC

70 60 50 40 30 20 10 0
COUGH
FEVER DIARRHEA EAR PROBLEM

FREQUENCY OF 4 MAIN SYMPTOMS IN EACH PATIENT VSMMC

62%

ONE SYMPTOM

2 SYMPTOMS

31%

3 SYMPTOMS

4%

4 SYMPTOMS

3%

20

40

60

IMCI
COMPONENTS 1. Improving case management skills of health workers. a. standard guidelines b. training (pre-service and in-service) c. follow-up after training

IMCI
2. Improving the health system to deliver IMCI. a. essential drug supply b. organization of health facilities c. management of supervision

IMCI

3. Improving family and community practices

IMCI
CASE MANAGEMENT PROCESS 1. Health worker assesses the sick child. - IDENTIFY any danger sign present (unable to feed and drink, vomits everything, convulsion, difficult to awaken or abnormally sleepy) - ASK about the four(4) main symptoms cough, diarrhea, fever, and ear problem - REVIEW nutrition, Vitamin A and immunization

IMCI
2. Health worker CLASSIFIES childs illness using a color-coded triage: PINK = urgent referral YELLOW = specific medical treatment and advice GREEN = simple advice on home care

IMCI

3. Heath worker then identifies SPECIFIC TREATMENT. - an INTEGRATED TREATMENT PLAN is developed

IMCI
4. TREATMENT INSTRUCTIONS are carried out: oral drugs, ORS, treat local infections, signs to come back immediately, when to return for routine follow-up. 5. COUNSELING mothers. 6. FF-UP instructions when the child returns to clinic.

IMCI
Management of sick children Nutrition Immunization Other disease Prevention Promotion of growth and development

Integrated Management of Childhood Illness (IMCI)

IMCI
CHILD HEALTH INTERVENTIONS IN IMCI Case Management Interventions: Pneumonia Malaria Diarrhea Malnutrition - dehydration Anemia - persistent diarrhea Measles - dysentery Ear infection Meningitis Dengue Sepsis

IMCI
Preventive interventions: Immunization during sick child visits Nutrition counseling Breastfeeding

Why is IMCI needed in medical education?

Gives priority and emphasis to the most frequent and serious health problems of children Provides a link to real-life situations where diagnostic tools and drugs may be scarce Promotes rapid recognition of the severity of a childs illness and action, including rapid referral for severely ill children Links preventive and curative care Provides additional skills in important areas such as nutrition counselling Emphasizes action-oriented and affordable interventions Links different levels of health professionals and different levels of a health system

IMCI
currently focused on first level facilities out-patient facility - initially in-patient facility - later comes as a generic guidelines for management which have been adapted to each country.

IMCI
Identification and provision of treatment Rehydration (diarrhea, DHF) Antibiotics ( e.g. pneumonias) Antimalarial Vitamin A

IMCI
Preventive and Promotive elements: Reducing missed opportunities for immunization Breastfeeding and other nutritional counseling Vitamin A and iron supplementation Treatment of helminthic infestations

IMCI
THE PROBLEMS: 1. The under five population is the most vulnerable group. 2. Child mortality remains UNACCEPTABLY HIGH. 3. Many of these deaths had no medical attendance or being seen by first level health facilities.

IMCI
4. First-level facilities: - undermanned/underpaid - health workers are not appropriately TRAINED - drug supply inadequate/not properly managed - inaccessible - poor laboratory support

IMCI
5. Family and community profile/ practices - late help seeking behavior - poor utilization of health facilities - literacy - traditional beliefs/traditions - economic - large families - crowded, dense, polluted environment

IMCI
TECHNICAL BASIS ARI and DIARRHEA

IMCI-ARI
ASSESSMENT SIGNS: 1. 2. 3. 4. BREATH RATE (FAST BREATHING) DURATION OF COUGH CHEST INDRAWING STRIDOR when CALM

IMCI-ARI
Children who have been coughing for 30 days or more are referred for FURTHER ASSESSMENT, to consider the possibility of tuberculosis and other conditions.

IMCI-ARI
STRIDOR > harsh noise when the child is breathing IN. > can be reliably assessed when the child is CALM.

IMCI-ARI
Why Wheezing was not included: 1. Mortality from asthma is relatively uncommon. 2. Children with severe bronchospasm will be referred on the basis of chest indrawing. (Training is simplified, concentrate on conditions contributing SUBSTANTIALLY to mortality)

IMCI-ARI
If wheezing is included in the guidelines: 1. Improves health worker credibility in managing difficult breathing. 2. Relieves suffering in child with significant wheezing. 3. Reduced referral. 4. More complex training (in-service).

IMCI-ARI
Wheezing was NOT included in IMCI so that: 1. 2. 3. 4. Training less COMPLEX Special supplies not needed Training FOCUSED on pneumonia Needless referral

IMCI-ARI
Objectives of the guidelines are to divide sick children with cough or difficult breathing into THREE categories:
1. Those who require admission for severe pneumonia 2. Those who require ANTIBIOTICS because they are LIKELY to have pneumonia 3. Those who simply have cough or cold and do not require antibiotics.

IMCI-ARI
Detecting Pneumonia by 2 key clinical signs: 1. Fast breathing 2. Lower chest wall indrawing

IMCI-ARI
Use of auscultation for predicting pneumonia in children Place 1. Baltimore, Maryland 2. New Haven, Connecticut 3. Nairobi, Kenya 4. Boston, Massachusetts Sensitivity 43% 33% 66% 57%

Note: Diagnosis of pneumonia is confirmed by x-ray.

IMCI-ARI
Comparison of methods for detection of pneumonia in children ( 2mos up to 59mos) METHOD Stethoscope (crepitations) Simple clinical signs (fast breathing or chest indrawing) SENSITIVITY 53% SPECIFICITY 59%

77%

58%

Note: Diagnosis of pneumonia is confirmed by X-ray.

IMCI-ARI
*Expert auscultation (crepitations) is less sensitive as a single sign, although when combined with FAST BREATHING, the two signs together will be more sensitive than either sign alone. *But if both SIGNS are required to be present, the two signs together will be more SPECIFIC but will lose SENSITIVITY.

IMCI-ARI
TECHNICAL BACKBROUND 1. Initial recommendation: 50/min or more (60% to 75% sensitive) 2. Lowered to 40/min for 12 mos. up to 59 mos. (62% to 79%) BUT at the same time SPECIFICITY fell from 92% to 77% and 80%

IMCI-ARI
Sensitivity of the RR for Predicting Pneumonia in Young Children RR50/min RR40/min 2-11 months 12-59 months Goroka, PNG 80 74 Vellore, India 89 71 Bsse, the Gambia 85 87 Manila, Phil. 77 78 Maseru, Lesotho 79 54 Place

IMCI-ARI
FAST BREATHING (as defined by WHO): 2 months - 11 months = 50 breaths/min 11 months - 59 months = 40 breaths/min

IMCI-ARI
Fast breathing as defined by WHO, detects about 80% of children with pneumonia who need antibiotic treatment, and using fast breathing to detect pneumonia has been shown to reduce mortality. Sazawal S., Black R.E.

Meta analysis of Intervention Trials on Case Management of Pneumonia in community settings; Lancet, 1992

IMCI-ARI
There is no uniform agreement about how to define the group of children with ARI who actually need antibiotics. The difficulty is how to distinguish those with potentially life-threatening disease from the rest by using SIMPLE SIGNS.

Radiology is helpful, but many children with relatively minor disease have MARKED radiological signs, while many who die have MINIMAL radiological signs. - Campbell H., et al. Assessment of Clinical Criteria for Identification of Severe ARI

IMCI-ARI
LOWER CHEST WALL INDRAWING 1. def: inward movement of the bony structures of the chest wall with inspiration. 2. Due: to increased tension on the anterior insertion of the diaphragm on the xiphoid process and the internal surfaces of the cartilages and adjacent parts of the lower SIX ribs, in overcoming respiratory obstruction 3. Mild chest indrawing is NORMAL in young infants below 2 mos. The abnormal sign is called SEVERE LOWER CHEST WALL INDRAWING

IMCI-ARI
LOWER CHEST WALL INDRAWING ISSUES: 1. Why not include intercostal indrawing? > Ninety two percent (92%) of children with chest indrawing has intercostal indrawing requiring both signs did not change sensitivity, with small decrease in specificity and positive predictive value . > Chest indrawing was found more specific than intercostal indrawing for a pediatricians diagnosis of severe pneumonia requiring admission. > Chest indrawing therefore will REFER more children than would be admitted by a pediatric expert , as severe pneumonia, because it is also present in bronchiolitis, and asthma.

IMCI-ARI
Duration of illness before death is often short, thus early maternal recognition of signs of pneumonia and prompt care seeking are essential to prevent deaths.

Children often die quickly from pneumonia if treated too late or not treated at all.

IMCI-ARI
Use of antibiotics by doctors for ARI Place 1. Algeria 2. Mexico 3. Christchurch, New Zealand Antibiotic given 76% 49% 62%

IMCI - DIARRHEA
ASSESSMENT SIGNS: 1. Duration 2. Blood in the stool 3. Signs of dehydration general condition => abnormally sleepy, difficult to awaken, restless or irritable sunken eyes _ not able to drink, drinking poorly, thirsty, drinks eagerly (if you offer a drink) skin pinch => goes back slowly or very slowly

IMCI - DIARRHEA
Duration of diarrhea 1. Acute diarrhea 2. Persistent diarrhea (could also be severe persistent) Blood in the stool or dysentery

IMCI - DIARRHEA
Assessment and classification of DHN Changes in the assessment of DHN: 1. Tears and dryness of mouth have been excluded, the signs add little in sensitivity or specificity to the classification. 2. Categories in the characterizations of sunken eyes difficulties in the field in differentiating very sunken and sunken. 3. The *stars* which marked essential items for a childs classification have been excluded. 4. The requirement for any two signs to classify as severe or some dehydration remains, ensuring that the previous criteria of at least one *sign* still exists.

IMCI - DIARRHEA
TREATMENT PLAN A
1. FLUIDS 2. FOOD RECOMMENDED FOR AGE

IMCI - DIARRHEA
TREATMENT PLAN A

3. reFERRAL
Previous SIX signs (CDD) > many watery stools not able to drink > repeated vomiting becomes sicker > marked thirst in IMCI > develops fever > blood in the stool > drinking poorly

4. ZINC

IMCI - DIARRHEA
TREATMENT PLAN A Home fluid should be: 1. Safe when given in large volumes. Avoid: 1. very sweet tea 2. soft drinks 3. sweetened fruit drinks Hyperosmolar solution above 300mOsm/L can cause worsening dehydration, osmotic diarrhea and hypernatremia. DO NOT GIVE PURGATIVES & STIMULANTS.

IMCI - DIARRHEA
TREATMENT PLAN A 2. Easy to prepare 3. Acceptable 4. Effective Home fluids for Philippines: Breastmilk, water, food-based fluid such as rice water, buko juice, ORS

IMCI - DIARRHEA
TREATMENT PLAN B ** No change** TREATMENT PLAN C **No change** Exception: Emphasis on giving anti-cholera antibiotic if child is 2 yrs. and above and there is cholera in the area

IMCI - DIARRHEA
PERSISTENT DIARRHEA ** No change** Except for re-emphasis on: 1. No routine use of antibiotic 2. Dietary management = breast milk, low lactose or lactose free, food recommendation for age 3. Vitamins and minerals = at least 2 RDAs of *folate, *iron, *zinc, *magnesium, *copper and *Vit A 4. Vitamin A (Philippines) as single dose.

IMCI - DIARRHEA
Key ingredients: 1. Vit A (gRE) 2. Folic acid(g) 3. Mg(mg) 4. Zinc(mg) 5. Copper(mg) 1 RDA 400 50 80 10 1 2RDA 800 100 160 20 2

IMCI - DIARRHEA
DYSENTERY Antibiotic is given for Shigella (which causes 50% of all bloody diarrheas) on the basis of presence of blood in the stools. Why? > Dysentery is 10% of all diarrheas but causes 15% of all deaths. > Stool culture in many settings is not feasible. > Stool microscopy to detect protozoa may be unavailable or unreliable. > Shigella is associated with severe complications especially when associated with measles.

IMCI
FEVER, EAR PROBLEM MALNUTRITION ANEMIA

IMCI - FEVER
FEVER A. 1. temperature of 37.5 C and above 2. history of fever by the mother 3. warm to touch B. Determine if malaria risk or no malaria risk -> if no malaria risk: ask if there was travel to malaria risk in 30 days -> if malaria risk: take a blood smear

IMCI-FEVER
ASSESSMENT SIGNS 1. Duration more than 7 days, present everyday 2. Stiff neck 3. Runny nose 4. Signs of measles Now: generalized rash AND any of the ff: cough, runny nose, red eyes Measles for the past 3 months 5. Signs of complications of measles Eyes: clouding of the cornea pus draining Mouth: ulcers = deep or extensive

IMCI-FEVER
MALARIA CLASSIFICATION 1. MALARIA IS CONSIDERED: > (+) positive blood smear > and IF BLOOD SMEAR is NOT DONE with NO OTHER CAUSES OF FEVER 2. MALARIA UNLIKELY > Blood smear negative > There is the presence of other possible CAUSES of fever.

IMCI-FEVER
Signs of DHF: > abdominal pain > vomiting > signs of shock >> cold clammy extremities >> slow capillary refill > positive (+) tourniquet test > bleeding = History and PE

IMCI-FEVER
TREATMENT 1. Limiting antipyretic treatment to high fever(38.5C and above) not just any fever >moderate rise in temperature MAY improve immune defense against infection > high fever should be treated because it increases O2 consumption Antipyretic: Paracetamol

IMCI-FEVER
MEASLES Complications 1. Stomatitis > caused by: herpes virus, candida, or by the measles virus > treated by: half strength gentian violet (0.25%) *if you use full strength = may cause mouth ulcers 2. Eye complications corneal ulceration

IMCI - EAR PROBLEM

Assessment Signs: 1. Ear pain 2. Ear discharge OTOSCOPY VS. IMCI GUIDELINES Sensitivity - 30% to 77% Specificity - 2% to 99% PPV = 63% Pneumatic otoscope is more accurate than simple otoscopy because the simple otoscope does not have the ability to determine whether the eardrum is RED and IMMOBILE.

IMCI-EAR PROBLEM
TREATMENT Various treatment regimens using different antibiotics showed varied results. 5 days vs. 10 days Cotrimoxazole vs. Amoxicillin Major rationale for treating ear infections is NOT TO RESOLVE THE SYMPTOMS BUT TO PREVENT MASTOIDITIS.

IMCI-EAR PROBLEM
EAR WICKING to dry the ear. 1. Strong tissue paper 2. Cotton cloth 3. If available: periodic suctioning using an ear bulb

IMCI-MALNUTRITION
ACUTE VS CHRONIC 1. Chronic also called stunting > begins in infancy > develops in the first 2 years 2. Acute malnutrition is a medical emergency.

IMCI-NUTRITION
1. 2. 3. Detecting Marasmus = visible severe wasting Detecting Kwasiorkor = edema of both feet Moderate malnutrition Indicators: Weight for Height Height for age

IMCI: Very Low Weight for Age The very low weight for age is used as a PROXY to the more reliable weight for height. weight for age = < -3 SD

IMCI-MALNUTRITION
IF LENGTH/HEIGHT IS AVAILABLE: 1. Most sensitive and specific indicator for acute changes in nutritional status. 2. The best method to identify a child who needs MOST from nutrition interventions. 3. Weight for height scores of < -3SD SHOULD BE ADDED TO VISIBLE WASTING AND EDEMA OF BOTH FEET AS INDICATORS FOR SEVERE MALNUTRITION.

IMCI - ANEMIA
PALMAR PALLOR 1. Shown in studies to have good performance as a SINGLE SIGN to detect anemia clinically. 2. Detecting anemia based on clinical guideline detects MODERATE and SEVERE ANEMIA but NOT MILD ANEMIA.

IMCI Technical Updates

May, 2005 Dr Carolyn Maclennan WHO-WPRO

IMCI technical updates : Why?

New research knowledge available on clinical management of childhood diseases. IMCI adaptation and implementation process provide experiences & lessons. IMCI implementation identified problems & questions, addressed through operational research in Regions and countries. Impact of some diseases has evolved (HIV/AIDS) : specific aspects require updating in the context of IMCI.

6 Areas Updated
1. Antibiotic treatment of severe and non-severe pneumonia. 2. Low osmolarity ORS and antibiotic treatment for bloody diarrhoea. 3. Treatment of fever/malaria 4. Treatment of ear infections 5. Infant feeding 6. Treatment of helminthiasis

ANTIBIOTIC TREATMENT OF PNEUMONIA

Frequency of administration of amoxicillin treatment of non-severe pneumonia

Study compared the pharmacokinetics & levels of oral amoxicillin (15 mg/kg of body weight/dose) thrice daily with the 25 mg/kg/dose twice-daily regimen in 66 children ages 3 to 59 months with pneumonia Conclusion: Amoxicillin twice-daily is a feasible alternative to thrice-daily dosing.

Frequency of administration of amoxicillin treatment of non-severe pneumonia

A randomized, controlled, double blind trial compared the clinical efficacy of twice daily oral Cotrimoxazole with twice daily oral Amoxicillin for treatment of childhood pneumonia in OPD of 7 hospitals & 1 community health service in Pakistan Conclusion: Both Amoxicillin and Cotrimoxazole provided equally effective therapy for nonsevere pneumonia.

Conclusion

Oral amoxicillin should be used twice daily for the treatment of non-severe pneumonia.

Duration of amoxicillin treatment of nonsevere pneumonia Two (2) double-blind randomized controlled trials in Pakistan & India compared treatment outcome with 3-day oral Amoxicillin with that of currently recommended 5-day therapy in children 2-59 months.

Duration of amoxicillin treatment of nonsevere pneumonia

Pakistan study: 2000 children with pneumonia diagnosed in the OPD of 7 hospitals enrolled. Patients were randomly assigned to three days or five days of treatment with oral Amoxicillin. Primary outcome was treatment failure & analyses were by intention to treat.

Duration of amoxicillin treatment of nonsevere pneumonia

Treatment failed in 209 (21%) patients in the 3-day group, & 202 (20%) in the 5-day group (difference 0.7%; 95% CI 1.8 to 3.2).

12 (1%) children in the 3-day group & 13 (1%) in the 5-day group the disease relapsed (difference 0.1%; - 0.6 to 0.8).

Duration of amoxicillin treatment of nonsevere pneumonia

Treatment more likely to fail in children who did not adhere to treatment (p < 0.0001), younger than 12 months (p < 0.0001), illness lasted for 3 days or longer (p = 0.004), respiratory rate was more than 10 breaths per min above the age-specific cut-off (p = 0.004) & with vomiting (p = 0.009).

Duration of amoxicillin treatment of nonsevere pneumonia

Non-adherence was also associated with failure of treatment in the 5-day group (p<0.0001). India study: conducted in ambulatory care settings in 7 referral hospitals. Children received oral amoxicillin, 3045 mg/kg/day, in 3 divided doses for the first 3 days & then either continued on an active drug or placebo for the next 2 days. Primary outcome was clinical cure.

Duration of amoxicillin treatment of nonsevere pneumonia 2,188 cases were randomized, 1,095 to 3day and 1,093 to 5-day treatment with amoxicillin Clinical cure was achieved in 980 (89.5%). 983 (89.9%) patients on 3-day & 5-day treatment respectively (difference 0.4, 95% CI: -2.1 to 3.0).

Duration of amoxicillin treatment of nonsevere pneumonia

Adherence assessed on day 3 and day 5 followup was 94% and 85.2%, respectively. Loss to follow-up was 5.4% by day 5. There were no deaths, 41 hospitalizations and 36 minor adverse reactions. 225 (10.28%) clinical failures and 106 relapses (5.3 %) & these rates were similar in both groups.

Conclusion

Oral amoxicillin should be given for 3 days for non-severe pneumonia in children 2-59 months of age.

Duration of oral cotrimoxazole therapy for non-severe pneumonia

Double-blind, randomized, placebo-controlled multicentre equivalence trial at 2 sites in Indonesia and Bangladesh. Studied 3-day versus 5-day oral cotrimoxazole for the treatment of non-severe pneumonia & effect on antimicrobial resistance in nasopharyngeal S. pneumoniae and H. influenzae isolates. Children were followed up for 15 days.

Duration of oral Cotrimoxazole therapy for non-severe pneumonia 84.3% (735/872) children in the 5-day group & 83.8% (737/879) in the 3-day group were cured 15 days after enrolment. at enrolment, cotrimoxazole nonsusceptible S. pneumoniae were 54.7% (359/656) & 51.3% (329/641) in the 5-day and 3-day groups.

Duration of oral Cotrimoxazole therapy for non-severe pneumonia This became 64.1% (409/262) & 61.5% (266/432) on day 15, in the 5-day and 3day groups (p = 0.50). For H. influenzae prevalence of nonsusceptible strains on 0 and 15 day were 44.6% vs. 61.9% and 41.7% vs. 53.7% in the 5-day and 3-day groups respectively (P= 0.06).

Conclusion

Oral Cotrimoxazole should be given for 3 days for non-severe pneumonia in children 2-59 months of age.

Use of oral amoxicillin versus injectable penicillin in children with severe pneumonia
Data from Amoxicillin Penicillin Pneumonia International Study, multinational, multicentre trial conducted in 8 countries compared injectable Penicillin (n = 857) with oral Amoxicillin (n = 845). Treatment failed in 187 (21.8%) patients in the injectable Penicillin group & 185 (21.8%) in the oral Amoxicillin group.

Use of oral amoxicillin versus injectable penicillin in children with severe pneumonia
26 (3.0%) children in the injectable Penicillin group & in 39 (4.6%) in the oral Amoxicillin group the disease relapsed. The results showed that the clinical outcome with oral Amoxicillin was comparable to injectable Penicillin in hospitalized children with severe pneumonia.

Conclusion

Where referral is difficult and injection is not available, oral Amoxicillin should be given to children with severe pneumonia.

Gentamicin plus Ampicillin versus Chloramphenicol for Very Severe Pneumonia Multicenter randomized clinical study conducted in 8 countries to compare the efficacy of Chloramphenicol with that of Ampicillin & Gentamicin in children aged 2 to 59 months with very severe pneumonia. 958 children were randomized, 122 (12.7%) patients failed treatment by day 6 (primary outcome).

Gentamicin plus Ampicillin versus Chloramphenicol for Very Severe Pneumonia Treatment failure was higher in the Chloramphenicol group, the relative risk being 1.5 ( 1.1 to 2.1). Common reasons for treatment failure by day 6 were: death (n = 44), development of septic shock (n = 29), persistence of very severe pneumonia (n = 21).

Gentamicin plus Ampicillin versus Chloramphenicol for Very Severe Pneumonia

Treatment failure at 48 hours, 10 and 30 days as secondary outcomes & 82 (8.6 %) patients had treatment failure by 48 hours; constituting about 51% of all treatment failure. Cumulative treatment failures on days 10 & 30 remained higher in the Chloramphenicol group & distribution of treatment failure categories remained the same as seen on day 6, 44 death were recorded as the reason for treatment failure.

Gentamicin plus Ampicillin versus Chloramphenicol for Very Severe Pneumonia

21 deaths occurred after change of antibiotics & after the patients were categorized as treatment failure. More deaths occurred in the Chloramphenicol group than the Ampicillin & Gentamicin group by day 30 (RR = 1.6; 95%CI 0.99-2.6). Most deaths (74%) occurred within 48 hours.

Conclusion

Injectable Ampillicin plus Gentamicin is a better choice than injectable Chloramphenicol for very severe pneumonia in children 2 - 59 months of age.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia Multicentre prospective study, children 1-59 months of age with auscultatory/audible wheeze with fast breathing &/or lower chest indrawing screened. Response to up to 3 cycles of inhaled salbutamol recorded. Responders were enrolled & sent home on inhaled bronchodilators and followed up on days 3 & 5.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia

In Pakistan, 1622 children with wheeze were screened, of which 1004 (61.8%) had WHO defined non-severe & 618 (38.2%) severe pneumonia. Wheeze was audible in only 595 (36.7%) of children. Of 1004 non-severe pneumonia children, 621 (61.8%) responded to up to three cycles of bronchodilator.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia
Of 618 severe pneumonia children only 166 (26.8%) responded. Among those, 93 (14.9%) children in non-severe & 63 (37.9%) in the severe pneumonia group showed subsequent deterioration on follow-ups. No family history of wheeze, temperature >100oF & severe pneumonia at the time of screening were identified as independent predictors of subsequent deterioration.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia In Thailand, 521 children with wheeze screened, 256 (49.1%) had WHO defined non-severe & 265 (50.9%) severe pneumonia. Wheeze audible in 48 (9.2%) children. Of 256 non-severe pneumonia children, 217 (84.8%) responded to up to 3 cycles of bronchodilator.

Trial of rapid acting bronchodilators in children with wheeze & signs of pneumonia Of 265 severe pneumonia children 189 (71.3%) responded. Among responders, 14 (6.4%) children in nonsevere & 24 (12.7%) in the severe pneumonia group showed subsequent deterioration on follow-ups. Body temperature >100oF & severe pneumonia identified as independent predictors of subsequent deterioration.

Conclusion
Children with wheeze and fast breathing and/or lower chest indrawing should be given a trial of rapid acting inhaled bronchodilator (up to 3 cycles), before they are classified as pneumonia and prescribed antibiotics.

DIARRHEAL DISEASES

Use of Low Osmolarity ORS

Studies have shown that the efficacy of ORS solution for treatment of children with acute noncholera diarrhea is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, & its total osmolarity to 245 mOsm/l. Results show the need for unscheduled supplemental IV therapy in children given this solution is reduced by 33%, stool output is reduced by about 20% & the incidence of vomiting by about 30%.

Use of Low Osmolarity ORS

For children with cholera, reduced osmolarity ORS solutions were at least as effective as standard ORS & safety data to date while limited are reassuring.

Conclusion

Countries should now use and manufacture the low sodium ORS for all children with diarrhea but keep the same label to avoid confusion.

Antibiotics in the management of bloody diarrhea (Shigella dysentery)

Ciprofloxacin has been shown to have some significant advantages over Nalidixic acid: 1. Its activity against Enterobacteriacae is several thousand fold greater than that of Nalidixic acid. 2. Ciprofloxacin is 100 to 1000-fold less prone than Nalidixic acid to selection of single step spontaneous highly resistant organisms.

Antibiotics in the management of bloody diarrhea (Shigella dysentery)

3. Ciprofloxacin given twice daily for 3 days

instead of 4 times daily for 5 days with Nalidixic acid has been shown to be very effective against all species of Shigella.

Antibiotics in the management of bloody diarrhea (Shigella dysentery) Strains of Shigella resistant to Nalidixic acid, show some degree of cross resistance to Ciprofloxacin & other newer Quinolones. Minimum Inhibitory Concentration (MIC) of Ciprofloxacin is increased in strains already resistant to Nalidixic acid.

Antibiotics in the management of bloody diarrhea (Shigella dysentery) Appearance of full resistance to Ciprofloxacin is likely hastened when this antibiotic is used as 2nd line treatment of strains already resistant to Nalidixic acid.

Cost & Safety of Ciprofloxacin Safety: No reports of arthropathy in children as a result of Nalidixic acid use in developed or developing countries. Extensive use of the newer Quinolones in children during the last few years has confirmed the safety of these antibiotics, including the lack of reported arthropathies.

Cost & Safety of Ciprofloxacin

Cost: The cost of treatment with Ciprofloxacin is now about 1/3 that of treatment with Nalidixic acid. For example, a 5-day course of treatment with Nalidixic acid for a 15 kg child costs about US $ 0.34, while treatment of the same child for 3 days with Ciprofloxacin costs about US $ 0.10.

Conclusion

Ciprofloxacin is the most appropriate drug in place of Nalidixic acid which leads to rapid development of resistance.

Zinc in the Management of Diarrhea

Meta-analysis of studies evaluating the impact of Zinc supplementation to prevent diarrhea concluded that Zinc supplementation given for 10-14 days lowered the incidence of diarrhea in the following 2-3 months. Cost effectiveness study of Zinc as adjunct therapy for the acute diarrhoea in children in Tanzania showed: Cost Effectiveness Ratio to be reduced by > 1/3 when ORS was combined with Zinc for the treatment in children with diarrhoea, from US $ 113 to US $ 73 per day averted.

Zinc in the Management of Diarrhea Preliminary results of pilot studies in a Brazil, Egypt, Ethiopia, India, Mali, Pakistan & Philippines showed ORS use rates increased, antidiarrheals and antimicrobial use rates significantly decreased when Zinc is prescribed with ORS solution.

Conclusion
Along with increased fluids and continued feeding, all children with diarrhoea should be given zinc supplementation for 10-14 days
DOSE: 20mg per day in children > 6 months 10mg per day in infants < 6 months

FEVER / MALARIA

Antimalarials for treatment of malaria Artemisinin-based combination therapies have been shown to improve treatment efficacy. Advantages of Artemisinin-based combination therapy (ACT) relate to the unique properties and mode of action of the Artemisinin.

Antimalarials for treatment of malaria

Component which include rapid substantial reduction of the parasite biomass and rapid resolution of clinical symptoms. Due to the very short half-life of Artemisinin derivatives, their use as monotherapy requires a multiple dose regimen of 7 days duration.

Antimalarials for treatment of malaria

Combination of one of these drugs with a longer half-life partner antimalarial drug allows a reduction in the duration of artemisinin treatment, while at the same time enhancing efficacy & reducing the likelihood of resistance development to the partner drug.

Antimalarials for treatment of malaria

Artesunate used in combination therapy have been shown to delay the development of resistance to its partner drug (Mefloquine) in low malaria transmission areas in Southeast Asia.

Conclusion
In malarious areas, treatment of falciparum malaria in most countries is with Artemisinin-based combination therapies due to high multi-drug resistance. Due to high cost, it is important that there is a laboratory-based diagnosis with microscopy or rapid diagnostic tests.

Conclusion
Vivax malaria also can cause severe morbidity and should also be diagnosed and treated. Treatment of both falciparum and vivax malaria should follow national guidelines.

EAR INFECTIONS

Management of acute ear infection

1. Ear discharge less than 14 days duration only (not ear pain), should be used in the classification of acute ear infection. 2. Oral Amoxicillin is a better choice for the management of acute ear infection in countries where antimicrobial resistance to Cotrimoxazole is high.

Management of chronic ear infection

Daily installation of topical antiseptics or topical antibiotics after meticulous aural toilet for at least 2 weeks is the most cost-effective treatment for the short-term resolution of otorrhoea. Topical Quinolones are particularly effective in resolving otorrhoea without the risk of ototoxicity. There is no evidence that the addition of oral antibiotics confers increased benefit.

INFANT FEEDING

Exclusive Breastfeeding
A systematic review of current scientific evidence on the optimal duration of exclusive breastfeeding identified & summarized studies comparing exclusive breastfeeding for 4 to 6 months, versus 6 months, in terms of growth, infant iron status, morbidity, atopic disease, motor development, post-partum weight loss & amenorrhoea.

Exclusive Breastfeeding

Evidence did not suggest an adverse effect of exclusive breastfeeding for six (6) months on infant growth on an overall population basis.

Exclusive Breast feeding

Available data suggested that exclusive breastfeeding for six months has a protective effect against gastrointestinal infection in developing & developed countries, & confers an advantage to the mother in prolonging the duration of lactational amenorrhoea.

Conclusion

Exclusive breastfeeding for 6 months should be strongly promoted.

Complementary feeding
Current IMCI guidelines for complementary feeding remain valid in developing countries. Updated standards for developing locally appropriate feeding recommendations are summarized in Guiding Principles for Complementary feeding the Breastfed Child & may be used to guide the generic IMCI guidelines for complementary feeding after 6 months of age.

HIV and infant feeding

In areas where HIV is a significant public health problem all women should be encouraged to receive HIV counselling and testing. If a mother is HIV-infected and when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life.

HELMINTHIC INFESTATIONS

Management of helminthic infestations in children below 24 months

Data from studies in Africa, Asia & Latin America, that included children below the age of 2 years, showed the drug of treatment choice to be albendazole in 8 studies & mebendazole in 2 studies. A recent study in Tanzania with children aged 6 to 59 months (212 were less than 24 months), mebendazole was the drug of treatment & parasitological, nutritional & cognitive variables were assessed.

Management of helminthic infestations in children below 24 months Mebendazole had a positive effect on motor & language development & comparison between the treated and placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhoea, dysentery & acute respiratory illness) one week after intervention.

Management of helminthic infestations in children below 24 months

A recent consultation addressing the use of Albendazole/Mebendazole in children under 24 months states that there is paucity of safety data regarding the use of these drugs in infants under 12 months. Due to the great distribution of parasites, safety & low cost of the treatment (< $ 0.017 for one dose of Mebendazole or Albendazole) & the relative high cost of diagnosis (need of microscope, lab material and training).

Management of helminthic infestations in children below 24 months In endemic areas, children that have not been dewormed in the previous 6 months should be offered deworming irrespective to the possibility to confirm their infectious status.

Conclusion
Albendazole and Mebendazole can be safely used in children 12 months or older.

Dengue
New evidence is emerging but cannot be recommended currently until results of further field testing becomes available.

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