IMCI This session introduces you to IMCI – Integrated Management of Childhood Illnesses - the strategy introduced in the Philippines in 1995 and known to be one of the most cost effective intervention for child survival. It is almost a decade ever since its inception and it is important that one looks back how the Philippines has progressed in its implementation.

Features of IMCI… not necessarily dependent on the use of sophisticated and expensive technologies a more integrated approach to managing sick children move beyond addressing single diseases to addressing the overall health and well-being of the child These are several advantages for adopting IMCI. First, it is not dependent on sophisticated and expensive equipment for diagnosis. Second, it is an integrated approach to managing sick children instead of giving separate treatment for each symptom and using disease-specific guidelines. Third, since there are relationships between illnesses as illustrated by diarrheal episodes with malnutrition or severe diarrhea following a bout of measles and frequent episodes of cough and colds in a malnourished child, it is important that one looks at the over-all well-being of the child,. This means that apart from addressing the main symptom, or sign there is a need to address other problems affecting the child’s health. Fourth, a health worker who is at the frontline in the community is taught how to carefully consider all of the child’s symptoms in a systematic manner without overlooking other problems. S/he can determine if a child is severely ill and needs urgent referral. If not, s/he can follow the guidelines to treat the child’s illnesses. Part of the guidelines include how to counsel the mother and the caretaker. The role of the mother and /or caretaker on continuing treatment at home and when to refer immediately is very important in the management of the sick child.

Features of IMCI… careful and systematic assessment of common symptoms and specific clinical signs to guide rational and effective actions integrates management of most common childhood problems (pneumonia, diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and anemia, ear problems) includes preventive interventions IMCI addresses the most common causes of child mortality. These are pneumonia, diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition, anemia and ear problems. Tuberculosis is one of the major health diseases still very prevalent in the country. However, it does not cause immediate death to a child. As its manifestations are varied the various signs and symptoms being expressed become entry points towards its early detection and appropriate management. The approach in IMCI consists of many preventive interventions. For one, the health worker gives the mother a follow-up care. Immunization is resumed as soon as the danger signs have resolved. Breastfeeding is strongly endorsed as the best food to an infant. Good complementary foods are enumerated.

Features of IMCI… adjusts curative interventions to the capacity and functions of the health system (evidence-based syndromic approach) involves family members and the community in the health care process The guidelines take an evidence-based syndromic approach to case management that supports the rational and effective use of drugs and diagnostic tools. In situations where laboratory support and clinical resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients. Furthermore, it involves the family members who are taught how to administer the drugs and watch out for danger signs in need of urgent referral. The community is in turn is mobilized to collaborate in ensuring a clean and safe environment for their children.

Objectives of IMCI (1) reduce deaths and the frequency and severity of illness and disability; and (2) contribute to improved growth and development No notes

IMCI Components 1. Improving case management skills of health workers standard guidelines training (pre-service/in-service) follow-up after training role of private providers The strategy is composed of three components: 1. Improvement of case management skills of health workers 2. Improving the health system to deliver IMCI 3. Improving family and community practices 1. Improving case management skills of health workers. The first component consists of providing locally adopted guidelines and promoting its use among the barangay health workers, nurses, midwives and doctors. The role of private providers is specifically highlighted as there are doctors in the private sector whose bulk of patients are children.

IMCI Components 2. Improving the health system to deliver IMCI essential drug supply and management organization of work in health facilities management and supervision referral system 2. Improvements in the health system is required for the effective management of childhood illnesses. Under this component are the provision and management of essential drug supplies, organization of work in health facilities, management and supervision of health workers and an effective referral system.

IMCI Components 3. Improving family and community practices for physical growth and mental development for disease prevention for appropriate home care for seeking care 3. Improving family and community practices – Under this component are four purposes being addressed: a. For physical growth and development – Activities include breastfeeding, complementary feeding, micronutrient supplementation, psychosocial stimulation. b. For disease prevention – activities include immunization, sanitary disposal of feces, handwashing, insecticide treated bednets, dengue prevention. c. For appropriate home care – activities include continuous feeding, increase fluids, appropriate home treatment d. For seeking care – areas included are when to seek care, follow health workers advice, prenatal, postnatal care (postpartum)

IMCI Components 3. Improving family and community practices -For physical growth and mental development Breastfeeding Complementary feeding Micronutrient supplementation Psychosocial stimulation 3. Improving family and community practices – Under this component is the first purpose being addressed: a. For physical growth and development – Activities to include health education on breastfeeding, complementary feeding, micronutrient supplementation, psychosocial stimulation.

IMCI Components - For disease prevention 3. Improving family and community practices - For disease prevention immunization handwashing sanitary disposal of feces use of insecticide-treated bednets dengue prevention and control 3. Improving family and community practices – Under this is the second purpose being addressed b. For disease prevention includes the following activities – immunization, sanitary disposal of feces, handwashing, insecticide treated bednets, dengue prevention.

IMCI Components 3. Improving family and community practices - For appropriate home care continue feeding increase fluid intake appropriate home treatment Improving family and community practices – includes the third purpose which is being addressed. 3. For appropriate home care – activities included are continuous feeding, increase fluids, appropriate home treatment

IMCI Components 3. Improving family and community practices - For seeking care Follow health workers advice When to seek care Prenatal consultation Postnatal (postpartum) consultation 3. Improving family and community practices – includes the fourth purpose which is being addressed. d. For seeking care – includes when mothers should seek care, how mothers should follow health worker’s advice, and when to seek prenatal and postnatal care (postpartum)

The Integrated Case Management Process Outpatient Health Facility check for danger signs assess main symptoms assess nutrition and Immunization status and potential feeding problems Check for other problems classify conditions and identify treatment actions Outpatient Health Facility Urgent referral pre-referral treatment advise parents refer child Home Outpatient Health Facility The Integrated Case Management Process shows at a glance the various elements as they occur initially in an outpatient facility, referral facility or hospital and the community or the home. These elements begin with assessment (taking a good history and performing a physical examination), then classifying the severity of the child’s illness using a colour coded triage system, identification of specific treatment, counselling on feeding problems and on the mother’s health, and lastly giving follow-up care and if necessary reassessing the child for new problems. Caretaker is counselled on: home treatment feeding &fluids when to return immediately follow-up Treatment treat local infection give oral drugs advise and teach caretaker follow up Referral facility emergency triage & treatment Diagnosis & treatment monitoring & ff-up

Target Groups Sick young infant 1 week up to 2 months Sick young children 2 months up to 5 years The under five age groups are the target population of IMCI. There are special problems among 1 week old neonates until they reach 2 months of age. Majority of children belong to the category of less than 2 months old.

Assessing the Sick Child lethargy or unconsciousness inability to drink or breastfeed vomiting convulsions General Danger Signs The first step after gathering the child’s weight, name and age, is to ask for general the danger signs. These are: unable to drink or breastfeed, vomiting, convulsions and lethargy.

Checking the Main Symptoms - cough and difficult breathing - diarrhea - fever - ear problem The next major step is to check for the main symptoms. The specific signs to watch for under each main symptom are presented in the next four slides

Checking the Main Symptoms 1. Cough or difficult breathing 3 clinical signs Respiratory rate Lower chest wall indrawing Stridor

Checking the Main Symptoms 2. Diarrhea Dehydration General condition Sunken eyes Thirst Skin elasticity Persistent diarrhea Dysentery

Checking the Main Symptoms 3. Fever Stiff neck Risk of malaria and other endemic infections, e.g. dengue hemorrhagic fever Runny nose Measles Duration of fever (e.g. typhoid fever)

Checking the Main Symptoms 4. Ear problems Tender swelling behind the ear Ear pain Ear discharge or pus (acute or chronic)

Checking Nutritional Status, Feeding, Immunization Status Malnutrition visible severe wasting edema of both feet weight for age Anemia palmar pallor Feeding and breastfeeding Immunization status

Assessing Other Problems Meningitis Sepsis Tuberculosis Conjunctivitis Others: also mother’s (caretaker’s) own health

IMCI Essential Drugs and Supply Appropriate antibiotics Quinine Vitamin A Paracetamol Oral antimalarial Tetracycline eye ointment ORS Mebendazole or albendazole Iron Vaccines Gentian violet

Overall Case Management Process Outpatient 1 - assessment 2 - classification and identification of treatment 3 - referral, treatment or counseling of the child’s caretaker (depending on the classification identified 4 - follow-up care Referral Health Facility 1 - emergency triage assessment and treatment 2 - diagnosis, treatment and monitoring of patient progress In the overall case management process, the initial 4 steps occur in a first level facility like an OPD clinic or a community health center, or a private clinic. Subsequent steps would entail referral to the hospital when the child has the 4 general danger signs.

SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESS For all sick children age 1 week up to 5 years who are brought to a first-level health facility ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems. CLASSIFY the child’s illnesses: Use a colour-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status. IF URGENT REFERRAL is needed and possible IF NO URGENT REFERRAL isneeded or possible IDENTIFY TREATMENT needed for the child’s classifications: Identify specific medical treatments and/or advice. IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) needed for the child’s classifications. . TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advise the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give immunizations. TREAT THE CHILD: Give urgent pre-referral treatment (s) needed. This is the summary of the Integrated Case Management Process REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital. COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health. FOLLOW-UP care: Give follow-up care when the child returns to the clinic and,if necessary, reassess the child for new problems.

Summary of the Integrated case Management Process For all sick children age 1 week up to 5 years who are brought to a first- level health facility The first step in the integrated case management process is to ask for the child’s name and age. After this, the management would defer for a sick young infant one week to 2 months and a sick child 12 months to 5 years. There is a difference in the approach of a sick young infant from that of a sick child because of the different illnesses besetting each category. In the first week of life, newborn infants are often sick from conditions related to labor and delivery or they have conditions which require special management. Newborns may suffer from asphyxia, sepsis from premature ruptured membranes or other intrauterine infections or birth trauma, or they may trouble breathing due to immature lungs. Jaundice also requires special management in the first week of life. A child may present several signs for a particular problem and overlooking other symptoms one can miss other signs of disease. A child might have pneumonia, diarrhea, malaria, measles or malnutrition and yet present only as fever and difficult breathing. These diseases if undetected can cause disability or death in young children if they are not treated.

Summary of the Integrated case Management Process ASSESS the Child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems Ask the mother or caretaker about the child’s problem. The first visit for the problem would follow the following steps in the next slides. However, if this is a follow-up visit for the problem, one will proceed to give follow-up care. After determining if this is an initial or follow-up visit for another problem, one immediately asks about the general danger signs and observes if the child is lethargic or unconscious. It is important to listen carefully to what the mother or caretaker tells you. Using words that the mother/caretaker can understand and giving her ample time to answer the questions, one can be assured of a good history. Ask also additional questions when the mother/caretaker is not sure of her answer. If the child has no general danger signs, ask the mother/caretaker the 4 main symptoms starting from (1) does the child have cough or difficult breathing? (2) does the child have diarrhea? (3) does the child have fever? and (4) does the child have an ear problem? Next thing to check would be signs of malnutrition and anemia. Then classify the child’s immunization status and decide if the child needs any immunization today. Then ask for other problems according to one’s experience and clinical practice guidelines. Examples of other problems are: skin infections, itching, swollen neck glands or eye infections.

Summary of the Integrated Case Management Process Classify the child’s illness: Use a color-coded triage system to classify the child’s main symptoms and his or her nutrition or feeding status. After assessing the child’s problem, one will classify the child’s illness using a color-coded triage system so that one can make a decision about the severity of the illness. For each of the child’s main symptoms, you will select a category or a classification that corresponds to the severity of the child’s illness. Because many children have more than 1 condition, each illness is classified according to whether his problem requires urgent pre-referral treatment and referral (pink row) or specific medical treatment and advice (yellow row) or a simple advice on home management (green row). After classifying how severe each of the 4 main symptoms, one proceeds to classifying the nutritional status and immunization status of the child.

Summary of the Integrated Case Management Process IF URGENT REFERRAL is needed and possible If the child needs urgent referral, one must identify urgent pre-referral treatments the child needs before transport to a hospital for additional care.

Summary of the Integrated Case Management Process IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) Needed prior to referral of the child according to classification If a child has only one classification, it is easy to see what to do for the child. However, many sick infants and children have more than one classification. For example, a child may have pneumonia or an ear infection at the same time. Some of the treatments may be the same but you will be the one to identify urgent pre-referral treatments. If there is no hospital in the area, you may make some decisions differently than what is described in the slides. You should only refer a child if you expect the child will actually receive better care. Sometimes, giving your best care is better than sending a child on a long trip to a hospital that may not have the supplies or expertise to care for the child. If referral is not possible or if the parents refuse to take the child, you should help the family care for the child. The child may stay near the clinic to be seen several times a day. Or a health worker may visit the home to help give drugs on schedule and to help give fluids and food. All severe classifications are colored pink and include severe pneumonia, or very severe disease, severe dehydration, severe persistent diarrhea, very severe febrile disease, severe complicated measles, mastoiditis, and severe malnutrition or severe anemia. Under this pink columns, the term “Urgent Refer to Hospitals” means that the child must immediately be referred after giving any necessary pre-referral treatments. However, if these treatments would unnecessarily delay referrals, it is advised not to give them at all. An exception would be for severe persistent diarrhea where the instruction is simply “Refer to Hospital.” This means referral is needed but not as urgently. There is time to identify treatments and give all of the treatments before referral. Another possible exemption is severe dehydration. You may keep and treat a child whose only classification is “Severe Dehydration” if the first level facility or clinic has the ability to treat the child. The child may have a general danger sign related to dehydration. For example, he may be lethargic or unconscious or unable to drink because he is severely dehydrated. If the child has another severe classification in addition to severe dehydration, the child should be urgently referred. Here, special skills and knowledge are required to rehydrate this child as too much fluid given too quickly could endanger this child’s life. In rare instances, children may have a general danger sign or signs without a severe classification. These children should be referred urgently. There are other problems that are not included in the IMCI process and it is up for you to decide if these other severe problems cannot be treated at this facility/clinic. If you cannot treat a severe problem like abdominal pain, then you will need to refer the child to the hospital. The following are urgent pre-referral treatments for sick children aged 2 months up to 5 years. (1) Give an appropriate antibiotic (2) Give quinine for severe malaria (3) Give Vitamin A (4) Treat a child to prevent low blood sugar (5) Give an oral anti-malarial (6) Give paracetamol for high fever (38.5 Celsius or above) or pain from mastoiditis (7) Apply tetracycline eye ointment (if clouding of the cornea or pus draining from the eye) (8) Provide oral rehydrating solution so that the mother can give frequent sips on the way to the hospital. The first 4 treatments above are urgent because they can prevent serious consequences such as progression of bacterial meningitis or cerebral malaria, corneal rupture due to lack of Vitamin A or brain damage from low blood sugar. The other listed treatments are also important to prevent worsening of the illness.

Summary of the Integrated Case Management Process TREAT THE CHILD: Give urgent pre- referral treatment(s) needed. When a young child needs urgent referral, you must quickly identify and begin the most urgent treatments for that child. Urgent treatments are in bold prints in the Classification Tables. You will give just the first dose of the child before referral. Appropriate treatments are recommended for each classification. A child with the classification of very severe febrile disease could have meningitis, severe malaria, septicemia or dengue fever. The treatments listed for very severe febrile disease are appropriate because they have been chosen to cover the most likely diseases included in the classification.

Summary of the Integrated Case Management Process REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital When one refers the child to a hospital, it must be explained clearly why this must be done urgently to the mother/caretaker. A good way to ensure compliance is to calm the mother/caretaker’s fears and help resolve problems of who will take care of the child while in the hospital. Accomplishing the referral form or writing all the treatments that were given is a good practice so as to facilitate the receiving hospital of the proper management. Making a phone call to the hospital will also facilitate communication to the attending physicians on duty.

Summary of the Integrated Case Management Process IF NO URGENT REFERRAL is needed or possible For patients who do not need urgent referral, you should record the treatments, advice to give to mother, and when to return for a follow-up visit. if a child has multiple classifications, identify treatment for all problems present. Some treatments are listed for more than one classifcation. An example is Vitamin A which is listed for both measles and severe malnutrition or sever anemia. If a patient ahs both of these problems, you need only list Vitamin A once on the Case recording form. However if an antibiotic is needed for more than one problem, you should identify it each time. For example: antibiotic for pneumonia, antibiotic for Shiegella. When the same antibiotic is appropriate for different problems, you can give that single antibiotic. However, 2 problems may require two different antibiotics. Some instructions that require special explanation: Malaria – children will usually be given the first line anti-malarial recommended by clinical protocols for each institution. However, if the child has cough and fast breathing (pneumonia), or another problem for which the antibiotic cotrimoxazole will be given (such as acute ear infection) cotrimoxazole will serve as treatment for malaria as well. (2) Anemia or very low weight - A child with palmar pallor should begin iron treatment for anemia. If there is high risk of malaria, a child with pallor should also be given an oral anti-malarial, even if the child does not have a fever. If the child is 2 years of age and older, and has not had a dose of mebendazole in the past 6 months, the child should also be given a dose of mebenndazole for possible hookworm or whipworm infection. If a child does not need urgent referral, check to see if the child needs non-urgent referral for further assessment. For example, for a cough which has lasted more than 30 days, or for fever which ahs lasted 7 days or more, you would record “ Refer for Assessment.” Although he mother should take the child for assessment promptly, these referrals are not as urgent. Any other necessary treatments may be done before referral.

Summary of the Integrated Case Management Process IDENTIFY TREATMENT needed for the child’s classifications: identify specific medical treatments and/or advice This slide shows how to do the treatment steps identified on the Assess and Classify Chart. Treat means giving treatment in the first level facility or health center or private clinic, prescribing drugs or other treatment to be given at home, and also teaching the child’s mother/caretaker how to carry out the treatments.

Summary of the Integrated Case Management Process TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advice the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give immunizations. This slide only highlights how it will appear on the Treat the Child Section. This describes also how: (1) give oral drugs (2) Treat local infections (3) Give intramuscular drugs (4) Treat the child to prevent low blood sugar (5) Give extra fluid for diarrhea and continue feeding (6) Give follow-up care If the child is scheduled for an immunization, it may be given depending upon the recommended contraindications being followed by the Expanded Program of Immunization.

Summary of the Integrated Case Management Process COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a healthy facility. Counsel the mother about her own health. If the infant is breastfeeding and was classified as feeding problem or low weight, you need to counsel the mother of the infant about any breastfeeding problems that were found during the assessment. If a mother is breastfeeding her infant less than 8 times in 24 hours, advise her to increase the frequency of breastfeeding. Breastfeed for as long as the infant wants day and night. If the infant receives other foods and drinks, counsel the mother about breastfeeding more, reducing the amount foods or drinks, and if possible, stopping altogether. Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle. If the mother does not breastfeed at all, consider referring her for breastfeeding counseling and possible relactation. If the mother seems interested, a breastfeeding may be able to help her to overcome difficulties and begin breastfeeding again. For many sick children, you will need to assess feeding and counsel the mother about feeding and fluids. Every mother/caretaker who is taking a sick young infant or child at home needs to be advised when to return to a health facility. You should advise her when to return for a follow-up visit and teach her signs that mean to return immediately for further care. During a sick child visit, listen for other problems that the mother herself may be having. The mother may need treatment or referral for her own problems.

Summary of the Integrated Case Management Process FOLLOW-UP CARE: Give follow-up care when the child returns to the clinic and, if necessary, re-asses the child for new problems. Some sick children need to return for follow-up care. Their mothers are told when to come for a follow-up visit, either two days or 14 days. At the follow-up visit, you can see if the child is improving on the drug or other treatment that was prescribed. Some may not respond and may need to try a second drug. Children with persistent diarrhea also need follow up to be sure that diarrhea has stopped. Children with fever or eye infection need to be seen if they are not improving. Follow up is specially important for children with a feeding problem to be sure they are feeding fed adequately and are gaining weight. Because follow-up is important, you should make special arrangements so that follow-up visits may be convenient for mothers. If possible, mothers should not have to wait in line for a follow-up visit. Not charging for follow-up visits is another way to make follow-up convenient and acceptable to mothers. Some use a system to make it easy to find the records of children scheduled for follow-up. At the follow-up visit, you should do different steps than at a child’s initial visit for a problem. Treatments given at the follow-up visit are often different than those given at initial visit.

SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic ASK THE CHILD’S AGE IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years USE THE CHART: œ ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT œ ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD COUNSEL THE MOTHER Select the appropriate case management chart according to age.