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Diagnosing Child Pneumonia: Learning from IMCI in LMICs 2014 AAFP Global Health Workshop San Diego, California Ronald Pust MD Director, Office of Global & Border Health University of Arizona College of Medicine--Tucson
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2 Activity Disclaimer It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Ronald Pust MD has indicated that he has no relevant financial relationships to disclose…………. …but he decided to use all this free space on this slide to say … 1.This presentation will be available of FMDRL 2.The content of the next 2 slides are on your handout…as are references 3.Thanks in advance for coming to this session….”Thanks in advance”
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1.Evaluate evidence for the role of diagnostic modalities for pneumonia in children under five anywhere in the world: imaging, bacteriology, pulse oximetry and specific aspects of physical examination. 2.Utilize the 2014 version of WHO Integrated Management of Childhood Illness [IMCI] as an evidence-based clinical approach to the sick child in resource-limited settings [RLS] 3.Debate the applicability of this and other "reverse clinical innovations,", i. e., learning from low & middle income countries [LMICs], keying off pneumonia within IMCI. Objectives: Diagnosing Child Pneumonia: Learning from IMCI in LMICs
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4 Abstract: Diagnosing Child Pneumonia: Learning from IMCI in LMICs How do we diagnose childhood pneumonia? Do resources dictate an alternative approach in developing LMICs [lower & middle income countries], where pneumonia is the leading cause of death from 2 months to 5 years? In this interactive presentation, we will explore evidence, including a new review of the role of imaging, leading to the 2014 IMCI revised guidelines. We will "walk through" this approach to triage and differential diagnosis of children with cough or labored breathing, based on the algorithm developed in India [Steinhoff] and in Papua New Guinea [Shaan], then adopted worldwide by WHO. We then consider the conundrum of tachypnea in children with severe malaria, often difficult to distinguish from pneumonia. Finally, we invite you to debate the likelihood that this IMCI approach to pneumonia will be adopted in resource-replete settings like North America, thus paralleling oral rehydration for diarrhea as a "reverse innovation” originating in research and practice in LMICs.
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Deaths under age 5 decreasing—except for neonatal Black et al. "Global, regional, and national causes of child mortality in 2008: a systematic analysis." Lancet. 2010; 375: 1969-1987.
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How do we diagnose childhood pneumonia in San Diego? 6
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7 Do resource limitations dictate an alternative approach … …in LMICs with resource constraints—where pneumonia [ALRI] is the leading cause of death from 2 months to 5 years ?
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This is the commonest cause of serious bacterial pneumonia world-wide at all ages …but of course you won’t see this classic Gram’s stain from a young child anywhere.
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Assessing and Treating Cough or Difficult Breathing: Outpatient Aspects https://www.youtube.com/watch?v=t4spsM24eHQ
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Some solutions for the paramedic who has no watch include…
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Videos from International Child Health Review Collaboration on IMCI and ALRI Background to WHO Guidelines Triage Assessment and Treatment Cough and Difficulty Breathing Next, look for “in-drawing” = retractions = paradoxical respiration “INDRAWING = INPATIENT” WHY? What is the evidence – based physiology that justifies: “Retractions = severe Pneumonia”, i.e., that : ‘INDRAWING = INPATIENT”?
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Page 16 [The 3 handbooks used as “required texts” in the annual Arizona August Clinical GH Course —are in use worldwide] IMCI for physicians: WHO’s Hospital Care for Children…With Limited Resources [2 nd ed, 2013]
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Yodit Z., intern at Mendefera, Eritrea uses IMCI to assess a sick child…
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…and at the Heart of IMCI is…
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Found on inside cover of WHO: Pocketbook of Hospital Care for Children. 2013. Based on Emergency Triage Assessment and Treatment (ETAT).
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What about the use of pulse oximetry?
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What if you actually took a chest film? Chest film of infant at San Xavier Indian Health Service Clinic, Tucson, AZ
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Lateral film of same infant at San Xavier IHS Clinic Would a chest film change your management?
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CXR may be most helpful in younger infants [under 2-3 months, when physical exam is not as reliable] and in settings where rates of other diseases, such as malaria in developing nations and asthma in any country, may increase risk of misdiagnosis in a tachypneic child. Pulse oximetry can add specificity to IMCI and CXR diagnostic methods. Child pneumonia is a diagnosis that should be made after consideration of the child’s complete history, circumstances, and physical exam—and CXR and pulse oximetry when available. However, IMCI guidelines remain the most important factor in limited resource settings to identify children who require life-saving medical attention. Black, White and Gray: The Use of Chest Radiography in the Diagnosis of Pediatric Pneumonia in Resource Limited Settings Kirsten Cooper MD Candidate 2014 University of Arizona College of Medicine Global Health Distinction Track Senior Project
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Mayan Paramedics apply IMCI in Chiapas, MX with J-Manuel Corrales, MD of Doctors for Global Health. Dr. Corrales was honored with the 2007 Global Health Council’s Jonathan Mann Humanitarian Award.
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IMCI 2014 ChartBook: Algorithm and checklists 2014 TOC and Let’s place the diagnosis and treatment of pneumonia in the context of the clinical algorithm for IMCI—the Integrated Management of Childhood Illness—in 2014
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IMCI Approach to Infant under 2 months of age
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IMCI approach via the 2014 revised 70 page IMCI “Chart Book”: Table of Contents for section on children 2 months to 5 years
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“General Danger Signs” = Emergency Triage
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https://www.youtube.com/watch?v=t4spsM24eHQ “Cough or Difficult Breathing?”
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“Cough or Difficult Breathing?”---expanded detail
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IMCI—and its ARI protocol, when followed—is just as vital in preventing the overuse of antibiotics in URIs as in promoting appropriate antibiotics in LRIs. Most children with coughs do NOT need antibiotics.
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Algorithm / checklist approach to the Integrated Management of Childhood Illness– IMCI
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“Diarrhea?”
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“Fever?” [measured] [ with no cough/difficult breathing or diarrhea]
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“Ear problem?” [ especially if ear pain or no other cause of fever]
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“Malnutrition?” acute = low wt / ht or low MUAC or edema
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“Anemia?” [palms or mouth pale?]
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“HIV infection?” [if risk and not tested earlier] IMCI Chartbook and Hospital Care for Children have modifications and details on management of HIV-positive children who are HIV positive.
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45 Is it the difference in resources that underlie differences in approach to the diagnosis of pneumonia [ALRI] and other childhood diseases between resource- replete and resource –limited countries?
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46 In USA and other “resource-replete” nations, we have adopted ORT—oral rehydration therapy. This is because it is the best evidence-based approach to child diarrhea, “even though” it came from Bangladesh research. But it took over 20 years to be accepted in USA. Should we adopt the IMCI approach to child pneumonia? “even though” it also came from research in LMICs …that, by now, was done over 20 years ago. Will we ?
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47 Salbutamol oral [tablets or liquid] as mainstay in treating asthma/RAD in resource-limited settings Dose 3 times daily: Infant – do not give Walking 1 mg School age 2 mg Adult 4 mg Not all tachypnea is pneumonia Asthma is rising in LMIC children. Why? Why not albuterol inhalers?
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Dennis L, aged 44 months, is from Lumaconda in Lugari District, Western Province of Kenya. His home is at the same 5500 ft elevation as the Quaker/Friends 100 bed hospital here in Lugulu. Dennis is a second-born child admitted to Lugulu hospital on May 16, 2005. His inpatient no. is 23320. After a couple days of fever and malaise at home, Dennis had been taken to a health center, where he was observed to be “breathing hard.” But he was considered to have malaria on the basis of a blood smear. Malaria treatment was prescribed. Because his breathing soon thereafter became increasingly deep and rapid, he was brought by his father into this hospital at 6 pm. I discovered him about 7:40 pm on the evening rounds when on call. Review of Dennis’ history confirmed the story above. There was no diarrhea, vomiting or rash. Dennis L: Another look at IMCI
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Dennis L was admitted to this children’s ward at Lugulu Hospital
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His father was carrying Dennis’ Child “Road to Health” Card, which recorded full immunizations and excellent growth at the 100% line [50th percentile] for his first 4-6 months. After Dennis’ measles immunization at 9 months, he had not attended the “Under-fives Clinic”. This is typical here once the “shots” are completed. On admission he weighed 13.0 kg which is just above the 80% line [3rd percentile] Vital signs: Pulse 154; respirations were very deep and somewhat labored at 72 per minute; temperature was 39 C. Blood pressure measurement was not attempted. The Clinical Officer’s impression on admission from the out- patient department [OPD] was: Complicated malaria with seizure [by history] as well as severe pneumonia. Parenteral treatment was begun with quinine, ampicillin and gentamicin.
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When I saw Dennis L. the above vital signs were confirmed. Pulse 154; respirations were very deep at 72 per minute; T = 39 C But he was now barely responsive, with a Blantyre Coma Scale score of 2 out of 5. The neck was not stiff. His mucous membranes were slightly pale. There was no cough, no chest indrawing [and no abnormal auscultatory signs…] Abdomen was flat, non-tender; liver and spleen barely palpable. The rest of Dennis’ physical examination was essentially normal. WHAT IS YOUR ASSESSMENT of DENNIS L. at this point? WHAT WOULD YOU DO NEXT? TREATMENT?
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My assessment was that this was indeed severe/complicated P. falciparum malaria. The main complications seemed to be cerebral malaria and also metabolic/lactic acidosis with decreased effective intravascular volume. I did not think Dennis L had pneumonia. I assessed the respiratory rate and depth [but with good lung compliance and only moderately increased “work of breathing] to be due to compensatory respiratory alkalosis in response to the severe metabolic acidosis brought about by complicated malaria. So, not all tachypnea is pneumonia. Hyperpnea, esp without retractions or “difficult” breathing may be compensating for metabolic acidosis… At that time [2005] I did not have a pulse-oximeter Would pulse oximetry help? So, what would you do about the ampicillin and gentamicin? [That is a whole other clinical and cultural question !]
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53 Take home messages: Use IMCI and WHO Hospital Care for Children Teach and reinforce IMCI Carry—and leave—a pulse oximeter
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WHO/UNICEF. Global Action Plan for Prevention and Control of Pneumonia (GAPP). 2009.
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References & Resources Univ of Arizona. Global Health: Clinical and Community Care. URL: http://globalhealth.arizona.edu/ August course open to allhttp://globalhealth.arizona.edu/ Walker CLF, Rudan I, Liu L, et al. Global Burden of childhood pneumonia and diarrhoea. Lancet 2013; 381: 1405-1416. Shann F. Children with cough: who needs antibiotic therapy, and who needs admission to hospital. Indian J Pediatri 1985;52:343-348. WHO IMCI chart book 2014. URL: http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/ http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/ WHO Pocketbook of Hospital Care for Children. 2 nd ed. WHO: 2013. [also in Spanish via PAHO] Follows the IMCI sequence at advanced level for doctors. http://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_eng.pdf?ua=1 WHO. Evidence for Technical Update of Pocket Book of Hospital Care for Children. Recommendations for management of common childhood conditions. 2012. http://whqlibdoc.who.int/publications/2012/9789241502825_eng.pdf http://whqlibdoc.who.int/publications/2012/9789241502825_eng.pdf Principi N, Esposito S. Management of severe community-acquired pneumonia of children in developing and developed countries. Thorax 2011;66:815-22. Ginsburg A, Van Cleve WC, Thompson IW, English M. Oxygen and Pulse Oximetry in Childhood Pneumonia: A survey of healthcare providers in resource-limited settings. J Trop Ped. 2012; 58(5): 389- 393. Subhi R, Smith K, Duke T. When should oxygen be given to children at high altitude? Arch Dis Child 2009;94:6-10. References conclude on next slide….
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Cooper, Kirsten.. Black, White and Grey: The Use of Chest Radiography in the Diagnosis of Pediatric Pneumonia in Resource Limited Settings. University of Arizona College of Medicine, Global Health Distinction Track Capstone Project; April, 2014. Santosham M, et al. Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama. N Engl J Med 1982;306:1070-6. Santosham M, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatr 1997;100(5) Managing Acute Gastroenteritis Among Children. MMWR Recommendations and Reports 2003;21/No. RR-16. (this is the “official” USA/CDC Guideline – agrees with its origins in LDC research (Santosham, et al. in Bangladesh in 1970s) Bhutta et al. Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost? Lancet 2013; 381: 1417-1429. WHO and UNICEF. Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025. The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). http://www.who.int/maternal_child_adolescent/documents/global_action_plan_pneumonia_diarrhoea/en/ http://www.who.int/maternal_child_adolescent/documents/global_action_plan_pneumonia_diarrhoea/en/ To continue this conversation and/or to enroll in the annual August clinical global health course, contact: Ron Pust MD rpust@email.arizona.edu or www.globalhealth.arizona.edurpust@email.arizona.eduwww.globalhealth.arizona.edu THANK YOU...again….for your participation !
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