IMCI Chart Booklet PDF

Integrated Management of Childhood Illness Chart Booklet March 2014 WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: - Introduction, self-study modules – Module 1: general d...

Integrated Management of Childhood Illness Chart Booklet March 2014 WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: - Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3 (NLM classification: WS 200) © World Health Organization 2014 All rights reserved. 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Printed in Switzerland Integrated Management of Childhood Illness SICK CHILD AGE 2 MONTHS UP TO 5 YEARS ASSESS AND CLASSIFY THE SICK CHILD ASSESS CLASSIFY IDENTIFY TREATMENT ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE problem. CHILD'S SYMPTOMS AND PROBLEMS if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS on TREAT THE CHILD chart. if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment breastfeed? or unconscious. DISEASE Give any pre-referal treatment immediately Does the child vomit Is the child convulsing URGENT attention Treat to prevent low blood sugar everything? now? Keep the child warm Has the child had Refer URGENTLY. convulsions? A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed. THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? If yes, ask: Look, listen, feel*: Any general danger sign Pink: Give first dose of an appropriate antibiotic For how long? Count the or SEVERE Refer URGENTLY to hospital** Classify breaths in COUGH or Stridor in calm child. PNEUMONIA OR one minute. DIFFICULT VERY SEVERE Look for BREATHING DISEASE chest CHILD Chest indrawing or Yellow: Give oral Amoxicillin for 5 days*** indrawing. MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly Look and CALM acting bronchodilator) give an inhaled listen for bronchodilator for 5 days**** stridor. If chest indrawing in HIV exposed/infected child, Look and give first dose of amoxicillin and refer. listen for Soothe the throat and relieve the cough with a wheezing. safe remedy If wheezing with either If coughing for more than 14 days or recurrent fast breathing or chest wheeze, refer for possible TB or asthma indrawing: assessment Give a trial of rapid acting Advise mother when to return immediately inhaled bronchodilator for up Follow-up in 3 days to three times 15-20 minutes No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting apart. Count the breaths and very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for look for chest indrawing 5 days**** again, and then classify. Soothe the throat and relieve the cough with a If the child is: Fast breathing is: safe remedy 2 months up to 12 months 50 breaths per minute or more If coughing for more than 14 days or recurrent wheezing, refer for possible TB or asthma 12 Months up to 5 years 40 breaths per minute or more assessment Advise mother when to return immediately Follow-up in 5 days if not improving *If pulse oximeter is available, determine oxygen saturation and refer if < 90%. ** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children. ***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings. **** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze. Does the child have diarrhoea? Two of the following signs: Pink: If child has no other severe classification: If yes, ask: Look and feel: Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C) For how long? Look at the child's general for DEHYDRATION Sunken eyes DEHYDRATION OR Is there blood in the stool? condition. Is the child: Not able to drink or drinking If child also has another severe Lethargic or poorly classification: unconscious? Classify DIARRHOEA Skin pinch goes back very Refer URGENTLY to hospital with mother Restless and irritable? giving frequent sips of ORS on the way slowly. Look for sunken eyes. Advise the mother to continue Offer the child fluid. Is the breastfeeding child: If child is 2 years or older and there is Not able to drink or cholera in your area, give antibiotic for drinking poorly? cholera Drinking eagerly, Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some thirsty? Restless, irritable SOME dehydration (Plan B) Pinch the skin of the Sunken eyes DEHYDRATION If child also has a severe classification: abdomen. Does it go back: Drinks eagerly, thirsty Refer URGENTLY to hospital with mother Very slowly (longer Skin pinch goes back giving frequent sips of ORS on the way than 2 seconds)? slowly. Advise the mother to continue Slowly? breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat as some or severe NO DEHYDRATION diarrhoea at home (Plan A) dehydration. Advise mother when to return immediately Follow-up in 5 days if not improving Dehydration present. Pink: Treat dehydration before referral unless the child and if diarrhoea 14 SEVERE has another severe classification days or more PERSISTENT Refer to hospital DIARRHOEA No dehydration. Yellow: Advise the mother on feeding a child who has PERSISTENT PERSISTENT DIARRHOEA DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days Blood in the stool. Yellow: Give ciprofloxacin for 3 days and if blood in stool DYSENTERY Follow-up in 3 days Does the child have fever? If yes: Any general danger sign or Pink: Give first dose of artesunate or quinine for severe malaria Decide Malaria Risk: high or low Stiff neck. VERY SEVERE FEBRILE Give first dose of an appropriate antibiotic High or Low Malaria DISEASE Treat the child to prevent low blood sugar Then ask: Look and feel: Risk For how long? Look or feel for stiff neck. or above) If more than 7 days, has fever been Look for runny nose. Classify FEVER Refer URGENTLY to hospital present every day? Look for any bacterial cause of Has the child had measles within the fever**. Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial last 3 months? Look for signs of MEASLES. MALARIA Generalized rash and or above) One of these: cough, runny nose, Give appropriate antibiotic treatment for an identified bacterial cause or red eyes. of fever Advise mother when to return immediately Do a malaria test***: If NO severe classification Follow-up in 3 days if fever persists In all fever cases if High malaria risk. If fever is present every day for more than 7 days, refer for In Low malaria risk if no obvious cause of fever present. assessment Malaria test NEGATIVE Green: Other cause of fever PRESENT. FEVER: or above) NO MALARIA Give appropriate antibiotic treatment for an identified bacterial cause of fever Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment Any general danger sign Pink: Give first dose of an appropriate antibiotic. No Malaria Risk and No Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar. Travel to Malaria Risk DISEASE Area or above). Refer URGENTLY to hospital. No general danger signs Green: No stiff neck. FEVER or above) Give appropriate antibiotic treatment for any identified bacterial cause of fever Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days, refer for assessment Any general danger sign or Pink: Give Vitamin A treatment If the child has measles now or Look for mouth ulcers. Clouding of cornea or SEVERE COMPLICATED Give first dose of an appropriate antibiotic within the last 3 months: Are they deep and extensive? If MEASLES now or within last 3 Deep or extensive mouth ulcers. MEASLES**** If clouding of the cornea or pus draining from the eye, apply Look for pus draining from the eye. months, Classify tetracycline eye ointment Look for clouding of the cornea. Refer URGENTLY to hospital Pus draining from the eye or Yellow: Give Vitamin A treatment Mouth ulcers. MEASLES WITH EYE OR If pus draining from the eye, treat eye infection with MOUTH tetracycline eye ointment COMPLICATIONS**** If mouth ulcers, treat with gentian violet Follow-up in 3 days Measles now or within the last 3 Green: Give Vitamin A treatment months. MEASLES **Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children. *** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA. **** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables. Does the child have an ear problem? If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital If yes, for how long? Feel for tender swelling Pus is seen draining from Yellow: Give an antibiotic for 5 days behind the ear. the ear and discharge is ACUTE EAR Give paracetamol for pain reported for less than 14 INFECTION Dry the ear by wicking days, or Follow-up in 5 days Ear pain. Pus is seen draining from Yellow: Dry the ear by wicking the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days reported for 14 days or INFECTION Follow-up in 5 days more. No ear pain and Green: No treatment No pus seen draining from NO EAR INFECTION the ear. THEN CHECK FOR ACUTE MALNUTRITION CHECK FOR ACUTE MALNUTRITION Oedema of both feet Pink: Give first dose appropriate antibiotic LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar STATUS scores OR MUAC less MALNUTRITION Keep the child warm Look for oedema of both feet. Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital Measure MUAC**____ mm in a child 6 months or older. one of the following: Medical If WFH/L less than -3 z-scores or MUAC less than 115 complication present mm, then: or Check for any medical complication present: Not able to finish RUTF Any general danger signs or Any severe classification Breastfeeding Pneumonia with chest indrawing problem. If no medical complications present: WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days Child is 6 months or older, offer RUTF*** to scores UNCOMPLICATED Give ready-to-use therapeutic food for a child eat. Is the child: OR SEVERE ACUTE aged 6 months or more MUAC less than 115 mm MALNUTRITION Counsel the mother on how to feed the child. Not able to finish RUTF portion? Assess for possible TB infection AND Able to finish RUTF portion? Advise mother when to return immediately Able to finish RUTF. Follow up in 7 days Child is less than 6 months, assess breastfeeding: WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the 2 z-scores MODERATE ACUTE mother on the feeding recommendations Does the child have a breastfeeding OR MALNUTRITION If feeding problem, follow up in 7 days problem? Assess for possible TB infection. MUAC 115 up to 125 mm. Advise mother when to return immediately Follow-up in 30 days WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the more NO ACUTE child's feeding and counsel the mother on OR MALNUTRITION feeding according to the feeding recommendations MUAC 125 mm or more. If feeding problem, follow-up in 7 days *WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts. ** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older. ***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition. THEN CHECK FOR ANAEMIA Check for anaemia Severe palmar pallor Pink: Refer URGENTLY to hopsital Look for palmar pallor. Is it: SEVERE ANAEMIA Severe palmar pallor*? Classify Some pallor Yellow: Give iron** Some palmar pallor? ANAEMIA Classification arrow ANAEMIA Give mebendazole if child is 1 year or older and has not had a dose in the previous 6 months Advise mother when to return immediately Follow-up in 14 days No palmar pallor Green: If child is less than 2 years old, assess the NO ANAEMIA child's feeding and counsel the mother according to the feeding recommendations If feeding problem, follow-up in 5 days *Assess for sickle cell anaemia if common in your area. **If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF. THEN CHECK FOR HIV INFECTION Use this chart if the child is NOT enrolled in HIV care. Positive virological test in Yellow: Initiate ART treatment and HIV care ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis* Classify OR INFECTION Has the mother or child had an HIV test? HIV counselling to the mother status Positive serological test in a IF YES: child 18 months or older Advise the mother on home care Decide HIV status: Asess or refer for TB assessment and INH Mother: POSITIVE or NEGATIVE preventive therapy Child: Follow-up regularly as per national guidelines Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as a breastfeeding child or only recommended If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status** unknown, ASK: ago Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother the test? Mother HIV-positive, child Advise the mother on home care Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines If breastfeeding ASK: Is the mother and child on ARV OR prophylaxis? Positive serological test in a IF NO, THEN TEST: child less than 18 months Mother and child status unknown: TEST mother. old Mother HIV positive and child status unknown: TEST child. Negative HIV test in mother Green: Treat, counsel and follow-up existing infections or child HIV INFECTION UNLIKELY * Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative after cessation of breastfeeding. ** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible. THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS IMMUNIZATION SCHEDULE: Follow national guidelines AGE VACCINE Birth BCG* OPV-0 Hep B0 VITAMIN A 6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1*** SUPPLEMENTATION Give every child a 10 weeks DPT+HIB-2 OPV-2 Hep B2 RTV2 PCV2 dose of Vitamin A every six months from the age of 6 months. Record the dose on the child's chart. 14 weeks DPT+HIB-3 OPV-3 Hep B3 RTV3 PCV3 ROUTINE WORM TREATMENT Give every child mebendazole every 6 9 months Measles ** months from the age of one year. Record the dose on the 18 months DPT child's card. *Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated. **Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose. ***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life. ASSESS OTHER PROBLEMS: MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low blood sugar. HIV TESTING AND INTERPRENTING RESULTS HIV testing is RECOMMENDED for: Types of HIV Tests What does the test detect? How to interpret the test? SEROLOGICAL These tests detect antibodies made by HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not TESTS immune cells in response to HIV. disappear until the child is 18 months of age. (Including rapid They do not detect the HIV virus itself. This means that a positive serological test in children less than 18 months in NOT a reliable way to check for infection of the child. tests) VIROLOGICAL These tests directly detect the presence of Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old. TESTS the HIV virus or products of the virus in the If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected. (Including DNA blood. or RNA PCR) For HIV exposed children 18 months or older, a positive HIV antibody test result means the child is infected. For HIV exposed children less than 18 months of age: If PCR or other virological test is available, test from 4 - 6 weeks of age. A positive result means the child is infected. A negative result means the child is not infected, but could become infected if they are still breast feeding. If PCR or other virological test is not available, use HIV antibody test. A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected. Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age Breastfeeding status POSITIVE (+) test NEGATIVE (-) test NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected last 6 weeks Repeat test at 18 months. BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks. breastfeeding has been discontinued for more than 6 weeks. WHO PAEDIATRIC STAGING FOR HIV INFECTION Stage 1 Stage 2 Stage 3 Stage 4 Asymptomatic Mild Disease Moderate Disease Severe Disease (AIDS) - - Unexplained severe Severe unexplained wasting/stunting/severe acute acute malnutrition not responding malnutrition not responding to standard therapy to standard therapy Symptoms/Signs No symptoms, or only: Enlarged liver and/or spleen Oral thrush (outside neonatal Oesophageal thrush Persistent generalized Enlarged parotid period). More than one month of herpes simplex ulcerations. lymphadenopathy (PGL) Skin conditions (prurigo, seborraic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacteria infections > 2 molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis herpes zoster) to standard pneumonia (PCP)* Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma. gingival Erythema) Diarhoea for over 14 days Extrapulmonary tuberculosis. Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess* (sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis* ortorrhea) 50,000/mm3 for 1month Acquired HIVassociated rectal Neutropenia* (under fistula 500/mm3 for 1 month) HIV encephalopathy* Anaemia for over 1 month (haemoglobin under 8 gm)* Recurrent severe bacterial pneumonia Pulmonary TB Lymp node TB Symptomatic lymphoid interstitial pneumonitis (LIP)* Acute necrotising ulcerative gingivitis/periodontitis Chronic HIV associated lung diseses including bronchiectasis* *Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment. TREAT THE CHILD CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Give an Appropriate Oral Antibiotic Also follow the instructions listed with each drug's dosage table. FOR PNEUMONIA, ACUTE EAR INFECTION: FIRST-LINE ANTIBIOTIC: Oral Amoxicillin Determine the appropriate drugs and dosage for the child's age or weight. AMOXICILLIN* Tell the mother the reason for giving the drug to the child. Give two times daily for 5 days AGE or WEIGHT Demonstrate how to measure a dose. TABLET SYRUP Watch the mother practise measuring a dose by herself. 250 mg 250mg/5 ml Ask the mother to give the first dose to her child. 2 months up to 12 months (4 -