Current Trends In Public Health: Global And National PDF

---------------------------------------------------------- **CURRENT TRENDS IN PUBLIC HEALTH: GLOBAL AND NATIONAL** ---------------------------------------------------------- - Caregiver, counselor, educator, referral resource, role model, and case manager (an important role) - Coordin...

---------------------------------------------------------- **CURRENT TRENDS IN PUBLIC HEALTH: GLOBAL AND NATIONAL** ---------------------------------------------------------- - Caregiver, counselor, educator, referral resource, role model, and case manager (an important role) - Coordinator, collaborator and liaison - Case finder, leader, change agent, community mobilizer, coalition builder, policy advocate, social marketer, researcher - utilizes the nursing process in the care of the client in the home setting through home visits and in public health care facilities; conducts referrals of patients to appropriate levels of care when necessary - As a caregiver, a nurse provides direct hands-on care to patients in a variety of settings. They help the ill patient to manage physical needs, prevent illness, and treat the health condition. They also prepare patients for exams or treatments and making assessments, including helping to perform diagnostic tests and analyzing results. - (*ex. PHN conducts follow-up home visits to families with children who are taking antibiotics for PTB*) - utilizes teaching skills to improve the health knowledge, skills and attitudes of individual, family, and community; conducts health information campaigns to various groups for the purpose of health promotion and disease prevention - It is widely recognized that health teaching is a part of good nursing practice and one of the major functions of a registered nurse. They teach patients and their families how to manage medical conditions and post-treatment care. They also provide health education to patients about self-care, healthy habits, and demonstrate ways how to promote health, prevent illness, maintaining and restoring health properly. - (ex. *The PHN conducts lecture on the different vaccines covered in the EPI and its importance to children at the health center*) - - - ***Supervisor*** - - - - - - - - - - - - - A registered nurse works as an advocate of patient's rights concerning their care. They provide sufficient information to the patient and their family members to make necessary health care decisions regarding their health. They also help them to navigate a complex medical system, translating medical terms, and helping patients make ethical decisions. Advocates ensure those patients' autonomy and self-determination. They also help the patient/family member in the decision-making process and speak up when problems go unnoticed or when the patient or family can't or won't address them. - Nurse administrators are licensed and have advanced degrees and field experience. Nurse administrator responsibilities involve overseeing nursing staff, motivating them to do their job well, and supervising assistant administrators. A nurse administrator's responsibility is to run health care settings dynamically with any interruption of patient care. - This is a critical role that registered nurse does regularly to identify patient's problems. They establish a care plan for the patient by setting measurable and achievable short- and long-term goals for the patient based on the assessment and diagnosis. Being assessors, nurses identify patient's problems, causes, and risk factors. They can alleviate suffering; prevent complications and relapse of their client's health problems - The registered nurse provides emotional and psychological support to the patients and their families to cope with the crisis. They help the patient to make proper healthy choices and decisions their throughout lifetime. - - - - - - - 1. 2. 3. 4. 5. - Provision of primary health care services - Development/utilization of family nursing care plan in the provision of care - Community organizing, mobilization, community development and people empowerment - Case finding and epidemiological investigation - Program planning, implementation and evaluation - Influencing executive and legislative individuals or bodies concerning health and development          ------------------------------------------------------------------ **DELIVERY OF HEALTH CARE TO THE FILIPINO FAMILY AND COMMUNITY** ------------------------------------------------------------------ - As the diversity in the patient population is growing, there is also an increasing number of diverse caregivers. Among them are the Filipino health care providers, most of whom are nurses. Understanding the culture, health care beliefs, and practices of Filipino nurses is important, as it affects the way they assess the needs and provide care for their clients. This lesson provides a general profile of the health care beliefs, behaviors, and practices of Filipino nurses within the context of the general Filipino culture. Like any other ethnic group, Filipinos have become acculturated at various levels over the years in working with countries other than the Philippines. It is the integration of their cultural beliefs, values, and behaviors that affects their caregiving attitudes and practices. - As a group, Filipino nurses are well liked because they are hardworking. They place high value on responsibility and seldom complain. Joyce and Hunt (1982) commented, "Many \[Filipino nurses\] work nights, holidays and/or overtime. - One can rely on a Filipino nurse to volunteer to cover the shift". It is not unusual to find Filipino nurses who work two jobs. The financial rewards, job security, and personal advancement that jobs provide to Filipino nurses are valued. - This leads to an attitude of perseverance, tolerance to poor working conditions, and accepting less pay for jobs offered to them. At work, sick call is a rarity for Filipino nurses. A joke among some Filipino nurses is to call in sick when one is dying, not before. In other words, they do not call in sick for casual reasons. They feel guilty if they call in sick, especially when the workplace is busy. Although management may favor such a work ethic, such practice may expose coworkers to communicable diseases such as the flu and upper respiratory tract infections when they prefer to work rather than nurture their bodies. - Filipino nurses are very religious people. There is a deep faith in God that is reflected in the expression of bahala na---"it is up to God" or "leave it to God." This tends to be incorrectly equated with an expression of fatalism and a passive acceptance of or resignation to fate. Bahala na may also apply to acceptance of illness or malady. Although it is an indication of acceptance of the nature of things including one's own inherent limitations, bahala na operates psychologically to elevate one's courage and conviction to persist in the face of adversity and improve one's situation (Okamura & Agbayani, 1991). - Filipinos are generally sensitive and equally sensitive to the feelings of others, so they try to find a way to say things diplomatically. - Being sensitive to the feelings of others is also reflected in the way Filipino nurses conduct patient teaching, especially with the elderly, immigrants, and the less fortunate. - Filipinos are generally quiet. Very conservative families do not allow their younger members to join the conversation of adults without an invitation. Hence, Filipinos are often misunderstood when they do not give feedback. They are sometimes hesitant to articulate their views, especially if it is different from the majority, as it might indicate discordance with the team or group. Engaging in arguments, especially with someone who is older or holds an authority position, is considered uncivilized. Filipinos also have difficulty turning down requests from supervisors to whom they feel obligated (Joyce & Hunt, 1982). - Because of the culturally determined nature, Filipinos are shy and appear timid, especially women. They are reluctant to express their opinions for fear of offending others. They are used to a culture of maintaining cordial relationships and group harmony. Raising questions may be considered offensive. In class, most Filipinos would rather ask the classmate sitting next to her or him to clarify ideas or instructions rather than asking the teacher. In this situation, the shyness predominates more than the concern of asking the teacher. - In terms of health assessments of Filipinos in general, health care providers are encouraged to probe more to ensure accuracy and completeness of health information and validate if the patient can actually demonstrate understanding of provided instructions regarding their care. - One's position in society, professional achievements, and age carry a lot of weight in the Philippine society. Physicians, lawyers, priests, engineers, teachers, and nurses are among the well-respected professionals in the Philippines. Hence, their opinion is generally accepted without question. - Filipino values and traditions provide a framework for conduct and mode of communication. Because of a high regard for the elderly and authority, Filipinos tend not to oppose or contradict other views for fear of embarrassing the other party. - "Filipinos generally are neither assertive nor aggressive and may often appear guarded or reticent. Nurses often misunderstand this need for passivity and do not appreciate the culturally induced motivation to maintain harmonious balance between man and nature" (Vance & Davidhizar, 1999, p. 16). - This nonconfrontational behavioral pattern accounts for the perception of Filipinos as being passive or timid. Few are cognizant that this conflict-management style stems from a culture of agreement and a virtue of pleasing others. - When a female Filipino nurse goes for a medical appointment, she is more likely to accept what her physician says. A second opinion is seldom sought, because that would mean questioning the wisdom of her physician. On the other hand, if there is a lingering doubt, it is discussed with friends and relatives who are likely to influence the decision on whether to seek a second opinion. This is an area where a Filipino nurse may readily advise her patient but rarely practice what she preaches. - Someone older is spoken to in the third person, which is perceived as a sign of respect. This is not even enough. The word po is a suffix added to practically every sentence when speaking with an older or elderly person. This kind of cultural value and corresponding behaviors may hinder some Filipino nurses from performing their patient advocacy role. For this reason, assertiveness training is very beneficial for Filipino nurses so that they can exercise patient advocacy in a more effective way. - Filipino nurses highly value their elderly clients. This may be influenced by the way they feel toward elderly parents and relatives. There is a sense of obligation and personal fulfillment in caring for one's parents. Elderly individuals are given high respect and revered. Family commitment fosters a sense of pride, and therefore, caring for others is embedded in the culture. "Concern for the welfare of the family is expressed in the honor and respect bestowed on parents and older relatives, the care provided to children, and the individual sacrifices that are made on behalf of family members" (Okamura & Agbayani, 1991, p 1). - Filipino nurses find it uncomfortable to accept even a well-deserved compliment. For example, if someone gives a complement like, "Your dress is beautiful!" the answer might be, "Not really. I bought it cheap." Or if someone says, "You are so knowledgeable," the answer might be, "Not really, I just happen to know it." Yet they are proud of their accomplishments in a sort of quiet way. As a result, many have culture-based barriers to marketing themselves. Filipino nurses are less likely to use I to express what they have achieved. More than likely, they will use we to acknowledge others' contributions no matter how insignificant the contributions might be. This may explain why they work well with others. This may come from the practice of Bayanihan. In the Philippines, if you want something done, it is easy to get a group together to work on a project so that it will get done faster and better. - Respect is integrated in the Filipino language. Reference to the elderly is the use of the third person. Hence, when spoken to assertively in a direct way, Filipinos feel offended. There is no gender differentiation in the Filipino language. Although they are fully aware of the male and female genders, their native language is what hinders them from precisely using he or she in spoken English. - Filipino nurses have strong family ties. Their close friends become their family members. As a result, they perpetuate the cultural burden (as a downside) thus making it more difficult and taking them longer to assimilate into the mainstream culture of their adopted country. They tend to eat the same food and mingle with individuals of the same ethnic background. Hence, the old health beliefs and practices continue. - One may hear a Filipino extolling the importance of preventive health to her patients or clients. Filipino nurses have a tendency to self-diagnose, self-medicate, and seek alternative therapies. In rural areas in the Philippines, people go for Hilot for relief of pain and aches instead of seeking medical attention. In an alternative context, Hilot may refer to a practitioner or the practice of chiropractic manipulation and massage for the diagnosis and treatment of musculo-ligamentous and musculoskeletal ailments (Stuart, 1977). - Home remedies in the form of medicinal plants are also popular for Filipino nurses who believe that plants can heal common ailments. The practice of self-healing and self-treatment prevents them from getting early formal medical access and interventions. This poses a great concern to most health care providers, as Filipino nurses only seek medical care when their medical condition is already very serious or in an advanced stage. - Three concepts underlie Filipino health beliefs and practices: flushing, heating, and protection. Each identifies a basic process used to promote good health. Flushing keeps the body free from debris, heating maintains a balanced internal temperature, and protection guards the body from outside influences. Although Western and scientific concepts are similar, Filipino theories are founded on different premises. Flushing is based on the notion that the body is a container that collects impurities, heating means that hot and cold qualities must be balanced in the body, and protection involves safeguarding the body's boundaries from supernatural as well as natural forces. - Another reason is that home remedies are readily available and cheap. An example is the consumption of tea for stomachaches, boiling ginger and drinking water for a sore throat, and boiling corn hair and drinking water to promote urination. Although the approach might be benign, it is the delay of medical attention that may worsen the medical ailment and miss the optimal treatment opportunity. - Generally speaking, Filipino nurses have a high tolerance to pain. For example, one has severe arthritis, yet she continues to do housework regardless of her pain. Filipino nurses normally use home remedies such as liniments and topical ointments and manage pain before seeking medical care or while under medical treatment. Health care providers need to probe more into the cause and degree of pain from Filipino patients to elicit more information. The elderly group, in particular, is unlikely to complain about their pain because they do not want to have extra burdens being imposed on caregivers. - The belief in the bahala na attitude predominates pain management, especially for first-generation Filipino immigrants. They value the opinion of elder family members regarding their condition or the opinion of a trusted friend before seeking medical attention. The elderly are also secretive of their ailments and the types of home remedies used to control their conditions. Such secrecy poses greater risks of herbal or medicinal interactions. Again, careful probing with increased sensitivity facilitates rapport and trust between caregivers and Filipino patients and the attainment of accurate health information - Filipinos are mostly reserved and private people. As patients, they may not readily reveal their personal and health information. Women in particular are sensitive to touching another individual as well as being touched. "Young female service providers should practice discretion with regard to touching older Filipino male patients such as laying one's hand on the patient's hand or shoulder to reassure comfort in moments of distress" - in gathering information for a more comprehensive health assessment, Filipino nurses would know how to probe without being aggressive. They would know how to express compassion without the perceived unnecessary physical intrusion. --------------------------------------------------------------- **POSITIVE QUALITIES AND VALUES OF A COMMUNITY HEALTH NURSE** --------------------------------------------------------------- - As the nation's largest healthcare profession, nurses are showing no signs of slowing down---in terms of projected job growth, influence, and leadership demand. Given the significant projections of nurses' national and global growth, understanding the qualities of a good nurse is invaluable to hospitals and health systems. As new nurses are entering the workforce, identifying and encouraging specific nursing qualities will help hospitals and health systems recognize potential nursing workforce and understand which current nurses would make great leade - While it may seem like a given, most people assume that all nurses enter the field because "caring" is one of their leading qualities---but this shouldn't necessarily be an assumed nursing characteristic. Many nurses who choose the nursing career path prioritize job security, are interested in using it as a starting point for another career, or have a lack of alternative ideas/options. - But as a nursing quality, caring makes all the difference to patients. A nurse showing a natural tendency to truly care about how their patients feel (and in turn, how well they perform their job) will have a significant impact on their success in the nursing field, which makes caring a key indicator of a nurse's success. - Strong communication skills are critical characteristics of a nurse. A nurse's role relies on the ability to effectively communicate with other nurses, physicians, disciplines across other units, patients, and their families. - Without the ability to interpret and convey communication correctly, medical errors are more likely to occur, patients often feel neglected or misinformed, and the entire unit will feel the impact. By prioritizing and practicing communication skills, nurses will provide safer care and benefit their patients, their unit, and the entire hospital/health system---not to mention, their long-term career. - With nurses caring for perhaps thousands of patients throughout their careers, it can be all too easy to become desensitized or remember what it was like to be a "nonclinical" person. A characteristic of a good nurse is one that shows empathy to each patient, making a true effort to put themselves in their patients' shoes. - By practicing empathy, nurses are more likely to treat their patients as "people" and focus on a person-centered care approach, rather than strictly following routine guidelines. When patients are fortunate enough to encounter these characteristics of a good nurse, it makes their care experience that much better. - Nurses are undoubtedly under immense pressure as they balance receiving orders from physicians with using their own knowledge skills and critical judgement to provide the highest quality patient care. Add to this combination caring for multiple patients simultaneously, and the risk for human error can seem almost inevitable. - A good nurse knows the stakes are high and that unlike in most other industries, they're responsible for peoples' well-being and more importantly---their lives. Having a strong attention to detail is one of the nurse personality traits that can easily and quickly determine how successful they'll be in their role. - While clinical knowledge and training is taught throughout a nurse's education, on the job training is the most effective way to help shape a nurse's problem-solving skills. And although years of experience can help hone this skill, some naturally possess better problem-solving skills as part of their qualities and traits of a nurse. - Problem solving skills are essential to nursing, as nurses generally have the most one-on-one time with patients and are often responsible for much of the decision-making related to their care. Even seemingly small decisions can have major impacts and cause adverse patient outcomes if incorrectly made. - The physical demand on nurses is perhaps one of the most underestimated aspects of their careers. Within one shift, a nurse lifts an average of 1.8 tons (roughly the weight of a hippo) with patient lifting and adjusting. Additionally, studies have found that nurses walk an average of 4-5 miles per shift. - In an average 12-hour shift, nurses exercise a unique balance of physical and emotional stamina that few other industries encounter. Effectively managing this skill is what makes a great nurse. This extremely important skill impacts nurses, their coworkers, and of course, the patients. Having sufficient stamina is one of the most important qualities of a great nurse. - To derive satisfaction from such a mentally and physically exhausting career, nurses that can find time for a laugh are typically more successful in their roles. Because nurses encounter varying degrees of high-stress situations, taking the opportunity to enjoy the downtime and incorporate a lighthearted attitude can provide a sense of stress relief beyond measure. - Having a good sense of humor also helps spread positivity to other nurses, patients, and their families. A good sense of humor is not only a characteristic of a nurse leader, but reminds patients and their families that "nurses are people, too" and ultimately increases their trust and openness with sharing feedback and concerns. In especially stressful times, patients and their family members are appreciative of any efforts (no matter how small) to help bring a bit of cheer. - This concept is the foundational core tenet of healthcare from the Hippocratic Oath to nearly every hospital's mission statement in one phrase or another: keep patients safe, deliver the highest quality of care. In other words, be an advocate for patients, with special attention on their overall safety. - As one of the leading qualities of a nurse leader, a great nurse understands that patient advocacy is a mindset that must be practiced every day, with every patient, throughout every stage of the care continuum. Many patients enter a hospital or healthcare setting disoriented, confused, and unable to truly "speak up" and advocate for their safety. Having a nurse that practices with a strong passion for patient advocacy will ensure they're always fighting for the very best care for their patients. - With technological improvements and breakthrough studies in science, the healthcare industry (and healthcare workers) must prove to be successfully adaptive to provide the highest quality patient care possible. Nurses spend more bedside time with patients than any other role in healthcare and their willingness to learn and put new knowledge into practice is one of the leading traits of a good nurse. - Improvements in education approaches (e.g., multidisciplinary training, personalized learning, etc.) can help foster successful learning environments, but a good nurse must possess a natural willingness to learn for them to be truly beneficial. This important skill applies to nurses of all ages, throughout every stage of their career, from recent graduates to the highly experienced. - While having a strong willingness to learn is an important skill in a good nurse, putting that knowledge into successful practice requires an ability to think critically---especially in high-stress situations. A nurse with highly functioning critical thinking skills is one of the most important characteristics of a professional nurse. - After years of education and training, the ability to apply clinical guidelines and best practices on the floor depends on a nurse's ability to think critically, which is quickly noticed (either positively or negatively) by leadership, other nurses, and ultimately, patients. While this skill can be improved over time, it's often something that comes more naturally to some nurses than others. - Balancing multiple patients, stressful care settings, and competing priorities is no small feat during a 12-hour shift. Having the ability to implement effective time management is a key personality trait for nursing, as is being able to concentrate on the most critical issues first, which isn't necessarily the patient/family that's demanding the most. - Setting time aside for selfcare is also a crucial component to time management. Refusing to take a quick break or regroup during an especially intense 12-hour shift won't benefit anyone involved in the care process. - While most nurses approach their careers with patient care in mind, many will unexpectedly transition into leadership roles. Unfortunately, it's all too common for this promotion to arrive without adequate training, development opportunities, or sufficient support/mentorship. - A quality of a good nurse that will become more and more valuable in the growing nursing field is the ability to successfully lead. However, if a nurse manager recognizes that their role isn't perhaps the right fit, knowing when/how to voice that concern is equally as admirable as thriving in the role. Exercising leadership skills in any role/level of the organization shows a willingness to grow and adapt at one's own pace. Mentorships from nursing leaders can also teach invaluable lessons on how to become a great nurse. - It's important to note that as veteran nurses leave the healthcare industry and begin retirement, they're taking with them years of experience and knowledge that cannot be quickly replaced. As nursing leaders work to bring new nurses in the door, most available candidates are predominantly new graduate nurses---a stark contrast to their predecessors in terms of experience and the many patient care skills and knowledge that can only come with time and practice. - By engaging with new nurses to instill an expectation of continuous learning, while creating a positive environment for them to learn from experienced nurses (without fear of judgement), nursing leaders will set new nurses up for success---benefiting their careers, the organization, and most importantly their patients. According to the World Health Report: - Children in low to middle income countries are 10 times more likely to die before reaching age 5 than children living in the industrialized world - Every year, almost 7.5 million children in the third world countries die before their 5^th^ birthday from preventable and treatable illnesses such as dehydration, acute respiratory infections (ARI), pneumonia, anemia, measles, malaria and dengue hemorrhagic fever. - Malnutrition complicates half of these cases - Many of these children have never even been seen at a health facility for several reasons -- no available services, inaccessible health care facility, caregivers do not recognize the warning signs of life-threatening diseases - Infant and child mortality are sensitive indicators of inequity and poverty - Quality of care is another important indicator of inequities in child health - Everyday millions of parents seek health care for their sick child to hospitals, health centers, doctors, pharmacists and traditional healers; - Surveys reveal that many of these sick children are not properly assessed and treated by these health providers and parents are poorly advised. - Improvements in child health are not necessarily dependent on the use of sophisticated and expensive technologies -- BUT rather on effective **STRATEGIES** that are based on a holistic approach. In the 1992, WHO in collaboration with UNICEF developed a STRATEGY known as the **INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) --** with the aim of prevention and early detection and treatment of the leading cause of childhood death. - Emphasizes prevention of illness through education on importance of immunization, micronutrient supplementation, and improved nutrition -- especially oral rehydration therapy (ORT), breastfeeding and infant feeding - Introduced in the Philippines in 1995, but implementation started only in 1997. **The objectives of the strategy:** 1. To reduce death and the frequency and severity of illness and disability; 2. To contribute to improved growth and development. IMCI is an integrated approach to child health that focuses on the wellbeing of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities. In summary, the IMCI strategy includes three main components: 1. 2. 3. In health facilities, the IMCI strategy: - - - - In the home setting, IMCI: - - - **Target age group**: 0-5 years old - The strategy makes use of the Evidence-based syndromic approach which can be used to determine the: - Health problems the child may have - Severity of the child's condition - Actions that can be taken to care for the child **IMNCI promotes**: 1. adjustment of the curative interventions to the capacity and functions of the health system 2. active involvement of family members and the community in the health care process **COMPONENTS OF THE INTEGRATED APPROACH:** - IMCI strategy includes both preventive and curative interventions that aim to improve practices in health facilities, the health system and at home. **3 MAIN COMPONENTS OF THE STRATEGY:** 1. Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on IMCI and activities to promote their use; 2. Improvements in the overall health system required for effective management of childhood illness 3. Improvements in family and community health care practices. **THE BENEFITS OF IMCI AND WHO WILL BENEFIT FROM IT** **C** -- cost effective group interventions -- gainful and profitable interventions for investors **H** -- high **I** - impact on health status of children **L** -- low cost and promotes cost saving of resources **D** -- demands of children answered -- IMCI focuses on the major causes of illness and death of **R** -- responsive to major child health problems **E** -- equity of access to health care improved **N** -- not only curative, but preventive as well OTHER BENEFITS: - Promotes accurate identification of childhood illness in outpatient settings - Ensures appropriate combined treatment for all major illness - Strengthens the counseling of caretakers and provision of preventive services - Speeds up referral of severely ill children - Promotion of appropriate care-seeking behaviors in the home setting, improved nutrition and preventive care, and the correct implementation of prescribed care. **FOCUS OF IMCI IN THE PHILIPPINES** - Pneumonia - Dengue - Diarrhea - Malaria - Measles - Malnutrition **PRINCIPLES OF INTEGRATED CARE** The IMCI guidelines are based on the following principles: 1. All sick children must be examined for **"general danger signs"** which indicate the need for immediate referral or admission to a hospital; 2. All sick children must be **routinely assessed for major symptoms** (for children age 2 months up to 5 years: cough or difficulty of breathing, diarrhea, fever & ear problems; for young infants 1 week up to 2 months: bacterial infection, diarrhea) 3. Only a limited number of carefully-selected clinical signs are used. **THE IMCI CASE MANAGEMENT PROCESS** **Outpatient Health Facility** - Assessment - Classification and identification of treatment - Referral, treatment or counseling of the child's caretaker (depending on the classifications identified) **Referral Health Facility** - Emergency Triage Assessment and Treatment (ETAT) - Diagnosis, Treatment and monitoring of patient progress **Appropriate Home Management** - Teaching the mother or other caretaker how to give oral drugs and treat local infections at home - Counseling the mother or caretaker about food (feeding recommendations, feeding problems) **CASE MANAGEMENT ON TWO CATEGORIES**: - **Children age 2 months up to 5 years** (up to 5 years means the child has not yet had his fifth birthday. For example, this age group includes a child who is 4 years and 11 months but not a child who is 5 years old) - **Young infants age 1 week up to 2 months** (a child who is 2 months old would be in the group 2 months up to 5 years) **THE INTEGRATED CASE MANAGEMENT PROCESS**  **OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS** **ASSESSMENT OF SICK CHILDREN:** The assessment procedure for this age group includes a number of important steps that must be taken by the health care provider including: **1. HISTORY TAKING -- COMMUNICATING WITH THE CARETAKER** - Communicate effectively with the child's mother or caretaker - When you see the mother and her sick child: a. Greet the mother appropriately and ask her to sit with her child - If the child is age 2 months up to 5 years, assess and classify the child according to the steps on the **ASSESS and CLASSIFY** chart. - If the child is 1 week up to 2 months, assess and classify the young infant according to the steps on the **YOUNG INFANT** chart - Look to see if the child's weight and temperature have been measured and recorded. If not, weigh the child and measure his temperature **later** when you assess and classify the child's main symptoms. Do not undress or disturb the child now. b. Ask the mother what the child's problems are and record in the recording form using good communication skills: - Listen carefully to what the mother tells you - Use words the mother understands - Give the mother time to answer the questions - Ask additional questions when the mother is not sure about the answer c. Determine if this is an initial visit or follow-up visit for this problem. - If this is the child's first visit for this episode of illness or problem, then this is the **initial visit** - If the child was seen a few days ago for the same illness, then this is a **follow-up visit** **2. CHECK FOR GENERAL DANGER SIGNS** - A sick child brought to an outpatient health facility may have signs that clearly indicate a specific problem - These signs should not be overlooked as they may suggest that a child is severely ill and needs urgent attention - Check **ALL** sick children for general danger signs - A general danger sign is present if: - The child is not able to drink or breastfeed - The child vomits everything - The child has had convulsions - The child is abnormally sleepy or difficult to awaken (unconscious or lethargic) When you check for general danger signs: **ASK: Is the child able to drink or breastfeed?** **ASK: Does the child vomit everything?** **ASK: Has the child had convulsions?** **LOOK: See if the child is abnormally sleepy or difficult to awaken.** If the child has one or more general danger sign, complete the rest of the assessment **immediately**. This child has a severe problem. The child is seriously ill. There must be no delay in his treatment. Case study 1.1 below illustrates the assessment process for general danger signs in practice. **Fatuma's Story:** Fatuma is 18 months old. She weighs 11.5 kg. Her temperature is 37.5°C. The health worker asked, 'What are the child's problems?' The mother said 'Fatuma has been coughing for six days, and she is having trouble breathing'. This is the initial visit for this illness. The health worker checked Fatuma for general danger signs. The mother said that Fatuma was able to drink. She had not been vomiting. She had not had convulsions during this illness. The health worker asked, 'Does Fatuma seem unusually sleepy?' The mother said, 'Yes'. The health worker clapped her hands. She asked the mother to shake the child. Fatuma opened her eyes, but did not look around. The health worker talked to Fatuma, but the child did not watch her face. Fatuma stared blankly and appeared not to notice what was going on around her. The top part of the sick child case recording form for the above case is reproduced for you in Figure 1.2 below. You can see the relevant information from the case study has been recorded.  If the child has a general danger sign you should complete the rest of the assessment process immediately. After checking the general danger signs, you should assess the child for cough/difficult breathing, diarrhea, fever, ear problems, malnutrition, anemia and HIV. The presence of any one of the general danger signs indicates a severe classification. A child with a general danger sign or a severe classification should be referred immediately to the health center after giving appropriate pre-referral treatments. In Case Study 1.1, Fatuma has the general danger sign 'lethargic or unconscious' which is a severe problem. You would complete the rest of the IMCI assessment and refer her urgently after giving the necessary pre-referral treatments for her classifications, including treatment to prevent low blood sugar. Since she is able to feed, you would ask the mother to breastfeed Fatuma or give her a coffee cup of milk or sugar-water solution.   **3. CHECKING MAIN SYMPTOMS** In order to assess coughs or difficult breathing, you need to know about the structure of the airways. Figure 4.1 shows the terms for the main structures that you need to know. You may already be familiar with some or even all of the terms. Figure 4.1 The respiratory tract. - How long the child has had cough or difficult breathing - Fast breathing (check respiratory rate) - Chest indrawing (lower chest wall indrawing indicates severe pneumonia) - Stridor in calm child (indicates severe pneumonia and requires hospitalization) **COUNT the breaths in one minute.** Note: The child who is exactly 12 months old has fast breathing if you count 40 breaths per minute or more.  **LOOK for chest indrawing** Look for chest indrawing when the child breaths IN. Look at the lower chest wall (lower ribs). **The child has chest indrawing if the lower chest wall goes IN when the child breaths IN**. In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breaths IN. When chest indrawing is present, the lower chest wall goes IN when the child breathes IN. If you are not sure that chest indrawing is present, look again. If the child's body is bent at the waist, it is hard to see the lower chest wall move. Ask the mother to change the child's position so he is lying flat on her lap. If you still do not see the lower chest wall go IN when the child breaths IN, the child does not have chest indrawing. For chest indrawing to be present, it must be clearly visible and present all the time. If you only see chest indrawing when the child is crying or feeding, the child does not have chest indrawing. If only the soft tissue between the ribs goes in when the child breaths in (also called intercostals indrawing or intercostals retractions), the child **does not have chest indrawing**. In this assessment, chest indrawing is ***[lower chest wall indrawing]***. It does not include "intercostals indrawing". If the child has abdominal distention and malnutrition, what appears to be chest indrawing may not be the "Real chest indrawing". **LOOK and LISTEN for STRIDOR** Stridor is a harsh noise made when the child breaths **IN**. Stridor happens when there is swelling of the larynx, trachea and epiglottis (croup). This swelling interferes with air entering the lungs. It can be life-threatening when the swelling causes the child's airway to be blocked. A child who has stridor when calm **has a dangerous condition.** To look and listen for stridor, look to see the child breaths in. Then listen for stridor. Put your ear near the child's mouth because stridor can be difficult to hear. Sometimes you will hear a wet noise if the nose is blocked. Clear the nose, and listen again. A child who is not very ill may have stridor only when he is crying or upset. Be sure to look and listen for stridor when the child is calm. You may hear a **wheezing** noise when the child breaths **OUT.** This is not stridor. This is most often associated with asthma. **b. Classify cough or difficult breathing** Classification tables: 1. 2. 3. Depending on the combination of the child's sign and symptoms, the child is classified in either the pink, yellow or green row. That is, the child is classified **only once** in each classification table. There are three possible classifications for a child with cough or difficult breathing (*Refer to treatment chart*). They are: - - - Whenever you use a classification table, start with the top row. In each classification table, a child receives only one classification. **If the child has signs from more than one row, always select the more serious classification.**  **Referring a child to the hospital** There are four steps you should follow when referring a child to the hospital: 1. - - - - 1. - - - - 1. - - - - - - - 1. - - - - **Case Study 2.1 Aziz's case** Aziz is 18 months old. He weighs 11.5 kg. His temperature is 37.5°C. His mother brought him to the health post because he had cough. She says he was having trouble breathing. This is his initial visit for this illness. The Health Worker checked Aziz for general danger signs. Aziz was able to drink. He had not been vomiting. He had not had convulsions. He was not convulsing, lethargic or unconscious. The Health Worker asked the mother, 'How long has Aziz had this cough?' His mother said that Aziz had been coughing for six or seven days. Aziz sat quietly on his mother's lap. The Health Worker counted the number of breaths the child took in a minute and counted 41 breaths. She thought, 'Since Aziz is over 12 months of age, the cut-off for determining fast breathing is 40. He has fast breathing'. The Health Worker did not see any chest in-drawing. She did not hear stridor. The chart below shows you how the Health Worker recorded Aziz\'s case information and signs of illness: To classify Aziz's illness, the Health Worker looked at the classification table for coughs or difficulties in breathing. First, she checked to see if Aziz had any of the signs in the pink row. She considered, 'Does Aziz have any general danger signs? No, he does not. Does Aziz have any of the other signs (chest in-drawing and stridor in a calm child) in this row? No, he does not. Therefore, Aziz does not have any of the signs for severe pneumonia or very severe disease.' Next, the Health Worker looked at the yellow (middle) row. She thought, 'Does Aziz have signs in the yellow (middle) row? He has fast breathing.' The Health Worker classified Aziz as having *pneumonia* and she wrote this down on the Recording Form (see below). **[II. DIARRHEA]** There are different kinds of diarrhea and you will need to know how to identify and assess these. Diarrhea may be loose or watery, with blood in the stool and may be with or without mucus. It frequently leads to dehydration in the child, and can be serious enough to lead not only to malnutrition but also to the child's death. It may be acute or persistent (you will learn about the difference between these below) and can be linked to a number of diseases, including cholera and dysentery. The most common cause of dysentery is *Shigella* bacteria (amoebic dysentery is not common in young children). Diarrhea occurs when stools contain more water than normal. Diarrhea is also called loose or watery stools. It is common in children, especially those between 6 months and 2 years of age. It is more common in babies under 6 months who are drinking cow's milk or infant feeding formulas. Frequent passing of normal stools is not diarrhea. The number of stools normally passed in a day varies with the diet and age of the child. In many regions diarrhea is defined as **three or more loose or watery stools in a 24 hour period**. **WHAT ARE THE TYPES OF DIARRHEA?** Most diarrheas which cause dehydration are loose or watery. **CHOLERA** is one example of loose or watery diarrhea. Only a small portion of all loose or watery diarrheas are due to cholera. If an episode of diarrhea lasts less than 14 days, it is **ACUTE DIARRHEA**. Acute watery diarrhea causes dehydration and contributes to malnutrition. The death of a child with acute diarrhea is usually due to dehydration. If the diarrhea lasts 14 days or more, it is **PERSISTENT DIARRHEA**. Up to 20% of episodes of diarrhea become persistent. Persistent diarrhea often causes nutritional problems. It contributes to death in children who have diarrhea. Diarrhea with blood in the stool, with or without mucus is called **DYSENTERY**. The most common cause of dysentery is **Shigella bacteria. Amoebic dysentery is common in young children. A child may have both watery diarrhea and dysentery.** 1. **Assess Diarrhea** - How long the child has had diarrhea - Blood in the stool to determine if the child has dysentery, and for - Signs of dehydration a. **Very slowly** (skin goes back after more than 2 seconds) b. **Slowly** (skin stays up even for a brief instant) c. **Immediately** 2. **Classify Diarrhea** - All children with diarrhea are classified for dehydration - If the child has had diarrhea for 14 days or more, classify the child for persistent diarrhea - If the child has blood in the stool, classify the child for dysentery 3. **Classify Dehydration** - **SEVERE DEHYDRATION** -- requires immediate IV infusion, nasogastric or oral fluid replacement according to the WHO treatment guidelines described in Plan C. If two or more of the signs in the pink row are present, classify the child as having SEVERE DEHYDRATION. The child has a combination of two of any of the following signs: - Lethargic or unconscious - Not able to drink or drinking poorly - Sunken eyes - Skin pinch that goes back very slowly - **SOME DEHYDRATION** -- requires active oral treatment with ORS solution according to WHO treatment guidelines described in Plan B. If two or more of the signs are not present, look at the yellow (or middle) row. If two or more of the signs are present, classify the child as having SOME DEHYDRATION. Children who have a combination of any of two of the following signs are included in this group: - Restless/irritable - Sunken eyes - Drinks eagerly, thirsty - Skin pinch goes back slowly - NO DEHYDRATION -- patients with diarrhea but with no signs of dehydration usually have a fluid deficit of less than 5% of their body weight. They should be given more fluid than usual to prevent dehydration from developing, as specified in WHO treatment Plan A. 4. **Classify Persistent Diarrhea** - **SEVERE PERSISTENT DIARRHEA** -- children who also have any degree of dehydration require special treatment and should be referred immediately to the hospital. As a rule, treatment of dehydration should be initiated first, unless there is another severe classification. - **PERSISTENT DIARRHEA** -- no signs of dehydration, can be easily managed in the out-patient clinic at least initially. - Temporarily reduce the amount of animal milk (or lactose) in the diet - Provide a sufficient intake of energy, protein, vitamins and minerals to facilitate the repair process in the damaged gut mucus and improve nutritional status - Avoid giving foods or drinks that may aggravate the diarrhea - Ensure adequate food intake during convalescence to correct any malnutrition 5. **Classify Dysentery** - **DYSENTERY** -- presence of blood in the stool. Usually a sign of invasive enteric infection that carries a substantial risk of serious morbidity and death. Severe in infants who are undernourished, those who developed clinically-evident dehydration during their illness and those who are not breastfed - Occurs with increased frequency and severity in children who have measles or had measles in the preceding month. - Bloody diarrhea in children under five is caused more frequently by shigella than by any other pathogen - Shigellosis is more likely to result in complications and death if not treated promptly - Early treatment of shigellosis substantially reduces the risk of severe morbidity and death. Case Study 3.1 below provides an example for you to see how you would classify a child in practice. **Case Study 3.1 Amina's story** A four-month-old child named Amina was brought to the health post because she had had diarrhea for five days. She did not have danger signs and she was not coughing. However, Amina was restless and irritable every time the health worker touched her and would not settle even when her mother tried to soothe her. The only time she was calm was when her mother was breastfeeding her. Amina was able to feed strongly. The health worker assessed the child's diarrhea. She recorded the following signs: Look at Table 3.2 below. Amina does not have any signs in the pink row. Therefore, Amina does not have SEVERE DEHYDRATION. Table 3.2 Classification of dehydration in a child   Amina had two signs from the yellow row. Therefore, the health worker classified Amina\'s dehydration as SOME DEHYDRATION. The health worker recorded Amina's classification on the recording form which is reproduced in Box 3.2 below. **Treatment for dehydration** There are three treatment plans for treating children with dehydration and for diarrhea: Plan C sets out the steps for treating children with severe dehydration, Plan B is for children with some dehydration, and Plan A sets out home treatment for children with diarrhea but no dehydration. First you are going to look at how to treat severe dehydration, using Plan C.   **TREATMENT OF SEVERE PERSISTENT DIARRHEA** Children with diarrhea lasting 14 days or more, who are also dehydrated, need to be referred to hospital. They may need laboratory tests of stool samples to identify the cause of the diarrhea. Treatment of dehydration in children with severe diarrhea can be difficult and it is much more likely that a hospital will be able to treat such children more effectively. Therefore, you should always refer these children, first giving a therapeutic dose of vitamin A before the child leaves your health post. A child who has had diarrhea for 14 days or more *but* who has no signs of dehydration is classified as having *persistent diarrhea*. Special feeding is the most important treatment for a child with persistent diarrhea. Feeding recommendations for persistent diarrhea are given in more detail later in this Module*.* Box 5.7 summarizes how a child with persistent diarrhea should be treated. You can see that it is important to treat the child with the recommended dose of vitamin A. Zinc supplements should also be given. **CLASSIFICATION FOR DYSENTERY** **TREATMENT**  For a child classified with dysentery, you need to provide follow-up care two days after the initial visit. Box 5.9 sets out the questions you need to ask at the follow-up care visit and what treatment should be provided. If you find the child's symptoms are the same or have got worse, you should refer the child to hospital. **Box 5.9 Follow-up care for dysentery** Give follow-up care after two days as follows: Ask: - - - - - Assess the child for diarrhea. (Use the Assess and Classify chart to help you.) Treatment: - - - **[III. FEVER]** Fever is a common symptom in many sick children. Think about your health post --- many of the mothers who bring their children to see you are likely to say that the reason for their visit is that the child has fever. Being able to assess fever and classify the illness that is causing the fever is therefore an important task for you as a Health Practitioner. This will introduce you to the common causes of fever in children. A child with fever may just have a simple cough or other viral infection. However, fever may also be caused by a more serious illness, such as malaria, measles or meningitis. Malaria is a major cause of death in children so it is important that you are able to identify the symptoms and ensure the sick child receives urgent treatment as quickly as possible. In this you will learn how to recognize and assess fever and which focused questions to ask so that you are able to classify the illness causing the fever. You will also learn how you treat the illness as effectively as possible and to support the mother in providing home care for her child. All sick children should be checked for fever. - **Stiff neck** -- this may be a sign of meningitis, cerebral malaria, or another very severe febrile disease. If the child is conscious and alert, check stiffness by tickling the feet, asking the child to bend his/her neck (or to look down), or by very gently bending the child's head forward. It should move freely. - **Runny nose** -- when malaria risk is low, a child with fever and a runny nose does not need an antimalarial drug. This child's fever is probably due to a common cold. - **Duration of fever** -- fever due to viral illnesses are self-limiting. Fever of more than five days can mean that the child has a more severe disease such as typhoid fever. In this instance, check if the fever has been present every day. - **Risk of malaria and other endemic infection** -- in situations where routine microscopy is not available or the results may be delayed, the risk of malaria transmission must be defined. The WHO has proposed definitions of malaria risk settings for countries and areas with risk of malaria caused by Plasmodium falciparum. Malaria and measles are the two major illnesses where fever is likely to be a symptom (although you should not rule out either illness even if fever is not present). **Malaria symptoms and possible complications** Fever is the main symptom of **malaria**. It can be present all the time or recur at regular intervals during the illness. Other signs of malaria are shivering, sweating and vomiting. A child with malaria may have chronic anemia (with no fever) as the only sign of illness. In areas with very high malaria transmission, malaria is a major cause of death in children. A case of uncomplicated malaria can develop into severe malaria within 24 hours of onset of the illness. The child can die if urgent treatment is not given. **Assessing for malaria** Malaria is caused by parasites in the blood called "plasmodia." They are transmitted through the bite of anopheles mosquitoes. Four species of plasmodia can cause malaria, but the only dangerous one is Plasmodium Falciparum. You need to decide whether the malaria risk is high or low. Risk is present throughout the country, excluding urban areas, and excluding the areas specified: Risk is generally low in rural areas. Low risk is also present on the islands of Mindanao (specifically Davao del Norte and Sultan Kudarat), Palawan, and the Sulu Archipelago. **Malaria risk is present below the altitude of:** 600 meters **High risk months for Malaria are:** January to December If you are not sure whether the child has been to a malarious area you should assume the malaria risk is high. If the malaria risk in the local area is low or absent, ask whether the child has travelled outside this area during the previous 15 days. If yes, then you should ask if the child has been to a malarious area. You should identify the malaria risk as high if there has been travel to a malarious area. If the mother does not know or is not sure, ask about the area and use your own knowledge of whether the area has malaria. If you are still not sure, then you should assume the malaria risk is high. To classify and treat children with fever, you must know the malaria risk in your area. Per Administration Order No. 129-S 2002 dated June 12, 2002, all provinces in the country are categorized according to malaria situation. In some parts of the Philippines, there is no risk of malaria. In such areas, you will not see cases of malaria at all among the people living there. In other places, malaria may occur throughout the year or at a certain time of the year. **Categories of Provinces** **Category A --** provinces with no significant improvement in malaria situation. ------------------- ------------------- -------------------- Kalinga Davao del Norte Apayao Davao del Sur Mt. Province Davao Oriental Ifugao Bukidnon Isabela Compostela Valley Cagayan Saranggani Quirino Zamboanga del Sur Zambales Agusan del Norte Agusan del Sur Mindoro Occidental Palawan Tawi-Tawi Quezon Sulu Misamis Oriental Basilan ------------------- ------------------- -------------------- **Category B** -- Provinces where situation has improved. Abra Laguna Pangasinan --------------------- ---------------- --------------- Camarines Norte Ilocos Norte Camarines Sur Nueva Ecija Sultan Kudarat Bulacan North Cotabato Bataan Lanao del Sur Mindoro Oriental Maguindanao Rizal Zamboanga del Norte Tarlac Romblon **Category C** -- Provinces with significant reduction in cases. Albay Batanes Benguet -------------------- ----------------- ------------------- Antique Ilocos Sur Sorsogon La Union Negros Oriental Pampanga Negros Occidental Batangas Eastern Samar Cavite Western Samar Marinduque Misamis Occidental Masbate Surigao del Norte **Category D** -- Provinces that are malaria free though are still potentially malarious due to presence of the vector; Cebu, Bohol, Catanduanes, Aklan, Capiz, Guimaras, Siquijor, Biliran, Leyte, Northern Samar and Camiguin. There are two fever classification tables in the ASSESS and CLASSIFY chart. One is for classifying fever when there is a Malaria Risk. The other is for classifying fever when there is no Malaria Risk. To classify fever, you must know if there is a malaria risk or not. Then you select the appropriate classification table. - - - **MALARIA RISK:** - - - **NO MALARIA RISK:** - - **CLASSIFICATION OF FEVER**: - - - - - - **OTHER CAUSES OF FEVER:** - - - - - - - - - - - - - - - - - - - - - - - A screenshot of a computer screen Description automatically generated **Assessing for other diseases** If you assess the child as not having malaria, you need to consider other possible causes for the child's fever. **ASK: How long has the child had fever?** If the fever has been present for more than seven days, ask if the fever has been present every day. Most fevers due to a virus infection go away within a few days. A fever which has been present every day for more than seven days can mean that the child has a more severe disease. In this case you should refer the child for further assessment. **ASK: Has the child had measles within the last three months?** A child with fever and a history of measles within the last three months may have an infection due to complications of measles. **LOOK or FEEL for stiff neck** A child with fever and a stiff neck may have meningitis. A child with meningitis needs urgent treatment with injectable antibiotics and referral to a hospital. While you talk with the mother during the assessment, look to see if the child moves and bends his neck easily as he looks around. If the child is moving and bending his neck, he does not have a stiff neck.  Checking the child's neck movements (1). If you did not see any movement, or if you are not sure, draw the child's attention to his umbilicus or toes. For example, you can shine a flashlight on his toes or umbilicus or tickle his toes to encourage the child to look down (see Figure 6.1). Look to see if the child can bend his neck when he looks down at his umbilicus or toes. Checking the child's neck movements (2). If you still have not seen the child bend his neck himself, ask the mother to help you lie the child on his back. Lean over the child; gently support his back and shoulders with one hand. With the other hand, hold his head. Then carefully bend the head forward toward his chest. If the neck bends easily, the child does not have a stiff neck. If the neck feels stiff and there is resistance to bending, the child has a stiff neck. Often a child with a stiff neck will cry when you try to bend his neck. **LOOK or FEEL for bulging fontanelle (age less than 12 months)** Hold the infant in an upright position. The infant must not be crying. Then look at and feel the fontanelle. The **fontanelle** is the soft (not hard or bony) part of the head normally found in infants. If the fontanelle is bulging rather than flat, this may mean the young infant has meningitis. **LOOK for runny nose** A runny nose in a child with fever may mean that the child has a common cold. When malaria risk is low, a child with fever and a runny nose does not need antimalarial drugs. The fever is probably due to the common cold.  **ASSESSING MEASLES** Fever and generalized rash are the main signs of measles. Measles is highly infectious. Maternal antibody protects young infants against measles for about 6 months. Then the protection gradually disappears. Most cases occur in children between 6 months and 2 years of age. Overcrowding and poor housing increase the risk of measles occurrence. Measles is caused by a virus. It infects the skin and the layer of cells that line the lungs, gut, mouth, and throat. The measles virus damages the immune system for many weeks after the onset of measles. This leaves the child at risk for other infections. Complications of measles occur in about 30% of all cases. The most important are: - Diarrhea (including dysentery and persistent diarrhea) - Pneumonia - Stridor - Mouth ulcers - Ear infection, and - Severe eye infection (which may lead to corneal ulceration and blindness) Encephalitis (a brain infection) occurs in about one thousand cases. A child with encephalitis may have a general danger sign such as convulsions or abnormally sleepy of difficult to awaken. Measles contributes to malnutrition because it causes diarrhea, high fever, and mouth ulcers. These problems interfere with feeding. Malnourished children are most likely to have severe complications due to measles. This is especially true for children who are deficient in Vitamin A. One in ten severely malnourished children with measles may die. For this reason, it is very important to help the mother continue to feed her child during illness. Assess a child with fever to see if there are signs suggesting measles. Look for a generalized rash and for one of the following signs: cough, runny nose or red eyes. **Generalized rash** In measles, a red rash begins behind the ears and on the neck. It spreads to the face first and then over the next 24 hours, the rash spreads to the rest of the body, arms and legs. After four to five days, the rash starts to fade and the skin may peel. Measles rash does not have blisters or pustules. The rash does not itch. You should not confuse measles with other common childhood rashes such as chicken pox, scabies or heat rash. Chicken pox rash is a generalized rash with vesicles (raised, fluid-filled spots). Scabies occurs on the hands, feet, ankles, elbows and buttocks, and is itchy. Heat rash can be a generalized rash with small bumps and is also itchy. A child with heat rash is not sick. You can recognize measles more easily during times when other cases of measles are occurring in your community. **Cough, runny nose or red eyes** To classify a child as having measles, the child with fever must have a generalized rash and one of the following signs: cough, runny nose or red eyes. If the child has measles now or within the last three months: **LOOK to see if the child has mouth or eye complications** You have already looked at how to assess other complications of measles, such as stridor in a calm child, pneumonia and diarrhea, in earlier study sessions in this Module. You will learn about other complication such as malnutrition and ear infection in later study sessions. **LOOK for mouth ulcers. Are they deep and extensive?** Mouth ulcers are common complications of measles which interfere with the feeding of a sick child. Look for mouth ulcers in every child with measles and determine whether they are deep and extensive. The mouth ulcers should be distinguished from **Koplik spots**. Koplik spots occur inside the cheek during the early stages of measles infection. They are small irregular bright spots with a white center. They do not interfere with feeding. Koplik Spots **LOOK for pus draining from the eye** Pus draining from the eye is a sign of conjunctivitis. If you do not see pus draining from the eye, look for pus on the eyelids. Often the pus forms a crust when the child is sleeping and seals the eye shut. It can be gently opened with clean hands. Wash your hands before and after examining the eye of any child with pus draining from the eye. **LOOK for clouding of the cornea** The cornea is the transparent covering of the front part of the eye. Look carefully for corneal clouding in every child with measles. The corneal clouding may be due to vitamin A deficiency which has been made worse by measles. If the corneal clouding is not treated, the cornea can ulcerate and cause blindness. A child with clouding of the cornea needs urgent referral and treatment with vitamin A. **CLASSIFY MEASLES** Children with fever should be assessed for signs of current or previous measles (within the last 3 months) A child who has the main symptom "fever" and measles now (or within the last 3 months) is classified both for fever and for measles. First you must classify the child's fever. Next, you classify measles. If the child has no signs suggesting measles, or has not had measles within the last three months, do not classify measles. Measles deaths occur from complications such as pneumonia and laryngotracheitis, diarrhea, measles alone, and a few from encephalitis. Non-fatal complications include conjunctivitis, otitis media, and mouth ulcers. Disabilities such as blindness, severe malnutrition, chronic lung disease (bronchiectasis and recurrent infection) and neurologic dysfunction may also result from measles. Detection of acute or current measles is based on fever with generalized rash, plus at least one of the following signs: - - - There are three possible complications of measles: - - - - **Treatment of measles** **Severe complicated measles** All children with severe complicated measles should receive urgent treatment and referral. Give the first dose of vitamin A to the child and an appropriate antibiotic and then refer the child urgently. If there is clouding of the cornea, or pus draining from the eye, apply eye ointment. **Measles with eye or mouth complications** Identifying and treating measles complications in infants and children in the early stages of the infection can prevent many deaths. As you read earlier, these children should be treated with vitamin A. It will help decrease the severity of the complications as well as correct any vitamin A deficiency. The mother should be taught how to treat the child's eye infection or mouth ulcers at home. Eye infections should be treated as follows: - - - Mouth ulcers should be treated with gentian violet twice daily as follows: - - - - Treating mouth ulcers helps the child to resume normal feeding more quickly.  **Follow-up care for measles with eye or mouth complications** You should give follow-up care to the child after two days: you should look for red eyes and/or pus draining from the eyes and you should check to see whether the child still has the mouth ulcers. If the child's mouth ulcers are worse, or there is a very foul smell from the mouth, you should refer the child to hospital. If the mouth ulcers are the same or better, you should tell the mother that she must continue to use the gentian violet for a total of five days. You are now going to do a short activity which will help you to understand the main points that you have covered in this study session Practice on the case of Pawlos below: **Case Study: Pawlos's story** Pawlos is ten-months-old. He weighs 8.2 kg. His temperature is 37.5°C. His mother says he has a rash and cough. The health worker checked Pawlos for general danger signs. Pawlos was able to drink, was not vomiting, did not have convulsions and was not lethargic or unconscious. The health worker next asked about Pawlos's cough. The mother said Pawlos had been coughing for five days. The health worker counted 43 breaths per minute. She did not see chest in-drawing nor hear stridor. Pawlos did not have diarrhea. The mother said Pawlos had felt hot for two days and that they lived in a high malaria risk area. Pawlos did not have a stiff neck. He has had a runny nose with this illness. Pawlos had a rash covering his whole body. Pawlos's eyes were red. The health worker checked the child for complications of measles. There were no mouth ulcers. There was no pus draining from the eye and no clouding of the cornea. **ASSESS DENGUE HEMORRHAGIC FEVER** Dengue Hemorrhagic Fever (DHF) is caused by a virus that is spread by Aedes mosquitoes. Like malaria, it occurs particularly in certain places and seasons. Children with DHF have fever which may last for 2-7 days. The disease causes damage to the blood and blood vessels which may lead to bleeding. This bleeding may occur in the skin, where petechiae are seen, or inside the body. Children may bleed from the mouth or nose or may vomit black fluid or may pass black stools, showing that they are bleeding from the stomach or intestines. In small proportion of cases, the child may become severely and rapidly shocked, and may die unless he/she receives urgent care. The most severe signs of DHF often occur in the 2 days after the fever has disappeared. The management of DHF depends on looking for signs that a child is bleeding and that he/she may become shocked. Shock must be treated with intravenous fluid and urgent referral. For safety, all cases of DHF should be referred. **All children two months of age or older with fever should be assessed for Dengue Hemorrhagic Fever**. These children should be assessed for other causes of fever, using the fever and measles boxes. **Assess Dengue**: Has the child had any bleeding from the nose or gums, in the vomitus or in the stools since the present illness started? Has the child had black vomitus in this illness? This is also a sign of bleeding from the stomach or intestines. Has the child had black stools? Black stools are a sign that the child is bleeding from the stomach or upper intestine. The stools are completely black and often sticky in consistency, like tar. You should be cautious with this question because intake of Ferrous Sulfate and foods such as chocolates will turn the stools black. Has the child had persistent abdominal pain? Has the child had persistent vomiting? Look and feel for signs of bleeding and shock **Bleeding Manifestations** Look for bleeding from the nose and gums. There may be dried blood in the nostrils. **Skin Petechiae** Petechiae are very small hemorrhages in the skin. They look like small, dark, red spots or patches in the skin. They are not raised and they are not tender. If you stretch the skin, they do not lose their color. They are most easily seen in the abdomen or chest and extremities.  **Look and Feel for signs suggesting shock** Shock is a condition where the blood circulation is failing. Children who have shock need urgent attention including referral. A child with shock will probably be pale and abnormally restless and abnormally sleepy or difficult to awaken. In a child at risk for DHF, feel for clammy extremities and check for slow capillary refill. These are signs suggesting shock. **Cold Clammy Extremities** Take the child's hands in yours. If the child's hand feels warm, the child has no circulation problem and you do not need to assess the capillary refill. If the hand feels cold or clammy, the child may have shock, and you should assess the capillary refill. If you are not sure whether the hand is warm or cold, you should assess the capillary refill. **Slow Capillary Refill** Hold the child's hand or foot. Look at the pink nailbed of the thumb or big toe. For two seconds apply the minimum pressure needed to make the nailbed lose its pink color. Release the pressure and watch to see how quickly the pink color returns to nailbed. If it takes less than three second, the circulation is adequate. If the capillary refill takes longer than three seconds, this may mean circulatory failure, which may progress to profound shock. **Tourniquet Test** If the child is not in shock, has no signs of bleeding or petechiae, has no abdominal pain or vomiting, and is 6 months older and has fever present for more than 3 days, you should do a tourniquet test. To perform the tourniquet test: 1. Take a systolic pressure and diastolic blood pressure using a pediatric cuff. 2. Inflate the cuff to a pressure halfway between the systolic and diastolic pressure and keep that pressure for 5 minutes. (if pediatric BP cuff is not available, use a rubber tourniquet. Check adequacy of pressure by looking at the color of the palm. It should turn pale and not bluish which indicates too much pressure. No color change indicates not enough pressure.) 3. Release the pressure and draw a one-inch sized square below the cuff / tourniquet on the front surface of the forearm (1 inch is about the size of the last joint of the index/pint finger). Count the number of petechiae inside the square. If there are 20 or more, the test is positive.  **CLASSIFY DENGUE HEMORRHAGIC FEVER** A child with fever when there is a risk of Dengue should first be classified for malaria and measles. Then you should classify for Dengue Hemorrhagic Fever. If there is no risk of dengue you should not classify for dengue. There are two possible classifications for Dengue Hemorrhagic Fever: - - Note that a child with fever and general danger signs of stiff neck will have been classified already as Very Severe Febrile Disease. If the child has any of the following signs: - Bleeding from the nose or gums or in the vomitus or stools, or - Black stools or vomitus, or - Skin petechiae, or - Shock-cold, clammy extremities with or without slow capillary refill, or - Persistent abdominal pain, or - Persistent vomiting - A positive tourniquet test, **[IV. EAR PROBLEM]** - EAR PAIN - EAR DISCHARGES - IF DISCHARGE IS PRESENT, HOW LONG THE CHILD HAS HAD DISCHARGE, and - TENDER SWELLING BEHIND THE EAR, A SIGN OF MASTOIDITIS - An ear discharge that has been present for [2 weeks or more] is treated as a **chronic ear infection.** - An ear discharge that has been present [less than 2 weeks] is treated as an **acute ear infection** - You do not need more accurate information about how long the discharge has been present - MASTOIDITIS - ACUTE EAR INFECTION - CHRONIC EAR INFECTION - NO EAR INFECTION ***MASTOIDITIS*** If a child has tender swelling behind the ear, classify the child as having MASTOIDITIS. Refer the child urgently to hospital. This child needs treatment with injectable antibiotics. He may also need surgery. Before the child leaves for hospital, give the first dose of an appropriate antibiotic. ***ACUTE EAR INFECTION*** If you see pus draining from the ear and discharge is reported present for less than two weeks, or if there is ear pain, classify the child's illness as ACUTE EAR INFECTION. Give a child with an ACUTE EAR INFECTION an appropriate antibiotic. Antibiotics for treating pneumonia are effective against the bacteria that cause most ear infections. Give paracetamol to relieve the ear pain (or high fever). If pus is draining from the ear, dry the ear by wicking. ***CHRONIC EAR INFECTION*** If you see pus draining from the ear and discharge has been present for two weeks or more, classify the child's illness as CHRONIC EAR INFECTION. Most bacteria that cause CHRONIC EAR INFECTION are different from those that cause acute ear infections. For this reason, oral antibiotics are not usually effective against chronic infections. Do not give repeated courses of antibiotics for a draining ear. ***NO EAR INFECTION*** If there is no ear pain and no pus is seen draining from the ear, the child's illness is classified as NO EAR INFECTION. The child needs no additional treatment. As you assess and classify ear problem, circle the signs found and write the classification on the case recording form. **Treatment:**  **CASE of Mbira:** Mbira is 3 years old. She weighs 13 kg. Her temperature is 37.5 °C. Her mother came to the clinic because Mbira has felt hot for 2 days. She was crying last night and complained that her ear was hurting. The health worker checked and found no general danger signs. Mbira does not have cough or difficult breathing. She does not have diarrhea. Her malaria risk is high. Her fever was classified as MALARIA. Next the health worker asked about Mbira's ear problem. The mother said she is sure Mbira has ear pain. The child cried most of the night because her ear hurt. There has not been ear discharge. The health worker did not see any pus draining from the child's ear. She felt behind the child's ears and found no tender swelling.  **4. CHECK FOR MALNUTRITION AND ANEMIA** - The child may become severely wasted, a sign of marasmus - The child may develop edema, a sign of kwashiorkor - The child may not grow well and become stunted (too short) - Not eating foods that contain vitamin A can result in vitamin A deficiency. A child with vitamin A deficiency is at risk of death from measles and diarrhea. The child is also at risk of blindness. - Infections - Parasites such as hookworm or whipworm. They can cause blood loss from the gut and lead to anemia - Malaria which can destroy red cells rapidly. Children can develop anemia if they have had repeated episodes of malaria or if the malaria was inadequately treated. The anemia may develop slowly. Often, anemia in these children is due to both malnutrition and malaria. a. **ASSESS FOR MALNUTRITION & ANEMIA** **LOOK for palmar pallor** Pallor is unusual paleness of the skin. It is a sign of anemia. To see if the child has palmar pallor, look at the skin of the child's palm. Hold the child's palm open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause pallor by blocking the blood supply. Compare the color of the child's palm with your palm and with the palms of other children. If the skin of the child's palm is pale, the child has some palmar pallor. If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor.  Palmar pallor **LOOK and FEEL for edema of both feet** A child with edema of both feet may have **KWASHIORKOR**, another form of severe malnutrition. Other common signs of kwashiorkor include thin, sparse, and pale hair which easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or "moon" face. Edema is when an unusually large amount of fluid gathers in the child's tissues. The tissues become filled with the fluid and look swollen or puffed up. Look and feel to determine if the child has edema of both feet. Use your thumb to press gently for a few seconds on the top side of each foot. The child has edema if a dent remains in the child's foot when you lift your thumb.  Positive sign of edema Kwashiorkor **Determine Weight for Age** Weight for age compares the child's weight with the weight of other children who are the same age. You will identify children whose weight for age is below the bottom curve of a weight for age chart. These are children who are very low weight for age. Children on or above the bottom curve of the chart can still be malnourished. But children who are below the bottom curve are very low weight and need special attention to how they are fed. 1. 2. 3. - - - 4. - - **Classify Nutritional Status** (refer to treatment chart) There are three classifications for a child's nutritional status: - SEVERE MALNUTRITION OR SEVERE ANAEMIA - ANAEMIA OR VERY LOW WEIGHT - NO ANAEMIA AND NOT VERY LOW WEIGHT  You need to assess the feeding of children who: You will learn more about how to assess feeding and counsel a mother about feeding and fluids in **Counsel the Mother about Feeding and Fluids**. ***SEVERE MALNUTRITION OR SEVERE ANEMIA*** If the child has visible severe wasting, severe palmar pallor or edema of both feet, classify the child as having **SEVERE MALNUTRITION OR SEVERE ANEMIA**. Children with edema of both feet may have other diseases such as nephrotic syndrome. It is not necessary to distinguish these other conditions from kwashiorkor since they also require referral. Children classified as having **SEVERE MALNUTRITION OR SEVERE ANEMIA** are at risk of death from pneumonia, diarrhea, measles, and other severe diseases. These children need urgent referral to hospital where their treatment can be carefully monitored. They may need special feeding, antibiotics or blood transfusions. Before the child leaves for hospital, give the child a dose of vitamin A. ***ANEMIA OR VERY LOW WEIGHT*** If the child is very low weight for age or has some palmar pallor, classify the child as having **ANEMIA OR VERY LOW WEIGHT**. A child classified as having ANEMIA OR VERY LOW WEIGHT has a higher risk of severe disease. When you record this classification, you can just write ANAEMIA if the child has only palmar pallor or VERY LOW WEIGHT if the child is only very low weight for age. Assess the child's feeding and counsel the mother about feeding her child according to the instructions and recommendations in the FOOD box on the *COUNSEL THE* *MOTHER* chart. A child with some palmar pallor may have anemia. Treat the child with iron. The anemia may be due to malaria, Hookworm or Whipworm. When there is a high risk of malaria, give an antimalarial to a child with signs of anemia. Hookworm and whipworm infections contribute to anemia because the loss of blood from the gut results in iron deficiency. Give the child mebendazole only if there is hookworm or whipworm in the area. Only give mebendazole if the child with anemia is 2 years of age or older and has not had a dose of mebendazole in the last 6 months. ***NO ANAEMIA AND NOT VERY LOW WEIGHT*** If the child is not very low weight for age and there are no other signs of malnutrition, classify the child as having NO ANAEMIA AND NOT VERY LOW WEIGHT. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children do. If the child is less than 2 years of age, assess the child's feeding. Counsel the mother about feeding her child according to the recommendations in the FOOD box on the *COUNSEL THE MOTHER* chart. **Treatment:**  **CASE of Alulu**: Alulu is 9 months old. He weighs 7 kg. His temperature is 36.8 °C. He is at the clinic today because his mother and father are concerned about his diarrhea. He does not have any general danger signs. He does not have cough or difficult breathing. He has had diarrhea for 5 days, and is classified as diarrhea with SOME DEHYDRATION. He does not have fever. He does not have an ear problem. Next, the health worker checked for signs of malnutrition and anemia. The child does not have visible severe wasting. There is some palmar pallor. He does not have edema of both feet. The health worker uses the Weight for Age chart to determine Alulu's weight (7 kg.) for his age (9 months). **5. CHECK THE CHILD'S IMMUNIZATION STATUS** - Do not give BCG to a child known to have AIDS - Do not give Pentavalent2 and Pentavalent3 to a child who has had convulsions or shock within 3 days of the most recent dose - Do not give Pentavalent to a child with recurrent convulsions or another active neurological disease of the central nervous system - If she has brought the card with her, ask to see the card - Compare the child's immunization record with the recommended immunization schedule. Decide whether the child has had all the immunizations recommended for the child's age. - On the Recording Form, check all immunizations the child has already received. Circle any immunizations the child needs today. - If the child is not being referred, explain to the mother that the child needs to receive an immunization (or immunizations) today. - Ask the mother to tell you what immunizations the child has received. - Use your judgment to decide if the mother has given a reliable report. If you have any doubt, [immunize the child]. Give the child BCG, OPV, Pentavalent, PCV, IPV and Measles vaccine according to the child's age. - Give an immunization card to the mother and ask her to please bring it with her each time she brings the child to the health center. **CASE of Salim**: Salim is 4 months old. He has no general danger signs. He is classified as diarrhea with NO DEHYDRATION. His immunization record shows that he has received BCG, OPV0, OPV1, OPV2, DPT/Pentavalent1, and DPT/Pentavalent2. **6. CHECK THE CHILD'S VITAMIN STATUS** - Is the child six months of age or older? - If yes, has the child had a dose of vitamin A supplementation in the past six months? Check the clinical record or the Growth Monitoring Chart the date on which vitamin A was last given. **7. ASSESS OTHER PROBLEMS**