Integrated Management of Childhood Illness PDF

INTEGRATED MANAGEMENT OF Department of Child and Adolescent Health and Development (CAH) CHILDHOOD ILLNESS...

INTEGRATED MANAGEMENT OF Department of Child and Adolescent Health and Development (CAH) CHILDHOOD ILLNESS FOR HIGH HIV SETTINGS SICK YOUNG INFANT CHILD AGE 2 MONTHS UP TO 5 YEARS TREAT THE CHILD, continued ASSESS AND CLASSIFY THE SICK CHILD AGE UP TO 2 MONTHS Assess, Classify and Identify Treatment Give Extra Fluid for Diarrhoea and Continue Feeding ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT Check for General Danger Signs.................................. 2 Then Ask About Main Symptoms: Plan A: Treat for Diarrhoea at Home........................16 Does the child have cough or difficult breathing?............ 2 Plan B: Treat for Some Dehydration with ORS........16 Assess, Classify and Identify Treatment Does the child have diarrhoea?.................................... 3 Plan C: Treat for Severe Dehydration Quickly.........17 Check for Very Severe Disease and Local Infection....................... 30 Does the child have fever?.......................................... 4 Does the young infant have diarrhoea?........................................... 31 Does the child have an ear problem?............................ 5 Give Follow-up Care Check for HIV Infection.................................................................... 32 Then check for Malnutrition and Anaemia.................... 6 Pneumonia...............................................................18 Then Check for Feeding Problem or Low Weight............................ 33 Then Check for HIV Infection........................................ 7 Dysentery.................................................................18 Then check feeding in non breastfed young infants........................ 35 Then Check the Child’s Immunization Status............... 8 Persistent Diarrhoea.................................................18 Then Check the Young Infant’s Immunization Status...................... 35 Assess Other Problems................................................ 8 Malaria......................................................................19 Assess Other Problems................................................................... 35 WHO Paediatric clinical staging for HIV……………… 9 Fever– malaria unlikely............................................19 Assess the mothers health.............................................................. 35 Ear Infection............................................................ 19 TREAT THE CHILD Anaemia.................................................................. 20 Treat the Young Infant and Counsel the Mother Teach the mother to give oral drugs at home: Very Low Weight......................................................20 Oral Antibiotic.................................................................................. 36 Feeding problem..................................................... 20 Intramuscular Antibiotics................................................................. 36 Oral Antibiotic....................................................... 10 Follow up care for HIV ……………………………….22 Immunize Every Sick Young Infant.................................................. 37 Ciproflaxacin......................................................... 10 HIV Testing …………………………………….......... 22 Treat Local Infections at Home........................................................ 37 Cotrimoxazole...................................................... 10 Keep the Low Weight Infant Warm.................................................. 38 Pain Relief........................................................... 11 COUNSEL THE MOTHER Correct Positioning and Attachment for Breastfeeding.................... 39 Iron...................................................................... 11 Safe preparation of formula milk...................................................... 40 Co-artemether..................................................... 11 Assess the Child’s Feeding......................................23 Teach a Mother how to Feed by cup............................................... 40 Bronchodilator...................................................... 11 Feeding Recommendations.....................................24 Home Care for Young Infant............................................................ 41 Feeding Recommendations for HIV infected mother.....25 Teach the Mother to Treat Local Infections at Home Counsel About Feeding Problems............................26 Give Follow-up Care for the Sick Young Infant Clear the ear by dry wicking and give eardrops... 12 Counsel the mother about feeding and HIV: Local Bacterial Infection.................................................................. 42 Treat for Mouth Ulcers and Thrush....................... 12 Stopping Breastfeeding for HIV exposed..............27 Thrush..........................................................................................… 42 Soothe throat, relieve cough with safe remedy... 12 Feeding advice for the HIV confirmed...................27 Feeding Problem............................................................................. 42 AFASS criteria for stopping breastfeeding............27 Confirmed HIV infection or HIV exposed......................................... 42 Give Preventive Treatments in Clinic Counsel the mother about her own health...............28 Low Weight...................................................................................... 43 Mebendazole ……………...………………………….13 Advise mother when to return..................................29 Vitamin A …………………………………………… 13 Advise mother when to return immediately..............29 ANNEX A: Skin conditions.......................................................... 44 Mouth conditions...................................................... 47 Give Emergency Treatment in Clinic only ANNEX B: Antiretroviral therapy: Dosages.... …………….50 Quinine for severe malaria................................... 14 Intramuscular Antibiotic....................................... 14 ANNEX C: Antiretroviral therapy: Side effects.....……….53 Diazepam for convulsions ………………...…….. 14 ANNEX D: Drug dosages for opportunistic infections.….54 Treat low blood sugar.......................................... 15 Recording Forms Sick Child........................................................................ 55 Sick young infant.......................................................... 56  ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS 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 problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows: CHECK FOR GENERAL DANGER SIGNS ASK: LOOK: USE ALL BOXES THAT MATCH THE Is the child able to drink or breastfeed? See if the child is lethargic or unconscious. CHILD’S SYMPTOMS AND PROBLEMS Does the child vomit everything? Is the child convulsing now? TO CLASSIFY THE ILLNESS. Has the child had 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: SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print.) Does the child have cough or Any general danger sign SEVERE Give first dose of an appropriate antibiotic IM. OR If wheezing give a trial of rapid acting bronchodilator for up to three difficult breathing? Chest indrawing PNEUMONIA times before classifying severe pneumonia* OR OR VERY Refer URGENTLY to hospital. Stridor in calm child SEVERE DISEASE IF YES, ASK: LOOK, LISTEN, FEEL: Give oral antibiotic for 5 days } Fast breathing. If wheezing give a trial of rapid acting bronchodilator for up to three For how Count the breaths Classify times before classifying pneumonia. If wheezing give an inhaled COUGH or PNEUMONIA long? in one minute. bronchodilator for five days* Look for chest CHILD MUST DIFFICULT If recurrent wheezing refer for an assessment indrawing. BE CALM BREATHING Soothe the throat and relieve the cough with a safe remedy Look and listen for Check for HIV infection stridor or wheezing. If coughing for more than 30 days refer for possible TB or asthma Advise the mother when to return immediately Follow-up in 2 days If the child is: Fast breathing is: No signs of pneumonia If wheezing give an inhaled bronchodilator for 5 days* 2 months up 50 breaths per or very severe disease. COUGH OR COLD If recurrent wheezing refer for an assessment Soothe the throat and relieve cough to 12 months minute or more If coughing for more than 30 days refer for possible TB or asthma 12 months up 40 breaths per Advise mother when to return immediately to 5 years minute or more Follow up in 5 days if not improving * In settings where inhaler is not available, oral salbutamol may be the second choice 2  Does the child have diarrhoea? Two of the following signs: If child has no other severe classification: - Give fluid for severe dehydration (Plan C). Lethargic or unconscious OR for Sunken eyes If child also has another severe classification: DEHYDRATION Not able to drink or drinking poorly SEVERE - Refer URGENTLY to hospital with mother Skin pinch goes back very slowly. DEHYDRATION giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. IF YES, LOOK AND FEEL: ASK: If child is 2 years or older and there is cholera in your area, Look at the child’s general condition. give antibiotic for cholera. For how long? Is the child: - Lethargic or unconscious? Two of the following signs: Give fluid, zinc supplements and food for some dehydration Is there blood - Restless and irritable? (Plan B). in the stool? Restless, irritable Look for sunken eyes. Sunken eyes SOME If child also has a severe classification: Classify Drinks eagerly, thirsty DEHYDRATION - Refer URGENTLY to hospital with mother Offer the child fluid. Is the child: Skin pinch goes back slowly. giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. - Not able to drink or drinking poorly? Advise mother when to return immediately. - Drinking eagerly, thirsty? Not enough signs to classify as some NO Give fluid, zinc supplements and food to treat diarrhoea at home Pinch the skin of the abdomen. or severe dehydration. DEHYDRATION (Plan A). Does it go back: Advise mother when to return immediately. - Very slowly (longer than 2 seconds)? - Slowly? Dehydration present. SEVERE Treat dehydration before referral unless the child has another and if diarrhoea for 14 days or more PERSISTENT severe classification. DIARRHOEA Refer to hospital. No dehydration. PERSISTENT Check for HIV Infection DIARRHOEA Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamins and Zinc for 14 days Follow up in 5 days and if blood Blood in the stool. Give ciprofloxacin for 3 days in stool DYSENTERY Follow-up in 2 days. *If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral Is Not Possible, and WHO guidelines for inpatient care. DANGER SIGNS, COUGH DIARRHOEA 3 Does the child have fever? HIGH MALARIA RISK (by history or feels hot or temperature 37.5°C** or above) Any general danger sign or Give quinine for severe malaria (first dose). · Stiff neck. VERY SEVERE Give first dose of an appropriate antibiotic. High FEBRILE Treat the child to prevent low blood sugar. IF YES: Malaria Risk DISEASE Give one dose of paracetamol in clinic for high fever Decide Malaria Risk: high or low (38.5°C or above). Refer URGENTLY to hospital. THEN ASK: LOOK AND FEEL: Fever (by history or feels hot or Give oral co-artemether or other recommended antimalarial. temperature 37.5°C** or above). Give one dose of paracetamol in clinic for high fever For how long? Look or feel for stiff neck. (38.5°C or above). Look for runny nose. MALARIA Advise mother when to return immediately. If more than 7 days, has fever been present every day? Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for Classify assessment. Has the child had measles Look for signs of MEASLES within the last 3 months? FEVER Generalized rash and One of these: cough, runny nose, LOW MALARIA RISK or red eyes. Any general danger sign or Give quinine for severe malaria (first dose) unless no malaria risk. Stiff neck. VERY SEVERE Give first dose of an appropriate antibiotic. Low FEBRILE Treat the child to prevent low blood sugar. Malaria Risk DISEASE Give one dose of paracetamol in clinic for high fever Look for mouth ulcers. (38.5°C or above). If the child has measles now Are they deep and extensive? Refer URGENTLY to hospital or within the last 3 months: Look for pus draining from the NO runny nose and Give oral co-artemether or other recommended antimalarial eye. NO measles and Give one dose of paracetamol in clinic for high fever Look for clouding of the cornea. NO other cause of fever. (38.5°C or above). MALARIA 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 Runny nose PRESENT or Give one dose of paracetamol in clinic for high fever Measles PRESENT or FEVER - (38.5°C or above). Other cause of fever MALARIA Advise mother when to return immediately. PRESENT. UNLIKELY Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for assessment. if MEASLES Any general danger sign or Give Vitamin A for treatment. now or within Clouding of cornea or SEVERE Give first dose of an appropriate antibiotic. last 3 months, Deep or extensive mouth COMPLICATED If clouding of the cornea or pus draining from the eye, Classify ulcers. MEASLES*** Apply tetracycline eye ointment. Refer URGENTLY to hospital. Pus draining from the eye or MEASLES WITH Give Vitamin A for treatment. Mouth ulcers. EYE OR MOUTH If pus draining from the eye, treat eye infection with ** These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C higher. COMPLICATIONS*** tetracycline eye ointment. *** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and If mouth ulcers, treat with gentian violet. malnutrition - are classified in other tables. Follow-up in 2 days. Measles now or within the MEASLES Give Vitamin A for treatment. last 3 months. 4 Does the child have an ear problem? Tender swelling behind the ear. Give first dose of an appropriate antibiotic. IF YES, ASK: LOOK AND FEEL: Classify MASTOIDITIS Give first dose of paracetamol for pain. EAR PROBLEM Refer URGENTLY to hospital. Is there ear pain? Look for pus draining from the ear. Is there ear discharge? Feel for tender swelling behind the ear. Pus is seen draining from the ear Give an antibiotic for 5 days. If yes, for how long? and discharge is reported for less ACUTE EAR Give paracetamol for pain. than 14 days, or INFECTION Dry the ear by wicking. Ear pain. If ear discharge, check for HIV Infection Follow-up in 5 days. Pus is seen draining from the ear Dry the ear by wicking. and discharge is reported for 14 CHRONIC EAR Treat with topical quinolone eardrops for 2 weeks days or more. INFECTION Check for HIV Infection Follow-up in 5 days. No ear pain and No treatment. No pus seen draining from the ear. NO EAR INFECTION FEVER MALARIA, MEASLES EAR PROBLEM 5  THEN CHECK FOR MALNUTRITION AND ANAEMIA Visible severe wasting Give Vitamin A for treatment Or SEVERE Treat the child to prevent low blood sugar Oedema of both feet MALNUTRITION Refer URGENTLY to hospital CHECK FOR MALNUTRITION Assess the child’s feeding and counsel the mother on feeding Very low weight for age VERY LOW according to the food box on the COUNSEL THE MOTHER chart WEIGHT - if feeding problems follow up in 5 days LOOK and FEEL: CLASSIFY Check for HIV Infection NUTRITIONAL Give mebendazole if child is 1 year or older and has not had a Look for visible severe wasting STATUS dose in the previous six months Give Vitamin A every 6 months from 6 months of age Feel for oedema of both feet Advise mother when to return immediately Follow up in 30 days Determine weight for age Not very low weight for If child is less than 2 years, assess and counsel on feeding according age and no other signs of to the food box on the COUNSEL THE MOTHER chart malnutrition NOT VERY LOW - if feeding problem follow up in 5 days WEIGHT Give routine Vitamin A every 6 months beginning from 6 months of age CHECK FOR ANAEMIA Severe palmar pallor SEVERE Refer URGENTLY to hospital ANAEMIA LOOK and FEEL: CLASSIFY Give iron Some palmar pallor ANAEMIA Give oral antimalarial if high malaria risk Look for palmar pallor. Is it: ANAEMIA Give mebendazole if child is 1 year or older and has not had a − Severe palmar pallor? dose in the previous six months − Some palmar pallor? Advise mother when to return immediately Follow up in 14 days no palmar anaemia NO ANAEMIA Give routine Vitamin A every 6 months from 6 months of age Malnutrition/ Anaemia Assess and classify 6  SIGNS CLASSIFY IDENTIFY TREATMENTS THEN CHECK FOR HIV INFECTION** Positive HIV antibody test in child 18 months and above Treat, counsel and follow-up existing infection Or CONFIRMED Give cotrimoxazole prophyaxis Does the mother or child have a HIV test done? Positive HIV virological test SYMPTOMATIC Check immunization status And HIV INFECTION Give Vitamin A supplement from 6 2 or more conditions months of age every 6 months Does the child have one or more of the following conditions: Assess the child’s feeding and provide appropriate counseling to the mother Positive HIV antibody test in Refer for further assessment including Pneumonia * child 18 months and above CONFIRMED HIV care/ART Or HIV INFECTION Advise the mother on home care Persistent diarrhoea * Positive HIV virological test Follow-up in 14 days, then monthly for 3 Ear discharge (acute or chronic) And Less than 2 conditions months and then every 3 months or as per immunization schedule Very low weight for age* No test results in child or Treat, counsel and follow-up existing positive antibody test in SUSPECTED infection * Note that the severe forms such as severe pneumonia, severe persistent diarrhoea and child 2 episodes in a year (not including Diarrhoea >14 days Lymphadenopathy (PGL) pneumonia) Skin conditions (prurigo, seborrhoeic der- Fever>1 month Thrombocytopenia* Pneumocystis pneumonia (PCP)* matitis, extensive molluscum contagiosum or warts, fungal nail infections, herpes ( 1 month) Kaposi's sarcoma zoster) Neutropenia* (1 month Toxoplasma brain abscess* Mouth conditions (recurrent mouth (haemoglobin < 8 gm)* Cryptococcal meningitis* ulcerations, lineal gingival Erythema) Recurrent severe bacterial pneumonia Chronic cryptosporidiosis Pulmonary TB Chronic isosporiasis Recurrent or chronic upper RTI (sinusitis, ear infections, tonsillitis, otorrhoea) Lymph node TB Acquired HIV-associated rectal fistula Symptomatic LIP* HIV encephalopathy* Acute necrotizing ulcerative gingivitis/ Cerebral B cell non-Hodgkins lymphoma* periodontitis Symptomatic HIV associated cardiomyopa- Chronic HIV associated lung disease thy/nephropathy* Indicated only if CD4 is Indicated only if CD4 or TLC# is including bronchiectasis* ARV available: available: Therapy Same as stage I OR < 11 mo and CD4 < 25% ART is indicated: ART is indicated: (or