Holistic/Integrated Approach to Sick Under 5 y.o.

Children
DR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM), MAFP (Mal.), FRACGP (Australia), FAFP (Mal.), Fellow in Adolescent Health (Melbourne)

Pakar Perubatan Keluarga Klinik Kesihatan Jaya Gading Kuantan, PAHANG

Millennium Development Goals (MDG) by 2015 UN/WHO

Integrated Management of Childhood Illness (IMCI) Program

Developed by WHO & UNICEF with objectives; reduce death & frequency & severity of illness & disability associated with major causes of disease in children, promote healthy growth & development of children.

Management of childhood illness: Rationale for an integrated strategy

Major causes of death under five, 2002

Other 25%

ARI 18%

Deaths associated with malnutrition 54%

Diarrhoea 15%

Perinatal 23% Malaria 10% HIV/AIDS 4% Measles 5% 6

These 5 conditions are also the main reason for seeking care in 3 out of 4 sick children who come to a health facility

Presenting complaint or sign can be associated with a number of conditions;

Presenting complaint Cough and/or Fast breathing Possible cause/ associated condition Pneumonia Severe anaemia P. falciparum malaria

Drowsy or Unconsciousness

Cerebral malaria Meningitis Severe dehydration Very severe pneumonia Pneumonia Diarrhoea Ear infection
Pneumonia Meningitis Sepsis

Measles rash

Very sick young infant

Integrated Strategy Rationale

A single diagnosis may not be adequate or appropriate in management of these children. IMCI looks at all relevant symptoms & considers them in combination to decide on best treatment for child. IMCI looks at whole child & addresses overall health of child for better outcome.

The IMCI Strategy

IMCI Strategy - 3 components

1. Improving case management skills of health workers (doctors, nurses, medical assistants) through provision of clinical guidelines & training. 2. Improving the health system for effective management of childhood illness. 3. Improving family & community practices.

IMCI Strategy
In the health facilities; Promotes accurate identification of childhood illness. Ensures appropriate combined treatment of all major illnesses. Strengthens counselling of caretakers & provision of preventive services. Speeds up referral of severely ill children.

In the home setting, it promotes; Appropriate care seeking behaviour. Improved nutrition & preventive care. Correct implementation of prescribed care.

IMCI Clinical Guidelines

IMCI Clinical Guidelines

Strategy focuses on improving case management of sick child in first level health facilities through provision of clinical guidelines & training. Clinical guidelines are based on expert clinical opinion & research results. Guidelines are based on seven principles.

IMCI Guidelines - Principles

1. All sick children are examined for general danger signs which indicate the need for immediate referral or admission to hospital.
2. All sick children are routinely assessed for major symptoms; 2 months to 5 years: cough or difficult breathing, diarrhoea, fever & ear problems. Newborn up to 2 months: bacterial infection & diarrhoea. All sick children are also assessed for nutritional & immunisation status, feeding problems & other problems (not covered in IMCI guidelines).

IMCI Guidelines - Principles

3. Limited number of carefully selected clinical signs are used, based on evidence of sensitivity & specificity of these signs to detect disease. These signs are also selected considering the conditions & realities of first level health facilities.

IMCI Guidelines - Principles

4. A combination of clinical signs leads to a childs classification(s), rather than diagnosis.

Classification(s) indicate severity of condition(s) & call for specific actions based on whether the child; should be urgently referred to hospital,
require specific treatment like antibiotics or oral rehydration, or

may be safely managed at home.

Guidelines - Classifications

IMCI Guidelines - Principles

5. Guidelines address most, but not all, of major reasons sick child is brought to clinic. Guidelines do not describe management of trauma or acute emergencies due to injuries/accidents. 6. Management procedures use limited number of essential drugs & encourage active participation of caretakers in treatment of children. 7. An essential component of the guidelines is counselling of the caretakers about home management, including counselling about feeding, fluids & when to return to health facility.

Case Management Guidelines

Depending on childs age, various clinical signs & symptoms have different degrees of reliability & diagnostic value & importance. Case management procedures based on 2 age categories; child aged 2 months up to 5 years. newborn up to 2 months

IMCI Case Management Process

IMCI Case Management Process

Includes number of important elements; Assessment

Classification
Identification of treatment, referral, treatment, counselling Follow-up care

IMCI Case Management Process

Complaint/Symptoms/Signs Check for Danger Signs! Ask/Assess 4 Main Symptoms:

Cough or Difficult Breathing? Diarrhoea? Fever? Ear Problem?

Then check for Malnutrition & Anaemia

Then check for Immunisation & Deworming status Assess other problems

IMCI Case Management Process

IMCI Case Management Process

Complaint/Symptoms/Signs Check for Very Severe Disease! Check for Local Bacterial Infection Then check for Jaundice Then ask/assess for Diarrhoea Then check for Feeding Problem or Low Weight for Age

Then check for Immunisation

Assess other problems

IMCI Case Management Process

Thank You
DR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM), MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.), Fellow in Adolescent Health (Melbourne)