Transcript Burden of the paediatric disese

Integrated Management of
Childhood Illnesses (IMCI)
Dr. Pushpa Raj Sharma
DCH, DTCH, FCPS
Professor of Child Health
Institute of Medicine, Kathmandu, Nepal
Burden of the Paediatric
Disease in Nepal
 40,000
deaths are pneumonia related.
 30, 000 deaths are diarrhea related
 40, 000 deaths are nutrition related
 50% deaths are related with neonatal
problems.
Burden of these diseases are
due to:
 Unskilled
health worker
 Bad family health practices
 Unequipped health facility
 Unavailability of health resources
Problems in different age groups:
 Neonatal
period: resuscitation problems,
infections, metabolic.
 Under five: infections, nutritional.
 Preadolescent: developmental, worms,
skin.
 Adolescent: psychological, sexual habits,
drugs.
Common causes of morbidity
and mortality
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Morbidity
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Acute respiratory
infections.
Diarrhea
Fever
Ear infections
Malnutrition
Local skin infections
Oral thrush
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Mortality
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Pneumonia
Severe dehydration
Meningitis/encephalitis
Cerebral malaria
Kwashiorkor/marasmus
Sepsis
Hypothermia
Hypoglycemia
Previous programmes
 Training
of health workers
 Vertical programmes
 Child problems were seen as a
separate issues
 Very little counseling training
 Little emphasis on clinical practice
What is needed?
 National
goal for reducing the morbidity
and mortality.
 Holistic approach.
 Improving family practices.
 Equipping the health facility.
 Upgrading the health workers skills.
 Emphasis on counseling.
How to do it?
 Targeting
the problem.
 All the components in one part.
 Optimal use of resources.
 Evidence based.
 Feasible.
 Acceptable by community.
Sensitivity and specificity
100%
Sensitivity
Specificity
Clinical signs
Investigations
Sensitivity: positive with disease
Specificity: negative without disease
The answer
 Integrated
 Management
 Childhood
 Illnesses
IMCI
of
How it helps?

Identifies a child who needs urgent referral.
 Gives evidenced based clinical signs for the
diagnosis of common problems.
 Provides guidelines for the appropriate
treatment.
 Educates the parent.
 Upgrades the health care facility.
 Follow-ups the child.
Conditions that it covers

Respiratory: pneumonia, cough/cold.
 Diarrhea: acute watery, dysentery, persistent.
 Fever: malaria, measles, meningitis,
encephalitis.
 Ear problems: mastoditis, acute and chronic
infections.
 Nutritional: kwashiorkor/marasmus, anemia
Conditions that it covers

Nutritional: feeding problems, breast feeding,
counseling.
 Neonatal sepsis.
 Local infections.
 Hypoglycemia, hypothermia.
 Oral thrush
 Immunization.
 Vit. A supplementation
 Deworming.
What it contains?
2 months up to 5 years
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Simple clinical signs of severe disease.
 Simple clinical signs to diagnose pneumonia.
 Simple clinical signs to identify three clinical
types of diarrhea.
 Simple clinical signs to identify malaria.
 Simple clinical signs to identify ear infections.
 Simple clinical signs to identify malnutrition.
What it contains?
Young infant.
 Simple
clinical signs to identify for
referral.
 Simple clinical signs to treat at health
facility.
 Simple signs to identify good breast
feeding.
What it contains?
General
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Simple guidelines for nutrition.
 Simple guidelines for treatment of severe
diseases, pneumonia, diarrhoea,
dysentery,fever,malaria, ear infections, local
infections, anaemia, malnutrition.
 Guidelines for counseling.
 Home care messages, safe practices.
 Immunization, vit A, deworming information.
What are the evidences?
 Trained
health worker identified target
disease better than doctors.
 Over prescriptions were reduced.
 Parents were more satisfied.
 Cost effective.
 Mortality and morbidity reduced.
 Health facility better equipped.
Some examples
 Simple
questions and simple
observations to find out the problem:
severe disease.
 Does
child vomits every thing?
 Is the child able to drink?
 History of convulsions?
 Is the child lethargic or unconscious?
Four main symptoms:
2 months up to 5 years
 Does
the child has cough or difficulty
breathing?
 Does the child has diarrhea?
 Does the child has fever?
 Does the child has ear problem?
Assess every child for:
2 months up to 5 years
 Malnutrition:
 Weight
for age
 Oedema
 anaemia
 Immunization
 Vitamin A supplementation
 Deworming
If the answer is yes:
 For
how long?
 Associated symptoms?
 Classify the illness
 Identify treatment
 Treat the child
My child has cough for 2 days:
(example)
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Observe for general danger signs.
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Count the respiratory rate: 60/50/40.
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Fast breathing indicates pneumonia.
Look for indrawing.
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If present refer the child with first dose of
antibiotics.
If present indicates severe pneumonia and needs
referral.
Look and listen for stridor in a calm child.
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If present indicates severe disease and referral is
needed.
Classify the disease (example)
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Age 9 months: no general danger signs, no
chest indrawing, no stridor, no fast breathing.
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Age 12 months: chest indrawing.
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Severe pneumonia.
Age 4 months: fast breathing only.
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No pneumonia (cough and cold).
Pneumonia.
Age 6 months: presence of general danger
sign.
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A child with very severe disease.
Identify treatment (example)
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No pneumonia:
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Pneumonia:
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Safe home remedies/ paracetamol/ when to
return? Counsel.
Antibiotic/paracetamol/safe home remedies/when
to return? Counsel.
Severe pneumonia/very severe disease:
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First dose of antibiotic/ referral note/ counsel.
Treat the child
 Essential
drugs.
 Safe home care.
 Duration of treatment.
 When to return.
 Change of treatment.
 Counsel the parent.
 Other problems.
Other Options in IMCI
 Neonatal
problems of first week
 Developmental pediatrics
 Perinatal problems
 Injury
 ……….
IMCI : model for other
problems in pediatric diseases
 Entry
questions.
 Threading questions.
 Evidenced based specific clinical signs.
 Treatment.
 Follow-up.
 Referral.
 Counsel.
History of IMCI in Nepal

1995: IMCI Activities started. District
identified, Saptari.
 1996: Orientation meeting, nutrition survey,
necessary adaptations to generic materials.
 1997: Nepali translation, TOT courses.
 1998: Follow-up visits, review meeting, preservice training.
 Expansion: at present 13 district.
Thank you.
Any questions?
Any clarifications?
Any suggestions for this presentation?