001 holistic approach sick under 5 y.o

Holistic/Integrated Holistic/Integrated Approach to SickApproach to Sick

Under 5 y.o. ChildrenUnder 5 y.o. Children

DR. ISKANDAR FIRZADA B. OSMANDR. ISKANDAR FIRZADA B. OSMANMD (USM), MMed (Family Medicine) (USM),MD (USM), MMed (Family Medicine) (USM),

MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),Fellow in Adolescent Health (Melbourne)Fellow in Adolescent Health (Melbourne)

Pakar Perubatan KeluargaPakar Perubatan KeluargaKlinik Kesihatan Jaya GadingKlinik Kesihatan Jaya Gading

Kuantan, PAHANGKuantan, PAHANG

Millennium Development Goals Millennium Development Goals (MDG) by 2015 – UN/WHO(MDG) by 2015 – UN/WHO

Integrated Management of Childhood Integrated Management of Childhood Illness (IMCI) ProgramIllness (IMCI) Program

Developed by WHO & UNICEF with objectives;Developed by WHO & UNICEF with objectives;

• reduce death & frequency & severity of reduce death & frequency & severity of illness & disability associated with major illness & disability associated with major causes of disease in children,causes of disease in children,

• promote healthy growth & development of promote healthy growth & development of children.children.

Management of childhood illness:Management of childhood illness:Rationale for an integrated strategyRationale for an integrated strategy

Major causes of death under five, 2002Major causes of death under five, 2002

ARI 18%

Diarrhoea 15%

Malaria 10%

Measles 5%HIV/AIDS 4%

Perinatal 23%

Other 25%

Deaths associated withmalnutrition

54%

6

These These 55 conditions are also the main conditions are also the main reason for seeking care in 3 out of 4 sick reason for seeking care in 3 out of 4 sick

children who come to a health facilitychildren who come to a health facility

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

Presenting complaint Possible cause/ associated Presenting complaint Possible cause/ associated conditioncondition

Cough and/orCough and/or PneumoniaPneumoniaFast breathingFast breathing Severe anaemiaSevere anaemia

P. falciparum malariaP. falciparum malaria

Drowsy orDrowsy or Cerebral malariaCerebral malariaUnconsciousnessUnconsciousness MeningitisMeningitis

Severe dehydrationSevere dehydrationVery severe pneumoniaVery severe pneumonia

Measles rashMeasles rash PneumoniaPneumoniaDiarrhoeaDiarrhoeaEar infectionEar infection

‘‘Very sick’ young infantVery sick’ young infant PneumoniaPneumoniaMeningitisMeningitisSepsisSepsis

Integrated Strategy - Integrated Strategy - RationaleRationale

• A single diagnosis may not be adequate or A single diagnosis may not be adequate or appropriate in management of these children.appropriate in management of these children.

• IMCI looks at all relevant symptoms & considers them IMCI looks at all relevant symptoms & considers them in combination to decide on best treatment for child.in combination to decide on best treatment for child.

• IMCI looks at whole child & addresses overall health IMCI looks at whole child & addresses overall health of child for better outcome.of child for better outcome.

The IMCI StrategyThe IMCI Strategy

1.1. Improving case management skills of health Improving case management skills of health workers (doctors, nurses, medical assistants) workers (doctors, nurses, medical assistants) through provision of clinical guidelines & training.through provision of clinical guidelines & training.

2.2. Improving the health system for effective Improving the health system for effective management of childhood illness.management of childhood illness.

3.3. Improving family & community practices.Improving family & community practices.

IMCI Strategy - 3 componentsIMCI Strategy - 3 components

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

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

IMCI StrategyIMCI Strategy

IMCI Clinical IMCI Clinical GuidelinesGuidelines

IMCI Clinical GuidelinesIMCI Clinical Guidelines

• Strategy focuses on improving case management of Strategy focuses on improving case management of sick child in first level health facilities through sick child in first level health facilities through provision of clinical guidelines & training.provision of clinical guidelines & training.

• Clinical guidelines are based on expert clinical opinion Clinical guidelines are based on expert clinical opinion & research results.& research results.

• Guidelines are based on seven principles.Guidelines are based on seven principles.

IMCI Guidelines - Principles

1.1.All sick children are examined for general danger signs which All sick children are examined for general danger signs which indicate the need for immediate referral or admission to hospital.indicate the need for immediate referral or admission to hospital.

2.2.All sick children are routinely assessed for major symptoms;All sick children are routinely assessed for major symptoms;

• 2 months to 5 years: cough or difficult breathing, diarrhoea, 2 months to 5 years: cough or difficult breathing, diarrhoea, fever & ear problems.fever & ear problems.

• Newborn up to 2 months: bacterial infection & diarrhoea.Newborn up to 2 months: bacterial infection & diarrhoea.All sick children are also assessed for nutritional & immunisation All sick children are also assessed for nutritional & immunisation status, feeding problems & other problems (not covered in IMCI status, feeding problems & other problems (not covered in IMCI guidelines).guidelines).

3.3.Limited number of carefully selected clinical Limited number of carefully selected clinical signs are used, based on evidence of sensitivity signs are used, based on evidence of sensitivity & specificity of these signs to detect disease.& specificity of these signs to detect disease.

These signs are also selected considering the These signs are also selected considering the conditions & realities of first level health conditions & realities of first level health facilities.facilities.


4.4.A combination of clinical signs leads to a child’s A combination of clinical signs leads to a child’s classification(s), rather than diagnosis.classification(s), rather than diagnosis.

Classification(s) indicate severity of condition(s) & call for Classification(s) indicate severity of condition(s) & call for specific actions based on whether the child;specific actions based on whether the child;

• should be urgently referred to hospital,should be urgently referred to hospital,

• require specific treatment like antibiotics or oral require specific treatment like antibiotics or oral rehydration, orrehydration, or

• may be safely managed at home.may be safely managed at home.


Guidelines - ClassificationsGuidelines - Classifications

5.5.Guidelines address most, but not all, of major reasons sick child is Guidelines address most, but not all, of major reasons sick child is brought to clinic.brought to clinic.

Guidelines do not describe management of trauma or acute Guidelines do not describe management of trauma or acute emergencies due to injuries/accidents.emergencies due to injuries/accidents.

6.6.Management procedures use limited number of essential drugs & Management procedures use limited number of essential drugs & encourage active participation of caretakers in treatment of children.encourage active participation of caretakers in treatment of children.

7.7.An essential component of the guidelines is counselling of the An essential component of the guidelines is counselling of the caretakers about home management, including counselling about caretakers about home management, including counselling about feeding, fluids & when to return to health facility.feeding, fluids & when to return to health facility.


• Depending on child’s age, various clinical signs & Depending on child’s age, various clinical signs & symptoms have different degrees of reliability & symptoms have different degrees of reliability & diagnostic value & importance.diagnostic value & importance.

• Case management procedures based on 2 age categories;Case management procedures based on 2 age categories;

• child aged 2 months up to 5 years.child aged 2 months up to 5 years.

• newborn up to 2 monthsnewborn up to 2 months

Case Management Guidelines

IMCI Case IMCI Case Management ProcessManagement Process

Includes number of important elements;Includes number of important elements;

• AssessmentAssessment

• ClassificationClassification

• Identification of treatment, referral, treatment, Identification of treatment, referral, treatment, counsellingcounselling

• Follow-up careFollow-up care

IMCI Case Management Process

Complaint/Symptoms/SignsComplaint/Symptoms/Signs

Check for Danger Signs!Check for Danger Signs!

Ask/Assess 4 Main Symptoms:Ask/Assess 4 Main Symptoms:Cough or Difficult Breathing?Cough or Difficult Breathing?

Diarrhoea?Diarrhoea?Fever?Fever?

Ear Problem?Ear Problem?

Then check for Malnutrition & Then check for Malnutrition & AnaemiaAnaemia

Then check for Immunisation & Deworming statusThen check for Immunisation & Deworming status

Assess other problemsAssess other problems

Complaint/Symptoms/SignsComplaint/Symptoms/Signs

Check for Very Severe Disease!Check for Very Severe Disease!

Check for Local Bacterial InfectionCheck for Local Bacterial Infection

Then check for JaundiceThen check for Jaundice

Then check for ImmunisationThen check for Immunisation

Assess other problemsAssess other problems

Then ask/assess for DiarrhoeaThen ask/assess for Diarrhoea

Then check for Feeding Problem or Then check for Feeding Problem or Low Weight for AgeLow Weight for Age

DR. ISKANDAR FIRZADA B. OSMANDR. ISKANDAR FIRZADA B. OSMANMD (USM), MMed (Family Medicine) (USM),MD (USM), MMed (Family Medicine) (USM),

MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),Fellow in Adolescent Health (Melbourne)Fellow in Adolescent Health (Melbourne)

Thank YouThank You

001 holistic approach sick under 5 y.o

Health & Medicine