imci technical updates.revised

IMCI TECHNICAL UPDATES

Why Update?

New knowledge on clinical management of childhood diseases are available

Implementation of IMCI has identified problems and questions which were addressed by operational research

Epidemiology of diseases has evolved thus a revised version has to accommodate and reflect these changes

Technical updates adapted in Philippine IMCI

Antibiotic treatment of non-severe and severe pneumonia

Low osmolarity ORS and antibiotic treatment for bloody diarrhea

Treatment of fever/malaria Treatment of ear infections Infant feeding Treatment of helminthiasis Management of sick young infant aged up to 2

months

I. Acute respiratory infection

First-line/second line antibiotic for non-severe pneumonia previous updated First line Cotrimoxazole Amoxicillin Second line Amoxicillin Cotrimoxazole

Duration of antibiotic treatment from 5 days to 3 days

Frequency of administration of antibiotics from 3x to 2x a day

ACUTE RESPIRATORY INFECTION

Management for non-severe pneumonia therefore:

First line: Oral amoxicillin to be given in 25mg/kg

dose twice daily in children 2-59 months of age for 3 days

Second line: Oral Cotrimoxazole to be given 2x daily

for 3 days

ACUTE RESPIRATORY INFECTION

Technical basis:

3 days treatment is equally effective as the 5 day treatment

Reduces cost of treatment Improves complianceReduces antimicrobial resistance in the

community

Acute Respiratory Infections

Use of oral Amoxicillin vs injectable penicillin in children with severe pneumonia

Where referral is difficult and injection is not available, oral Amoxicillin in 45 mg/kg/dose 2x daily should be given to children with severe pneumonia for 5 days

Technical basis:

Clinical outcome with oral amoxicillin was comparable to injectable penicillin in hospitalized children with severe pneumonia

Acute Respiratory Infections

Gentamicin plus ampicillin vs chloramphenicol for very severe pneumonia

Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol for very severe pneumonia in children 2-59 months of age.

A pre-referral dose of 7.5mg/kg intramuscular injection gentamicin and 50 mg/kg injection ampicillin can be used

Acute Respiratory Infections

Inclusion of Wheeze For children with wheeze and fast breathing

and/or lower chest wall indrawing

Give a trial of rapid-acting inhaled bronchodilator (up to 3 cycles) before they are classified as pneumonia and prescribed antibiotics.

0.5 ml salbutamol diluted in 2.0 ml of sterile water per dose nebulization should be used

DIARRHEAL DISEASES

Use of low osmolarity oral rehydration salts

Technical basis: Efficacy of ORS solution for tx of acute non-cholera in

children is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245mOsm/l.

The need for unscheduled supplemental IV is reduced by 33%, stool output is reduced by about 20% and the incidence of vomiting by about 30%

Diarrheal Diseases

Use of antibiotics in the management of bloody diarrhea (shigella dysentery) Ciprofloxacin is the most appropriate

drug in place of nalidixic acid which leads to rapid development of resistance

Dose: 15 mg/kg body weight 2x a day for 3 days

Diarrheal diseases

Technical basis:- Ciprofloxacin is several thousand-fold greater

than that of nalidixic acid- Ciprofloxacin is 100 to 1000-fold less prone to

selection of single-step spontaneous highly resistant organisms

- Simplified tx regimens (2 doses /day x 3 days instead of 4 doses/day x 5 days with nalidixic acid)

- Considered for its safety, efficacy and reduced cost

DIARRHEAL DISEASES

Giving of Zinc supplements in the management of diarrhea

Dose: 2 mos. up to 6 mos. - ½ tab daily for 10-14 days 6 mos. or more – 1 tab daily for 10-14 days

Giving of multivitamins and minerals (with zinc) for 14 days is added in the treatment of persistent diarrhea

Technical basis: reduced duration and severity of diarrhea episode lowered incidence of diarrhea in the ff. 2-3

months

DIARRHEAL DISEASES

Fever

First line antibiotic for Malaria (Artemether-lumefantrine)

For children 1-3 yrs old

Day 1 1 tablet

after 8 hrs 1 tablet

Day 2 1 tablet 2x a day

Day 3 1/2 tablet 2x a day

Fever

For children 4-8 yrs old

Day 1 2 tablets

after 8 hrs 2 tablets

Day 2 2 tablets 2x a day

Day 3 2 tablets 2x a day

Day 4 Primaquine, ½-3/4

tablets for 14 days

Fever

Treatment schedule for uncomplicated P. falcifarum malaria

day 1-3 Artemether-Lumefantrine (Coartem)

day 4 Primaquine, single dose only on day 4

Note: Primaquine is contraindicated in children < 1y.o.

Fever

Treatment schedule for confirmed P. vivax cases

Day 1-3 Chloroquine for 3 days

Day 4-17 Primaquine for 14 days

Mixed P.falciparum and P. vivax Day 1-3 Artemether + lumefantrine

Day 4-17 Primaquine

Fever

Treatment of drug-resistant malaria In case of parasitological or clinical failure to a

given drug, refer patient to the next level with proper documentation (blood smear result incl. parasite count on day7, 14, 21, & 28

Quinine sulfate(300 or 600 mg/tab)

10 mg/kg/dose every 8 hours for 7 days

+ Clindamycin 10 mg/kg 2x a day for 3 days

Fever

Pre-referral treatment:

Artesumate suppository for uncomplicated P. falciparum malaria in infants or young children who cannot swallow.

FEVER/MALARIA

Antimalarials for treatment of Malaria

The following therapeutic options are available and have potential for deployment (in prioritized order) if costs are not an issue: Artemether-lumefantrine (Coartem TM) Artesunate (3 days) plus amodiaquine Artesunate (3 days) plus SP in areas where SP

efficacy remains high SP plus amodiaquine in areas where efficacy of

both amodiaquine and SP remain high (limited in west African countries)

Technical basis: Artemisin-based combination therapy

(ACT) result in rapid substantial reduction of the parasite biomass and rapid resolution of clinical symptoms

In combination, allows reduction of artemisin tx, while enhancing efficacy and reduce likelihood of resistance development to the partner drug

EAR INFECTIONS

Chronic ear infection Chronic ear infection

should be treated with optical quinolone ear drops for at least 2 weeks in addition to dry ear by wicking

Acute ear infection Oral amoxicillin is a

better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimixazole is high

EAR INFECTIONS

Technical basis: Cochrane review of randomized

controlled trials published in the Cochrane Library

Aural toilet combined with antimicrobial treatment is more effective than aural toilet alone; oral antibiotics were found to be better than aural toilet alone

Topical antibiotics were found to be better than aural toilet alone; the addition ot topical; antibiotics to aural toilet was associated with a 57% rate of otorrhea resolution compared to 27% with aural toilet alone

Topical antibiotics were found to be better than systemic antibiotics in resolving otorrhea and eradicating middle ear bacteria; in general topical quinolones were found to be better than topical non-quinolones; finally combined topical and systemic antibiotics are no better than topical antibiotics alone

The safety of topical quinolones in children has been well documented without good evidence of a risk of ototoxicity

Malnutrition and anemia

MUAC (mid-upper arm circumference) less than 10 mm is now considered an indicator for severe malnutrition

Use of the new WHO Growth Standards Inclusion of management of severely

malnourished children where referral is not possible

Immunization Schedule

Age Vaccine

Birth BCG, HepB1

6 weeks DPT1, OPV1, HepB2

10 weeks DPT2, OPV2

14 weeks DPT3, OPV3, HepB3

9 months Anti-measles

INFANT FEEDING

Exclusive breastfeeding up to 6 mos.

Breastfeed as often as the child wants, day and night at least 8 times in 24 hours

Breastfeed when the child shows signs of hunger, beginning to fuss, sucking fingers, or moving the lips

Do not give other foods or fluids Only if the child is older than 4 mos. and appears

hungry after breastfeeding and is not gaining weight adequately, add complementary foods. Give 1-2 tablespoons, 1-2 times per day after breastfeeding

Infant Feeding . . .

Complementary feeding 6 mos. up to 23 mos. Breastfeed as often as the child wants Give adequate serving of complementary foods: 3

times per day if breastfed, with 1-2 nutritious snacks as desired from 9-23 mos.

Give foods 5 times per day if not breastfed with 1 or 2 cups of milk

Give small chewable items to eat with fingers. Let the child try to feed itself, but provide help

Do not give other foods or fluids Only if the child is older than 4 mos. and appears

hungry after breastfeeding and not gaining weight adequately, add complementary foods.

Give 1-2 tablespoons, 1-2 times per day after breastfeeding

Infant Feeding . . .

Management of severe malnutrition where referral is not possible Where a child is classified as having severe

malnutrition and referral is not possible, the IMCI guidelines should be adapted to include management at first-level facilities

modified milk diet is given

Infant Feeding . . .

HIV and Infant Feeding In areas where HIV is a public health problem all

women should be encouraged to receive HIV testing and counseling

Avoid breastfeeding If a mother is HIV-infected and replacement feeding is acceptable, feasible, affordable, sustainable and safe for her and her infant.

The child of HIV-infected mother who is not breastfed should receive complementary foods

HELMINTH INFESTATIONS Helminth infestations in children below 24 months

Albendazole and mebendazole can be safely used in children 12 months or older

Give 500 mg Mebendazole or 400 mg Albendazole in single dose

Technical basis:

Tanzania study: Mebendazole had a positive effect on motor and language development and compared with placebo groups revealed no difference in the occurrence of adverse effects (fever, cough, diarrhea, dysentery and ARI) one week after intervention

Sick young infant aged up to 2 months

Previous UpdatedAge: 1 week up to Birth up to 2

2 months months

Main symptom:Previous: Possible serious bacterial infection

Updated: Very severe disease and local bacterial infection

Sick young infant – cont’d

Signs to look for in assessment:

Previous: 12 signs

Updated: 7 signs

Any one of the following signs • Not feeding well or • Convulsions or • Fast breathing (60 breaths per minute or more) or

• Severe chest indrawing or • Fever (37.5°C* or above) or • Low body temperature (less than 35.5°C*) or • Movement only when stimulated or no

movement at all

Sick young infant – cont’d

Classification:

Previous: Updated:

Very severe disease (pink) Very severe disease

Local bacterial infection (yellow) Severe disease

Severe disease or local Severe disease or

bacterial infection unlikely local bacterial

(green) infection unlikely

Sick young infant – cont’d

Checking for jaundice is added in the protocol

Classification: Severe jaundice (pink)

Jaundice (yellow)

No jaundice (green)

Acute Respiratory Infections

Technical basis: Multicentre randomized clinical study in 8 sites in 7

countries (N=958) 12.7% failed treatment by day 6 – higher in

Chloramphenicol group (RR of 1.5); common reasons were deaths (n=44), development of septic shock (n=29), or persistence of very severe pneumonia (n=21)

Tx failure at 48 hours (8.6%), constituting 51% of all tx failure.

Overall more deaths occurred at the chloramphenicol group than the ampicillin-gentamicin group by day 30.

Based on these results the use of gentamicin plus ampocillin for the management of very severe pneumonia is warranted

Acute Respiratory Infections

Technical basis: WHO supported studies on “The assessment & management

of wheeze in children 1-59 months of age presenting with cough and /or difficult breathing” in several countries

Pakistan (n=1622)595 (36.7% w/ audible wheeze)

Thailand (n=521) 48 (9.2% w/ audible wheeze)

number Response Subsequent deterioration

number Response Subsequent deterioration

Non-severe

pneumonia1004(61.8%)

621 (61.8%)

93(14.9%)

256(49.1%)

217(84.8%)

14

(6.4%)

Severe

pneumonia618(38.2%)

166(26.8%)

63(37.9%)

265(50.9%)

189(71.3%)

24(12.7%)

-These data show a large no. of children w/ wheeze are being classified as pneumonia and are being prescribed antibiotics unnecessarily.

- Bronchodilators are being underutilized in children with wheeze.

-Majority of children with wheeze who respond to a trial of inhaled bronchodilators continue to do well when sent home without an antibiotic.

Acute Respiratory Infections