Evaluation of the WHO IMCI Guidelines in Haiti

1. Evaluation of the WHO IMCI Guidelines in Haiti PRESENTED BY DR. HARRY HAZELWOOD,MD WORLD HEALTH ORGANIZATION/ GENEVA FOUNDATION FOR MEDICAL EDUCATION GENEVA,SWITZERLAND

2. Evaluation of the WHO IMCI Guidelines AIMS AND OBJECTIVES To improve the overall assessment-skills of skilled healthcare workers in order for them to better ASSESS, CLASSIFY, and IDENTIFY the at-risk child in need of treatment and referral To increase the training and education of lay-workers and peer-counselorsto be able to ASSESS, CLASSIFY, and IDENTIFY the particular signs of the “at-risk” child in need of treatment and referral To empower healthcare workers through IMCI training to be able to ASSESS, CLASSIFY,and IDENTIFY anything unusual about the general health of the child,and to recognize whether what is unusual is nothng to worry about (IMCI green),can be successfully home- treated with a “follow-up” plan to evaluate the child (IMCI yellow),or whether an immediate “urgent” referral is needed (IMCI red or pink)

3. Evaluation of the WHO IMCI Guidelines SPECIFIC COMPONENTS OF THE IMCI STRATEGY The Child with a Cough The Child with Diarrhea The Child with Fever due to Malaria The Child with Fever due to Measles The Child with an Ear Problem The Child with Malnutrition and Anemia The Immunization status of the Child

4. Evaluation of the WHO IMCI Guidelines Advantages/Disadvantages of each IMCI component In the IMCI strategic plan, the child is observed first for any of the “general danger signs” of: 1) convulsions 2) vomiting everything up 3) not able to breastfeed or to drink well 4) Lethargy If any general danger sign is observed, code is Red; referral is “urgent” and “immediate” Identify the child for the possibility of having pneumonia: To Classify Pneumonia as Severe or depends on the Age of Child: fast-breathing (greater than 50 breaths/minute if the child is age 2 months-12 months),or (greater than 40 breaths/minute if the child is between 12 months -5 years ) If the child also has chest-retractions (indrawn-chest) then, put the child on an antibiotic for 5-days (eg, co-trimoxazole) I

5. Evaluation of the WHO IMCI Guidelines Advantages of the IMCI strategic plan applied to the Child with a Cough component are: It is an easy method to teach a Healthcare worker (HCW) to count the number of breaths per minute (tachypnea) or to observe chest-indrawing as a diagnostic criteria for Pneumonia • Disadvantages of the IMCI strategic plan are that there is a potentially-high “False Negative “possibility (ie, problems in design and construction with “Sensitivity”): • The child classified by the IMCI strategic plan as not having pneumonia could have pneumonia • The child who is misclassified and does have Pneumonia could develop severe disease from lack of treatment which may have been able to make a difference Some types of pneumonia are NOT characterized by tachypnea(eg, Mycoplasma pneumonia, or Tuberculosis, and the IMCI classification makes no mention of, or provision for, this possibility Another potential disadvantage is that the Health Care Worker (HCW) may not have a watch to be able to count the number of breaths per minute; also, Fast-breathing could be due to Malaria ! Another possible Disadvantage could be that the IMCI does NOT have ANY “general danger signs” for infants less than 2 months, or for children greater than 5-years of age; For infants less than 2 months, Bacterial infection and Diarrhea have to be used instead

6. Evaluation of the WHO IMCI Guidelines The Child with Diarrhea Management of the child with Diarrhea involves the assessment of the child for Severe Dehydration (IMCI code red for “urgent” immediate referral); Moderate Dehydration with ORS given at home, (IMCI code yellow); Continue Breastfeeding frequently throughout the day (IMCI green); Assessment Teaching the Healthcare worker to look at the stool for the presence of blood; if no blood is seen, no Shigella; then, assess the child for the presence of “sunken-eyes”, “irritability” or “restlessness” or the “child’s inability to breastfeed, bottle-feed, to drink from a cup, or to eat solids well. The Healthcare worker is taught that a “lethargic” child who is not drinking or eating well is the case-definition for “dehydrated”

7. Evaluation of the WHO IMCI Guidelines The Child with Diarrhea (continued) • The Healthcare worker is taught that the child with sunken eyes, who is irritable, with a pinch-test slow to return to normal has “moderate dehydration” The Healthcare worker is instructed to give fluids and foods at home if the dehydration is not severe and to have follow-up in 5-days if there is no improvement The Healthcare worker is instructed that any diarrhea lasting more than 14 days is classified “Persistent Diarrhea” The Healthcare worker is instructed that any sign of blood in the stool is considered “dysentery” and the child then needs antibiotic treatment for Shigella

8. Evaluation of the WHO IMCI Guidelines Advantages of the IMCI approach to managing Diarrhea are: • The Healthcare worker has a reference guide to the severity and duration of diarrhea • Diarrhea greater than 14 days is “Persistent Diarrhea” • Blood in the stool is considered to be “dysentery” • The Healthcare worker is given a severity-index to “Mild-Moderate-Severe“ Dehydration, and is taught to administer fluids to correct fluid-imbalances, and to encourage the mother to continue breastfeeding frequently throughout the day and night to provide a source of fluids to correct the dehydration in the child

9. Evaluation of the WHO IMCI Guidelines Disadvantages to the IMCI approach to the Management of the Child with Diarrhea include: • There is no mention about the color of the urine • Normal urine will appear pale-to-clear in color • The urine of a dehydrated child will be dark in color • A child who is severely-dehydrated is often too weak to cry,so is often mistakenly considered to be a “good baby” who never cries or makes a fussy noise A lethargic child does not have to necessarily be dehydrated Lethargy may be due to other conditions such as Meningitis, or severe Anaemia from Malaria This is not accounted for under the IMCI guidelines

10. Evaluation of the WHO IMCI Guidelines The Child with a Fever due to Malaria or Measles: • The Healthcare worker is instructed to assess the malaria risk for areas to which malaria is known to be endemic, or non-endemic. • The Healthcare worker is taught to keep a record of whether or not the fever lasts for greater than 7 days • Todistinguish between fever due to malaria, or fever due to Measles virus, the mother or caregiver is shown how to look for mouth ulcers,Koplik spots,pus draining from the eye, corneal claudication as signs pathognomonic of Measles • TheHealthcare worker is taught to treat fever (temp. Greater than 38.5 degrees) by administering paracetamol if there is no evidence of pneumonia (or Fast-breathing) • If pneumonia ( tachypnea, or fast-breathing), assess for Malaria , if in a endemic malaria location. • If in a malarious area, treat for high-risk malaria possibility by giving anti-malarial drugs • If in a low–risk malarious area, treat with co-trimoxazole for 5 days • Malaria can be ruled-out by the absence of fever and/or absence of alternating hot-sweats and cold chills • Healthcare worker is taught to Assess for Measles by looking for Koplik spots and mouth ulcers • Health care worker is taught to treat mouth ulcers with gentian violet; treat eye-infection with eye-ointment • If Measles,Healthcare worker is taught to give large amounts of Vitamin A and to follow-up with patient in 2 days ADVANTAGE of TREATMENT OF CHILD WITH FEVER: Fever lasting greater than 7 days is urgent; is easy to r/o malaria by absence of fever , or by Fever in a non-endemic area for malaria DISADVANTAGE: No mention of the importance to continue Breastfeeding during a fever; Breast milk is major source of Vitamin A and anti-pyretic cytokines and immune factors DISADVANTAGE: Diarrhea could be another important cause of fever that is not mentioned in the IMCI protocol

11. Evaluation of the WHO IMCI Guidelines The Child With Ear Pain • Teach the Healthcare worker to look for discharge draining from the ear for less than 14 days (Acute OM) or for more than 14 days (Chronic OM); if greater than 14 days, consider ear pain Urgent and refer • If ear pain is less than 14 days, Teach the HCW to treat and send home with a “follow-up” plan in 5 days • Teach the Healthcare worker to administer antibiotics for 5 days (Acute OM) and to Dry the ear with wick (Chronic OM) • Advantages: Simple easy-to-follow regimen which can treat and Cure most child ear problems • Disadvantage: No mention is made of the importance in holding the child while feeding to prevent milk-drainage into the eustachian tube & ear canal which can introduce lactose as a nutrition source for bacterial growth in the ear; breastfeeding protects the child from external ear-rotation & limits milk-drainage to the middle-ear thus reducing the likelihood of Acute Otitis Media

12. Evaluation of the WHO IMCI Guidelines The child with Malnutrition and Anemia Instruct the Healthcare worker to look for signs of visible, severe wasting; if severe wasting is seen, consider IMCI code red, and refer immediately Instruct the Healthcare worker to look at the palms of the hands for evidence of severity of pallor; if severe pallor (anemia), Give Vitamin A and Refer Instruct the Healthcare worker to examine both feet for signs of Edema and fluid retention (ascites due to malnutrition and Kwashiorkor) If less-severe signs of pallor are found, instruct the Healthcare worker to give iron to the child and follow an “at-home” protocol with iron and then bring the child back for a “follow-up” visit If the child has pallor and is also in an area which is endemic for Malaria, then instruct the Healthcare worker to give “anti-malarial” medications to the child Instruct the Healthcare worker to assess the child for malnutrition by the weight/age indicator system Advantages: The color of the palmar creases of the hands is an excellent indicator of anemia because it shows delayed capillary-filling time very clearly in Pallor which reflects the lack of oxyhemoglobin Disadvantage: Pallor of the nail beds from delayed capillary-refilling is a much more reliable method

13. Evaluation of the WHO IMCI Guidelines Assessment of feeding problems: Counseling the Mother • Assess the age of the child to determine if he/she isgreater than 4-months old, or less than 4-months old • If the child is greater than 4-months old, determine if the mother is still breastfeeding exclusively, or is now beginning to do complementary feedings (with bottle-milk and weaning foods) • If the mother is using a bottle, the health worker may recommend that the mother substitute a cup for the bottle, and show the mother how to feed the child from a cup • If mother is doing both breast-and-bottle feeding, determine which method she is using most-0ften; encourage breastfeeding • Help the mother to increase her breast milk supply by giving more frequent feedings throughout the day and night

14. Evaluation of the WHO IMCI Guidelines Assessment of feeding problems: Counsel the Mother • Is the baby’s chin touching the breast? • Is the baby’s mouth wide open (like a fish-mouth)? • Is the baby’s lower-lip turned outward? • Is more of the areola visible above than below the mouth? • A ll of the above signs should be present if the “latch” onto the breast (or, the “attachment” is good) • Does the infant take slow deep (audible) sucks? • Does the infant have any white patches (thrush) in the mouth?

15. Evaluation of the WHO IMCI Guidelines Assessment of Feeding Problems: Counseling the Mother If the mother is having problems breastfeeding a younger child (2 months or less than 2 months), • The Healthcare worker should instruct the mother that the child should be assessed for visual cues that he/she is hungry and is ready to take the mother’s breast • (Non-verbal )Visual Cues of readiness should be observed: the baby may be trying to suck his/her fingers or trying to put the toes into his/her mouth the baby is displaying “mouthing behavior” indicating he/she is ready to feed verbal cues (eg, “crying”) are often “late-signs” of hunger that has turned to unmanageable distress and frustration and screaming

16. Evaluation of the WHO IMCI Guidelines Counseling the Mother The healthcare worker should instruct the mother to breastfeed as much as possible during the day and at night, gradually reducing other milk and/or weaning foods • The mother should be taught how to assess the child that breastfeeding is going well: • Look for 6 -8 wet-diapers per 24-hours; if less than 6 wet-diapers x2 days, refer • Look for 1-3 formed stools per 24-hours (or, q.48hrs) • Examine the breasts before a feed: they should be “firm and full” • Examine the breasts after a feeding should be “softer “and easier for “latch” • Examine the baby’s fontanelle, and “skin pinch-test” for dehydration signs • Examine the color of the urine: non-concentrated urine should be clear-to-pale in color; concentrated urine may be darker and a sign of dehydration • Dehydration may often present as a “good baby” who is too weak to ever cry

17. Evaluation of the WHO IMCI Guidelines Assessment of the Immunization status of the child Instruct the Healthcare worker to assess the child for any vaccinations that may have been given already or to administer the vaccine herself/himself addcording to the recommended schedule of (BCG at birth, OPV at birth, DPT at 6 wk, 10 wk, and 14 wk) Instruct the Healthcare worker to assess the child for any vaccine-preventable diseases (VPD) where the child needs to be given a vaccine booster for previous vaccine injections, or a new vaccine at a later age (eg,MMR at 9 mo) Advantages: vaccines create an antibody -titer to protect against common childhood diseases Disadvantages: Instruct the Healthcare worker NOT to give BCG to a child with HIV/AIDS Instruct the Healthcare worker NOT to give the 2nd or 3rd DPT within 3 days of a convulsion or seizure following the last DPT