Review
A review of Integrated Management of Childhood Illness (IMCI) Kerry T, MBChB, MFamMed, DipMid COG(SA) uMgungundlovu Health District, KwaZulu-Natal. Keywords: IMCI, case management, sick children, pneumonia, diarrhoea, fever, malnutrition, anemia, HIV/AIDS, sick young infant, feeding assessment. Correspondence: Dr. Kerry T, District Medical Manager, uMgungundlovu Health District, KwaZulu-Natal. PO Box 21741, Mayors Walk, Pietermaritzburg, 3208, Tel:033 Tel:033 3426675, Fax:033 3943235, e-mail:
[email protected]
(SA Fam Pract 2005;47(8): 32-38)
Introduction
The Integrated Management of Childhood Illness (IMCI) strategy is the primary child-care approach of choice for South Africa.1,2 IMCI training was introduced into South Africa in 1996 by WHO and a nd UNICEF. UNICEF. Since then 8695 health workers have been trained in IMCI – mainly primary health care nurse practitioners, but also primary care doctors and paediatricians. The basic 11-day course comprises classroom activities, assessing children both in an outpatient setting and paediatric ward.3 A compact 4day course has been developed for doctors and is being taught in some medical schools. IMCI has been very well received by nurse practitioner and doctor alike in empowering them to make easy, evidence-based decisions in the management of sick children at first contact level. However many doctors continue to work with children without knowledge of IMCI. Thus, the purpose of this review is two-fold: • Fir Firstl stly y, many many doctor doctors s workin working g in hospitals receive referrals from clinic-based IMCI nurse practitioners. Doctors need to be informed what an IMCI classification means. For example, 32
•
children are commonly referred with a classification of “Severe “Severe Pneumonia or Very Severe Disease ”. ”. What does this mean? How should the doctor manage this child? Secondl Seco ndly y, this this revie review w intro introduc duces es some of the basic IMCI skills. An understanding of these skills could be helpful for doctors working with sick children in general practice, clinics, community health centres or in an outpatient outpatie nt setting. However, to become a skilled IMCI practitioner, it is essential for a doctor to attend an IMCI course.
The IMCI approach
IMCI focuses on illnesses that cause the majority of deaths in children under-6 years, many of which are preventable or readily treatable using simple interventions: These are pneumonia, diarrhoea, meningitis, malaria, malnutrition, anemia and HIV/ AIDS. This is called a “child survival” approach. Other important aspects of child health are also addressed such as ear infections, the sick young infant (under 2 months), breast-feeding and feeding assessment. Doctors attending a 4-day IMCI course work from two main
documents: Firstly, a short textbook called IMCI: A Handbook for Medical Practitioners.4 The second is a desk reference, used by all nurses and doctors practicing IMCI, called the Chart Booklet.5 These were developed by WHO and adapted to the South African setting. The Chart Booklet contains all the information needed to conduct a comprehensive primary child-care consultation and is available on the website . The key information in the Chart Booklet has been summarized into Table I of this review. Table I is designed as an easy reference on the wall of the consultation room. The rest of this review revolves around the information in Table I. As can be seen in Table Table I, the IMCI practitioner asks pertinent questions, examines the child and will then assess these assess these signs. Depending on the signs present, one or often more classifications are classifications are made. Classification is similar to a diagnosis but is contextspecific: For example, in a primary care setting, a classification of Suspected Meningitis is Meningitis is made in a feverish child with neck stiffness. Only when this child is referred to hospital where a lumbar puncture can be performed and the cerebr cerebro-spinal o-spinal fluid SA Fam Pract 2005;47(8)
Review
examined under the microscope can a diagnosis be made. The classifications are graded into levels of seriousness and are colour-coded. A severe classification, coloured red, requires urgent treatment and referral to hospital. The less serious classification, coloured yellow, requires some treatment at home such as amoxycillin for Pneumonia. The least severe classification, coloured green, requires supportive treatment at home.
the calm child breathes in (Figure 1).
Assessing children between 2
If the child has none of these signs, but has fast breathing, then the classification is Pneumonia. The cutoff rates for breathing rate decrease with age and are written in Table I for the older child and the sick young infant. The breathing should be counted for a full minute in a calm child. The breathing rate has been shown to be much more reliable in diagnosing pneumonia than listening with a stethoscope.6 A child with none of the severe signs and a normal breathing rate is classified as Cough or Cold . Using these simple signs, it is easy to decide which child needs referral to hospital, an oral antibiotic or supportive care at home. Treatment Treatment is listed in the right hand column. Full dosages for all medicines used can be found in the Chart Booklet. The presence of a wheeze is also considered together with cough. Diarrhoea is also a common childhood illness. The first step is to decide on the degree of dehydration: 4 signs are assessed: general condition (restless/ irritable or lethargic/ unconscious), sunken eyes, skin pinch (slow or very slow if the skin returns to normal only after 2 seconds) and response to a cup of Oral Rehydration Solution (ORS) (drinking eagerly or unable to drink). As can be seen in Table I, at least 2 signs need to be present to classify the child as either Diarrhoea with Severe Dehydration or Diarrhoea with Some Dehydration. Dehydration. Plan C is used to treat Severe
months and 5 years
The IMCI practitioner performs the consultation in a systematic manner, checking the important systems in the same order as in Table I. Start by checking for the 4 General Danger (GDS).. These are: A child who Signs (GDS) Signs is unable to drink or breastfeed; a child who vomits everything taken by mouth; convulsions in this illness; a child who is lethargic or even unconscious. If one or more of these signs are present, the child is likely to be seriously ill and require hospital care. The practitioner then asks for all 4 of the main symptoms, even if the caregiver does not mention them. These are: cough or difficult breathing, diarrhoea, fever and ear problem. The relevant symptoms and signs are listed in the left hand column of Table I. Cough is one of the most common presenting complaints among sick children. The practitioner needs to be able to efficiently identify which children do not just have coryza, but may have pneumonia. When making a classification, always start with the severe, red row: Then very sick children will not be missed – IMCI is like a safety net catching the very sick children. A child with cough or difficult breathing together with a GDS, chest indrawing or stridor would be assigned to the severe, red classification, called Severe Pneumonia or Very Severe Disease. Chest indrawing is an inward movement of the lower chest wall when SA Fam Pract 2005;47(8)
Figure 1: Chest Indrawing
33
Review Table I: Summary of IMCI Case Management
Summary of IMCI Case Management
1
CHECK FOR GENERAL DANGER SIGNS: ASK
• •
Is the the child child able able to drin drink k or brea breastf stfeed eed? ? Does Doe s the the chi child ld vom vomit it ever everyth ything ing? ?
CHILD 2 MONTHS TO 5 YEARS:
2
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? • For ho how lo long? • Cou Count nt the the bre breath aths s in in one one minu minute te • Lo Look ok fo forr che chest st in indr draw awin ing g • Lo Look ok and and lis liste ten n for for stri strido dorr or wheeze
Age Fast breathing 2 - 12 mths = 50 or > breaths/min 1 – 5 yrs = 40 or > breaths/min
ASSESS
•
Any General Danger Sign OR Che hest st Ind Indrraw awin ing g OR Stri St rido dorr in in a ca calm lm ch chil ild d
•
Fas Fa st bre brea ath thin ing g
•
No si signs gns of pneu pneumon monia ia or ver very y severe disease
• •
• •
Convulsio Convul sions ns in thi this s ill illnes ness? s? Is the the child child letha lethargi rgic c or unco unconsc nsciou ious? s?
CLASSIFY
TREATMENT •
SEVERE PNEUMONA OR VERY SEVERE DISEASE
PNEUMONIA
COUGH OR COLD
• • • • • • • • •
DOES THE CHILD HAVE DIARRHOEA? • For ho how lo long? • If >14 >14 days, days, has has chil child d lost lost weight weight? ? • Is the there re blo blood od in in the the stoo stool? l? • Wh What at Rx Rx is the the mot mothe herr givi giving ng? ? • Loo Look k at chi child’ ld’s s gene general ral con conditi dition on • Lo Look ok fo forr sun sunke ken n eye eyes. s. • Of Offe ferr the the ch child ild flu fluid ids. s. • Pi Pinc nch h the the skin skin of of the the abdo abdome men n
3
CLASSIFY FOR DEHYDRATION (All children with diarrhoea)
Two of the following signs: • Le Letha tharg rgic ic or or unco uncons nsci ciou ous s • Sunken eyes • No Nott able able to to drin drink k or dri drink nkin ing g poorly • Sk Skin in pin pinch ch goe goes s bac back k ver very y slowly (>2 secs) Two of the following signs: • Re Rest stle less ss or ir irri ritab table le • Sunken eyes • Child ld drin drinks ks eage eagerly rly and is thirs thirsty ty • Sk Skin in pin pinch ch goe goes s back back slo slowl wly y • No Nott enou enough gh sig signs ns to to clas classi sify fy as severe or some dehydration • •
Child has Child has sig signs ns of dehy dehydra dratio tion n Child Ch ild ha has s hist histor ory y of wei weigh ghtt loss
• •
No de dehy hydr drat atio ion n No hi hist stor ory y of of weig weight ht lo loss ss
• •
Child has Child has sig signs ns of dehy dehydra dratio tion n Child Ch ild le less ss tha than n 12 mo month nths s of age
CLASSIFY FOR DYSENTERY (If diarrhoea with blood)
•
Blo lood od in sto tool ol
DOES THE CHILD HAVE A FEVER?
•
Any General Danger Sign OR St ififf neck O R Bulg Bu lgin ing g font fontan anel elle le No Gen Genera erall Dange Dangerr Sign Signs s and. and... No st stif ifff nec neck k or or bul bulgi ging ng fontanelle
CLASSIFY FOR PERSISTENT DIARRHOEA (If diarrhoea for 14 or more days)
• • • •
For ho how lo long? Exam Ex amin ine e for for st stif ifff nec neck k Examine Exa mine for bul bulgin ging g font fontane anelle lle Look Loo k for for other other cau causes ses of feve feverr
• • • • • •
4
•
IF EXPOSED TO MALARIA, ALSO CLASSIFY FOR MALARIA •
•
Any General Danger Sign OR Stiff neck OR Bulg Bu lgin ing g font fontan anel elle le (Malaria rapid test or positive or negative or not done) Rapi Ra pid d malar malaria ia test test pos posit itiv ive e
DIARRHOEA WITH SEVERE DEHYDRATION
DIARRHOEA WITH SOME DEHYDRATION NO VISIBLE DEHYDRATION
SEVERE PERSISTENT DIARRHOEA PERSISTENT DIARRHOEA
SEVERE DYSENTERY DYSENTERY
SUSPECTED MENINGITIS FEVER, OTHER CAUSE
SUSPECTED SEVERE MALARIA
MALARIA
• • • •
Startt Flu Star Fluid ids s for for Pl Plan an C Refer Ref er URG URGENT ENTL LY to hos hospit pital al Give Giv e frequ frequent ent sip sips s of ORS on the the way,, continue breastfeeding way Keep Ke ep th the e chi child ld wa warm rm
• • •
Give fl Give flui uids ds:: Pla Plan nB Continu Con tinue e brea breastfe stfeedin eding g or or feedi feeding ng Follow Fol low up in 2 days days ifif not imp improv roving ing
• •
Give fluid Give fluid and foo food d to Rx Rx diarr diarrhoe hoea a at home: Plan A Follow Fol low up in 5 days days ifif not imp improv roving ing
• • • • • • • •
Rx for for deh dehyd ydra ratio tion n if pres presen entt Refer Ref er URG URGENT ENTL LY to hos hospit pital al Give Giv e Vit Vit A unl unless ess give given n in last last month month Give Giv e frequ frequent ent sip sips s of ORS ORS on on the the way way Coun Co unse sell the moth mother er abou aboutt feedi feeding ng Give Giv e Vit Vit A unl unless ess give given n in last last month month Consid Con sider er symp symptoma tomatic tic HIV infe infecti ction on Foll Fo llow ow up in 5 day days s
• • •
Rx for for deh dehyd ydra ratio tion n if pres presen entt Refer Ref er URG URGENT ENTL LY to hos hospit pital al Give Giv e frequ frequent ent sip sips s of ORS ORS on on the the way way
• •
Nalidi Nali dixi xic c aci acid d for for 5 days days Foll Fo llow ow up in 2 day days s
• • • • • • •
Give ceftr Give ceftriax iaxone one IMI (80 (80mg/k mg/kg) g) Chec Ch eck k blo blood od su suga garr Rx t he he fever Refer Ref er URG URGENT ENTL LY to hos hospit pital al Rx the ca caus use e of of the the fev fever er Rx t he he fever Follow Fol low up in 2 days days if feve feverr persis persists ts
•
If chil child d > 12 12 month months, s, give give fir first st dose dose of co-artemether Give Gi ve cef ceftr tria iaxo xone ne IMI IMI Refer Ref er URG URGENT ENTL LY to hos hospit pital al If chil child d <12 <12 month months s refer refer URG URGENT ENTL LY to hospital for malaria Rx
• • • •
Do a rapid rapid mal malaria aria tes testt if ava availab ilable le • •
34
•
Rapi Ra pid d mala malari ria a test test not not don done e
POSSIBLE MALARIA
•
Rapi Ra pid d malar malaria ia test test neg negati ative ve
FEVER, OTHER CAUSE
Give ceftr Give ceftriax iaxone one IMI (80 (80mg/k mg/kg) g) and if child < 6 mths also give cotrimoxazole Give O2 and check blood sugar If strid stridor or,, nebuliz nebulize e with with adren adrenali alin n Keep Ke ep ch chil ild d war warm m and and ref refer er URGENTLY URGENTL Y to hospital Give Gi ve amox amoxyc ycill illin in for for 5 day days s Cons Co nsid ider er sym sympt ptom omati atic c HIV HIV Foll Fo llow ow up in 2 day days s Soothe Soo the the thr throat oat and rel reliev ieve e the the cough If coug coughin hing g for for more more than than 21 day days s consider TB or asthma Follow Fol low-up -up 5 days days if not bet better ter
• • • •
If chi child ld >12 >12 mon month ths, s, giv give e cocoartemether at clinic and then for 3 days at home Rx fever Foll Fo llow ow up up in 2 day days s if the the fev fever er persists Refe Re ferr for for mal malar aria ia tes testin ting g Rx fever Rx the fe feve verr and and th the e cau cause se Follow Fol low up in 2 days days if feve feverr persis persists ts
SA Fam Pract 2005;47(8)
Review
DOES THE CHILD HAVE AN EAR PROBLEM?
5
ASSESS
CLASSIFY
•
Tend ender er swe swellin lling g behi behind nd the ear
MASTOIDITIS
•
•
Ear pain OR Red Re d tym tympa pani nic c me memb mbra rane ne OR Pus Pu s drai draini ning ng fro from m the the ear ear < 14 days Pus Pu s drai draini ning ng fro from m the the ear ear > 14 days No ea earr pai pain n and and no pu pus s draining
ACUTE EAR INFECTION
• •
• • •
Ear pain? Is ther there e ear ear disch discharg arge? e? IfIf yes yes for for how long?
• • • •
CHECK FOR MALNUTRITION AND ANAEMIA
6
• • • •
• •
7
Has the Has the chi child ld los lostt weig weight ht? ? Plot Pl ot the the wei weigh ghtt on th the e RTH RTHC C Look Loo k for for visi visible ble sev severe ere was wasting ting Feel Fe el for for oe oede dema ma of of both both fee feett
Look for pa Look palma lmarr pal pallo lorr Chec Ch eck k hemo hemogl glob obin in le leve vell
ASSESS FOR SYMPTOMATIC HIV INFECTION: •
3 OR OR MOR MORE E POS POSIT ITIV IVE E FINDINGS OF THESE 8 SYMPTOMS AND SIGNS
•
Ver ery y low low weig weight ht (<60 (<60% % exp’d exp’d)) OR Visi Vi sibl ble e sev sever ere e was wastin ting g OR Oede Oe dema ma of bo both th fe feet et Low weight OR Poo oorr wei weigh ghtt gai gain n OR Moth Mo ther er rep repor orts ts wei weigh ghtt loss loss
• •
Not low Not low we weig ight ht an and. d... Good Go od we weig ight ht ga gain in
• • • •
Severe Seve re pa palma lmarr pa pallo llorr Hb < 6 g/dl Some So me pa palm lmar ar pa pall llor or Hb < 10 g/dl
•
No pa pall llor or an and d Hb Hb > 10 g/ g/dl dl
• • • • • •
Any pn Any pneu eumo moni nia a no now w Earr discha Ea scharg rge e now now or in the the past? past? Low Lo w wei weigh ghtt for for ag age e Poorr weig Poo weight ht gai gain n or or weig weight ht los loss? s? Persis Per sistent tentdiar diarrho rhoea ea in last ast 3 mths? mths? Enlar En larged ged ly lymph mph nod nodes es in 2 or more of the following 3 sites: Neck, axilla or groin Oral thrush Paro Pa roti tid d gland gland enla enlarg rgem emen entt
• • • •
• •
OR
TREATMENT
• • • •
Give ceftr Give ceftriax iaxone one IMI and ref refer er URGENTLY URGENTL Y to hospital Rx amo amoxy xyci cill llin in for for 5 days days If ear ear disc dischar harge ge tea teach ch moth mother er dry wicking and consider symptomatic HIV Analg An algesi esia a and and follo follow w up in 5 day days s if pain or discharge persists Tea each ch mot mothe herr dry dry wick wickin ing g Cons Co nsid ider er sym sympt ptoma omatic tic HI HIV V Foll Fo llow ow up in 14 da days ys No Rx
• • •
Vit A unl Vit unless ess giv given en in in the las lastt month month Refer Ref er URG URGENT ENTL LY to hos hospit pital al Check Ch eck blo blood od suga sugarr and and keep keep warm warm
NOT GROWING WELL
• • •
GROWING WELL
• • • •
Consider Consid er Vit Vit A and meb mebend endazo azole le Check Che ck and tre treat at for for ora orall thrus thrush h Consid Con sider er sym sympto ptomati matic c HIV HIV,, TB TB contact Asse As sess ss fee feedi ding ng and and cou couns nsel el Foll Fo llow ow up in 14 da days ys Che heck ck fe feed edin ing g Consid Con sider er Vit Vit A and meb mebend endazo azole le
•
CHRONIC EAR INFECTION
NO EAR INFECTION SEVERE MALNUTRITION
SEVERE ANAEMIA
OR
• • •
ANAEMIA NO ANAEMIA
• • •
SUSPECTED SYMPTOMATIC HIV (3 or > positive findings)
SYMPTOMATIC HIV UNLIKELY (< 3 positive findings)
• • • •
Refer URG Refer URGENT ENTL LY to hos hospit pital al Keep Ke ep th the e chi child ld wa warm rm Rx with with iro iron n and and coun counse sell abou aboutt feeding Foll Fo llow ow up in in14 14 da days ys No ad addi diti tion onal al Rx Offer HIV tes Offer testing ting for mot mother her and child if status unknown Start Sta rt co-t co-trim rimoxa oxazol zole e proph prophyla ylaxis xis Coun Co unse sell the the mo moth ther er Follow Fol low up for cou counse nsellin lling g about about results Counsell mothe Counse motherr abou aboutt her her heal health th and precautions against HIV infection
INFANT:: 1 WEEK - 2 MONTHS INFANT
1
One of the following signs: • Fas Fastt brea breathin thing g 60 or > bre breath aths/m s/min. in. (Repeat if fast) Severe ere chest chest indra indrawin wing g (deep (deep and easy easy to see) see) CHECK FOR • Sev • Na Nasa sall flar flarin ing g or gr grun unti ting ng POSSIBLE BACTERIAL • Convulsions • Bu Bulg lgin ing g font fontan anel elle le INFECTION • Umbi Umbilica licall redness redness extend extending ing to skin, skin, and or or draining draining pus pus • F ev ever (> (> 37 37. 5 C) or low body temperature (<35.5 C) • Man Many y or sever severe e skin skin pustule pustules s (> 5 pustu pustules les)) • Letha Lethargic rgic,, unconscio unconscious us or less than normal normal move movements ments • Ap Apne nea a at atta tack cks s • Not taki taking ng feeds feeds or or taking taking feed feeds s poorly poorly • Jaundi Jaundice ce worsen worsening ing or still still prese present nt after after 2 weeks • Re Red d um umbi bili lic cus • Sk Skin in pu pus stu tule les s • Pu Pus s dra drain inin ing g from from the ey eye e None of the above signs: °
CHECK FOR FEEDING PROBLEM OR LOW WEIGHT IN BREASTFED BABIES:
°
• • • • • • • •
2
• • •
SA Fam Pract 2005;47(8)
POSSIBLE SERIOUS BACTERIAL INFECTION
Not abl Not able e to to fee feed d Infant Inf ant not ab able le to to attac attach h to brea breast st Nott suc No suckl klin ing g at at all all Infa In fant nt not not wel welll attac attache hed d to breast Infant Infa nt not suc suckli kling ng eff effect ective ively ly Less Les s than than 8 breas breastfe tfeeds eds in 24 24 hrs hrs Infa In fant nt rece receiv ivin ing g other other food foods s Low wei weight ght for age or poor poor wt. gain Oral thrush Usin Us ing g a fee feedi ding ng bo bottl ttle e Nott low No low weig weight ht and and feed feeding ing we wellll
LOCAL BACTERIAL INFECTION NO BACTERIAL INFECTION NOT ABLE TO FEED
FEEDING PROBLEM OR NOT GROWING WELL
NO FEEDING PROBLEM
• • • • • • •
Give IMI ceftriaxone (80mg/kg) Give O2 Give rectal diazepam if convulsing Check and Rx low blood sugar Refer URGENTLY to hospital Continue breastfeeding Keep the child warm
• • • •
Give erythromycin for 7 days For eye infection give ceftriaxone IMI Advise mother on care of the infection Relevant health counselling
• • • •
• •
Give IMI Give IMI cef ceftri triaxo axone ne (80 (80mg/k mg/kg) g) Check Ch eck blo blood od suga sugarr and and keep keep warm warm Refer Ref er URG URGENT ENTL LY to hos hospit pital al Advise Adv ise on bre breast astfee feedin ding g esp esp.. correct positioning and attachment Breast Bre astfee feed d > 8x in 24 hrs hrs and at night Breast Bre astfee feed d more more,, redu reducin cing g other other foods Foll Fo llow ow up up weig weight ht gai gain n Nys ysta tati tin n dr drop ops s
•
Rele Re leva vant nt heal health th coun counse sell llin ing g
• •
35
Review
Dehydration: Until the child can be referred to hospital, hospital, Ringers Lactate 20ml/kg is given IV in the first 30 minutes and then 20ml/kg/hour IV for the next 5 hours. Plan B is used for Some Dehydration: Dehydration: ORS 20ml/kg/hour is given per os for os for 4 hours in the first contact health facility. The child is then reassessed and sent home if better. Plan A is used for the child with No Visible Dehydration Dehydration:: For the child under 2 years, give 50-100ml ORS after each loose stool; For the child older than 2 years, give 100-200ml after each loose stool. If diarrhoea is present for 14 days or more, assess for Persistent Diarrhoea. Diarrhoea. If there is diarrhoea with blood, then assess for Dysentery . Fever i s v e r y c o m m o n i n childhood illness but can indicate serious illnesses especially if prolonged. Meningitis should always be excluded by feeling for a bulging fontanelle and testing for neck stiffness. If one or both signs or a General Danger Sign are present, the classification becomes Suspected Meningitis. Children with a febrile convulsion may present like this, and meningitis should be excluded. Urgent treatment should be instituted with IM ceftriaxone and the child referred to hospital for lumbar puncture. In a malaria area such as northern KwaZulu-Natal, malaria should always be considered in a child with fever. Severe signs in the red row make the classification Suspected Severe Malaria and the child should be r e f e r r e d t o h o s p i t a l. l. O t h e r classifications depend on the result of the malaria rapid test as can be seen in Table I. Ear infections, although not life threatening, may cause deafness and learning problems. With a chronic ear infection, dry wicking with thick paper towel is an effective means of drying the discharge. (Figure 2) Follow up is very important to ensure healing and proper function of the ear ear.. 36
Figure 2: Ear wicking
Malnutrition and anemia should
be checked in all children. The proper use of the Road to Health Chart (RTHC) is essential. The first step is to write the birth month in the first column of the RTHC. The weight for the current month is then plotted on the dotted line for that month (Figure 3). Figure 3: RTHC
is a reliable indicator of anaemia. Compare the child’s palm to that of the mother’s. mother’s. Just a trace of pinkness around the outside of the palm indicates Anaemia. However if the palm is completely pale, classify as Severe Anaemia and check the hemoglobin level. HIV infection has become very common. As seen in Table I, Eight signs have been identified as best determining the presence of HIV infection 7. The presence of 3 or more of these signs makes the classification Suspected Symptomatic HIV and HIV and the child should be formally tested. PCP prophylaxis with cotrimoxazole should be considered especially before the age of 1 year. Assessing infants between 1 week and 2 months
Signs of visible severe wasting (marasmus) are loss of muscle and subcutaneous tissue. The child’s arms and legs are thin with ribs and spine prominent. The buttocks become flatter and the skin hangs in folds, giving the appearance of “baggy pants”. Oedema of the dorsa of the feet may indicate kwashiorkor. If wasting, oedema or very low weight-for-age are present, the classification is Severe Malnutrition. The classification Not Growing Well indicates Well indicates a more minor nutritional problem. Pallor of the palm
Sick infants presenting in this age group should all be carefully checked for Possible Serious or Serious or Local Bacterial Infection:: Because sick young infants Infection die quicker than older children, the IMCI approach for this age group is rigorous: The breathing rate of all infants should be counted – the cutoff rate being 60 breaths per minute. Look for severe chest indrawing: Mild indrawing is normal in a young infant because the chest wall is soft. Fever or low body temperature are significant at this age are indicators of a serious illness as is the non-specific sign of not taking feeds. As can be seen from Table I, any 1 of the signs present from the red row makes the classification to be Possible Serious Bacterial Infection. These infants should be treated and referred urgently to hospital. An infant classified as Local Bacterial Infection is treated appropriately at home. Feeding Assessment
The IMCI practitioner assesses feeding problems in all children under-2 years or who are low weight-for-age. More complete information on assessing SA Fam Pract 2005;47(8)
Review
the older child’s feeding can be found in the Chart Booklet. In the young infant, a feeding or low weight problem should be checked as per Table I. The severe classification is Not Able to Feed. However many more infants are classified as Feeding Problem or Problem or Not Growing Well. Infants should be breastfed at least 8 times in 24 hours. Attachment refers to how well the infant suckles on the breast – all breastfeeding mothers should be checked and counselled for attachment. Figure 3: Breastfeeding
The 4 signs of good attachment are: Infant’s mouth wide open; chin touching the breast; lower lip turned outward; more areola visible above than below the infants mouth while feeding. Oral thrush or the concurrent use of a feeding bottle also indicates Feeding Problem.
(012-3120199) can supply information on doctor courses being conducted throughout the countr y.
In summary
References
The IMCI approach ensures that a comprehensive and accurate assessment is made of a sick child using simple yet reliable clinical signs at the first contact level. Also doctors, especially those working in the public sector need to understand the IMCI approach that is used in primary health care throughout South Africa: They will be better able to receive referrals and send the child back for care and follow up into the primary health care system. All doctors who manage sick children should consider updating their skills to include IMCI. The National Child and Youth Health Directorate
UNIVERSITY OF LIMPOPO (MEDUNSA CAMPUS)
MASTERS DEGREE IN FAMILY MEDICINE M Med (Family Medicine) The Department of Family Medicine & Primary Health Care, Univesity of Limpopo (Medunsa Campus) invites applications from doctors who wish to enroll for its M Med (Family Medicine) program in the year 2005, and on completion register as Family Physicians with HPCSA. The program spans a minimum of four years with regular contact sessions five times per year at the department and in provincial groups and with local facilitators. Requirements: Requirements: 1. Pos Possess session ion of MBChB MBChB degree degree plus complete completed d community community service service year or equivalent qualification for at least two years for foreign graduates 2. Clinic Clinical al work work should should be done done in Primar Primary y Health Health Care setting settings s or district hospitals with a strong association with PHC patients. 3. Regi Registrat stration ion as a medical medical practiti practitioner oner with with the Health Health Professio Professions ns Council of South Africa or with the regulatory body of the country in which the doctor is practising.
38
Acknowledgements
Thanks to Prof. W Loening, Dr. C Horwood and Dr. G Morris for constructive comments.
1.
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Additional reguirements for International Students(Foreign Graduates) a) SAQA evaluaton of academic academic qualificatio qualifications ns must must accommpany accommpany the application for admission: SAQB Postnet Suit 248, P/B X05, Waterkloof 0145 (Telephone 012 431 500, Fax 012 4315039) b) Details regarding the requirements requirements for obtaining obtaining a study permit may be obtained from the South African Embassy or South African High Commissioner in the country of origin Contact Sessions: Trainees/registrars will be expected to attend contact session at Medunsa and in the provincial provincial groups throughout the years. The programme covers the following modules: The consultation; Human development (including whole person medicine); The Faamily; Ethics including screening; Research Methods; Applied Social Science in Medicine; Learning: Portfolio development; Practice management & organisation of health services; Evidence Based Medicine; Clinical reasoning & Therapeutics; Prevention and health promotion; Quality improvement; Principles & Foundations of Family Medicine. Applications close 30th November 2005 Application forms and further information are obtainable from: HOD, Department of Family Medicine & Primary Health Care, PO Box 222, Medunsa 0204 Tel: (012) 521 4314/4528 Fax: (012) 521 4172 e-mail:
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SA Fam Pract 2005;47(8)
