Acute respiratory tract infection control programme IMNCI pneumonia Dr GRK

ARI control programme

1. Dr.G.Rajkumar Professor Paediatrics ACUTE RESPIRATORY TRACT INFECTION CONTROL PROGRAMME IMNCI PNEUMONIA

2. LRTI- mortality < 5 years In developing countries the cause is bacterial in 50-60% Preschool-H.influenzae, Pneumococci, Staphylococci Sensitive to amoxicillin, cotrimoxazole and death can be prevented

3. For all countries with IMR > 40/1000 live births Criteria-Rapid respiration with or without difficulty Rapid respiration 60 < 2 months 50 2-12 months 40 > 1-5 years Difficulty in respiration is lower chest indrawing

4. Signs, symptoms Classification Therapy Where to treat Cough or cold No fast breathing, chest indrawing or indications of severe illness No pneumonia Home remedies Home Increased respiratory rate 60 < 2 months 50 2-12 months 40 > 1-5 years Pneumonia Cotrimoxazole or amoxicillin Home Chest indrawing Severe pneumonia IV/IM penicillin Hospital Cyanosis, severe chest indrawing, inability to feed Very severe pneumonia I V penicillin + gentamycin Hospital

5. In children with cough between 2months to 5 years Examine for rapid respiration Difficulty in breathing Cyanosis Difficulty in feeding

6. RR normal No chest indrawing Feeding well URI Symptomatic management

7. RR increased Chest indrawing No hypoxia Feeding well No danger signs Ambulatory treatment- Amox-40mg/kg/dose BD for 5 days

8. Severe chest indrawing Evidence of hypoxia Danger signs-lethargy, cyanosis, poor feeding, seizures Severe pneumonia Admission IV penicillin or ampicillin & gentamycin for 5 days IV ceftriaxone second line

9. Severe pneumonia if any of the following Fever ≥ 38 C Seizures Abnormally sleepy Difficult to wake Stridor Wheezing Not feeding Tachypnoea Chest indrawing Altered sensorium Central cyanosis Grunting Apnoeic spells Distended abdomen IV Ampicillin + getamycin

10. IMNCI PNEUMONIA

11. The assessment procedure for 2months- 5 years includes ( 1) history taking and communicating with the caretaker about the child’s problem; ( 2) checking for general danger signs; ( 3) checking main symptoms ; ( 4) checking for malnutrition; (5) checking for anaemia; ( 6) assessing the child’s feeding ; ( 7) Checking immunization status; and ( 8) assessing other problems.

12. If a child has one or more of these signs, s/he must be considered seriously ill and will almost always need referral.

13. ASK : Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions during this illness? LOOK : Is the child a) lethargic or b) unconscious A child with any general danger sign requires urgent attention: complete the assessment, start pre-referral treatment and refer urgently. Test for low blood sugar– then treat or prevent.

14. After general danger signs, check for the main symptoms: ( 1) cough or difficult breathing; ( 2) diarrhoea; ( 3) fever; and ( 4) ear problems. The first three symptoms -often result in death. Ear problems - main causes of childhood disability.

15. A child with cough or difficult breathing may have pneumonia or another severe respiratory infection. Pneumonia -Both bacteria and viruses can cause pneumonia. In developing countries, often due to Streptococcus pneumoniae and Hemophilus influenzae . Children with bacterial pneumonia may die from hypoxia or sepsis

16. Identify almost all cases of pneumonia by checking for these two clinical signs: Fast breathing and Chest indrawing. When children develop pneumonia, their lungs become stiff and the body’s responses to stiff lungs and hypoxia (too little oxygen) is fast breathing. When the pneumonia becomes more severe, the lungs become even stiffer Chest indrawing may develop. Chest indrawing is a sign of severe pneumonia.

17. Three key clinical signs Respiratory rate , which distinguishes children who have pneumonia from those who do not; Lower chest wall indrawing , which indicates severe pneumonia; and Stridor , which indicates those with severe pneumonia who require hospital admission . No single clinical sign has a better combination of sensitivity and specificity to detect pneumonia in children under 5 than respiratory rate, specifically fast breathing . Even auscultation by an expert is less sensitive as a single sign.

18. Lower chest wall indrawing, defined as the inward movement of the bony structure of the chest wall with inspiration, is a useful indicator of severe pneumonia . It is more specific than “intercostal indrawing,” which concerns the soft tissue between the ribs without involvement of the bony structure of the chest wall

19. Chest indrawing should only be considered present if it is consistently present in a calm child . Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing . Any chest indrawing, even if it is not severe , is an indicator of severe pneumonia in a child age 2 months up to 5 years . Stridor happens when there is a swelling of the larynx, trachea or epiglottis . A child who has stridor when calm has a dangerous condition.

20. • Safe remedies to recommend: - Breast milk for exclusively breastfed infant - Honey and lemon • Harmful remedies to discourage: - Herbal smoke inhalation - Vicks® drops by mouth

21. Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 C. The physician asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6 days, and she is having trouble breathing." This is the initial visit for this illness . The physician checked Fatima for general danger signs. The mother said that Fatima is able to drink. She has not been vomiting. She has not had convulsions during this illness . The physician asked, "Does Fatima seem unusually sleepy?" The mother said , “NO." The physician clapped his hands. He asked the mother to shake the child. Fatima opened her eyes, looked around . The physician talked to Fatima, she watched his face. The physician asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a minute. He counted 44 breaths per minute. The physician did not see any chest indrawing. He did not hear stridor . Classification ? Pneumonia

22. MAHIMA is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 C. The physician asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6 days." This is the initial visit for this illness . The physician checked Fatima for general danger signs. The mother said that Fatima is able to drink. She has not been vomiting. She has not had convulsions during this illness . The physician asked, "Does Fatima seem unusually sleepy?" The mother said , “No ." The physician clapped his hands. He asked the mother to shake the child. Fatima opened her eyes, looked around. The physician talked to Fatima, she watched his face. The physician asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a minute. He counted 28 breaths per minute. The physician did not see any chest indrawing. He did not hear stridor . Classification ? Cough or Cold

23. Manisha is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 C. The physician asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6 days, and she is having trouble breathing." This is the initial visit for this illness . The physician checked Fatima for general danger signs. The mother said that Fatima is able to drink. She has not been vomiting. She has not had convulsions during this illness . The physician asked, "Does Fatima seem unusually sleepy?" The mother said , " Yes." The physician clapped his hands. He asked the mother to shake the child. Fatima opened her eyes, but did not look around. The physician talked to Fatima, but she did not watch his face. She stared blankly and appeared not to notice what was going on around her. The physician asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a minute. He counted 42 breaths per minute. The physician did not see any chest indrawing. He did not hear stridor . Classification ? Severe pneumonia or very severe disease

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