II} Control of Acute Respiratory Infection [ARI]:
ARI is a world wide problem and it forms a main cause of morbidity and mortality among children in developing countries. ARI contributes 30-60% of all children attending outpatient department of health facilities, 70% of which are upper respiratory infection.Although the overall incidence of ARI among children is within the same rang in developed and developing countries, the annual incidence of pneumonia is 3-4 % in children < 5 in developed countries and 10-20% in developing countries. This shows that the majority of these infections are mild.
The objectives of this program:
Identify the few serious cases of ARI
TO treate the mild cases at home without the use of antibiotics.
To follow the correct standard case management for ARI.
On average, a child living in an urban area gets 5-8 attacks of ARI /year, and each attack last for 7-9 days[ 35- 72 of illness/ year].
The primary offenders are viruses, which are responsible for a high proportion of the primary infections; Bacteria may be primary or secondary offenders. Streptococcus pneumonia and haemophilus influenza are most frequent causes of pneumonia in developing countries.
Standard case management includes:
[Assessment, Classification, Management]
Assessment:
Ask:
How old is the child?
2 months 5 years: is the child able to drink?
< 2 months: the amount the child normally takes[less than half the amount he normally takes]
Is the child coughing? For how long? Acute <30 days
Chronic 30 days
-Has the child had fever? For how long?
- Has the child had convulsions?
Look and listen : The child has to be calm
chest in drawing
strider
Wheeze.
Count the breath in one minute: to detect fast breathing , that cut off point is determined according to age of child:
Age RR/ minute
< 2 months 60+
2 12 months 50+
12 months 5 years 40+
Chest in drawing: if the lower chest wall goes in when the childes breaths in, this happens because the effort required to breath in is much greater than normal.
Stidor: is a harsh noise made when the child breaths in, due to narrowing of the larynx, trachea or epiglottis.
Wheeze: is a soft musical noise made when the child breaths out due to narrowing of the air passages in the lungs and it takes longer than normal and requires effort.
See: If the child is abnormally sleepy or difficult to wake [drowsy child who does not look at this mother, may not watch the doctor when he talks or moves, and may star blankly and not appear to see]
Feel: for fever or low body temperature [measure].
Check: for sever malnutrition
Marasmus: extreme wasting of fat and muscles.
Kwashiorkor: generalized edema and thin sparse hair.
Classification:
Age 2 months- 5 years:
very sever disease: any danger sign, which include:-not able to drink
- Convulsion
- Abnormally sleep or difficult to awake.
-stridor in a calm child
- Severe under nutrition.
This is a child at high risk of dying, act urgently, and refers to hospital.
Severe pneumonia:
A child with chest in drawing, who may also have nasal flaring, grunting, cyanosis. This child is also at high risk of dying, act urgently, and refers to hospital.Pneumonia:
No chest in drawing has fast breathing.
50+/minute 2 up to 12 months
40+/minute 12 months up to 5 years
No pneumonia:
No pneumonia [cough or cold] no chest in drawing no fastBreathing.
Age < 2 months:
Young infant become sick and die very quickly. They frequently have non specific signs such as:Poor feeding, or law body temperature, and may normally have mild chest in drawing because of their soft chest walls.
Very severe disease: dangerous sign
Abnormally sleepy child or difficult to wake.Convulsions.
Stridor in a calm child.
Stopped feeding well.
Wheeze.
Fever [38+] or low body temperature [< 35].
Grunting.
Cyanosis.
Severe disease: fast breathing [60+/ minute] or severe chest in drawing.
No pneumonia: no fast in drawing, no danger sign.
Management:
No pneumonia, cough and cold: no antibiotics:
2 months- 5 years:consider other problems:
Chronic cough [> 30 days], refer to hospital for further assessment [TB, asthma or whooping cough].
Ear problem or some throat ------- further assessment.
Advise mother to give home care.
Treat fever if present.
Treat wheezing if present.
< 2 months: no antibiotics:
Advise home care:
- Keep warm
- BF.
- Clear nose.
- Watch for signs of illness
- Return immediately if:
Breathing becomes difficult, breathing becomes fast, feeding becomes a problem, infant become sicker, high fever.
Home care for the older children[ 2 months- 5 years]:
Feed the child, increase feeding during and after illness, and clear the nose.Increase fluid: give him extra fluid to drink, increase BF.
Sooth throat and relieve cough with a safe remedy.
Return quickly if any of the following develop
Breathing difficult, breathing becomes fast, child is not able to drink, and child becomes sicker.
Pneumonia:[ 2 months- 5 years]
Treat at home with antibiotics, give one of the following for 5 days, Cotrimoxazole, Amoxacilline, [syrup or tablet], procaine penicillin.
Give the first dose in the health center
Teach the mother how to give the dose , how much, how many times/ day, how many days
Advise on home care.
Reassess in 2 days or sooner if the child gets worse.
When you reassess in 2 days:
-Worse: refer to hospital
- Improving: finish the 5 days of antibiotics
-Same: ask the mother if the child has received his antibiotics properly. If yes, change the antibiotics.
Very severe disease and severe pneumonia:
Refer urgently to hospital.
Give the first dose of antibiotics[ pre-referral treatment]
Treat fever, if present.
Wheezes: treated by bronchodilators according to condition of the child [other classification, first or recurrent attacks].
Ear problem:
Ask: - does the child have ear pain?
-does the child have pus draining from the ear? For how long?
Look and feel: - look for pus draining from the ear, or red
Immobile ear drum.
- feel for tender swelling behind the ear.
- Classify:
Tender swelling behind the ear.
Mastoiditis
Treat: - refer urgently to hospital.-give pre-referral antibiotics.
- treat fever and pain [paracetamol].
Pus draining from the ear [< 2 week]
or ear pain, red immobile ear drum.
Acute ear infections.
Treat: - antibiotics for 5 days-dry ear buy wicking.
- reassess in 5 days.
- treat fever and pain [paracetamol].
Pus draining from the ear[2+ weeks]
Chronic ear infection
Treat: - dry ear by wicking
- treat fever and pain [paracetamol]
- If no improvement [refer to hospital].
Soar throat:
-Assess:Ask: -is the child able to drink?
- does the child have a sore throat?
Look, feel:
- feel the front of the neck for L.nodes
- look for exudates.
- Classify:
Not able to drink
Throat abscess
Treat: - refer to hospital- give pre- referel antibiotics.
- treat fever and antibiotics.
Tender enlarged L.N white
exudates on throat
Streptococcal infection
Treat: - Benzathin penicillin or amoxicillin.
- safe soothing remedy.
- treat fever and pain [ paracetamol].
Pain on drinking
Viral soarthroat
Treat: - soft food and fluids.
- treat fever and pain [ paracetamol].
Prevention of ARI:
Specific measures: immunization.Non specific measures:
Health education.
ANC [increase BW]
BF.
Proper nutrition
Prevention of air pollution [ smoking, gas heating---]
Primary Health Care Lec: 7