this was d presentation that I had in paediatrics classroom this is on the topic IMNCI STRIDOR ARI

1. IMNCI
Integrated Management
of Neonatal and
childhood illness
strategy

2. The 3 MAIN components
 Improvement in the case management skills of health
staff through use of locally adapted guidelines.
 Improvements in the overall health systems
 Improvements in family and community health center
practices

4. GUIDELINES
 Target children less than 5 year old
 Evidence based syndromic approach
 (1)health problems the child may have
 (2)severity of the childs condition
 (3)action that can be taken to the care of the child.

5. The PRINCIPLES
1
 All children under 5 year of age must be examine3d for
conditions which indicate immediate referral
 Children must be routinely assessed for major symptoms
nutritional ,immunization status , feeding problems and other
problems
 Only a limited number of clinical signs are used for assessment
 CLASSIFICATION:
REFERRAL---PINK
TREATMENT IN HEALTHY FACILITY—YELLOW
MANAGEMENT AT HOME --- GREEN

6. Color code:
Referral for PINK
Treatment in healthy facility for YELLOW
Management at home is GREEN

7. THE PRINCIPLES
2
 IMNCI addresses most common but not all pediatric
problems.
 IMNCI uses a limited number of essential drugs
 Care takers are actively involved in the treatment of
children.
 IMNCI includes counseling of care takers about home
care including feeding, fluids and when to return to
health facility.

8. CASE MANAGEMENT
 STEP1:Acess the young infant
 STEP2:classify the illness
 STEP3:identify treatment
 STEP4:treat the young infant
 STEP5:counsel the mother
 STEP6:follow up care

9. ASSESSMENT
 History taking and communication with the care taker
 Checking for general danger sign
 Checking main symptoms
 Checking for malnutrition
 Checking for anemia
 Assessing child feeding
 Checking immunization status
 Assessing other problems

10. General danger signs
 h/o of convulsion
 Unconsciousness or lethargy
 Inability to drink or breast feed
 Child vomit everything
 If the child have one or more of theses sign the child is
said to be seriously ill.

11. CLASSIFICATION
 Assessing the sick child age 2 month upto 5 year
 Assessing the sick child from age 2 month to 5 year

15.  OP Management of sick child age 2 month to 5years

21. TREATMENT GUIDELINES
1
 Tt of local infections:
#Local Bacterial Infectioins:oral cotrimoxazole or
amoxicillin *5days
#Skin pustules:apply gentian violet paint twice daily at
home
#discharge from ear: try to dry the ear by wicking

22. TREATMENT GUIDELINES
2
 Some or no dehydration:treat dehydration as per WHO
guidelines.
 Feeding problem:
#teach the correct positioning and attatchment for breast
feeding
#teach the mother to manage the breast feeding and
correct the nipple problem.
#treat thrush:use gentian violet to clean childs mouth
#feeding with cup and spoon.
#counsel the mother abt feeding problems

23. Pre referral treatments
1
 Convulsions: diazepam IV or rectally
 Severe pneumonia, febrile illness, measles ,mastoiditis
:chloramphenicol or ampicillin plus gentamycin or
ceftriaxone i.m
 Severe malaria:first dose of quinine
 Persistent diarrhea,measles severe malnutrition:vitamin
A

24. Pre referral treatments
 Hypoglycemia prevention:breast feeding and sugar
 Oral antimalarial as per guidelines.
 High fever:paracetamol
 Clouding of cornea:tetracycline eye ointment
 Diarrhea:ORS
2

25. APAC
 For effective communication and counseling APAC
 ASK
 PRAISE
 ADVICE
 CHECK

26. COUNSELLING
 Advice to continue breast feeding
 Teach how to give oral drugs or to treat local infections
 Counsel to solve feeding problems
 Advise when to return

27. WHEN TO RETURN!
Mother should bring her child if she notices the below…..
 Young infant (age 0-2m)
#breastfeeding or drinking
poorly
#becomes sicker
#develops fever or cold to
touch
#fast/difficult breathing
 Sick child(2month to 5 year)
#ANY CHILD
*not able to drink or breast feed
*becomes sicker
*develops faster
#CHILD WITH COUGH AND COLD
*develops fast/difficult breathing
#blood in stool
#CHILD WITH DIARRHEA
#yellow palms and soles.
*has blood in stool
*drinking poorly

28. Treatment guideline in OP & at home 1
 Pneumonia:1st dose of Antibiotic in clinin and teach
mother how to give oral drug cotrimoxazole 1st line,
amoxicillin 2nd dose
 Dysentry:cotrimoxazole 1st line nalidixic acid 2nd line
 Cholera: single dose of doxycycline
 Dehydration and persistent diarrhea: teat as per WHO gl

29. Treatment guideline in OP & at home 2
 Persistent diarrhea: Zn 20 mg elemental daily for 14
days and a single dose of vitamin A
 Malaria: as per recommendations
 Anemia: Fe and Folic acid tabs for 14 days
 Cough and cold: continue breast feeding, honey , tulsi
 Local inf:Tt eye with tetracycline

30. ARI
ACUTE RESPIRATORY
TRACT INFECTIONS
CONTROL PROGRAMME

31. Acute respiratory tract infections
ARI
 The common bacteria causing
ARI:H.influenza,S.pneumonia and staphylococci.
 Leading cause of mortality below 5 years
 Clinical criteria for diagnosis:1.rapid respiration with or
without difficulty in respiration. rapid respiration is
respiration greater than 60/min in children below 2 mnth
of age between 2mnth to 1 year and between 1yr to 5
yr.
 Difficulty in respiration is lower chest indrawing.

32. ARI
 In children below 2months of age , presence of any one
of the following indicates severe diseases : fever(38
degree or more), convulsions, abnormally sleep or
difficulty to wake , stridor in calm child, wheezing, not
feeding , tachypnea, chest indrawing, altered sensorium,
central cyanosis, grunting apneic spells or distended
abdomen.

34. Signs and
symptoms
classification
therapy
Where to treat
Cough or cold
No fast breathing
No chest indrawing
Or indicators of
severe illness
NO pneumonia
Home remedies
Home
RR/minute
Age 60 or more ;
less than 2 months
50 or more;2-12
months
40 or more;12 -60
months
Pneumonia
cotrimoxazole
Home
Chest indrawing
Severe
pneumonia
IV/IM pencillin
Hospital
Cyanosis, severe
chest indrawing,
inability to feed
Very severe
pneumonia
IV
chloramphenicol
Hospital

35. Less than 2 month- its treatment

36. 2 month to 5 years- its treatment

37. Cotrimoxazole - treatment for
pneumonia –its dosage

38. STRIDOR

39. STRIDOR
 It is a musical sound of single pitch that is produced by
oscillation of critically narrowed extra thorassic
pathways.
 Initially its inspiratory but when obstruction become
more severe it become both inspiratory and expiratory.
 When stridor is high pitched the child is more distressed.
 With the resolution of disease sridor becomes low in
pitch

40. 2 TYPES OF STRIDOR
SUPRAGLOTTIC
OBSTRUCTION
TRACHEAL OBSTRUCTION
Inspiratory stridor
Weak cry/dyspnea
Dyspnea is generally mild
Less pronounced cough
Biphasic or expiratory
Normal cry/voice
May have severe dyspnea
Deepbarking,brassy cough
Physical findings: nasal flaring,suprasternal and intercostal
indrawing
Radiographs: Cxrays OF LATERAL NECK FILM.
barium esophagogram

41. CAUSES for STRIDOR
 INFECTIONS:CROUP , ACUTE EPIGLOTITTIS ,
BACTERIAL TRACHEITIS , RETROPHARYNGEAK ABCESS
 CONGENITAL CAUSES:LARYNGOMALACIA , VOCAL CORD
PARALYSIS , CONGENITAL SUBGLOTTIC STENOSIS ,
VASCULAR RING , SUBGLOTTIC HEMANGIOMA ,
CONGENITAL SACCULAR CYST, LARYNGEAL WEB ,
LARYNGEAK ATRESIA
 IATROGENIC CAUSE: ACQUIRED SUBGLOTTIC
STENOSIS, LARYNGEAL GRANULOMA
 NEOPLASM:RECURRENT RESPIRATORY PAPILLOMA
 FOREIGN BODY

42. INFECTIONS
CROUP
AC
EPIGLOTITTIS
BACTERIAL
TRACHEITIS
RETROPHARYN
GEAL ABCESS
1-5 years
Barking type
Onset: several
days
Cxray:steeple
sign
Resolve in 1-2
days
Supplemenal O2
Steroids
h.Influenza
And
staphylococcus
Acute onset
Sore throat
dysphagia fever.
Tripod posture
Cough is absent
Lateral x ray:
Thumb like
thickening of
epiglottis
Young children
Brassy cough
stridor
Life threatening
High fever
Reduced
morbidity of neck
Toxic appearing
S.aureus
Lateral xray:
bulge in post
pharyngeal wall
Cefuroxime iv
antibiotics
H.influenza
Tt:surgical
drainage

43. RETROPHARYNGEAL ABCESS
CROUP
EPIGLOTITTIS

44. Congenital
LARYNGO VC
MALACIA PARALYSIS
CONG.
SUPRA
GLOTTIC
STENOSIS
VASCULAR
RING
SUBGLOT
TIC
HEMANGI
OMA
CONG
SACCUL
AR
CYST,L
ARYNG
EAL
WEB,LA
RYNGE
AL
ATRESI
A
Inspiratory
stridor
Aggravate
d:crying
supine
Self
limited
3rd MC
Incomplete
recanalizati
on of
laryngotrac
heal tube
during
embryonic
developme
nt, 1st 6
month.
Extrinsic
compression
of both
trachea and
esophagus
Symptoma
tic in 3-6
months
Biphasdic
stridor
barking
cough
Endoscopy
tracheosto
my,intra
lesion strd
rare
BL:arnold
chiari
syndrome,hy
drocephalus,
hypoxia
UL:accidental
injury during
ligation of
PDA
Dysphagia
plus stridor
esphagogra
m

45. LARYNGOMALACIA
SUBGLOTTIC STENOSIS
SUBGLOTTIC CYST
VOCAL CORD PARALYSIS
VASCULAR RING
SUB GLOTTIC HEMANGIOMA

46. Iatrogenic
Acquired subglottic
stenosis
Laryngeal granuloma
MC acquired
Long term endotracheal tube
intubation
Tracheostomy
Widening of stenosis with
cartilage grafts
Excision of stenotic graft
Result from prolonged
intubation
Endoscopy:granuloma in
vocal cord

47. Neoplasm & foreign body
RECURRENT RESPIRATORY
PAPILLOMA
FOREIGN BODY
MC tumor of Larynx
HPV type 6 and 11
Cause genital condyloma
Infection via passaage through
birth canal
Tt with CO2 laser
ablation/microdebrider excission
of papilloma
Alpha interferon,intra lesional
cedofovir
Potential cause
Food and coins
Young age at great risk
Endoscopic visualization and
removal
Foreign
body

48. TRACHEOSTOMY
 INDICATION:ventilator dependance and
airway obstruction
 MC comlication:tube obstructions,accidental
decannulation that occur months after injury
 But Long term tracheostomy in children may affect
speech and language development

49. Hoarseness
 VOCAL NODULES: shouting and screaming children
endoscopy BL opposing nodules at junction of ant
&middle 1/3rd
 REFLUX LARYNGITIS: Gastric secretions spilling on to
larynx- laryngitis, subglottic stenosis, chr sinusitis otitis
media with effussion.
 HYPOTHYROID MYXODEMA: increased vocal fold edema
look for thyroid function test.
 LARYNGOTRACHEAL CLEFT :Cong defect in post cricoid
cartilage in larynx. child experience recc RTI, feeding
difficulty, hoarseness, severe cleft cause aspiration
pneumonia

50. Reflux
laryngitis
hypothyroidism

51. Wish you a joyful life…. & thank you
IMNCI - INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS .ARI-ACUTE RESPIRATORY TRACT INFECTION CONTROL PROGRAME .STRIDOR