Practice Guidelines for Family Physicians Volume 1

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Volume 1

Message from His Excellency

Prof. Dr. Hatem El Gabaly

Compre ens ve eve opment an mo ern zat on s one o Egypts pr or t es anpursue o ect ves. Out o t s ru e, we are comm tte towar s mprov ng t equality of health care services available for all Egyptians; adults, children, the pooran t e we -o .

T e M n stry o Hea t an Popu at on as a opte , as a top pr or ty, eve op ngcurrent systems to prov e an nance ea t serv ces n gu ance an v s on o t epo t ca ea ers p to ensure g qua ty n serv ce prov s on an meet nee s anexpectat ons o t e popu at on as we as eep ng up w t top-notc eve opmentsat all levels primary, preventive, curative, diagnostic and rehabilitation.

T s v s on as een trans ate nto a prom s ng an am t ous F ve Years P an tonst tut ona ze t e Hea t Sector Re orm Program on t e nat ona eve . T e p ans ocus ng on mp ement ng t e Fam y Hea t Mo e at a pr mary ea t careac t es n t e 27 Governorates.

Our ream as een rea ze nto a competent program o Hea t Sector Re ormaiming to provide every person with high quality health services. These includep ys ca , psyc o og ca an soc a we are, w c trans ate nto g pro uct onan progress or our c er s e Country, Egypt.

am e g te to ntro uce to one o t e mportant pu cat ons or t e Sectoro Tec n ca Support an Pro ects, represent ng a great team e ort ract ceGuidelines for Family Physicians or t e am y p ys c an at a Fam y Hea t

nites of MOHP Distributed all over the Country .

Prof. Dr. Hatem El Gabaly

Minister of Health and Population


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Preface

T e M n stry o Hea t an popu at on s wor ng gent y to ac eve equa anava a e qua ty ea t serv ces or a c t zens o Egypt. Our o ect ve s to s apenat ona po c es or t e goa o a vanc ng ea t care e very n a parts o t ecoun ry.

x years ago, t e M n stry as a opte new po c es an strateg es n or er toprov e as c ea t serv ces o g qua ty or a c t zens n t e ramewor o t e

amily Health Model. This has led to introducing new nancing mechanisms thatensure t e susta na ty o nance an resources, an ava a ty o a or a eserv ces a ong w t e ect veness an e c ency o t ese serv ces.

av ng ma e s tuat ona ana ys s n eta s, g g t ng po nts o wea nesses anstrengt s an en ng actua nee s, strateg c p ans were su sequent y eve opeputt ng nto pract ce t e re orm ng n rastructure an uman resources as we aspartnerships between governmental, private and national sectors.

t g ves me great p easure to present t s ocument. T s system s n cont nuousre orm, progress ng ncrementa y, ren ng t e now e ge ase, an mo y ngconcepts. T s ocument s not t e en pro uct, ut rat er t e rst step o manyot ers.

owever, I hope it will help us towards our ultimate goal of a quality, effective,e c ent, ev ence ase serv ce to a Egypt ans rrespect ve o geograp ca orsoc a econom c arr ers.

T e ocument s a co a orat ve wor o t e M n stry o Hea t an Popu at on sta ,an t e Sector or Tec n ca Support an Pro ects on ot centra an per p eraeve s. Wor n t s ocument s su ecte to cont nuous assessment, operat on

researc , many o t e ssues presente n t s ocument w e up ate n urt erersion.

r. mam ossan ersecretary o t e ector orec n ca upport an ro ects


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Volume 1

Table of Contents

essage from His Excellency .................................................................................................... iPreface iiist of Figures ........................................................................................................................... vist of Tables ............................................................................................................................ v

Abbreviations and acronyms vi

1- I NTRODUCTION

ealth Sector Reform Program (HSRP)The Family Health Unit / Center ............................................................................................... 9

amily Health Unit Vision and Mission ................................................................................. 1Vision ...................................................................................................................................... 1

ission ............................................................ ........................................................................ 10The Family Health Team ......................................................................................................... 10

amily Physician ..................................................................................................................... 1Accreditation of the FHU ............................ ............................................................................ 11

amily Practice ........................................................................................................................ 11The Human Life Cycle ................................... ........................................................................ 1Proactive measures in Family Practice 1

on-clinical activities that are dealt with by the Family Health Team .................................... 1

2- W ORKING W ITH T HE C OMMUNITY

ow to Work with the Community ......................................................................................... 17nitiation of Rosters and creation of Family Folders ................................................................ 1

Completing the Family Roster forms 1

3- N EONATAL C ARE

esuscitatory Immediate InterventionsChest compression: .......................... ....................................................................................... 22

eonatal Jaundice ...................................................................................................................eonatal Conjunctivitis ........................................................................................................... 5

Congenital Anomalies ............................................................................................................. 25eferral Guidelines for the Neonate ........................................................................................ 26

Transport Vehicle and Equipment ........................................................................................... arly Detection of Congenital Hypothyroidism (CH) 7

4- C HILD H EALTH

Components of Child Health Programme in the FHU 1

egistration ............................................................................................................................. 1Periodic Examination: ............................................................................................................. 1


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At-risk children ....................................................................................................................... 1Growth Monitoring .................................................................................................................

evelopmental Screening .......................................................................................................ealth education ......................................................................................................................utrition Care .........................................................................................................................

Promotion of breast feeding ....................................................................................................Weaningmmunization .......................................................................................................................... 4

Conditions which are NOT contraindications to immunization ..............................................Child Late for Vaccination 5Principles of prescribing in pediatrics ..................................................................................... 41Pharmacokinetic Aspects ........................................................................................................ 1

5- I NTEGRATED M ANAGEMENT O F C HILDHOOD I LLNESS

ntegrated Management of Childhood Illness (IMCI) ............................................................. 65Table of Contents for IMCI 7


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v

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List of Figures

No Title Page

Humen Life Cycle 1

2 Diagram for Neonatal Resuscitation 21

3 Diagram for Neonatal Resuscitation Medication 22

Diagram for Management of Neonatal Jundice

5 Diagram for Management of Neonatal Conjunctivitis 25

Form of Child Health Screening Guide

7 Form of Growth Curve (Arabic version ) 38

Form for Neonatal and child follow up since birth ( Arabic Version)

9Diagram for developmental Milestones since birth till under 5 years old- Gross

Motor (Arabic version )39

1Diagram for Developmental Milestones since birth till under 5 years old -FineMotor and Vision ( Arabic version )

11Diagram for Developmental Milestones since birth till under 5 years old - Hearing& Language ( Arabic version )

12Diagram for Developmental Milestones since birth till under 5 years old -SocialBehavior ( Arabic version )

41

List of Tables

No Title pag

1 Neonatal Resuscitation Medications -Dose and Routes

2 Neonatal Examination 23

Common Neonatal Life Threatening Anomalies

4 Anthropometrics Measurements 32

Teeth Development

6 National Compulsory Vaccination Schedule for Communicable Diseases TargetingInfancy & Pre- School Children

35

Vaccine Reactions8 Developmental Examination 38

Water Distribution in Different Body Compartments

1 Half- Lives of some Drugs in Neonate and Adults

11 Determination of Drug Dosage from Surface Area 43


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Abbreviations and Acronyms

BBP : Basic Benets Package

BPM : Beat Per MinuteCDAs : Community Development Agencies

CDAs : Community Development Associations

CHC : Community Health Committee

PI : Client-Provider Interaction

I : Continuous Quality Improvement

D T : Directly Observed Treatment Short Course

DP : District Provider Organization

EDL : Essential Drug List

FH : Family Health CenterFHF : Family Health Fund

FHT : Family Health Team

FHU : Family Health Unit

FP : Family Physician

6PD : Glucose-6-Phosphate Dehydrogenate

H MI : Health/Management Information System

HMH Pro ect : Healthy Mother/Healthy Child Project

HR : Heart Rate

H RP : Health Sector Reform ProgramIM I : Integrated Management of Childhood Illness

IU : International Unit

MCH : Maternal and Child Health

MMR : Measles-Mumps-Rubella Vaccine

M HP : Ministry of Health and Population

N s : Non-governmental Organizations

NHI : National Health Insurance System

NI U : Neonatal Intensive Care Unit

PV : Oral Polio VaccinePD : Patant Ductus Arteriosus.

PHC : Primary Health Care

PPV : Positive Pressure ventilation

RH/FP : Reproductive Health/Family Planning

D : Standard Deviation

T P : Sector for Technical Support and Projects

UNI EF : United Nation International Education Childrens Emergency Fund

U ID : United State Aid International Development

WHO : World Health Organization


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Introduction


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Introduction

IntroductionThese guidelines are intended

o support the Family Healtheam (FHT) in providing qualityealth care to individuals,

families, and communities inhe catchments areas of the

Family Health Unit (FHU).It provides the technical andmanagerial details requiredfor efcient implementation ofeffective health services thatfulf ill the requirements of theHealth Sector Reform Program

(HSRP). The guidelines coverall aspects of the Basic BenetsPackage (BBP). In additionit deals with other primaryHealth Care (PHC) activities

that should be performed by theHealth Team.

The information includedhere is based on an extensive listof existing excellent materialincluding guidelines, standardsand protocols prepared byall vertical programmes,and by the different MOHP

ectors, Departments andUnits. These efforts are greatlyacknowledged. We hope thatthe present guidelines wouldbring all these previous effortsinto focus, and maximize theirbenets.

The Sector for Technicalupport and Projects (STSP) is

developing these guidelines toadapt the available material to theneeds of the Family Physicians

and to provide health careproviders with a user-friendlyresource to support them in theprovision of evidence-based

est practices, and to contributeo improved quality of services

provided through the FHU. Thedocument presents informationin a format that would allow forquick retrieval and act as a useful job-aid. Each partition contain a

separate section dealing with aspecic topic as referred to inhe table of contents. This design

allows for updating of specicsections as deemed necessary.

Def inition: Clinical guidelines are recommendations on

the appropriate treatment & care of peoplewith specic diseases & conditions withinFamily Medicine Programs in Egypt. They

are based on the best available evidence. Guidelines help healthcare professionals

in their work, but they do not replace theirknowledge and skills.

Aim:Good clinical guidelines can change the

process of healthcare and improve outcomes. Forexample, well constructed and up-to-date clinical

uidelines:

Provide recommendations for the treatmentand care of people by health professionals

Can be used to develop standards to assessthe clinical practice of health professionals

Can be used in education and training ofhealth professionals

Can help patients to make informed decisions,and improve communication between thepatient and health professionals.

Health Sector Reform Program

(HSRP)The goal of the HSRP: is to achieve universal

coverage for the entire population with a basicpackage of primary promotive, preventive, andcurative care and public health services.

he basic principles are : to improve the qualityof public and private services; promote equity

in the nancing and delivery of care; enhancethe allocative and technical efciency; provideuniversal insurance coverage and access to care;and assure long-term nancial sustainability of thehealth system.

he HSRP strategy: aims at separating servicedelivery from nancing the health services.

he services are provided by the Family healthteam (FHT) working in the family health unit(FHU), referrals are made to the family health

center (FHC) and district hospital as appropriate.Financing the health services is done through

the family health fund (FHF) which will graduallymerge in a unied National Health Insurance(NHI) system.

The Family Health Unit / Centerhe FHU is the f irst level of the family

health model. It provides comprehensive bio-psychosocial care at the level of the individual, thefamily, and the community. The FHU provides thebasic Benets Package (BBP), and implement theHSRP policies (see the BBP). All primary health


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care functions are still delivered by the FHU.he present guide is an attempt to help health

service providers to do their job as efciently and

effectively as possible.

Family Health Unit Vision andMission

The health team should dene the vision andmission of the FHU. This will be a driving forceo provide quality health care and to implement

performance improvement approaches. Thefollowing are suggested vision and mission thatcan be used to build on / modify / update as time

oes on. Each FHU is expected to develop furtherheir own vision and mission

VisionVision is idealistic aspirations. It describes what

he organization (FHU) hopes to be, and spellsout the highest ideals and wishes. It is a drive forcontinuous improvement. You are expected todevelop the vision with your staff.

Example for FHU vision:

Our unit is a distinguished and accredited healthfacility, recognized by providing comprehensivequality health care. The unit meets clientsand community expectations and fulf ills theirsatisfaction. This is reected as high utilizationrates for health promotion, preventive, and curativeservices. The high utilization rate, and the qualityof service are evidenced by better quality of life,improved health status, decrease in morbidity andmortality rates in the catchments area.

If you can dream it, you can make ithappen

MissionMission is a statement of purpose. It denes

he reason / why this organization (FHU) existsand its role, what are the main services, who areour customers, how do we offer the service. Themission is exible, dynamic and responds tochanging roles as they occur.

Example of a FHU mission:The FHU provides comprehensive health care

for individuals, families and communities. Thiscare covers physical, social and psychologicalaspects throughout the human life cycle. All vertical

programmes are delivered in an integrated patternthat fulf ills the principles of quality, efciency,and effectiveness. The FHU implements BestPractices, and the staff provides evidence-basedmedical care.

The Family Health TeamIn addition to the FP, the FHT includes:

Dentists, Nurses, Pharmacists, Pharmacy Clerk,Lab Technicians, Lab Assistant, Social Worker,Sanitarian, Adm/Finance, Assistant Adm/Finance,

Medical Records, Births and Deaths Ofcer, FrontOfce, Storage Room, Janitors and Guards.

he FP directs the team and supports teambuilding. FHT is responsible for implementingall Primary Health Care (PHC) activities, andprovides the Basic Benets Package (BBP) at theFamily Health Unit/Center.

In relation to family practice activities, the FHTis responsible for a roster of families (600 - 700,sometimes more) in the catchments area.

The Team Provides The Following Mainerv ces: Creating family folders

Conducting initial examination for all familymembers

Providing appropriate bio-psycho-social careat all stages of the human life cycle

Early detection of health problems amongfamily members, and the community throughperiodic examination and screening tests

Providing curative care and referral whenneeded

Follow-up of chronic conditions, especiallyhypertension, diabetes and tuberculous casesreceiving DOTS

Implementing specic programmes as MCH,RH/FP, School Health, etc.

Family Physician:he FP is a medical doctor working in the

front line of health care, and is responsible for

providing comprehensive (physical, socialand psychological) and continuous care for theindividual in the context of the family, and the

Note


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family in the context of the community.

xpectat ons rom t e am y ys c an

Responds to the total health needs ofindividuals. Promotes healthy life styles.

Reconciles individual and community healthrequirements.

Assesses and improves the quality of care.

Makes optimal use of new technologies.

Works efciently in a health team.

rector o ut es anespons t es

Issues orders based on instructions receivedfrom the Health District / District ProviderOrganization (DPO).

Distributes work to the staff according toguidelines and protocols.

Monitors staff performance.

Provides health care to individuals, familiesand communities.

Maintains self development.

Participate in relevant training activities.

ut es an respons t es can ecategor ze un er t e o ow ng areas: Technical.

Management (including planning,implementation, monitoring & evaluation)

Administrative.

Personnel.

Finance.To fulf ill their duties, team members require

clinical / technical skills, management / leadership

skills, and communication skills. These guidelinesare expected to provide the health team with theneeded information to help self learning andsupport them in delivering quality care.

Accreditation of the FHUAccreditation is a process for evaluating the

facility according to a set of standards that deneactivities and structures that directly contribute toimproved patient outcome. Accordingly the unit iseligible to contract with the (FHF). If the primary

assessment denies accreditation the process will berepeated in 6 months. Partial fulf illment of criteria,o a stated extent would result in provisional

accreditation. The process would be repeated inone year. If the unit is fully accredited the processhas still to be repeated after two years to assure

conforming with criteria over time. Fulf illing theaccreditation criteria is a joint responsibility of theFHU and The DPO staff.

he steps to be taken to fulf ill the accreditationcriteria include the following:

Improved infra structure Equipments in place according to standards

Enumeration of all the houses in thecatchments area

Creation of the family folders

Comprehensive initial medical examinationto all members of the families

Implement the BBP

Availability of the Essential Drug List (EDL)

Implementing quality improvementprogrammes

Medical guidelines and protocols used

Stafng pattern according to standards Implement staff training

Referral system

Accredited units should implement Co-ntinuous Quality Improvement (CQI)approaches to conform to standards,and still be legible for re-accreditationafter two years.

Family PracticeFamily practice is the core for providing

comprehensive health care. It refers to bio-psycho-

social care at the level of the individual and thefamily, within the context of community. Familypractice covers individuals throughout the humanlife cycle. It thus include all services providedby the PHC programmes and maximize theirefciency and effectiveness through a human lifecycle and family life cycle approaches, consideringthe health needs of all members of the family at thedifferent stages of the human life cycle within thecontext of a changing family environment.

The Family Life CycleDiffers between the nuclear and the extended

families, The extended families may have more

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family setting. The family life cycle passes throughhe following stages:

Pre and early marital.

The expectant couple.

The f irst child. The Family with an adolescent.

Middle age.

Old age and widowhood.The FP should be aware of the bio-psycho-social

changes associated with each stage and deal withthe family as a unit.

The Human Life Cycleis characterized by several stages merging

through each other through transitional events.Each stage has its own characteristics, health risksand problems, and health needs. The transitionalevents may have a hazardous effect, and has to beproperly handled. The FP has the responsibilityfor providing promotive, preventive and curativecare needed by family members at different stagesof the human life cycle.

Proactive measures in FamilyPractice:

Family practice is characterized by being proactiveo meet the health needs of the served population, in

addition to reactive interventions to respond to their

demands.. Proactive measures include:

Bio-psycho-social promotion and preventive

services to individuals, families andcommunities

The initial comprehensive examination andthe follow-up according to the results

The periodic examination for the healthyaccording to age and physiologic state, e.g.pregnant and lactating mothers, growingchildren, etc., and the periodic examination

Phase of Development Transitional EventPreconception

Conception

Fetal life

Birth

Breast dependence

Weaning

Preschool age

chool entrance

(or equivalent)chool age

Puberty

Adolescence

ttainment of maturity

Age of production AndReproduction

Climacteric

enescence

Death

Source of the f igure : WHO (1972). Human Development and Public Health. Technical Report Series No. 485

Figure "1": Human Life Cycle


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chronic diseases (example hypertensionand diabetes). The medical records

provide the information needed for theperiodic examination of different subjects /conditions.

Application of the at-risk approach tomembers of families having identiedrisk factors. In such cases, the periodicexamination need to be more frequent anddirected to relevant screening tests.

Control measures to family members who arecontacts to an infectious disease according toprotocols.

Health education services at the clinic, thehousehold (home visits), and the communityat-large (See the section on Working withthe Community)

Customized and incidental health educationgeared to the needs of individual families or

family members; e.g. a teenager who startssmoking or drugs need to be specicallydirected and followed.

Out-reach activities.

Non-clinical activities that are dealt with by the Family Health Team:

Management issues including planning,monitoring, supportive supervision, perfo-rmance improvement, continuous qualityimprovement, evaluation, etc.

The record system

The Health / Management Informationystem (H/MIS)

Infection Control

Clinic waste management

This will be dealt with in aseparateuidelines.


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WORKING

WITH THE

COMMUNITY


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Working with the Community

WORKING WITH THE COMMUNITY The FHU provides comprehensive health

care to improve the health status of the peoplein the catchments area and address their healthproblems. This is best achieved when there isactive community involvement and partnership.

To achieve this partnership the health team,specially the FHP should play an active role in

nderstanding the community, mobilizing allpotential community resources, and activelyinvolving the community in participatory planningfor FHU activities, in supporting the health serviceo effectively implement relevant interventions

e.g. arrangements for on-the-clock transportationin cases of emergency, and to watch for communitybehavior in relation to several health issues e.g.environmental sanitation.

How to Know and Work with theCommunity:

To be able to work effectively with thecommunity and get them involved into actions forimproving the health status, you must dene theboundaries of your community, geographic andadministrative. This is done through:

Drawing sketch maps for the catchmentsarea including the mother village and thesatellites

Enumeration of the houses, which is the f irststep for creation of the family folders

The family folders will identify every memberin the community, the socio-economic and thehousing conditions; thus providing baselineinformation for the community served.

The initial comprehensive medical checkwill dene the health prole and identifymain health problems in the community.

t n t e ent e commun ty you s ounow t e o ow ng:

Demographic features and populationcharacteristics (the family folders willprovide this information).

Economic activities.

Social stratication and power relations (theleading families, and community leaders).

Organizations and their functions and activities(including governmental organizations,

schools, social services, agriculture services,NGOs, community development associationsCDAs, youth clubs, etc).

Community committees and communitydevelopment organizations.

Existing health or community developmentprojects and activities and the involvedorganizations.

Leadership pattern (formal and informal) andits inuence.

Culture and traditions.

Education levels. Environmental sanitation situation and

problems. Critical issues and problems.

Schools can provide a very importantopportunity for implementing health,environmental, and developmentalactivities for families of the schoolchildren and communities at large

Mechanism for working with the communityhere are several mechanisms through which

the FHU could work with the community. TheFHU should build partnership with the community,conduct needs assessment and participatoryplanning to address specic health issues through

concerted efforts that could be mainstreamed in theDistrict/FHU plans. The existing mechanism is thecommunity representation in the Board of FHU.A potential mechanism is the Community HealthCommittee. In addition to specially arranged publicmeetings to discuss specic issues.

he FHU Board include two members fromthe community. Criteria for selection of thesemembers should be:

1. They should be genuine members from thecommunity, living in the community for atleast 10 years.

2. Have good relations and communicationwith different groups in the community.

3. Enthusiastic, dedicated and willing toactively participate in board activities.

4. Have an acceptable standard of education tobe able to contribute.

community health committee (CHC) may beexisting, or needs to be created. The creation of anCHC will help to:

Add authority to community work which

often lacks a constituency; Serve as alink between the community and the

Note


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Working with the Community

health facility, and between the communityand the district

Capture the synergism possible through

concerted government and community groupaction

Build broad commitment and support for theoverall health issues in the community

Ensures continuity of work Provide amechanism to facilitate

development of new and innovative solutionsto identied needs and problems, as well ascreate partnerships within the community

uggested structure of the CHC The chief executive of the local village

council The chairman of the local elected council Two representatives from active NGOs

(rotated every year to secure widerepresentation)

Two natural community leaders (rotatedevery year to secure wide representation)

FHU director, physicians, head nurse, and arepresentative for Raedat (rotated every yearto secure wide representation)

The social worker

A representative for women (rotated everyyear to secure wide representation)

A representative from the youth club (rotatedevery year to secure wide representation)

Initiation of Rosters and creationof Family Folders

This is an initial step in implementing the FamilyHealth Model and bringing the community and theFHU in close contact.

In rural areas, enumerate the houses in themother village and satellites. A folder is thencreated for each family. The comprehensive initialexamination for all family members will bring allindividuals in the community in close contact withhe FHU team.

In urban areas creation of family folders canfollow almost the same lines in small townswith clear catchments areas, and in new housingcompounds having a clear design, and the houses

are well identied.In big cities and over crowded areas it will be

practically impossible to cover all houses/familiesin the surrounding, Self selection may be theappropriate approach. This can be done throughcommunity mobilization efforts, working withother organizations who could provide familyhealth care as NGOs, or who would market theservices of the FHU. A practical approach wouldbe that every client, from the catchments area,entering the unit for any reason (almost all wouldcome for child vaccination) is identied as acandidate for the roster. S/he is asked to consultwith the family head and bring all family membersto be registered and subjected to the initial clinicalexamination.

he District Provider Organization (DPO) wouldidentify other organizations in the community asNGOs or later private sector to complement the workof the FHU in order to achieve universal coverage.

Completing the Family Roster formsAs mentioned above, in rural this is done through

home visiting. Home visiting brings the FHU teamin close contact with community members. It hasto be tactfully done to build good relations and

avoid any antagonism from the community.

Steps for entering a householdhe nurse, Raeda Rifeya, or any other health

care service representative entering the householdis directed to the following basic principles:

1. Greet the f irst person to see and every oneelse you meet in the household

2. Introduce yourself by name and afliation3. Take sometime to be acquainted with the

people in the room, notice how they relate to

each other, who seems to be the leader?4. always be friendly and polite, and establish

rapport5. Explain the purpose of your visit6. Assure them that any information they give

will be kept condential7. Apply good communication skills, specially

if the purpose of the visit is health education

OHP Reference(s)

, rectorate o , pro ect, , A ; ommun ty ee s ent cat on an ec s on a ng oo ; romot ng ea t y e av or n ouse o s an ommun t es: A anua or utreac or ers.

" "


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Neonatal Care


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Neonatal Care

Neonatal CareThe neonatal period extends from delivery to

8 days after birth. It represents the most critical

period of life associated with high morbidity andmortality. It is responsible for more than 50% ofdeaths in the f irst year of life.

The role of the Family Physician in neonatal care:1. Neonatal resuscitation

. Neonatal examination3. Identify, assess, manage and refer neonatal

health problems including:

Neonatal jaundice Congenital abnormalities Hypothyroidism

Neonatal care is asharedresponsibility between the family physician and the pediatrician.

Timely reference is very important.Follow-up by the family physician is

essential to ensure continuity of care.

Resuscitatory immediate interventions*

Is there adequate spontaneous respiration without apnea or gasping

Yes No

Give free ow oxygen Gentle tactile stimulation for not more than 20 seconds

Did a good response occur?

No Yes

STOP

RESUSCITATION

Positive pressure ventilation (PPV)with oxygen by bag and mask

Heart rate >100 bpm without cyanosis Yes

No

Give oxygen

Heart rate


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Neonatal Care

Resuscitatory ImmediateInterventions

Place the neonate under a radiant warmer. Dry the neonate to prevent heat loss and

position him to open the airway. Place him supine with his neck in a neutral

position. Atowel neck roll under the shouldersmay help prevent neck exion and airwayocclusion.

Clear the upper airway by suctioning themouth f irst and then the nose, using a bulbsyringe. The mouth should be suctioned

f irst to prevent aspiration in case the neonatetakes a deep gasp when the nose is suctioned.uctioning should be limited to ve seconds

at a time. Vigorous suctioning should bedone only if moderate- to- thick meconium ispresent in the airway (the condition may leadto bradycardia).

Initiate medications if HR below60 after 30 seconds of PPVith 100% oxygen and chest

compressions**

Give epinephrine

HR > 100 bpm?

Assume metabolic acidosis andgive sodium bicarbonate

May be repeated every 5 minutes

Discontinue medications

No

Yes

HR > 100 bpm?

No

Evidence of acute bleeding withsigns of hypovolemia?

No

If there is respiratorydepression and a history ofnarcotics administered to themother within the past 4 hours,give naloxone hydrochloride

HR > 100 bpm?

Discontinue medicationses

Give volume expanderYes

HR > 100 bpm?

Discontinue medications

Yes Discontinue medications

Do not forget

Dry the neonate to prevent heat loss andposition him to open the airway.

Suctioning should be limited to veseconds at a time.

Chest compression: If the heart rate is still < 60 beats / min. after

15-30 seconds of adequate ventilation, chestcompression should be started.

Compression is applied to the lower sternum just below the nipple line, but above thexiphoid. The resuscitators thumbs are used

Th s chart s ma nly or the spec al st

Figure 3: Diagram for Neonatal Resuscitation Medication


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surround the chest or the middle and Indexngers of one hand may be used to compress

while the other hand supports the neonatesback. The sternum is compressed to 2 cm. Chest compressions are alternated with

ventilation at a ratio of 3:1. The combined rate

should be 120 / min. ( i.e., 90 compressions and30 ventilations). After 30 seconds evaluatethe response. If the Pulse is > 60 beats / min.,

chest compressions can be stopped and PPVcontinued until the heart rate is 100 beats /min. and effective breathing is maintained.

Table. 1: Neonatal Resuscitation Medications Doses And Routes

Medication Concentration Preparation Dosage and Routes Rate precautions

p nep r ne : . 1 cc ampou es .1- . m g or .ay ute 1:1 w t normasa ne g ven v a .

ve rap y. ay repeat n -5m nutes < pm

o umcar onate

.

1 m q 1 m .

5 m q 1 m

1 m ampou es

5 m ott es

m g

m g

A m n ster s ow y

o umeexpan ers

o e oo , A um n5 orma sa ne,

ngers actate

ar a e,

5 m

5 m

5 m

1 m g ve over 5-1 m n y syr nge orr p

a oxone . mg m 1 m .1mg g ( . 5 m g)

, , ,

or on y

* Naloxone hydrochloride: In neonates 0.01mg/kgcan be administered I.V,S.C,or I.M to reverse the effects of analgesicsiven to mothers prior to delivery -0.2mg given I.M to infants whose mothers had received meperidine in labor.

Table. 2: Neonatal Examination

. enera appearance Weig t: sma or gestation or arge or gestation S in: irt mar s, meconium

sta n ng, traumat c cyanos s or purpura

a or, aun ce or cyanoss yn romes c usters o eatures : anugo or ev ence o postmaturity

owns syn rome or urners syn rome. ea an ac a eatures

Head circumference Accessory auricles Hare lip ep a o aematoma tos s otters acies

Fontane es size an tension Su conjunctiva aemorr a e ataract erre o n aw rece ng aw w t c e t pa ate) Red reex Sternomastoid swelling

. rms an an Proportion o arms/ ngers Num er o ngers Norma movements e ng o ngers xtra g ts e ema

a mar creases ssng g ts r s pa sy

4. Chest

Distortion Respiratory rate Air entry reast enargement A e reat soun s ecess on

. ar ovascuar examnat on Pu ses ( emora an rac ia ) Heart soun s Murmers

. omen Umbilical infection Umbilical hernia Masses

. en ta a Ma e: Penis size an s ape; position o uret ra ori ce; testes (norma, un- escen e or ma- escen e ), ernia or y rocee ema e: toromega y; vag na ee ng; poster or vag na s n tag common

. egs an eet Femoral pulses Proportion Club foot

. Is t e a y e aving norma y? Is t e cry norma ? Are a 4 im s moving equa y? Is t e Moro re ex symmetrical?

. ac

Sacral pit Spina bida Scoliosis. out

C e t pa ate? Pro use sa iva Epstiens pear s


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Neonatal JaundiceWhen a mother visits you carrying a 1*jaundiced

infant, history, examination and laboratoryinvestigations are your tools to suspect the 2*type

of hyperbilirubinemia you have and whether toreassure the mother and send her home or refer herto a higher level, being mandatory.

1. Most of infants become visiblyjaundiced when:

serum bilirubin exceeds 7 mg/dl.

2. Types of neonatalhyperbilirubinemia:

ys o og c n rect or ncon ugateyper ru nem a

Physiological jaundice occurs in 60 % of healthy

full term babies and 80% of preterm babies. It is byfar the most common cause of neonatal jaundice.

In full term the healthy babies jaundice appearsat day 2-3 and usually disappear by 6-8 dayssometimes lasts for 14 days, with a maximumbilirubin level < 12 mg/dl.

at o og c n rect ncon ugate

Hyperbilirubinemia This is the most common cause of jaundice in

the f irst 24 hours of life.

3* Identify signs of serious illness

> w

Follow up

2 wks

No

Provide routine care,recommend routine feeding

and follow-up

No Yes

Yes

Yes

es

Yes

R

F

E

R

R

A

L

Figure 4: Diagram for Management of Neonatal Jundice


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Neonatal Care

Neonatal ConjunctivitisNeonate with eye discharge

Take history and examine

Bilateral or unilateral(reddish), swollen eyelidswith purulent discharge?

- Reassure mother- Advise to return if not better

Yes

- Treat for gonorrhoea- Treat mother and partner(s) forgonorrhoea and Chlamydia- Educate mother- Counsel mother if needed- Advise to return in 3 days

Improved? - Treat for chlamydia- Advise to return in 7 days

Reassure motherImproved? Refer

Continue Treatment

No

Yes

Yes

No

No

This occurs in cases of Rhesusincompatibility, ABO incompatibility, G6PDdeciency and Spherocytosis. Other causesinclude congenital infection, septicemia,cephalohematoma, metabolic disorders (asgalactosemia), hypothyroidism and pyloricstenosis.

Breast milk jaundice is a form of mildneonatal jaundice occurring in breast fedinfants as a result of maternal hormonespresent in breast milk and competing withbilirubin for enzyme activity.

at o og c rect con ugatehyperbilirubinemia (Neonatal cholestasis

It is caused by obstruction to the bile ow. Itis characterized by clinical triad of persistent jaundice, hepatomegaly and clay colored stool.

Do not forgetgns o ser ous ness: Lethargy, apnea, tachypnea Temperature instability Hepatosplenomegaly Persistent vomiting Persistent feeding difculty

Treatment of Neonatal Conjunctivitis1. Crystalline penicillin 50.000 units/Kg/day

I.V. in 3 divided doses X7 days.. Saline irrigations 4-5 times a day followed byTetracycline 1% OR Erthromycin 0.5% eyedrops 4-5 times a day X 2 weeks.

If not improved treat for Chlamydia

1. Erythromycin 10 mgm/kg orally Q.I.D X 14 days

2. Saline irrigation 4-5 times a day followed byetracycline 1% OR Erythromycin 0.5% eye

drops 4-5 times a day X 2 weeks.

Congenital AnomaliesCongenital anomalies can be detected by routine

Family physician

Pediatrician / Neonatologist

Figure 5: Diagram for Management of Neonatal Conjunctivitis


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neonatal care. Look for the orices and introducea nasogastric tube, a ryle or a thermometerinto the anus to diagnose atresia. Then look for

other anomalies allover every part of the body.Congenital anomalies can be associated with eachother.

Anomaly Detection Immediate intervention

Referral

(see referralguidelines)

any ser ous ancar ovascu ar anoma es

erent egrees o resp ratorystress; tac ypnea, retract on,

grunt ng cyanos s

ee neonata resusc tat on A

e t p an e t a ate enera neonata exam nat on - ncourage reast ee ng(spec a teats)

- em -upr g t pos t onur ng ee ng to avo

asp rat on

- urg ca

consu tat on

oana Atres a (c oseposter or nares)

ass a nasogastr c tu e n otnasa open ngs

- nsert an ora a rwayatera - cyanos s

A

Tracheoesophageal

stu a ( )

Chocking and frothy secretionur ng reast ee ng

on rme y a ure to passa nasogastric tube beyond

prox ma esop agus

- Suction of secretion

- top ee ng

- ea y oxygen ur ngre erra

A

ap ragmat c ern a cap o a omen

- m n s e a r entry on onec est s e

esp ratory stress

- use am u ag

ve oxygen

-Insert NGT forecompress on

A

mp a oce e ( ern ateoop o ntest ne ns e

um ca cor )

A mass n um ca cor not covere y s ncover t y a p ece o gauze

soa e n warm sa ne

A

astrosc s s ( ern ateoop o ntest ne t roug ae ect n a om na wa )

A mass n a om na wa not covere y s ncover t y a p ece o gauze

oa e n sa ne

A

mper orate Anus ass a t ermometer t roug anaor ce

A

ypospa as urve pen s w t a normameata open ng

c rcumc s e t e oy urg ca consu tat on

en ngomye oce e en ngea cyst w t sp na an ower ac

not covere y s ncover y a p ece o gauze

soa e n warm sa ne

- e or rone eep ng

urg ca consu tat on

Spina Bida

ccu ta (a var ant omen ngomye oce e)

Hair tuft, lipoma or a dimple

over y ng sp na cor ( mp esn coccygea reg on are nots gn cant )

Surgical consultation

Congenita Hip Dis ocation - Bar ows test- Ortolani test- Abduction test

Keep ower im s inbduction position byouble pampers

rt ope iconsultation

Do not forget

Look for the orices to diagnose atresia.

Referral Guidelines for the NeonateTransport Personnel

Transport personnel should be fully skilled inhe care of the high-risk neonate and trained in

neonatal resuscitation. The personnel may includea physician, neonatal nurse and specially trainedtransport technician.

Transport Vehicle and Equipmentn am u ance s ou e prepare w t

t e o ow ng: Transport incubator

Table: 3 Common Neonatal Life Threatening anomalies


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Monitorso Heart rateo Respiratory rate

o Temperatureo Blood pressureo Inspired oxygen concentrationo Oxygen saturation

Oxygen delivery system (cylinder, regulatorand tubing)

Intravascular infusion equipmento Cannulae (sizes 22, 24)o Syringes (sizes 2.5, 3, 5, 10, 20 and 50 cc)o IV infusion setso Adhesive tape

o Alcohol swabso Gauze Suction equipment

o Bulb syringeo Mechanical suctiono Suction catheters (size 6, 8 and 10)

Medications for resuscitationo Epinephrineo Sodium bicarbonate 8.4% ampuleso Volume expanders (Ringers or saline)o Sterile water

Equipment for intubationo Laryngoscope (straight blades size 0 and 1)o Extra bulbs and batteries for laryngoscopeo Endotracheal tubes (size 2.5, 3 and 3.5

mm internal diameter)o Ambu bag with cushioned rim mask

Other equipmento Stethoscopeo Oral airways (size 0 and 00)

Assisted ventilation equipment if available Records of each transport should include the

complete prenatal history, delivery recordand Apgar scores from the hospital of originand the transport form.

Achieving SuccessfulResuscitation and Transport

All personnel in the transport team should betrained in neonatal resuscitation.

All necessary equipment should be availableand working.

Do not wait for the one (1) minute Apgar scoreto start resuscitation; the later you begin, themore difcult resuscitation will be.

The neonate should be dried to prevent heatloss and properly positioned to maintain anopen airway.

The upper airway should be cleared by usinga bulb syringe; suctioning the mouth f irst andthen the nose.

Place the neonate in the incubator to minimizeheat loss.

Do not forget

Do not wait for the one (1) minute Apgar scoreto start resuscitation; Communication with thereferral hospital should be done prior transportto ensure a place for the mother and neonate

Early Detection of CongenitalHypothyroidism (CH)

Early detection of Congenital hypothyroidismis very important to avoid mental and physicalretardation resulted from the untreated CH.

Routine neonatal screening is done between the

3rd and 7th day of birth.

Do not forget

Early detection of Congenital hypothyroidismis very important to avoid mental and physicalretardation

he nurse is responsible to take a blood samplefrom the newborn on a lter paper by a heel prick.

Samples are collected on Saturday anduesday of each week

They are sent to the Health Directorate on the

same day of collection Samples are sent to the Central Lab next day Positive cases are referred to Health insurance

to conrm diagnosis and provide treatmentand follow up.

ReferThe FHU will ensure continuity oftreatment through counseling and regularchecking during child health care

e erences; entra A m. or , pro ect A ; ( une, ), eonata are rotoco s or ys c ans

; ompre ens ve ssent a stetr c are: rotoco or ys c ans; as c ssent a stetr c are: ow arts or ys c ans

; as c ssent a stetr c are: rotoco or ys c ansOHP , Sector for Technical Support and Projects, Human Resource General Department (March, 2005); Introduction to Family Medicinera n ng rogram or am y ys c anso erty et a , : anua o eonata are

t ona re erence: " "


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4

CHILD HEALTH


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Child Health

CHILD HEALTHn er , on tor ng o rowt

an eve opment

Optimum Health is a right for allEgyptian children

The Goal of Child Health is to have a healthyfuture generation

The a m of child health is to ensure that everychild, whenever possible, lives and grows in afamily unit, with love and security, in healthysurroundings, receives adequate nourishment,

ealth supervision, and efcient medical care,

and taught the elements of healthy living (WHO&UNICEF, 1993)

The FHU actively participate in fulf illingthe rights of children (and youth)

To opt m ze the health o our young and todevelop our human resources, every infant / childmust be granted

The right to be wanted

The right to be healthy

The right to live in a healthy environment The right to satisfaction of basic needs

The right to continuous loving care

The right to acquire the intellectual andemotional skills necessary to achieveindividual aspirations and to cope effectivelyin our society

To achieve optimum health for ourchildren the FHU should implementcomprehensive bio-psycho-social care

at the level of the individual, the family,and the community

Components of Child HealthProgramme in the FHU:

Registration and record keeping

Periodic examination, including growth anddevelopment monitoring

Health education

Nutrition care

Immunization

Management of sick children / IMCI

Referral as needed

Out-reach programme Social care

RegistrationEvery newborn is issued a Health Card (Blue for

the boys and Pink for the girls). This card is keptby the mother. S/he is added to the family folder:

In the family composition table and

An under 5 periodic checkup form (attached)

Periodic Examination:Examination of the child starts by the neonatal

check It is then followed by periodic examinationat the FHU. According to the form in the familyhealth folder the child is examined at 2, 4, 6, 9,12, 18, 24, 36, 48 & 60 months. At risk childrenare examined earlier if pre-term or subjected tohazards during delivery, or more frequently asneeded- if they belong to an at-risk group.

t-risk approach: there is standard care forall individuals, and more care to those in needaccording to the need

At-risk children:Fam ly actors as low socio-economic standard

and illiterate parents; bad housing conditions,large family size; repeated infant and child deathin the family; one parent child; other.

Maternal actors as age(teen age and theelderly); maternal health; complications duringpregnancy; difcult labor; other.

h ld actors as unwanted child; preterm (


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Periodic examination includes two maincomponen s

Growth and development monitoring:These are basic screening tools to detect earlydeviation from good nutrition or good health.

Full cl n cal and laboratory exam nat onto identify the nature of the problem.

Children do not all grow or develop at the samepace; however, there is a normal range to varywithin. Some babies may be taller or heavier thanothers and they are both normal. Again a mothermay get worried because the older daughter startedo talk much earlier than the present brother, butsually both are normal.

Clinical examination should include systematicexamination of the child from head to toe, detectionof any congenital abnormalities, examine for hearingand vision to detect any abnormalities early in life.

Growth MonitoringGrowth monitoring means follow-up of growth

by repeated measurements to assess whether theRATE of growth is within normal limits or not, inorder to detect early deviations from normal.

Steps for growth monitoring:1. Anthropometrical measurements

. Plotting the growth chart

3. Interpretation of the growth curve to detectfalters

. If there is deviation from normal, investigatethe cause

5. Management to treat or correct the cause6. More frequent monitoring until the child is

back to normal rate of growth.nthropometr cal measurements include

weight, length/height, and head circumference.

uggested frequency for anthropometricalmeasurements

Table.4: Anthropometrics Measurements

Weight Length/heightHead

circumference rst year

econ year

r year

years

ont y

very m

very m

very m

very m

very m

very m

ear y

ont y

very m t 1 m

For simplicity the child is checked when he iscoming for vaccination and during the month of

his/her birthday (This will conform with the datespresented in the follow-up form)

ample of Growth curves for height and headcircumference can be kept in the unit as a guide,not for every child

The growth chart: now present in the familyfolder, child health record is a standard deviationchart showing the range between two linespresenting -2 SD and +2 SD. Weight is plottedagainst age.

Weighting the child: Adjust the balance andweigh the child with no clothes (if with minimumclothes, subtract the estimated weight of the

clothes from the measured weight)ge calculat on: For easy calculation of the age

complete the growth chart to be used as a personalcalendar for child. On the f irst visit, the f irst box atthe age axis is f illed by the name of the month ofbirth e.g. September 2004, the agenda for the childis then completed by f illing the boxes sequentially(Oct., November,). When you reach Januarymark 2005, and continue. When the child comesfor monitoring, the weight is plotted against thedate of examination; the age of the child could be

immediately read from the growth chart.Interpretation of the growth chart: The

weight curve for the child is expected to go parallelto the curve to indicate acceptable growth. Anydeviations should be detected. If the monitoring isdone according to the recommended schedule, theMCH should be able to detect early falters beforethey reach the level of malnutrition. Deviations canbe due to inadequate nutrition, an acute disease,a chronic disease, emotional upset, etc. Clinicalexamination and investigation to nd and correctthe cause and correct it, is very important.

Remember: Growth falters shouldbe monitored more frequently untilthey are back to normal rate of growth

Developmental ScreeningNormal development is simply checked by

developmental milestones. Rapid assessmentis done with every visit. Suspected deviationshould be referred to the pediatrician for morecomprehensive evaluation.

pecic developmental achievements to be

Note


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Promotion of breast feeding

When breast feeding is the social

norm in a community, most mothersill succeed in breast feeding.

Support for breast feeding practically startsduring antenatal care.

Preparation of the breast and nipples is doneduring the last trimester, specially in caseof retracted nipple. (See breast care in theantenatal care section)

Inform the mother about:o the importance and benets of lactation

for herself and the baby,

o the importance of initiating lactationvery early after delivery as soon as thecondition of the mother and the babyallows and not later than one hour,

o the importance of feeding on demand,day and night.

Teach the mother the correct posture forholding the baby, and how to achieve mother/ child bonding.

After birth the child is kept with the motherin the same room.

Exclusive breast feeding should be practicedfor the f irst 4-6 months, guided by growthmonitoring of the child. It can be continuedfor two years; however, care should be givento provide the infant with appropriate diet tomaintain growth.

WeaningWeaning is a gradual process. It starts by

introducing new foods and ends by stopping breastfeeding.

Principles for weaningee also IMCI page 18&19

Introduce new foods one at a time.

Start with a small quantity and increasegradually.

Give the new food when the baby is hungrybefore the breast feed; when s/he gets used

to the food give it after the breast feed totake advantage of suckling of a hungry baby

which stimulated lactation.

In the f irst 6 months all food has to be in asemi-liquid form to be directly swallowed.From 6-9 months food has to be nely mashed

radually changing to coarsely mashed by 9-11 months. At the age of one year the childcan eat solid food from the family table,provided it is not spicy.

Foods can start with fruit juices, pureedvegetables, egg yolk after 6 months, wholeegg by one year, beans & rice by 6 months,meat by 9 months. Yogurt can be given earlyif needed. With decrease in breast feedingand after cessation of lactation the baby needs

to have an external source of milk or milkproducts as cheese, yogurt, mehalabeya /pudding, etc. equivalent to liter of milk.

Care should be given to have good sources ofprotein.

By the age of three years the child can eat thenormal family diet provided that the wholefamily is having an adequate diet and isconsidering the needs of the different familymembers.

Immunization:A corner stone in child health care. Be sure to

have a 100% coverage by all the basic vaccines(see table)

Remember: Check for immunizationhenever the child is visiting the FHU

Make use of the immunization day to

- Promote/provide well baby careand health education

- Provide inter-conception care forthe mother

- Check the mothers for use ofcontraceptives for spacing

Conditions which are NOTcontraindications to immunization

1. Prematurity (Immunize at usual chronologicalage)

2. Recent infection such as otitis media

3. Penicillin allergy

4. Local reaction to previous vaccine

Note

Note


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5. Pregnant mother (e.g., of child gettingMMR)

6. Breast feeding mother (e.g., of child gettingOPV)

Child Late for Vaccination- Start an accelerated scheme immediately.

Follow the same sequence for polio and DPTwith 4 weeks apart (minimum time interval).

- Measles can be given with polio and DPT onthe same sitting, if the child is 9 months orolder.

- Hepatitis B follows the recommendedschedule: F irst dose, one month later second

dose, 2 - 6 months later third dose.- If the child has starte vaccination but is

late for the second or third dose (up to 12months), continue vaccination according ofthe minimum time interval of 4 weeks.

Do not forget

rue ontra n cat on to mmun zat on1. Anaphylactic reaction to a vaccine2. Seizure or fever > 40.5 C within 48 hr of

pertussis vaccine

3. True Egg Allergy (MMR)4. Neomycin allergy (MMR)

5. Immunocompromized patient (OPV)

6. Untreated moderate to severe illness +fever

Table. 6: National Compulsory Vaccination Schedule for Communicable DiseasesTargeting Infancy & Pre-School Children

Age of Infant/Child Type of Vaccine

At rt ero ose mmun zat on aga nst po o y ( ) ora po o vacc ne rops ontongue

1st contact o c w tea t aut or ty

mmun zat on aga nst tu ercu os s y ( .1 m ntra erma n ect one t s ou er)

n ont o age

1. mmun zat on aga nst po omye t s (1st ose) rops on tongue ( )

. mmun zat on aga nst p t er a, w oop ng coug an tetanus

(1st ose) e t t g3. Immunization against Hepatitis B 0.5ml intra-muscular injection into

e r g t t g .

t ont o age

1. mmun zat on aga nst po omye t s ( n ose) rops on tongue ( )

. mmun zat on aga nst p t er a, w oop ng coug an tetanus( n ose) e t t g

. mmun zat on aga nst epat t s .5m ntra-muscu ar n ect on ntot e r g t t g

t ont o age

1. mmun zat on aga nst po omye t s ( r ose) rops on tongue ( )

. mmun zaton aga nst p t er a, w oop ng coug an tetanus( r ose) e t t g

. mmun zat on aga nst epat t s .5m ntra-muscu ar n ect on ntot e r g t t g

t ont o age

1. Immunization against measles 0.5 ml subcutaneous injection in right

. tam n A apsu e 1 .

. mmun zat on aga nst po omye t s ( t ose) rops on tongue ( )

1 ont s o age

1. ooster ose o vacc ne aga nst po omye t s rops on tongue

. ooster ose o ( p t er a, ertuss s an etanus) .5 m ntra-muscu ar n ect on nto t e e t t g

. .5 m su cutaneous n ect on n t e r g t upper arm an (v tam nA capsu e) .

Remember

Children < 2 years should not have IM injections in the gluteal region.


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Table. 7: Vaccine Reactions

Vaccine reaction Action Counseling

A small red papule develops after- wee s, u cerates n anot er t ree

wee s, ea s eav ng a permanent

ap react on: A sma re papu eeve ops w t n ew ays n cates

prev ous sease or prev ousmmun zat on

oca severe react on w t no ympno es

Ax ary ymp no es

o react on

Normal reaction

e er

genera con t on s goo , notreatment s nee e except ry

ress ng o t e e s on

Refer for treatment

epeat vacc nat on

Tell the mother that this ist e norma react on

ee ear y me ca a v ce

- ee ear y me ca a v ce

- ee ear y me ca a v ce

- ec w t t e center n

t ree wee so not put any ress ng.

Oral polio

o react ons

If the child has diarrhea vaccinateas usua , an g ve an extra oseone mont a ter t e ast

Mild disease or diarrheas no contra n cat on tommun zat on

ever, ten erness, an n urat on ont e same ay

ery g ever or onvu s ons

we ng, n urat on an ever onewee or ater n cates a scessormat on

ve paracetamo

o not g ve t e pertuss s port onany more, g ve

e er

e uce ever

Bath with water just coolert an t e o y temperature tore uce temperature

ee ear y me ca a v ce

epat t s o react on

eas es

A most none w t t e presentvacc nes. ever an or meas eslike rash after one week

ve paracetamo eassure t e mot er

at w t water ust coo ert an t e o y temperature toreduce temperature

Cold Chain:Vaccines should be kept at the appropriate

emperature from the manufacturer until it is

sed.The FHU need to be care ul w th:

Proper packing of the refrigerator.

Proper transfer of vaccines from place toplace.

Vaccine carrying for house hold vaccination.

ac ng o t e e r gerator: To pack the refrigerator:

Do not put vaccine in the refrigerator

ntil the temperature inside it reach +80 C or less.

Note

1. Place polio and measles vaccine on the f irstshelf under the freezer and the rest of thevaccines on the second shelf.

2. Vaccines and diluents are stacked in rows.3. Clearly separate the different types of

vaccines.

4. Leave 1 - 2 cm between rows of vaccine topermit air circulation.

5. The newest vaccine should be placed on theright, so that when vaccine is removed youcan always take the oldest f irst by going fromleft to right.

6. DPT, DT and TT should not touch theevaporator plate at the back of the top shell ofthe refrigerator. They may freeze.

7. Vaccine should not be kept in the door


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8. Keep ice packs in the freezer.

9. Place containers of water in the bottom of therefrigerator.

10.Put a thermometer inside the refrigerator

11.Check the temperature of the refrigeratortwice every day (when start work in themorning and when you leave in the afternoon)and record it on the refrigerator temperaturechart.

acc ne o oxIs used to:

Transfer large quantities of vaccines from placeo place

Carry a vaccines for several days.

To pack:

Place fully frozen ice packs around theinside walls of the carrier.

Stack vaccine and diluents in thecarrier.

Put plastic foam or packing materialbetween the DPT vaccine and ice toprevent them from touching.

Place ice packs over the top of thevaccine and diluents.

Secure the lid tightly.

o pack vaccine carrier follow the same steps asthe cold box vaccine

Name of child --------------------DoB --------------

Child Health Screening Guide

Screening Test 2m 4m 6m 9m 12m 18m 24m 36m 48m 60m

History update

P ysica exam

Weig t

Lengt / eig tHea circum erence

Deve opmenta Ass

utr t on rev ew

Breast ee ing

Weaning & Diet

Eye & vision

Hearing screening

B oo pressure

Denta care

Hemog o in

Stoo (as nee e )

Urine (as nee e )

BCG ( e ore 3 m)

OPV

DPT

HBV

Meas es

MMR

Fami y Assessment

Socia Assessment

Progressive Healthgui ance

Figure 6: Form of Child Health Screening Guide


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Table. 8 Developmental Examination

Figure 7: Form of Growth Curve ( Arabic version )


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Gross Motor

Figure 8: Form for Neonatal and child follow up since birth ( Arabic Version)

Figure 9: Diagram for developmental Milestones since birth till under 5 years old Gross Motor (Arabic version)


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Fine Motor

Language

3

Figure10: Diagram for Developmental Milestones since birth till under 5 years old Fine Motor and Vision ( Arabic version )

Figure11: Diagram for Developmental Milestones since birth till under 5 years old Hearing & Language ( Arabic version )


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Social Behavior

PRINCIPLES OF PRESCRIBING INPEDIATRICS

According to British Pediatric AssociationChildhood is classied into:

1-Neonate: f irst THIRTY days of life.-Infant: from 1 month to TWO years.

3- Child: from 2 years to TWELVE years.- Adolescent:from 12 to 18 years.

Changes in response to drug therapy in this agegroup depends upon the following factors:

1. Changes in drugs pharmacokinetics.. Changes in drugs pharmacodynamics

3. Patient and guardian compliance.

Pharmacokinetic Aspectsbsorption:

rom :1. Gastric acidity:

- Established few hours after birthnormally,in preterm after four days.Itreaches adult value after TWO years.

So, Acid sensitive Penicillins e.g.(Ampici

llin,Amoxicillin) are absorbed more at thisage.Penicillin G can be used effectively andeconomically in preterms and neonates.

. IT enzymes and B le ac ds:

They are low up to FOUR months, so fat sol.

Vitamins and drugs are poorly absorbed.. astr c empty ng:

It is delayed for 6:8 hours in f irst day, itreaches adult value after SIX months.

. Per stals s:

It is irregular and slow, but increased indiarrhoeal conditions,with short transit timefor drugs in intestine.

From SKIN:Being delicate and thin, Good absorption of

drugs takes place,e.g.Corticosteroids,which maylead to Cushing disease.Topical Sulpha creamsmay cause Methemoglbinemia.

From Muscles&Subcutaneous routes:It is affected by the state of peripheral circulation,

which is affected in cases of shock, dehydration,etc..leading to decreased response early,with toxiceffects later.

his is commonly seen with Cardiac glycosides,Aminoglycosides, and Anti-epileptic drugs.

Muscle bulk is small in premature.It is a Painfulroute of admin., with hazards of introduction ofinfection to site of injections.

Figure 12: Diagram for Developmental Milestones since birth till under 5 years old - Social Behavior (Arabic version )


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D str but on:

Water is distributed in different compartmentsof the body as follows:

Table. 9: Water Distribution in DifferentBody Compartments

Preterm Full term Adult

Total B.water 5 7 :75 :

5

1

at 1- 1 -15 15

gn cance:

Water soluble drugs e.g. Aminoglycosidesare given in larger doses / Kg for preterm >term > Adults.

BBB is not well developed in pediatric age,sodrugs can pass easily to CNS.

Prote n B nd ng o Drugs:

It is low in young age groups, So, FREE partis high,may lead to toxicity.

e.g. with Diazepam,phenytoin, ampicillin,phenobarbitone.

Drugs compete with Bilirubin for albuminbinding, leading to Kernicterus,e.g.

ulphonamides. Bilirubin can displace drugs from their

protein binding, e.g. Phenytoin, leading totoxicity.

B otrans ormat on:

MFO(Mixed Function Oxidases) is only 50- 70 % of adult activity.

Glucuronidation reaches adult value at 3-4years. Thus Drug Clearance is reduced,andT1/2 is prolonged,leading to toxicity e.g.Chloramph enicol (Grey Baby Syndrome).

If mothers are receiving enzyme inducers e.g.phenobarbital the foetal enzymes developearlier.

This is useful in treatment of indirecthyperbilirubinemia in cases of Blood Groupsincompetability(RH- incompatibility).

Excret on :

GFR in neonates is 30-40% of adult value

in 1st day, 50-60% of adult value after onemonth, 100% after 6-12 months.

Thus, Renal clearance of drugs is Low inearly life,and doses must be reduced both indose and frequency. e.g.

Ampicillin in < 7 days neonates=50-100 mg/ Kg/d BID.

In > 7 days neonate =100-200 mg/Kg/d TDS.Gentamycin in < 7 days neonates-= 5mg/Kg/ d BID.

in > 7 days neonates = 7.5 mg/Kg/d TDS. Digoxin doses for this age group is very

difcult in absence of monitoring its plasmalevel(TDM).

Approximate half-lives of some drugs in

Neonates and adults:Table. 10: Half- Lives of some Drugs in

Neonate and Adults

Drug Neon.T1/2 Adult T1/2

Acetam nop en . -5 rs . - . rs

azepam 5-1 -5

gox n -7 -

a cy ate .5-11 1 -15

eop y ne 1 - 5-1

eno ar -

enyto n -

Pharmacodynam c spect

As adults,except for special features e.g. inPDA

- Indomethacin causes rapid closureof PDA, whether given to mother orneonate.

- PGE1 infusion to keep it open in TGA &Fallot tetralogy.

- PGE1 infusion causes antral hyperplasia,with gastric outlet obstruction inneonates.

Target organ sensitivity and pattern ofreceptors is not well developed in young age,e.g. B2 agonists in asthmatic children, versusspasmolytics.

Ped atr c Dosage orms: REMARKS to keep inmind with pediatric medications:

1. Sugar free forms are used for Diabeticchildren, and to prevent dental caries.

2. The sweetener ASPARTAME is avoided


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phenylalanine content.

3. Sorbitol and Glycerol -Sweeteners- maycause Diarrhoea.

. Lactose-as excipient-causes Diarrhoea inlactase deciency.

5. High osmolality infant feeding formulaecause Necrotizing Entero-colitis, and shouldbe avoided.

6. Dont add drugs to MILK or Juices, or FoodFormulae.

7. Remember that skin is thin and drugs can beabsorbed from it, giving systemic effects andside effects.

8. MDIs as anti asthmatic drug therapy isdifcult to apply for this age group.

9. Use of SPACERS, NEBULIZERS, andBreath activated devices e.g. Rotahalers,Diskhalers make it easier.

Ped atr c ompl ance n drug use

For better Compliance in drug use:

1. Palatable forms (Acceptable taste andodour).

. Use of Calibrated Spoons,Bottle capmeasures, or Syringes, for proper doseadministration.

3. The lesser the frequency, of administration,zthe better the patient compliance.

. Education of the parents especially themothers, about the dose, the frequency, andthe duration of treatment.

DOSE CALCULATION IN PEDIATRICSDoses are Calculated by:

AGE,or WEIGHT,or SURFACE AREA.

The best Golden RULE is to follow theManufacturers Dosage Schedule in the leaetinsert of the drugs.

Young s Formula age):

Child dose = Adult dose X age (years)/(age +12)

larke s Formula We ght )

Child dose= Adult dose X Weight (Kg) /60

Weight (Lb ) / 150

In children less than ONE year age,theyhave Large surface area,and to avoid

Overestimation of dosage,it is advisableto use weight in calculations,especially inoncology where surface area is widely used

in calculations. In obese children, calculate dose according to

Ideal Body weight,depending on age and height.

Using Surface area for calculation:- Body surface area = Square root of ( Height

(cm)XWt (Kg) / 3600)- Special Nomograms are available for

correlating weight,age, height and surfacearea.

Child dose = Adult dose X Childs S.A. / 1.73

Table.11: Determination of Drug Dosagefrom Surface Area

Weight(Kg) Age SA(m2) % of adultdose

ew orn .

mont s .

year .

5.5 y .

1

1 1.

5 1 1.5

a u t 1.7 1

7 a u t 1.7 1

Frequent Adverse drug reactions in infants andchildren beyond the neonatal period:

IT Nausea,Vomiting

many drugs

Diarrhoea AmpicillinMoniliasis Ampicillin

Stained teeth Tetracyclines

Blood BM depression Chloramphenicol &cytotoxics

Megaloblasticanemia

Phenytoin, Septrin

Skin Maculopap.rash

Ampicillin,Phenytoin

Urticaria Pen, Aspirin

V Bradycardia Digoxin

HTN teroids (evenLocal)


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Drowsiness Phenobarb,Carbamazepine,Anti - hist (1st Gen.)

Ataxia Phenytoin,Carbamazepine

Dyskinesia Metoclopramide,Domperidone

Metabol c Hypokalemia Frusemide,Thiazides

Hyperglycemia Thiazides, SteroidsCushingoid

yndromeSteroids

Raised liver

enzymes

NSAIDs, INH,

ParacetamolJaundice Hemolytic Aspirin, Sulpha,Vit.

K(W.sol)Cholestatic Macrolides, CPZ,

Amox.Clav.

DiscoloredUr ne

Rifampicin

Per natal drug hazards .e.Drugs

given to mothers affecting Neonates

Opiates Neonatal depression,Seizures.

Ethanol Foetal alcoholSyndrome

Barbiturates Neonatal dep, Enzymeinduction.

Phenothiazines Neonatal dep,Extrapyramidalmanifest.

Diazepam Neonatal depLorazepam Hypothermia

Lithium Goitre

minoglycosides Ototoxicity,Nephrotoxicity

etracyclines Teeth hypoplasia &discoloration, impairedfoetal bone growth.

ulphonamides Kernicterus, Hemolyticanemia

Chloroquine Retinopathy,Ototoxicity

Beta blockers Bradycardia

Reserpine Bradycardia, lethargy.

Androgens Virilization &Ambigious genitalia

Progestogens Virilization &Ambigious genitalia

Oestrogens Feminization, VaginalAdenocarcinoma inTeens

Iodides Euthyroid Goitre

Carbimazole Hypothyroid goitre.

Drugs in Breast Milk Affecting infants:

Phenobarb Drowsiness

PZ Drowsiness,?Cholestasis.

L th um Hypotonia,Hypothermia, Cyanosis

hlorphen ram ne, Ephedrine

Irritability,insomnia.

enna, ascara Diarrhoea

Aspirin.

Vitamin D injections (600,000 IU). Aminoglycosides as antibiotics.

Aminoglycosides(Streptomycin/Neomycin)in anti-diarrhoeal mixtures.

Halogenated Quinolines(Diiodo,or dichloroquinoline) in anti-diarrhoeal mixtures.

Dipyrone (Novalgin) and related drugs. Chloramphenicol as a routine antibiotic.

Diclofenac and related compounds asantipyretics.

MDIs misuse in asthmatic children.

Quinolones in Pediatrics and adolescents.

Cold preparations containing PPA. Cold preparations containing antihistaminics

(1st gen.) in Bronchitis.

Cough suppressants (anti - tussives) inproductive cough.


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Use of Ampicillin /Sulbactam vials afterdissolution. {5-8 hours}

Anti-amoebic mixtures dosing.

Topical use of steroids.

Use of steroids in Chicken pox (Topically orystemically).

Herbal products misuse without EB, e.g:Nigella sativa, Echinacea,Badly stored seedsof Anise, Carawy, etc.

Drugs avoided in G.6.P.D. deciency Sulphonamides & their combinations. Chloramephnicol

PAS (Anti-TB)

Nitrofurantoin Pyrimethamine,proguanil,primaquine.

Aspirin.

Water soluble vitamin K. Novalgin

o how can you prevent your ch ld

rom be ng n ured by med cal errors

The most important thing is to nd a

Pediatrician that you know and trust.

Learn about your childs illness, especiallyif it is a chronic condition, like asthma ordiabetes.

Ask questions about your childsprescriptions.

Ask questions about medical treatments. Ask about potential side effects.

Be sure to mention your childs allergieseverytime your child is prescribed oradministered a medication.

Also mention your childs other medicalproblems.

And mention other medications your child is

taking, including herbal or over the countermedications, Ask about what symptoms to look for that

can mean your childs illness is worsening.

Seek a second opinion if you really thinkyour child isnt being cared for correctly.

e erences:, ect on or ec n ca upport ro ects, uman resources entra epartment ( arc 5); ntro uct on to am y e c ne

ra n ng rogram or am y ys c ans: ect on on e atr cs.OHP; WHO/CHD; UNICEF; USAID; ntegrate anagement o oo ness

, ector; A : gypt an A aptat on"

"


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INTEGRATED

MANAGEMENTOF CHILDHOOD

ILLNESS


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INTEGRATED MANAGEMENT OFCHILDHOOD ILLNESS

Integrated Management ofChildhood Illness

This manual is prepared by the MOHP supportedby WHO/CHD, UNICEF & USAID

The IMCI manual guides you in the managementof a sick child from birth to 5 years of age. F irst itstarts with the child 2 months to 5 years old then itdescribes how to deal with the younger infant upo 2 months.

The manual presents n ow charts and tablesow to

Assess, classify and identify treatment

Treat the child, and give follow-up care

Counsel the mother

The manual expla ns protocols oranagement and re erral

The topics covered for the 2m - 5 years childnclude:

Danger signs, cough, diarrhea

Sore throat, ear problems, fever, measles

Malnutrition and anemia

Immunization status, and Vit. Asupplement

Appropriate oral antibiotic

Teach mother to give oral drugs at home

Teach mother to treat local infections athome (eye infection, mouth ulcers, relievecough safely)

Treat a convulsing child

Treat wheezing,

Treat the child

Date post:	03-Jun-2018
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Practice Guidelines for Family Physicians Volume 1

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