Republic of the Philippines

Department of Health

July 30, 2008

DEPARTMENT CIRCULAR
No. 2008________

FOR:

THE UNDERSECRETARIES, ASSISTANT SECRETARIES, SECRETARY OF HEALTH FOR ARMM,

CHDs/BUREAU/SERVICE/PROGRAM/PROJECT DIRECTORS, MEDICAL CENTER & SPECIALTY
HOSPITAL CHIEFS, EXECUTIVE DIRECTOR OF THE NATIONAL NUTRITION COUNCIL, ASSOCIATION
OF DEANS OF PHILIPPINE COLLEGES OF NURSING (ADPCN Inc.), ASSOCIATION OF PHILIPPINE
SCHOOLS OG MIDWIFERY (APSOM) MEMBER SCHOOLS, ASSOCIATION OF PHILIPPINE MEDICAL
SCHOOLS, AND OTHERS CONCERNED.

SUBJECT:

TECHNICAL UPDATE ON THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

PROTOCOL.

Over the years since IMCI has been introduced, much has been learnt through the adaptation and
implementation processes in countries. The Department of Child and Adolescent Health and Development (CAH)
and other institutions have undertaken work to evaluate the evidence base for the technical guidelines of the IMCI
strategy. Research results have emerged and these results lead to the updating the technical guidelines on IMCI.
CAH conducted a series of meetings and in 2004 it was recommended that CAH finalize the IMCI updates on the
basis of the best available and country program feedback, prioritizing those updates most likely to reduce child
mortality.

The World Health Organization came up with document on IMCI Technical Updates entitled: “Technical
Updates of the Guidelines on Integrated Management of Childhood Illness, Evidence and Recommendations for
further Adaptations”, 2005. The adaptation of the recommendations underwent consultations with experts on child
health.

The technical updates were considered necessary for the following reasons:

• New knowledge becomes available through research into clinical management of childhood diseases.
Research results should be examined in a systematic manner to improve and update the IMCI guidelines.
• IMCI guidelines should be reviewed with regard to experiences and lessons learned through the adaptation
and implementation process.
• Implementation of IMCI has identified problems and questions, some of which have been addressed
through operational research in regions and countries.
• Since the development of the IMCI guidelines, the epidemiology of diseases has evolved and thus a revised
version has to accommodate and reflect these changes. For example, the prevalence of HIV/AIDS has
increased significantly over the last 10 years and specific aspects require updating in the context of IMCI.
The current technical update have compiled new evidence and recommended adaptation in the following six areas:

SICK CHILDREN AGED 2 MONTHS TO 59 MONTHS

Main Symptom 1- Cough or Difficult Breathing

• Three days antibiotic treatment of non-severe and severe pneumonia. Oral antibiotic for non-severe
pneumonia should be given for three (3) days instead of 5 days to sick children 2-59 months old. Shorter
courses of antibiotic were found to be equally effective as the five-day duration, reduces cost of treatment
in the addition to improving compliance and reduces the antimicrobial resistance in the community.

Injectable ampicillin plus injectable gentamicin is a better choice than injectable chloramphenicol of
severe pneumonia in children 2-59 months old of age. A pre-referral dose of 7.5mg/kg intramuscular
injection gentamicin and 60 mg/kg injection ampicillin can be used.

Use of amoxicillin and first line antibiotic and Cotrimoxazole as a second line antibiotic in the
treatment of pneumonia, very severe disease, ear problem is recommended.

Main Symptom 2 – Diarrhea

• Use of Reformulated Oral Rehydration Salts which should contain 75mEq/L, 75mmol/L glucose
concentration and has a total osmolarity of 245 mOsm/L.

Use of Zinc supplements for 10-14 days in the management of diarrhea. Zinc supplementation during
the episodes of acute diarrhea reduced the duration and severity of the episode. In addition, studies showed
that zinc supplementation given for 10-14 days lowered the incidence of diarrhea in the following 2-3
months. Inclusion of zinc in the management of diarrhea could prevent 300,000 children dying every year.

In the treatment of bloody diarrhea (Dysentery) Ciprofloxacin is the most appropriate drug in place
of Nalidixic acid which leads to rapid development of resistance. Ciprofloxacin is given in a dose of 15
mg/kg two times per day for three (3) days.

Giving of multivitamins and minerals (including Zinc) for 14 days is added in the treatment
protocol of PERSISTENT DIARRHEA in addition to continue feeding and follow-up.

Main Symptom 3 – Fever

• First line antibiotic for Malaria – Chloroquine, Primaquine, Sulfadoxine and Pyrimethamine.
Second line Antibiotic – Artemeter-Lumefantrine

Main Symptom 4 – Ear Problem

• Chronic ear infection to be treated with topical quinolone ear drops for at least two weeks in
addition to dry ear by wicking.

Oral Amoxicillin is first-line antibiotic for the management of acute ear infection and is given
two times a days for three (3) days. Even though antibiotics may provide a small benefit for acute
ear infection in children, oral amoxicillin plays an important role in reducing the risk of
mastoiditis.

Malnutrition and Anemia

 • Where available, MUAC (Mid-upper arm circumference) less than 110mm is now an
indicator for severe malnutrition. If MUAC is not available, look visible severe wasting.

Malnutrition and anemia presented in two separate algorithms

Use of WHO Growth standards instead of the international Reference Standard (explanation of
the WHO GPRS)

Management of severe malnutrition where referral is not possible, manage the child at the
health center.

If the child has no appetite, a modified milk diet is give. This is made by dried skimmed milk
(DSM) sugar and oil.
Mix: 25g dried skimmed milk
70g sugar
35g rice flour
27g oil and some water
Boil: 5-7 minutes
Allow to cool and then add 20 ml WHO vitamin mineral for severe malnutrition and mix again.

Make up the volume to 1,000ml by adding previously boiled water.

Feed for a few days 11ml/kg every 2 hours.

Once appetite is restored, a diet with 80g dried skimmed milk, 50g sugar and 60g of oil is
prepared. Add water up to 1000ml and 20ml WHO mineral and vitamin solution. Increase
progressively the feeds up to 200ml/kg in 6 feeds (30ml/kg every 4 hours adjusted to the child’s
appetite).

New Immunization Schedule:

Age Vaccine
Birth BCG HepB1
6 weeks OPV1 HepB2 DPT1
10 weeks OPV2 _____ DPT2
14 weeks OPV3 HepB3 DPT3
9 months Measles

VITAMIN A Capsule Distribution Schedule:

PROPHYLAXIS;

Give first dose at age 6 moths or above; give subsequent dose every 6 months.

TREATMENT: for nightblindness, bitot’s spot, xeropthalmia, corneal xerosis

Give 1 capsule today

Give 1 capsule tomorrow
Give 1 capsule 2 weeks after, subsequent dose after 6 months, then follow the every six months
dose.
Routine Worm Treatment
Give every child Mebendazole/Albendazole every 6 months from the age of one (1) year.

SICK YOUNG INFANT AGED UP TO 2 MONTHS

The first symptom to manage among sick young infants, check for possible bacterial infection was
changed to check to very severe diseases and local bacterial infection and the signs to look for in the
assessment of this symptom was reduced from 12 to 7 signs.

The seven signs include: not feeding well, or convulsion, or fast breathing (60bpm or more), or
severe chest indrawing, or fever (37.5 C or above), or low body temperature (less than 35.5 C), or
movement only when stimulated, or no movement at all.

The new classifications include: Very sever disease (pink), Sever disease (yellow), Sever disease or
local bacterial infection unlikely (green).

Checking for JAUNDICE is added in protocol for Sick Young Infant aged up to 2 months.
Classifications include SEVERE JAUNDICE (pink row), JAUNDICE (yellow row) and NO
JAUNDICE (green row).

UPDATES ON INFANT FEEDING

HIV and Infant Feeding

In areas where HIV is public health problem all women should be encouraged to receive HIV
testing and counseling. If a woman is HIV infected and replacement feeding is acceptable,
feasible, affordable, sustainable and safe for her and her infant, avoidance of all
breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during
the first 6 months of life.

Infant and Young Child Feeding Policy

Early initiation of breastfeeding within the first hour of life;

Exclusive breastfeeding up to six months;
Addition of safe, adequate complementary foods at age 6 completed months while;
Continuing breastfeeding up to 2 years and beyond.

The updates in the IMCI protocol will be disseminated to all concerned including the academe
now integrating IMCI in the curriculum through organized meetings, for a, or as a “rider agenda” to
scheduled symposia, workshops, training, LGU meetings/sessions. Updated IMCI training materials will
also be developed and distributed to the different stakeholders on IMCI.

Please be guided accordingly.

By the Authority of the Secretary of Health:

MARIO C. VILLAVERDE, M.D., MPH, MPM, CESO II

Undersecretary of Health