For DIARRHOEA 1. New ORS (sodium 60) will be used in place of standard ORS (sodium 90) for children with diarrhea, including cholera.

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1 TECHNICAL UPDATES: The document lists the recommended changes in national IMCI treatment protocols. The summarized recommendations are listed first. The evidence and the implications for practice are listed in the pages that follow. Summary list of new recommendations For DIARRHOEA 1. New ORS (sodium 60) will be used in place of standard ORS (sodium 90) for children with diarrhea, including cholera. 2. Oral zinc 20mg per day for days (10mg/day if less than 6 months of age) will be added to the treatment of all children with diarrhea. 3. Oral Ciprofloxacin (15mg/kg bd for 3 days) will be first-line treatment for dysentery in place of cotrimoxazole or nalidixic acid. For EAR INFECTIONS 4. Chronic ear infection will be treated with ciprofloxacin ear drops for at least 2 weeks in addition to thorough dry wicking. For FEEDING 5. The IMCI protocol will include referral of underweight children to a supplementary feeding program if it exists in their district. For ACUTE RESPIRATORY INFECTION 6. The dose of oral amoxicillin for non-severe pneumonia will change to 25mg/kg twice daily instead of 15mg/kg three times a day. 7. Where referral of children with severe pneumonia is not possible and injection is not available, oral amoxicillin 45 mg/kg bd should be given for 5 days. 8. Wheeze will be included in the diagnostic part of the IMCI algorithm but management will be to refer all children with suspected wheeze to the doctor for further assessment and treatment. For FEVER / MALARIA In order to update the IMCI protocol in accordance with the new malaria protocol for Timor-Leste the following changes will be made:- 9. Wherever possible, children with fever will have a blood test for malaria parasites prior to commencing treatment. 1

2 10. Children older than 2 months with uncomplicated falciparum or mixed malaria infection will be treated with Artemether-Lumefantrine (Coartem TM). 11. Children older than 2 months with complicated malaria will be treated with artesunate suppository or, if artesunate is not available, intramuscular quinine and will be referred to hospital. Complicated malaria will need to be redefined using current IMCI signs (ie danger signs or malaria not improving on treatment). 12. Children less than 2 months of age with fever should be tested for malaria and, if positive, treated with artesunate or oral quinine. All children less than 2 months with fever require referral to hospital. 13. Children with fever and rapid-test negative will be treated with chloroquine. 14. Children with convulsions will be treated with anticonvulsants prior to referral. Children older than 2 months with convulsions will be treated with rectal diazepam. Children less than 2 months will be treated with intramuscular phenobarbitone. For DENGUE 15. Only children with fever for 2 or more days (and less than 7) will be assessed for dengue. 16. Children with classifications possible dengue or fever-maybe not dengue will be followed up DAILY (not every 2 days). 17. Follow-up of children with possible dengue should continue until the fever has resolved for 1-2 days or until another cause for fever is identified. 18. Specific return immediately signs for children with possible dengue or fevermaybe not dengue should be added to the other conditions in this section. The WHO report recommends including the signs child is sicker, bleeding, acute and severe abdominal pain and vomiting, weak or drowsy, refusing to eat, restless, altered behaviour, cold and clammy skin, no urine for 4-6 hours. 19. All children with possible dengue should also be reviewed by a doctor when one is present. These recommendations come from the Child Health Working Group, August

3 Diarrhoeal Disease There are 3 new recommendations for treatment of diarrhoeal disease. 1) Changing the formulation of oral rehydration solution (ORS). 2) Adding zinc to the routine treatment of diarrhea. 3) Changing the first line antibiotic for dysentery from nalidixic acid to ciprofloxacin. Changing the formulation of ORS The formulation of ORS has changed. The new solution new-ors contains less sodium than the standard formulation. Standard ORS contains 90mmol of sodium per litre; new ORS contains 75mmol per litre. The lower sodium content means the solution has lower osmolality (245 vs 311mosm/L) so the preparation is also called low osmolality ORS. Using the new ORS for diarrhea significantly reduces the amount of diarrhoea (20% reduction) and vomiting (30% reduction). It also reduces by 1/3 the number of children with diarrhea who need to be treated with intravenous fluids. New ORS is recommended for all diarrhea, including cholera, however children with acute severe malnutrition and diarrhea should still be treated with Resomal (sodium 60). Unicef is able to procure the new ORS. There are no forseen problems in the changeover. The dose is the same as for standard ORS. Standard ORS should be used until stock has run out. Zinc Trials in many countries have repeatedly demonstrated that treating children who have diarrhea with oral zinc (as well as ORS) reduces the duration and the severity of diarrhea. It also reduces the likelihood of recurrence of diarrhea in the following 3 months. Use of zinc also increases the use of ORS and reduces the community s use of antidiarrhoeals and antibiotics for diarrhea. Giving zinc for diarrhea is one of the key child survival interventions for achieving the MDG 4. Oral zinc 20mg per day for days (10mg/day if less than 6 months of age) will be added to all diarrhea treatment protocols. Unicef will procure the zinc. Health education will be developed to promote this new therapy. Ciprofloxacin as first line for bloody diarrhoea Current IMCI protocols for the treatment of dysentery (bloody diarrhea usually caused by Shigella) in Timor-Leste recommend using Cotrimoxazole (first choice) or Nalidixic acid (second choice). International research has found that Shigella is increasingly resistant to these antibiotics so the antibiotics are no longer effective. Ciprofloxacin is now recommended as first line treatment for children with dysentery. It is more effective than naladixic acid, it is less likely to result in resistance and it is now cheaper than naladixic acid. Previous concerns about ciprofloxacin causing joint problems have not been confirmed. For these reasons oral Ciprofloxacin (15mg/kg bd for 3 days) is now recommended as first-line treatment for dysentery even in areas where naladixic acid may still be effective. Ear Infections Review of evidence has found that children with chronic ear discharge (chronic suppurative otitis media) are best treated with dry wicking with gauze together with topical antibiotics; 30% more cases are cured than with dry wicking alone. Current IMCI 3

4 protocols recommend dry wicking only. Chronic ear infection should now be treated with ear drops for at least 2 weeks in addition to thorough dry wicking. Ciprofloxacin or ofloxacin are more effective than other drops currently available in Timor-Leste such as gentamicin. MOH will procure ciprofloxacin ear drops as they are not currently on the essential medicine list. Infant Feeding According to current the IMCI protocol, children who have clinical signs of severe malnutrition should be referred to hospital for further treatment (therapeutic feeding). Children who are underweight, but do not have these signs, are managed with vitamin A, counseling, iron and deworming and are reviewed again in one month. WHO now recommends that health facilities should provide outpatient therapeutic feeding for children with severe malnutrition if referral is not possible. The IMCI protocol should be updated to include referral of underweight children to a supplementary feeding program if it exists in their district. As outpatient therapeutic feeding (community therapeutic feeding) is still only in planning phase for pilot testing in one district it will not yet be included in the IMCI protocol. All efforts should be made to ensure children with severe malnutrition complete referral. Acute respiratory infection There are 3 new recommendations for the management of acute respiratory infection. 1. Changing the treatment regime for non-severe pneumonia. 2. Adding a treatment option for severe pneumonia where referral is not possible. 3. Including wheeze in the algorithm for assessing for respiratory signs. Changing the treatment regime for non-severe pneumonia Timor-Leste IMCI currently recommends cotrimoxazole (1 st line) and amoxicillin (2 nd line) as the treatment for non-severe pneumonia. Cotrimoxazole is given twice daily and amoxicillin is given three times daily. New studies have shown that twice daily treatment with oral amoxicillin (25mg/kg) is as effective as three times a day treatment (15mg/kg). The American Academy of Paediatrics also now recommends this new regime. It is recommended to change the dosage regimen for Amoxicillin for Timor- Leste because this will probably improve compliance. Adding a treatment option for non-severe pneumonia where referral is not possible. Current IMCI protocol manages children classified as having very severe pneumonia with an intramuscular injection of chloramphenicol and urgent referral. Sometimes parents are unwilling for their child to be referred. Other times referral is not possible. A recent multi-country study showed that treating children with severe pneumonia with high dose oral amoxicillin achieves comparable results to treating with injectable penicillin. Therefore WHO now recommends that where referral is difficult and injection is not available, oral amoxicillin 45 mg/kg bd should be given to children with severe pneumonia for 5 days. This recommendation will be included in the Timor-Leste IMCI but referral will still be the treatment of choice. Including wheeze in the algorithm for assessing for respiratory signs. Currently children with wheeze and fast breathing are classified as pneumonia because IMCI does not address wheeze. Children with wheeze are treated with antibiotics and 4

5 not with bronchodilators. WHO has now tested new IMCI algorithms including wheeze in several countries. The new algorithm dictates children with wheeze and fast breathing and / or lower chest indrawing are given a trial of ventolin before they are classified as pneumonia and prescribed antibiotics. Using the new algorithm WHO found that most children with wheeze responded well to the ventolin and were able to be sent home without antibiotic. They concluded that, using current IMCI algorithms, large numbers of children with wheeze are being incorrectly classified and treated as pneumonia. Therefore WHO now recommends that children with wheeze and fast breathing and / or lower chest indrawing should have a trial of rapid-acting bronchodilator (ventolin) before being classified as pneumonia and prescribed antibiotics. We recommend including wheeze in the Timor-Leste algorithm because wheeze is quite common. Making this change however is relatively difficult. Nurses will need significant training in how to correctly identify wheeze and how to distinguish between wheeze and stridor (a sign already in IMCI). New video resources will be needed. In order to make it easier for nurses to manage children with possible wheeze we recommend to include wheeze in the algorithm but management will be to refer all children with suspected wheeze to the doctor for further assessment and treatment. Fever / Malaria As malaria testing facilities have, until now, not been available outside of large hospitals, IMCI protocols in Timor-Leste recommend treating all children with fever, or a history of fever, with Chloroquine and Fansidar. In practice, if blood testing is available in the workplace, treatment is often only given if a child is slide positive, Chloroquine for P.vivax and Fansidar for P.falciparum. Due to widespread resistance to Chloroquine and Fansidar, WHO now recommends the new Artemisin-based combination drugs for the treatment of malaria. These drugs are much more effective than Chloroquine / Fansidar and they delay the development of resistance to other important drugs. Independent of the IMCI review, the Timor-Leste malaria protocol was recently updated in accordance with this new recommendation. Other important additions to the new protocol include treatment options for the young infant with malaria and pre-referral treatment for seizures complicating malaria. Coincident with introducing the new protocol the MOH/WHO plan that all health centres will have the capacity for laboratory confirmation of malaria via rapid testing and, at higher level centres, by microscopy. The Timor-Leste IMCI protocol will be updated in accordance with the new malaria protocol. The following changes will be made:- - Wherever possible, children with fever will have a blood test for malaria parasites prior to commencing treatment. If no facility exists for testing the child will either be referred for testing at a nearby centre or will be treated empirically. - Children older than 2 months with uncomplicated falciparum or mixed malaria infection will be treated with Artemether-Lumefantrine (Coartem TM). - Children older than 2 months with complicated malaria will be treated with artesunate suppository or, if artesunate is not available, intramuscular quinine and will be referred to hospital. For IMCI, complicated malaria will need to be redefined using current IMCI signs (ie danger signs or malaria not improving on treatment). 5

6 - Children less than 2 months of age with fever should be tested for malaria and, if positive, treated with artesunate or oral quinine. All children less than 2 months with fever require referral to hospital. - Children with fever and rapid-test negative will be treated with chloroquine. - Children with convulsions will be treated with anticonvulsants prior to referral. This is not currently included in Timor-Leste IMCI. Nurses will require training in the firstaid management of convulsions as well as in the administration of the drugs which will be added to the protocols. Children older than 2 months with convulsions will be treated with rectal diazepam. Children less than 2 months will be treated with intramuscular phenobarbitone. Intramuscular phenobarbitone will need to be added to the EML and will need to be procured. - Training in the malaria protocol for managing children less than 5 years old will be done in conjunction with IMCI facilitators. Dengue Some relatively minor changes and additions will be made to the dengue section of the IMCI algorithm in keeping with recommendations from a WHO technical review of dengue in Only children with fever for 2 or more days (and less than 7) should be included in the dengue section. - Children with classifications possible dengue or fever-maybe not dengue should be followed up DAILY (not every 2 days). Following children only every 2 days risks missing early signs that the child is deteriorating. - Follow-up of children with possible dengue should continue until the fever has resolved for 1-2 days or until another cause for fever is identified. - Specific return immediately signs for children with possible dengue or fever-maybe not dengue should be added to the other conditions in this section. The WHO report recommends including the signs child is sicker, bleeding, acute and severe abdominal pain and vomiting, weak or drowsy, refusing to eat, restless, altered behaviour, cold and clammy skin, no urine for 4-6 hours. - All children with possible dengue should also be reviewed by a doctor when one is present. 6