NLE Paediatric Nursing — Communicable & Infectious Diseases in Children (IMCI)Summary

Measles is caused by the measles virus and spreads by **airborne transmission**—highly contagious. The pathognomonic hallmark sign is **Koplik spots**: tiny bluish-white spots on a red base on the buccal mucosa (inside the cheeks), appearing **before the characteristic rash** and lasting 2–3 days. Clinically, the **3 C's** describe the prodromal phase: **Cough, Coryza (runny nose), and Conjunctivitis**, accompanied by high fever and photophobia. The rash appears 3–4 days after fever onset as a **red maculopapular rash spreading in a cephalocaudal pattern** (from face and hairline downward) and **fades in the same order**, often turning brownish. Key complication is **pneumonia** (the leading cause of measles death in children), plus otitis media and encephalitis. Management is supportive—fluids, antipyretics, rest, dim lights for photophobia, and **Vitamin A supplementation (given to all measles cases to reduce severity and mortality)**. **Airborne precautions** are mandatory. Prevention is through the **MMR vaccine** in the EPI.

Mumps is caused by the mumps virus and transmits via **droplet** spread. The hallmark sign is **painful bilateral or unilateral swelling of the parotid (salivary) glands**, with fever and pain exacerbated by chewing, swallowing, or sour/acidic foods. The swelling typically appears 1–2 days after fever onset. Serious complications include **orchitis** (testicular inflammation in post-pubertal males that can affect future fertility), oophoritis (in females), **meningitis**, and **permanent deafness**. Management is supportive: **analgesics and antipyretics, soft bland diet (avoid sour foods), and warm or cool compresses** to the parotid glands. **Droplet precautions** apply. Prevention is through the **MMR vaccine** in the EPI.

Varicella is caused by the varicella-zoster virus and transmits via **airborne and direct contact with vesicle fluid**—highly contagious. The hallmark is a **highly pruritic vesicular rash appearing in successive crops, so lesions are present in all stages simultaneously**: macules → papules → vesicles ('**dewdrops on a rose petal**') → crusts. Unlike measles (uniform stage), varicella lesions are polymorphous. The child is **contagious from 1–2 days before rash onset until ALL lesions have crusted over** (usually 1–2 weeks). Management includes **cool baths, calamine lotion, antihistamines, keeping nails short to prevent scratching and secondary bacterial infection, and acyclovir for immunocompromised/high-risk children**. **CRITICAL: Never give aspirin**—it increases the risk of **Reye's syndrome** (a life-threatening encephalopathy). Use paracetamol or ibuprofen for fever. **Airborne + contact precautions** are required. Prevention is through the **varicella vaccine** (not yet routine in all Philippine schedules but increasingly available).

Rubella is caused by the rubella virus and transmits via **droplet** spread. It is milder than measles. The hallmark is a **pink maculopapular rash starting on the face and spreading downward, lasting approximately 3 days**, often with **postauricular, occipital, and posterior cervical lymphadenopathy** and low-grade fever. The clinical presentation is usually mild in children. **The critical danger is NOT to the infected child but to the FETUS**: if a pregnant woman contracts rubella (especially in the first trimester), **Congenital Rubella Syndrome (CRS)** results—a devastating constellation including **cataracts, congenital heart defects (patent ductus arteriosus), sensorineural deafness, intellectual disability, growth restriction, and hepatosplenomegaly**. Management is supportive. **Infected children must be kept away from pregnant women.** Prevention is through the **MMR vaccine**—a critical strategy to protect pregnant women and prevent CRS.

Pertussis is caused by the bacterium *Bordetella pertussis* and transmits via **droplet** spread. It is vaccine-preventable through the **DPT or pentavalent vaccine** in the EPI. The hallmark is a distinctive **paroxysmal (sudden, severe) cough followed by a characteristic high-pitched inspiratory 'WHOOP' sound**, often accompanied by **post-tussive vomiting and cyanosis**. The disease has three clinical stages: (1) **catarrhal stage** (1–2 weeks)—mild upper respiratory symptoms; (2) **paroxysmal stage** (2–8 weeks or longer)—classic whooping cough; (3) recovery stage. **Pertussis is most dangerous in young infants** (<3 months), who may not produce the classic whoop and are at high risk of **apneic episodes (sudden breath-holding/cessation), seizures, and hypoxia** requiring hospitalization and intensive monitoring. Older children fare better. Complications include **pneumonia, atelectasis, seizures, encephalopathy, and death** (rare but serious in infants). Management includes **macrolide antibiotics: erythromycin, azithromycin, or clarithromycin** (shortens contagious period if given early); supportive care—gentle suctioning, oxygen, hydration, small frequent feeds, and monitoring for apnea. **Droplet precautions** are required. Prevention through the **pentavalent vaccine** in the EPI (given at 6, 10, 14 weeks) is the most effective strategy.

Diphtheria is caused by the bacterium *Corynebacterium diphtheriae* (a toxin-producing strain) and transmits via **droplet** spread. It is vaccine-preventable through the **DPT or pentavalent vaccine** in the EPI. The hallmark is a **thick greyish-white pseudomembrane covering the tonsils, pharynx, or larynx**, accompanied by sore throat, low-grade fever, and cervical lymphadenopathy with swelling ('**bull neck**' appearance). The membrane is adherent and does not bleed easily when attempts to remove it are made—**CRITICAL: never attempt to remove the membrane** (risk of bleeding and complete airway obstruction). The *Corynebacterium diphtheriae* toxin damages the heart (**myocarditis**—potentially fatal) and nerves (**neuritis**, causing cranial nerve palsies). Complications include **airway obstruction, myocarditis (arrhythmias, heart failure), and neuritis (especially affecting the soft palate and vocal cords)**. Management includes **immediate diphtheria antitoxin (specific antibody against the toxin) plus antibiotics** (penicillin G or erythromycin); **maintain strict bed rest** (cardiac risk from myocarditis); keep **emergency airway equipment at the bedside**; manage the airway carefully without disturbing the membrane; monitor cardiac status closely. **Droplet precautions** are mandatory. Prevention through the **pentavalent vaccine** in the EPI is highly effective.

Dengue is a vector-borne viral infection caused by dengue virus (4 serotypes: DENV 1–4) and transmitted by the **Aedes aegypti mosquito**—a **daytime biter** that breeds in **clean, stagnant water** (contrasting with *Anopheles* malaria mosquitoes that breed in dirty water and bite at night). Dengue is **endemic in the Philippines**, particularly during rainy seasons. Clinical presentation includes **high fever (often biphasic), severe headache, retro-orbital pain (pain behind the eyes), myalgia and arthralgia ('breakbone fever'—severe muscle/joint pain), and a rash** (often appearing as fever subsides). A positive **tourniquet test** (petechiae appearing after tourniquet pressure) suggests dengue. Dengue can progress to **severe dengue** with warning signs that require immediate referral: **severe abdominal pain, persistent vomiting, bleeding (gum bleeding, epistaxis, hemoptysis, melena), mucosal bleeding, restlessness or lethargy, and a sudden drop in temperature with cold, clammy skin**. Further progression leads to **dengue shock syndrome (DSS)** with plasma leakage, hypotension, and shock—a medical emergency. **Management is entirely supportive—there is NO specific antiviral.** The cornerstone is **fluid and electrolyte management** (prevent/correct dehydration and shock), monitor **platelets and hematocrit** (watch for bleeding/plasma leakage), and supportive care. **CRITICAL: Avoid aspirin and NSAIDs** (increase bleeding risk); use **paracetamol for fever**. Prevention follows the **DOH 4-S approach: Search and destroy breeding sites, Self-protection (insect repellent, long sleeves, window screens), Seek early consultation, Support fogging during outbreaks.** Community education on dengue prevention is a key nursing role.

Diarrheal disease is a leading cause of under-5 mortality in the Philippines, typically caused by **viral (rotavirus is major—vaccine available in EPI), bacterial, or parasitic pathogens** from contaminated food or water. The primary danger is **dehydration**—loss of fluids and electrolytes leading to hypovolemia, shock, and death if untreated. **IMCI and DOH protocols classify dehydration into three plans and prescribe management accordingly.** **PLAN A (No Dehydration):** Child has **normal skin turgor, normal eyes, drinks normally, urine output adequate**. Management: **home-based with extra fluids (ORS after each loose stool), zinc supplementation, continue normal feeding/breastfeeding, and maternal counseling**. **PLAN B (Some Dehydration):** Child shows **slightly reduced skin turgor, slightly sunken eyes, drinks eagerly, may have decreased urine**. Management: **supervised oral rehydration with low-osmolarity ORS at ~75 mL/kg body weight given over 4 hours at the health facility, then reassess**; give zinc; continue feeding. **PLAN C (Severe Dehydration):** Child has **very poor skin turgor (skin pinch goes back very slowly), very sunken eyes, unable to drink or drinks poorly, may be lethargic/unconscious**. Management: **IMMEDIATE IV fluid replacement** (e.g., Ringer's lactate or normal saline) to restore circulating volume, prevent shock, and correct electrolytes; then transition to ORS once oral intake is tolerated. **ORS + ZINC supplementation is the evidence-based cornerstone of diarrheal management.** **Low-osmolarity ORS** (WHO/UNICEF standard) is used in the Philippines—it reduces stool output and vomiting compared to older high-osmolarity formulations. **Zinc supplementation: 10 mg/day for infants <6 months, 20 mg/day for children 6 months–5 years, for 10–14 days**—reduces diarrhea duration and severity, and prevents future episodes. **CRITICAL: Continue feeding/breastfeeding throughout all plans**—do NOT withhold food (prolonged fasting worsens malnutrition and delays recovery). Counsel caregivers on **hand-washing, safe water, sanitation, and when to return immediately** (blood in stool, severe dehydration signs, persistent vomiting, fever >38.5°C, abdominal distension).

**IMCI** is a WHO/UNICEF/DOH strategy launched to reduce under-5 mortality by managing the **whole sick child** rather than isolated symptoms or diseases. It is the **primary framework for pediatric nursing at rural health units (RHUs), health centers, and primary-care facilities** in the Philippines. IMCI combines **assessment, classification, treatment, counseling, and follow-up** in a systematic, evidence-based manner. **Two age-specific assessment charts exist: (1) Young infant (1 week–2 months) and (2) Child (2 months–5 years).** The **assessment process** uses a standardized checklist to evaluate for **danger signs, main symptoms (cough/difficult breathing, diarrhea, fever, ear problems), nutritional status, anemia, immunization status, and feeding/breastfeeding.** After assessment, the nurse **classifies the child** using a **color-coded triage system: PINK (urgent—refer/hospitalize), YELLOW (needs specific treatment at the facility + home care), GREEN (home management with counseling and follow-up).** This color coding rapidly guides triage urgency. **General danger signs** (present in ANY sick child) that mandate **urgent referral** include: (1) **unable to drink or unable to breastfeed**, (2) **vomits everything**, (3) **convulsions or history of convulsions during this illness**, (4) **lethargic or unconscious** (abnormally sleepy, difficult to arouse). Any child with a danger sign is **PINK—refer urgently.** The nurse then **assesses the main symptoms** that affect under-5 mortality: **Cough or Difficult Breathing** (assess respiratory rate for fast breathing and chest indrawing—signs of pneumonia); **Diarrhea** (classify dehydration using Plans A/B/C); **Fever** (assess for malaria in endemic areas, measles, and dengue); **Ear Problem** (assess for infection/discharge). The nurse applies **fast-breathing thresholds specific to age**: <2 months **≥60 breaths/min**, 2–12 months **≥50 breaths/min**, 12 months–5 years **≥40 breaths/min**. **Chest indrawing (inward drawing of the lower chest wall during inspiration) classifies as severe pneumonia**—urgent referral required. Non-severe fast breathing (without chest indrawing) is classified as non-severe pneumonia—managed with **oral antibiotics (e.g., amoxicillin) and close home follow-up**. The nurse also **checks for malnutrition and anemia**, reviews **immunization status**, and assesses **feeding/breastfeeding** (attachment, technique, frequency). Finally, the nurse **counsels the caregiver** on home management, warning signs requiring immediate return/referral, medication administration, feeding, hygiene, and follow-up timing. **For the young infant (1 week–2 months)**, assessment is **different** because infants deteriorate rapidly and present differently. The chart checks for **possible serious bacterial infection or very severe disease, jaundice, diarrhea, umbilical cord issues, feeding problems, and low weight**. Danger signs in young infants include: **not feeding well, convulsions, fast breathing (≥60/min), severe chest indrawing, fever (≥37.5°C) or very low temperature (<35.5°C), movement only when stimulated or no movement, or severe skin pustules**—all warrant **urgent referral**. The nurse assesses **breastfeeding and attachment**, corrects feeding problems, and ensures the infant stays **warm during referral** (temperature maintenance is critical in young infants).

Correct application of **isolation precautions** prevents nosocomial (hospital-acquired) transmission of communicable diseases and protects vulnerable hospitalized children, staff, and visitors. **Standard Precautions** (hand hygiene, gloves, eye protection, gown) apply to all patients. **Transmission-based precautions** are added based on the suspected pathogen's transmission route. **Airborne Precautions** (for measles, varicella, tuberculosis) require: **negative-pressure room, N95/FFP2 mask for staff, visitors, and the patient during transport, and exclusion of susceptible persons**. **Measles and varicella are highly contagious by airborne route.** **Droplet Precautions** (for mumps, rubella, diphtheria, pertussis, meningitis) require: **private room or cohorting with same pathogen, surgical mask for staff/visitors within 1 meter, and respiratory hygiene (hand-hygiene after respiratory contact)**. **Contact Precautions** (for varicella vesicle fluid, skin infections) require: **gloves and gown, dedicated equipment (stethoscope, blood pressure cuff)**, and strict hand-hygiene. **Varicella uses both Airborne + Contact precautions.** The nurse must **know which precautions apply to each disease** and implement them consistently—critical for infection control and exam success.

**The Expanded Program on Immunization (EPI)** is the Philippine DOH's vaccine program that prevents major childhood communicable diseases through routine immunization. **EPI vaccines include: BCG (birth), Hepatitis B (birth), Pentavalent (DPT + Hib + Hep B at 6, 10, 14 weeks), OPV/IPV (polio at 6, 10, 14 weeks), Pneumococcal Conjugate Vaccine (PCV at 6, 10, 14 weeks, and booster at 12–15 months), Measles-containing vaccine (at 9 and 12 months—critical for rubella and measles prevention), and Rotavirus (in many schedules).** Through EPI, **measles, mumps, varicella (where available), pertussis, diphtheria, tetanus, polio, TB, hepatitis B, Hib, and pneumococcal disease are preventable.** **Guarantisadong Pambata (GP)** is a **biannual (twice-yearly) child-health package** delivered by RHUs to all children 12–59 months, providing: **(1) Vitamin A supplementation: 100,000 IU once for infants 6–11 months; 200,000 IU every 6 months for children 12–59 months; (2) Deworming (albendazole for helminth infections); (3) Immunization catch-up (for missed doses); (4) Health and nutrition education to caregivers.** **Vitamin A is also given in acute measles cases** (100,000 IU for children 6–11 months; 200,000 IU for children ≥12 months; a second dose the next day and a third dose 2 weeks later for severe/complicated measles)—this supplementation **reduces measles severity and mortality by ~50%**. Both EPI and GP are **foundational to Philippine child-health strategy** and reduce under-5 mortality.

Most communicable diseases discussed (measles, mumps, varicella, pertussis, diphtheria, rubella) are **vaccine-preventable through the Philippine EPI**. Measles and rubella prevention via MMR; pertussis, diphtheria, tetanus via pentavalent; varicella via varicella vaccine (where available). **High immunization coverage (>95%) in a community leads to herd immunity, protecting even unvaccinated individuals.** EPI adherence is the most effective prevention strategy for these diseases.

Each communicable disease has a specific **transmission route**—understanding it guides **correct isolation precautions.** Airborne diseases (measles, varicella) require N95 masks and negative-pressure rooms. Droplet diseases (mumps, rubella, diphtheria, pertussis) require surgical masks and private rooms. Varicella (airborne + contact) requires both. **Incorrect precautions allow nosocomial spread, endangering other patients and staff.** Infection control knowledge is inseparable from disease knowledge.

**IMCI diarrheal disease classification (Plans A/B/C) is based on dehydration severity, assessed by clinical signs: skin turgor, eye appearance, alertness, and drinking ability.** Plan A (no dehydration) = safe home ORS. Plan B (some dehydration) = facility ORS 75 mL/kg over 4 hours. Plan C (severe dehydration) = urgent IV fluids. **The degree of dehydration directly determines the site of care and urgency of referral.** Misclassification (e.g., treating severe dehydration at home with ORS alone) leads to shock and death. Correct assessment is life-saving.

IMCI assesses the febrile child by determining the **cause of fever: measles (rash + 3 C's), malaria (in endemic areas, splenomegaly, parasitemia), dengue (retro-orbital pain, myalgia, warning signs), or other.** Each cause requires different management. For example, **measles requires Vitamin A and airborne precautions; dengue requires supportive fluids and warning-sign monitoring; malaria requires specific antimalarials.** The same fever can have vastly different aetiologies—IMCI systematically differentiates them.

Each communicable disease carries specific, sometimes life-threatening complications: **Measles → pneumonia (leading cause of measles death); Diphtheria → myocarditis (arrhythmias, heart failure); Pertussis → apnea (infants); Dengue → dengue shock syndrome; Diarrhea → severe dehydration → hypovolemic shock.** Early recognition of **danger signs (IMCI) and warning signs (dengue) allows timely referral and treatment**, preventing progression to complications and death. **For example, recognizing chest indrawing in a child with fast breathing allows urgent referral for oxygen/antibiotics, preventing respiratory failure.** Conversely, missed danger signs lead to preventable deaths.

IMCI assessment includes **checking for malnutrition and anemia** and reviewing **immunization status**. Malnourished and anemic children have **weaker immune systems and are more susceptible to severe infections.** Similarly, **unvaccinated or incompletely vaccinated children are at high risk of communicable diseases.** **Garantisadong Pambata (Vitamin A supplementation and deworming) addresses malnutrition and helminth burden, improving immune function.** The relationship is bidirectional: good nutrition + vaccination → better infection outcomes; infection + malnutrition → worse outcomes.

IMCI emphasizes **caregiver counseling on home management, medication administration, feeding continuation, warning signs, and follow-up timing.** **Caregivers who understand the illness and management plan are more likely to adhere to treatment and recognize warning signs early.** For example, a caregiver counseled on **'continue breastfeeding during diarrhea'** will not withhold food (a harmful practice). A caregiver who knows **dengue warning signs (severe abdominal pain, vomiting, bleeding) will return immediately if they appear,** enabling urgent intervention. **Poor caregiver understanding leads to non-adherence, delayed care-seeking, and poor outcomes.**