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Ishara Ramkissoon

on 11 June 2015

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Transcript of The JOURNEY

In practice
The need for integrated care
Site visits
Moving from fragmented care to providing comprehensive comprehensive care of children

Meet, greet and seat
Create a safe space and establish rapport
Identify the link between maternal and child health

Maternal health and well being

Any physical/health problems?
HIV status
Any chronic conditions?
Screening for depression & anxiety

Maternal social risk factors
Biopsychosocial approach

Age of mother
Coping skills and support
Home circumstances
Relationship with the child's father
Financial concerns
Substances of abuse: alcohol, tobacco use, recreational drugs

Nutritional advice and support

What method of feeding is used? EBF vs. Formula feeds
Are there any problems with feeding?
BF at 14wks - RMR indicator
Is referral to the breast feeding sister necessary?
Vitamin A Supplementation & Deworming

At 6 months: 100 000 IU
From 12months - 5years: 200 000 IU
NB! Check RtHB and document
The consultation

Questionnaire developed
Visual aid reminder
Maternal Reproductive Health

Is the mother receiving any family planning currently?
Offer education and contraception if required
When last did she have a PAP Smear?

Growth Monitoring

Head circumference

NB! Documentation and interpretation in RTHB!
MDT: Refer to appropriate team member when deviated from the norm

Developmental Screening

Has the mother/caregiver noticed a problem?
Is referral to the OT necessary?

Refer to page 13 of RTHB

Are the immunizations up to date?
Are catch-ups necessary?
Is it recorded in the immunization register?


Does the child have any symptoms of illness?
Refer to page 28 of RtHB
Are any referrals necessary to the Multi-Disciplinary Team?
Social Worker
Occupational Therapist
Speech Therapist
Existing stationery -2012
Maternal health: breast exam, gynecological symptoms - identify limitations
No family planning included in template
Myth: Vitamin A can only be dispensed by a PN
Implementation by-in
Infrastructure - delay in moving to upgraded premises
Accountability/job requirements
Next Group

Explain & train the nurses
Defining the roles of each stage
Pilot study
In Practice

Regular review of system
Statistic recordings
1. Mash B (Ed) Handbook of Family Medicine (3rd edition) Cape Town: Oxford University Press
2. Mash B, Blitz J (Eds.) South African Family Practice Manual (2nd Edition) Cape Town: Van Schaik 2008
3. WHO: Division of Child Health, Integrated Management of Childhood Ilnesses
4. www.westerncape.gov.za
5. Literature: tripdatabase.com
6.Road to Health Booklet
7. PACK Guidelines: Western Cape Adult edition 2015
8. Lecture notes: Paediatric lectures, Family Medicine
Mother is Negative

When was the last test done?
Repeat rapid test every 3months after 6week visit
Mother is positive

Is she on ARV's? (adherence?)
If not, REFER!

PCR at 6weeks
PCR 6weeks after breastfeeding has stopped
Rapid Test at 9 and 18 months
PCR if child is <9months
Rapid Test if child is >9months
Co-Trimoxazole for all breastfeeding infants
Du Noon CHC
Michael Mpongwana CHC
Stake Holders involved
Occupational Therapist

Dr Janet Giddy, Dr Elmarie Malek, Dr Abi Blumenthal, Dr Kathy Murie, Dr Jonel vd Westhuizen, Dr Srini Govender
Community Based Workers
Health Promoters
Integrated care
Provides holistic care to both mother and child
One healthcare worker
Referrals where necessary
Reduces number of patients 'lost' to long waiting times etc.
Screening for all problems e.g. developmental delays, feeding problems, social .
Reduce maternal and childhood morbidity and mortality - Millennium Development Goals
Full transcript