imci 110925054333-phpapp02

INTEGRATED

MANAGEMENT OF

CHILDHOOD ILLNESS

TCAP CHN 2

CURRENT HEALTH SITUATION

1.Increasing number

of childhood deaths

2.Poor situation in

First-Level Health

Facilities

4

Distribution of 10.5 million deaths among

children less than 5 years old in all

developing countries, 1999

Malaria

Diarrhea

Measles

Pneumonia

Perinatal

OTHERS

Undernutrition

54%

5

Causes of Deaths among Children

Under Five Years Old

Top T en Lead ing C ause o f U nderf ive M ort alit y

2 0 0 0 Philipp ine Healt h St at ist ics

7.6

8.310.6

11.516.8

22.724.2

30.431.7

51.6

0 10 20 30 40 50 60

perinat al causes

malignant neoplasmcongeninit al anomalies

meningit isdiarrhea

nut r it ional disordersmeasles

sept icemiaaccident s

pneumonia

no. of Underive Deat hs Per 1000LB

Source: 2000 Philippine Health Statistics

7

Rationale for IMCI

Features of IMCI…

•not necessarily

dependent on the use of

sophisticated and

expensive technologies

8

Rationale for IMCI

Features of IMCI…

•a more integrated

approach to

managing sick

children

9

Rationale for IMCI

Features of IMCI…

•careful and systematic

assessment of common

symptoms and specific

clinical signs to guide

rational and effective

actions

10

Rationale for IMCI

Features of IMCI…

• integrates management of most

common childhood problems

(pneumonia, diarrhea, measles,

malaria, dengue hemorrhagic

fever, malnutrition and anemia,

ear problems)

11

Rationale for IMCI

Features of IMCI…

•includes preventive

interventions

12

Rationale for IMCI

Features of IMCI…

•adjusts curative

interventions to the

capacity and functions

of the health system

13

Rationale for IMCI

Features of IMCI…

•involves family members

and the community in

the health care process

14

Objectives of IMCI

(1) reduce deaths and the

frequency and severity of

illness and disability; and

(2) contribute to improved

growth and development

IMCI Case Management

Danger signs (CANS)Main Symptoms (CDEF)Nutritional statusImmunization statusOther problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

TreatmentCounsel & Follow-up

ASK:PVA

16

Target Groups

• Sick young infant

▫ 1 week up to 2 months

• Sick young children

▫ 2 months up to 5 years

IMCI Booklet

THE SICK CHILD

AGE: 2 MONTHS UP TO 5

YEARS

PART I

Check all sick children for general danger signs

REMEMBER:

C - CONVULSIONS

A – ABNORMALLY SLEEPY

N – NOT ABLE TO DRINK

S – (SEVERE) VOMITS EVERYTHING

Need to Refer(except in severe dehydration)

General

Danger

Signs

CHILD HAS A

SEVERE

PROBLEM.

DO NOT

DELAY

TREATMENT.

1

•Cough or difficulty in breathing

•Diarrhea

•Ear problem

•Fever

COUGH OR

DIFFICULTY IN

BREATHING

Cough or difficulty in breathing

Ask:

• For how long?

Look:

• Chest indrawing

• Stridor

• Count RR

The child must be calm.

FAST

BREATHING

AGE

≥ 60 breaths

/ min

< 2 months

≥ 50 breaths

/ min

2 – 12

months

≥ 40 breaths

/ min

1-5 years

28

Any general danger

sign or

Chest indrawing or

Stridor in calm

child.

SEVERE

PNEUMONIA

OR VERY

SEVERE

DISEASE

Give first dose of an appropriate antibioticVitamin ABreastfeeding/sugar water

If wheezing give a trial of rapid acting

bronchodialator for three cycles EVERY 15 MIN before

classifying pneumonia

Refer URGENTLY to hospital.

Fast breathing PNEUMONIA

•Give oral antibiotic for 3 days

•If wheezing give a trial of rapid acting

bronchodialator three times before classifying

pneumonia

•Soothe the throat and relieve the cough with a

safe remedy

•If recurrent wheezing refer for an assessment

•If coughing for more than 30 days refer for

possible TB or asthma

•Advise the mother when to return immediately

•Follow-up in 2 days

•No signs of

pneumonia

or very severe

disease.

NO PNEUMONIA:

COUGH OR COLD

If coughing more than 30 days, refer TO HOSPITAL for

assessment.

Soothe the throat and relieve the cough with a safe

remedy.

Advise mother when to return immediately.

Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT

BREATHING

SIGNS CLASSIFY AS IDENTIFY TREATMENT

(Urgent pre-referral treatments are in bold

print.)

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

1st dose of antibiotic Vitamin A Bronchodilator Breastfeeding/sugar water URGENT REFERRAL

Any general danger sign or Chest indrawing or Stridor in a calm child

Fast breathing2 – 12 months old: ≥ 50/minute

1 year or older: ≥ 40/minute

PNEUMONIA

Antibiotic for 3 days Bronchodialator Safe remedy If recurrent wheezing refer for an assessment If coughing for more than 30 days refer for possible

TB or asthma Advise the mother when to return immediately Advise mother on danger signs Follow up in 2 days

NO PNEUMONIA: COUGH OR COLD

If cough ≥ 30 days , refer to hospital for assessment

Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement

No signs of pneumoniaor a very severe disease

DIARRHEA

Types of Diarrhea

•ACUTE DIARRHEA

•PERSISTENT

DIARRHEA

•DYSENTERY

ASSESS

AND

CLASSIFY

35

Checking the Main Symptoms

2. DIARRHEA

ASK

▫ How long?

▫ Is there blood in the stool

36


2. DIARRHEA

LOOK

▫ GENERAL CONDITION OF THE

CHILD

Restless or irritable

Abnormally sleepy or difficult to

awaken

Sunken eyes

38


2. DIARRHEA

LOOK

▫ OFFER FLUID

Not able to drink

Drinking poorly

Drinking eagerly, thirsty

39


2. DIARRHEA

LOOK

▫ PINCH SKIN

Very slowly

Slowly

immediately

ASSESS

AND

CLASSIFY

Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

SEVERE

SOME

NO

+DHN=

SPD

NDHN=

PD

44

Severe Dehydration

SEVERE DEHYDRATION

2 or more of the following:

Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly

Classify for dehydration

Plan C if no other severe classification Refer if with other severe disease BF or ORS along the way Give Tetracycline for cholera

if there is cholera in the area and the child is 2 years or more

46

Severe Dehydration

Treatment Plan C

To treat severe dehydration (IV fluid: pLRS)

Age Initial Phase Subsequent Phase

(30 ml/kg) (70 ml/kg)

Infants (<12 mos) 1 hour * 5 hours

Older children 30 minutes* 2½ hours

*Repeat once if radial pulse is still very weak or

imperceptible.

47

SOME DEHYDRATION

SOME DEHYDRATION

2 of the following:

Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly


Give ORS/ BF, food for some dehydration Plan B If with other severe disease, REFER Follow up in 5 days Advice when to return immediately

400-700200-400Amount

4-12 mos< 4 mosAge

Determine the amount (in ml) of Oresol to be given in 4 hours

= weight of the child (in kg) X 75, or if weight is unknown, use this chart.

Plan B: Treat some dehydration with ORS

900-1400700-900Amount

2-5 yrs12 mos-2 yrsAge

Determine the amount (in ml) of Oresol to be given in 4 hours

= weight of the child (in kg) X 75, or if weight is unknown, use this chart.

Plan B: Treat some dehydration with ORS

51

No Dehydration

NO DEHYDRATION

Not enough signs to classify as SEVERE DEHYDRATION orSOME DEHYDRATION


Give ORS, zinc and food to treat diarrhea at home

Plan A Follow up in 5 days Advise mother when to return immediately

Give extra fluid.

Plan A: Treat diarrhea at home

100 – 200 ml after each LBM2 -4 yrs

50 – 100 ml after each LBMUp to 2 yrs

Continue feeding.

Know when to return.

Persistent diarrhea: 14 days or more

• Treat dehydration before referral, unless with other severe disease

• Give Vitamin A

• Refer to hospital

+ Dehydration=severe persistent diarrhea

Persistent diarrhea: 14 days or more

• Advise regarding feeding

• Give Vitamin A

• Give vitamins and minerals including zinc for 14 days

• Follow up in 5 days

• Advise when to return immediately

No dehydration= persistent diarrhea

Blood in the stool = dysentery

• Oral antibiotic for shigella for 3 days (CIPROFLOXACIN)



57

• EXCEPTIONS:

If the child is less than 12 months old

or was dehydrated on the 1st

visit or

had measles within the last 3 months.

REFER TO HOSPITAL.

If fewer stools, less blood in stools,

less fever, less abdominal pain &

eating better, continue antibiotics.

Dysentery

58

• After 2 days:

Ask:

• if the child is dehydrated, treat

hydration.

• if the number of stools, amount

of stools, fever, abdominal pain

or eating is same or worse:

Change to 2nd

line antibiotics &

give for 5 days. Advise to return

in 2 days.

Dysentery

ASSESS

AND

CLASSIFY

Malaria risk?

Measles now or w/in last 3 mos

Dengue risk?

VSFD:M

MALARIA

F:M unlikely

VSFD

F: NM

N MRMR

SCM M:EMC MEASLES

S DHF F: DHF unlikely

62

Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk

Ask:

• Does the child live in a malaria

area?

• Has the child visited malaria area

in the past 4 weeks?

• If yes to either, obtain a blood

smear.

63



Then Ask:

For how long does the child has

fever?

If >7 days, has the fever been

present everyday?

Has the child had measles within

the last 3 months?

64



Look and Feel:

Look and feel for stiff

neck.

Look for runny nose

65



Look for signs of Measles:

• Generalized rash.

• One of these: cough, runny nose or

red eyes

Fever: Ask about malaria risk

• Residing in endemic area?OR:• Travel & overnight stay in endemic area, or

• Blood transfusion w/in past 6 month

67

Malaria Risk Areas

1. Palawan

2. Davao Oriental

3. Davao del Norte

4. Compostela

Valley

5. Tawi-tawi

6. Sulu

7. Agusan del Sur

8. Mindoro

Occidental

9. Kalinga Apayao

10. Agusan del Norte

11.Isabela

12.Cagayan

13.Quezon

14.Ifugao

15.Zamboanga del

Sur

16.Bukidnon

17.Misamis Oriental

18.Quirino

19.Mountain

Province

20.Basilan

Malaria risk +

• Blood smear

• Ask: Duration of fever?

Present everyday?

• Look: Stiff neck

Runny nose

Other signs of measles

Malaria risk + any general danger sign or stiff neck

• 1st dose of Quinine (under med. Supervision or if hospital is not accessible within 4 hours)

• 1st dose of antibiotic, Paracetamol

• Treat to prevent low blood sugar

• Send the blood smear with the patient

• Urgent referral

Very severe febrile disease/malaria

Malaria risk and + blood smear if no blood smear there should be

No runny nose, no measles, no other cause of fever

• Oral antimalarial

• Paracetamol


• > 7 days fever hospital for

assessment

Malaria

Malaria risk and - blood smear +runny nose or +measles or + other causes of fever

• Paracetamol for fever more than 38deg C



• > 7 days fever hospital for assessment

• Treat other causes of fever

Fever: Malaria Unlikely

• No malaria risk

Any general danger sign or stiff neck

• 1st dose of antibiotic

• Paracetamol for fever 38.5 deg above

• Treat for low blood sugar

• Urgent referral

Very severe febrile disease

• No malaria risk

No signs of severe febrile disease

• Paracetamol for fever more than 38deg C



• > 7 days fever hospital for assessment

• Treat other causes of fever

Fever: No malaria

75

If child has measles now or within the

last three months:

• Look

• For mouth ulcers. Are they deep

and extensive?

• For pus draining from the eyes

• Look for clouding of the cornea

Measles now or w/in last 3 monthsAny general danger sign orClouding of cornea orDeep or extensive mouth ulcers


• Vitamin A

• Apply tetracycline ointment if corneal clouding is present

• Urgent referral

Severe complicated measles

Measles now or w/in last 3 monthsPus draining from the eye orMouth ulcers

• Vitamin A

• Tetracycline eye ointment

• Gentian violet


• Advise mother when to return immediately

Measles with eye or Mouth complications

Measles now or w/in last 3 monthsNo other signs

• Vitamin A• Advise mother when to

return immediately

Measles

79

Then Ask:

• Has the child had any

bleeding from the nose

or gums or in the

vomitus or stools?

• Has the child had black

vomitus or stools?

• Has the child had

abdominal pain?

• Has the child been

vomiting?

Look and Feel:

• Look for bleeding from nose

or gums.

• Look for skin petechiae

• Feel for cold clammy

extremities.

• Slow capillary refill

If none of the above ASK or

LOOK and FEEL signs are

present and the child is 6

months or older and fever

present for more than 3

days.

Perform Torniquet Test.

Decide Dengue Risk: Yes or No

If Dengue Risk:

Slow capillary refill

• Indicates poor skin perfusion

• Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

Any of the danger sign or

Bleeding gums, nose, in vomitus or stools or

Black vomitus or stools or

Persistent abdominal pain or

Persistent vomiting or

Skin petechiae or

Cold and clammy skin or

Slow capillary refill or

Tourniquet test

SEVERE DENGUE

HEMORRHAGIC FEVER

• If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS

• Any other signs of bleeding Plan C

• Urgent referral

• Treat other cause of fever

• Do not give aspirin

No signs of severe DHF

• Follow up in 2 days• Advise mother when to

return immediately or when fever persist or sign of bleeding manifest

• Do not give aspirin

FEVER: Dengue Hemorrhagic Fever Unlikely

EAR PROBLEM

YES

NO

MALNUTRITION AND

ANEMIA

86


4. Ear problems

ASK

• Does the child have ear pain?

• Is there ear discharge?

▫ If yes, how long?

87


4. Ear problems

LOOK

• For pus draining from the ear

FEEL

• Tender swelling behind the

ear

Structure:

3 Divisions

1. external ear

2. middle ear

3. inner ear

Tympanic

membrane or

“ear drum”

4. EAR PROBLEM


• Paracetamol for pain

• Urgent referral

Mastoiditis

tender swelling behind ear

• Antibiotic for 5 days

• Paracetamol for pain

• DRY Wicking



Acute ear infection

Ear discharge < 14 days orEar pain

• Wicking

• Instill Quinolone otic drops for two weeks


• Advice the mother when to return immediately

Chronic ear infection

Ear discharge for 14 days or more

No ear pain or pus draining

from ears

No Ear Infection

•No additional treatment

•Advise mother when to return

immediately

CHECK FOR

MALNUTRITION AND

ANEMIA

ASSESS

AND

CLASSIFY

NUTRITIONAL

STATUS

If age up to 6 months and Visible severe wasting or Edema on both feetIf age 6 months and above and MUAC is less than 115 mm or has edema of both feet or severe muscle wasting


• Vitamin A

• Urgent referral

Severe malnutrition or severe anemia

Very low for weight

• Assess feeding and counsel mother regarding feeding recommendation and care for development

• Vitamin A



Very low weight

Not very low weight for age and no other sign of malnutrition


• If feeding becomes a problem, follow up in 5 days


Not very low weight

ASSESS

AND

CLASSIFY

ANEMIA

10

6

Check for Anemia

• Look for palmar pallor

▫ Severe palmar pallor

▫ Some palmar pallor

▫ No palmar pallor

107

Anemia

Conditions Predisposing to

Anemia

• infections

• hookworm and whipworm

infections

• malaria

108Children with Anemia

How to check for Anemia

SEVERE

PALMAR

PALLOR

NO

ANEMIA

SOME

PALMAR

PALLOR

ASSESS

AND

CLASSIFY

ANEMIA

CHECK FOR ANEMIA

SEVERE PALMAR PALLOR

• Refer urgently to hospital

Severe Anemia

SOME PALMAR PALLOR


• Give IRON

• Give ALBENDAZOLE/MEBENDAZOLE if child is 1 year or older and has not received a dose for previous 6 months



Anemia

NO PALMAR PALLOR

• If the child is less than 2 years old, assess feeding and counsel mother regarding feeding recommendation and care for development

• If feeding becomes a problem, follow up in 5 days


No Anemia

THE SICK YOUNG

INFANT

AGE:

1 WEEK UP TO 2

MONTHS

PART II

IMCI Case Management

Danger signs (CANS)Main Symptoms (BJDF)Nutritional statusImmunization statusOther problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

TreatmentCounsel & Follow-up

ASK:PVA

BACTERIAL INFECTION

117

Check for very severe disease

and local infection

ASK

• Is the infant having difficulty of

feeding?

• Had the infant have convulsions?

118


and local infection

LOOK, LISTEN

Count the breaths in one minute.

Repeat the count if more than 60 bpm.

Look for severe chest in -drawing.

Measure axillary temperature.

THE CHILD

MUST BE

CALM

119


and local infection

Look at the umbilicus. Is it red or draining pus?

Does the redness extend to the skin?

Look for skin pustules. Are there many or

severe pustules?

Look at the young infants' movements. Are they less than normal?

LOOK, LISTEN

120

Umbilicus with infection

Normal healing of umbilicus

123

normal dried umbilical stump

BACTERIAL INFECTION

Any of the followingNot feeding well or

convulsions orFast breathing 60 bpm or more

severe chest indrawingfever

low body tempMovement only when stimulated or no movement at all

• Give 1st dose of IM antibiotics


• Refer urgently

• Advise mother on how to keep infant warm on the way to the hospital

Very severe disease

Umbilicus red or draining pus orSkin pustules

• Give oral antibiotic

• Teach mother to treat local infection at home

• Advise the mother to give home care for the young infant

• Assess and counsel mother on care and development


Local Bacterial Infection

None of the signs of very severe disease or local bacterial infection

• Advise the mother to give home care for the young infant

• Assess and counsel the mother on care for development

Severe Disease or Local Infection UNLIKELY

ASSESS AND CLASSIFY

JAUNDICE

CHECK FOR JAUNDICE

•LOOK

▫ For yellow eyes or skin

▫ Look at palms and soles. Are

they yellow?

Any jaundice if age is less than 24 hours oryellow palms and soles at any age

• Refer urgently to hospital


• Advise how to keep the infant warm on the way to the hospital

Severe Jaundice

•Jaundice appearing after 24 hours of age andpalms and soles NOT yellow

• Advice the mother to give home care for young infant

• Advise to return immediately if palms and soles appear yellow

• If the young infant is older than 14 days, refer for assessment


• Follow up in 1 day

JAUNDICE

No jaundice


• Advice the mother to give home care for young infant

No jaundice

ASSESS

AND

CLASSIFY

DIARRHEA

CHECK FOR DIARRHEA

•ASK

▫For how long?

▫ Is there blood in the

stool?

CHECK FOR DIARRHEA

• Look and Feel

• Look at the young infant’s general condition

▫ Infant’s movement

Does the infant move on his/her own

Does the infant move only when stimulated then

stop

Does the infant not move at all

▫ Is the infant restless or irritable

▫ Look for sunken eyes

▫ Pinch the skin of the abdomen. Does it

goes back

Very slowly

Slowly

immediately

ASSESS

AND

CLASSIFY

DIARRHEA

Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

SEVERE

SOME

NO

SPD

Two of any of the following:Movement only when stimulated or no movement at all

sunken eyesskin pinch goes back very slowly

• If the infant does not have VERY SEVERE DISEASE, nor DYSENTERY, give fluid for severe dehydration or PLAN C

OR

• If the infant also has a VERE SEVERE DISEASE, SEVERE JAUNDICE OR DYSENTERY:

• Refer urgently to hospital, with mother giving frequent sips of ORS on the way

• Advise to continue breastfeeding

• Keep the infant warm

Severe Dehydration

•Two of the following signs:Restless or irritable

Sunken eyesSkin pinch goes back slowly

• Give fluid for some dehydration (PLAN B)

• If the infant also has a VERE SEVERE DISEASE, SEVERE JAUNDICE OR DYSENTERY:

• Refer urgently to hospital, with mother giving frequent sips of ORS on the way



SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration

• Give fluid to treat diarrhea at home (PLAN A)


NO DEHYDRATION

Diarrhea: Classify

Persistent diarrhea

Diarrhea lasting for 14 days or more

• If the young infant has dehydration, treat dehydration before referral, unless infant also has VERY SEVERE DISEASE

• Refer to Hospital

SEVERE,

PERSISTENT DIARRHEA

Diarrhea: Classify

Blood in the stool

Blood in the stool

• Refer urgently to Hospital, with mother giving frequent sips of ORS on the way


DYSENTERY

ASSESS

AND

CLASSIFY

FEEDING PROBLEM

LOW WEIGHT FOR AGE

149

Assess and Classify a Young Infant for

a Feeding Problem or Low Birth Weight

ASK:

•Is the infant breastfed?

▫If yes, how many times in a 24 hours?

•Does the infant usually receive any

other food or drink?

▫If yes, how often

▫What do you use to feed the infant?

150



LOOK:

•Determine the weight for age?

•Look for ulcers or white patches

in the mouth (oral thrush)

151



ASSESS BREASTFEEDING:

•Has the infant breastfed in the previous

hour?

▫Observe attachment

Not well attached

Good attachment

•Is the infant sucking effectively?

▫Slow, deep sucks, sometimes pausing

Not sucking effectively

Sucking effectively

Check for good attachment

• Chin touching the breast

• Mouth wide open

• Lower lip turned outward

• More areola above than below

Good Wrong

154

Problems Associated with Breastfeeding

• problems with attachment

• problems with sucking

• blocked nose

• ulcers or white patches in the mouth



ASSESS

AND

CLASSIFY

FEEDING PROBLEM

LOW WEIGHT FOR AGE

•Not well attached to the breast ORNot sucking effectively OR

Less than 8 breastfeeds in 24 hours ORReceives other foods or drinks OR

Low weight for ageThrush

FEEDING PROBLEM OR LOW WEIGHT FOR AGE

• If not able to attached well or not sucking effectively, teach correct positioning and attachment

• If feeding is less than 8 times a day, advised to increase frequency as often as the child wants night and day

• If giving other food and drinks, advise to reduce and counsel further regarding breastfeeding

• If not breastfeeding at all, counsel regarding breastfeeding or teach proper ways of preparing milk substitute

• Advise the mother how to feed and keep the low weight infant warm at home

• If with thrush, teach the mother how treat at home

• Advise to give home care

• Follow up any feeding problem or thrush in 2 days

• Follow up low weight for age in 14 days


Not low weight for age and no other signs of inadequate feeding


• Advise mother to give home care for the young infant

• Praise the mother for feeding the infant well

NO FEEDING PROBLEM

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant

When to return immediately

– Signs of any of the following:

– Breastfeeding or drinking poorly

– Becomes sicker

– Develops a fever

– Fast breathing

– Difficult breathing

– Blood in the stool

Follow-up care for the sick young infant

Follow-up in 2 days – on antibiotics for

local bacterial infection or dysentery

Follow-up in 2 days - with a feeding

problem or oral thrush

Follow-up in 14 days – with low weight

for age

If the child has: Return for follow-up in:

PNEUMONIA

DYSENTERY

MALARIA, if fever persists

FEVER—MALARIA UNLIKELY, if fever persists

MEASLES WITH EYE OR MOUTH

COMPLICATIONS

2 days

PERSISTENT DIARRHOEA ACUTE EAR

INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEM

ANY OTHER ILLNESS, if not improving

5 days

PALOR VERY 14 days

LOW WEIGHT FOR AGE 30 days

FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

imci 110925054333-phpapp02

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