Flip Chart: Integrated Management of Childhood Illness

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Facilitated by Moyo wa Bana Capacity Building Initiative through CARE with funding fron CIDA

World Health

Organisation

Integrated Management of Childhood Illnesses

April 2013

JOB AID


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Table of Contents

Recording Form for a Sick Child 2 Months to 5 Years.

o Good Home Care For Your Child

Recording Form for a Sick Young Infant age up to 2 Months.

o Good Posioning For Breaseeding

Charng and Abbreviaons in IMCI.o When to Return Immediately

Key on Abbreviaons Used in IMCI.

o Feeding Recommendaons During Sickness and Health.

Weight For Age.

o Boy

Boys Diagram.

o Girl

Girls Diagram.

This desk calenadr is for use by health care workers as a quick reference aid when aending to paents


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Recording form for a sick child young infant age up to 2 months

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS

Name: Age: Weight (kg): Temperature (C):Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?ASSESS (Circle all signs present) CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTIONIs the infant having difficulty in feeding?

Has the infant had convulsions?

Count the breaths in one minute. ___ breaths per minuteRepeat if elevated: ___ Fast breathing?

Look for sever chest indrawing.

Look and listen for grunting.

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

Fever (temperature 38C or above fells hot) orlow body temperature (below 35.5C or feels cool)

Look for skin pustules. Are there many or severe pustules?

Movement only when stimulated or no movement even whenstimulated?

DOES THE YOUNG INFANT HAVE

DIARRHOEA?

Look at the young infant's general condition. Does the infant:

move only when stimulated?

not move even when stimulated?

Is the infant restless and irritable?

Look for sunken eyes.

Pinch the skin of the abdomen. Does it go back:

Very slowly?

Slowly?

Yes ___ No ___

THEN CHECK FOR JAUNDICEWhen did the jaundice appear first? Look for jaundice (yellow eyes or skin)

Look at the young infant's palms and soles. Are they yellow?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

If the infant has no indication to refer urgently to hospital

Is there any difficulty feeding? Yes ___ No ___

Is the infant breastfed? Yes ___ No ___If yes, how many times in 24 hours? ___ times

Does the infant usually receive any other foods ordrinks? Yes ___ No ___If yes, how often?

What do you use to feed the child?

Determine weight for age. Low ___ Not low ___

Look for ulcers or white patches in the mouth (thrush).

ASSESS BREASTFEEDING

Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put herinfant to the breast. Observe the breastfeed for 4 minutes.

Is the infant able to attach? To check attachment, look for:

Chin touching breast: Yes ___ No ___

Mouth wide open: Yes ___ No ___

Lower lip turned outward: Yes ___ No ___

More areola above than below the mouth: Yes ___ No ___not well attached good attachment

Is the infant sucking effectively (that is, slow deep sucks, sometimespausing)?not suckingeffectively

sucking effectively

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for nextimmunization on:

________________(Date)

BCGOPV-0

DPT+HIb-HB-1OPV-1

DPT+HIb-HB-2OPV-2

Rota 1

Pneumo1

Rota 2

Pneumo2

200,000 I.U vitamin A to mother

50,000 I.U to non brest feeding infant from 6 weeks age.

ASSESS OTHER PROBLEMS: Ask about mother's own health


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Good positionPoor position

1. Hold baby close to her.

2. Face the baby to the breast.

3. Hold the babys body in astraight line with the head.

4. Support the babys whole body.

5. Make sure that the baby is well-

attached to the breast.

Mother should not squeeze the breast itself, for

example, with a scissors hold. Squeezing will

interfere with the flow of milk


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EXAMPLE OF CHARTING IN IMCI

1. Sex/Age: F 8/12

2. Bwt: 9Kg3. Temp.: 37.8C

7. P/S: Cough x 2/7

4. Fever x 2/7

5. NOS

6. No GDS

7. Cough x 2/7; B/min 54Pneumonia

8. CI; S; W F/up 2/7

9. Fever x 2/7; SN; RDT ve -

10. Malnutrion: VSW; OBF Not very low wt for age, &10. GF; Not VLWA No growth faltering

12. MUAC - green

13. Aneamia: PP No Anaemia

14. HIV/AIDs; Mother ve HIV infecon unlikely

15. Immunizaon up-todate

16. Measles vaccine at 9/12

17. No feeding problem

18. R/:Amoxicillin 125mg tds x 5/7

19. Sooth throat with safe remedy

20. F/up 2/7

21. Advised when to return immediately


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KEY ON ABBREVIATION USED IN IMCI

E. P/S Presenng symptoms

F. NOS No other symptoms

G. GDS General danger sign

H. B/min Breath per minute

I. CI No chest in-drawing

J. S No stridor

K. W No wheeze

L. F/up Follow up

M. SN No s neck

N. RDT Rapid diagnosc test

O. VSW No visible severe wasng

P. OBF No Oedema of both feet

Q. MUAC Mid-Upper Arm Circumference

R. GF No growth faltering

S. VLWA Very low weight for age;

T. PP No palmer pallor

U. PP+ Some palmer pallor

V. PP+++ Severe palmer pallor

W. R/ Treatment


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NOT FOR SALE


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NOT FOR SALE


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Assess and classify the sick child aged 2 months up to 5 years

ASSESS AND CLASSIFY

ASSESS CLASSIFY IDENTIFY TREATMENT

ASK THE MOTHER WHAT THE CHILD'S

PROBLEMS ARE

Determine if this is an initial or follow-up visit for thisproblem.

if follow-up visit, use the follow-up instructions

on TREAT THE CHILD chart.

if initial visit, assess the child as follows:

USE ALL BOXES THAT MATCH THE

CHILD'S SYMPTOMS AND PROBLEMS

TO CLASSIFY THE ILLNESS

CHECK FOR GENERAL DANGER SIGNS

Ask: Look :

Is the child able to drink or breastfeed?

Does the child vomit everything?

Has the child had convulsions?

See if the child is lethargic or unconscious.

Is the child convulsing now?

A child with any general danger sign needs URGENTattention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.


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Does the child have fever?

(by history or feels hot or temperature 37.5C* or above)

If yes:

Then ask: Look and feel:

For how long?If more than 7 days, has

fever been present every

day?

Has the child had measles

within the last 3 months?

Look or feel for stiff neck.Do Rapid Diagnostic Test

(RDT) or Microscopy if NO

general danger sign or

stiff neck. If malaria test is

negative look for other

causes of fever***

Look for signs of

MEASLES.

Generalized rash and

One of these: cough,

runny nose, or red

eyes.

Look for any other cause

of fever.

Any general danger sign

or

Stiff neck.

Pink:

VERY SEVERE

FEBRILE DISEASE

Give first dose of quinine or artesunate for

severe malaria

Give first dose of an appropriate antibiotic

Treat the child to prevent low blood sugar

Give one dose of paracetamol in clinic for

high fever (38.5C or above)

Refer URGENTLY to hospital

Malaria test POSITIVE.** Yellow:

MALARIA

Give recommended first line oral

antimalarial

Give one dose of paracetamol in clinic for

high fever (38.5C or above)

Advise mother when to return immediately

Follow-up in 3 days if fever persists

If fever is present every day for more than 7

days, refer for assessment

Malaria test NEGATIVE.

Runny nose PRESENT or

Measles PRESENT or

Other cause of fever

PRESENT

Green:

FEVER : NO

MALARIA

Assess for possible bacterial cause of fever***

and treat with appropriate drugs

Give one dose of paracetamol in clinic for high

fever (38.5C or above)


Follow-up in 2 days if fever persists

If fever is present every day for more than 7

days, refer for assessment

Classify

FEVER

If the child has measles

now or within the last 3

months:

Look for mouth ulcers.

Are they deep and

extensive?

Look for pus draining from

the eye.

Look for clouding of the

cornea.

Any general danger sign

or

Clouding of cornea or

Deep or extensive mouth

ulcers.

Pink:

SEVERE

COMPLICATED

MEASLES****

Give Vitamin A treatment

Give first dose of an appropriate

antibiotic

If clouding of the cornea or pus draining

from the eye, apply tetracycline eye

ointment


Pus draining from the eye

or

Mouth ulcers.

Yellow:

MEASLES WITH EYE

OR MOUTH

COMPLICATIONS****


If pus draining from the eye, treat eye

infection with tetracycline eye ointment

If mouth ulcers, treat with gentian violet

Follow-up in 2 days

Measles now or within

the last 3 months.

Green:

MEASLES


If MEASLES now or withinlast 3 months, Classify

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5C higher.

** If no malaria test available and NO obvious cause of fever - classify as MALARIA.

***Look for local tenderness, refusal to use a limb, hot tender swelling, red tender skin or boils, lower abdominal pain or pain on passing urine.

**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables .


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Does the child have an ear problem?

If yes, ask: Look and feel:

Is there ear pain?

Is there ear discharge?If yes, for how long?

Look for pus draining from

the ear.Feel for tender swelling

behind the ear.

Tender swelling behind the

ear.

Pink:

MASTOIDITIS

Give first dose of an appropriate antibiotic

Give first dose of paracetamol for pain


Pus is seen draining from

the ear and discharge is

reported for less than 14

days, or

Ear pain.

Yellow:

ACUTE EAR

INFECTION

Give an antibiotic for 5 days

Give paracetamol for pain

Dry the ear by wicking

Follow-up in 5 days

Pus is seen draining from

the ear and discharge is

reported for 14 days or

more.

Yellow:

CHRONIC EAR

INFECTION

Dry the ear by wicking

Treat with topical quinolone eardrops for 2

weeks

Follow-up in 5 days

No ear pain and

No pus seen draining from

the ear.

Green:

NO EAR

INFECTION

No treatment

Classify EAR PROBLEM


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THEN CHECK FOR MALNUTRITION AND ANAEMIA

CHECK FOR MALNUTRITION

LOOK AND FEEL:

For all children

Determine weight for ageLook for oedema of both feet

Look for visible severe wasting

For children aged 6 months or more

Determine if MUAC* less than 110 mm

If age up to 6 months:

and visible severe

wasting

or oedema of both feetIf age 6 months and above

and:

MUAC less than 110

mm or

oedema of both feet or

visible severe wasting

Pink:

SEVERE

MALNUTRITION

Treat the child to prevent low blood sugar


Very low weight for age Yellow:

VERY LOW

WEIGHT

Assess the child's feeding and counsel the

mother on feeding according to the feeding

recommendations.

If feeding problem, follow up in 5 days


Follow-up in 30 days

Not very low weight for

age and no other signs of

malnutrition

Green:

NOT VERY LOW

WEIGHT

If child is less than 2 years old, assess the

child's feeding and counsel the mother on

feeding according to the feeding

recommendationsIf feeding problem, follow-up in 5 days

CLASSIFY NUTRITIONAL

STATUS

CHECK FOR ANAEMIA

LOOK AND FEEL:

Look for palmar pallor. Is it:

Severe palmar pallor?

Some palmar pallor?

Severe palmar pallor Pink:

SEVERE

ANAEMIA


Some palmar pallor Yellow:

ANAEMIA

Give iron

Give oral antimalarial if high malaria risk

Give mebendazole if child is 1 years or older

and has not had a dose in the previous 6

months


Follow-up in 14 days

No palmar pallor Green:

NO ANAEMIA

If child is less than 2 years old, assess the

child's feeding and counsel the mother on

feeding according to the feedingrecommendations

If feeding problem, follow-up in 5 days

CLASSIFYANAEMIA

* MUAC is mid-upper arm circumference. If tapes are not available, look for oedema of both feet or visible severe wasting.


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Does the child have diarrhoea?

If yes, ask: Look and feel:

For how long?

Is there blood in the stool?

Look at the child's general

condition. Is the child:

Lethargic or

unconscious?

Restless and irritable?

Look for sunken eyes.

Offer the child fluid. Is the

child:

Not able to drink or

drinking poorly?

Drinking eagerly,

thirsty?

Pinch the skin of the

abdomen. Does it go back:

Very slowly (longer

than 2 seconds)?

Slowly?

Two of the following signs:

Lethargic or unconscious

Sunken eyes

Not able to drink or

drinking poorlySkin pinch goes back

very slowly.

Pink:

SEVERE

DEHYDRATION

If child has no other severe

classification:

Give fluid for severe dehydration

(Plan C)

ORIf child also has another severe

classification:

Refer URGENTLY to hospital with

mother giving frequent sips of ORS

on the way

Advise the mother to continue

breastfeeding

If child is 2 years or older and there is

cholera in your area, give antibiotic for

cholera

Two of the following signs:

Restless, irritable

Sunken eyes

Drinks eagerly, thirsty

Skin pinch goes back

slowly.

Yellow:

SOME

DEHYDRATION

Give fluid, zinc supplements, and food

for some dehydration (Plan B)

If child also has a severe classification:

Refer URGENTLY to hospital with

mother giving frequent sips of ORS

on the way

Advise the mother to continue

breastfeedingAdvise mother when to return immediately

Follow-up in 5 days if not improving

Not enough signs to classify

as some or severe

dehydration.

Green:

NO

DEHYDRATION

Give fluid, zinc supplements, and food to treat

diarrhoea at home (Plan A)


Follow-up in 5 days if not improving

for DEHYDRATION

Classify DIARRHOEA

and if diarrhoea 14

days or more

Dehydration present. Pink:

SEVERE

PERSISTENT

DIARRHOEA

Treat dehydration before referral unless the

child has another severe classification

Refer to hospital

No dehydration. Yellow:

PERSISTENT

DIARRHOEA

Give fluids Plan A

Advise the mother on feeding a child who has

PERSISTENT DIARRHOEA

Give Vitamin A, multivitamins and

minerals (including zinc) for 14 days

Follow-up in 5 days

and if blood in stoolBlood in the stool. Yellow:

DYSENTERY

Give ciprofloxacin for 3 days

Treat dehydration and gve zinc

Follow-up in 2 days


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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home

Counsel the mother on the 4 Rules of Home Treatment:

1. Give Extra Fluid

2. Give Zinc Supplements

3. Continue Feeding

4. When to Return.

1. GIVE EXTRA FLUID (as much as the child will take)

TELL THE MOTHER:Breastfeed frequently and for longer at each feed.

If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.

If the child is not exclusively breastfed, give one or more of the following:ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water.

It is especially important to give ORS at home when:

the child has been treated with Plan B or Plan C during this visit.

the child cannot return to a clinic if the diarrhoea gets worse.

TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME.

SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Tell the mother to:

Give frequent small sips from a cup.

If the child vomits, wait for 10 minutes. Then continue, but more slowly.

Continue giving extra fluid until the diarrhoea stops.

2. GIVE ZINC

TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):

Up to 6 months 1/2 tablet daily for 10 days

6 months or more 1 tablet daily for 10 days

SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS

Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup.

Older children - tablets can be chewed or dissolved in a small amount of water.

3. CONTINUE FEEDING(exclusive breastfeeding if age less than 6 months)

4. WHEN TO RETURN

Plan B: Treat Some Dehydration with ORS

In the clinic, give recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

WEIGHT < 6 kg 6 -


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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO

DOWN.

START HERE Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip

is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normalsaline), divided as follows

AGE First give 30 ml/kg

in:

Then give 70 ml/kg

in:

Infants (under 12 months) 1 hour* 5 hours

Children (12 months up to 5years)

30 minutes* 2 1/2 hours

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the child every 1-2 hours. If hydration status is not improving, give the

IV drip more rapidly.

Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4hours (infants) or 1-2 hours (children).

Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration.

Then choose the appropriate plan (A, B, or C) to continue treatment.

Can you give intravenous (IV)fluid immediately?

YES

NO

Is IV treatment available

nearby (within 30 minutes)?YES

Refer URGENTLY to hospital for IV treatment.

If the child can drink, provide the mother with ORS solution and show her how to

give frequent sips during the trip or give ORS by naso-gastric tube.NO

Are you trained to use a naso-gastric (NG) tube for

rehydration?

YES

Start rehydratin by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6

hours (total of 120 ml/kg).

Reassess the child every 1-2 hours while waiting for transfer:

If there is repeated vomiting or increasing abdominal distension, give the fluidmore slowly.

If hydration status is not improving after 3 hours, send the child for IV therapy.

After 6 hours, reassess the child. Classify dehydration. Then choose the

appropriate plan (A, B or C) to continue treatment.

NO

Can the child drink? YES

NO


for IV or NG treatment

NOTE:

If the child is not referred to hospital, observe the child at least 6 hours after

rehydration to be sure the mother can maintain hydration giving the child ORS

solution by mouth.

IMMUNIZE AND GIVE VITAMIN A TO EVERY SICK CHILD,AS NEEDED

When immunizing, make sure you explain to the caretaker: Type of immunization and protection

side effects of the vaccines

When to return for the next immunization(s)

When give vitamin A, make sure you explain to the caretaker: How to give the vitamin A capsule at home

When to return for the next vitamin A supplementation


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CHECK FOR HIV INFECTION

If a child is already on ART or is HIV infected do not enter this box.

NOTE OR ASK IF CHILD HAS: LOOK ANDFEEL

Child HIV statusis:

Mothers HIVstatus

seropositive

PCR positive

Seronegative

PCR negative

unknown*

Seropositive

Seronegative

Unknown*

Pnuemonia

Persistent diarrhoea now

Chronic ear infection now

Very low weight or growth faltering

Is there parotid enlargment for 14 days

or more

Any enlarged

lymph glands

now in two or

more of the

following

sites: Neck,

axilla or

groin?

Is there oral;

thrush?

Check

for parotid

enlargement

Positive HIV antibody test

in a child 18 months old or

stopped breastfeeding 3

months ago OR

Positive HIV virological test

Yellow:

CONFIRMED HIV

INFECTION

Treat counsel and follow up other

classifications

Give cotrimoxazole porphylaxis daily

Check immunisation status

Give vitamin A supplement every 6 months from

6 months of age

Assess the child's feeding and counsel on

feeding according to the FOOD BOX on the

Counsel the caretaker chart

Stage the disease and refer for further

assessment including HIV care/ART

Advise the caretaker on home care

No test done or no test

results in a child with 2 or

more conditions OR

Positive antibody test in a

child less than 18 months

with 2 or more conditions

Yellow:

SUSPECTED

SYMPTOMATIC

HIV INFECTION

Treat counsel and follow up other classifications



Give vitamin A supplement every 6 months from 6

months of age


feeding according to the FOOD BOX on the Counsel

the caretaker chart

test to confirm HIV INfection

Stage disease and refer for further assessement

including HIV care/ART

If child less than 18 months collect dried bloodspot sample and refer sample for PCR (check

annex for DBS procedure)

Advise the caretaker on home care

Mother HIV positive and no

test result on child with

less than 2 conditions OR

Child less than 18 months

with positive antibody test

with less than 2 conditions

Yellow:

POSSIBLE HIV

INFECTION or HIV

EXPOSED

Treat counsel and follow up other

classifications



Give vitamin A supplement every 6 months from

6 months of age


feeding according to the FOOD BOX on the

Counsel the caretaker chart

Confirm HIV infection status of child as soon as

possible with best available test

No test done or no test results

in child or mother OR less than

two conditions

Green:

SYMPTOMATIC

HIV INFECTION

UNLIKELY

Treat counsel and follow-up other

classifications.

Advice the caretaker about feeding and about

her/his own health

Counsel and offer HIV testingNegative HIV test in the

mother or child

Green:HIV INFECTION

UNLIKELY

Treat, counsel and follow-up other

classifications

Counsel the caretaker about feeding and about

her/his own health

Classifyfor HIV

infection

*If the HIV status is unknown and the child has no severe classification offer PITC.


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WHO PAEDIATRIC CLINICAL STAGING FOR HIVHas the child been confirmed HIV infection? if yes, perform clinical staging: any one condition in the highest staging determines stage, If no, you

cannot stage the patient.

WHO PaediatricClinical stage 1-Asymptomatic

WHO Paediatric Clinicalstage 2- Mild Disease

WHO Paediatric Clinical stage 3-Moderate Disease

WHO Paediatric Clinical stage 4- SevereDisease (AIDS)

Grow h - - Moderate unexplained malnutrition notresponding to standard therapy

Severe unexplained Wasting/Stunting/Severe malnutrition not respondingto standard therapy

Symptoms /Signs

No symptoms or only:

Persistent

Generalised

Lymphadenopathy

(PGL)

Unexplained persistent

enlarged liver and or spleen.

Unexplained persistent

enlarged parotid glands,

Skin conditions (prurigo,

seborrhoeic dermatis,

extensive molleusoum

contegiosum or warts, fungul

nail infections, herps zoster).

Mouth conditions ( recurrent

mouth ulcerations, gingival

erythema),

Recureent or chronic RTI

(Sinusitis, ear infections,

tonsillitis, otorrhoea)

Oral thrush (outside neonatal period).

Oral hairy leucoplakia

Unexplained and unresponsive to

standard therapy:

- Diarrohoea > 14 days

- Fever more than one mouth

- Thrombopsytopenia*

(50,000/mm3for

more than 1 mouth), Neutropenia

(500/mm3for 1 mouth)

- Aneamia for > 1 month (heamoglobin

< 8gm)*

Recurrent severe bacterial pneumonia

Pulmonary TB, Lymphomoid TB,

Symptomatic LIP*

Acute necrotizing ulcerative gingivitis/

periodontitis,

Chronic HIV associated lung disease

including bronchiectasis*

Oesophageal thrush,

More than 1 month of herps simplex

ulcerations,

Severe multiple or recurrent bacterial

infections 2 episodes in a year ( not

including pneumonia)

Pneumocystis pneumonia (PCP)*

Kaposis Sarcoma,

Extra pulmonary TB, Toxoplasma brain

abscess*

Cryptococcal meningitis,

Chronic cryptosporidioasis, Chronic

isosporiasis

Acquired HIV associated rectal fistula,

HIV encephalopathy*

Cerebral B cell non- hodgkins lymphoma*

Symptomatic HIV associated

cardiomyopathy/nephropathy

ARV therapy Indicated only if CD4is available: 11 month and DC4 25% ( or 1500cells)12 35 months andCD4 20% ( or 750cells)36 59 months andCD4 15% ( or 360cells) 5 years and CD4

15% (< 200 cells/mm3

)

Indicated only if CD4 or TLC# isavailable:Same as stage 1 OR 11 monthTLC 3000 cells36 59 moth and TLC 2500cells

5 - 8 years and TLC

2000 cells**There is not adequate data forchildren older than 8 years.

ART is indicated; Child less than 12

months regardless of CD4

Child is over 12 months - usually

regardless of

CD4 but if LIP/ TB/ Oral hairyleucoplakia - ART

Initiation may be delayed if CD4 oboveage related threshhold for advanced orsevere immune deficiency

ART is indicted:Irrespective of the CD4 count, and should bestarted as soon as possible

Note that these are interim recommendations and may be subject to change.

# Total lymphocyte count (TLC) has been proposed as surrogate marker or an alternative to CD4 cell count or CD4% in resource - constrained settings

*conditions requiring diagnosis by a Doctor or medical officer - should be refered for appropriate diagnosis and treatment

In a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated

Flip Chart: Integrated Management of Childhood Illness

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