IMCI Chart -Zambia August 2012

7/27/2019 IMCI Chart -Zambia August 2012

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Integrated Management of Childhood Illness

MaryGenericJune2011

Assess and classify the sick child aged 2 months up to 5 yearsASSESS AND CLASSIFY

CHECKFORGENERALDANGERSIGNS 4

THENASKABOUTMAINSYMPTOMS: 5

Doesthechildhavediarrhoea? 6

Doesthechildhavefever? 7

Doesthechildhaveanearproblem? 8

THE N CH EC K FO R MA LN UTRI TI ON A ND A NA EM IA 9

CHECKFORHIVINFECTION 10

WHO PAEDIATRIC CLINICAL STAGING FOR HIV 11THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A ANDDEWORMING STATUS 12

TREAT THE CHILDTEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME 14

GiveanAppropriateOralAntibiotic 14

G iv e an A pp ro pr ia te O ra l An ti bi ot ic f or D YS EN TE RY 1 4

Givecotrimoxazoleprophylaxis 14

GiveOralAntimalarial 15

GiveparacetamolforFeverorEarpain 15

GiveVitaminA 15

Giveironandorfolate 15

GiveMebendazoleoralbendazole 16

GiveInhaledSalbutamolforWheezing 16

Giveoralsalbutamol 16

TeachCaretakertoGiveARVs 18

GivepainreliefforChronicPain 18

TreatOpportunisticInfections 18TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME 19Tre at E ye I nf ec ti on w it h Te tr ac yc li ne E ye O in tm en t 1 9

C le ar t he E ar b y Dr y Wi ck in g an d Gi ve E ar d ro ps * 1 9

TreatMouthUlcerswithGentianVioletGV 19TREATTHRUSHWITHORALNYSTATIN 19

SoothetheThroat,RelievetheCoughwithaSafeRemedy 19

GIVE THESE TREATMENTS IN THE CLINIC ONLY 20

GiveanIntramuscularAntibiotic 20

Giveintramuscularquinine 20

GiveDiazepamtoStopConvulsions 20

TreattheChildtoPreventLowBloodSugar 21

Giveepinephrine 21

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING 21PlanA:TreatDiarrhoeaatHome 22

PlanB:TreatSomeDehydrationwithORS 22

PlanC:TreatSevereDehydrationQuickly 23

IMMUNIZEANDGIVEVITAMINATOEVERYSICKCHILD,ASNEEDED

23

FOLLOW-UPGIVE FOLLOW-UP CARE 24

PNEUMONIA 24

PERSISTENTDIARRHOEA 24

DYSENTERY 26

ORALTHRUSH 26

MALARIA 26M EA SL ES W ITH EY E OR M OU TH C OM PL IC ATIO NS 2 7

EARINFECTION 27

FEEDINGPROBLEM 27

VERYLOWWEIGHT 27ANAEMIA 27

HIVINFECTION 28

COUNSELFOOD 29

AssesstheFeedingofSickchildUnder2Yearsorifchildhasverylowweightforage 30FeedingRecommendationsDuringSicknessandHealth 31

FOOD 32

FeedingRecommendationsForaChildWhoHasPERSISTENTDIARRHOEA

32

CounseltheMotherAboutFeedingProblems 32

Counsel 33CounseltheMotheraboutherOwnHealth 33

FLUID 33AdvisetheMothertoIncreaseFluidDuringIllness 33WHEN TO RETURN 34

Recording Form 67


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Assess, classify and treat the sick young infant aged up to 2 monthsASSESS AND CLASSIFY

CHECKFORVERYSEVEREDISEASEANDLOCALBACTERIALINFECTION

36

THE N AS K: D oe s th e yo un g in fa nt h av e di ar rh oe a* ? 3 7

CHECKFORJAUNDICE 37

THENCHECKFORHIVINFECTION 38

THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFORAGE:FORBREASTFEEDINGINFANTS

39

THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFORAGEinNON-breastfedinfants

40

THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMINA STATUS: 41ASSESSOTHERPROBLEMS 41

TREAT AND COUNSELTREAT THE YOUNG INFANT AND COUNSEL THE MOTHER 42

GiveFirstDoseofIntramuscularAntibiotics 42Tre at t he Y ou ng I nf an t to P re ve nt L ow B lo od S ug ar 4 3

TeachtheMotherHowtoKeeptheYoungInfantWarmontheWaytotheHospital

43

GiveanAppropriateOralAntibioticforLocalBacterialInfection 44

Tea ch t he M ot he r to Tre at L oc al I nf ec ti on s at H om e 4 5

To Tr ea t Di ar rh oe a, S ee TRE ATTHE C HI LD C ha rt . 4 5

Im mu ni ze Ev er y Si ck Yo un gI nfa nt, as Ne ed ed 4 5COUNSEL THE MOTHER 46TeachCorrectPositioningandAttachmentforBreastfeeding 46

T ea ch t he M oth er Ho w to Ex pre ss Br ea st Mil k 4 6

TeachtheMotherHowtoFeedbyaCup 46

TeachtheMotherHowtoKeeptheLowWeightInfantWarmatHome 46AdvisetheMothertoGiveHomeCarefortheYoungInfant 46

FOLLOW-UPGIVE FOLLOW-UP CARE FOR THE YOUNG INFANT 47

ASSESSEVERYYOUNGINFANTFOR"VERYSEVEREDISEASE"DURINGFOLLOW-UPVISIT

47

LOCALBACTERIALINFECTION 47

DIARRHOEA 48

JAUNDICE 48

FEEDINGPROBLEM 49

LOWWEIGHTFORAGE 50

THRUSH 50

Recording Form 69


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AnnexAnnex A: Skin and Mouth ConditionsIdentify Skin Problem 51

Ifskinisitching 52

Identify Skin Problem 53Ifskinhasblisters/sores/pustules 53

Identify Papular Lesions 54Non-Itchy 54

Mouth Problems 55Thrush 55

HerpesSimplex 56

ASSESS,CLASSIFYANDTREATSKINANDMOUTHCONDITIONS 57

Clinical reaction 58DrugandAllergicReactions 58

Annex B: ARV dosages andcombinationsARV dosage tables 59

EfivarenzEFV 59AbacavirABC 59Stavudined4T 59

Lamivudine3TC 59L amiv ud in e fo r PMT CT pr op hy la xi s in n ewb or ns 5 9

Combination ARV dosages 60DualFDCs 60

DualFDCs 60

TripleFDCs 60

TripleFDCs 60

Annex C: ARVs SIDE EFFECTSSideEffects* 61

Annex D: DRIED BLOOD SPOT DBSCOLLECTION FOR PCR - SUMMARY A good health care worker carrying out DBS procedure will: 62Annex E: TO MEASURE MID UPPERARM CIRCUMFERENCEMUACHOW TO MEASURE MID UPPER ARM CIRCUMFERENCEMUAC 65

STEPSFORMEASURINGMIDUPPERARMCIRCUMFERENCEMUAC 65


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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 this

problem.if follow-up visit, use the follow-up instructionson 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: L o o k :

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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THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?

If yes, ask: Look , l i s ten , feel :

For how long? Count the

breaths in

one minute.

Look for

chest

indrawing.

Look and

listen forstridor.

Look and

listen for

wheezing.

CHILD

MUST BE

CALM

If wheezing and either

fast breathing or chest

indrawing:

Give a trial of rapid acting

inhaled bronchodilator for up

to three times 15-20 minutes

apart. Count the breaths and

look for chest indrawingagain, and then classify.

If the ch i ld is : Fas t b reath ing is :

2 months up to 12 months 50 breaths per minute or more

12 Monts up to 5 years 40 breaths per minute or more

Any general danger sign or

Chest indrawing or

Stridor in calm child.

P i n k :

SEVERE

PNEUMONIA OR

VERY SEVERE

DISEASE

Give first dose of an appropriate antibiotic

If wheezing give a rapid acting

bronchodilator or subcutanousadrenaline

Refer URGENTLY to hospital*

Fast breathing. Yel low:

PNEUMONIA

Give oral antibiotic for 5 days

If wheezing (even if it disappeared after rapidly

acting bronchodilator) give an inhaled

bronchodilator for 5 days**Soothe the throat and relieve the cough with a

safe remedy

If coughing for more than 3 weeks or if

having recurrent wheezing, refer for

assessment for TB or asthma

Advise mother when to return immediately

Follow-up in 2 days

No signs of pneumonia or very

severe disease.

Green:

COUGH OR COLD

If wheezing (even if it disappeared after rapidly

acting bronchodilator) give an inhaled

bronchodilator for 5 days**

Soothe the throat and relieve the cough with a

safe remedy

If coughing for more than 3 weeks or if havingrecurrent wheezing, refer for assessment for TB

or asthma


Follow-up in 5 days if not improving

Classi fy COUGH or

DIFFICULT BREATHING

* If referral is not possible, manage the child as described in In tegrated Management of Chi ldhood I l l ness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient

care.

** In settings where inhaled bronchodilator is not available, oral salbutamol may be the second choice.

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Does the child have diarrhoea?

If yes, ask: L oo k 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 ordrinking 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 poorly

Skin pinch goes back

very slowly.

P i n k :

SEVERE

DEHYDRATION

If child has no other severe

classification:

Give fluid for severe dehydration

(Plan C)

OR

If child also has another severe

classification:

Refer URGENTLY to hospital with

mother giving frequent sips of ORS

on the way

Advise the mother to continuebreastfeeding

If child is 2 years or older and there is

cholera in your area, give antibiotic for

cholera


Restless, irritable

Sunken eyes

Drinks eagerly, thirsty


slowly.

Yel low:

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

breastfeeding



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)



for DEHYDRATION

Classi fy DIARRHOEA

and if diarrhoea 14

days or more

Dehydration present. P i n k :

SEVERE

PERSISTENT

DIARRHOEA

Treat dehydration before referral unless the

child has another severe classification

Refer to hospital

No dehydration. Yel low:

PERSISTENT

DIARRHOEA

Give fluids Plan A

Advise the mother on feeding a child who has

PERSISTENT DIARRHOEAGive Vitamin A, multivitamins and

minerals (including zinc) for 14 days

Follow-up in 5 days

and if blood in stoolBlood in the stool. Yel low:

DYSENTERY

Give ciprofloxacin for 3 days

Treat dehydration and gve zinc

Follow-up in 2 days

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Does the child have fever?

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

If yes:

Then ask : L ook 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.

P i n k :

VERY SEVERE

FEBRILE DISEASE

Give first dose of quinine or artesunate for

severe malaria


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.** Yel low:

MALARIA

Give recommended first line oral

antimalarialGive one dose of paracetamol in clinic for

high fever (38.5C or above)


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

Class i fy

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.

P i n k :

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.

Ye l l ow:

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


I f MEASLES now or wi th in

last 3 months, Class i fy

* 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 f ever - 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: L oo k 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.

P i n k :

MASTOIDITIS


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.

Yel low:

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 isreported for 14 days or

more.

Yel low:

CHRONIC EARINFECTION

Dry the ear by wicking

Treat with topical quinolone eardrops for 2weeks

Follow-up in 5 days

No ear pain and

No pus seen draining from

the ear.

Green:

NO EAR

INFECTION

No treatment

Classi fy EAR PROBLEM

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THEN CHECK FOR MALNUTRITION AND ANAEMIA

CHECK FOR MAL NUTRITION

LOOK AND FEEL:

For all children

Determine weight for age

Look 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 feet

If age 6 months and above

and:

MUAC less than 110

mm or

oedema of both feet or

visible severe wasting

P i n k :

SEVERE

MALNUTRITION

Treat the child to prevent low blood sugar


Very low weight for age Yel low:

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

recommendations

If 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 P i n k :

SEVERE

ANAEMIA

Refer URGENTLY to hosp i tal

Some palmar pallor Yel low:

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 feeding

recommendations

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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CHECK FOR HIV INFECTION

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

NOTE OR A SK IF CHILD HAS: LOOK AND

FEEL

Child HIV status

is:

Mothers HIV

status

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

Ye l l ow :

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/ARTAdvise 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

Ye l l ow :

SUSPECTED

SYMPTOMATIC

HIV INFECTION

Treat counsel and follow up other classifications



Give vitamin A supplement every 6 months from 6

months of age

Assess the child's f eeding and counsel on

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 blood

spot sample and refer sample for PCR (checkannex 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

Ye l l ow :

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

Assess the child's feeding and counsel on

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 otherclassifications.

Advice the caretaker abou t feeding and about

her/his own health

Counsel and offer HIV testing

Negative 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

Class i fy

for HIV

in fec t i on

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

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WHO PAEDIATRIC CLINICAL STAGING FOR HIV

Has the child beeen confirmed HIV infection?

If yes, perform clinical staging: any one condition in the highest staging determinanes stage, If no, you cannot stage the patient.

WHO PaediatricClinical

stage 1-Asymptomatic

WHOPaediatricClinical

stage 2- mildDisease

WHO Paediatric Clinical

stage 3 - ModerateDisease

WHO Paediatric Clinical

stage 4 - Severe Disease (AIDS)

Growth - - Moderate unexplainedmalnutrition not respondingto standard therapy

Severe unexplained wasting/stunting/severemalnutrition not responding to srtandardtherapy

Symptoms/

signs

No symptoms oronly:

PersistantGeneralised

Lymphadenopathy(PGL)

unexplainedpersistentenlargedliver and/orspleen

Unxeplainedpersistentenlargedparotidglands

Skinconditions(prurigo,seborrhoeicdermatitis,extensivemolleuscumcontegiosumor warts,fungal nailinfections,herpeszoster)

Mouthconditions(recurrentmouthulcerations,gingivalerythema)

Recurrent orchronic RTI(sinusitis,earinfections,tonsilitis,otorrhoea)

Oral thrush ( outsideneonatal period)

Oral hairy leucoplakia

Unexplained andunresponsive to standardtherapy;

Diarrhoea > 14 days

Fever more than 1month

thrombopcytopeania*(< 50,000/mm3 formore than 1 month)

Neutropenia* ( 1month (heamoglobin< 8gm)*

Recurrent severebacterial pneumonia

Pulmonary TB

Lymphonoid TB

Symptomatic LIP*

Acute necrotisingulcerativegivingivitis/periodontitis

Chronic HIV assosiatedlung disease includingbronchiectasis*

Oesophageal thrush

More than 1 month of herpes simplexulcerations

Severe multiple or recurrent bacterialinfections 2 episodes in a year (notincludinig pneumonia)

Pneumocystis pneumonia (PCP)*

Kaposis sarcoma

Extra pulmonary TB

Toxoplasma brain abcess*

Cryptococcal meningitis*

Chronic cryptosporidiosis

Chronic isosporiasis

Acquired HIV-associated rectal fistula

HIV encephalopathy*

Cerebral B cell non-Hodgkinslymphoma*

Symptomatic HIV associatedcardiomyopathy/nephropathy*

ARV

Therapy

Indicated only ifCD4 is available:

11 mo andCD4

25% ( or 1500cells)

12 - 35 mo andCD4

20% (or 750cells )

36 - 59 mo andCD4 15% (or

350 cells)

5 years andCD4 15%(


12/74

THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND

DEWORMING STATUS

IMMUNIZATION

SCHEDULE:If the child did not receive

OPV- 0 at birth or within 13 days

after birth, give OPV- 4 at 9

months with measles

Follow national guidelines

AGE VACCINE

Birth BCG OPV-06 weeks DPT-Hib-HepB1 OPV-1 Rota vacine1 Pnuemo1

10 weeks DPT-Hib-HepB2 OPV-2 Rota vacine 2 Pnuemo2

14 weeks DPT-Hib-HepB3 OPV-3 Pnuemo3

9 months Measles 1

15 Months Measles 2

VITAMIN A SUPPLEMENTATION

VITAMIN A SUPPLEMENTATION SCHEDULE AGE FREQUENCY

BIRTH to 6 months NONE*6 months up to 5 years Every 6 months

*Exception: Give 50,000 IU for infants less than 6 months who are not breastfed.

Record the dose on the child's card.

ROUTINE WORM TREATMENT

Give every child mebendazole every 6 months from the age of one year. Record the dose on the child's card.

* Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities

as early as one month following the first dose.

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THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND

DEWORMING STATUS

ASSESS AND LOOK IF THE CHILD HAS OTHER PROBLEMS

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERREDafter first dose of an appropriate antibiotic and other urgent

treatments.

Exception:Rehydration of the child according to plan C may resolve danger

signs so that referral is no longer needed.

check the blood sugar in all children with a general dangar sign and treat or

prevent low blood sugar

ASSESS THE CARETAKER'S HEALTH

NEEDSASK

Do you have any health problemsyourself?.

Do you want help with family planning

Did you bring your health card? Ifyes, may I please look at the card?

If applicable check whether the

caretaker needs Tetanus toxoid orvitamin A supplementation

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TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLA SSIFYCHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at

home.

Also follow the instructions listed with each drug's dosage table.

Determine the appropriate drugs and dosage for the child's age or weight.

Tell the mother the reason for giving the drug to the child.

Demonstrate how to measure a dose.

Watch the mother practise measuring a dose by herself.

Ask the mother to give the first dose to her child.

Explain carefully how to give the drug, then label and package the drug.

If more than one drug will be given, collect, count and package each drug

separately.

Explain that all the oral drug tablets or syrups must be used to finish the course of

treatment, even if the child gets better.

Check the mother's understanding before she leaves the clinic.

Give an Approp riate Oral Antibiotic

FOR PNEUMONIA, ACUTE EAR INFECTION:

FIRST-LINE ANTIBIOTIC: AMOXICILLIN

SECOND-LINE ANTIBIOTIC: ERYTHROMYCIN

AGE or WEIGHTAMOXICILLIN

Give 3 times daily for 5 daysERYTHROMYCIN

Give four times daily for 5 days

Tablet 250mg Syrup 125mls/5mls Tablet 250mg Syrup 125mls/5mls

2 months up t o 4 months (4 -


15/74



home.


Give Oral Antimalarial

FIRST-LINE ANTIMALARIAL: ARTEMETHER-LUMEFANTRINE (AL)

Give Sulfadoxine + Pyrimethamine if cjild is less than 5kg or AL is not availableSECOND - LINE ANTIMALARIAL: ORAL QUININE

If Artemether-Lumefantrine (AL)

Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child vomits within an hour repeat thedose.

Give second dose at home after 8 hours.

Then twice daily for further two days as shown below.

Artemether-lumefantrine should be taken with food.

Explain to the caretaker to watch the child carefully for 30 minutes after giving a dose of artemether-lumefantrine. If the child vomiteswithin 30 minutes, inform the caretaker to repeat the dose and return to the clinic for additional tablets

If Sulfadoxine + Pyrimethamine:

Give single dose in the health center per table below using the fixed dose combination

AGE or WEIGHT

Artemether-Lumefantrine tablets(20 mg artemether and 120 mg

lumefantrine)

Give first dose in the clinic, 2nd dose

after 8 hoursThen twice daily for 2 days

Sulfadoxine + Pyrimethamine (give single dose inthe clinic)

TABLET (Give twice daily) SYRUP TABLET (500mg sulfadoxine + pyrimethamine)

2 months up to 12 months (5 -


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home.


Teach Caretaker to Give ARVs

ARV DOSAGES

WEIGHT (kg)

Efavirenz (EFZ)15 mg/kg/day (capsule or tablet) for age 3 years or more

Once daily

Capsule 200mg Capsule 100mg Capsule 50mg If no capsule give tablet Tablet 600mg

10-13.9 1

14-19.9 1 1

20-24.9 1 1

25-29.9 1 1 1

30-39.9 2

40 and over 3 OR 1

WEIGHT (kg)

STAVUDINE (d4T)1mg/kg/dose (to maximum 30mg dose)

Give dose twice daily

Solution Capsule 15mg Capsule 20mg Capsule 30mg

5-5.9 6mls

6-9.9 1/2

10-13.9 1

14-24.9 1

25 and above 1

WEIGHT (kg)

ABACAVIR (ABC)8mg/kg/dose (to maximum dose of 300mg/dose)


Syrup 20mg/ml If no syrup give tablet Tablet 300mg

5-5.9 2mls

6-6.9 3mls

7-9.9 4mls

10-10.9 5mls

11-11.9 5mls OR 1/2

12-13.9 6mls OR 1/2

14-19.9 1/2

20-24.9 1 AM and 1/2 PM

25 and above 1

WEIGHT (kg)

LAMIVUDINE (3TC)

I4mg/kg/dose (to maximum 150mg dose)Give dose twice daily

Syrup 10mg/ml If no syrup give tablet Tablet 150mg

30 DAYS OR OLDER

5-6.9 3mls

7-9.9 4mls

10-11.9 5mls

12-13.9 6mls OR 1/2

14-19.9 1/2

20-24.9 1 AM and 1/2 PM

25kg and above 1

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WEIGHT

zidovudine (AZT or ZDV)TREATMENT DOSE:

180-240 mg/meter square/dose


Syrup 10mg/mlIf no syrup give

capsule or tabletCapsule 100mg/ Tablet 300mg

5 - 5.9 6 ml

6 - 6.9 7 ml

7 - 7.9 8 ml

8 - 8.9 9 ml or 1

9 - 11.9 10 ml or 1

12 - 13.9 11 ml or 1

14 - 19.9 2 1/2

20 - 24.9 2 1/2

25 - 29.9 2 1AM & 1/2 PM

WEIGHT

Neverapine (NVP)TREATMENT: Maintenence dose: 160 - 200mg/msq/ dose

(To maximum 200mg twice daily dose)

Maintenwence dose - give dose twice daily

Lead - in dose during weeks 1 and 2 = only give AM dose

Syrup 10 mg/ml If no syrup give tablet Tablet 200mg

5 - 5.9 6 ml

6 - 6.9 7 mls

7 - 7.9 8 mls

8 - 8.9 9 mls

9 - 9.9 9 mls or 1/2

10 - 11.9 10 mls or 1/2

12 - 13.9 11 mls or 1/2

14 - 24.9 1 AM & 1/2 PM

25 and above

PMTCT prophylaxis in newborns

weight in kgsNiverapine 2 mg/kg/dose

Give within 72 hours of birth once daily Zidovidine 10mg /ml

Give 4 mg/kg/ dose twice daily

Dose Dose

Unknown weight 0.6 ml

1 -1.9 0.2 ml 0.4 ml

2 -2.9 0.4 ml 0.8 ml

3 - 3.9 0.6 ml 1.2 ml

4 - 4.9 0.8 ml 1.6 ml

COMBINATION ARV DOSAGES

Weight (Kg)

Stavudine + Lamivudine

(d4T - 3TC)30 mg d4T/ 150 mg 3TC tablet

Stavoidine + Lamividine + Niverapine

(d4T - 3TC - NVP)30 mg d4T/ 150 mg 3TC/ 200mg NVP tablets

AM PM AM PM

10 - 13.9 1/2 1/2 1/2 1/2

14 - 24.9 1 1/2 1 1/2

25 - 34.9 1 1 1 1

WEIGHT(Kg)

Zidovidine + Lamivudine (ZDV- 3TC = AZT-3TC)

300mg ZDV/ 150 mg 3TC tablet

Zidovudine + Lamivudine + Abacavir(ZDV-3TC-ABC = AZT-3TC -ABC)

300 mg ZDV/150mg 3TC/ 300mg ABC tablet

AM PM AM PM

14 - 19.9 1/2 1/2 1/2 1/2

20 - 29.9 1 1/2 1 1/2

30 or above 1 1 1 1

Give pain relief for Chronic Pain

Safe doses of paracetamol can be slightly higher for pain. use the table and teach mother to measure the right dose

Give paracetamol every 6 hours if pain persists

Stage 2 pain is chronic severe pain as might happen in illness such as HIV infection

Start treating Stage 2 pain with regular paracetamol

In older children, 1/2 tablet of paracetamol can replace 10mls syrup

If the pain is not controlled, add regular codeine 4 hourly

For severe pain morphine syrup can be given

AGE or WEIGHTPARACETAMOL

CODEINE30mg Tablet

ORAL MORPHINE5ng/5mls

Syrup(120mg/5mls)

TABLET100mg

TABLET500mg

2 months up to 4 months (4 - 2 years 400mg 8 hourly for 5 days

FOR SEVERE STAPHYLOCOCAL INFECTION OF MOUTH OF SKIN

WEIGHTCloxacillin / Flucloxacillin dosage every 6 hour for 5 days

Capsule 250 mg Suspension 125 mg / 5 mls

3 - < 6 kg - 5 mls

6 - < 10 kg 1 10 mls

10 - < 15 kg 1 10 mls

15 - < 20 kg 2 20 mls

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TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given.

Describe the treatment steps listed in the appropriate box.

Watch the caretaker as she does the first treatment in the clinic (except for remedy

for cough or sore throat).

Tell her how often to do the treatment at home.

If needed for treatment at home, give mother the tube of tetracycline ointment or a

small bottle of gentian violet.

Check the mothers understanding before she leaves the clinic.

Treat Eye Infection w ith Tetracycl ine Eye Ointment

Clean both eyes 3 times daily.

Wash hands.

Use clean cloth and water to gently wipe away pus.

Then apply tetracycline eye ointment in both eyes 3 times daily.

Squirt a small amount of ointment on the inside of the lower lid.

Wash hands again.

Treat until there is no pus discharge or redness is gone.

Do not use other ointments or drops, or put anything else in the eye.

Clear the Ear by Dry Wick ing and Give Ear drops *Dry the ear at least 3 times daily.

Roll clean absorbent cloth or soft, strong tissue paper into a wick.

Place the wick in the child's ear.

Remove the wick when wet.

Replace the wick with a clean one and repeat these steps until the ear is dry.

If chronic ear infection, instill quinolone eardrops after dry wicking three times daily for two weeks.

* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.

Treat Mou th Ulcers with Gentian Violet (GV)

Treat mouth ulcers twice daily.

Wash hands.

Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.Paint the mouth with half-strength gentian violet (0.25% dilution).

Wash hands again.

Continue using GV for 48 hours after the ulcers have been cured.

Give paracetamol for pain relief.

TREAT THRUSH WITH ORAL NYSTATIN

Treat thrush four times daily for 7 days:

Wash hands.

Wet a clean soft cloth with salt water and use it to wash childs mouth.

Instill nystatin 1 ml four times a day

Avoid feeding for 20 minutes after medication.

If breastfed, check mothers breast for thrush. If present, treat with nystatin.

Advise mother to wash breast after feed. If bottle fed advise change to cup and spoon

If severe, recurrent or pharyngeal thrush consider symptomatic HIV and refer

Give paracetamol if needed for pain (Page 14)

Follow-up if not improving.

Soothe the Thro at, Rel ieve the Cough with a Safe Remedy

Safe remedies to recommend: Breast milk for a breastfed infant.

Tea with sugar or honey

Lemon drink

Harmful remedies to discourage: Cough syrup with codein, ephedrine, atropine or alcohol

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GIVE THESE TREATMENTS IN THE CLINIC ONLY

Explain to the mother why the drug is given.

Determine the dose appropriate for the child's weight (or age).

Use a sterile needle and sterile syringe when giving an injection.

Measure the dose accurately.

Give the drug as an intramuscular injection.

If child cannot be referred, follow the instructions provided.

Give an Intramus cular Antibiotic

FOR SEVERE PNEUMONIA OR SEVERE DISEASE OR VERY SEVERE FEBRILE ILLNESS OR MASTOIDITIS

For children being referred urgently:

Give first dose of intramuscular benzylpenicillin and gentamicin and refer child urgently to hospital.

If referral is not possible:

Repeat the benzylpenicillin every 6 hours and gentamicin injection every 8 hours for 5 days.

Then change to an appropriate oral antibiotic to complete 10 days of treatment.

Do not attempt to treat with benzylpenicillin alone.

AGE or WEIGHT

GENTAMICIN

2ml/40mg/mlvial

Give 2.5mgper kg

BENZYLPENICILLIN

To a vial of 600mg (1 000 000 IU): add 2.1mlof sterile water = 2.5mls at 400 000IU/ml

Give 50 000IU per kg exactly

CHLORAMPHENICOL40mg/kg

Add 5.0ml sterile water to vialcontaining 1 000mg = 5.6ml at

180mg/ml

2 up to 4 months (4 -


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GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Chi ld to Prevent Low Blood Sugar

If the child is able to breastfeed: Ask the mother to breastfeed the child.

If the child is not able to breastfeed but isable to swallow:

Give expressed breast milk or a breast-milk substitute.

If neither of these is available, give sugar water*.

Give 30 - 50 ml of milk or sugar water* before departure.

If the child is not able to swallow: Give 50 ml of milk or sugar water* by nasogastric tube. (See severemalnutrition guidelines for IV Dextrose)

To treat low sugar give 2ml/kg body weight of 10% dextrose

* To make sugar water: Dissolve 4 level teaspoons o f sugar (20 grams) in a 200-ml cup of clean water.

Give epinephrin e

For wheezing with respiratory distress

PREPARATION DOSE

Subcutaneous ephinephrine (adrenaline) 1:1 000= 0.1% 0.01ml per kg body weight

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice o n COUNSEL THE MOTHER chart)

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(See FOOD advice o n 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 Feeding4. 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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Plan C: Treat Severe Dehydr ation Quic kly

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

AGE First give 30 ml/kgin:

Then give 70 ml/kgin:

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 theIV 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 availablenearby (within 30 minutes)?

YESRefer URGENTLY to hospital for IV treatment.

If the child can drink, provide the mother with ORS solution and show her how togive 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 theappropriate plan (A, B or C) to continue treatment.

NO

Can the child drink? YES

NO

Refer URGENTLY to hospitalfor IV or NG treatment

NOTE:

If the child is not referred to hospital, observe the child at least 6 hours afterrehydration to be sure the mother can maintain hydration giving the child ORSsolution by mouth.

IMMUNIZE AND GIVE VITAMIN A TO EVERY SICK CHILD,

AS NEEDEDWhen 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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FOLLOW-UP

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the

child's previous classifications.

If the child has any new problem, assess, classify and treat the new problem as on

the ASSESS AND CLASSIFYchart.

PNEUMONIA

After 2 days:

Check the child for general danger signs.Assess the child for cough or difficult breathing.Ask:

SeeASSESS & CLASSIFYchart.

Is the child breathing slower?

Is there less fever?

Is the child eating better?

Treatment:

Ifchest indrawing or a general danger sign, give a dose of second line antibiotic or intramuscular chloramphenicol. Then referURGENTLY to hospital.

Ifbreathing rate, fever and eating are the s ame, change to the second-line antibiotic and advise the mother to return in 2 days orrefer. (If this child had measles within the last 3 months or is known to have HIV infection , refer.)

If the child has wheezing, give oral salbutamol

Ifbreathing slow er, less fever, or eating better, complete the 5 days of antibiotic.

PERSISTENT DIARRHOEA

After 5 days:Ask:

Has the diarrhoea stopped?

How many loose stools is the child having per day?

Check for HIV infection if it was not done before

Treatment:

Ifthe diarrhoea has not stopped(child is still having 3 or more loose stools per day), do a full reassessment of the child. Treat fordehydration if present. Then refer to hospital.

Ifthe diarrhoea has stopped(child having less than 3 loose stools per day), tell the mother to follow the usual feedingrecommendations for the child's age. SHE SHOULD CONTinue giving zinc and multivitamins

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GIVE FOLLOW-UP CARE

Page 25 of 74


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DYSENTERY

After 2 days:

Check the child for generaldanger signs.Assess the child fordiarrhoea

See ASSESS &CLASSIFY chart

Ask:

Are there fewer stools?

Is there less blood in the stool?

Is there less fever?

Is there less abdominal pain?

Is the child eating better?

Treatment:If the child is dehydrated, treat dehydration.

Advise caretaker to continue giving zinc supplements until it is given for 14 days

Ifnumber of stoo ls, amount of blood in s tools, fever, abdominal pain, or eating are worse or the same:

Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days. Advise the mother to return in2 days. If you do not have the second line antibiotic, REFER to hospital.

Exceptions - if the child: is less than 12 months old, or

was dehydrated on the first visit, or

if he had measles within the last 3 months

REFER to hospital.

Iffewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving ciprofloxacin and zincsupplements until finished.

Ensure that mother understands the oral rehydration method fully and that she also understands the need for an extra mealeach day for at least a week.

ORAL THRUSH

AFTER 2 DAYS:

Look for mouth ulcers or thrush.

If thrush is worse, give 100,000IU of oral nystatin orally 4 times daily for 7 days

If thrush is the same or better, continue half-strength gentian violet for a total of 7 days

MALARIA

If fever persists after 2 days or returns after 14 days:

Do a full reassessment of thechild.

Measure the child's temperature

Assess for other problems

See ASSESS & CLASSIFY chart.

> DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.

Treatment:

If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.

If the child has any cause of fever other than malaria, provide appropriate treatment.

If there is no other apparent cause of fever:

If fever has been present for 7 days, refer for assessment.

Do a microscopy to look for malaria parasites. If parasites are present and the child has finished a full course of the first lineantimalarial, give oral quinine, if available, or if quinine not available refer the child to a hospital.

If there is no other apparent cause of fever and you do not have a microscopy to check for parasites, refer the child to ahospital.

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GIVE FOLLOW-UP CARE

MEASLES W ITH EYE OR MOUTH COMPLICATIONS

After 2 days:

Look for red eyes and pus draining from the eyes.

Look at mouth ulcers.

Smell the mouth.

Treatment for eye infection:

Ifpus is draining from the eye, ask the caretaker to describe how she has treated the eye infection. If treatment has been correct,

refer to hospital. If treatment has not been correct, teach caretaker correct treatment.Ifthe pus is gone but redness remains, continue the treatment.

Ifno pus or redness, stop the treatment.

Treatment for mouth ulcers:

Ifmouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.

Ifmouth ulc ers are the same or better, continue using half-strength gentian violet for a total of 5 days.

EAR INFECTION

After 5 days:

Reassess for ear problem.

Measure the child's temperature.

See ASSESS & CLASSIFYchart.

For chronic ear infection check for HIV infection if it was done

Treatment:

If there is tender swelling behind the ear or high fever (38.5C or above), refer URGENTLY to hospital.

Acute ear infection: if ear pain or dischargepersists, treat with 5 more days of the same antibiotic. Continue wicking to dry theear. Follow-up in 5 days.

Chronic ear infection:Check that the caretaker is wicking the ear correctly and instilling ciprofloxacin drops tree times a day.Encourage her to continue. Explain to the caretaker the importance of keeping the ear dry and instilling ear drops.

Ifno ear pain or discharge, praise the caretaker for his/her careful treatment. For acute ear infection if the caretaker has not yetfinished the 5 days of antibiotic, tell him/her to use all of it before stopping. For a child with chronic ear infection tell the caretaker tocontinue instilling ciprofloxacin ear drops for a total of 14 days.

FEEDING PROBLEM

After 5 days: Reassess feeding. See questions at the top of the COUNSEL chart.

Ask about any feeding problems found on the initial visit.

Counsel the caretaker about any new or continuing feeding problems. If you counsel the caretaker to make significant changes infeeding, ask him/her to bring the child back again in 5 days.

If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child's weight gain.

VERY LOW WEIGHT

After 30 days: Weigh the child and determine if the child is still very low weight for age or faltering.Reassess feeding. See questions at the top of the COUNSEL chart.

Treatment:

If the child is no longer very low weight for age or growth falter ing, praise the caretaker and encourage him/her to continuefeeding the child appropriately.

If the child is still very low weight for age or growth faltering, counsel the caretaker about any feeding problem found. Askthe caretaker to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weightregularly or is no longer very low weight for age.

Exception:If you do not think that feeding will improve, or if the child has lost weight, refer the child.

ANAEMIA

After 14 days:

Give iron and or folate. Advise mother to return in 14 days for more iron.

Continue giving iron and or folate every 14 days for 2 months.

If the child has palmar pallor after 2 months, refer for assessment.

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GIVE FOLLOW-UP CARE

HIV INFECTION

FIRST FOLLOW UP

Check if the child has had an HIV test and the result has been received. Make sure that the care taker receiveappropriate post-test counseling.

Assess the child's general condition.Do a full assessment > see Assess and Classify Pages 2 to 6

Treat the child for any classification found.

Check for oral thrush and mouth ulcers

Ask for any new feeding problems.Counsel the caretaker about any new or continuing feeding problems.

Check the child's weight and refer if there is growth faltering despite adequate diet

Check if the child is due for Vit A and de - worming or any immunizations. Give dose if due

Advise caretaker when to return immediately.

If HIV test positive

Continue cotrimoxazole prophylaxis for PCP. Counsel caretaker on importance of contnuing treatment

Counsel caretaker on any other problems and ensure community support is being given. Refer for furthercounselling if necessary

Follow up monthly after follow up

If HIV test is negative

Discountnue cotrimoxazole prophylaxis

If HIV test is not done

Continue cotrimoxazole prophylaxis for PCP

REPEAT FOLLOW UP EVERY MONTH

Asses the child's generalk condition. Do a full asssessment < see Assess and Clasify pages 2 - 6

Treat the Child for any classifications found

Check for oral thrush and mouth ulcers

Ask for any new feeding problems. Counsel ythe caretaker aboout any new or continuing feeding problemsCheck the child's weight and refer if there is growth faltering despite adequate diet

Check if child is due for Vitamin A and de-worming or any immunisation. Give dose if due

Advise caretaker when to return immediately

Give supply of cotrimoxazole for prophylaxis for PCP. Cousell caretaker on importance of continuing treatments

Counsel caretaker on any other problems and ensure community support is being given. Refer for further copunseling ifnecessary

Folllow - up monthly

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE CARETAKEROF THE NEXT FOLLOW-UP VISIT

ALSO, ADVISE THE CARETAKER WHEN TORETURN IMMEDAITELY . (SEE CPUNSEL CHART)

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COUNSEL

FOOD

Page 29 of 74


30/74

FOOD

Assess the Feeding o f Sick ch ild Under 2 Years (or if ch ild

has very low weight for age)Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the FeedingRecommendationsfor the child's age.

ASK - How are you feeding your child?

If the child is receivinganybreast milk, ASK:

How many timesduring the day?

Do you alsobreastfeed duringthe night?

If the receiving replacement millk, Ask;

What replacement milk are yougiving?

How many times during day andnight?

How much is given at each feed?

How is the milk prepared and whoprepares it?

What do you use to feed the child?

How are you cleaning the utensils?

Does the child take

any other food orfluids?

What food or fluids?

How many times perday?

What do you use tofeed the child?

If very low weight forage, ASK:

How large areservings?

Does the child

receive his ownserving?

Who feeds the childand how?

During this illness,has the child's feedingchanged?

If yes, how?

Health worker to encourage care taker togive extra feeds and discourage mixiedfeeing

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FOOD

Feeding Recommendatio ns During Sickness and Health

Up to 6 Months of age

Breastfeed as often as the childwants, day and night, at least 10times in 24 hours.

Do not give other foods or fluids.(noteven water, traditional medice,glucose, gripe water, other milks or

porridge unless medically advised)

6 Months up to 12 months

Continue breast feedingday and nightr - at least 8times in 24 hours

Breastfeed as often as thechild wants.

Give adequate servings of

complementary foods atleast 3 times per dayif breastfed plus snacks.

5 times per day if notbreastfed plus snacks.

Give to 1 cup (150 -200ml) per feeding of:

Thick porridge enrichedwith suger, oil, poundedground nuts or Kapentamashed beans oravocado, soya flour,egg, pounded driedcatapillars or greenleafy vigitables or

Nshima mashed withrelish cooked in oil orpounded g/nuts

Between main meals giveother foods, such as fruits(banana, mango, avocado,etc) or chikanda, mashedpumpkins, beans, g/nuts orboiled sweet potatoes, milk,

munkoyo or fiseke.serve and feed the childseparately in own dish.

12 months up to 2 years

Breastfeed as often as the child wants.

Actively feed the child at least 5 times a day.

Give 1-1 cups (200-300ml) of the followingper feeding:

Nshima with mashed or pounded relish.Do not feed only the soup.

Thick porridge enriched with one or moreof the following: sugar, oil, poundedkapenta, g/nuts, or dried catapillars,mashed beans, egg, milk.

In between main meals give other foods suchas fruits, samp, boiled casava, mashed beans, g/nuts, pumpkins, sweet potatoes, rice withsugar or oil.

Serve the child separetly and encourage orsupervise the eating.

,

2 years and older

Give family foods at least 3 mealseach day.

Also, twice daily, give nutritiousfruits/foods between meals, (suchas: banana, avocado, oranges,mango, pawpaw, guava), samp,

fried sweet potatoes, bred, rice, withsugar or oil, egg or beans.

* A good daily diet should be adequate in qua ntity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, o r pulses; and fruits and

vegetables.

Feeding recommendation for a child who is not feeding well during or after an illness

If still breast feeding, give more frequent, longer breast feeds, day and night.

Offer frequent small feedings

Use soft, varied, appetizing, favourite foods.

Clear a blocked nose if it interfers with the feeding.

Encourage andd assist the chilkd to eat if necessary

For a week after the illness is over, offer increased amount of food and continue to give favourite food and

encourage the cjhild to feed as much as possible

Feeding recommendations for a child who has PERSISTANT DIA

If still breastfeeding, give more frequent, longer breastfeeds, .

If taking other milk:

Replace with increased breastfeeding OR

Replace witgh fermented milk products, such as sour milk

Replace half the milk with thick porridge and added vegetavegetables and finely ground chicken or fish OR

For other foods, follow feeding recomendation for the child's a .

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FOOD

Feeding Recommendations For a Chi ld Who Has


If still breastfeeding, give more frequent, longer breastfeeds, day and night.

If taking other milk:

replace with increased breastfeeding OR

replace with fermented milk products, such as yoghurt OR

replace half the milk with nutrient-rich semisolid food.

For other foods, follow feeding recommendations for the child's age.

Counsel the Mother Abou t Feeding Problems

If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT

chart.)As needed, show the mother correct positioning and attachment for breastfeeding.

If the child is less than 6 months old and is taking other milk or foods:

Build mother's confidence that she can produce all the breast milk that the child needs.

Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk orfoods.

If other milk needs to be continued, counsel the mother to:

Breastfeed as much as possible, including at night.

Make sure that other milk is a locally appropriate breast milk substitute.Make sure other milk is correctly and hygienically prepared and given in adequate amounts.

Finish prepared milk within an hour.

If the mother is using a bottle to feed the child:

Recommend substituting a cup for bottle.

Show the mother how to feed the child with a cup.

If the child is not feeding well during illness, counsel the mother to:

Breastfeed more frequently and for longer if possible.

Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, andoffer frequent small feedings.

Clear a blocked nose if it interferes with feeding.

Expect that appetite will improve as child gets better.

If the child has a poor appetite:

Plan small, frequent meals.

Give milk rather than other fluids except where there is diarrhoea with some dehydration.

Give snacks between meals.

Give high energy foods.

Check regularly.

If the child has sore mouth or ulcers:

Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.

Avoid spicy, salty or acid foods.

Chop foods finely.

Give cold drinks or ice, if available.

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Counsel

Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.

If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.

Advise her to eat well to keep up her own strength and health.

Check the mother's immunization status and give her tetanus toxoid if needed.

Make sure she has access to:

Family planning

Counselling on STD and AIDS prevention.

FLUID

Advise the Moth er to Increase Fluid During Il lness

FOR ANY SICK CHILD:

Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milkgiven.

Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

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WHEN TO RETURN

Advise the Mother When to

Return to Health Wo rkerFOLLOW-UP VISIT:Advise the mother to come for follow-up atthe earliest time listed for the child's problems.

If the child has: Return for follow-up

in:

PNEUMONIA

DYSENTERY

FEVER: NO MALARIA, if fever persistsMEASLES WITH EYE OR MOUTHCOMPLICATIONS

2 days

MALARIA, if fever persists 3 days


ACUTE EAR INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEM

COUGH OR COLD, if not improving

5 days

ANAEMIA 14 days

VERY LOW WEIGHT FOR AGE 30 days

NEXT WELL-CHILD VISIT:Advise the mother to return for nextimmunization according to immunization schedule.

WHEN TO RETURN IMMEDIATELY

Advise mother to return immediately if the child has anyof these signs:

Any sick child Not able to drink orbreastfeed

Becomes sicker

Develops a fever

If child has COUGH OR COLD,also return if:

Fast breathing

Difficult breathing

If child has Diarrhoea, also returnif:

Blood in stool

Drinking poorly

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Assess, classify and treat the sick young infant aged up to 2

monthsASSESS AND CLASSIFY

ASSESS CLASSIFY IDENTIFY TREATMENT

DO A RAPID APRAISAL OF ALL WAITING INFANTS

ASK THE MOTHER WHAT THE YOUNG INFANT'S

PROBLEMS ARE

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

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

if initial visit, assess the child as follows:

USE ALL BOXES THAT MATCH THE

INFANT'S SYMPTOMS AND

PROBLEMS TO CLASSIFY THE

ILLNESS

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CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION


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ASK : LOOK , L ISTEN, FEEL:

Is the infant having

difficulty in feeding?

Has the infant had

convulsions (fits)?

Count the

breaths in one

minute. Repeat

the count if

more than 60

breaths per

minute.

Look for

severe chest

indrawing.

YOUNG

INFANT

MUST

BE

CALM

Measure axillary

temperature.

Look at the umbilicus. Is it

red or draining pus?

Look for skin pustules.

Look at the young

infant's movements.

If infant is sleeping, ask

the mother to wake

him/her.

Does the infant moveon his/her own?

If the young infant is not

moving, gently stimulate

him/her.

Does the infant not

move at all?

Any one of the following

signs

Not feeding well or

Convulsions or

Fast breathing (60 breaths

per minute or more) or

Severe chest indrawing or

Fever (37.5C* or above)

or

Low body temperature

(less than 35.5C*) orMovement only when

stimulated or no movement

at all.

P i n k :

VERY SEVERE

DISEASE

Give first dose of intramuscular antibiotics

Treat to prevent low blood sugar

Refer URGENTLY to hospital **

Advise mother how to keep the infant

warm on the way to the hospital

Umbilicus red or draining

pus

Skin pustules

Ye l l ow:

LOCAL

BACTERIAL

INFECTION

Give an appropriate oral antibiotic

Teach the mother to treat local infections at home

Advise mother to give home care for the young

infant

Follow up in 2 days

None of the signs of very

severe disease or local

bacterial infection

Green:

SEVERE DISEASE

OR LOCAL

INFECTION

UNLIKELY

Advise mother to give home care.

Class i fy ALL YOUNG

INFANTS

* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher.

** If referral is not possible, see I n teg ra ted Managemen t o f Ch i l dhood I l l ness, Management of the sick young infant module, Annex 2 "Where referral is not possible".

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THEN ASK: Does the young infant have diarrhoea*?


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IF YES, LOOK AND FEEL:

Look at the young infant's general condition:

Infant's movements

Does the infant move on his/her own?

Does the infant not move even when stimulated but

then stops?

Does the infant not move at all?

Is the infant restless and irritable?

Look for sunken eyes.

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

Very slowly (longer than 2 seconds)?or slowly?


Movement only when

stimulated or no

movement at all

Sunken eyes


very slowly.

P i n k :

SEVERE

DEHYDRATION

If infant has no other severe classification:

Give fluid for severe dehydration (Plan C)

OR

I f in fant a lso has another s evere

c lass i f i ca t ion:

Refer URGENTLY to hosp i tal with

mother g iv ing f requent s ips of ORS on

the way

Adv ise the mother to cont inue

breas t feeding


Restless and irritable

Sunken eyes


slowly.

Yel low:

SOME

DEHYDRATION

Give fluid and breast milk for somedehydration (Plan B)

I f in fant has any severe c lass i f i ca tion:

Refer URGENTLY to hosp i tal with

mother g iv ing f requent s ips of ORS on

the way

Adv ise the mother to cont inue

breas t feeding



Not enough signs to classify

as some or severe

dehydration.

Green:

NO

DEHYDRATION

Give fluids to treat diarrhoea at home and

continue breastfeeding (Plan A)



Classi fy

DIARRHOEA for

DEHYDRATION

* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than fecal matter).

The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

CHECK FOR JAUNDICE

I f jaund ice p resen t, ASK : LOOK AND FEEL :

When did the jaundice

appear first?

Look for jaundice (yellow

eyes or skin)

Look at the young infant's

palms and soles. Are theyyellow?

Any jaundice if age less

than 24 hours or

Yellow palms and soles at

any age

P i n k :

SEVERE

JAUNDICE

Treat to prevent low blood sugar

Refer URGENTLY to hosp i tal

Adv ise mother how to keep the in fant

warm on the way to the hospi ta l

Jaundice appearing after

24 hours of age and

Palms and soles not

yellow

Yel low:

JAUNDICE

Advise the mother to give home care for the

young infant

Advise mother to return immediately if palms

and soles appear yellow.

If the young infant is older than 14 days, refer

to a hospital for assessment

Follow-up in 1 day

No jaundice Green:

NO JAUNDICE

Advise the mother to give home care for the

young infant

CLASSIFYJAUNDICE

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THEN CHECK FOR HIV INFECTION


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ASK

Has the mother and/or young infant had an HIV test?

IF YES: Then note mother's and/or you ng infant 's HIV

status

Mother's HIV status:

Serological test POSITIVE or NEGATIVE

Young infant's HIV status:

Virological test POSITIVE or NEGATIVE

Serological test POSITIVE or NEGATIVE

I f mother is HIV pos i t i ve and NO p os i t i ve v i ro log ica l

tes t in chi ld ASK:

Is the young infant breastfeeding now?

Was the young infant breastfeeding at the time of test

or before it?

Is the mother and young infant on ARV prophylaxis?*

IF NO tes t : Mother and young in fant s ta tus unknown

Perform HIV test for the mother; if positive, perform

virological test for the young infant

Positive virological test in

young infant

Yel low:

CONFIRMED HIV

INFECTION

Give cotrimoxazole prophylaxis from age 4-6

weeks

Give HIV care/ART

Advise the mother on home care

Consider presumptive severe HIV disease as

described before

If infant less than 3 days old give Nevirapine and

start AZT if not yet administered

Follow-up in one month.

Mother HIV positive ANDnegative virological test

in young

infant breastfeeding or if

only stopped less than 6

weeks ago.

OR

Mother HIV positive, young

infant not yet tested

OR

Positive serological test in

young infant

Yel low:POSSIBLE HIV

INFECTION or HIV

EXPOSED

Give cotrimoxazole prophylaxis from age 4-6weeks

Start or continue ARV prophylaxis as per

national recommendations*

Do virological test at age 4-6 weeks or repeat 6

weeks after the child stops breastfeeding

Advise the mother on home care

Follow-up regularly as per national guidelines

Negative HIV test in mother

or young infant

Green:

HIV INFECTIONUNLIKELY

Treat, counsel and follow-up existing infections

No HIV test in the child or

mother.

Green:

HIV INFECTION

STATUS

UNKNOWN

Treat, counsel and follow-up existing

classification.

Advise the mother about feeding and about her

health.

Refer/do counselling and testing for HIV.

Classi fy

HIV

status

* PMTCT for breastfed child:

OPTION A - If the mother is already on AZT prophylaxis and the baby is on NVP prophylaxis, continue until 1 week after breastfeeding has stopped.

OPTION B - If the mother is already on triple ARV regime, continue until 1 week after breastfeeding has stopped and give the baby AZT or NVP from birth until 4-6 weeks of age.

PMTCT for non-breastfed child: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.

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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE: FOR BREAST FEEDING INFANTS


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If an infant has no indications to refer urgently to hospital:

Ask : LOOK, L ISTEN, FEEL :

Is the infant breastfed? If

yes, how many times in 24

hours?

Does the infant usually

receive any other foods or

drinks? If yes, how often?

If yes, what do you use to

feed the infant?

Determine weight for age.

Look for ulcers or white

patches in the mouth

(thrush).

Not well attached to breast

or

Not suckling effectively or

Less than 8 breastfeeds in

24 hours or

Receives other foods or

drinks or

Low weight for age or

Thrush (ulcers or white

patches in mouth).

Ye l low:

FEEDING

PROBLEM

OR

LOW WEIGHT

If not well attached or not suckling effectively,

teach correct positioning and attachment

If not able to attach well immediately, teach

the mother to express breast milk and feed by

a cup

If breastfeeding less than 8 times in 24 hours,

advise to increase frequency of feeding. Advise

the mother to breastfeed as often and as long as

the infant wants, day and night

If receiving other foods or drinks, counsel the

mother about breastfeeding more, reducing other

foods or drinks, and using a cupIf not breastfeeding at all:

Refer for breastfeeding counselling and

possible relactation

Advise about correctly preparing breast-

milk substitutes and using a cup

Advise the mother how to feed and keep the low

weight infant warm at home

If thrush, teach the mother to treat thrush at home


infant

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 ofinadequate feeding.

Green :

NO FEEDINGPROBLEM


infantPraise the mother for feeding the infant well

Classify FEEDING

ASSESS BREA STFEEDING:

Has the infant breastfed in the previous hour?

If the infant has not fed in the previous hour, ask the

mother to put her infant to the breast. Observe the

breastfeed for 4 minutes.

(If the infant was fed during the last hour, ask the mother

if she can wait and tell you when the infant is willing to

feed again.)

Is the infant well attached?

not wel l at tached good at tachment

TO CHECK ATTACHMENT, LOOK FOR:

Chin touching breast

Mouth wide open

Lower lip turned outwards

More areola visible above than below the mouth

(All of these signs should be present if the attachment is

good.)

Is the infant suckling effectively (that is, slow deep

sucks, sometimes pausing)?

not suckling effectively suckling effectively

Clear a blocked nose if it interferes with breastfeeding.

Page 39 of 74

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in NON-breastfed infants


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Use this chart for HIV EXPOSED infants when the national authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding AND the infant has no

indications to refer urgently to hospital:

Ask: LOOK, LISTEN, FEEL :

What milk are you giving?

How many times during

the day and night?

How much is given at

each feed?

How are you preparing

the milk?

Let mother demonstrate orexplain how a feed is

prepared, and how it is

given to the infant.

Are you giving any breast

milk at all?

What foods and fluids in

addition to replacement

feeds is given?

How is the milk being

given?

Cup or bottle?

How are you cleaning the

feeding utensils?

Determine weight for age.

Look for ulcers or white

patches in the mouth

(thrush).

Milk incorrectly or

unhygienically prepared o r

Giving inappropriate

replacement feeds or

Giving insufficient

replacement feeds or

An HIV positive mother

mixing breast and otherfeeds before 6 months or

Using a feeding bottle or

Low weight for age or

Thrush (ulcers or white

patches in mouth).

Yel low:

FEEDING

PROBLEM

OR

LOW WEIGHT

Counsel about feeding

Explain the guidelines for safe replacement

feeding

Identify concerns of mother and family about

feeding.

If mother is using a bottle, teach cup feeding

Advise the mother how to feed and keep the low

weight infant warm at home

If thrush, teach the mother to treat thrush at home


infant

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.

Green:

NO FEEDING

PROBLEM


infant

Praise the mother for feeding the infant well

Classif y FEEDING

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THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN

A STATUS:

S

IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN ABirth BCG OPV-0 200 000 IU to the mother within 6

weeks of delivery6 weeks DPT+HIB-1 OPV-1 Hepatitis B110 weeks DPT+HIB-2 OPV-2 Hepatitis B2

Give all missed doses on this visit.

Include sick infants unless being referred.

Advise the caretaker when to return for the next dose.

ASSESS OTHER PROBLEMS

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TREAT AND COUNSEL

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give First Dose of Intramuscu lar Antibiot ics

Give first dose of ampicillin intramuscularly and

Give first dose of gentamicin intramuscularly.

WEIGHT

AMPICILLINDose: 50 mg per kgTo a vial of 250 mg

GENTAMICIN

Add 1.3 ml sterile water = 250 mg/1.5ml

Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml

ORAdd 6 sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml

AGE = 7 daysDose: 7.5 mg per kg

1-


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Treat the Young Infant to Prevent Low Blood Sugar

If the young infant is able to breastfeed:

Ask the mother to breastfeed the young infant.

If the young infant is not able to breastfeed but is able to swallow:

Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10ml/kg) sugar water(To make sugar water: Dissolv e 4 level teaspoons of sugar (20 grams) in a 200-ml cu p of clean water).

If the young infant is not able to sw allow:

Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.

Teach the Mother How to Keep the Young Infant Warm on

the Way to the Hosp ital

Provide skin to skin contactOR

Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat,gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.

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Give an Appropriate Oral Antibiot ic for Local Bacterial

InfectionFirst-line antibiotic: ___________________________________________________________________________________________

Second-line antibiotic:_________________________________________________________________________________________

AGE or WEIGHT

COTRIMOXAZOLEtrimethoprim + sulphamethoxazole

Give 2 times daily for 5 days

AMOXICILLINGive 2 times

daily for 5 days

Adult Tabletsingle strength

(80 mg trimethoprim +400 mg sulphamethoxazole)

Pediatric Tablet(20 mg trimethoprim +

100 mg sulphamethoxazole)

Syrup(40 mg trimethoprim +

200 mg sulphamethoxazole)

Tablet

250 mg

Syrup125 mg

in 5 ml

Birth up to 1 month(


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Teach the Mother to Treat Local Infect ions at Home

Explain how the treatment is given.Watch her as she does the first treatment in the clinic.

Tell her to return to the clinic if the infection worsens.

To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth)

The mother should do the treatment twice daily for 5days:

Wash hands

Gently wash off pus and crusts with soap and water

Dry the areaPaint the skin or umbilicus/cord with fullstrength gentian violet (0.5%)

Wash hands

The mother should do the treatment four times daily for 7 days:

Wash hands

Paint the mouth with half-strength gentian violet (0.25%) using a soft clothwrapped around the finger

Wash hands

To Treat Diarrhoea, See TREAT THE CHILD Chart .

Immun ize Every Sick Young Infant, as Needed

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COUNSEL THE MOTHER


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COUNSEL THE MOTHER

Teach Correct Posit ioning and Attachment for

Breastfeeding

Show the mother how to hold her infant.

with the infant's head and body in line.

with the infant approaching breast with nose opposite to the nipple.

with the infant held close to the mother's body.

with the infant's whole body supported, not just neck and shoulders.

Show her how to help the infant to attach. She should:touch her infant's lips with her nipple

wait until her infant's mouth is opening wide

move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple.

Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Teach the Moth er How to Express Breast Milk

Ask the mother to:

Wash her hands thoroughly.

Make herself comfortable.

Hold a wide necked container under her nipple and areola.

Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other (at least 4

cm from the tip of the nipple).Compress and release the breast tissue between her finger and thumb a few times.

If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast asbefore.

Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not tosqueeze the nipple or to rub the skin or move her thumb or finger on the skin.

Express one breast until the milk just drips, then express the other breast until the milk just drips.

Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.

Stop expressing when the milk no longer flows but drips from the start.

Teach th e Mother How to Feed by a Cup

Put a cloth on the infant's front to protect his clothes as some milk can spill.

Hold the infant semi-upright on the lap.

Put a measured amount of milk in the cup.

Hold the cup so that it rests lightly on the infant's lower lip.Tip the cup so that the milk just reaches the infant's lips.

Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.

Teach the Moth er How to K eep the Low Weight Infant Warm

at Home

Keep the young infant in the same bed with the mother.

Keep the room warm (at least 25C) with home heating device and make sure that there is no draught of cold air.

Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately andthoroughly after bathing and clothe the young infant immediately.

Change clothes (e.g. nappies) whenever they are wet.

Provide skin to skin contact as much as possible, day and night. For skin to skin contact:

Dress the infant in a warm shirt open at the front, a nappy, hat and socks.

Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's head turned to one side.

Cover the infant with mother's clothes (and an additional warm blanket in cold weather).

When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infantwith extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket.

Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.

Breastfeed the infant frequently (or give expressed breast milk by cup).

Adv ise the Mother to Give Home Care for the Young Infant

1. EXCLUSIVELY BREASTFEED THE YOUNG INFANTGive only breastfeeds to th

IMCI Chart -Zambia August 2012

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