Integrated Management of Childhood Illness 80 Pages

8/9/2019 Integrated Management of Childhood Illness 80 Pages

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INTEGRATED MANAGEMENT OF CHILDHOODILLNESS (IMCI)

Integrated Management of Childhood Illne (IMCI) is an integrated and systematicapproach to child health which developed by United Nations Childrens Fund (UNICEF) and

World ealth !rgani"ation (W!) in #$$% in response o& a serious challenge in providing'uality care to sic children

I*CI &ocuses on the well+being o& the whole child ,lthough the ma-or stimulus &or I*CI came&rom the needs o& curative care. the strategy combines improved management o& childhoodillness with aspects o& nutrition. immuni"ations. and other important disease prevention andhealth promotion elements that are implemented by &amilies and communities as well as byhealth &acilities

GOAL OF IMCI

/y %0#0. to reduce the in&ant and under+&ive mortality rate by at least one third. in pursuit o&

the goal o& reducing it by two thirds by %0#1

O!"ECTI#ES OF IMCI

2educe deaths and the &re'uency and severity o& illness and disability

3o contribute to improved growth and development under &ive years o& age

Includes both preventive and curative elements implemented by &amilies. communities and

health &acilities

IM$LEMENTATION OF IMCIIntroducing and implementing the I*CI strategy in a country is a phased process that re'uiresa great deal o& coordination among e4isting health programs and services It involves woring

closely with local governments and ministries o& health to plan and adapt the principles o& theapproach to local circumstances 3he main steps are5

,dopting an integrated approach to child health and development in the national health

policy

,dapting the standard I*CI clinical guidelines to the countrys needs. available drugs.

policies. and to the local &oods and language used by the population

Upgrading care in local clinics by training health worers in new methods to e4amine and

treat children. and to e&&ectively counsel parents

*aing upgraded care possible by ensuring that enough o& the right low+cost medicines

and simple e'uipment are available

6trengthening care in hospitals &or those children too sic to be treated in an outpatientclinic

7eveloping support mechanisms within communities &or preventing disease. &or helping

&amilies to care &or sic children. and &or getting children to clinics or hospitals when needed

A$$LICATION OF IMCII*CI is applied in outpatient settings lie clinics. health centers. maternal and child health andhospitals It relies on (#) case detection (using simple clinical signs) and (%) empirical treatment(based on action+oriented classi&ications) 3he empirical treatment attempts to combine the

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lessons learned &rom disease+speci&ic control programs over the past #1 years into an e&&ectiveapproach &or managing the sic child

!ENEFITS OF IMCI

Cost+e&&ective

2esponds to demand

,ddresses ma-or child health problems by addressing the most important causes o&childhood death and illness

8romotes prevention as well as cure

8romotes cost

Improves e'uity

%H& IS IMCI !ETTER THAN SINGLE'CONDITION A$$ROACHES

Children brought &or medical treatment in the developing world are o&ten su&&ering &rom

more than one condition. maing a single diagnosis impossible

I*CI ensures the combined treatment o& the ma-or childhood illnesses. emphasi"ing

prevention o& disease through immuni"ation and improved nutrition

IMCI STRATEG&3he core o& the I*CI strategy is integrated case management o& the most common childhoodproblems. with a &ocus on the most important causes o& death , guided process o& adaptationensures that the guidelines. and the learning materials that go with them. re&lect theepidemiology within a country and are tailored to &it the needs. resources and capacity o& acountrys health system

3he strategy &ocuses on the child as a whole. rather than on a single disease or condition 6icchildren o&ten arrive at primary health care &acilities with a number o& sicnesses and have tobe managed in an integrated manner at home and at the clinic

In Health Failitie. I*CI strategy promotes

6peeding up the re&erral o& severely ill children

Improving sills o& 8C sta&&

3he accurate diagnosis o& childhood illnesses in outpatient clinics

,ppropriate combined treatment o& all ma-or illnesses

In the Home Setting. I*CI strategy promotes

Correct implementation o& prescribed care9and drugs

Improved nutrition and preventative care

,ppropriate care seeing behaviors

3he I*CI 6trategy has * om+onent 3hese are5(#) Improvement o& ealth Worer 6ills

+3his taes the &orm o& training in the case management o& sic children(%) Improvement o& the ealth 6ystem

+2e'uires that the health system is strengthened to support the strategy in the &ollowingways5

Ensuring the availability o& essential drugs and supplies

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!rgani"ation o& the hospital emergency area to support rapid evaluation and

management o& sic children

3raining o& health worers in Emergency 3riage ,ssessment and 3reatment (E3,3)

,dherence to National policies &or standards o& care

,vailing -ob aides in critical areas

(:) Improvement o& Family and Community 8ractices

+,ddresses the household and community+ealth care strategies will start at the community level

, !road Area of $oiti-e $ratie+I& communities and households observed some positive practices. it would go a long way in

reducing child deaths, ;rowth 8romotion and 7evelopment

E4clusive breast&eeding &or


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3he I*CI process can be used by doctors. nurses and other health pro&essionals who see sicin&ants and children aged &rom # wee up to &ive years Case management can only bee&&ective to the e4tent that &amilies bring their sic children to a trained health worer &or care ina timely way

. MOST COMMON CA/SES OF ILL HEALTH AND DEATH AMONG THE /NDER'FI#ES

8neumonia

7iarrhea

*alaria

*easles

*alnutrition

ELEMENTS OF IMCI CASE MANAGEMENT $ROCESS(#) Focused ,ssessment

+,ssess a child by

checing &irst &or danger signs (or possible bacterial in&ection in a young in&ant)

asing 'uestions about common conditions

e4amining the child. and checing nutrition and immuni"ation status

assessment includes checing the child &or other health problems

(%) Classi&ication+Classi&y a childs illnesses using a color+coded triage system /ecause many children have

more than one condition. each illness is classi&ied according to whether it re'uires5

, classi&ication in a +in0 ro1 needs urgent attention and re&erral or admission &or

inpatient care 3his is a severe classi&ication

, classi&ication in a 2ello1 ro1means that the child needs an appropriate oral drug or

other treatment 3he treatment includes teaching the childs caretaer how to give oraldrugs or to treat local in&ections at home Aou also must advise her about caring &or the

child at home and when she should return, classi&ication in a green ro1means the child does not need speci&ic medical treatment

such as antibiotics 3each the childs caretaer how to care &or the child at home(:) 3reatment

+,&ter classi&ying all conditions. identi&y speci&ic treatments &or the child I& a child re'uiresurgent re&erral. give essential treatment be&ore the patient is trans&erred I& a child needstreatment at home. develop an integrated treatment plan &or the child and give the &irst dose o&drugs in the clinic I& a child should be immuni"ed. give immuni"ations

+8rovide practical treatment instructions. including teaching the caretaer how to give oraldrugs. how to &eed and give &luids during illness. and how to treat local in&ections at home ,sthe caretaer to return &or &ollow+up on a speci&ic date. and teach her how to recogni"e signs

that indicate the child should return immediately to the health &acility(=) Counsel

+,ssess &eeding. including assessment o& breast&eeding practices. and counsel to solve any&eeding problems &ound 3hen counsel the mother about her own health(1) Follow+up

+When a child is brought bac to the clinic as re'uested. give &ollow+up care and necessary@reassess the child &or new problems

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S/MMAR& OF THE INTEGRATED CASE MANAGEMENT $ROCESS

1

IF NO /RGENT REFERRALis needed or possible

IDENTIF& TREATMENTneeded &or the childs classi&ications5Identi&y speci&ic medical treatmentsand9or advice

FOLLO%'/$ care5 ;ive &ollow+up care when the child returns to the clinic and. i& necessary. reassess the child&or new problems

CO/NSEL THE MOTHERUsing the process5 AS3. $RAISE. AD#ISE. CHEC3*Food and feeding *Fluid intake during illness *When toreturn *Her own health.

TREAT THE CHILD;ive the &irst dose o& oral drugs in the clinicand9or advise the childs caretaer 3each thecaretaer how to give oral drugs and how totreat local in&ections at home I& needed. giveimmuni"ations

3hen chec the child malnutrition andanemia3hen chec the childs immuni"ation status

3hen chec the child &or other problems

For all sic children age # wee up to 1 years who are brought to a &irst+level health &acility

ASSESS THE CHILD

Che0 the child &or danger signs

Then a04

7oes the child have cough or di&&icultyin breathingB7oes the child have diarrheaB7oes the child have &everB7oes the child have ear problemsB

For any 52e6answerAS3&urther 'uestionsLOO37 LISTEN7 FEEL/ased on this classi&y illness

CLASSIF& THE CHILD8S ILLNESSUse a color+coded triage system to classi&y the childs main symptoms and his or her nutrition or&eeding status

IF /RGENT REFERRALis needed and possible

IDENTIF& /RGENT$RE'REFERRAL TREATMENT(S)

needed &or the childs classi&ications

TREAT THE CHILD;ive urgent pre+re&erraltreatment(s) needed

REFER THE CHILD


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ASSESSMENT /SING THE IMCI STRATEG&4 IMCI CASE MANAGEMENT CHARTSIMCI CASE MANAGEMENT CHART

3he I*CI case management process is presented on a series o& charts that show these'uence o& steps and provide in&ormation &or per&orming them7ecide which age group the child is in5

,ge # wee up to % months. or

,ge % months up to 1 years

+Up to 1 years means the child has not yet had his or her &i&th birthday+, child who is % months old would be in the group % months up to 1 years. not in the group

# wee up to % months3he case management process &or sic childrenage9 month :+ to . 2earis presented onthree charts titled5

,66E66 ,N7 C,66IFA 3E 6ICD CI7. 32E,3 3E CI7 and C!UN6E 3E

*!3E2*anagement o& the young in&ant age; 1ee0 :+ to 9 monthis somewhat di&&erent &rom olderin&ants and children It is described on a di&&erent chart titled5

,66E66. C,66IFA ,N7 32E,3 3E 6ICD A!UN; INF,N3

STE$S IN THE IMCI CASE MANAGEMENT $ROCESS# ,ssess the sic child or sic young in&ant

% Classi&y the illness: Identi&y treatment= 3reat the child or young in&ant1 Counsel the mother


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ASSESS AND CLASSIF& THE SIC3 CHILD AGED 9 MONTHS /$ TO . &EARS

,s the mother or caretaer about the childs problem

7etermine i& this is an initialor follo1':+visit &or this problem

I& FOLLO%'/$ #ISITS(the child has been seen a &ew days ago &or the sameillness9i& the childs condition improved. still the same or is getting better). use the&ollow+up instructions on the TREAT THE CHILD hart< I& INITIAL #ISIT (#st visit &or this episode o& an illness or problem). assess thechild as &ollows5

CHEC3 FOR GENERAL DANGER SIGNSAS3G Is the child able to drin or breast&eedBG 7oes the child vomit everythingBG as the child had convulsionsB

LOO3G 6ee i& the child is lethargic or unconsciousG Is the child convulsing nowB

If &ES

MA3E S/RE THE CHILD %ITHAN& GENERAL DANGER SIGNIS REFERRED a&ter the &irst doseo& an appropriate antibiotic andother urgent treatments

, child with any general danger

sign needs U2;EN3 attention@complete the assessment and anypre+re&erral treatment immediatelyso that re&erral is not delayed

,s the mother or caretaer about the %hen a main 2m+tom i +reent4Main S2m+tom assess the child &urther &or signs related to Cough or di&&icult breathing the main symptom 7iarrhea classi&y the illness according to the signs Fever and which are present or absent Ear problem*alnutrition9,nemia

Chec &or signs o& malnutrition and anemia and classi&y the childs nutritional status

Chec the childs immuni"ation status and decide i& the child needs any immuni"ationstoday

,ssess any other problems

3hen5 Identi&y 3reatment. 3reat the Child and Counsel the *other


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GENERAL DANGER SIGNS'AS3'(#) Unable to drin or breast&ed

+too wea to drin and is not able to suc or swallow when o&&ered a drin or breast+&eed+i& you are not sure about the mothers answer. as her to o&&er the child a drin o& cleanwater or breast mil oo to see i& the child is swallowing the water or breast mil+a child who is breast&ed may have di&&iculty sucing when his nose is bloced I& the childsnose is bloced. clear it I& the child can breast&eed a&ter the nose is cleared. the child doesnot have the danger sign

(%) >omits Everything+a child who vomits everything will not be able to hold down &ood. &luids or oral drugs , childwho vomits several times but can hold down some &luids does not have this general dangersign+I& you are not sure o& the mothers answers. as her to o&&er the child a drin 6ee i& the childvomits

(:) Convulsions (during the present illness)+during a convulsion. the childs arms and legs sti&&en because the muscles are contracting+the child may lose consciousness or not be able to respond to spoen directions orhandling. even i& eyes are open+as the mother i& the child has had convulsions during this current illness Use words themother understands 3he mother may now convulsions as H&its or Hspasms or H-erymovements

'LOO3'(=),bnormally sleeping or di&&iculty to awae (lethargic or unconscious)

+a lethargic child is not awae and alert when she should be 3he child is drowsy and doesnot show interest in what is happening around him !&ten the lethargic child does not loo athis mother or watch your &ace when you tal+the child may stare blanly and appear not to notice what is going on around him ,nunconscious child cannot be waened e does not respond when he is touched. shaen or

spoen to+as the mother i& the child seems unusually sleepy or i& she cannot wae the child oo tosee i& the child waens when the mother tals or shaes the child or when you clap yourhands

MAIN S&M$TOMS(;) Co:gh or diffi:lt2 in =reathing

+, child with cough or di&&icult breathing may have pneumonia or another severe respiratoryin&ection $ne:monia is an in&ection o& the lungs /oth bacteria and viruses can causepneumonia 8neumonia is o&ten due to bacteria 3he most common are 6treptococcuspneumoniae and emophilus in&luen"ae Children with bacterial pneumonia may die &rom

hypo4ia (too little o4ygen) or sepsis (generali"ed in&ection)+Diffi:lt =reathing is any unusual pattern o& breathing *others describe this in di&&erentways 3hey may say that their childs breathing is H&ast or Hnoisy or Hinterrupted

FOC/SED ASSESSMENTDOES THE CHILD HA#E CO/GH OR DFFIC/LT& IN !REATHING

J

If NOAS3about the ne4t main symptoms5 diarrhea. &ever. earproblemsCHEC3&or malnutrition and anemia. immuni"ation statusand &or other problems


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,6D5 For ow ongB

+, child who has had cough or di&&icult breathing &or more than :0 days has a chroniccough 3his may be a sign o& tuberculosis. asthma. whooping cough or another problem

Count the /reaths in !ne *inute

+Aou must count the breaths the child taes in one minute to decide i& the child has &astbreathing 3he child must be 'uiet and calm when you loo and listen to his breathing+I& the child is &rightened. crying or angry. you will not be able to obtain an accurate count o&the childs breaths+3he cut+o&& &or &ast breathing depends on the childs age Normal breathing rates arehigher in children age % months up to #% months than in children age #% months up to 1years For this reason. the cut+o&& &or identi&ying &ast breathing is higher in children %months up to #% months than in children age #% months up to 1 years

AGE FAST !REATHING IS4

K% months old


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+3o loo and listen &or stridor. loo to see when the child breathes IN 3hen listen &or stridor 8utyour ear near the childs mouth because stridor can be di&&icult to hear 6ometimes you willhear a 1et noiei& the childs nose is bloced Clear the nose. and listen again /e sure toloo and listen &or stridor when the child is calm Aou may hear a 1hee>ing noiewhen thechild breathes !U3 3his is not stridor

CLASSIF& CO/GH OR DIFFIC/LT !REATHING

SIGNS CLASSIF& ASTREATMENT

(Urgent pre+re&erral treatments are in boldprint)

IF THE CHILD HAS ,ny o& general

danger signs Chest indrawing

6tridor in a

calm child

SE#ERE$NE/MONIA OR#ER& SE#ERE

DISEASE

Gi-e firt doe of a++ro+riate

anti=ioti Refer /RGENTL& to ho+ital

/RGENTREFERRAL

IF THE CHILD HAS Fast /reathing

$NE/MONIA

Gi-e oral anti=ioti for * da2 I& whee"ing (even i& it disappeared

a&ter rapidly acting bronchodilator) give aninhaled bronchodilator &or 1 days 6oothe the throat and relieve the

cough with a sa&e remedy I& coughing &or more than : wees or i&

having recurrent whee"ing. re&er &orassessment &or 3/ or asthma ,dvise the mother when to return

immediately Follow+up in % days

S$ECIFICTREATMENT

IF CHILD HAS No signs o&

pneumonia or verysevere disease

CO/GH ORCOLD

I& whee"ing (even i& it disappeared

a&ter rapidly acting bronchodilator) give aninhaled bronchodilator &or 1 days 6oothe the throat and relieve the

cough with a sa&e remedy

I& coughing &or more than : wees or i&

having recurrent whee"ing. re&er &orassessment &or 3/ or asthma

HOMEMANAGEMENT

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

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TREATMENT

GI#E AN A$$RO$RIATE ORAL ANTI!IOTICFOR $NE/MONIA7 AC/TE EAR INFECTIONFI263+INE ,N3I/I!3IC5Co'trimo?a>ole6EC!N7+INE ,N3I/I!3IC5 Amo?2illin

AGE OR%EIGHT

CO'TRIMO@AOLE(trimethoprim L sulphametho4a"ole)

;ive two times daily &or : days &or pneumonia;ive two times daily &or 1 days &or acute ear in&ection

AMO@&CILLIN;ive two times daily &or :

days &or pneumonia;ive two times daily &or 1

days &or acute ear in&ection

AD/LT TA!LETJ0 mg trimethoprim

L =00 mgsulphametho4a"ole

$EDIATRICTA!LET

%0 mg trimethoprim L#00 mg

sulphametho4a"ole

S&R/$=0 mg trimethoprim

L %00 mgsulphametho4a"ole

per 1 ml

TA!LET%10 mg

S&R/$#%1 mg per 1

ml

% months up to#% months

(=MK#0 g)

% 10 ml O 1 ml

#% months upto 1 years

(#0MK#$ g)# : 1 ml #1 #1 ml

,mo4ycillin should be used i& there is high co+trimo4a"ole resistance

GI#E INHALED SAL!/TAMOL FOR %HEEING/e of S+aer

+, spacer is a way o& delivering the bronchodilator drugs e&&ectively into the lungs No childunder 1 years should be given an inhaler without a spacer , spacer wors as well as anebuli"er i& correctly used

From salbutamol metered dose inhaler (#00 Pg9pu&&) give % pu&&s 2epeat up to : times every #1 minutes be&ore classi&ying pneumonia

+6pacers can be made in the &ollowing way5

Use a 100ml drin bottle or similar

Cut a hole in the bottle base in the same shape as the mouthpiece o& the inhaler 3his can

be done using a sharp ni&e

Cut the bottle between the upper 'uarter and the lower :9= and disregard the upper

'uarter o& the bottle

Cut a small > in the border o& the large open part o& the bottle to &it to the childs nose and

be used as a mas

Flame the edge o& the cut bottle with a candle or a lighter to so&ten it In a small baby. a mas can be made by maing a similar hole in a plastic (not

polystyrene) cup

,lternatively commercial spacers can be used i& available

+3o use an inhaler with a spacer

2emove the inhaler cap 6hae the inhaler well

Insert mouthpiece o& the inhaler through the hole in the bottle or plastic cup

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3he child should put the opening o& the bottle into his mouth and breathe in and out

through the mouth

, carer then presses down the inhaler and sprays into the bottle while the child continues

to breathe normally Wait &or three to &our breaths and repeat &or total o& &ive sprays

For younger children place the cup over the childs mouth and use as a spacer in the

same way

+I& a spacer is being used &or the &irst time. it should be primed by =+1 e4tra pu&&s &rom theinhaler

TREAT THE CHILD TO $RE#ENT LO% !LOOD S/GAR LE#EL

I& the child is able to breast&eed

+,s the mother to breast&eed the child

I& the child is not able to breast&eed but is able to swallow

+;ive e4pressed breast mil or a breast mil substitute+I& neither o& these is available. give sugar water+;ive :0+10 ml o& mil or sugar water be&ore departure

To ma0e :gar 1ater5 7issolve = level teaspoons o& sugar (%0 grams) in a %Q!+mlcup o&

clean water I& the child is not able to swallow

+;ive 10 ml o& mil or sugar water by nasogastric tube

I& the child is di&&icult to awaen or unconscious. start I> in&usion

+;ive1 ml9g o& #0Ro& de4trose solution (7#0) over a &ew minutes+;ive # ml9g o& 10R (710) by slow push

SOOTHE THE THROAT AND RELIE#E CO/GH %ITH A SAFE REMED&

Safe remedie to reommend5 /reast mil &or e4clusively breast&ed in&ant

3amarind. Calamansi and ;inger

Harmf:l remedie to dio:rage5 Codeine cough syrup

!ther cough syrups !ral and nasal decongestants

(9) Diarrhea+7iarrhea occurs when stools contain more water than normal It is also called loose orwatery stools It is de&ined as three or more loose or watery stools in a %=+hour period+It is common in children. especially those between < months and % years o& age It is morecommon in babies under < months who are drining cows mil or in&ant &ormulas Fre'uentpassing o& normal stools is not diarrhea

T2+e of Diarrhea

Looe or %ater2+ most diarrheas which cause by dehydration

A:te diarrhea+ an episode o& diarrhea lasts less than #= days which causes dehydration

and contributes to malnutrition

$eritent diarrhea+ diarrhea lasts #= days or more o&ten causes nutritional problems that

contribute to deaths in children who have diarrhea

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D2enter2+ diarrhea with blood in the stool. with or without mucus@ the most common

cause o& dysentery is 6higella bacteria ,moebic dysentery is not common in young children, child may have both watery diarrhea and dysentery

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FOC/SED ASSESMENTDOES THE CHILD HA#E DIARRHEA

,6D5 For ow ongB

+7iarrhea which lasts #= days or more is persistent diarrhea

,6D5 Is there /lood in the 6toolB

+,s the mother i& she has seen blood in the stools at any time during this episode o&diarrhea

!!D at the Childs ;eneral Condition

+Chec &or ign of deh2dration

child is restless and irritable all the time or every time he is touched or handled I&an in&ant or child is calm when breast&eeding but again restless and irritable when hestops breast&eeding. he has the sign Hrestless and irritable child was lethargic or unconscious

sunen eyes

child is not able to tae &luid in his mouth and swallow it

child is drining poorly i& the child is wea and cannot drin without help e may

be able to swallow only i& &luid is put in his mouth drining eagerly. thirsty i& it is clear that the child wants to drin When the water

is taen away. see i& the child is unhappy because he wants to drin more 6in pinch goes bac5 very slowly (longer than % seconds)@ slowly (sin stays up

even &or a brie& instant)

#=

If NOAS3 about the ne4t main symptoms5 &ever. ear problemCHEC3 &or malnutrition and anemia. immuni"ation statusand &or other problems

If &ESAS34 LOO37 LISTEN7 FEEL4 For how longB oo at the childs general condition

Is the child Is there blood in the ethargic or unconsciousBstool 2estless or irritableB

oo &or sunen eyes !&&er the child &luid Is the child

Not able to drin or drining poorlyB7rining eagerly. thirstyB

8inch the sin o& the abdomen 7oes it go bac

>ery slowly (longer than % seconds)B6lowlyB


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CLASSIF& DEH&DRATION


(Urgent pre+re&erral treatments are inbold print)

9 or more of thefollo1ing ign4 ethargic or

unconscious 6unen eyes

Not able to

drin or driningpoorly 6in pinch

goes bac veryslowly

SE#EREDEH&DRATION

I& child has no other severeclassi&ication

;ive &luid &or severedehydration (8lan C)If hild alo ha another e-erelaifiation Refer /RGENTL& to ho+ital

1ith mother gi-ing freB:enti+ of ORS on the 1a2 Ad-ie the mother to

ontin:e =reatfeedingIf hild i 9 2ear or older andthere i holera in 2o:r area Gi-e anti=ioti for holera

/RGENTREFERRAL

9 of the follo1ingign4 2estless.

irritable 6unen eyes

7rins eagerly.

thirsty 6in pinch

goes bac very slowly

I& a child has one

sign in the pin (top)

row and one sign inthe yellow (middle)row. classi&y the childin the yellow row

SOME DEH&DRATION

;ive &luid and &ood &or

some dehydration (8lan /)If hild alo ha another e-erelaifiation4 Refer /RGENTL& to

ho+ital7 1ith mother gi-ingfreB:ent i+ of ORS on the1a2< Ad-ie mother to

ontin:e =reatfeeding< ,dvise the mother when to

return immediately Follow up in 1 days i& not

improving

S$ECIFICTREATMENT

Not enough signs toclassi&y as some orsevere dehydration

NO DEH&DRATION

;ive &luid and &ood to treat

diarrhea at home(8lan ,) ;ive Sinc supplements

,dvise mother when to

return immediately Follow up in 1 days i& not

improving

HOMEMANAGEMENT

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CLASSIF& $ERSISTENT DIARRHEA



7ehydrationpresent

SE#ERE $ERSISTENTDIARRHEA

3reat

dehydration be&ore re&erral unless

the child has another severeclassi&ication 2e&er to

hospital

/RGENTREFERRAL

No

dehydration

$ERSISTENTDIARRHEA

,dvise the mother on &eeding a

child who has 8E26I63EN37I,22E, ;ive multivitamins and minerals

(including "inc) &or #= days Follow up in 1days

,dvise mother when to return

immediately

S$ECIFICTREATMENT

CLASSIF& D&SENTER&



/lood in the

stoolD&SENTER&

Gi-e i+roflo?ain for *

da2 Follow up in % days

S$ECIFICTREATMENT

TREATMENT

GI#E AN A$$RO$RIATE ORAL ANTI!IOTICFOR D&SENTER&;ive Cipro&lo4acin (#1mg9g9dayT% times a day &or : days)

AGE

TA!LET%10 mg

TA!LET100 mg

DOSE ta= DOSE ta=

ess than < months tablet tablet

< months up to 1 years # tablet tablet

FOR CHOLERAFI263+INE ,N3I/I!3IC5Tetra2line6EC!N7+INE ,N3I/I!3IC5 Er2throm2in

AGE or %EIGHT TETRAC&CLINE;ive = times daily &or : days

ER&THROM&CIN;ive = times daily &or : days

TA!LET TA!LET

#


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%10 mg %10 mg

% years up to 1 years(#% + #$ g)

# #

GI#E #ITAMIN A#ITAMIN A S/$$LEMENTATION

;ive &irst dose any time a&ter < months o& age to , CI72EN

3herea&ter give vitamin , every si4 months to , CI72EN

#ITAMIN A TREATMENT

;ive an e4tra dose o& >itamin , (same dose as &or supplementation) as part o& treatment i&

the child has measles or 8E26I63EN3 7I,22E,

I& the child has had a dose o& >itamin , within the past month. 7! N!3 ;I>E >I3,*IN ,

,lways record the dose o& >itamin , given on the childs chart

AGE #ITAMIN A DOSE

< months up to #% months #00 000 IU

!ne year and older %00 000 IU

E@TRA FL/ID FOR DIARRHEA AND CONTIN/ED FEEDING

$LAN A4 TREAT DIARRHEA AT HOME+3reat a child who has diarrhea and N! 7EA72,3I!N with 8lan ,

, R:le of Home TreatmentR/LE ;4 GI#E E@TRA FL/ID

+;ive as much &luid as the child will tae 3he purpose o& giving e4tra &luid is to replace the&luid lost in diarrhea and thus to prevent dehydration 3he critical action is to give more &luidthan usual. as soon as the diarrhea starts

3ell the mother or caretaer

/reast&eed &re'uently and longer at each &eeding

I& the child is e4clusively breast&ed. give !26 or clean water in addition to breast

mil I& the child is not e4clusively breast&ed. give one or more o& the &ollowing5

!26 solution

Food+based &luids (such as soup. rice water. or Vbuo -uiceV).

It is especially important to give !26 at home when5

the child has been treated with 8lan / or 8lan C during the visit

the child cannot return to a health center i& the diarrhea gets worse 3each the mother or caretaer how to mi4 and give !26 ;ive % pacets o& !26 to use at

home+When you give the mother !26. show her how to mi4 the !26 solution and how to give it

to her child ,s the mother to practice doing it hersel& while you observe her+E4plain to the mother that she should mi4 &resh !26 solution each day in a cleancontainer. eep the container covered. and throw away any solution remaining &rom the daybe&ore

Ste+ for ma0ing ORS ol:tion#


18/86

a Wash your hands with soap and waterb 8our all the powder &rom one pacet into a clean container Use any available container.

such as a -ar. bowl or bottlec *easure # liter o& clean water (or correct amount &or pacet used) It is best to boil and

cool the water. but i& this is not possible. use the cleanest drining water availabled 8our the water into the container *i4 well until the powder is completely dissolvede 3aste the solution so you now how it tastes

6how the mother or caretaer how much &luid to give in addition to the usual &luid intae

+E4plain to the mother that her child should drin the usual &luids that the child drins eachday and e4tra &luid 6how the mother how much e4tra &luid to give a&ter each loose stool

Up to % years 10 to #00 ml a&ter each loose stool% years or more #00 to %00 ml a&ter each loose stool

+3he bene&it o& !26 solution is that it replaces the &luid and salts that the child loses in thediarrhea and prevents the child &rom getting sicer 3ell the mother to5

;ive &re'uent small sips &rom a cup

I& the child vomits. wait #0 minutes 3hen continue. but more slowly

Continue giving e4tra &luid until the diarrhea stopsR/LE 94 GI#E INC S/$$LEMENTS (age 9 month :+ to . 2ear)

+3ell the mother how much "inc to give (%0mg tab)

% months up to < monthsT#9% tablet daily &or #= days

< months or moreT# tablet daily &or #= days

+6how the mother how to give Sinc 6upplements

InfantTdissolve tablet in a small amount o& e4pressed breast mil. !26 or clean water

in a cup

Older hildrenTtablets can be chewed or dissolved in a small amount o& clean water in

a cupR/LE *4 CONTIN/E FEEDING(e?l:i-e =reatfeeding if age le than month)

R/LE ,4 %HEN TO RET/RN 3ell the mother o& any sic child that the signs to return are5

Not able to drin or breast&eed

/ecomes sicer

7evelops a &ever

I& the child has diarrhea. also tell the mother to return i& the child has5

/lood in stool

7rining poorly

$LAN !4 TREAT SOME DEH&DRATION %ITH ORS

+3reat a child who has diarrhea and 6!*E 7EA72,3I!N with 8lan /+;ive in health center recommended amount o& !26 over =+hour period

DETERMINE AMO/NT OF ORS TO GI#E D/RING THE FIRST , HO/RS

AGEup to = *onths = *onths+#%

*onths#% *onths+%

Aears% Aears +1

Aears

%EIGHT K< g < to K#0 g #0 to K#% g #% to K%0 g

AMO/NT OF FL/ID (ml)O#ER , HO/RS

%00+=10 =10+J00 J00+$


19/86

Use the childs age only when you do not now the weight 3he appro4imate amount o& !26 re'uired(in ml) can also be calculated by multiplying the childs weight in g times 1

I& the child wants more !26 than shown. give more

For in&ants under < months o& age who are not breast&ed. also give #00+%00 ml clean water

during this period

SHO% THE MOTHER HO% TO GI#E ORS SOL/TION

I& the child is less than % years. show her how to give a spoon&ul &re'uently I& the child is

older. show her how to give &re'uent sips &rom a cup

I& the child vomits. the mother should wait about #0 minutes be&ore giving more !26

solution 6he should then give it more slowly

Continue breast&eeding whenever the child wants 3he mother should not give the child

&ood during the &irst = hours o& treatment with !26AFTER , HO/RS

2eassess the child and classi&y the child &or dehydration

6elect the appropriate plan to continue treatment I& the child has improved and has N! 7EA72,3I!N. choose 8lan ,

+I& the childs eyes are pu&&y. it is a sign o& over hydration It is not a danger sign or asign o& hypernatremia It is simply a sign that the child has been rehydrated and doesnot need any more !26 solution at this time 3he child should be given clean water orbreast mil 3he mother should give !26 solution according to 8lan , when thepu&&iness is gone

I& the child still has 6!*E 7EA72,3I!N. choose 8lan / again /egin &eeding

the child in clinic !&&er &ood. mil or -uice ,&ter &eeding the child. repeat the =+hour 8lan /treatment !&&er &ood. mil and -uice every : or = hours I& the child is worse and now has 6E>E2E 7EA72,3I!N. you will need to

begin8lan C

/egin &eeding the child in health center

IF THE MOTHER M/ST LEA#E !EFORE COM$LETING TREATMENT

6how her how to prepare !26 solution at home

6how her how much !26 to give her child to &inish =+hour treatment at home

;ive her enough !26 pacets to complete rehydration ,lso give her % pacets. as

recommended in 8lan ,

;ive her instructions how to prepare salt and sugar solution &or use at home

E4plain the = rules o& home treatment5 (#) ;ive e4tra &luid (%) ;ive Sinc 6upplements

(:) Continue Feeding and (=) Dnow when to return

$LAN C4 TREAT SE#ERE DEH&DRATION /IC3L&+6everely dehydrated children need to have water and salts 'uicly replaced Intravenous(I>) &luids are usually used &or this purpose 2ehydration therapy using I> &luids or using anasogastric (N;) tube is recommended only &or children who have 6E>E2E7EA72,3I!N +3he treatment o& the severely dehydrated child depends on5

the type o& e'uipment available at your clinic or at a nearby clinic or hospital

the training you have received#$


20/86

whether the child can drin

%0


21/86

F!!W 3E ,22!W6 IF ,N6WE2 I6 VAE6.V ;! ,C2!66 IF VN!.V ;! 7!WN

(*) Fe-er+, child with &ever may have malaria. measles or another severe disease !r. a child with&ever may have a simple cough or cold or other viral in&ection+,ssess &ever by history or &eels hot or i& temperature is :1C or above

%#

&ES

&ES

&ESCan you give intravenous

(I>) &luid immediatelyB

NO

Is I> treatment availablenearby (within :0 minutes)B

6tart I> &luid immediately+I& the child can drin. give !26 by mouth while the drip is set up+;ive #00ml9g 2ingers actate 6olution (or. i& not available.normal saline). divided as &ollows5

AGEFirt gi-e * ml0g inThen gi-e ml0g in In&ants

(under #% mos)# hourX1 hoursChildren(#% mos+1 years):0 minutesX% #9% hoursX 2epeat once i& radialpulse is still very wea or not detectable

Reae the hild e-er2 ;9 ho:r I& hydration status is notimproving. give the I> drip more rapidly ,lso give !26 (about 1 ml9g9hour) as soon as the child candrin5 usually a&ter :M= hours (in&ants) or #M% hours (children) 2eassess an in&ant a&ter < hours and a child a&ter : hoursClassi&y dehydration 3hen choose the appropriate plan (,./. orC) to continue treatment

Refer /RGENTL& to ho+ital for I# treatmentI& the child can drin. provide the mother with !26 solutionand show her how to give &re'uent sips during the trip

NO

,re you trained to use anasogastric (N;) tube &or

rehydrationB

Start reh2dration =2 t:=e (or mo:th) 1ith ORS ol:tion5give %0 ml9g9hour &or < hours (total o& #%0 ml9g)

Reae the hild e-er2 ;9 ho:r 1hile 1aiting fortranfer

+I& there is repeated vomiting or increased abdominaldistension. give the &luid more slowly+I& hydration status is not improving a&ter : hours. send thechild &or I> therapy

,&ter < hours reassess the child Classi&y dehydration 3henchoose the appropriate plan (,. /. or C) to continue treatment

NO

Can the child drinB

NO

2e&er urgently to a hospital&or I> or N; treatment

Note5 I& possible. observe the child at least < hours a&ter rehydration to besure the mother can maintain hydration giving the child !26 solution

by mouth


22/86

Malaria

+*alaria is caused by parasites in the blood called Hplasmodia 3hey are transmittedthrough the bite o& anopheline mos'uitoes Four species o& plasmodia can cause malaria.but the most dangerous one is 8lasmodium &alciparum+Fever is the main symptom o& malaria It can be present all the time or go away andreturn at regular intervals !ther signs o& &alciparum malaria are shivering. sweating andvomiting

Meale

+Fever and a generali"ed rash are the main signs o& measles *easles is highlyin&ectious+*easles is caused by a virus

Com+liation of meale diarrhea (including dysentery and persistent diarrhea)

pneumonia

stridor

mouth ulcers

ear in&ection severe eye in&ection (which may lead to corneal ulceration and blindness)

Encephalitis (a brain in&ection)

Deng:e Hemorrhagi Fe-er

FOC/SED ASSESSMENTDOES THE CHILD HA#E FE#ER

%%

If &ESDeide the Malaria Ri05 high or lowAS37oes the child live in a malaria areaBas the child visited9traveled or stayed overnight in a malaria area in the past = weesB

I& Aes to either. obtain a blood smear

AS3 LOO3 AND FEEL For how long has the child oo or &eel &or sti&& nechad &everB oo &or runny nose I& more than days.had been present every dayB as the child had measles withinthe last : monthsB oo &or signs o& *E,6E6

+;enerali"ed rash and+!ne o& these5 cough. runny nose. or red eyes

If the hild ha meale no1 or oo &or mouth ulcers

1ithin the lat * month4 +,re they deep and e4tensiveB oo &or pus draining &rom the eye oo &or clouding o& the cornea

Ae Deng:e Hemorrhagi Fe-erAS3 LOO3 AND FEELas the child had any bleedingY oo &or bleeding &rom nose or&rom the nose or gums or in the gumsvomitus or stoolsB oo &or sin petechiaeas the child had blac vomitusB Feel &or cold and clammy e4tremitiesas the child had blac stoolB Chec &or slow capillary re&ill I& none o&as the child had persistent the above AS37 LOO37 and FEELsignsabdominal painB are present ? the child is < months oras the child had persistent vomitingB older ?&ever present &or more than : days

8er&orm the tourni'uet test


23/86

7ecide the *alaria 2is

+3o classi&y and treat children with &ever. you must now the malaria ris in your area 3here is a high malaria ri0in areas where more than 1R o& the &ever cases in

children are due to malaria 3here is a lo1 malaria ri0in areas where 1R or less o& the &ever cases in

children are due to malaria 3here is no malaria ri0in areas where no transmission o& malaria occurs

+*alaria ris can vary by season 3he breeding conditions &or mos'uitoes are limited orabsent during the dry season ,s a result. during the dry season. the ris o& malaria isusually low ,reas where malaria occurs. but only rarely. are also identi&ied as low malariaris

,6D5 For ow ongB I& more than days. has &ever been present every dayB

+,s the mother how long the child has had &ever I& the &ever has been present &or morethan days. as i& the &ever has been present every day+, &ever which has been present every day &or more than days can mean that the childhas a more severe disease such as typhoid &ever

,6D5 as the child had *easles within the last : monthsB

+, child with &ever and a history o& measles within the last : months may have an in&ection.such as an eye in&ection. due to complications o& measles

!!D or FEE &or sti&& nec

+, child with &ever and sti&& nec may have meningitis , child with meningitis needs urgenttreatment with in-ectable antibiotics and re&erral to hospital

+I& the child is moving and bending his nec. he does not have a sti&& nec I& the nec &eelssti&& and there is resistance to bending. the child has a sti&& nec !&ten a child with a sti&&nec will cry when you try to bend the nec

!!D &or 2unny Nose

+, runny nose in a child with &ever may mean that the child has a common cold I& the childhas a runny nose. as the mother i& the child has had a runny nose only with this illness I&she is not sure. as 'uestions to &ind out i& it is an acute or chronic runny nose+When malaria ris is low or no. a child with &ever and a runny nose does not need an anti+malarial 3his childs &ever is probably due to a common cold

!!D &or signs suggesting *easles

Generali>ed rah

+In measles. a red rash begins behind the ears and on the nec It spreads to the &ace+7uring the ne4t day. the rash spreads to the rest o& the body. arms and legs ,&ter = to 1days. the rash starts to &ade and the sin may peel+, measles rash does not have vesicles (blisters) or pustules 3he rash does not itch

Co:gh7 r:nn2 noe7 or red e2e+3he child has Hred eyes i& there is redness in the white part o& the eye In a healthy eye.the white part o& the eye is clearly white and not discolored

%:

If NOAS3 about the ne4t main symptoms5 ear problemCHEC3 &or malnutrition and anemia. immuni"ation statusand &or other problems


24/86

I& the child has *easles now or within the last : months

+oo to see i& the child has mouth or eye complications !ther complications o& measlessuch as stridor in a calm child. pneumonia. and diarrhea are assessed earlier *alnutritionand ear in&ection are assessed later

!!D &or mouth ulcers are they deep and e4tensiveB

+oo inside the childs mouth &or mouth ulcers Ulcers are pain&ul open sores on the insideo& the mouth and lips or the tongue 3hey may be red or have white coating on them Insevere cases. they are deep and e4tensive When present. mouth ulcers mae it di&&icult &orthe child with measles to drin or eat+*outh ulcers are di&&erent than the small spots called Dopli spots Dopli spots occur inthe mouth inside the chee during early stages o& the measles in&ection Dopli spots aresmall. irregular. bright red spots with a white spot in the center 3hey do not inter&ere withdrining or eating 3hey do not need treatment

!!D &or pus draining &rom the eye

+8us draining &rom the eye is a sign o& con-unctivitis Con-unctivitis is an in&ection o& thecon-unctiva. the inside sur&ace o& the eyelid and the white part o& the eye

+!&ten the pus &orms a crust when the child is sleeping and seals the eye shut It can begently opened with clean hands

!!D &or clouding o& the cornea

+When clouding o& the cornea is present. there is a ha"y area in the cornea oo care&ullyat the cornea &or clouding 3he clouding may occur in one or both eyes+Corneal clouding is a dangerous condition 3he corneal clouding may be due to vitamin ,de&iciency which has been made worse by measles I& the corneal clouding is not treated.the cornea can ulcerate and cause blindness , child with clouding o& the cornea needsurgent treatment with vitamin ,

!!D and FEE &or signs o& bleeding and shoc (7engue emorrhagic Fever)

bleeding &rom the nose and gums sin petechiae M small hemorrhages in the sin@ loo lie small dar red spots

or patches in the sin@ not raised. not tender@ i& you stretch the sin they do not lose theircolor cold and clammy e4tremities

slow capillary re&ill ( longer than : seconds)

+I& there are no signs in the ,6D or !!D and FEE. the child is < months or older. and the&ever is present &or more than : days5 8er&orm the tourni'uet test

%=


25/86

CLASSIF& HIGH MALARIA RIS3+there may be &amilies who have traveled to areas where the ris o& malaria is high I& themother or caretaer tells you that the child has traveled to an area where you now there is ahigh malaria ris


(Urgent pre+re&erral treatments are in

bold print)

,ny general

danger sign 6ti&& nec

#ER& SE#EREFE!RILE DISEASE

Gi-e B:inine for e-ere

malaria (firt doe) Gi-e firt doe of an

a++ro+riate anti=ioti Treat the hild to +re-ent

lo1 =lood :gar Gi-e one doe of

+araetamol in lini for highfe-er (*


26/86

CLASSIF& LO% MALARIA RIS3 AND NO TRA#EL TO A HIGH RIS3 AREA



,ny general



MALARIA

Gi-e B:inine for e-ere

malaria (firt doe) :nle no

malaria ri0 Gi-e firt doe of an

a++ro+riate anti=ioti Treat the hild to +re-ent

lo1 =lood :gar Gi-e one doe of



27/86

CLASSIF& NO MALARIA RIS3 AND NO TRA#EL TO A MALARIA RIS3 AREA



,ny general



Gi-e firt doe of an

a++ro+riate anti=ioti

Treat the hild to +re-entlo1 =lood :gar Gi-e one doe of



28/86

*easles now

or within the last :months

MEASLES

Gi-e #itamin A


return immediately

HOMEMANAGEMENT

%J


29/86

CLASSIF& DENG/E HEMORRHAGIC FE#ER


(Urgent pre+re&erral treatmentsare in bold print)

/leeding &rom nose

or gums

/leeding in stools orvomitus /lac stools or

vomitus 6in petechiae

Cold and clammy

e4tremities Capillary re&ill more

than : seconds 8ersistent abdominal

pain 8ersistent vomiting3ourni'uet test positive

SE#EREDENG/E

HEMORRHAGICFE#ER

If +eritent -omiting or

+eritent a=dominal +ain

or 0in +etehiae or +oiti-eto:rniB:et tet are the onl2+oiti-e ign7 gi-eORS($lan !)If an2 other ign of

=leeding i +oiti-e7 gi-efl:id ra+idl27 a in $lan CTreat the hild to +re-ent

lo1 =lood :garRefer all hildren

/RGENTL& to ho+italDO NOT GI#E AS$IRIN

/RGENTREFERRAL

No signs o& severe

dengueemorrhagic &ever

FE#ER4 DENG/EHEMORRHAGIC

FE#ER /NLI3EL&


return immediately Follow up in % days i&

&ever persists or child showssigns o& bleeding

DO NOT GI#E

AS$IRINitamin , (same dose as &or supplementation) as part o& treatment i&

the child has measles or 8E26I63EN3 7I,22E,

I& the child has had a dose o& >itamin , within the past month. 7! N!3 ;I>E >I3,*IN ,

,lways record the dose o& >itamin , given on the childs chart

AGE #ITAMIN A DOSE%$

OTHER CA/SES OF FE#ER

8neumonia 6evere 7engue emorrhagic Fever

7ysentery *astoiditis6evere complicated measles ,cute ear in&ection*easles with eye or mouth complications ,bscess. Cellulites. !steomyelitis 6evere8neumonia or very severe disease


30/86

< months up to #% months #00 000 IU

!ne year and older %00 000 IU

GI#E ORAL CO'ARTEMETHER+;ive the &irst dose o& co+artemether in the clinic and observe &or one hour I& child vomitswithin an hour repeat the dose %nd dose at home a&ter J hours+3hen twice daily &or &urther two days

+Co+artemether should be taen with &ood

%EIGHT (age)

Co'artemether ta=let(%0mg artemether and #%0mg lume&antrine)

hr hr 9,hr *hr ,hr hr

1 + K#1 g(1 months up to : years)

# # # # # #

#1 + K%0 g(: years up to 1 years)

% % % % % %

GI#E $ARACETAMOL FOR HIGH FE#ER (* &or =J hours a&ter the ulcers have been cured

;ive paracetamol &or pain relie&

:0


31/86

TREAT E&E INFECTION %ITH TETRAC&CLINE E&E OINTMENT+I& the child will be U2;EN3A re&erred. clean the eye gently+3reat both eyes until the redness is gone &rom the in&ected eye 3he in&ected eye isimproving i& there is less pus in the eye or the eyes are not stuc shut in the morning+7o not put any other eye ointments. drops or alternative treatments in the childs eyes 3heymay be harm&ul and damage the childs eyes 8utting harm&ul substances in the eye maycause blindness+,&ter % days. i& there is still pus in the eye. bring the child bac to the clinic

Wash her hands be&ore and a&ter treating the eye

Clean the childs eyes immediately be&ore applying the tetracycline eye ointment Use a

clean cloth to wipe the eye and wipe away pus

8ull down the lower lid 6'uirt the &irst dose o& tetracycline eye ointment onto the lower

eyelid 3he dose is about the si"e o& a grain o& rice

2epeat the process (cleaning the eye and applying ointment) : times per day. in the

morning. at mid+day and in the evening

GI#E THESE TREATMENTS IN HEALTH CENTER ONL&

GI#E AN INTRAM/SC/LAR ANTI!IOTIC+*any severe cases need the &irst dose o& an antibiotic be&ore re&erral owever. i& a child5

is not able to drin or breast&eed

vomits everything

has convulsions

is lethargic or unconscious

3he child cannot tae an oral antibiotic Instead. and then re&er the child U2;EN3A tohospitalFOR CHILDREN !EING REFERRED %HO CANNOT TA3E ORAL ANTI!IOTIC

+;ive this child ampicillin (10 mg9g) and gentamicin (1mg9g) and re&er child urgently tohospital

IF REFERRAL IS NOT $OSSI!LE+2epeat the ampicillin in-ection every < hours. and the gentamicin in-ection once daily

AGE %EIGHTAM$ICILLIN

100 mg vialGENTAMICIN

%ml vial (at =0 mg9ml)

% months up to = months = M K< g # ml 01 + #0 ml

= up to #% months < M K#0 g % ml ## + #J ml

#% months up to : years #0 M K#= g : ml #$ + % ml

: up to 1 years #= M #$ g 1 ml %J + :1 ml

GI#E /ININE FOR SE#ERE MALARIA+, child with >E2A 6E>E2E FE/2IE 7I6E,6E may have severe malaria 3o ill malariaparasites as 'uicly as possible. give a 'uinine in-ection be&ore re&erral Quinine is thepre&erred anti+malarial because it is e&&ective and it acts rapidly Intramuscular 'uinine is alsosa&er than intramuscular Chloro'uine

FOR CHILDREN !EING REFERRED %ITH A #ER& SE#ERE FE!RILE DISEASEMALARIA+;ive &irst dose o& intramuscular QUININE and re&er urgently to hospital

:#


32/86

IF REFERRAL IS NOT $OSSI!LE+;ive &irst dose o& intramuscular QUININE+3he child should remain lying down &or one hour+2epeat the QUININE in-ection at = and J hours later. and then every #% hours until the childis able to tae an oral anti+malarial 7o not continue QUININE in-ections &or more than #wee+I& low ris o& malaria5 7! N!3 ;I>E QUININE 3! , CI7 E66 3,N = *!6 !F ,;E

AGE OR %EIGHTINTRAM/SC/LAR /ININE

;. mg mlK (in 9 ml) * mg mlK (in 9 ml )

% months up to = months (= + K < g) 0= ml 0% ml

= months up to #% months (< + K #0 g) 0< ml 0: ml

#% months up to % years (#0 + K #% g) 0J ml 0= ml

% years up to : years (#% + K #= g) #0 ml 01 m

: years up to 1 years (#= + #$ g) #% ml 0< ml

GI#E DIAE$AM TO STO$ CON#/LSIONS+3urn the child to his9her side and clear the airway ,void putting things in the mouth+;ive 01mg9g dia"epam in-ection solution per rectum using a small syringe (lie atuberculin syringe) without a needle. or using a catheter+Chec &or low blood sugar. then treat or prevent+;ive o4ygen and 2EFE2+I& convulsions have not stopped a&ter #0 minutes repeat dia"epam dose

%EIGHT AGEDOSE OF DIAE$AM

(#0 mg 9 % ml)

K 1 g K< months 01 ml

1 + K #0 g < months up to #% months #0 ml#0 + K #= g #% months up to : years #1 ml

#= + #$ g : years up to 1 years %0 ml

(,) Ear $ro=lem+, child with an ear problem may have an ear in&ection+When a child has an ear in&ection. pus collects behind the ear drum and causes pain ando&ten &ever+I& the in&ection is not treated. the ear drum may burst 3he pus discharges. and the child&eels less pain

+3he &ever and other symptoms may stop. but the child su&&ers &rom poor hearing becausethe ear drum has a hole in it Usually the ear drum heals by itsel& ,t other times thedischarge continues. the ear drum does not heal and the child becomes dea& in that ear+6ometimes the in&ection can spread &rom the ear to the bone behind the ear (the mastoid)causing *astoiditis In&ection can also spread &rom the ear to the brain causing meningitis3hese are severe diseases 3hey need urgent attention and re&erral+Ear in&ections rarely cause death owever. they cause many days o& illness in children Earin&ections are the main cause o& dea&ness and dea&ness causes learning problems in school

:%


33/86

FOC/SED ASSESSMENTDOES THE CHILD HA#E AN EAR $RO!LEM

,6D5 7oes the child have ear pain

+Ear pain can mean that the child has an ear in&ection I& the mother is not sure that thechild has ear pain. as i& the child has been irritable and rubbing his ear

,6D5 Is there ear dischargeB I& yes. &or how longB

+Ear discharge is also a sign o& in&ection I& the child has had ear discharge. as &or how

long Aou will classi&y and treat the ear problem depending on how long the ear dischargehas been present Ear discharge reported &or % wees or more (with pus seen draining &rom the ear)

is treated as a chronic ear in&ection Ear discharge reported &or less than % wees (with pus seen draining &rom the

ear) is treated as an acute ear in&ection

!!D &or pus draining &rom the ear

+8us draining &rom the ear is a sign o& in&ection. even i& the child no longer has any painoo inside the childs ear to see i& pus is draining &rom the ear

FEE &or tender swelling behind the ear

+Feel behind both ears Compare them and decide i& there is tender swelling o& the mastoid

bone In in&ants. the swelling may be above the ear /oth tenderness and swellingmust bepresent to classi&y *astoiditis. a deep in&ection in the mastoid bone 7o notcon&use thisswelling o& the bone with swollen lymph nodes

::

If NOCHEC3 &or malnutrition and anemia. immuni"ation statusand &or other problems

If &ESAS3 LOO3 AND FEEL Is there ear painB oo &or pus draining &rom the ear Is there ear dischargeB Feel &or tender swelling behind the earI& yes. &or how longB


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CLASSIF& EAR $RO!LEM



3enderswelling behind the

ear

MASTOIDITIS

Gi-e firt doe of an

a++ro+riate anti=ioti

Gi-e firt doe of$araetamol for +ain Refer /RGENTL& to

ho+ital

/RGENTREFERRAL

8us is seen

draining&rom the earanddischarge isreported&or less than#= days Ear pain

AC/TE EARINFECTION

Gi-e an oral anti=ioti for .

da2 ;ive 8aracetamol &or pain

7ry the ear by wicing

Follow+up in 1 days

,dvise the mother when to

return immediately

S$ECIFICTREATMENT

8us is seendraining&rom the earanddischarge isreported&or #= daysor more

CHRONIC EARINFECTION

7ry the ear by wicing

Follow+up in 1 days

,dvise the mother when to

return immediately

S$ECIFICTREATMENT

No ear pain

Nopus seen

draining&rom the ear

NO EARINFECTION No additional treatmentHOME

MANAGEMENT

TREATMENT

GI#E AN A$$RO$RIATE ORAL ANTI!IOTICFOR $NE/MONIA7 AC/TE EAR INFECTIONFI263+INE ,N3I/I!3IC5Co'trimo?a>ole6EC!N7+INE ,N3I/I!3IC5 Amo?2illin

AGE OR%EIGHT

CO'TRIMO@AOLE(trimethoprim L sulphametho4a"ole)

;ive two times daily &or : days &or pneumonia;ive two times daily &or 1 days &or acute ear in&ection

AMO@&CILLIN;ive two times daily &or :

days &or pneumonia;ive two times daily &or 1

days &or acute ear in&ection

AD/LT TA!LET

J0 mg trimethoprimL =00 mg

sulphametho4a"ole

$EDIATRIC

TA!LET%0 mg trimethoprimL #00 mg

sulphametho4a"ole

S&R/$=0 mg trimethoprim

L %00 mgsulphametho4a"ole

per 1 ml

TA!LET%10 mg

S&R/$#%1 mg per

1 ml

% months up to#% months(=MK#0 g)

% 10 ml O 1 ml

#% months up to1 years

(#0MK#$ g)# : 1 ml #1 #1 ml

:=


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,mo4ycillin should be used i& there is high co+trimo4a"ole resistance

GI#E $ARACETAMOL FOR HIGH FE#ER (*


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3he child may become severely wasted. a sign o& marasmus

3he child may develop edema. a sign o& washioror

3he child may not grow well and become stunted (too short)

+, child whose diet la0 reommended amo:nt of eential -itamin and mineralcan develop malnutrition 3he child may not be eating enough o& the recommended amountso& speci&ic vitamins (such as vitamin ,) or minerals (such as iron)

Not eating &oods that contain vitamin , can result in vitamin , de&iciency , child with

vitamin , de&iciency is at ris o& death &rom measles and diarrhea 3he child is also at riso& blindness

Not eating &oods rich in iron can lead to iron de&iciency and anemia

+Anemia is a reduced number o& red cells or a reduced amount o& hemoglobin in each redcell , child can also develop anemia as a result o&5

In&ections

8arasites such as hooworm or whipworm that can cause blood loss &rom the gut and

lead to anemia

*alaria. which can destroy red cells rapidly Children can develop anemia i& they have

repeated episodes o& malaria or i& malaria was inade'uately treated 3he anemia maydevelop slowly

FOC/SED ASSESSMENTCHEC3 FOR MALN/TRITION CHEC3 FOR ANEMIA

!!D &or visible severe wasting

+, child with visible severe wasting has maram:7a &orm o& severe malnutrition , childhas this sign i& he is very thin. has no &at. and loos lie sin and bones+3o loo &or visible severe wasting

2emove the childs clothes

oo &or severe wasting o& the muscles o& the shoulders. arms. buttocs and

legs oo to see i& the outline o& the childs ribs is easily seen

oo at the childs hips 3hey may loo small when you compare them with the

chest and abdomen oo at the child &rom the side to see i& the &at o& the buttocs is missing When

wasting is e4treme. there are many &olds o& sins on the buttocs and thigh 3he &ace o& a child with visible severe wasting may still loo normal 3he childs

abdomen may be large or distended

!!D ,N7 FEE &or edema o& both &eet

: in&usion

+;ive1 ml9g o& #0Ro& de4trose solution (7#0) over a &ew minutes

+;ive # ml9g o& 10R (710) by slow push

GI#E IRON+;ive one dose daily &or #= days

AGE or %EIGHT

IRONFOLATE TA!LETFerrous sul&ate

%00 mg L %10 Pg Folate(


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able to &ight the disease very well ,lso. i& the child does not receive an immuni"ation as soonas he is old enough. his ris o& getting the disease increases+,ll children should receive all the recommended immuni"ations be&ore their &irst birthday I&the child does not come &or an immuni"ation at the recommended age. give the necessaryimmuni"ations any time a&ter the child reaches that age+For each vaccine. give the remaining doses at least = wees apart Aou do not need torepeat the whole schedule

O=er-e Contraindiation to Imm:ni>ation+3here are only three situations at present that are contraindications to immuni"ation5

7o not give /C; to a child nown to have ,I76

7o not give 783% or 783 : to a child who had convulsions. shoc or any other adverse

reaction a&ter the most recent dose Instead. give 73

7o not give 783 to a child with recurrent convulsions or another active neurological

disease o& the central nervous systemR/LE TO FOLLO%43here are no contraindications to immuni"ation o& a sic child i& the childis well enough to go home I& the child has diarrhea. give a dose o& !8>. but do not count the

dose ,s the mother to return in = wees &or the missing dose o& !8>

Ho1 to deide if a hild need imm:ni>ation toda2+3he child may receive immuni"ation today and9or the childs caretaer may be ased toreturn with the child on a particular date &or an immuni"ation. or the child may be re&erredwith a note that indicates an immuni"ation is needed 7ecide i& the child needs immuni"ation+,s the mother to tell you what immuni"ations the child has received Use your -udgment todecide i& the mother has given a reliable report I& you have any doubt. immuni"e the child;ive the child !8>. 783 and measles vaccine according to the childs age+,s you chec the childs immuni"ation status. use the case recording &orm to chec theimmuni"ations already given and circle the immuni"ations needed today I& the child should

return &or an immuni"ation. write the date that the child should return in the classi&icationcolumn

Imm:ni>ation Shed:le5 Follow national guidelines

AGE #ACCINE

/irth /C; !8>+ 0

< wees 783LI/+# !8>+# epatitis /+#

#0 wees 783LI/+% !8>+% epatitis /+%

#= wees 783LI/+: !8>+: epatitis /+:

$ months *easles

6econd dose o& measles vaccine may be given at any opportunistic moment during periodic

supplementary immuni"ation activities as early as one month &ollowing the &irst dose

(9) #itamin A S:++lementation+;ive every child a dose o& >itamin , every si4 months &rom the age o& < months 2ecord thedose on the childs card

(*) De1orming Stat:

RO/TINE %ORM TREATMENT

=#


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+;ive every child *ebenda"ole every < months &rom the age o& one year 2ecord the doseon the childs card

ASSESS FOR OTHER $RO!LEMS+!bserve another problem during the assessment Identi&y and treat any other problemsaccording to your training. e4perience and clinic policy+2e&er the child &or any other problem that you cannot manage+*,DE 6U2E CI7 WI3 ,NA ;ENE2, 7,N;E2 6I;N I6 2EFE22E7 a&ter &irst doseo& an appropriate antibiotic and other urgent treatments

E?e+tion 2ehydration o& the child according to 8lan C may resolve danger signs so thatre&erral is no longer needed

COMM/NICATE AND CO/NSEL

/SE GOOD COMM/NICATION S3ILLS+It is important to have good communication with the childs mother or caretaer &rom thebeginning o& the visit Using good communication helps to reassure the mother or caretaerthat the child will receive good care+3he success o& home treatment depends on how well you communicate with the childsmother or caretaer 6he needs to now how to give the treatment 6he also needs tounderstand the importance o& the treatment

AS3 AND LISTENto &ind out what the childs problems are and what the mother is already

doing &or the child+,sing 'uestions to assess the childs problems isten care&ully to &ind out what the childsproblems are and what the mother is already doing &or her child 3hen you will now whatshe is doing well. and what practices need to be changed

$RAISE the mother &or what she has done well

+It is liely that the mother is doing something help&ul &or the child 8raise the mother &orsomething help&ul she has done

AD#ISE her how to care &or her child at home

+imit your advice to what is relevant to the mother at this time Use language that the motherwill understand I& possible. use pictures or real ob-ects to help e4plain+,dvise against any harm&ul practices that the mother may have used When correcting aharm&ul practice. be clear. but also be care&ul not to mae the mother &eel guilty orincompetent E4plain why the practice is harm&ul 3eaching how to do a tas re'uires severalsteps+When you teach a mother how to treat a child. use : basic teaching steps5

(#) ;ive in&ormation

+E4plain to the mother how to do the tas(%) 6how an e4ample+6how how to do the tas

(:) et her practice+,s the mother to do the tas while you watch

+When teaching the mother Use words that she understands

Use teaching aids that are &amiliar

;ive &eedbac when she practices 8raise what was done well and mae corrections

=%


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,llow more practice. i& needed

Encourage the mother to as 'uestions ,nswer all 'uestions

CHEC3 the mothers understanding

+,s 'uestions to &ind out what the mother understands and what needs &urther e4planation+,n important communication sill is nowing how to as good checing 'uestions ,

checing 'uestion must be phrased so that the mother answers more than Hyes or Hno+;ood checing 'uestions re'uire that she describe why. how or when she will give atreatment ,s 'uestions that re'uire the mother to e4plain what. how. how much. how

many. when. or why ,void asing leading 'uestions (that is. 'uestions which suggest the right

answer) 7o not as 'uestions that can be answered with -ust a Hyes or Hno ;ive the mother time to thin and then answer

8raise the mother &or correct answers

I& she needs it. give more in&ormation. e4amples or practice

TEACH THE CARETA3ER TO GI#E ORAL DR/GS AT HOME+Follow the instructions below &or every oral drug to be given at home ,lso &ollow theinstructions listed with each drugs dosage table

7etermine the appropriate drugs and dosage &or the childs age or weight

+Use the 32E,3 3E CI7 chart to determine the appropriate drug and dosage to give thechild+Use the A!UN; INF,N3 chart to determine the appropriate drug and dosage &or youngin&ants

3ell the mother the reason &or giving the drug to the child

+Why you are giving the oral drug to her child and what problem it is treating

7emonstrate how to measure a dose

+Collect a container o& the drug and chec its e4piry date 7o not use e4pired drugsCount out the amount needed &or the child Close the container

If 2o: are gi-ing the mother ta=let+6how the mother the amount to give per dose+I& needed. show her how to divide a tablet I& a tablet has to be crushed be&ore it is given to achild. add a &ew drops o& clean water and wait a minute or so 3he water will so&ten the tabletand mae it easier to crush

If 2o: are gi-ing the mother 2r:++6how the mother how to measure the correct number o& millilitres (ml) &or one dose at home+Use the bottle cap or a common spoon. such as a spoon used to stir sugar into tea or co&&ee+6how her how to measure the correct dose with the spoon

One tea+oon (t+


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#1ml : tsp

If 2o: are gi-ing the mother a+:le+6how the mother the amount to give per dose

+I& a child needs less than a whole vitamin , capsule (or cannot swallow a whole capsule).show the mother how to open the capsule and s'uirt part o& its li'uid into the childs mouth

Watch the mother practice measuring a dose by hersel&

+,s the mother to measure a dose by hersel&+I& the dose is in tablet &orm and the child cannot swallow a tablet. tell the mother to crush thetablet+Watch her as she practices 3ell her what she has done correctly I& she measured the doseincorrectly. show her again how to measure it

,s the mother to give the &irst dose to her child

+E4plain that i& a child is vomiting. give the drug even though the child may vomit it up

+3ell the mother to watch the child &or :0 minutes I& the child vomits within the :0 minutes(the tablet or syrup may be seen in the vomit). give another dose+I& the child is dehydrated and vomiting. wait until the child is rehydrated be&ore giving thedose again

E4plain care&ully how to give the drug. then label and pacage the drug

+3ell the mother how much o& the drug to give her child+3ell her how many times per day to give the dose+3ell her when to give it (such as early morning. lunch. dinner. be&ore going to bed) and &orhow many days

I& more than one drug will be given. collect. count and pacage each drug separately

+Collect one drug at a time Write the instructions on the label Count out the amount needed

+8ut enough o& the drug into its own labeled pacage Finish pacaging the drug be&ore youopen another drug container+E4plain to the mother that her child is getting more than one drug because he has more thanone illness+6how the mother the di&&erent drugs E4plain how to give each drug I& necessary. draw asummary o& the drugs and times to give each drug during the day

E4plain that all the tablets or syrup must be used to &inish the course o& treatment. even i& the

child gets better+E4plain to the mother that i& the child seems better. continues to treat the child 3his isimportant because the bacteria or the malaria parasite may still be present even though thesigns o& disease are gone

+,dvise the mother to eep all medicines out o& the reach o& children ,lso tell her to storedrugs in a dry and dar place that is &ree o& mice and insects

Chec the mothers understanding be&ore she leaves the clinic

+,s the mother checing 'uestions. such as5How much will you give each timeBHWhen will you give itB HFor how many daysBHow will you prepare this tabletBHWhich drug will you give : times per dayB

==


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+I& you &eel that the mother is liely to have problems when she gives her child the drug(s) athome. o&&er more information7 e?am+le and +ratie , child needs to be treated correctlyto get better

TEACH THE CARETA3ER TO TREAT LOCAL INFECTIONS AT HOME+ocal in&ections include cough. sore throat. eye in&ection. mouth ulcers. ear in&ection. anumbilicus that is red or draining pus. sin pustules. and thrush+When teaching a mother or caretaer

E4plain what the treatment is and why it should be given

7escribe the treatment steps listed in the appropriate bo4 on the 32E,3 charts

Watch the mother as she does the &irst treatment in the clinic (e4cept remedy &or cough or

sore throat)

3ell her how o&ten to do the treatment at home

I& needed &or treatment at home. give mother the tube o& tetracycline ointment or a small

bottle o& gentian violet

Chec the mothers understanding be&ore she leaves the clinic

+6ome treatments &or local in&ections cause discom&ort Children o&ten resist having theireyes. ears or mouth treated 3here&ore. it is important to hold the child still 3his will preventthe child &rom inter&ering with the treatment

3ilt the childs head bac when applying eye ointment or treating mouth ulcers

3ilt the childs head to the side when wicing the ear 7o not attempt to hold the child still

until immediately be&ore treatment

CO/NSEL THE MOTHER A!O/T FEEDING AND FL/IDS

ASSESS THE FEEDING OF SIC3 INFANTS /NDER 9 &EARS(OR IF CHILD HAS #ER& LO% %EIGHT FOR AGE)

+,s 'uestions about the childs usual &eeding and &eeding during this illness Compare themothers answers to the Feeding 2ecommendations &or the childs age

,

=1

AS3ow are you &eeding your childB

If the infant ireei-ing an2=reat mil0

AS3+ow many times during the dayB+7o you also breast&eed during the nightB

AS3+What &ood or &luidsB+ow many times per dayB

+What do you use to &eed the childB

Doe the infantta0e an2 other

food or fl:id

If -er2 lo11eight for age

AS3+ow large are servingsB+7oes the child receive his own servingB+Who &eeds the child and howB

D:ring thiillne7 ha theinfant8 feeding

hanged

AS3+I& yes. howB


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FEEDING RECOMMENDATIONS D/RING SIC3NESS AND HEALTH+3hese &eeding recommendations are appropriate both when the child is sic and when thechild is healthy

Reommendation for age :+ to , month+3he best way to &eed a child &rom birth to at least = months o& age is to breast&eede4clusively E4clusive breast&eeding means that the child taes only breast mil and noadditional &ood. water. or other &luids (with the e4ception o& medicines and vitamins. i&needed)+/reast&eed children at this age as o&ten as they want. day and night 3his will be at least Jtimes in %= hours

Reommendation for age , month :+ to month+*ost babies do not need complementary &oods be&ore < months o& age /reast mil remainsthe childs most important &ood. but at some time between the ages o& = and < months. somechildren begin to need &oods in addition to breast mil 3hese &oods are o&ten calledcomplementary or weaning &oods because they complement breast mil+/y < months o& age. all children should be receiving a thic. nutritious complementary &oodIt is important to continue to breast&eed as o&ten as the child wants. day and night

3he mother should give the complementary &oods #M% times daily a&ter breast&eeding toavoid replacing breast mil

Reommendation for age month :+ to ;9 month+3he mother should continue to breast&eed as o&ten as the child wants owever. a&ter< months o& age. breast mil cannot meet all o& the childs energy needs From age< months up to #% months. gradually increase the amount o& complementary &oods given+/y the age o& #% months. complementary &oods are the main source o& energy I& the child isbreast&ed. give complementary &oods : times daily I& the child is not breast&ed. givecomplementary &oods 1 times daily (I& possible. include &eedings o& mil by cup owever.cows mil and other breast mil substitutes are not as good &or babies as breast mil)+It is important to actively &eed the child ,ctive &eeding means encouraging the child to eat

+,n Hade'uate serving means that the child does not want any more &ood a&ter active&eeding

Reommendation for age ;9 month :+ to 9 2ear+7uring this period the mother should continue to breast&eed as o&ten as the child wants andalso give nutritious complementary &oods 3he variety and 'uantity o& &ood should be

increased+Family &oods should become an important part o& the childs diet Family &oods should bechopped so that they are easy &or the child to eat+;ive nutritious complementary &oods or &amily &oods 1 times a day ,de'uate servings andactive &eeding (encouraging the child to eat) continue to be important

=) &luids are usually used &or this purpose 2ehydration therapy using I> &luids or using anasogastric (N;) tube is recommended only &or children who have 6E>E2E7EA72,3I!N +3he treatment o& the severely dehydrated child depends on5

the type o& e'uipment available at your clinic or at a nearby clinic or hospital

the training you have received

whether the child can drin


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F!!W 3E ,22!W6 IF ,N6WE2 I6 VAE6.V ;! ,C2!66 IF VN!.V ;! 7!WN

FEEDING $RO!LEM OR LO% %EIGHT FOR AGE+,de'uate &eeding is essential &or growth and development 8oor &eeding during in&ancy canhave li&elong e&&ects ;rowth is assessed by determining weight &or age It is important toassess a young in&ants &eeding and weight so that &eeding can be improved i& necessary

) &luid immediatelyB

NO

Is I> treatment availablenearby (within :0 minutes)B

6tart I> &luid immediately+I& the child can drin. give !26 by mouth while the drip is set up+;ive #00ml9g 2ingers actate 6olution (or. i& not available.normal saline). divided as &ollows5

AGEFirt gi-e * ml0g inThen gi-e ml0g in In&ants

(under #% mos)# hourX1 hoursChildren(#% mos+1 years):0 minutesX% #9% hoursX 2epeat once i& radialpulse is still very wea or not detectable

Reae the hild e-er2 ;9 ho:r I& hydration status is notimproving. give the I> drip more rapidly ,lso give !26 (about 1 ml9g9hour) as soon as the child candrin5 usually a&ter :M= hours (in&ants) or #M% hours (children) 2eassess an in&ant a&ter < hours and a child a&ter : hoursClassi&y dehydration 3hen choose the appropriate plan (,./. orC) to continue treatment

Refer /RGENTL& to ho+ital for I# treatmentI& the child can drin. provide the mother with !26 solutionand show her how to give &re'uent sips during the trip

NO

,re you trained to use anasogastric (N;) tube &or

rehydrationB

Start reh2dration =2 t:=e (or mo:th) 1ith ORS ol:tion5give %0 ml9g9hour &or < hours (total o& #%0 ml9g)

Reae the hild e-er2 ;9 ho:r 1hile 1aiting fortranfer

+I& there is repeated vomiting or increased abdominaldistension. give the &luid more slowly+I& hydration status is not improving a&ter : hours. send thechild &or I> therapy

,&ter < hours reassess the child Classi&y dehydration 3henchoose the appropriate plan (,. /. or C) to continue treatment

NO

Can the child drinB

NO

2e&er urgently to a hospital&or I> or N; treatment

Note5 I& possible. observe the child at least < hours a&terrehydration to be sure the mother can maintain hydration givingthe child !26 solution by mouth


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+3he best way to &eed a young in&ant is to breast&eed e4clusively E4clusive breast&eedingmeans that the in&ant taes only breast mil. and no additional &ood. water or other &luids(*edicines and vitamins are e4ceptions)+E4clusive breast&eeding gives a young in&ant the best nutrition and protection &rom diseasepossible+3he assessment has two parts

In the &irst part. you as the mother 'uestions Aou determine i& she is having di&&iculty

&eeding the in&ant. what the young in&ant is &ed and how o&ten Aou also determine weight&or age

In the second part. i& the in&ant has any problems with breast&eeding or is low weight &or

age. you assess how the in&ant breast&eeds

FOC/SED ASSESSMENTCHEC3 FOR FEEDING $RO!LEM OR LO% %EIGHT

0

If an infant ha no indiationto refer :rgentl2 to ho+ital

AS3Is there any di&&iculty &eedingBIs the in&ant breast&edB I& yes. how many times in %= hoursB7oes the in&ant usually receive any other &oods or drinsB I& yes. how o&tenBI& yes. what do you use to &eed the in&antB

LOO37 LISTEN7 FEEL7etermine weight &or ageoo &or ulcers or white patches in the mouth (thrush)

IF AN INFANT as any di&&iculty &eedingIs breast&eeding less than J times in %= hours.Is taing any other &oods or drins. orIs low weight &or ageB

,N7ave no indications to re&er urgently to hospital

,66E66 /2E,63FEE7IN;as the in&ant breast&ed in I& the in&ant has not &ed in the previous hour. as the motherthe previous hourB to put her in&ant to the breast !bserve the

breast&eed &or = minutesI& the in&ant was &ed during the last hour. as the mother i& shecan wait and tell you when the in&ant is willing to &eed againIs the in&ant well attachedB

not well attached good attachment Is the in&ant sucling e&&ectively (that is. slow deep sucs.sometimes pausing)B

no sucling at allnot sucling e&&ectivelysucling e&&ectively

Clear a bloced nose i& it inter&eres with breast&eeding oo &or ulcers or white patches in the mouth (thrush)

TO CHEC3 ATTACHMENT7

LOO3 FOR+Chin touching breast+*outh wide open+ower lip turned outward+*ore areola visible abovethen below the mouth

,ll these signs should bepresent i& the attachment isgood


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Integrated Management of Childhood Illness 80 Pages

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