INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS(as of 2009 update)

8/9/2019 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS(as of 2009 update)

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INTEGRATED

MANAGEMENT OFCHILDHOOD ILLNESS

Chart Booklet

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ASSESS AND CLASSIFY THE SICK CHILD

AGE 2 MONTHS UP TO 5 YEARS

Determine if this is an initial or

follow-up visit for this problem

If follow-up visit, use the follow-up

instruction on TREAT THE CHILDchart

If initial visit, assess the child as

follows:

USE ALL BOXES THAT

MATCH THE CHILDS

SYMTOMS AND

PROBLEMS TO

CLASSIFY THE

ILLNESS

ASK THE MOTHER WHAT THE

CHILDS PROBLEM ARE

IDENTIFY

TREATMENT

CLASSIFYASSESS

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CHECK FOR GENERAL DANGER SIGNS

A child with any general danger signs need URGENT attention; complete the

assessment and any pre-referral treatment immediately so referral is not delayed.

LOOK: See if the child is abnormally sleepy or

difficult to awaken

ASK: Is the child not able to drink or

breastfeed?

Does the child vomit everything?

Has the child had convulsions?

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED

after 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.

IF YES:

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Classify COUGH or DIFFICULT BREATHINGTREATMENT

(Urgent pre-referral treatments are in bold print)

CLASSIFY ASSIGNS

Give an appropriate antibiotic for 3 days.

If wheezing (even if it disappeared after rapid acting

bronchodilator) give an inhaled bronchodilator for 5

days.

Soothe the throat and relieve the cough with a safe

remedy.

Advise mother when to return immediately.

Follow-up in 2 days.

PNEUMONIA Fast breathing

If wheezing (even if it disappeared after rapid acting

bronchodilator) give an inhaled bronchodilator for 5

days.

If coughing more than 30 days, refer for assessment.

Soothe the throat and relieve the cough with a safe remedy.


Follow-up in 5 days if not improving.

NO PNEUMONIA:

COUGH OR COLD

No signs of

pneumonia or very

severe disease

Give first dose of an appropriate antibiotic

Give Vitamin A.

Treat the child to prevent low blood sugar

Refer URGENTLY to hospital *.

SEVERE

PNEUMONIA OR

VERY SEVERE

DISEASE

Any general danger

sign or

Chest indrawing or

Stridor in calm child

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*If referral is not possible, manage the child asdescribed in management of Childhood Illness, Treat

the Child, Annex: Where Referral is not Possible, and

WHO guidelines for in-patient care.

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THEN ASK: Does the child have diarrhea?

LOOK AND FEEL: Look at the childs general condition.

Is the child:

o Abnormally sleepy or difficult to awaken?

o Restless and irritable?

Look for sunken eyes.

Offer the child fluid. Is the Child:

o Not able to drink or drinking poorly?

o Drinking eagerly, thirsty?

Pinch the skin of the abdomen

Does it go back:

Very slowly (longer than 2 seconds)?

Slowly?

IF YES, ASK:

For how long?

Is there blood in the

stool?

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Signs Classify Treatment

Give ORS, zinc supplements and food for some

dehydration (Plan B)

If child also has a severe classification:

ReferURGENTLYto hospital with mother givingfrequent sips of ORS on the way.

Advise mother to continue breastfeeding.

Advise mother when to return immediately

Follow-up in 5 days if not improving

SOME

DEHYDRATION

Two of the following signs:

Restless, irritable

Sunken eyes

Drinks eagerly, thirsty

Skin pinch goes back

slowly

Give ORS, zinc supplements and food for some

dehydration (Plan B)

Give fluid and food to treat diarrhea at home (Plan A)


Follow-up in 5 days if not improving

NO

DEHYDRATION

Not enough signs to

classify as some or

severe dehydration

If child has no other severe classification:

Give fluid for severe dehydration (Plan C) OR

If child also has another severe classification:

ReferURGENTLYto hospital with mother

giving frequent slips of ORS on the way.

Advise the mother to continue breastfeeding.

If child is 2 years or older and there is cholera in

your area, give antibiotic for cholera

SEVERE

DEHYDRATION

Two of the following signs:

Abnormally sleepy or

difficult to awaken

Sunken eyes

Not able to drink or

drinking poorly

Skin pinch goes back very

slowly

Classify DIARRHEA for dehydration

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Classify DIARRHEA and if diarrhea 14 days or more

Advise the mother on feeding a child who

has PERSISTENT DIARRHEA

Give Vitamin A

Follow-up in 5 days


PERSISTENT

DIARRHEA

No dehydration

Treat dehydration before referral unless

the child has another severe classification

Give Vitamin A

Refer to hospital

SEVERE

PERSISTENT

DIARRHEA

Dehydration

present

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Classify DIARRHEA and if blood in stool

Give ciprofloxacin for 3 days.

Follow-up in 2 days

Advise mother when to returnimmediately.

DYSENTERYBlood in the stool

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THEN ASK: Does the child have fever?

(by history, or feels hot, or if temp. Is 37.5 *C or above)

LOOK AND FEEL:

Look or feel for stiff neck

Look for runny nose

Look for signs of MEASLES: Generalized rash and

One of these: cough, runny nose,

or red eyes

THEN ASK:

For how long has the child had

fever?

If more than 7 days, has fever been

present every day?

Has the child had measles within the

last 3 months?

Decide Malaria Risk

Ask:

Does the child live in a malaria area?

Has the child visited /stayed overnight in a malaria area in the past 4 weeks?

If Yes to either, obtain a blood smear - Pv Pf + Not Done

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11


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Treat the child with an oral antimalarial

Give one dose of paracetamol in health center

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

MALARIA

Blood smear(+)

If blood smear not

done:

NO runny nose, and

NO measles, and

NO other causes of

fever

Give one dose of paracetamol in health center for

high fever (38.5C or above)



If fever is present every day for more than 7 days, refer

for assessment

FEVER:

MALARIA

UNLIKELY

Blood smear( - ) or

Runny nose, or

Measles, or

Other causes of fever

Give first dose of quinine (under medical supervision

or if a hospital is not accessible within 4 hours). Give first dose of an appropriate antibiotic.

Treat the child to prevent low blood sugar.

Give one dose of paracetamol in health center for

high fever (38.5C or above).

Send a blood smear with the patient.

ReferURGENTLYto hospital.

VERY

SEVERE

FEBRILE

DISEASE/

MALARIA

Any general

danger sign or

Stiff neck

Classify FEVERMalaria Risk(including travel/overnight stay to malaria area)

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If fever is present every day for more than 7 days,refer for assessment

FEVER:

NO

MALARIA

No sign of very

severe febrile

disease


Treat the child to prevent low blood sugar



ReferURGENTLYto hospital

VERY

SEVERE

FEBRILE

DISEASE

Any general

danger sign or

Stiff neck

Classify FEVERNo Malaria Risk

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Look for mouth ulcers.

Are they deep and extensive?

Look for pus draining from the eye.

Look for clouding of the cornea.

If the child has

measles now or

within the lastthree months:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Give Vitamin A

If pus draining from the eye, apply

tetracycline eye ointment

If mouth ulcers, teach the mother to treat with

gentian violet.

Follow-up in 2 days


MEASLES

WITH EYE OR

MOUTHCOMPLICATIONS ***

Pus draining

from the eye or

Mouth ulcers

Give Vitamin A

Advise mother when to return immediatelyMEASLES

Measles now or

within the last 3

months

Give Vitamin A.


If clouding of the cornea or pus draining

from the eye, apply tetracycline eye

ointment.


SEVERE

COMPLICATED

MEASLES***

Any general dangersign or

Clouding of cornea

or

Deep or extensive

mouth ulcers

If MEASLES now or within the last 3 months,classify

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LOOK AND FEEL:

Look for bleeding from nose or

gums.

Look for skin petechiae.

Feel for cold and clammyextremities.

Check for slow capillary refill

Ifnone of above ASK or LOOK and

FEEL signs are presentandthe

child is 6 months or olderandfeverpresent for more than three days

do

Perform the tourniquet test

ASK:

Has the child had any

bleeding from the nose or

gums or in the vomitus or

stools?

Has the child had black

vomitus?

Has the child had black

stools?

Has the child had persistent

abdominal pain?

Has the child had persistent

vomiting?

Assess Dengue Hemorrhagic Fever:

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Advise mother when to returnimmediately

Follow-up in 2 days if fever persists or

child shows signs of bleeding

DO NOTGIVE ASPIRIN

FEVER:DENGUE

HEMORRHAGIC

FEVER

UNLIKELY

No signs of severe dengue

hemorrhagic fever

If persistent vomiting or persistent

abdominal pain or positive

tourniquet test are the only positive

signs give ORS (Plan B).

If any other signs of bleeding are

present, give fluids rapidly as in

Plan C. Treat the child to prevent low blood

sugar.


DO NOTGIVE ASPIRIN.

SEVERE

DENGUEHEMORRHAGIC

FEVER

Bleeding from nose or gums or

Bleeding in stools or vomitus or

Black stools or vomitus or

Skin petechiae or

Cold and clammy extremities or

Capillary refill more than 3seconds or

Persistent Abdominal pain or

Persistent Vomiting or

Tourniquet test positive

Classify DENGUE HEMORRHAGIC FEVER

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THEN ASK: Does the child have an ear problem?

LOOK AND FEEL:

Look for pus draining from the

ear

Feel for tender swelling behind

the ear

IF YES, ASK:

Is there ear pain?

Is there ear

discharge?

If yes, for how long?

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Dry the ear by wicking.

Instill Quinolone otic drops for2 weeks Follow-up in 5 days.

Advise mother when to return

immediately.

CHRONIC

EARINFECTION

Pus is seen draining from

the ear and discharge isreported for 14 days or

more

Give an antibiotic for 5 days.

Give paracetamol for pain. Dry ear by wicking.



immediately..

ACUTE EARINFECTION

Pus is seen draining from

the ear and discharge isreported for less than 14

days, or

Ear pain

No treatment..


immediately

NO EAR

INFECTION

No ear pain and

No pus seen draining from

the ear

Give first dose of an appropriate

antibiotic.

Give first dose of paracetamol for

pain.


MASTOIDITIS Tender swelling behind the

ear

Classify EAR PROBLEM

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THEN CHECK FOR MALNUTRITION & ANEMIA

LOOK AND FEEL:

Determine weight for age.

Look for edema of both feet.

Look for visible severe wasting.

For children aged 6 months or more,determine if MUAC* is less than 110 mm.

CHECK FOR MALNUTRITION

*MUAC is Mid-Upper Arm Circumference. If tapes are notavailable, look for visible severe wasting.

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Classify NUTRITIONAL STATUS

Assess the childs feeding and counsel the

mother on feeding recommendations

Give Vitamin A.



VERY LOW

WEIGHT Very low weight for age

If the child is less than 2 years old, assessthe childs feeding and counsel the mother

on feeding recommendations

If feeding is a problem, follow-up in 5

days


NOT VERYLOW WEIGHT Not very low weight for age

and no other signs of

malnutrition

Give Vitamin A

Treat the child to prevent low blood

sugar.

ReferURGENTLYto hospital

SEVERE

MALNUTRITION

If age up to 6 months and

- visible severe wasting or

- edema of both feet

If age 6 months and above

and:

-MUAC less than 110 mm or

-edema of both feet

- visible severe wasting

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CHECK FOR ANEMIA

LOOK AND FEEL:

Look for palmar pallor. Is

it:

Severe palmar pallor? Some palmar pallor?

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Classify ANEMIA

Assess the childs feeding and counsel

the mother on feeding according to the

feeding recommendations

Give iron

Give oral anti-malarial if malaria risk

Give Mebendazole/Albendazole if child is

1 year or older and has not had a dose in

the previous 6 months


immediately

Follow-up in 14 days

ANEMIASome palmar

pallor

If the child is less than 2 years old,

assess the childs feeding and counsel

the mother on feeding according to

feeding recommendations If feeding is a problem, follow-up in 5 days


NO ANEMIANo palmar pallor

ReferURGENTLYto hospitalSEVEREANEMIA

Severe palmar

pallor

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THEN CHECK THE CHILDS IMMUNIZATION, VITAMIN AND DEWORMING STATUS:

IMMUNIZATION SCHEDULE:

AGE VACCINE

Birth BCG Hep B-1

6 weeks DPT-1 OPV-1 Hep B-2

10 weeks DPT-2 OPV-2

14 weeks DPT-3 OPV-3 Hep B-3

9 months Measles

VITAMIN A PROPHYLAXIS

VITAMIN A SUPPLEMENTATION SCHEDULE:

The first dose at 6 months or above. Subsequent doses every 6 months.

ROUTINE WORM TREATMENTGive every child mebendazole/albendazole every 6 months from the age of

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ASSESS OTHER PROBLEMS

MAKE SURE CHILD WITH ANYGENERALDANGER SIGN IS REFERRED after firstdose of an appropriate and other urgent

treatments

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TREAT THE CHILD

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TREAT THE CHILDCARRY OUT THE TREATMENT STEPS IDENTIFIED ON

THE ASSESS AND CLASSIFYCHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Determine the appropriate drugs and dosage for the childs age or weight.

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

Demonstrate how to measure a dose.

Watch the mother practice 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 mothers understanding before she leaves the health center.

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AGE OR

WEIGHT

AMOXYCILLIN

Give 2x daily for 3 days

(pneumonia)

Give 3x daily for 5 days (acute earinfection)

COTRIMOXAZOLE

Give 2x daily for 3 days (pneumonia)

Give 3x daily for 5 days (acute ear

infection)

ADULT TABLET

(250 MG)

SYRUP

(125 MG/5 ML)

TABLET

80 mg

trimethoprim+

400 mg sulfame-

thoxazole)

TABLET

40 mg trimethoprim

+ 200 mg sulfame-

thoxazole)

2 mos up

to 6 mos

(3-5 kg) 5 ml 5 ml

Give an Appropriate Oral Antibiotic

FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS

FIRST-LINE ANTIBIOTIC: AMOXYCILLIN

SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE

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AGE ORWEIGHT

AMOXYCILLIN



infection)

COTRIMOXAZOLE



infection)

ADULT

TABLET (250

MG)

SYRUP

(125 MG/5 ML)

TABLET

80 mg

trimethoprim+

400 mg sulfame-

thoxazole)

TABLET

40 mg trimethoprim

+ 200 mg sulfame-

thoxazole)

6 mos. Upto 12 mos.

(6-9kg) 1 10 ml 5 ml

12 mos. 3

yrs.

(10-14 kg) 1 15 ml

1 10 ml3 yrs up to5 yrs.

(15-19 kg.) 2 --

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FOR CHOLERA:

FIRST-LINE ANTIBIOTIC: TETRACYCLINE

SECOND-LINE ANTIBIOTIC: ERYTHROMYCIN

AGE OR

WEIGHT

TETRACYCLINE ERYTHROMYCIN

Give 4x daily for 3 days Give 4 x daily for 3 days

250 MG TABLET 250 MG TABLET

2 years up to 5 years

(10-19 kg) 1 1

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FOR DYSENTERY:

Give antibiotic recommended for Shigella in your area for 3 days.

FIRST-LINE ANTIBIOTIC FOR SHIGELLA: CIPROFLOXACIN

CIPROFLOXACIN

Give 2 times daily for 3 days

AGE OR WEIGHT 100 mg Tablet

(dose/tabs)

250 mg Tablet

(dose/tabs)

2 mos up to 6 mos.

(3-5 kg) 1/4

6 mos. Up to 12 mos.

(6-9kg)1

12 mos. 3 yrs.

(10-14 kg)1

3 yrs up to 5 yrs.

(15-19 kg.)2 1

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Give an Oral Antimalarial

FIRST-LINE ANTIMALARIAL: ARTEMETHER-LUMEFRANTINE

SECOND-LINE ANTIMALARIAL: CHLOROQUINE , PRIMAQUINE,

SULFADOXINE and PYRIMETHAMINE

If ARTEMETHER-LUMEFRANTINE combination: Give 3 days.

If CHLOROQUINE:

Explain to the mother that she should watch her child carefully for 30

minutes after giving a dose of chloroquine. If the child vomits within

30 minutes, she should repeat the dose and return to the health

center for additional tablets.

Explain that itching is a possible side effect of the drug, but is notdangerous.

If SULFADOXINE + PYRIMETHAMINE: Give single dose in health center

2 hours before intake of Chloroquine

If PRIMAQUINE: Give single dose on Day 4 for P. Falciparum

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DAY 0 8 HRS

AFTER

DAY 1 DAY 2 DAY 3

6 mos. Up

to 3 years

(5 - < 15 kg.)

1 tab 1 tab 1 tab BID 1 tab BIDGive Primaquine

only to > 1 yr ,

tab SINGLE

DOSE

4 years up

to 8 years

(15 - < 25

kg)

2 tabs 2 tabs 2 tabs BID 2 tabs BID Primaquine

to tab,SINGLE DOSE

Dose ofArtemether-Lumefrantine (20 and 120 mg

respectively)

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Preferably taken with high fat diet

Not recommended during pregnancy/lactation and in infant < 1 yr, and is severemalariaSee

Preferably taken with high fat diet

Not recommended during pregnancy/ lactationand in infant < 1 yr, and is Severe Malaria See other table for Primaquine dosage

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Treatment Schedule for Probable Malaria and

Confirmed P. falciparum Cases

AGE

Chloroquine(150 mg base/tab)

Day 1 10 mg base/kg body wt.

Day 2 10 mg-base/kg body wt.

Day 3- 5 mg base/kg body wt.

Sulfadoxine +

Pyrimethamine(500 mg/25mg/tab)

SINGLE DOSE

ONLY

Primaquine

(15 mg/tab)

SINGLE DOSE

ONLY

DAY1 DAY2 DAY3 DAY1 DAY4

0-4 mos. Not indicated

5-11 mos. Not indicated

1-3 yrs. 1 1 1

4-6 yrs. 1 1 1 1 135


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Treatment Schedule for Mixed P. falciparumandP. Vivax Infection Cases

AGE

Chloroquine

(150 mg base/tablet)

DAY 1 DAY 2 DAY3

Sulfadoxine +

Pyrimethamine

(500 mg/25 mg

Tablet)

Single doseonly

DAY 1

Primaquine

(15 mg/tablet)

for 14 days

0-4 months Not indicated

5-11 months Not indicated

1-3 years 1 1 1 daily

4-6 years 1 1 1 1 daily37


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AGE or WEIGHT

IRON/FOLATE

TABLET

Ferrous sulfate

200 mg +250 mcg

Folate

(60 mg elemental

iron)

IRON SYRUP

Ferrous sulfate

150 mg per 5 ml (6

mg elemental iron

per ml)

IRON DROP

Ferrous sulfate25mg

(25 mg elementaliron per ml)

2 months up to 4 months

(4-


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AGE OR WEIGHT Albendazole 400 mg tablet Mebendazole 500 mg tablet

12 months up to 24

months

1/2 1

24 months up to 59months

1 1

Give Mebendazole / Albendazole

Give 500 mg Mebendazole/ 400 mg Albendazole as a single dose in health center if:

hookworm/whipworm are a problem in children in your area, and

the child is 12 months of age or order, and

the child has not had a dose in the previous 6 months

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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 mother as she does the first treatment in the healthcenter (except 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 small bottle of gentian violet.

Check the mothers understanding before she leaves the healthcenter.

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Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 3 times daily.

Wash hands.

Ask child to close the eye.

Use clean cloth and water to gently wipe away pus.

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

Ask the child to look up.

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

Wash hands again.

Treat until redness is gone.

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

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Dry the Ear by Wicking and Instill Quinolone

Eardrops 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 childs ear.

Remove the wick when wet.

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

Instill Quinolone (may include Ciprofloxacine, Norfloxacin eardrops) eardrops

after dry wicking 3X daily for2 weeks

Treat Mouth Ulcers with Gentian Violet

Treat the mouth ulcers twice daily.

Wash hands.

Wash the childs mouth with clean soft cloth wrapped around the finger andwet with salt water.

Paint the mouth with half-strength gentian violet (0.25% dilutiion)

Wash hands again.

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

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Soothe the Throat, Relieve the Cough with a Safe

Remedy

Safe remedies to recommend:

Breastmilk for exclusively breastfed infant.

Tamarind, Calamansi and Ginger.

Harmful remedies to discourage:

Codeine cough syrup

Other cough syrups

Oral and nasal decongestants

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GIVE THESE TREATMENTS IN HEALTH CENTER ONLY

Explain to the mother why the drug is given.

Determine the dose appropriate for the childs weight (or age).

Use a sterile needle and sterile syringe. Measure the dose accurately.

Give the drug as an intramuscular injection.

If children cannot be referred, follow the instructions provided on the next

slides.

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Give An Intramuscular Antibiotic

GIVE TO CHILDREN BEING REFERRED URGENTLY

Give GENTAMICIN (7.5mg/kg) and BENZYL PENICILLIN (50,000 units per kg)

Age or Weight GENTAMICINDose (7.5 mg/kg)

80 mg vial (40mg/ml)

Undiluted

BENZYL PENICILLINDose (50,000 units/kg)

To a vial of 600mg

(1,000,000 units)= add 1.6 ml

Sterile water to give

500,000 units/ml

3 - < 6 kg 0.5 ml 0.9 ml 0.4 ml

6 - < 10 kg 1.1 ml 1.7 ml 0.75 ml

10 - < 15 kg 1.9 ml 2.6 ml 1.2 ml

15 - < 20 kg 2.8 ml 3.5 ml 1.7 ml

NOTE: Calculate EXACT DOSE ofGENTAMICIN BASED ONBODY WEIGHT

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Give Quinine for Severe Malaria

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE/MALARIA:

Check which Quinine formulation is available in your clinic

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

IF REFERRAL IS NOT POSSIBLE:

Give first dose of intramuscular QUININE.

The child should remain lying down for one hour.

Repeat the QUINNE injection at 4 and 8 hours later, and then every 12 hours until the child isable to take an oral antimalarial. Do not continue QUININE injections for more than 1 week.

DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE.

* quinine salt

AGE OR WEIGHT INTRAMUSCULAR QUININE

150mg/ml* (in 2ml) 300mg/ml*(in 2ml)

2 months up to 4 months (4 - < 6 kg) 0.4 ml 0.2 ml

4 months up to 12months (6 - < 10 kg) 0.6 ml 0.3 ml

12 months up to 2 years (10 - < 12 kg) 0.8 ml 0.4 ml

2 years up to 3 years (12 - < 14 kg) 1.0 ml 0.5 ml

3 years up to 5 years (14 19 kg) 1.2 ml 0.6 ml

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Give Inhaled Salbutamol for Wheezing

Use of a Spacer

A spacer is a way of delivering the bronchodilator drugseffectively into the lungs. No child under 5 years shouldbe given an inhaler without a spacer. A spacer works aswell as a nebulizer if correctly used.

From salbutamol metered dose inhaler (100ug/puff)give 2 puffs

Repeat up to 3 times every 15 minutes before

classifying pneumonia.

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Spacers are made on the following way:

Use a 500ml drink bottle or similar.

Cut a hole in the bottle base in the same shape as themouthpiece of the inhaler. This can be done using asharp knife.

Cut the bottle between the upper quarter and thelower and discard the upper quarter of the bottle.

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Cut a small V in the border of the large open partof the bottle to fit the childs nose and be used as

mask.

Flame the edge of the cut bottle with a smallcandle or lighter to soften it. In a small baby, a

mask can be made by making a similar hole in aplastic (not polystyrene) cup.

Alternatively commercial spacers can be used if

available.

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To use an inhaler with a spacer

Remove the inhaler cap. Shake the inhaler well.

Insert mouthpiece of the inhaler through the hole

in the bottle or plastic cup.

The child should put the opening of the bottleinto his mouth and breath in and out through the

mouth.

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A cared then presses down the inhaler and sprayinto the bottle while the child continue to breathnormally.

Wait for3 to 4 breaths and repeat for total of fivesprays.

For younger children place the cup over thechilds mouth and use as a spacer in the sameway.

If a spacer is being used for the first time, itshould be primed by 4-5 extra puffs from theinhaler.

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Treat the Child 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 is able to swallow

Give expressed breastmilk or a breastmilk substitute.

If neither of these is available, give sugar water.

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

To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams)

in a 200-ml cup of clean water.

If the child is not able to swallow:

Give 50 ml of milk or sugar water by nasogastric tube.

If child is difficult to awaken or unconscious, start IV infusion:

Give 5mg/kg of 10% dextrose soln (D10) over a few minutes OR

Give 1ml/kg of 50% dextrose soln (D50) by slow push.

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Plan A: Treat No Dehydration at Home

Counsel the mother on the 3 Rules of Home Treatment:

Give Extra Fluid, Give Zinc Supplements (age 2 months up to 5 years), Continue Feeding & 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 breastfeed, give ORS or clean water in addition to breastmilk.

If the child is not exclusively breastfeed, give one or more of the following: ORS solution,

food-based fluids (such as soup, rice water, or buko juice), 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 the visit.

The child cannot return to a health center if the diarrhea gets worse.

TEACH THE MOTHER HOW TO MIX AND GIVE ORS.

GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME.

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Plan A: Treat Some Dehydration with ORS

2. GIVE ZINC SUPPLEMENTS (age 2 months up to 5 years)

Tell the mother how much ZINC to give (20mg/tab)

2 months up to 6 months ------------------- tablet daily for 14 days

6months or more ------------------- 1 tablet daily for 14 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 clean water in

a cup

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

4. WHEN TO RETURN

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Plan B: Treat Some Dehydration with ORS

Give in health center recommended amount of ORS over 4-hour period

960 1600800 960450 800200 450In ml

12 -20 kg

2 years up to

5 years

* Use the childs age only when you do not know the weight. The approximate amount of ORSrequired(in ml) can also be calculated by multiplying the childs weight(in kg) times 75.

If the child wants more ORS than shown, give more.

For infants under6 months who are not breastfeed, also give 100-200 ml clean

water during this period.

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

Give frequent small sips from a cup.

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

Continue breastfeeding whenever the child wants.

10 -< 12 kg6 -< 10 kg< 6 kgWEIGHT

12 months up to

2 years

4 months up to

12 months

Up to 4 monthsAGE

DETERMINE AMOUNT OR ORS TO GIVE DURING FIRST 4 HOURS

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Plan B: Treat Some Dehydration with ORS

AFTER 4 HOURS:

Reassess the child and classify the child for dehydration.

Select the appropriate plan to continue treatment.

Begin feeding the child in health center.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

Show her how to prepare ORS solution at home.

Show her how much ORS to give to finish 4-hour treatment at home.

Give her enough ORS packets to complete rehydration. Also give her 2 packets asrecommended in Plan A.

Explain the 4 rules of home Treatment.

1. GIV EEXTRA FLUID

2. GIV EZINCSUPPLEMENTS (age 2months up to 5 years)

3. CON TINUEFEEDING (exclusive breastfeeding if age less than 6months

4. WH ENTO RETURN

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GIVE VITAMIN A

SUPPLEMENTATION

AS NEEDED

IMMUNIZE EVERY

SICK CHILD AS

NEEDED

GIVEMEBENDAZOLE/ALBE

NDAZOLE AS

NEEDED

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GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all theboxes that match the childs previous classifications

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

the new problem as on the ASSESSAND CLASSIFYchart.

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PNEUMONIA

After2 days:

Check the child for general danger signs.

Assess the child for cough or difficult breathing.

Ask:

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 refer URGENTLY to hospital.

Ifbreathing rate, fever, and eating are the same, change to the second-line antibiotic

and advise the mother to return in 2 days or refer. (If this child had measles within the

last 3 months, refer.)

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

SeeASSESS & CLASSIFYchart.

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PERSISTENT DIARRHEA

After 5 days:

Ask:

Has the diarrhea stopped?

How many loose stools is the child having per day?

Treatment:

Ifthe diarrhea has not stopped (child is still having 3 or more loose stools per

day), do a full reassessment of the child. Give any treatment needed. Then refer to

hospital.

Ifthe diarrhea has stopped (child having less than 3 loose stools per day), tell the

mother to follow the usual recommendations for the childs age.

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DYSENTERY

After2 days:

Assess the child for cough or difficult breathing. > SeeASSESS & CLASSIFYchart.

Ask:

Are there fewer stools? Is there less abdominal pain?

Is there less blood in the stool? Is the child eating better?

Is there less fever?

Treatment:

If the child is dehydrated, treat dehydration.

ifnumber of stools, amount of blood in stools, fever, abdominal pain, oreating is the

same or worse:

Change to second-line oral antibiotic recommended for Shigella in your area. Give it for 5days. Advise the mother to return in 2 days.

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

Was dehydrated on the first visit, or

Had measles within the last 3 months

Iffewer stools, less blood in the stools, less fever, less abdominal pain, and eating

better, continue giving the same antibiotic until finished.

Refer to

hospital

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MALARIA

If fever persists after2 days, or returns within 14 days:

Do a full assessment of the child. > See ASSESS & CLASSIFYchart.

Treatment:

If the child has any general danger signs or stiff neck, treat as VERY SEVERE

FEBRILE DISEASE/MALARIA. If the child has any cause of fever other than malaria, provide treatment.

Ifmalaria is the only apparent cause of fever:

Take a blood smear.

Give second-line oral antimalarial without waiting for result of blood smear.

Advise mother to return in 2 days if fever persists.

If fever persists after2 days treatment with second line oral antimalarial, refer with

blood smear for reassessment.

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

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FEVER-MALARIA UNLIKELY

If fever persists after2 days:

Do a full reassessment of the child. > SeeASSES & CLASSIFYchart.

Assess for other causes of fever.

Treatment: If the child has any general danger signs or stiff neck, treat as VERY SEVERE

FEBRILE DISEASE/MALARIA.

Ifmalaria is the only apparent cause of fever:

Take a blood smear.

Treat with the first-line oral antimalarial. Advise the mother to return again in 2 days ifthe fever persists.

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

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FEVER (NO MALARIA)

If fever persists after2 days:

Do a full assessment of the child. > SeeASSESS & CLASSIFYchart.

Make sure that there has been no travel to malarious area.

If there has been travel, take blood smear, if possible.

Treatment:

If there has been travel to a malarious area and the blood smear is positive or there is

no blood smear classify according to fever with Malaria Risk and treat accordingly.

If there has been no travel to malarious area or blood smear is negative:

If child has any general danger signs of stiff neck, treat as VERY SEVERE

FEBRILE DISEASE.

If the child has any apparent cause of fever, provide treatment.

If no apparent cause of fever, advice the mother to return again in 2 days if fever

persists.

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

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MEASLES WITH EYE OR MOUTH COMPLICATION

After2 days:

Look for red eyes and pus draining from the eyes.

Look at mouth ulcers.

Smell the mouth

Treatment for eyes Infection:

Ifpus is draining from the eye, ask the mother to describe how she has treated the

eye infection. If treatment has been correct, refer to hospital. If treatment has not

been correct, teach mother correct treatment.

If thepus 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 ulcers are the same or better, continue using half-strength gentian violet

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EAR INFECTION

After 5 days:Reassess for ear problem. > See ASSESS & CLASSIFY chart

Measure the childs temperature.

Treatment:

If there is tender swelling behind the ear or high fever (38. 5C or above),treat as MASTOIDITIS.

Acute ear infection: If ear pain discharge persists, treat with 5 more days of

the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days

Chronic ear infection: Check that the mother is wicking the ear correctly.

Encourage her to continue.

Ifno ear pain or discharge, praise the mother for her careful treatment. If shehas not yet finished th e 5 days of antibiotic, tell her to use all of its before

stopping .

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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 mother about any new or continuing feeding problems. If you counsel the

mother to make significant changes in feeding, ask her to bring the child back again.

If the child is very low weight for age, ask the mother to return 30 days after the initialvisit to measure the childs weight gain.

ANEMIA

After 5 days:

Given iron. Advise mother to return in 14 days for more iron.

Continue giving iron every day for2 months with follow-up every 14 days.

If the child has any palmar pallor after2 months, refer for assessment.

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VERY LOW WEIGHT

After30 days:

Weight the child and determine if the child is still very low weight for age.

Reassess feeding. > See question at the top of the COUNSEL chart.

Treatment

If the child is no longer very low weight for age, praise the mother and encourageher to continue.

If the child is still very low weight for age, counsel the mother about any feeding

problem found. Continue to see the child monthly until the child is feeding well and

gaining weight regularly 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 weightrefer the child.

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IF ANY MORE FOLLOW-UP VISITS ARE NEEDEDBASED ON THE INITIAL VISIT OR THIS VISIT,

ADVISE THE MOTHER OF THE

NEXT FOLLOW-UP VISIT

ALSO, ADVISE THE MOTHER

WHEN TO RETURN IMMEDIATELY.(See COUNSEL CHART.)

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FOOD

Assess the Childs Feeding

Ask questions about the childs usual feeding and feeding during this illness. Compare the

mothers answer to the FeedingRecommendations for the childs age in the box below.

ASK:

Do you breastfeed your child? How many times during the day?

Do you also breastfeed during the night?

Does the child take any other food or fluids?

What food or fluids?

How many times per day?

What do you use to feed the child?

If very low weight for age: How large are servings? Does the child receive his own

serving? Who feeds the child and how?

During this illness has the child s feeding charged? If yes, how?

COUNSEL THE MOTHER

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Counsel the Mother About Feeding Problems

If the mother reports difficulty with breastfeeding, assess breastfeeding.

(See YOUNG INFANT chart). As needed, show the mother correctpositioning and attachment for breastfeeding.

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

Build mothers confidence that she can produce all the breastmilk that the

child needs.

Suggest giving more frequent, longer breastfeeds, day and night, andgradually reducing other milk or foods.

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

Breastfeed as much as possible, including at night.

Make sure other milk is a locally appropriate breastmilk substitute, give

only when necessary. Make sure other milk is correctly and hygienically prepared and given in

adequate amounts.

Prepare only an amount of milk which the child can consume within an

hour. If there is some left-over milk, discard.

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

Recommended substituting a cup for bottle.

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

If the child is not being fed actively, counsel the mother to:

Sit with the child and encourage eating.

Give the child and adequate serving in a separate plate or bowl.

Observe what the child likes and consider these in the preparation of his/her

food.

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

Breastfeed more frequently and for longer if possible.

Use soft, varied, appetizing, favorite foods to encourage the child to eat as much

as possible, and offer frequent small feedings.

Clear a blocked nose if it interferes with feeding.

Expect that appetite will improve as child gets better.

Follow-up any feeding problem in 5 days.

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FLUID

Advise the Mother to Increase FluidDuring Illness

FOR ANY SICK CHILD:

Breastfeed more frequently and for longer at each feed.

Increase fluid. For example, give soup, rice water, buko juice or clean water.

FOR CHILD WITH DIARRHEA:

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

NEXT WELL-CHILD VISIT

Advise mother when to return for next immunization according to immunization schedule.

30 daysVERY LOW WEIGHT FOR AGE

5 daysANEMIA

5 days

PERSISTENT DIARRHEA

ACUTE EAR INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEM

ANY OTHER ILLNESS, if not improving

2 days

PNEUMONIA

DYSENTERY

MALARIA, if fever persists

FEVER-MALARIA UNLIKELY, if fever persists

FEVER (NO MALARIA), if fever persists

MEASLES WITH EYE OR MOUTH COMPLICATIONS

DENGUE HEMORRHAGIC FEVER UNLIKELY, if fever persist

Return for

Follow-up in:If the child has:

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT

Advise the mother to come for follow-up at the earliest time listed for the childs problems.

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Any sick child Not able to drink or breastfeed

Becomes sicker

Develops a fever

If child has NO PNEUMONIA:

COUGH OR COLD, also return if:

Fast breathing

Difficult breathing

If child has diarrhea, also return if: Blood in stool

Drinking poorly

If child has FEVER:DENGUE HEMORRHAGIC FEVER

UNLIKELY,

Also return if:

Any sign of bleedingPersistent abdominal pain

Persistent vomiting

Skin petechiae

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

WHEN TORETURN IMMEDIATELY

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Counsel the MotherAbout 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 mothers immunization status and give her Tetanus Toxoid if needed.

Make sure she has access to:

Family Planning

Counseling on STD and AIDS prevention

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WEIGHT FOR AGE CHART

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS(as of 2009 update)

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