Imci Chart Booklet

CHILD AGED 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD

Assess, CIassify and Identify Treatment
Check for General Danger Signs..................................2
Then Ask About Main Symptoms:
Does the child have cough or difficult breathing?.............2
Does the child have diarrhoea?....................................3
Does the child have fever?..........................................4
Does the child have an ear problem?............................5
Then Check for Malnutrition and Anaemia....................6
Then Check the Child's mmunization Status ...............7
Assess Other Problems ...............................................7

TREAT THE CHILD
Teach the mother to give oraI drugs at home:
Oral Antibiotic.........................................................8
Ciprofloxacin..........................................................8
ron .......................................................................9
Co-artemether .......................................................9
Bronchodilator........................................................9

Teach the Mother to Treat LocaI Infections at Home
Clear the ear by dry wicking and give eardrops....10
Treat for mouth ulcers and thrush ........................10
Soothe throat, relieve cough with safe remedy....10
Treat eye infection ..............10

Give Preventive Treatments in CIinic
Vitamin A ................. 11
Mebendazole ...................11

Give Emergency Treatment in CIinic onIy
Quinine for severe malaria...................................12
ntramuscular Antibiotic .......................................12
Diazepam for convulsions ............. 12
Treat low blood sugar ..........................................13

TREAT THE CHILD, continued

Give Extra FIuid for Diarrhoea
and Continue Feeding
Plan A: Treat for Diarrhoea at Home....................... 14
Plan B: Treat for Some Dehydration with ORS........ 14
Plan C: Treat for Severe Dehydration Quickly......... 15

Give FoIIow-up Care
Pneumonia ............................................................. 16
Dysentery ............................................................... 16
Persistent diarrhoea................................................ 16
Malaria ................................................................... 17
Fever malaria unlikely........................................... 17
Measles with eye or mouth complications .... 17
Ear nfection .......................................................... 18
Feeding problem................................................... . 18
Anaemia................................................................ 18
Pallor ....................18
Very Low Weight .................................................... 18
Severe uncomplicated malnutrition ........18

COUNSEL THE MOTHER
Assess the feeding of sick infants........................... 19
Feeding Recommendations.................................... 20
Counsel the mother about feeding Problems .......... 21
Counsel the mother about her own health............... 22
Advise mother to increase fluids during illness........ 23
Advise mother when to return to health worker ..23
Advise mother when to return immediately ............. 23

SICK YOUNG INFANT AGED UP TO 2 MONTHS

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

Assess, CIassify and Identify Treatment
Check for Severe Disease and Local nfection...................................... ..24
Then check for Jaundice ...................................................................... ..25
Then ask: Does the young infant have diarrhoea?..................................... ..26
Then check for Feeding Problem or Low Weight for Age..........27
Then check the young infant's immunization status... ........................... ..28
Assess Other Problems............................................................................. ..28

Treat the Young Infant and CounseI the Mother
ntramuscular antibiotics.........................29
Treat the young infant to prevent low blood sugar..............29
Keep the young infant warm on the way to hospital..............30
Oral antibiotic............................30
Treat local infections at home......................31
Correct positioning and attachment for breastfeeding...........32
Teach mother how to express breast milk ..................32
Teach mother how to feed by cup........................33
Teach the mother to keep the low weight infant warm at home.......33
Advice mother to give home care to the young infant..............34

Give FoIIow-up Care for the Sick Young Infant
Local Bacterial nfection................................................................................ 35
Jaundice....................................................................................................... 35
Diarrhoea....................................................................................... ............. 35
Feeding Problem.......................................................................................... 36
Low Weight for age....................................................................................... 37
Thrush........................................................................................... .............. 37

Recording Forms: Sick ChiId .....................................................................38
Sick young infant ........................................................39

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&+,/'+22',//1(66 Department of Child and Adolescent
Health and Development (CAH)

2
THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?
ASSESS AND CLASSIFY THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS
TREATMENT
(Urgent pre-referraI treatments are in boId print)

CIassify
COUGH or
DIFFICULT
BREATHING
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE
x Determine whether this is an initial or follow-up visit for this problem.
- if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart
- if initial visit, assess the child as follows:
CHECK FOR GENERAL DANGER SIGNS
A chiId with any generaI danger sign needs URGENT attention; compIete the assessment and
any pre-referraI treatment immediateIy so that referraI is not deIayed.
ASK:

x s the child able to drink or breastfeed?
x Does the child vomit everything?
x Has the child had convulsions?
LOOK:

x See if the child is lethargic or unconscious.
x s the child convulsing now?
USE ALL BOXES THAT MATCH THE
CHILD'S SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS.
CLASSIFY IDENTIFY TREATMENT ASSESS
If the chiId is: Fast breathing is:

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

12 months up 40 breaths per
to 5 years minute or more
SIGNS CLASSIFY AS
x Any general danger sign or

x Chest indrawing or

x Stridor in a calm child

SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE

PNEUMONIA

COUGH OR COLD
Give first dose of an appropriate antibiotic
Refer URGENTLY to hospital*

x Fast breathing

Give oral antibiotic for 3 days
f wheezing (even if it disappeared after rapidly acting
bronchodilator) give an inhaled bronchodilator for 5 days**
Soothe the throat and relieve the cough with a safe remedy
f coughing for more than 3 weeks or if having recurrent
wheezing, refer for assessment for TB or asthma
Advise the mother when to return immediately
Follow-up in 2 days
x No signs of pneumonia
or very severe disease

f wheezing (even if it disappeared after rapidly acting
bronchodilator) give an inhaled bronchodilator for 5 days**
Soothe the throat and relieve the cough with a safe remedy
f coughing for more than 3 weeks or if having recurrent
wheezing, refer for assessment for TB or asthma
Advise mother when to return immediately
Follow up in 5 days if not improving
IF YES,
ASK:
LOOK, LISTEN, FEEL:

xFor how
long?
x Count the breaths
in one minute.
x Look for chest indrawing.
x Look and listen for stridor.
x Look and listen for wheezing.

If wheezing and either fast
breathing or chest indraw-
ing: Give a trial of rapid acting
inhaled bronchodilator for up to
three times 15-20 minutes
apart. Count the breaths and
look for chest indrawing again,
and then classify.
CHLD
MUST
BE CALM
`
**In settings where inhaled bronchodilator is not available, oral salbutamol may be the second choice *If referral is not possible, manage the child as described in Integrated Management of Childhood Illness,
Treat the Child, Annex: Where Referral Is Not Possible, and WHO guidelines for inpatient care.
3

Does the chiId have diarrhoea?

Classify
DIARRHOEA

for
DEHYDRATION

and if blood
in stool

LOOK AND FEEL:

x Look at the child's general condition.
s the child:

- Lethargic or unconscious?
- Restless and irritable?

x Look for sunken eyes.

x Offer the child fluid. s the child:

- Not able to drink or
drinking poorly?
- Drinking eagerly, thirsty?

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

- Very slowly (longer than
2 seconds)?
- Slowly?
and if diarrhoea for
14 days or more

IF YES,
ASK:

x For how long?

x s there blood
in the stool?

Two of the following signs:

x Lethargic or unconscious
x Sunken eyes
x Not able to drink or drinking poorly
x Skin pinch goes back very slowly.

SEVERE
DEHYDRATION

Two of the following signs:

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

SOME
DEHYDRATION

f child has no other severe classification:
- Give fluid for severe dehydration (Plan C)
OR
If child also has another severe classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
- Advise the mother to continue breastfeeding

If child is 2 years or older and there is cholera in your area,
give antibiotic for cholera
Give fluid, zinc supplements and food for some dehydration
(Plan B)

If child also has a severe classification:
Advise the mother to continue breastfeeding

Follow-up in 5 days if not improving.
Not enough signs to classify as some
or severe dehydration

Give fluid, zinc supplements and food to treat diarrhoea at home
(Plan A)
Follow-up in 5 days if not improving.
NO
DEHYDRATION

x Dehydration present

SEVERE
PERSISTENT
DIARRHOEA
Treat dehydration before referral unless the child has another
severe classification
Refer to hospital

x No dehydration

PERSISTENT
DIARRHOEA

Advise the mother on feeding a child who has PERSSTENT
DARRHOEA
Give multivitamins and minerals (including zinc) for 14 days
Follow up in 5 days

DYSENTERY
x Blood in the stool

Give ciprofloxacin for 3 days
Follow-up in 2 days
4
IF YES:
Decide Malaria Risk: high or low

THEN ASK:

x For how long?

x f more than 7 days, has fever
been present every day?

x Has the child had measles
within the last 3 months?

LOOK AND FEEL:

x Look or feel for stiff neck.

x Look for runny nose.

Look for signs of MEASLES

x Generalized rash and

x One of these: cough, runny nose,
or red eyes.

Give quinine for severe malaria (first dose)
Treat the child to prevent low blood sugar
Give one dose of paracetamol in clinic for high fever
(38.5C or above)
Refer URGENTLY to hospital
x Stiff neck.

VERY SEVERE
FEBRILE
DISEASE

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

MALARIA

Give oral co-artemether or other recommended antimalarial
(38.5C or above)
Follow-up in 2 days if fever persists
f fever is present every day for more than 7 days, refer for
assessment

Classify
FEVER
HIGH MALARIA RISK

if MEASLES
now or within
last 3 months,
Classify
Does the chiId have fever?
(by history or feels hot or temperature 37.5C** or above)
LOW MALARIA RISK

High
Malaria Risk

Low
Malaria Risk

If the child has measles now
or within the last 3 months:

x Look for mouth ulcers.

Are they deep and extensive?

x Look for pus draining from the
eye.

x Look for clouding of the cornea.

Give quinine for severe malaria (first dose) unless no malaria risk
Treat the child to prevent low blood sugar
(38.5C or above)
x Stiff neck

VERY SEVERE
FEBRILE
DISEASE

Give oral co-artemether or other recommended antimalarial
(38.5C or above)
assessment
x NO runny nose and
NO measles and
NO other cause of fever

MALARIA

x Runny nose PRESENT or
x Measles PRESENT or
x Other cause of fever
PRESENT

(38.5C or above)
assessment

FEVER -
MALARIA
UNLIKELY

x Clouding of cornea or
x Deep or extensive mouth
ulcers
Give Vitamin A treatment
If clouding of the cornea or pus draining from the eye, apply
tetracycline eye ointment
x Pus draining from the eye or
x Mouth ulcers

If pus draining from the eye, treat eye infection with
tetracycline eye ointment
f mouth ulcers, treat with gentian violet
Follow-up in 2 days.
x Measles now or within the
last 3 months

SEVERE
COMPLICATED
MEASLES***
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS***

MEASLES
** These temperatures are based on axillary temperature. Rectal temperature readings are
approximately 0.5C higher.
*** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and
malnutrition - are classified in other tables.
5

Does the chiId have an ear probIem?

IF YES, ASK:
x s there ear pain?

x s there ear discharge?
f yes, for how long?

Classify
EAR PROBLEM

LOOK AND FEEL:

x Look for pus draining from the ear.
x Feel for tender swelling behind the ear.

ACUTE EAR
INFECTION

CHRONIC EAR
INFECTION

MASTOIDITIS

Give an antibiotic for 5 days.
Give paracetamol for pain.
Dry the ear by wicking.

Give first dose of an appropriate antibiotic.
Give first dose of paracetamol for pain.
Refer URGENTLY to hospital.
Dry the ear by wicking.
Treat with topical quinolone eardrops for 2 weeks
x Pus is seen draining from the ear
and discharge is reported for less
than 14 days, or
x Ear pain.

x Tender swelling behind the ear.

x Pus is seen draining from the ear
and discharge is reported for 14
days or more.

x No ear pain and
No pus seen draining from the ear.

NO EAR
INFECTION
No treatment.

6
THEN CHECK FOR MALNUTRITION AND ANAEMIA

CHECK FOR MALNUTRITION

CHECK FOR ANAEMIA

CLASSIFY
ANAEMIA

LOOK and FEEL:

x Look for palmar pallor. s it:
Severe palmar pallor?
Some palmar pallor?

CLASSIFY
NUTRITIONAL
STATUS
x Severe palmar pallor

SEVERE ANAEMIA Refer URGENTLY to hospital

x Some palmar pallor

ANAEMIA

Give iron
Give oral antimalarial if high malaria risk
Give mebendazole if child is 1 year or older and has not had
a dose in the previous six months
Follow up in 14 days

xNo palmar pallor

NO ANAEMA

f child is less than 2 years old, assess the child's feeding and
counsel the mother on feeding according to the feeding
recommendations
- f feeding problem, follow-up in 5 days
LOOK AND FEEL:

xLook for visible severe wasting
xLook for oedema of both feet
xDetermine weight for age
Treat the child to prevent low sugar

Refer URGENTLY to a hospital
x Visible severe wasting or
x Oedema of both feet

x Not very low wight for age and

no other signs of malnutrition

NOT VERY
LOW WEIGHT
f child is less than 2 years old, assess the child's feeding

and counsel the mother on feeding according to the feeding
recommendations
- f feeding problem, follow-up in 5 days

SEVERE
MALNUTRITION

x Very low weight for age
VERY LOW
WEIGHT
Assess the child's feeding and counsel the mother on feed-
ing according to the feeding recommendations
Follow-up in 30 days
7
ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments.
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

VITAMIN A SUPPLEMENTATION

Give every child a dose of Vitamin A every six
months from the age of 6 months. Record the dose
on the child's card.

ROUTINE WORM TREATMENT

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

IMMUNIZATION SCHEDULE:
AGE
Birth

6 weeks

10 weeks

14 weeks

9 months

Follow national guidelines

VACCINE
BCG OPV-0

DPT+HB-1 OPV-1 Hepatitis B1



Measles*

* Second dose of measles vaccine may be given at any
opportunistic moment during periodic supplementary immunisation
activities as early as one month following the first dose
8
TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON
THE ASSESS AND CLASSIFY CHART
For dysentery give CiprofIoxacin
15mg/kg/day-2 times a day for 3 days

SECOND-LNE ANTBOTC FOR DYSENTERY: ____________________________________________

TEACH THE MOTHER TO GIVE ORAL DRUGS AT
HOME

FoIIow the instructions beIow for every oraI drug to be given at home.
AIso foIIow the instructions Iisted with each drug's dosage tabIe.

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

TeII the mother the reason for giving the drug to the chiId

Demonstrate how to measure a dose

Watch the mother practise measuring a dose by herseIf

Ask the mother to give the first dose to her chiId

ExpIain carefuIIy how to give the drug, then IabeI and package the drug.
If more than one drug wiII be given, coIIect, count and package each drug
separateIy

ExpIain that aII the tabIets or syrup must be used to finish the course of
treatment, even if the chiId gets better

Check the mother's understanding before she Ieaves the cIinic
Give an Appropriate OraI Antibiotic

FOR PNEUMONIA, ACUTE EAR INFECTION:
FRST-LNE ANTBOTC: __________________________________________________________

SECOND-LNE ANTBOTC: __________________________________________________________

* Amoxycillin should be used if there is high co-trimoxazole resistance.

FOR CHOLERA:
FRST-LNE ANTBOTC FOR CHOLERA: ____________________________________________

SECOND-LNE ANTBOTC FOR CHOLERA: ____________________________________________

250 mg TABLET

500 mg TABLET
AGE DOSE/ tabs DOSE/ tabs
Less than 6 months 1/2 tablet 1/4 tablet
6 months up to 5 years 1 tablet 1/2 tablet

CO-TRIMOXAZOLE
(trimethoprim / sulphamethoxazole)
Give two times daily for 3 days for
pneumonia
Give two times daily for 5 days for acute ear
infection

AGE or
WEIGHT

ADULT
TABLET
(80/400mg)

PAEDIATRIC
TABLET
(20/100 mg)

SYRUP
(40/200 mg/5ml)

TABLET
(250 mg)

SYRUP
(125 mg /5 ml)
2 months up to
12 months
(4 - <10 kg)
1/2 2 5.0 ml 3/4 7.5 ml
12 months up to
5 years
(10 - 19 kg)
1 3 7.5 ml 1.5 15 ml

AMOXYCILLIN*
Give two times daily for 3
days for pneumonia
Give two times daily for 5
days for acute ear infection
TETRACYCLINE
Give 4 times daily for 3 days
AGE or WEIGHT TABLET
250 mg

2 years up to 5 years
(12 - 19 kg)

1
ERYTHROMYCIN
Give 4 times daily for 3 days
TABLET
250 mg
1
9

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
GIVE INHALED SALBUTAMOL for WHEEZING
USE OF A SPACER*
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No
child under 5 years should be given an inhaler without a spacer. A spacer works as
well as a nebuliser if correctly used.
From salbutamol metered dose inhaler (100 Pg/puff) give 2 puffs.
Repeat up to 3 times every 15 minutes before classifying pneumonia.
Spacers can be made in the foIIowing way:
Use a 500ml drink bottle or similar.
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler.
This can be done using a sharp knife.
Cut the bottle between the upper quarter and the lower 3/4 and disregard the up-
per quarter of the bottle.
Cut a small V in the border of the large open part of the bottle to fit to the child's
nose and be used as a mask.
Flame the edge of the cut bottle with a candle or a lighter to soften it.
n a small baby, a mask can be made by making a similar hole in a plastic (not
polystyrene) cup.
Alternatively commercial spacers can be used if available.
To use an inhaIer with a spacer:
Remove the inhaler cap. Shake the inhaler well.
nsert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
The child should put the opening of the bottle into his mouth and breath in and out
through the mouth.
A carer then presses down the inhaler and sprays into the bottle while the child
continues to breath normally.
Wait for three to four breaths and repeat for total of five sprays.
For younger children place the cup over the child's mouth and use as a spacer in
the same way.

* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs
from the inhaler.

Give Iron
Give one dose daily for 14 days
Give OraI Co-artemether

Give the first dose of co-artemether in the clinic and observe for one hour f child vomits
within an hour repeat the dose. 2nd dose at home after 8 hours
Then twice daily for further two days as shown below
Co-artemether should be taken with food

Co-artemether tabIets
(20mg artemether and 120mg lumefantrine)
WEIGHT (age) 0hr 8h 24h 36h 48h 60h
5 - <15 kg (5 months up to 3 years) 1 1 1 1 1 1
15 - <20 kg (3 years up to 5 years) 2 2 2 2 2 2

AGE or WEIGHT

IRON/FOLATE TABLET
Ferrous sulfate 200 mg +
250 Pg Folate
(60 mg elemental iron)

IRON SYRUP
Ferrous fumarate
100 mg per 5 ml
(20 mg elemental iron per ml)
2 months up to 4 months (4 - <6 kg) 1.0 ml (< 1/4 tsp)
4 months up to 12 months (6 - <10kg) 1.25 ml (1/4 tsp)
12 months up to 3 years (10 - <14 kg) 1/2 tablet 2.0 ml (<1/2 tsp)
3 years up to 5 years (14 - 19 kg)

1/2 tablet 2.5 ml (1/2 tsp)
10

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

CIear the Ear by Dry Wicking and Give Eardrops*

Do the foIIowing 3 times daiIy

x Roll clean absorbent cloth or soft, strong tissue paper into a wick
x Place the wick in the child's ear
x Remove the wick when wet
x Replace the wick with a clean one and repeat these steps until the ear is dry
x nstil quinolone eardrops* for two weeks
Treat Mouth UIcers with Gentian VioIet (GV)

Treat the mouth uIcers twice daiIy
x Wash hands
x Wash the child's mouth with a clean soft cloth wrapped around the finger
and wet with salt water
x Paint the mouth with 1/2 strength gentian violet (0.25% dilution)
x Wash hands again
x Continue using GV for 48 hours after the ulcers have been cured
x Give paracetamol for pain relief

Soothe the Throat, ReIieve the Cough with a Safe Remedy

Safe remedies to recommend:
- Breast milk for a breastfed infant
_______________________________________________________

_______________________________________________________

Harmful remedies to discourage:

________________________________________________________

________________________________________________________

ExpIain to the mother what the treatment is and why it shouId be given

Describe the treatment steps Iisted in the appropriate box

Watch the mother as she gives the first treatment in the cIinic (except for remedy for cough or sore throat)

TeII her how often to do the treatment at home

If needed for treatment at home, give mother a tube of tetracycIine ointment or a smaII bottIe of gentian vioIet

Check the mother's understanding before she Ieaves the cIinic
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin
Treat Eye Infection with Tetracycline Eye
Ointment
Clean both eyes 4 times daily.

x Wash hands.
x Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
x Squirt a small amount of ointment on the inside of the lower lid.

x Wash hands again.
Treat until there is no pus discharge.

Do not put anything else in the eye.
11

GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC

ExpIain to the mother why the drug is given

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

Measure the dose accurateIy

Give Vitamin A

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHLDREN
Thereafter give vitamin A every six months to ALL CHLDREN

VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) as part of
treatment if the child has measles or PERSSTENT DARRHOEA.

f the child has had a dose of Vitamin A within the past month, DO NOT GVE
VTAMN A

Always record the dose of Vitamin A given on the child's chart
Age VITAMIN A DOSE

6 months up to 12 months 100 000 U
One year and older 200 000 U

Give MebendazoIe
Give 500 mg mebendazole as a single dose in clinic if:
- hookworm/ whipworm is a problem in your area
- the child is 1 year of age or older, and
- has not had a dose in the previous 6 months
12

GIVE THESE TREATMENTS IN THE CLINIC ONLY

ExpIain to the mother why the drug is given
Determine the dose appropriate for the chiId's weight (or age)
Use a steriIe needIe and steriIe syringe when giving an injection
Measure the dose accurateIy
Give the drug as an intramuscuIar injection
If the chiId cannot be referred, foIIow the instructions provided

Give An IntramuscuIar Antibiotic
GIVE TO CHILDREN BEING REFERRED URGENTLY
Give ampicillin (50 mg/kg) and gentamicin (7.5mg/kg)

AMPICILLLIN
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml)
Where there is a strong suspicion of meningitis the dose of ampiciIIin
can be increased 4 times

GENTAMICIN
Use undiluted 2 ml vial (40mg/ml)
Of the dose range provided below, use lower dose for children with weight at lower
end of the category, and higher dose for children at the higher end of the category

F REFERRAL S NOT POSSBLE OR DELAYED, repeat the ampicillin injection
every 6 hours, and the gentamicin injection once daily

Give Quinine for Severe MaIaria
FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
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 quinine injection at 4 and 8 hours later, and then every 12 hours
until the child is able to take an oral antimalarial. Do not continue quinine
injections for more than 1 week
f low risk of malaria, do not give quinine to a child less than 4 months of age

Give Diazepam to Stop ConvuIsions

Turn the child to his/her side and clear the airway. Avoid putting things in the mouth
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe
(like a tuberculin syringe) without a needle, or using a catheter
Check for low blood sugar, then treat or prevent
Give oxygen and REFER
f convulsions have not stopped after 10 minutes repeat diazepam dose

WEIGHT AGE DOSE OF DIAZEPAM
(10 mg / 2 ml)
< 5 kg <6 months 0.5 ml
5 - < 10 kg 6 months up to 12 months 1.0 ml
10 - < 14 kg 12 months up to 3 years 1.5 ml
14 - 19 kg 3 years up to 5 years 2.0 ml
AGE or WEIGHT
150 mg /ml* (in 2 ml) 300 mg /ml* (in 2 ml )
2 months up to 4 months (4 - < 6 kg) 0.4 ml 0.2 ml
4 months up to 12 months (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
INTRAMUSCULAR QUININE
AGE WEIGHT AMPICILLIN
500 mg viaI
GENTAMICIN 2mI viaI
(at 40 mg/mI)
2 months up to 4 months 4 <6 kg 1 ml 0.5 - 1.0 ml
4 up to 12 months 6 <10 kg 2 ml 1.1 - 1.8 ml
12 months up to 3 years 10 <14 kg 3 ml 1.9 - 2.7 ml
3 up to 5 years 14 19 kg 5 ml 2.8 - 3.5 ml
*quinine salt
13

Treat the ChiId to Prevent Low BIood Sugar

If the chiId is abIe to breastfeed:

Ask the mother to breastfeed the child

If the chiId is not abIe to breastfeed but is abIe to swaIIow:

x Give expressed breast milk or breast-milk substitute
x f neither of these is available give sugar water
x 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 chiId is not abIe to swaIIow:

x Give 50ml of milk or sugar water by naso-gastric tube
14
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)
PIan A: Treat for Diarrhoea at Home
CounseI the mother on the 4 RuIes of Home Treatment:

1. Give Extra FIuid 2. Give Zinc SuppIements (age 2 months up to 5 years)
3. Continue Feeding 4. When to Return

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

TELL THE MOTHER:
x Breastfeed frequently and for longer at each feed
x f the child is exclusively breastfed, give ORS or clean water in addition to breast milk
x f the child is not exclusively breastfed, give one or more of the following:
food-based fluids (such as soup, rice water, and yoghurt drinks), or ORS

It is especiaIIy important to give ORS at home when:
x the child has been treated with Plan B or Plan C during this visit
x the child cannot return to a clinic if the diarrhoea gets worse
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2
PACKETS OF ORS TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE

USUAL FLUID INTAKE:
Up to 2 years: 50 to 100 ml after each loose stool
2 years or more: 100 to 200 ml after each loose stool

TeII the mother to:
x Give frequent small sips from a cup.
x f the child vomits, wait 10 minutes then continue - but more slowly
x Continue giving extra fluid until the diarrhoea stops

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

TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab) :
2 months up to 6 months - 1/2 tablet daily for 14 days
6 months or more - 1 tablet daily for 14 days

SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
x nfantsdissolve tablet in a small amount of expressed breast milk, ORS
or clean water in a cup
x 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 6 months)

4. WHEN TO RETURN
PIan B: Treat for Some Dehydration with ORS

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

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in
ml) can also be calculated by multiplying the child's weight in kg times 75.

xf the child wants more ORS than shown, give more
xFor infants below 6 months who are not breastfed, also give 100-200ml clean
water during this period
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION:

x Give frequent small sips from a cup
x f the child vomits, wait 10 minutes then continue - but more slowly
x Continue breastfeeding whenever the child wants

AFTER 4 HOURS:
x Reassess the child and classify the child for dehydration
x Select the appropriate plan to continue treatment
x Begin feeding the child in clinic

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
x Show her how to prepare ORS solution at home
x Show her how much ORS to give to finish 4-hour treatment at home
x Give her instructions how to prepare salt and sugar solution for use at home
x Explain the 4 Rules of Home Treatment:

1. GIVE EXTRA FLUID
2. GIVE ZINC (age 2 months up to 5 years)
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
AGE* Up to 4 months 4 months up

to 12 months
12 months up
to 2 years
2 years up
to 5 years
WEIGHT < 6 kg 6 - < 10 kg 10 - < 12 kg 12 - <20kg
Amount of fIuid
(mI) over 4 hours
200 - 450 450 - 800 800 - 960 960 - 1600
15
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)
PIan C: Treat for Severe Dehydration QuickIy
FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO DOWN
x Start IV fIuid immediateIy.

x f the child can drink, give ORS by mouth while the drip is set up.
x Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normal saline), divided as follows:

x Reassess the chiId every 1- 2 hours. f hydration status is not improving, give the V drip more rapidly.
x Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants)
or 1-2 hours (children).
x Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose
the appropriate plan (A, B, or C) to continue treatment.
x Refer URGENTLY to hospitaI for IV treatment.
x f the child can drink, provide the mother with ORS solution and show her how to give frequent sips
during the trip or give ORS by naso-gastic tube.
x Start rehydration by tube (or mouth) with ORS soIution: give 20 ml/kg/hour for 6 hours
(total of 120 ml/kg).
x Reassess the chiId every 1-2 hours whiIe waiting for transfer:
- f there is repeated vomiting or abdominal distension, give the fluid more slowly.
- f the hydration status is not improving after 3 hours, send the child for V therapy.
x After 6 hours reassess the child. Classify dehydration. Then choose the appropriate plan
(A, B, or C) to continue treatment.
NOTE:
x f the child is not referred to hospital, observe the child at least 6 hours after rehydration to be sure
the mother can maintain hydration giving the child ORS solution by mouth.
Refer URGENTLY to
hospital for V or
NG treatment
Can you give
intravenous (V)
fluid immediately?
Can the child drink?
AGE First give 30mI/kg in:
nfants
(under 12 months)
1 hour
Then give 70mI/kg in
5 hours
Children
(12 months up to 5 years)
30 minutes 2 hours
12
YES
YES
NO
NO
YES
NO
NO
IMMUNIZE EVERY SICK
CHILD, AS NEEDED
s V treatment
available nearby
(within 30 minutes)?
Are you trained to use
a naso-gastric (NG) tube
for rehydration?
16
GIVE FOLLOW-UP CARE

Care for the chiId who returns for foIIow-up using aII the boxes that match the chiId's previous cIassification
If the chiId has any new probIems, assess, cIassify and treat the new probIem as on the ASSESS AND CLASSIFY chart

PNEUMONIA

After 2 days:

Check the child for general danger signs.
Assess the child for cough or difficult breathing.
Ask:
- s the child breathing slower?
- s there less fever?
- s the child eating better?

Treatment:

f chest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular chloramphenicol. Then refer URGENTLY to hospital.
f breathing rate, fever and eating are the same, change to the second-line antibiotic
and advise the mother to return in 2 days or refer. (f this child had measles within the
last 3 months, refer.)
f breathing slower, less fever, or eating better, complete the 3 days of antibiotic.

See ASSESS & CLASSIFY chart.
}
DYSENTERY:

After 2 days:

Assess the child for diarrhoea > See ASSESS & CLASSIFY chart

Ask:
- Are there fewer stools?
- s there less blood in the stool?
- s there less fever?
- s there less abdominal pain?
- s the child eating better?

Treatment:

f the child is dehydrated, treat for dehydration.

f number of stooIs, bIood in the stooIs, fever, abdominaI pain, or eating is
worse or the same:

Change to second-line oral antibiotic recommended for dysentery in your area.
Give it for 5 days. Advise the mother to return in 2 days. f you do not have the
second line antibiotic, REFER TO HOSPTAL.

Exceptions: if the child is less than 12 months old or was dehydrated on the
first visit, or if he had measles within the last 3 months, refer to hospital.

If fewer stooIs, Iess fever, Iess abdominaI pain, and eating better, continue
giving ciprofloxacin until finished.

Ensure that the mother understands the oraI rehydration method fuIIy and that
she aIso understands the need for an extra meaI each day for a week.
PERSISTENT DIARRHOEA

After 5 days:
Ask:
- Has the diarrhoea stopped?
- How many loose stools is the child having per day?

Treatment:
f the diarrhoea has not stopped (child is still having 3 or more loose stools per day)
do a full assessment of the child. Treat for dehydration if present. Then refer to hospital.

f the diarrhoea has stopped (child having less than 3 loose stools per day), tell the
mother to follow the usual feeding recommendations for the child's age.
17

GIVE FOLLOW-UP CARE

Care for the chiId who returns for foIIow-up using aII the boxes that
match the chiId's previous cIassification

If the chiId has any new probIems, assess, cIassify and treat the new
probIem as on the ASSESS AND CLASSIFY chart

MALARIA (Low or High MaIaria Risk)

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

Do a full reassessment of the child > See ASSESS & CLASSIFY chart.
Assess for other causes of fever.

Treatment:

f the child has any general danger sign or stiff neck, treat as VERY SEVERE
FEBRLE DSEASE.
f the child has any cause of fever other than malaria, provide treatment.
f malaria is the only apparent cause of fever:
- Treat with the second-line oral antimalarial (if no second-line antimalarial is
available, refer to hospital.) Advise the mother to return again in 2 days if the fever
persists.

- f fever has been present for 7 days, refer for assessment.
FEVER-MALARIA UNLIKELY (Low MaIaria Risk)

If fever persists after 2 days:

Do a full reassessment of the child > See ASSESS & CLASSIFY chart.
Assess for other causes of fever.

Treatment:

f the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRLE DSEASE.
f the child has any cause of fever other than malaria, provide treatment.
f malaria is the only apparent cause of fever:
- Treat with the first-line oral antimalarial. Advise the mother to return again in 2 days if the fever
persists.
- f fever has been present for 7 days, refer for assessment.

MEASLES WITH EYE OR MOUTH COMPLICATIONS

After 2 days:

Look for red eyes and pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth.

Treatment for Eye Infection:

f pus is draining from the eye, ask the mother to describe how she has treated the eye infection. f
treatment has been correct, refer to hospital. f treatment has not been correct, teach mother correct
treatment.

f the pus is gone but redness remains, continue the treatment.

f no pus or redness, stop the treatment.

Treatment for Mouth UIcers:

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

f mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days.
18

GIVE FOLLOW-UP CARE

Care for the chiId who returns for foIIow-up using aII the boxes that match the chiId's previous cIassification

If the chiId has any new probIems, assess, cIassify and treat the new probIem as on the ASSESS AND CLASSIFY chart

EAR INFECTION

After 5 days:

Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.

Treatment:

f there is tender swelling behind the ear or high fever (38.5C or above), refer URGENTLY to
hospital.
Acute ear infection: if ear pain or 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.
f no ear pain or discharge, praise the mother for her careful treatment. f she has not yet finished the
5 days of antibiotic, tell her to use all of it before stopping.
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. f you counsel the mother to make
significant changes in feeding, ask her to bring the child back again.
f the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure
the child's weight gain.

ANAEMIA

After 14 days:

Give iron. Advise mother to return in 14 days for more iron.
Continue giving iron every 14 days for 2 months.
f the child has palmar pallor after 2 months, refer for assessment.
VERY LOW WEIGHT

After 30 days:

Weigh the child and determine if the child is still very low weight for age.
Reassess feeding. > See questions at the top of the COUNSEL chart.

Treatment:

f the child is no longer very low weight for age, praise the mother and encourage
her to continue.
f the child is still very low weight for age, counsel the mother about any feeding
problem found. Ask the mother to return again in one month. 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:
f you do not think that feeding will improve, or if the child has lost weight, refer the child.

19
COUNSEL THE MOTHER

Assess the Feeding of Sick Infants under 2 years
(or if chiId has very Iow weight for age)

Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the Feeding
Recommendations for the child's age.

ASK - How are you feeding your chiId?

If the infant is receiving any breast miIk, ASK:

- How many times during the day?
- Do you also breastfeed during the night?

Does the infant take any other food or fIuids?

- What food or fluids?
- How many times per day?
- What do you use to feed the child?

If very Iow weight for age, ASK:

- How large are servings?
- Does the child receive his own serving?
- Who feeds the child and how?

During this iIIness, has the infant's feeding changed?

- f yes, how?
20

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH

* A good quality diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs or pulses; and fruits and vegetables.

Feeding Recommendations for a chiId who has PERSISTENT DIARRHOEA

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

x f taking other milk:
- replace with increased breastfeeding OR
- replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food

x Breastfeed as often as the child
wants, day and night, at least
8 times in 24 hours.

x Do not give other foods or fluids.

Up to 6 Months
of Age

x Breastfeed as often as the child wants.

x Give adequate servings of:
___________________________
___________________________
___________________________
___________________________ *

- 3 times per day if breastfed plus
snacks
- 5 times per day if not breastfed.

6 Months up
to 12 Months

x Breastfeed as often as the child
wants.

x Give adequate servings of:
__________________________
__________________________
__________________________
__________________________*

or family foods 3 or 4 times per day
plus snacks.
12 Months
up to 2 Years

x Give family foods at 3 meals
each day. Also, twice daily, give
nutritious food between meals,
such as:
__________________________
__________________________
__________________________
__________________________
__________________________
2 Years
and OIder

21

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS

If the chiId is not being fed as described in the above recommendations, counseI the mother accordingIy. In addition:

If the mother reports difficuIty with breastfeeding, assess breastfeeding (see YOUNG INFANT chart).
As needed, show the mother correct positioning and attachment for breastfeeding.
If the chiId is Iess than 6 months oId and is taking other miIk or foods:
- Build mother's confidence that she can produce all the breast milk that the child needs.
- Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods.

If other miIk needs to be continued, counseI the mother to:
- Breastfeed as much as possible, including at night.
- Make sure that other milk is a locally appropriate breast milk substitute.
- Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
- Finish prepared milk within an hour.
If the mother is using a bottIe to feed the chiId:
- Recommend substituting a cup for bottle.
- Show the mother how to feed the child with a cup.
If the chiId is not feeding weII during iIIness, counseI the mother to:
- Breastfeed more frequently and for longer if possible.
- Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer
frequent small feeds.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.

If the chiId has a poor appetite:
- Plan small, frequent meals.
- Give milk rather than other fluids except where there is diarrhoea with some dehydration.
- Give snacks between meals.
- Give high energy foods.
- Check regularly.
If the chiId has sore mouth or uIcers:

- Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
- Avoid spicy, salty or acid foods.
- Chop foods finely.
- Give cold drinks or ice, if available.
22
COUNSEL THE MOTHER ABOUT HER OWN HEALTH
f the mother is sick, provide care for her, or refer her for help.

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

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

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

Make sure she has access to:

x Family planning
x Counselling on STD and ADS prevention.

23

FLUID

WHEN TO RETURN

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 child's problems.

NEXT WELL CHILD VISIT
Advise mother when to return for next immunization according to
immunization schedule.
If the chiId has: Return for first foIIow-up in:
x PNEUMONA
x DYSENTERY
x MALARA, if fever persists
x FEVER-MALARA UNLKELY, if fever persists
x MEASLES WTH EYE OR MOUTH COMPLCATONS

2 days
x PERSSTENT DARRHOEA
x ACUTE EAR NFECTON
x CHRONC EAR NFECTON
x FEEDNG PROBLEM
x COUGH OR COLD, if not improving

5 days
x ANAEMA
14 days
x VERY LOW WEGHT FOR AGE
30 days
Any sick child x Not able to drink or breastfeed
x Becomes sicker
x Develops a fever
f child has COUGH OR COLD, also
return if:
x Fast breathing
x Difficult breathing
f child has Diarrhoea, also return if: x Blood in stool
x Drinking poorly
Advise mother to return immediateIy if the chiId has any of these signs:

Advise the Mother to Increase FIuid During IIIness

FOR ANY SICK CHILD:

f child is breastfed, breastfeed more frequently and for longer at each feed. f child is taking breast-milk substitutes, increase
the amount of milk given
ncrease other fluids. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on the TREAT THE CHILD chart
WHEN TO RETURN IMMEDIATELY
24

CHECK FOR VERY SEVERE DISEASE AND
LOCAL BACTERIAL INFECTION

Give an appropriate oral antibiotic.

Teach mother to treat local infections at
home.
Advise mother to give home care
for the young infant.
Follow up in 2 days.

VERY
SEVERE
DISEASE
xUmbilicus red or draining pus

xSkin pustules

LOCAL
BACTERIAL
INFECTION

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

SEVERE DISEASE
OR LOCAL
INFECTION
UNLIKELY

Advise mother to give home care for
the young infant.
Give first dose of intramuscular

antibiotics.

Treat to prevent low blood sugar.

Refer URGENTLY to hospital.**
Advise mother how to keep the infant

warm on the way to the hospital.

Any one of the foIIowing signs

x Not feeding well or
x Convulsions or
x Fast breathing (60 breaths per minute or
more) or
x Severe chest indrawing or
x Fever (37.5C* or above) or
x Low body temperature (less than 35.5C*)
or
x Movement only when stimulated or no
movement at all
ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
AGED UP TO 2 MONTHS
DO A RAPID APRAISAL OF ALL WAITING INFANTS

ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE
x Determine if this is an initial or follow-up visit for this problem.
- if follow-up visit, use the follow-up instructions
- if initial visit, assess the young infant as follows:
USE ALL BOXES THAT MATCH INFANT'S
SYMPTOMS AND PROBLEMS TO
CLASSIFY THE ILLNESS.
SIGNS CLASSIFY AS
TREATMENT

CIassify
ALL
YOUNG
INFANTS

LOOK, LISTEN, FEEL:

x Count the breaths in one minute.
Repeat the count if 60 or more
breaths per minute.
x Look for severe chest indrawing.
x Measure axillary temperature.
x Look at the umbilicus. s it red or draining pus?
x Look for skin pustules.

xLook at the young infant's movements. If infant is
sleeping, ask the mother to wake him/her.

- Does the infant move on his/her own?

If the infant is not moving, gently stimulate him/her.

- Does the infant move only when stimulated but
then stops?

- Does the infant not move at all ?

ASK:

x s the infant having
difficulty in feeding?

xHas the infant had
convulsions (fits)?

YOUNG
NFANT
MUST
BE
CALM
}
* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher.
** If referral is not possible, see Integrated Management of Childhood Illness, Management of the sick young infant module, Annex 2 "Where referral is not possible"
25

THEN CHECK FOR JAUNDICE

If jaundice present,
ASK:

xWhen did jaundice first
appear?
LOOK, LISTEN, FEEL:

xLook for jaundice (yellow eyes or
skin).

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

Classify
Jaundice
x Any jaundice if age less than 24

hours or

x Yellow palms and soles at any age

SEVERE
JAUNDICE

Treat to prevent low blood sugar.

Refer URGENTLY to hospital.

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

x Jaundice appearing after 24 hours of
age and

x Palms and soles not yellow

JAUNDICE
Advise the mother to give home care for the

young infant
Advise mother to return immediately if palms

and soles appear yellow.
f the young infant is older than 3 weeks, refer

to a hospital for assessment.

Follow-up in 1 day.

x No jaundice

NO
JAUNDICE
Advise the mother to give home care for the

young infant.
SIGNS
CLASSIFY AS
TREATMENT
26
THEN ASK: Does the young infant have diarrhoea*?

CIassify
DIARRHOEA
FOR DEHYDRATION
f infant has no other severe classification:

- Give fluid for severe dehydration (Plan C)

OR
If infant also has another severe
classification:
- Advise the mother to continue
breastfeeding

Give fluid and for some dehydration and
continue breastfeeding (Plan B).

If infant has any severe classification:

giving frequent sips of ORS on the way.
- Advise mother to continue breastfeeding.
Follow-up in 2 days if not improving

Give fluids to treat for diarrhoea at home and
continue breastfeeding (Plan A)
Follow up in 2 days if not improving
Two of the foIIowing signs:

x Movement only when
stimulated or no movement
at all
x Sunken eyes
x Skin pinch goes back very
slowly.

SEVERE
DEHYDRATION

Two of the foIIowing signs:

x Restless, irritable
x Sunken eyes
x Skin pinch goes back
slowly.

SOME DEHYDRATION

x Not enough signs to classify

as some or severe
dehydration.

NO DEHYDRATION

* What is diarrhoea in a young infant?

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

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

IF YES, LOOK AND FEEL:

x Look at the young infant's general condition:

- nfant's movements
- Does the infant move on his/her own?
- Does the infant move only when stimulated but then
stops?
- Does the infant not move at all ?

- s the infant restless and irritable?
x Look for sunken eyes.

x Pinch the skin of the abdomen.
Does it go back:
- Very slowly (longer than 2 seconds)?
- or slowly?

SIGNS
CLASSIFY AS
TREATMENT
27
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
SIGNS CLASSIFY AS
TREATMENT

Classify
FEEDING
x Not well attached to
breast or

xNot suckling effectively,
or

x Less than 8 breastfeeds
in 24 hours, or

x Receives other foods or
drinks, or

x Low weight for age, or

x Thrush (ulcers or white
patches in mouth)

FEEDING
PROBLEM
OR
LOW WEIGHT
FOR AGE

f not well attached or not suckling
effectively, teach correct positioning and
attachment.
x f not able to attach well immediately,
teach the mother to express breast milk
and feed by a cup
f breastfeeding less than 8 times in 24

hours, advise to increase frequency of
feeding. Advise her to breastfeed as often
and for as long as the infant wants, day
and night.

f receiving other foods or drinks, counsel
mother about breastfeeding more,
reducing other foods or drinks, and using
a cup.
x f not breastfeeding at all:
- Refer for breastfeeding counselling
and possible relactation.
- Advise about correctly preparing
breastmilk substitutes and using a
cup.

Advise the mother how to feed and keep
the low weight infant warm at home
f thrush, teach the mother to treat thrush

at home.

Advise mother to give home care for the
young infant.

Follow-up any feeding problem or thrush
in 2 days.
Follow-up low weight for age in 14 days.

x Not low weight for age
and no other signs of
inadequate feeding.
NO FEEDING
PROBLEM

Advise mother to give home care for
the young infant.

Praise the mother for feeding the
infant well.
ASK:

x s the infant breastfed? f yes,
how many times in 24 hours?
x Does the infant usually receive

any other foods or drinks?
f yes, how often?

x f yes, what do you use to feed the infant?
LOOK, LISTEN,FEEL:

x Determine weight for age.

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

x Has the infant breastfed in
the previous hour?

f the infant has not fed in the previous hour, ask the mother
to put her infant to the breast. Observe the breastfeed for
4 minutes.

(f the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)

x s the infant well attached?

not well attached good attachment

ASSESS BREASTFEEDNG:
x s the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?

not suckling effectively suckling effectively

Clear a blocked nose if it interferes with breastfeeding.

TO CHECK ATTACHMENT, LOOK FOR:

- More areola seen above infant's top lip than below
bottom lip
- Mouth wide open
- Lower lip turned outwards
- Chin touching breast

(All of these signs should be present if the attachment is good).
If an infant has no indications to refer urgentIy to hospitaI:
28

THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:

Give aII missed doses on this visit.
mmunize sick infants unless being referred.
Advise the caretaker when to return for the next dose.

IMMUNIZATION
SCHEDULE:

AGE

Birth
6 weeks
10 weeks

VACCINE VITAMIN A

BCG OPV-0 200 000 U to the mother within 6 weeks of delivery
DPT+HB-1 OPV-1 Hepatitis B 1
DPT+HB-2 OPV-2 Hepatitis B 2

ASSESS OTHER PROBLEMS

29
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give First Dose of Intramuscular Antibiotics
Give first dose of ampicillin intramuscularly and

Give first dose of gentamicin intramuscularly.

*Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified as VERY SEVERE DSEASE. f referral is not possible, continue to
give ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3
times daily to infants one week or older. Give gentamicin once daily.
AMPICILLIN
Dose: 50 mg per kg
GENTAMICIN

To a vial of 250 mg Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml
OR
WEIGHT Add 1.3 ml sterile water =
250 mg/1.5 ml
AGE <7 days
Dose: 5 mg per kg
AGE>7 days
Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml 0.9 ml
1.5-<2 kg 0.5 ml 0.9 ml 1.3 ml
2-<2.5 kg 0.7 ml 1.1 ml 1.7 ml
2.5-<3 kg 0.8 ml 1.4 ml 2.0 ml
3-<3.5 kg 1.0 ml 1.6 ml 2.4 ml
3.5-<4 kg 1.1 ml 1.9 ml 2.8 ml
4-<4.5 kg 1.3 ml 2.1 ml 3.2 ml
Add 6 ml sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml
Treat the Young Infant to Prevent Low Blood Sugar

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.

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

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

If the young infant is not able to swallow:

Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by naso-gastric tube.
30

TREAT THE YOUNG INFANT

Teach the Mother How to Keep the Young Infant Warm on the Way to the Hospital

Provide skin to skin contact, OR

Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing
including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.
Give an Appropriate Oral Antibiotic for local infection

For local bacterial infection:

First-line antibiotic : ___________________________________________________________________________________________
Second-line antibiotic: ___________________________________________________________________________________________

* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.
COTRIMOXAZOLE
(trimethoprim + sulphamethoxazole)
Give two times daily for 5 days

AGE or WEIGHT
Adult Tablet
single strength
(80 mg trimethoprim + 400
mg sulphamethoxazole)
Paediatric Tablet
(20 mg trimethoprim
+100 mg
sulphamethoxazole)
Syrup
(40 mg trimethoprim
+200 mg
sulphamethoxazole)
Tablet

250 mg
Syrup

125 mg in 5 ml
Birth up to 1 month (<4 kg) 1/2* 1.25 ml* 1/4 2.5 ml
1 month up to 2 months (4-<6 kg) 1/4 1 2.5 ml 1/2 5 ml
AMOXICILLIN
Give two times daily for 5 days
31
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
To Treat Diarrhoea, See TREAT THE CHILD CHART.

Immunize Every Sick Young Infant, as needed.

Teach the Mother How to Treat Local Infections at Home

Explain how the treatment is given.
Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.

To Treat Skin PustuIes or UmbiIicaI Infection

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

Gently wash off pus and crusts with soap and water
Dry the area
Paint the skin or umbilicus/cord with full strength gentian

violet (0.5%)
Wash hands again

To Treat Thrush (uIcers or white patches in mouth)

The mother should do the treatment four times daily for 7 days:
Wash hands
Paint the mouth with half-strength gentian violet (0.25%) using a

clean soft cloth wrapped around the finger
Wash hands again

32
COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding

Show the mother how to hold her infant

- with the infant's head and body in line

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

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

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

Show her how to help the infant to attach. She should:

- touch her infant's lips with her nipple

- wait until her infant's mouth is opening wide

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

Look for signs of good attachment and effective suckling. f the attachment or suckling is not good, try again.
Teach the Mother How to Express Breast Milk

Ask the mother to:
Wash her hands thoroughly

Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other
(at least 4 cm from the tip of the nipple).
Compress and release the breast tissue between her finger and thumb a few times.
f the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before.
Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not to squeeze the
nipple or to rub the skin or move her thumb or finger on the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.
33
COUNSEL THE MOTHER

Teach the Mother How to Keep the Low Weight Infant Warm at Home

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

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

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

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

- Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mother's chest between the mother's breasts. Keep the infant's head turned to one side
Cover the infant with mother's clothes (and an additional warm blanket in cold weather)

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

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

- Breastfeed (or give expressed breast milk by cup) the infant frequently
Teach the Mother How to Feed by a Cup

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

Hold the infant semi-upright on the lap.

Put a measured amount of milk in the cup.

Hold the cup so that it rests lightly on the infant's lower lip.

Tip the cup so that the milk just reaches the infant's lips.

Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
34
COUNSEL THE MOTHER

Advise the Mother to Give Home Care for the Young Infant

Advise the caretaker to return immediateIy

if the young infant has any of these signs:

Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow

1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT

Give only breastfeeds to the young infant.
Breastfeed frequently, as often and for as long as the infant wants.
WHEN TO RETURN IMMEDIATELY:
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.

n cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
FoIIow up visit
If the infant has: Return for first foIIow-up in:
x JAUNDCE
1 day
x LOCAL BACTERAL NFECTON
x FEEDNG PROBLEM
x THRUSH
x DARRHOEA

2 days
x LOW WEGHT FOR AGE 14 days
35
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

LOCAL BACTERIAL INFECTION

After 2 days:
Look at the umbilicus. s it red or draining pus?
Look for skin pustules.
Treatment:
f umbilical pus or redness remains same or is worse, refer to hospital. f pus and redness are improved, tell the mother to continue giving the 5
days of antibiotic and continue treating the local infection at home.
f skin pustules are same or worse, refer to hospital. f improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
DIARRHOEA
After 2 days:
Ask: -Has the diarrhoea stopped ?

Treatment:
f the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE Does the Young nfant Have Diarrhoea ?
f the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
ASSESS EVERY YOUNG INFANT FOR 'VERY SEVERE DISEASE" DURING FOLLOW UP VISIT.
JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?

f palms and soles are yellow, refer to hospital.
f palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for
follow up in 1 day.
f jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at three
weeks of age. f jaundice continues beyond three weeks of age , refer the young infant to a hospital for further assessment.
36


FEEDING PROBLEM

After 2 days:

Reassess feeding. > See Then Check for Feeding Problem or Low Weight above.
Ask about any feeding problems found on the initial visit.

Counsel the mother about any new or continuing feeding problems. f you counsel the mother to make significant changes in feeding,
ask her to bring the young infant back again.

f the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young infant's
weight gain.

Exception:
f you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

37


LOW WEIGHT FOR AGE

After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.

f the infant is no longer low weight for age, praise the mother and encourage her to continue.

f the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within a month
or when she returns for immunization.

f the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother
to return again in 14 days (or when she returns for immunization, if this is within 14 days). Continue to see the young infant every few
weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age.

Exception:
f you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

THRUSH

After 2 days:
Look for ulcers or white patches in the mouth (thrush).

f thrush is worse, or the infant has problems with attachment or suckling, refer to hospital.

f thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 7 days.
38
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WeighI-!or-age charI !or girIs

Weeks
Mcnths
W
e
i
g
h
I

(
k
g
)
Age (compleIed weeks ahd mohIhs)
0 1 2 3 4 5 6 7 8 9
4
th
year 5
th
year
6 4 8 10 14 16 20 22 26 28 30
Median
very Iow
weight
for age
32 34 18
2
nd
year 3
rd
year
2
4
6
8
2
4
6
8
10
12
14
16
18
20
8
10
12
14
16
18
20
22
24
2 12 24 36
36 39 42 45 48 51 54 57 60
0-2 mcnths
Low weight
for age
WeighI-!or-age charI !or boys
Weeks
Mcnths
W
e
i
g
h
I

(
k
g
)
Age (compleIed weeks ahd mohIhs)
0 1 2 3 4 5 6 7 8 9
4
th
year 5
th
year
6 4 8 10 14 16 20 22 26 28 30
Median
very Iow
weight
for age
32 34 18
2
nd
year 3
rd
year
2
4
6
8
2
4
6
8
10
12
14
16
18
20
8
10
12
14
16
18
20
22
24
2 12 24 36
36 39 42 45 48 51 54 57 60
0-2 mcnths
Low weight
for age

Integrated Management of Childhood Illness Chart booklet

Process of updating the chart booklet

The generic IMCI chart booklet was developed and published in 1995 based on evidence existing at that time (Reference: Integrated
management of Childhood Illness Adaptation Guide: C. Technical basis for adapting clinical guidelines, 1998). New evidence on the
management of acute respiratory infections, diarrhoeal diseases, malaria, ear infections and infant feeding, published between 1995
and 2004, was summarized in the document "Technical updates of the guidelines on IMCI : evidence and recommendations for further
adaptations, 2005".

Evidence reviews supported the formulation of recommendations in each of these areas (see document and the references). Reviews
were usually followed by technical consultations where the recommendations and their technical bases were discussed and consensus
reached. Similarly, a review and several expert meetings were held to update the young infant section of IMCI to include "care of the
newborn in the first week of life". More recently, findings of a multi-centre study (Lancet, 2008) led to the development of simplified
recommendations for the assessment of severe infections in the newborn

Who was involved and their declaration of interests

The following experts were involved in the development of the updated newborn recommendations: Zulfiqar Bhutta, Ayivi Blaise,
Wally Carlo, Rolando Cerezo, Magdy Omar, Pavel Mazmanyan, MK Bhan, Helenlouise Taylor, Gary Darmstadt, Vinod Paul, Anne
Rimoin, Linda Wright and WHO staff from Regional and Headquarter offices. Dr. Gul Rehman and a team of CAH staff members
drafted the updated chart booklet based on the above. Dr Antonio Pio did the technical editing of the draft IMCI chart booklet, in
addition to participating in its peer-review. Other persons who reviewed the draft chart booklet and provided comments include Ashok
Deorari, Teshome Desta,, Assaye Kassie, Dinh Phuang Hoa, Harish Kumar, Vinod Paul and Siddhorth Ramzi.. Their contributions are
acknowledged.

None of the above experts declared any conflict of interest.

The Department plans to review the need for an update of this chart booklet by 2011.
WHO Library Cataloguing-in-Publication Data :
Integrated Management of Childhood Illness chart booklet.
1.Integrated management of childhood illness. 2.Infant, Newborn. 3.Child. 4.Infant. 5.Disease management. 6.Teaching materials. I.World Health
Organization. II.UNICEF.
ISBN 978 92 4 159728 9 (NLM classification: WC 503.2)
World Health Organization 2008
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia,
1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce
or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address
(fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the
part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the
published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of
the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

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CHILD AGED 2 MONTHS UP TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD

THEN ASK ABOUT MAIN SYMPTOMS:

x Look for mouth ulcers.

x s there ear pain?

THEN CHECK FOR MALNUTRITION AND ANAEMIA

xNo palmar pallor

x Visible severe wasting or

x Oedema of both feet

x Not very low wight for age and

f child is less than 2 years old, assess the child's feeding

Advise mother when to return immediately

ASSESS OTHER PROBLEMS:

TREAT THE CHILD

FRST-LNE ANTBOTC: __________________________________________________________

FRST-LNE ANTBOTC FOR CHOLERA: ____________________________________________

Harmful remedies to discourage:

Clean both eyes 4 times daily.

Then apply tetracycline eye ointment in both eyes 4 times daily.

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

Age VITAMIN A DOSE

IF REFERRAL IS NOT POSSIBLE:

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

CounseI the mother on the 4 RuIes of Home Treatment:

SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION:

AGE* Up to 4 months 4 months up

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

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

x Start IV fIuid immediateIy.

GIVE FOLLOW-UP CARE

FEVER-MALARIA UNLIKELY (Low MaIaria Risk)

MEASLES WITH EYE OR MOUTH COMPLICATIONS

VERY LOW WEIGHT

COUNSEL THE MOTHER

If the chiId has sore mouth or uIcers:

COUNSEL THE MOTHER ABOUT HER OWN HEALTH

Give an appropriate oral antibiotic.

xUmbilicus red or draining pus

Give first dose of intramuscular

Advise mother how to keep the infant

x Measure axillary temperature.

x Look at the umbilicus. s it red or draining pus?

x Look for skin pustules.

x Any jaundice if age less than 24

Treat to prevent low blood sugar.

Advise the mother to give home care for the

Advise mother to return immediately if palms

f the young infant is older than 3 weeks, refer

Advise the mother to give home care for the

THEN ASK: Does the young infant have diarrhoea*?

f infant has no other severe classification:

Advise mother when to return immediately

Follow-up in 2 days if not improving

x Not enough signs to classify

x Look for sunken eyes.

f breastfeeding less than 8 times in 24

f thrush, teach the mother to treat thrush

Follow-up low weight for age in 14 days.

x Does the infant usually receive

x s the infant suckling effectively (that is, slow deep sucks,

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give first dose of ampicillin intramuscularly and

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER