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SICK CHILD AGED 2 MONTHS TO 5 YEARS SICK YOUNG INFANT
AGED 1 WEEK TO 2 MONTHS
ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD, continued ASSESS, CLASSIFY, AND TREAT THE SICK YOUNG INFANT
Assess, Classify, and Identify the Treatment Give Extra Fluid for Diarrhea and Continue Feeding
2 Plan A: Treat Diarrhea at Home 12 Assess, Classify, and Identify the Treatment
Check for General Danger Signs .................. Check for Possible Bacterial Infection 23
Then Ask About the Main Symptoms: Plan B: Treat Some Dehydration with ORS 12
Plan C 13 Then Ask: Does the Young Infant have Diarrhea? 24
Does the child have cough or difficult breathing? 2 Then Check for Feeding Problems or Low Weight 25
Doesthe child havediarrhea? 3 .
Does the child have fever? 4 Check the Young Infant's Immunization Status 26
Immunize Every Sick Child, as Needed 13 Assess Other Problems 26
Classify malaria 4 Give Every Sick Child Vitamin A, as Needed 13
Classify measles 4
Treat the Young Infant and Counsel the Mother
Classify dengue 4 Give Follow-up Care Oral Antibiotics 27
Does the child have an ear problem? 5 Pneumonia 14
Intramuscular Antibiotics 27
Then Check for Malnutrition and Anemia 6 Persistent Diarrhea , 14
To Treat Diarrhea, See TREAT THE CHILD Chart 28
Then Check the Child's Immunization Status 6 Dysentery 14
Malaria 15 Immunize Every Sick Young Infant, as Needed 28
Then Check the Child's Vitamin A Status 6 Treat Umbilical Infections in the Health Center 28
Assess Other Problems 6 Fever: Malaria Unlikely 15 Treat Local Infections at Home 28
Fever: No Malaria 15
TREA T THE CHILD Correct Positioning and Attachment for Breastfeeding 29
Measles with Eye or Mouth Complications 16 Home Care for the Young Infant 29
Fever: Dengue Hemorrhagic Fever Unlikely 16
Teach the Mother How to Give Oral Drugs at Home Ear Infection 16
Give Follow-up Care for the Sick Young Infant
Oral Antibiotics. 7 Feeding Problem 17 Local Bacterial Infection 30
Oral Antimalarial 8 Anemia 17 31
Feeding Problem
Paracetamol 8 Very Low Weight 17 31
Vitamin A 8 Low Weight
Thrush 31
Iron ......... 8 COUNSEL THE MOTHER
Mebendazole 8 RECORDING FORMS
Food SICK YOUNG INFANT 33
Teach the Mother How to Treat Assess the Child's Feeding 18

.
SICK CHILD 53
Local Infections at Home 19

-
Feeding Recommendations
Treat Eye Infection with Tetracycline Eye Ointment 9 Counsel about Feeding Problems 20 WEIGHT-FOR-AGE CHART on the back cover
Dry the Ear by Wicking 9
Treat Mouth Ulcers with Gentian Violet 9 Fluid 8

UnICef
~ tlfi~

~
21 '-
Soothe the Throat and Relieve Cough with
a Safe Remedy 9
Increase Fluid during Illness
~ .1. ~ WORLD HEALTH

When to Return ~I 11 ORGANIZATION

"
"4"'~'"
Advisethe MotherWhento Return ~ '"",,',:' i ..

Give These Treatments in the Health Center Only Association of Deans t"""
Intramuscular Antibiotic 10 to the HealthWorker 21 of Philippine Colleges . "

Quinine for Severe Malaria 10 of Nursing,Inc. . .'. .'


~. .
Counsel the Mother about Her Own Health 22 DEPARTMENTOF HEALTH
Prevent Low Blood Sugar 11
Republicof the Philippines ECD Project
2

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


ASSESS CLASSIFY IDENTIFY
TREATMENT
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE USE ALL BOXES THAT MATCH THE
Determine if this is an initial or follow-up visit for this problem. CHILD'S SYMPTOMS AND PROBLEMS TO
if follow-up visit, use the follow-up instructions on the TREAT THE CHILD chart. CLASSIFY THE ILLNESS.
if initial visit, assess the child as follows:

ASK: LOOK:
. Is the child not able to drink or . See if the child is abnormally
breastfeed? sleepy or difficult to awaken.
.. Does the child vomit everything?
Has the child had convulsions? (during the present illness)

AnYr&£e1'l e raJ ~ Givefirsl dqse of anapprop


signor
IF YES, ASK:
. For how long?
LOOK, LISTEN:
. Count the breaths in one minute.
CHILD
. .

Chestlndrawing ~(
. Stridor';i'nc~lm
~ Give VitarhjJt A.
~ Treatthe;~hildtopre.;erillo
cbll:Q
".. ~ Refer URG~TL Y to hQ$pita

. Look for chest indrawing.


MUST

. Look and listen for stridor. }


BE CALM.
. Fastbreathing PNEUMONIA
~ Give an appropriate antibiotic 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.
If the child is: Fast breathing is:
. 50 breaths per minute or more ~ If coughing for more than 30 days, refer for
2 months up to 12 months old

12 months up . 40 breaths per minute or more


. No signs of pneumonia
or very severe
NO PNEUMONIA
COUGH OR COLD
assessment.
~ Soothe the throat and relieve the cough with
disease. safe remedy.
~ Advise mother when to return immediately.
~ Follow up in 5 days if not improving.

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Does Jhe child have diarrhea?

IF YES, ASK: LOOK AND FEEL:


for
. Forhowlong? . Lookat the child'sgeneralcondition.
DEHYDRATION

. Is there blood in
the stool?
Is the child:
- Abnormally sleepy or difficult to
awaken?
- Restlessand irritable?

. Lookforsunkeneyes. Twoof the followingsigns: ~ Givefluid andfoodfor somedehydration(PlanB).

. Offerthe childfluid. Is the child:


..
. Restless,irritable
Sunkeneyes
Drinks eagerly, thirsty SOME
~ If child also has another severe classification:
- Refer URGENTLYto hospital, with mother giving
frequent sips of ORSon the way.
- Notableto drink or drinkingpoorly? . Skinpinchgoes back DEHYDRATION - Advise mother to continue breastfeeding.
- Drinkingeagerly,thirsty? ~ Advisethe motherwhento returnimmediately.
veryslowly
~ Followup in 5 days if not improving.
. Pinchtheskinoftheabdomen.
Doesitgoback:
- Veryslowly(longerthan2 seconds)?
- Slowly?
. Not enough signs to
classify as some or
NO
DEHYDRATION
~
~
~
Givefluid and foodto treatdiarrheaat home(PlanA).
GiveZincsupplements.
Advisemotherwhento returnimmediately.
severedehydration ~ Followupin 5 days if not improving.

. Dehydration
present
II
~ Treatdehydrationbeforereferralunlessthe child has
anothersevereclassification.
~ Give Vitamin A.
~ ijf!fer to hospital.

~ Advise the mother on feeding a child who has


. No dehydration PERSISTENT
DIARRHEA
PERSISTENTDIARRHEA.
~ Give Vitamin A.
~ Followup in 5.days.
~ Advise motherwhento returnimmediately.

and if blood
in stool
. Blood in the stool DYSENTERY
~ Treat for 5 days with an oral antibiotic
recommended for Shigella in your area.
~ Follow up in 2 days.
~ Advise mother when to return immediately.

*If referral is not possible, manage the child as described in Management of Childhood Illness, Treat the Child,
Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care.

3
DANGER SIGNS, COUGH,
DIARRHEA
_LY, FEVER: NO MALARIA .,~\;I"E:~VIVIIVIE:I'\IU/"\IIVI';:> ,OIVII~;:>
ASSESS AND CLASSIFY 3SESS AND CLASSIFY
AT s FOLLOW-UP UNSEL THE MOTHER FOllOW-UP
4

THEN ASK: Does the child have feve.r?


(by history, or feels hot Or if temperature is 37.5°C** or abov~)

MalariaRisk
Decide Malaria Risk (including travel or
overnightstay in
. Bloodsmear(+)
If bloodsmearnotdone:
~
~
Treatthe child with an oral antimalarial. ,
Give onedoseof paracetamolin healthcenter for high fever (38.5°Cor above).
Ask:
. Does the child live in a malaria area?
malariaarea) . NOrunnynose,
NOmeasles,and
and
MALARIA
~
~
Advisemotherwhento returnimmediately.
Followup in 2 daysif fever persists.
. Has the child visited/travelled or stayed overnight in a malaria area NOothercausesof fever ~ If fever is presenteverydayfor morethan7 days,referfor assessment.
in the past 4 weeks?
.. Bloodsmear(-)or FEVER:
~
~
Give onedoseof paracetamolin health centerfor high fever (38.5°cor above).
Advisemotherwhento returnimmediately.
If Yes to either, obtain a blood smear. .. Othercauses
Runnynoseor
Measlesor
offever
MALARIA
lINLIKELY
~
~
Followup in 2 daysif fever persists.
If feveris presenteveryday for morethan 7 days,referfor assessment.
THEN ASK: LOOK AND FEEL: ~ Treatothercausesof fever.
.
.
Forhowlong hasthe child had'
fever?
If more than 7 days, has the
. Lookor feel for stiff neck.
Lookfor runny nose.

. fever beenpresenteveryday?
Has the child had measles
within the last 3 months?
. Lookfor signs of MEASLES:
- Generalrashesand
VERYSEVERE ~ Giveone dose of an appropriateantibiotic.
FEBRILE ~ Treatthe child to prevent low blood sl1gar.
a
~ Giveone doseof par.acetamolin healthcenterfor high fever (38.5°cor above).
No MalariaRisk DISEASE
- One of these: cough, runny ~ Refer URGENTLY to hospital.
nose, or red eyes
. disease
Nosignsof a veryseverefebrile
~
~
Give onedoseof paracetamolin health centerfor high fever (38.5°cor above).
Advisemotherwhento returnimmediately.
. FEVER:
NO MALARIA ~
~
Followup in 2 daysif the feverpersists.
If feveris presenteverydayfor morethan7 days,referfor assessment.
If the child has measles now or . Lookfor mouthulcers. ~ Treatother causesof fever. ~
within the last three months:
.
Are they deep and extensive?
Lookfor pusdrainingfromthe eyes. . Cloudingof the corneaor
a
SEVERE,
~ Give VitaminA.
. Lookfor cloudingof the cornea. . ulcers
Deepor extensi~emouth COMPLICATED ~ Give first dose of an appropriate antibiotic.
MEASLES*** ~ If clouding of the cornea or pus draining from the eye, apply tetracycline
.. ....... . Any dangersign eye ointment.
~ Refer URGENTLYto hospital.

Assess Dengue Hemorrhagic Fever .. Pus drainingfromthe eye or


Mouth ulcers
MEASLESWITH
~ Give Vitamin A.
EYEOR MOUTH ~ If pus draining from the eye, apply tetracycline eye ointment.
ASK: LOOKAND FEEL:
. Hasthe child hadany bleeding'
fromthe noseor gums,or inthe
Look for bleeding from nose or
gums.
COMPLICATIONS'" ~ If mouthulcers, teachthe mother to treat with gentian "iolet.
~ Followup in 2 days.
~ Advise motherwhen to return immediately.
vomitusor stools? .
Look for skin petechiae.
.
. Hasthe child had black
vomitus?
.
Feel for cold and clammy
extremities.
Measlesnow or within the
last 3 months
MEASLES ~ Give Vitamin A.
~ Advise motherwhen to return immediately.

. Hasthe child had black


stools?
.
Check for slow capillary refill. If
none of the aboveASK, LOOK,and . Bleedingfromnoseor gumsor ~ If persistent vomiting or persistent abdominal pain or skin petechiae or
. Bleedingin stoolsor vomitusor SEVERE positive tourniquet test are the only positive signs, give ORS(Plan B).
. Hasthe child had persistent FEELsigns are present& the child
.. BlackIIItools
or vomitusor DENGUE ~ If any other signs of bleeding is positive, give fluids rapidly, as in Plan C.
. abdominalpain?
Has the child had persistent
vomiting?
is 6 monthsor older &fever present
for morethan 3 days.
.
Performthe tourniquettest.
Assess DENGUE
Hemorrhagic Fever
S~inpetechiaeor
. Coldandclammyextremitiesor
. Capillaryrefillmorethan3 seconds
HEMORRHAGIC
FEVER
~ Treat the child to prevent low blood sugar.
~ Refer all children URGENTLYto hospital.
~ DO NOTGIVEASPIRIN.
or
.. Persistentabdominalpainor
Persistentvomitingor
. Tourniquettest positive

. No signsof severedengue
ilemorrhaglcfever
FEVER:DENGUE ~ Advise motherwhen to return immediately.
HEMORRHAGIC ~ Follow up in 2 days if fever persistsor child shows signs of bleeding.
FEVERUNLIKELY ~ DO NOTGIVEASPIRIN.

* If referral is not possible, see manage the child as described in Management of Childhood Illness, Treat the Child, Annex: When Referral is Not Possible, and WHO guidelines for inpatient care.
** These temperatures are based on axillary temperature. Rectal temperature readings are approximately a.5°C higher.
*** Other important complications of measles-pneumonia, stridor, diarrhea, ear infection, and malnutrition-are classified in other tables.

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Other Causes of Fever:


. pneumonia ..
. dysentery
severe dengue hemorrhagic fever

. severe complicatedmeasles . mastoiditis


acute ear infection
.. measleswith
measles
eye or mouth complications . abscess, cellulites, osteomyelites
. severe pneumonia or very severe disease

5
FEVER, MALARIA,
MEASLES, EAR PROBLEM
_I, r-I:.VI:.K: I'IV MALAKI'" ,~'" I"\I:.I."UIVIIVII:.I'IIU1"\IIVh;:>

.AT 3SESS AND CLASSIFY


FOLLOW-UP UNSEL THE MOTHER FOLLOW-UP
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TREAT THE CHILD


CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

Give an Appropriate Oral Antibiotics


MOTHER TO GIVE ORAL ~ FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS:
FIRST-LINE ANTIBIOTIC COTRIMOXAZOLE
SECOND-LINE ANTIBIOTIC: AMOXYCILLIN
COTRIMOXAZOLE AMOXYCILLIN
(trimethoprim + sulphamethoxazole) Give three times
Give two times daily for 5 days. dailyfor 5 days.
AGE OR WEIGHT
ADULT TABLET SYRUP TABLET SYRUP
80 mg trimethoprim 40 mg trimethoprim 250 mg 125 mg per
+ 400 mg sulphamethoxazole + 200 mg sulphamethoxazole per 5 ml 5 ml
2 months up to 12 months 1/2 5.0 ml 1/2 5ml
(4 - <10 kg)

12 months up to 5 years 1 10.0 ml 1 10 ml


(10-19 kg)
FOR DYSENTERY:
Give antibiotic recommended for Shigella in your area for 5 days.
FIRST-LINE ANTIBIOTIC FOR SHIGELLA. COTRIMOXAZOLE
SECOND-LINE ANTIBIOTIC FOR SHIGELLA NALIDIXIC ACID
COtRIMOXAZOLE NALIDIXIC ACID
(trimethoprim + sulphamethoxazole)
Give two times daily for 5 days. Give four times daily for 5 days.
AGE OR WEIGHT
SYRUP 250 mg/5 ml
2 months up to 4 months (4-<6 kg) 1.25 ml (1/4 tsp)
See doses Above.
4 months up to 12 months (6 - <10 kg) 2.5 ml (1/2 tsp)

12 months up to 5 years(10- 19 kg) 5 ml (1 tsp)


~ FOR CHOLERA:
Give an antibiotic recommended for Cholera in your area for 3 days.
FIRST-LINE ANTIBIOTIC FOR SHIGELLA TETRACYCLINE
SECOND-LINE ANTIBIOTIC FOR SHIGELLA COTRIMOXAZOLE
TETRACYCLINE COTRIMOXAZOLE
(trimethoprim + sulphamethoxazole)
~ Give four times daily for 3 days. Give two times daily for 5 days.
AGE OR WEIGHT CAPSULE (250 mg)
2 months up to 4 months (4 - <6 kg)

4 months up to 12 months (6 - <10 kg) 1/2 See doses Above.

12 months up to 5 years (10 - <19 kg) 1

MALNUTRITIONand ANEMIA,
7
IMMUNIZATIONAND VITAMINA STATUS
ANTIBIOTICS

[
_LY, FEVER: NO MALARIA

,
.~ 1"\E:I."UIVIIVIE:I'IIU/,\IIVI"v .CIVllv,:)
TREAT
" FOLLOW-UP JNSEl THE MOTHER
)SESS AND CLASSIFY
FOLLOW-UP
J

aTeACH THe MOTHeR TO Give ORAL DRUGS AT HOMe


Followthe instructions belowfor every oral drug to be given at home. Also followthe instructions listed with each drug's dos

~ Give an Oral Antimalarial ~ Give Vitamin A


FIRST-LINE ANTIMALARIAL: CHLOROQUINE, PRIMAQUINE, SULFADOXINE AND PYRIMETHAMINE
TREATMENT SUPPLEMENT A TlON
SECOND-LINE ANTIMALARIAL: ARTEMETER-LUMEFRANTIN E
~ Give one dose in the health center. ~ Give one dose in health center if:

~ IF CHLOROQUINE: - child is six months of age or older,

. Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine.
child vomits within 30 minutes, she should repeat the dose and return to the health center for additional tablets.
If the
- child has not received a dose of Vitamin A in the
past six months.

. Explain that itching is a possible side effect of the drug, but is not dangerous. AGE VITAMIN A CAPSULES

~ IF SULFADOXINE + PYRIMETHAMINE: Give a single dose in the health center 2 hours before intake of Choroquine. 100,0001U 200,000 IU

~ IF PRIMAQUINE: Give single dose on Day 4 for P. falciparum 6 months up to 12 months 1 1/2 capsule

12 months.up to 5 years - 1 capsule


~ IF ARTEMETER-LUMEFRANTINE combination: Give for 3 days.

PRIMAQUINE PRIMAQUINE SULFADOXINE +


CHLOROQUINE
Give single dose in Give daily for PYRIMETHAMINE
Give for 3 days health center for
P. falciparum
14 days for
P. vivax
Give single dose in
health center
~ Give Iron
TABLET TABLET TABLET TABLET ~ Give one dose daily for 14 days.
(150 mg base) (15 mg base) (15 mg base) (500 mg sulfadoxine)
AGE DAY 1 IRON/FOLATE
TABLET IRONSYRUP IRONDROPS
DAY 2 DAY 3 25 mg pyrimethamine
AGEORWEIGHT Ferroussulfate200mg + Ferroussulfate150mg Ferroussulfate
2 months up to 5 months y" 250mcgFolate per5 ml 25 mg
(4 - <7 kg) (60mgelementaliron) (6 mgelementalironperml) I (25mgelementalironperml)
3 monthsupto 4 months
5 months up to 12 months 2.5ml(1/2tsp) 0.6ml
(4- <6kg)
(7 - <10 kg)
4 monthsupto 12months 1.0ml
4 ml (3/4tsp)
1 1 y" % (6-<10kg)
12 months up to 3 years
(10-<14kg) 12monthsupto 3 years 1/2tablet
5 ml(1tsp) 1.5ml
(10-<14kg)
3 years up to 5 years 1 1 1 % 1 3 yearsupto 5years 1 tablet 2.0 ml
10ml(1112tsp)
(14 - <19 kg) (14-19 kg)

See additional handout for drug table on second line antibiotics.

~ Give Mebendazole/Albendazole
~ Give Paracetamol for High Fever (38.5°C or above) or Ear Pain ~ Give 500 mg Mebendazole/400 mg Albendazole as a single dose in the health center if the
PARACETAMOL chileJis 12 months up to 59 months and has not had a dose in the previous 6 months, with
the following dose.
AGE OR WEIGHT TABLET (500 mg) SYRUP (120 mg/5 ml)
AGE OR WEIGHT Albendazole 400 mg tablet Mebendazole500 mg tablet
2 months up to 3 years (4 - <14 kg) y" 5 ml (1 tsp) 12 months up to 23 months }2 1

3 years to 5 years (14 - <19 kg) 10 ml (2 tsp) 24 months up to 59 months 1 1

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TEACH THE MOTHE.R TO TREAT LOCAL INFECTIONS AT HOM.E


~ to the mother what the treatment is and why it should be
given. ~ Dry the Ear by Wicking
~ Dry the ear at least 3 times daily.
~ .Roll clean absorbent cloth or soft, strong tissue paper into a

~ . wick.
Place the wick in the child's ear.
. Remove the wick when wet.
. Replace the wick with a clean one and repeat these steps
until ear is dry.

Treat Mouth Ulcers with Gentian Violet


~ Treat the mouth ulcers twice daily.
.Wash hands.
. Wash child's mouth clean using soft cloth wrapped around the
finger and wet with salt water.
. bud.
Paint'the mouth with half-strength gentian violet, using cotton

~ Treat Eye Infection with Tetracycline Eye Ointment . Wash hands again.

~ Clean both eyes 3 times daily


. Wash hands.
.. Ask child to close eyes.
Use clean cloth and water to gently wipe away pus.
~ Soothe the Throatand Relieve Cough
with a Safe Remedy
~ Then apply tetracycline eye ointment in both eyes 3 times daily. ~ Safe remedies to recommend:
. Ask the child to look up. . Breastmilk for exclusively breastfed infant
. Squirt a small amount of oitment on the inside of the lower lid. . Tamarind, Calamansi and Ginger
. Wash hands again.
~ Harmful remedies to discourage:
~ Treat until redness is gone. . Codeine cough syrup
. Other cough syrups
~ Do not use other eye ointments or drops, or put anything else in the eye. . Oral and nasal decongestants

cL Y, FEVER: NO MALARIA .,'Il:i KI:.\,,;UMMI:.NUAIIUI\i::)

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ORAL DRUGS iSESS AND CLASSIFY
LOCALINFECTIONS FOLLOW-UP UNSEL THE MOTHER L FOLLOW-UP
J J

10

GIVE THESE TREATMENTS IN HEALTH CENTER ONLY


~ lain to the mother why the drug is given.
.
.

~ Give an IntramuscularAntibiotic ~ Give Quinine for Severe Malaria


FOR CHILDREN BEING REFERRED WHO CANNOT TAKE ORAL ANTIBIOTIC: FOR CHILDREN BEING REFERRED WITH A VERY SEVERE FEBRILE DISEASE/MALARIA:

~ Give the first dose of intramuscular chloramphenicol and refer child urgently to ~ Give first dose of intramuscular QUININE and refer urgently to hospital.
hospital.
IF REFERRAL IS NOT POSSIBLE:
IF REFERRAL IS NOT POSSIBLE: ~ Give first of intramuscular QUININE.
~ Repeat the chloramphenicol injection every 12 hours for 5 days. ~ The child should remain lying down for one hour.
~ Then change to an appropriate oral antibiotic to complete 10 days of treatment. ~ 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.
CHLORAMPHENICOL ~ DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE.
AGE OR WEIGHT Dose: 40 mg per kg
Add 5.0 ml sterilewaterto vial containing INTRAMUSCULAR QUININE
1,000mg = 5.6 ml at 180mg/ml AGE OR WEIGHT
300 mg/ml* (in ml ampoules)
2 months up to 4 months (4 - <6 kg) 1.0 ml = 180 mg
4 months up to 12 months (6 - <10 kg) 0.3 ml
4 months up to 9 months (6 - <8 kg) 1.5 ml = 270 mg
12 months up to 2 years (10- <12 kg) 0.4 ml
9 months up to 12 months (8 -<10 kg) 2 ml = 360 mg

12 months to 3 years (10 - <14 kg) 2.5 ml = 450 mg 2 years up to 3 years (12 - <14 kg) 0.5 ml

3 to 5 years (14 -19 kg) 3.5 ml = 630 mg 3 years up to 5 years (14 -19 kg) 0.6 ml

*quinine salt

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~ Treat the Child to Prevent Low Blood Sugar Level


~ 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 2QO-mlcup of clean water. .

~ If the child is not able to swallow:

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

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


Give5 mllkgof 10%of dextrosesolution(D10)over a few minutes
Or give 1 mllkg of 50% (D50)by slowpush

11

INTRAMUSCULARANTIBIOTIC
~ Y, rtVER: NO MALARIJ.\ .,>jl;j KtL;UMMt:NUAIIU~::) ~IVllvv

,
INTRAMUSCULARQUININE
iSESS AND CLASSIFY
LOW BLOOD SUGAR LEVEL FOllOW-UP UNSEl THE MOTHER FOLLOW-UP
f f
12
- ---~
E EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
:See FOOD advice on COUNSEL THE MOTHE,

~ Plan A: Treat Diarrheaat Home ~ Plan B: Treat Some Dehydration with ORS
Counsel the Mother on the 4 Rules of Home Treatment: Give in health center recommended amount of ORS over 4-hour period
Give Extra Fluid, Give Zinc Supplements, Continue Feeding, When to Return
DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS.
1. GIVE EXTRA FLUID (as much as the child will take) AGE Up to 4 months 4 months up to 12 months up to 2 years up to'
12 months 2 years 5 years
~ TELL THE MOTHER:
Breastfeed frequently and longer at each feeding. WEIGHT 12 to 19 kg
<6 kg 6 to -< 10 kg 10 to -< 12 kg
If the child is exclusively breastfed, give ORS or clean water in addition to
breastmilk. 900-1400
AMOUNT (ml) 200-400 400-700 700-900
If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fluids (such as soup, rice water, or "buko juice"),
* Use the child's age only when you do not know the weight. The approximate amount of ORS required
or clean water. (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.

It is especially important to give ORS at home when: If the child wants more ORS than shown, give more.
the child has been treated with Plan B or Plan C during the visit, or
For infants under 6 months of age who are not breastfed, also give 100-200 ml clean
the child cannot return to a health center if the diarrhea gets worse.
water during this period.
~ TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
PACKETS OF ORS TO USE AT HOME. Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more slowly.
~ SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE Continue breastfeecHng whenever the child wants.
USUAL FLUID INTAKE: '
AFTER 4 HOURS.
Up to 2 years 50 to 100 ml after each loose stool Reassess the child and classify the child for dehydration.
2 years or more 100 to 200 ml after each loose stool Select the appropriate plan to continue treatment.
Begin feeding the child in health center.
Tell the mother:
IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
- Give frequent small sips from a cup.
- If the child vomits, wait 10 minutes. Then continue, but more slowly. Show her how to prepare ORS solution at home.
- Continue qivinq extra fluid until the diarrhea stoDS. Show her how much ORS to give her child to finish 4-hour treatment at home.
Give her enough ORS packets to complete rehydration. Also give her 2 packets,
2. GIVE ZINC SUPPLEMENTS as recommended in Plan A.
.. 10 mg per day in infants - < 6 mos. for 10-14 days
20 mg per day in children 6 mos. - 5 years old for 10-14 days See COUNSEL
Explain the 4 rules of home treatment:

THE MOTHER 1. GIVE EXTRA FLUID


.
2. GIVE ZINC SUPPLEMENTS See Plan A for the recommended fluids
3.
4.
CONTINUE FEEDING
WHEN TO RETURN } chart
3.
4.
CONTINUE FEEDING
KNOW WHEN TO RETURN }
and .
See the COUNSEL THE MOTHER chart.

1 .~ W ~ ,~ J~ JT 1T ,~ 'T 'T .~~~.


l1J n~jj]jjJJj1J]J]Jl]lJjl]jj]IJ]I1]I1]IJ]Jl]j"J]IJ],IJ]jj1J

EXTRA FLUID FOR DIARRHEA AND CONTINUE FEE.DING


OhOOI1NSEL THlZlVIOTHER chart.

Plan C: Treat Severe Dehydration Quickly


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

Can you give intravenous (IV)


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

AGE First give Then give


30 ml/kg in: 70 ml/kg in:
Infants (under 12 months) 1 hour* 5 hours

Children (12 months up to 5 years) 30 minutes* 2 1/2 hours


NO
) * Repeat once if radial pulse is still very weak or not detectable.

. Reassess the child every 1-2 hours. If hydration status is not improving, give the IV
drip more rapidly.
. Also give ORS (about 5 mllkg/hr) as soon as the child can drink: usually after 3-4
hours (infants) or 1-2 hours (children).
. Reassess an infant after 6 hours and a child after 3 hours. Classify the dehydration.
Then choose the appropriate plan (A, S, or C) to continue treatment.
Is IV treatment available
nearby (within 30 minutes)? YES.
. Refer URGENTLY to hospital for IV treatment.
NO
. If the child can drink, provide the mother with ORS solution and show her how to
give frequent sips during the trip.

Are you trained to use a


nasogastric (NG) tube for . Start rehydration by tube (or mouth) with ORS solution: give 20 mllkg/hr for 6 hours
rehydration? (total of 120 mllkg).
. Reassess the child every 1-2 hours:
- If there is repeated vomiting or increasing abdominal ditension, give more fluid
NO YESI. slowly.
" - If hydration status is not improving after 3 hours, send the child for IV therapy.
Can the child drink? . After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate
plan (A, S, or C) to continue treatment.
NO
" NOTE:
Refer urgently to a hospital
for IV or NG treatment.
. If possible, observe the child at least 6 hours after rehydration to be sure that the
mother can maintain hydration, giving the child ORS solution by mouth.

13

\
UNLIKELY, FEVER: NO MALARIA ,,'OJ\,:!~~vVMM~I'OjUI-\IIVI~;) .OIV I Iv;;)
,SESS AND CLASSIFY
PLANA, PLANS, PLAN C FOllOW-UP JUNSEl THE MOTHER FOLLOW-UP
J If
14

,~FO~LI-OW-UP
CARE

~ PNEUMONIA ~ DYSENTERY
After 2 days:
After 2 days:
Check the child for general danger signs.
Assess the child for cough or difficult breathing. } See the ASSESS AND CLASSIFY chart. Assess the child for diarrhea. > See Assess & Classify chart

Ask: Ask:
- Are there fewer stools?
- Is the child's breathing slower?
- Is there less fever? - Is there less blood in the stool?
- Is there less fever?
- Is the child eating better?
- Is there less abdominal pain?
Treatment: - Is the child eating better?
. Ifchest indrawing or a general danger sign, give a dose of second-line antibioticor intramuscular Treatment:
chloramphenicol. Then refer URGENTLY to hospital.
. If the child is dehydrated, treat dehydration.
. If breathing rate, fever, and eating are the same, change to the second-line antibiotic and If number of stools, amount of blood in stools, fever, abdominal pain, or
advise the mother to return in 2 days or refer. (If this child had measles within the last 3 months, eating is the same or worse:
refer.) Change to second-line oral antibiotic recommended for Shigella in your area.
Give it for 5 days. Advise the mother to return in 2 days.
. If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.
Exceptions -if the child:
. If cough is more than 30 days, refer for assessment.
- is less than 12 months old, or
- was dehydrated on the first visit, or
- had measles within the last 3 months } Refer to hospital

~ PERSISTENT DIARRHEA . If fewer stools, less blood in the stools, less fever, less abdominal pain,
and eating better, continue giving the same antibiotic until finished.
After 5 days:

Ask:
- Has the diarrhea stopped?
- How many loose stools is the child having per day?

Treatment:
. If the diarrhea has not stopped (child is still having less than 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 child's age.

""II '.'1 ',..q ~i


f;lt 011'11
I I '~I' '''11 ~~'1 ~" I I 1 {~'1 I I 1 ~" I I, ~, ~, rn rT' rI' rI'1 11' ,1 r;'J r7'1
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FOllOW-UP CARE
~ FEVER-MALARIA UNLIKELY
If fever persists after 2 days:

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

Treatment:
~ If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE
DISEASE/MALARIA.

~ If malaria 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 if
the fever persists.
~ MALARIA - If fever has been present for 7 days, refer for assessment.

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

Do a full assessment of the child. > See ASSESS & CLASSIFY chart. ~ FEVER (NO MALARIA)
Treatment: If fever persists after 2 days:
~ If the child has any general danger sign or stiff neck, treat as VERY
SEVERE FEBRILE DISEASE/MALARIA. Do a full assessment of the child. > See ASSESS & CLASSIFY chart.
Make sure that there has been no travel to malarious area and overnight stay in malaria area.
~ If the child has any cause of fever other than malaria, provide If there has been travel and overnight stay take blood smear, if possible.
treatment.
Treatment:
~ If malaria is the only apparent cause of fever. ~ If there has been travel and overnight stay to a malarious area and the blood smear is posi-
tive or there is no blood smear - classify according to Fever with Malaria Risk and treat
- Take a blood smear accordingly.
- Give second-line oral antimalarial without waiting for result of blood ~ If there has been no travel to mfllarious area or blood smear is negative:
smear. - If the child has any general danger sign or stiff neck, treat as VERY SEVERE
- Advise mother to return if fever persists. FEBRILE DISEASE.
- If fever persists after 2 days treatment with second-line oral - If the child has any apparent cause of1ever, provide treatment.
antimalarial, refer with blood smear for reassessment. - If no apparent cause of fever, advise the mother to return again in 2 days if fever
- If fever has been present for 7 days, refer for assessment. persists.
- If fever has been present for 7 days, refer for assessment.

PNEUMONIA, PERSISTENT
15
DIARRHEA, DYSENTERY,
MALARIA, FEVER: MALARIA
UNLIKELY, FEVER: NO MALARIA ,~l:; Kt:t;UMMt:NUAIIUI'i':) .:IIUllv;:'

, FOLLOW-UP UNSEL THE MOTHER


»SESS AND CLASSIFY
FOLLOW-UP
f If f
16

EFO OW-UP CARE


~ FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
~
If fever persists after 2 days:

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

Treatment:
~ Ifthe child has any signs of bleeding, including skin petechiae or a positive tourniquet
test, or signs of shock, or persistent abdominal pain or persistent vomiting.
~ MEASLES WITH EYE OR MOUTH ~ If the child has any other apparent cause of fever, provide treatment.
COMPLICATIONS ~ If fever has been present for 7 days, refer for assessment.
~ If no apparent cause of fever, advise the mother to return daily until the child has had no
After 2 days: fever for least 48 hours.
~ Advise mother to make sure child is given more fluids and is eating.
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth.

Treatment for Eye Infection:


~ EAR INFECTION
~ If pus is draining from the eye, ask the mother to describe how
she has treated the eye infection. If treatment has been correct,
After 5 days:
refer to hospital. If treatment has not been correct, teach mother
Reassess for ear problem. > See ASSESS & CLASSIFY chart.
correct treatment. Measure the child's temperature.

Treatment:
~ If pus is gone but redness remains, continue the treatment.
~ If there is tender swelling behind the ear or high fever (38.5°C or above), treat as
MASTOIDITIS.
~ If no pus or redness, stop the treatment.
~ Acute earinfection:if earpain or discharge persists,treatwith5 moredaysof thesame
Treatment for Mouth Ulcers: 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
~ If mouth ulcers are worse, or there is a very foul smell from to continue.
the mouth, refer to hospital.
~ If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
~ If mouth ulcers are the same or better, continue using half-
strength gentian violet for a total of 5 days.
finished the 5 days of antibiotic, tell her to use all of it before stopping.

r;..
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....

VE FOLLOW-UP CARE

. ~ ANEMIA
After 14 days:
IF ANY MORE FOllOW-UP VISITS ARE NEEDED BASED ON THE
~ Give iron. Atlvise mother to return in 14 days for more iron. INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER OF THE
NEXT FOllOW-UP VISIT.
~ Continue giving iron every day for 2 months with follow-up every 14 days.
0
~ If the child has any palmar pallor after 2 months, refer for assessment.
ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.
(See the COUNSEL THE MOTHER chart.)

17
MEASLES,FEVER:DENGUE
HEMORRHAGICFEVERUNLIKELY,
EARINFECTION, ING RECOMMENDATIONS

\ FEEDINGPROBLEM,ANEMIA,
VERYLOWWEIGHT, UNSEL THE MOTHER
SESS AND CLASSIFY
l FOllOW-UP
f Jj J

18

COUNSEL THE MOTHER

~ Assess the Child's Feeding ~ Assess the Child's Care for Development
Ask questions about the child's usual feeding and feeding during Ask questions about how mother cares for her child. Compare the
this illness. Compare the mother's answers to the Feeding mother's answers to the Recommendations for Care for
Recommendations for the child's age in the box below. Development.
ASK: ~ Do you breastfeed your child? ASK: - How do you play with your child?
- How many times during the day? - How do you communicate with your child?
- 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?
Sample Feeding Problem
- What do you use to feed the child?
- If very low weight for age: How large are servings? 1. difficulty in breastfeeding
Does the child receive his own serving? 2. child less than 4 months taking other milk/food
Who feed the child and how? 3. use of breastmilk substitute/cow's milk/evap milk
4. use of feeding bottles
~ During this illness, has the child's feeding changed? 5. lack of active feeding
If yes, how? 6. not feeding well during illness
7. complementary food not enough in quantity/quality/variety
8. child 6 months above not yet given complementary foods
9. infant not exclusively breastfed
10. improper handling and use of breastmilk substitute

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l111J1l1l1J111l1l111I111J1l111l1l1lJ;J1l1l1-

Recommendations for Feeding and Care for Development


Birth up to 6 Months 6 months to 12 months 12 months to 2 years 2 years and older

/
. Give adequate amount of family foods at 3
. Breastfeed as often as the child wants. . Breastfeed as often as the child wants.
.
meals every day.

. Add any of the following: . Give adequate amount of family foods, such
Give twice daily nutritious
meals such as: Boiled
foods, between

. Exclusively breastfeed as often as the child . Lugawwith added oil, mashedvegetablesor as: rice, camote, potato, fish, chicken, meat,
monggo, steamed tokwa, pulverized roasted
yellow camote,
wants, day and night, at least 8 times in 24 beans, steamed tokwa, flaked fish,
boiled yellow corn,
hours. pulverized roasted dilis, finely ground meat, dilis, milk and eggs, dark-green, leafy and
. Do not give other foods or fluids. egg yolk, bite-size fruits yellow vegetables (malunggay,
squash), fruits (papaya,
peanuts, boiled
saba, banana, taho,
. 3 times per day if fruits, and fruit

Play:
. breastfed
5 times per day if not
breastfed
.
.
banana)
Add oil or margarine.
5 times per day
juices.

. Provide an area where the child could move, play, . Feed the baby nutritious
snacks like fruits.
and develop his senses of sight, touch, and
Play:
hearing.
" Have large, colorful things for your child to reach
Play:
. Help your child count,
for and new things to see.
. Give your child clean, safe household
Play:
name, and compare
things.
Communicate:
things to handle, bang, and drop. . Give your child things to stack up, and to put . Make simple toys for
. Look into your child's eyes and
smile at him or her.
into containers, and take out. your child.

b
Communicate: Communicate:
When you are
breastfeeding, it is . Ask your child simple '. ' . ''' . Encourageyourchild
to talk, and answer
a good time to talk questions. Respond
'

to your child and to your child's ,, your child's questions.


.

get a conversation attempts to talk. , . Teach your child stories,


going with sounds or Playgames like ~ ~~ - songs, and games.
gestures. "bye." e.~@ ,
,

Feeding Recommendations for a child who has PERSISTENT DIARRHEA


~ If still breastfeeding, give more frequent, longer breastfeeds, day and night. Replace half the milk with nutrient-rich, semi-solid foods.
~ If taking other milk such as milk supplements; Do not use condensed or evaporated filled milk.
Replace these with increased breastfeeding, or For other foods, follow the feeding recommendations for the child's age.

19

ASSESS FEEDING,
FEEDINGRECOMMENDATIONS
iSESS AND CLASSIFY
I ~ COUNSEL THE MOTHER L FOLLOW-UP
r f J1 f J

20

~ Counsel the Mother About Feeding Problems


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

~ Ifthe mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.) As needed, show
the mother correct positioning and attachment for breastfeeding.

~ Ifthe child is less than 6 months old and is taking other milk or foods:
-Build mother's confidence that she can produce all the breastmilk that the child needs.
- Suggest giving more frequent, longer breastfeeding, day and night, and gradually 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 that other milk is a locally appropriate breastmilk substitute, give only when necesarry.
- 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.

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


- Recommend substituting a cup for bottle.
- Show the mother how to feed the child with a cup.

~ Ifthe child is not being fed actively, counsel the mother to:
- Sit witbthechild and encourage eating.
- Give the child an adequate serving in a separate plate or bowl.
- Observe what the child likes and consider this in the preparation of his/her food.

~ Ifthe child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and longer if possible.

- Use soft, varied, appetizing, favorite foods to encourage the child to eat as much as possible, and offer frequent small feeding.
- 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.

-- -- - ---- - - -- - -- --- -----------

ft1 ~ " ,~ 1~ 111 111 ~l1l ,~ '111 ~" 111 11f 111 i11 Ii 111 'i1 ~ ~ r1
il. 1~ 11J li lj .il li U]j-illJll11--11 11 II u il lJJ il il llJ

~ Advise the Mother to Increase Fluid During Illness


FOR ANY SICK CHILD:
~Breastfeed more frequently and longer at each feed.
~ Increase fluid. For example, give soup, rice water, buko juice or clean water.

FOR CHILD WITH DIARRHEA:


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

Advise the Mother When to Return to Health Worker


FOLLOW-UP VISIT
Advisethe motherto comefor follow-upat the earliesttime listedfor the child'sproblems.
If the child has: Return for follow-up in:
PNEUMONIA 2 days
DYSENTERY
MALARIA,if the fever persists
WHEN TO RETURN IMMEDIATELY
FEVER-MALARIAUNLIKELY,if the fever persists
FEVER(NO MALARIA)if the fever persists
Advise the mother to return immediately if the child has any of these signs:
MEASLESWITH EYEOR MOUTHCOMPLICATIONS
DENGUEHEMORRHAGICFEVERUNLIKELY,if the fever persists Any sick child .. Not able to drink or breastfeed

PERSISTENTDIARRHEA 5 days
. Becomes sicker
Develops a fever
ACUTE EAR INFECTION
CHRONICEAR INFECTION Ifthe childhas NO PNEUMONIA: .. Fast breathing
FEEDINGPROBLEMS COUGHORCOLD,also returnif: Difficultbreathing
MANY OTHER ILLNESSES,if not improving

ANEMIA 14 days
If the child has Diarrhea, also return if: .. Bloodin stool
Drinkingpoorly
VERY LOWWEIGHT FORAGE 30 days If the childhasFEVER:DENGUE .. Any sign of bleeding
HEMORRHAGIC
also return if:
FEVERUNLIKELY,
.. Persistentvomiting
Persistent abdominal pain

. Skin petechiae
Skin rash

21
FEEDING AND CARE FOR
DEVELOPMENT,
FEEDING PROBLEMS, .,)IVllvv I nn.vvl I
SSESS AND CLASSIFY
, FLUID, WHEN TO RETURN
FOLLOW-UP
r If f f
22

~ Counsel the Mother about Her Own Health


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

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

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

Check the mother's immunization status and give her Tetanus Toxoid if needed.
Make sure she has access to:
. Family Planning
. Counseling on STD and AIDS prevention.

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..

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~
-- ~- ~ - ~-
~l
ASSESS, CLASSIFY, AND TREAT THE SICK INFANT
AGE 1 WEEK TO 2 MONTHS

I
ASSESS CLASSIFY IDENTIFY
TREATMENT
ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE USE All BOXES THAT MATCH THE
Determine if this is an initial or follow-up visit for this problem. INFANT'S SYMPTOMS AND PROBLEMS
If follow-up visit, use the follow-up instructions in the follow-up section. TO CLASSifY THE IllNESS.
If initial visit, assess the young infant as follows:

CHECK FOR POSSIBLE BACTERIAL INFECTION


SIGNS CLASSIFY AS TREATMENT
. Con""Jlsions or ,. . Give ,first dose of intramt1scalar
ASK:
Has the infant .
LOOK, LISTEN:
Count the breaths in one minute.
Classify
ALL
YOUNG
Fast breatbing (60 breClths;per minute or
more)or
.
POSSIBLE .
antibiotics.

had convulsions? Repeat the count if elevated. Severe ch indrawing or Treat the chirtJto prevent low blood
CHILD INFANTS Nasal flaring or SERIOUS sugar.
Look for chest indrawing. MUST Grunting or BACTERIAL
BECALM. INFECTION . Advise m,pther how to keep the
Look for nasal flaring.

Look and listen for grunting. } Bulging fontanelle or


Pus draining from the ear or
Umbilical rednes§ extending to the skin or
infant warm on the way to the
hospital. I

. Look and feel for bulging fontanelle. Fever (37.5°C*or above, or feels hot) or low
bodytemperature (less than 35.5°8*,or . Refer URGENTLY to the hospital.
. Look for pus draining from the ear.
feels cold)or
**

I!I
. Look at the umbilicus.
Does the redness
Is it red or draining
extend to the skin?
pus? Many or severe skin pustules or
Abnormly; sleepy or diffcUlt to awaken or
Less Ulan normal movement.
.
. Measure temperature (or feel for fever or low body temperature).

. Look for skin pustules. Are there many or severe pustules? Red umbilicus or draining pus or LOCAL . Give an appropriate oral antibiotic.
BACTERIAL . Treat the local infection in the health
. See if the young infant is abnormally sleepy or
Skin pustules
INFECTION center, and teach the mother to treat
difficult to awaken. local infections at home.
. Look at the young infant's movements. . Advise mother how to give home care
for young infant.
Are they less than normal? . Follow up in 2 days.

. These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately a.sac higher.
.. If referral is not possible, manage the child as described in Management of Childhood Illness.
Treat the Child, Annex: Where Referral is Not Possible.

l.-

23
MOTHER'SHEALTH
BACTERIALINFECTION

,\ ASSESS AND CLASSIFY


l FOLLOW-UP
J if I r f
24

rrhea'? . If infant does not have POSSIBLE SERIOUS


.
Two of the following signs:
Abnormally sleepy or
difficult to awaken
BACTERIALINFECTION.nor DYSENTER){:
- Giv~fluid for severe dehydration (Plan C)
IF YES, ASK:
.. For how long?
LOOK AND FEEL:
. Look at the young infant's general
for
. Sunkeneyes
. SkJ,npinchgoes back seveRE
OR
If infant also has a POSSIBLE SERIOUS
Is there blood in condition. Is the young infant: DEHYDRATION veryslowly DEHYDRATION BACTERIAL INFECTIONor DYSENTERY:
the stool? - Abnormally sleepy or difficult to - Refer URGENTLYto hospital, with mother
awaken? giving frequent sips of ORS on the way.
- Restless or irritable? - Advise mother to continue breastfeeding.
- Advise mother how to keep the young.
. Look for sunken eyes. ..
infant warm on the way to the hospital.

. Pinch the skin of the abdomen. Two of the following signs:


. Restless, irritable
.
.
Give fluid for some dehydration (Plan B).
If infant also has POSSIBLE SERIOUS
Does it go back:
. Sunken eyes SOME BACTERIAL INFECTIONor DYSENTERY:
- Very slowly (longer than 2
seconds )? . Skin pinch goes back DEHYDRATION Refer URGENTLY to hospital with mother
- Slowly? slowly giving frequent sips of ORS on the way.
Advise mother to continue breastfeeding.

. Not enough signs to


classify as some or
NO . Give fluid to treat diarrhea at home (Plan A).
DEHYDRATION
severedehydration

. If the young infant has dehydration, treat


. Diarrhea lasting for 14 days SEVERE, dehydration bW'ore referral unless the infant
or more PERSISTENT has also POSSIBLE SERIOUS BACTERIAL
DIARRHEA INFECTION.

. Refer to hospital.

and if blood
. Blood inthe stool
DYSENTERY
. Refer URGENTLY to hospital, withamother
giving frequent sips of ORS on the way.
in stool
. Advise mother to continue breastfeeding.

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r111l1l1lj;--?1lIuJ ~~~uJl.1~~~

THEN CHECK. FOR FEEDING PROBLEMS OR LOW WEIGHT:

IF YES, ASK: LOOK and FEEL:


Classify
Is there any difficulty feeding? Determine weight for age.
FEEDING
Is the infant breastfed? If yes,
how many times in 24 hours?

Does the infant usually receive


any other food or drink? If yes,
how often?
WP
. Not well attached to
breast or
~ Advise the mother to breastfeed as often and
for as long as the infant wants, day and night.
@
. orNot sucking effectively

---------------------------------------
What do you use to feed the infant?

. . FEEDING
. If not well attached or not sucking effectively,
teach correct positioning and attachment.

IF AN INFANT: Has any difficulty feeding.


Less than 8 breastfeeds
in 24 hours or
. drinks or
Receives other foods or
PROBLEM . If breastfeeding less than 8 times in 24
hours, advise to increase frequency of
Is breastfeeding less than 8 times in 24 hours, OR
breastfeeding.
Is taking any other foods or drinks, or LOWWEIGHT
.
Is low weight for age,
AND . Low weight for age or
Thrush (ulcers or white
patches in the mouth)
~ If receiving other foods or drinks, counsel
mother about breastfeeding more, reducing
Has no indications to refer urgently to hospital: other foods and drinks, and using a cup:
If not breastfeeding at all:
ASSESS THE INFANT'S BREASTFEEDING:
Refer to breastfeeding counseling and
Has the infant breastfed If the infant has not fed in the previous hours, ask the mother to possible relactation.
in the previous hour? put her infant to the breast. Observe the breastfeed for 4 minutes.
Advise about the correct preparing of
breastmilk substitutes, and using a
(If the infant was fed during the last hour, ask the mother if she cup.
can wait, and to tell you when the infant is willing to feed again.)
~ If thrush, teach the mother to treat thrush at
Is the infant able to attach? home. .

.
~ Advise the mother to give home care for the
no attachment at all not well attached good attachment young infant.
~ Follow up any feeding problem or thrush in 2
TO CHECK ATTACHMENT, LOOK FOR: days.
Chin touching the breast 8< ~ Follow up low weight for age in 14 days.
Mouth wide open
Lower lip turned outward
More areola visible above than below the mouth
(All these signs shouldbe present if the attachment is good.)
.
Is the infant sucking effectively (that is, slow, deep sucks,
sometimes pausing)? . Not low weight for age,
and no other signs of
NO FEEDING ~ Advise mother to give home care for the young
not sucking at all not sucking effectively good effectively PROBLEM infant.
inadequate feeding.
Clear a blocked nose if it interferes with breastfeeding. ~ Praise the mother for feeding the infant well.

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

25

...IVII\.,,':' IHKU~H
DIARRHEA
\ FEEDING PROBLEMS FOLLOW-UP
/ ]J f r J

26

;'fl '11/ 1111 1111 11') 11') 11'1 "11 111) t1" lfl 11'1 1111 11'] TII' 11'J 11" rt'J ITI iT] IT]
llJ !lj-!1uJL]Jl111JllJl]Jl1!J~L1UJl]~il1 u.I1---u.~
~'"~ '-- ~ ~,- ---- - - ~ '* ,,<m - =-~

T :r THE YOUNG INFANT AND COUNSEL THE MOTHER


~ Give an Appropriate OralAntibiotic
For local bacterial infection:
First-line antibiotic: COTRIMOXAZOLE
Second-line antibiotic: AMOXICILLIN

COTRIMOXAZOLE AMOXYCILLIN
(trimethoprim + sulphamethoxazole)
~ Give two times daily for 5 days ~ Give three times daily for 5 days

ADULT TABLET SYRUP TABLET SYRUP


AGE OR WEIGHT single strength (80 mg trimethoprim + 40 mg trimethoprim + 200 mg 250 mg 125 mg per 5 ml
400 mg sulphamethoxazole) sulphamethoxazole per 5 ml

Birth up to 1 month «3 kg) 1.25 ml* 1.25 ml

1 to 2 months (3-4 kg) 2.5 ml 2.5 ml

* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.

~ Give First Dose of Intramuscular Antibiotics


~ Give the first dose of both benzylpenicillin and gentamicin intramuscular.

GENTAMICIN BENZYLPENICILLIN
Dose: 5 mg per kg Dose: 50,000 units per kg

WEIGHT Undiluted 2 ml or Add 6 ml sterile water To a vial of 600 mg (1,000,000 units):


vial containing to 2 ml vial containing Add 2.1 ml sterile water = OR Add 3.6 ml sterile water =
20 mg = 2 ml at 10 mg/ml 80 mg* = 8 ml at 10 mg/ml 2.5 ml at 400,000 units/ml 4.0 ml at 250,000 units/ml

1 kg 0.5 ml* 0.1 ml 0.2 ml

2 kg 1.0 ml* 0.2 ml 0.4 ml

3 kg 1.5 ml* 0.4 ml 0.6 ml

4 kg 2.0 ml* 0.5 ml 0.8 ml

5 kg 2.5 ml* 0.6 ml 1.0 ml

* Avoid using undiluted 40 mg/ml gentamicin.

Referral is the best option for a young infant classified with POSSIBLE SERIOUS BACTERIAL INFECTION. If referral is not possible, give
benzylpenicillin and gentamicin for at least 5 days. Give benzylpenicillin every 6 hours plus gentamicin one dose daily.

27

IMMUNIZATION STATUS ANTIBIOTICS THRUSH

\ TREAT AND COUNSEL FOLLOW-UP


"'
J j J J
r I
28

T THE YOUNG INFANTAND COU L THE MO

~ To treat Diarrhea, See TREAT THE CHILD chart.

~ 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 health center.
~ Tell her to do the treatment twice daily. She should return to the health center if the infection worsens.

To Treat Skin Pustules To Treat Umbilical Infection To Treat Oral Thrush (ulcers or white patches in mouth)
The mother should: The mother should: The mother should:
~ Wash hands. ~ Wash hands. ~ Wash hands.

~ Gently wash off pus and ~ Clean with 70% ethyl alcohol ~ Wash mouth with clean soft cloth wrapped around the finger
and wet with salt water.
crusts with soap and water. ~ Paint with gentian violet.
~ Dry the area. ~ Wash hands. ~ Paint the mouth with half-strength gentian violet.
~ Wash hands.
~ Paint with gentian violet.
~ Wash hands.

1~1~1~j]~J~]~j]'~]~1'J]I~]~~]~
.]J:}JIJJl}J1J1!1!1~;!1!.1;!];U~;-!1lJ~-u.L1!.1L1~~

TREAT THE YOUNG INFANT AND 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 straight.
- facing her breast, with infant's nose opposite her nipples
- with infant's body close to her body
- supporting infant's whQle body, 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 breast, aiming the infant's lower lip well below the nipple.
~ Look for signs of good attachment and effective sucking. If the attachment or sucking is good, try again.

~ Advise Mother to Give Home Care for the Young Infant


~ FOOD Breastfeed frequently, as often and for as long as the infant wants,
~ FLUID } day and night, during sickness and health.
~ WHEN TO RETURN

Follow-up Visit When to Return Immediately:


Ifthe infant has: Return for follow-up in: Advise the mother to return immediately ifthe young
infant has any of these signs:
LOCAL BACTERIAL INFECTION
ANY FEEDING PROBLEM 2 days Breastfeeding or drinking poorly
THRUSH Becomes sicker
Develops a fever
LOW WEIGHT FOR AGE Fast breathing
14days
Difficult breathing
Blood in stool
~ MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.
In cool weather, cover the infant's head and feet, and dress
the infant with extra clothing.

29

LOCAL INFECTIONS
BREASTFEEDING THRUSH

\ HOME CARE
FOLLOW-UP
,
p
J j J ] J ] f
30

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG IN NT

~ LOCAL BACTERIAL INFECTION


After 2 days:
Look at the umbilicus. Is red or draining pus? Does redness extend to the skin?
Look at the skin pustules. Are there many or severe pustules?

Treatment
~ If the pus or redness remains or is worse, refer to hospital.

~ If the pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic
and continue treating the local infection at home.

~I~J~]~]~]'~]I~]~]~jl~]I~]~]~]~~]~]~]~]~]~~
III J1\ 1Jl l]~1 J'I' l' ,.
111 11, 11; 1'\- 111 1"j; rJ~ . -1 . J~ I'll ]j1 Ij~ ]]~ JJj ! ]1 1 JI ! I,

GIVE-FOLLOW UP CARE FOR THE SICK YOUNG INFANT


~ 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. If you counsel the mother to make significant changes in feeding, ask her to
bring the young infant back again.
If the young infant is low weight for age, ask mother to return in 14 days after the initial visit to measure the young infant's weight gain.

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

~ LOW WEIGHT
After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above.

If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the young infant is still low weight for age, but is feeding well, praise mother. Ask her to come again within a month or when she returns for immunization.
If the young 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 2 weeks).
Continue to see the young infant every few weeks until infant is feeding well and gaining weight regularly or is no longer low weight for age.

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

~ ORAL THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above.
~ If thrush is worse, or if the infant has problems with attachment or sucking, refer to hospital.
~ If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.

31
FEEDING PROBLEM,
LOW WEIGHT FOR AGE,
THRUSH

\ FOLLOW~UP
~
I ~
0
r-,! MANAGEMENTOFTHE SICKYOUNGINFANTAGE 1 WEEK UPTO 2 MONTHS LL

6
C)
z
Date: 2i
~
°C 0

6
Child'sName: Age:- Sex:- Weight: kg . Temperature: U
W
ASK:Whataretheinfant'sproblems? Initialvisit: Follow-upvisit: ~

r ASSESS(Circleallsignspresent) CLASSIFY

.
CHECK FOR POSSIBLE BACTERIAL INFECTION
Has the infant had convulsions? . Count the breaths in one minute. breaths
per minute. Repeat if elevated-

.. Fast Breathing?
Look for severe chest indrawing.
Look for nasal flaring.
.
F .. Look and listen for grunting.
Look and feel for bulging fontanelle.
Look for pus draining from the ear.
. Look at the umbilicus. Is it red or draining pus?
Does the redness extend to the skin?
. Fever (temperature 37.5°C or above or feels hot)
or low body temperature (below 35.5°C or feels cool)
. Look for skin pustules. Are there many or severe pustules?
.
F .
See if the young infant is abnormally sleepy or
difficult to awaken.
Look at the young infant's movements. Less than normal?

F
DOES THE YOUNG INFANT HAVE DIARRHEA? YES_NO-
.. For how long?
Is there blood in the stool?
days . Look at the young infant's general condition. Is the infant:
Abnormally sleepy or difficult to awaken
.-~ ..
Restless or irritable?

6
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

6 THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT


.. Is there difficulty
Is the infant breastfed?
feeding Yes
Yes
If Yes, how many times in 24 hours? -
-
-
No -
No -
times
. Determine weight for age. Low - Not low -
('f)

6 .
('f)

Does the infant usually receive any other foods or drinks? Yes - No-
If Yes, how often?

r
. What do you use to feed the child? -----
-----------------------------------
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or
drinks, or is low weight for age AND has no indications to refer urgently to hospital:

r-:=! ASSESS BREASTFEEDING:


Has the infant breastfed in the previous hour? If infant has not fed in the previous hour, ask the mother to put her
infant on her breast.
[, Observe the breastfeed for 4 minutes.
. Is the infant able to attach? To check attachment, look for:
- Chin touching breast Yes - No-
r~
r.,
- Mouth wide open Yes - No-
- Lower lip turned outward Yes - No-
- More areola above than below the mouth Yes - No-

l~ no attachment at all not well attached good attachment


r-~
r.l . Is the infant sucking effectively (that is, slow deep sucks,
sometimes pausing)?

L:! not sucking at all not sucking effectively sucking effectively

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

-...~1
CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS Circle immunization needed today.
Return for next
immunization on:
- - -
BCG DPT1 OPV1 HEPB1 "
(Date)
r-.1
-.. ASSESS OTHER PROBLEMS

~
~

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Returnfor follow-upin: ~
~
Advisemotherwhento returnimmediately.
Giveany immunizationsneededtoday: I='
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~
-
.--

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----- ,.r-

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~ -idJ-fU.allbtaJ~Mad1~-"43.jd1d3Jd1~~EI1 a1d3J~~-.

GROWTH CHART
Record the information along the month-of-weighing line using the symbols below:

weight
F fever
B breastfeeding
C cough/cold
CF - complementary foods introduced
D diarrhea
4 5-6 years
01 other illnesses +2S0 Boys
+250 Girls
A Vitamin A given
H hospitalized 4-5years
1 sign of injuries such as
abrasions/hematoma

20
19

.2S0 Boy.

-280 Girts

14
13
12
11
10
9
8
7 A child who is...
6 not gaining weight has a plotted growth
curve that flattens off or looks like a flat
5
line between the "reference" curves;
4
3 The child's weight should be between
the ~reference~ curves.
2
The plotted growth curve should go in
1 an upward direction

III
0
0 1 2 3 4 5 6 7 8 9 10 11 12
I 1 I 1 1 I I 1 1 I I 1 I A child who is...
. losing weight has a plott edgrDWt h curve
that goes in a downward/declining
. .

Distributed by- direction between the ~reference" curves.


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