IMCI Chart Booklet | Hiv/Aids | Breastfeeding

1

CHILD AGED 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD
Assess, Classify 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 for HIV Infection........................................ 7
Then Check for Mound and Gum Conditions................ 8
Then Check the Child’s Immunization Status ............... 9
Assess Other Problems ................................................ 9
Then Establish HIV Infection Status............................ 10
WHO Paediatric clinical staging for HIV………………. 11
HIV testing for the exposed child ………………………11
TREAT THE CHILD
Teach the mother to give oral drugs at home:
Oral Antibiotic. ....................................................... 12
Ciprofloxacin ......................................................... 12
Co-trimoxazole ..................................................... 12
Pain Relief ............................................................ 13
Iron ....................................................................... 13
Co-artemether ...................................................... 13
Bronchodilator ....................................................... 13
Teach the Mother to Treat Local Infections at Home
Clear the ear by dry wicking and give eardrops.... 14
Treat for mouth ulcers and thrush......................... 14
Soothe throat, relieve cough with safe remedy.... 14
Treat eye infection ………………………………….14
Give Preventive Treatments in Clinic
Vitamin A …………………………………………… 15
Mebendazole ……………...…………………………15
Give Emergency Treatment in Clinic only
Quinine for severe malaria.................................... 16
Intramuscular Antibiotic ........................................ 16
Diazepam for convulsions ………………...…….. 16
Treat low blood sugar .......................................... 17
TREAT THE CHILD, continued
Give Extra Fluid for Diarrhoea
and Continue Feeding
Plan A: Treat for Diarrhoea at Home ....................... 18
Plan B: Treat for Some Dehydration with ORS........ 18
Plan C: Treat for Severe Dehydration Quickly......... 19
Give Follow-up Care
Pneumonia............................................................... 20
Dysentery................................................................. 20
Persistent diarrhoea................................................. 20
Malaria ..................................................................... 21
Fever– malaria unlikely............................................ 21
Measles with eye or mouth complications ………… 21
Ear Infection............................................................ 22
Feeding problem.................................................... . 22
Anaemia.................................................................. 22
Very Low Weight...................................................... 22
Follow up care for child with possible HIV
infection / suspected symptomatic /confirmed HIV ..23
COUNSEL THE MOTHER
Assess the feeding of sick infants............................ 24
Feeding Recommendations..................................... 25
Counsel the mother about feeding and HIV:
Feeding advice for the HIV confirmed.................. 26
Stopping breastfeeding for HIV exposed ............. 26
AFASS criteria for stopping breastfeeding........... 26
Counsel the mother about feeding Problems .......... 27
Feeding Recommendations for HIV exposed child.. 28
Counsel the mother about her own health............... 29
Advise mother to increase fluids during illness........ 30
Advise mother when to return to health worker ……30
Advise mother when to return immediately.............. 30
SICK YOUNG INFANT AGED UP TO 2 MONTHS
ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
Assess, Classify and Identify Treatment
Check for Severe Disease and Local Infection................................................. 31
Then check for Jaundice .................................................................................. 32
Then ask: Does the young infant have diarrhoea?........................................... 33
Then check the young infant for HIV Infection.................................................. 34
Then check for Feeding Problem or Low Weight for Age in breastfed……. …. 35
Then check for Feeding Problem or Low Weight for Age in non-breastfed ….. 36
Then check the young infant’s immunization status ........................................ 37
Assess Other Problems .................................................................................... 37
Treat the Young Infant and Counsel the Mother
Intramuscular antibiotics................................................................................... 38
Treat the young infant to prevent low blood sugar............................................ 38
Keep the young infant warm on the way to hospital ......................................... 39
Oral antibiotic.................................................................................................... 39
Treat local infections at home........................................................................... 40
Correct positioning and attachment for breastfeeding...................................... 41
Teach mother how to express breast milk ....................................................... 41
Teach mother how to feed by cup .................................................................... 42
How to prepare commercial formula milk ......................................................... 42
Teach the mother to keep the low weight infant warm at home ....................... 43
Advice mother to give home care to the young infant....................................... 44
Give Follow-up Care for the Sick Young Infant
Local Bacterial Infection.................................................................................... 45
Jaundice ........................................................................................................... 45
Diarrhoea .......................................................................................................... 45
Possible HIV/HIV exposed................................................................................ 46
Feeding Problem .............................................................................................. 46
Low Weight for age........................................................................................... 47
Thrush............................................................................................................... 47
Recording Forms: Sick Child.......................................................................... 48
Sick young infant............................................................. 49
ANNEX A: Skin and mouth conditions........................................... 51
ANNEX B: Antiretroviral therapy: Dosages ............................... 56
ANNEX C: Antiretroviral therapy: Side effects.......................... 60
ANNEX D: Drug dosages for opportunistic infections........ 61
INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS
FOR HIGH HIV SETTINGS
Department of Child and Adolescent
Health and Development (CAH)
2
ASSESS AND CLASSIFY THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS
CLASSIFY IDENTIFY TREATMENT ASSESS
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE
• 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 child with any general danger sign needs URGENT attention; complete the assessment and any pre-
referral treatment immediately so that referral is not delayed.
ASK:
• Is the child able to drink or breastfeed?
• Does the child vomit everything?
• Has the child had convulsions?
LOOK:

• See if the child is lethargic or
unconscious.
• Is the child convulsing now?
USE ALL BOXES THAT MATCH THE
CHILD'S SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS.
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)
• Any general danger
sign or
• Chest indrawing or
• Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE
DISEASE
¾ Give first dose of an appropriate antibiotic
¾ Refer URGENTLY to hospital
• Fast breathing
PNEUMONIA
¾ Give oral antibiotic for 5 days
¾ If wheezing (even if it disappeared after rapidly acting
bronchodilator) give an inhaled bronchodilator for five days*
¾ Soothe the throat and relieve the cough with a safe remedy
¾ If coughing for more than 3 weeks or if having recurrent
wheezing, refer for assessment for TB or asthma
¾ Advise the mother when to return immediately
¾ Follow-up in 2 days
• No signs of
pneumonia or very
severe disease
COUGH OR
COLD
¾ If wheezing (even if it disappeared after rapidly acting
bronchodilator) give an inhaled bronchodilator for 5 days*
¾ Soothe the throat and relieve cough with a safe remedy
¾ If coughing for more than 3 weeks or if having recurrent
wheezing, refer for assessment for TB or asthma
Classify
COUGH or
DIFFICULT
BREATHING
If the child 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
IF YES, ASK: LOOK, LISTEN, FEEL:
y For how long? y Count the breaths
in one minute.
y Look for chest indrawing.
y Look and listen for stridor.
y Look and listen for wheezing.
If wheezing and either fast
breathing or chest indrawing:
Give a trial of rapid acting inhaled
bronchodilator for up to three times
15-20 minutes apart. Count
the breaths and look for chest indrawing
again, and then classify.
* In settings where inhaled bronchodilator is not available, oral salbutamol may be the second choice
}
CHILD
MUST
BE
CALM
3
Does the child have diarrhoea?
Classify
DIARRHOEA
for
DEHYDRATION
and if blood
in stool
and if diarrhoea
for 14 days or
more
Two of the following signs:
• Lethargic or unconscious
• Sunken eyes
• Not able to drink or drinking poorly
• Skin pinch goes back very slowly.
SEVERE
DEHYDRATION
¾ If child has no other severe classification:
- Give fluid for severe dehydration (Plan C)

OR
If child also has another severe classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue breastfeeding
¾ If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera
Two of the following signs:
• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
SOME
DEHYDRATION
¾ Give fluid, zinc supplements and food for some
dehydration (Plan B)
¾ If child also has a severe classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue breastfeeding
¾ Advise mother when to return immediately
¾ Follow-up in 5 days if not improving.
Not enough signs to classify as some
or severe dehydration NO
DEHYDRATION
¾ Give fluid, zinc supplements and food to treat
diarrhoea at home (Plan A)
¾ Advise mother when to return immediately
¾ Follow-up in 5 days if not improving.
• Dehydration present
SEVERE
PERSISTENT
DIARRHOEA
¾ Treat dehydration before referral unless the child has
another severe classification
¾ Refer to hospital
• No dehydration
PERSISTENT
DIARRHOEA
¾ Check for HIV Infection
¾ Advise the mother on feeding a child who has
PERSISTENT DIARRHOEA
¾ Give multivitamins and minerals including zinc for 14
days
¾ Follow up in 5 days
• Blood in the stool DYSENTERY
¾ Give ciprofloxacin for 3 days
¾
* 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.
IF YES, ASK : LOOK AND FEEL :
• For how
long?
• Is there
blood in the
stool?
• Look at the child’s general
condition.Is the child :
− Lethargic or
unconscious?
− Restless and irritable?
• Look for sunken eyes.
• Offer the child fluid. Is the child:
− Not able to drink or
drinking poorly?
− Drinking eagerly,
thirsty?
• Pinch the skin of the
abdomen. Does it go back:
− Very slowly (longer
than 2 seconds)?
− Slowly?
4
Does the child have fever?
(by history or feels hot or temperature 37.5°C** or above)
if MEASLES
now or within
last 3 months,
Classify
High
Malaria Risk
Low
Malaria Risk
IF YES:
Decide Malaria Risk: high or low
THEN ASK:
• For how long?
• If more than 7 days, has fever
been present every day?
• Has the child had measles
within the last 3 months?
LOOK AND FEEL:
• Look or feel for stiff neck.
• Look for runny nose.
Look for signs of MEASLES
• Generalized rash and
• One of these: cough, runny nose,
or red eyes.
If the child has measles now
or within the last 3 months:
• Look for mouth ulcers.
Are they deep and extensive?
• Look for pus draining from the
eye.
• Look for clouding of the cornea.
Classify
FEVER
** These temperatures are based on axillary temperature. Rectal temperature readings are
approximately 0.5°C higher.
*** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and
malnutrition - are classified in other tables.
HIGH MALARIA RISK
• Any general danger sign or
• Stiff neck.
VERY SEVERE
FEBRILE
DISEASE
¾ Give quinine for severe malaria (first dose)
¾ Give first dose of an appropriate antibiotic
¾ Treat the child to prevent low blood sugar
¾ Give one dose of paracetamol in clinic for high
fever
(38.5°C or above)
¾ Refer URGENTLY to hospital
• Fever (by history or feels hot or
temperature 37.5°C** or above)
MALARIA
¾ Give oral co-artemether or other recommended
antimalarial
¾ Give one dose of paracetamol in clinic for high fever
(38.5°C or above)
¾ Advise mother when to return immediately
¾ Follow-up in 2 days if fever persists
¾ If fever is present every day for more than 7 days,
refer for assessment
LOW MALARIA RISK
• Any general danger sign or
• Stiff neck
VERY SEVERE
FEBRILE
DISEASE
¾ Give quinine for severe malaria (first dose) unless no
malaria risk
¾ Give first dose of an appropriate antibiotic
¾ Treat the child to prevent low blood sugar
¾ Give one dose of paracetamol in clinic for high
fever
(38.5°C or above)
¾ Refer URGENTLY to hospital
• NO runny nose and
NO measles and
NO other cause of fever
MALARIA
¾ Give oral co-artemether or other recommended
antimalarial
¾ Give one dose of paracetamol in clinic for high fever
(38.5°C or above)
¾ Advise mother when to return immediately
¾ Follow-up in 2 days if fever persists
¾ If fever is present every day for more than 7 days,
refe for assessment
• Runny nose PRESENT or
• Measles PRESENT or
• Other cause of fever
PRESENT
FEVER -
MALARIA
UNLIKELY
¾ Give one dose of paracetamol in clinic for high
fever
(38.5°C or above)
¾ Advise mother when to return immediately
¾ Follow-up in 2 days if fever persists
¾ If fever is present every day for more than 7 days,
refer for assessment
• Any general danger sign or
• Clouding of cornea or
• Deep or extensive mouth
ulcers
SEVERE
COMPLICATED
MEASLES***
¾ Give Vitamin A treatment
¾ Give first dose of an appropriate antibiotic
¾ If clouding of the cornea or pus draining from the
eye, apply tetracycline eye ointment
¾ Refer URGENTLY to hospital
• Pus draining from the eye or
• Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS***
¾ Give Vitamin A treatment
¾ If pus draining from the eye, treat eye infection with
tetracycline eye ointment
¾ If mouth ulcers, treat with gentian violet
¾ Follow-up in 2 days.
• Measles now or within the
last 3 months
MEASLES ¾ Give Vitamin A treatment
5
Does the child have an ear problem?
IF YES, ASK:
• Is there ear pain?
• Is there ear discharge?
If yes, for how long?
Classify
EAR PROBLEM
LOOK AND FEEL:
• Look for pus draining from the ear.
• Feel for tender swelling behind the ear.
¾ Give an antibiotic for 5 days.
¾Give paracetamol for pain.
¾ Dry the ear by wicking.
¾ If ear discharge, check for HIV Infection
¾ Follow-up in 5 days.
¾Give first dose of an appropriate antibiotic.
¾Give first dose of paracetamol for pain.
¾Refer URGENTLY to hospital.
¾ Dry the ear by wicking.
¾ Treat with topical quinolone eardrops for 2 weeks
¾ Check for HIV Infection
¾ Follow-up in 5 days
• Pus is seen draining from the ear
and discharge is reported for less
than 14 days, or
• Ear pain.
• Tender swelling behind the ear.
• Pus is seen draining from the ear
and discharge is reported for 14
days or more.
• No ear pain and
No pus seen draining from the ear.
¾ No treatment.
ACUTE EAR
INFECTION
CHRONIC EAR
INFECTION
MASTOIDITIS
NO EAR
6
THEN CHECK FOR MALNUTRITION AND ANAEMIA
CHECK FOR MALNUTRITION
CHECK FOR ANAEMIA
CLASSIFY
NUTRITIONAL
STATUS
LOOK AND FEEL:
• Look for visible severe wasting
• Look for oedema of both feet
• Determine weight for age


CLASSIFY
ANAEMIA
LOOK and FEEL:
• Look for palmar pallor. Is it:
− Severe palmar pallor?
− Some palmar pallor?
• Severe palmar pallor SEVERE
ANAEMIA
¾ Refer URGENTLY to hospital
• Some palmar pallor ANAEMIA
¾ Give iron
¾ Give oral antimalarial if high malaria risk
¾ Check for HIV infection
¾ Give mebendazole if child is 1 year or older and has not had a
dose in the previous six months
¾ If child is less than 2 years old, assess the child's feeding and
counsel the mother on feeding according to the feeding
recommendations
- If feeding problem, follow-up in 5 days
¾ Advise mother when to return immediately
¾ Follow up in 14 days
• No palmar pallor NO ANAEMIA If child is less than 2 years old, assess the child's feeding and counsel
the mother on feeding according to the feeding recommendations
- If feeding problem, follow-up in 5 days
• Visible severe
wasting or
• Oedema of both feet
· Not very low wight for age
and
no other signs of
malnutrition
NOT VERY
LOW WEIGHT
¾ If child is less than 2 years old, assess the child's feeding and
counsel the mother on feeding according to the feeding
recommendations
- If feeding problem, follow-up in 5 days
¾Advise mother when to return immediately
SEVERE
MALNUTRITION
• Very low weight for age VERY LOW
WEIGHT
¾ Treat the child to prevent low sugar
¾ Refer URGENTLY to a hospital
¾ Assess the child’s feeding and counsel the mother on feeding
according to the feeding recommendations
- If feeding problem, follow-up in 5 days
¾Check for HIV infection
¾Advise mother when to return immediately
¾Follow-up in 30 days
7
• Pneumonia * *
• Persistent diarrhoea * *
• Ear discharge (acute or chronic)
• Very low weight for age* *
THEN ASSESS FOR HIV INFECTION**
¾ Has the mother or child had an HIV test?
OR
¾ Does the child have one or more of the following
conditions?:
NOTE OR ASK:
• PNEUMONIA ?
• PERSISTENT DIARRHOEA?
• EAR DISCHARGE?
• VERY LOW WEIGHT?
HIV test result available for mother/child?
**A child who is on ART does not need to enter this HIV box.
* Includes severe forms such as severe pneumonia. In the case of severe forms,
complete assessment quickly and refer child
URGENTLY.
*A child with these classifications or on ART, assess for mouth and gum
conditions as in next page.
LOOK and FEEL:
• Oral thrush
• Parotid enlargement
• Generalized
persistent
lymphadenopathy
If yes to one of the two questions above, enter the
box below and look for the following conditions
suggesting HIV infection:
„ If the child also has a severe
classification give appropriate pre
referral treatment and refer urgently
„ Treat, counsel and follow-up existing
infection
„ Give co-trimoxazole prophylaxis
„ Give Vitamin A supplements
„ Assess the child’s feeding and provide
appropriate counselling to the mother
„ Test to confirm HIV infection
„ Refer for further assessment
including HIV care/ART
„ Advise the mother on home care
„ Follow up in 14 days, then monthly for 3 months
and then every 3 months
• 2 or more conditions
AND
• No test results for child
or mother
SUSPECTED
SYMPTOMATIC
HIV INFECTION
„ If the child also has a severe
classification give appropriate pre
referral treatment and refer urgently
„ Treat, counsel and follow-up existing
infection
„ Give co-trimoxazole prophylaxis
„ Check immunization status
„ Give Vitamin A supplements
„ Assess the child’s feeding and provide
appropriate counselling to the mother
„ Refer for further assessment including HIV
care/ART
„ Advise the mother on home care
„ Follow up in 14 days, then monthly for 3 months
and then every 3 months
• Positive HIV antibody
test for child 18 months
and above
OR
• Positive HIV virological
test
• Less than 2 conditions
AND
• No test result for child
or mother
SYMPTOMATIC
HIV INFECTION
UNLIKELY
„ Treat, counsel and follow-up existing infection
„ Advise the mother about feeding and about her
own health
„ Encourage HIV testing
CONFIRMED
HIV INFECTION*
• Negative HIV test in
mother or child AND not
enough signs to classify
as suspected
symptomatic HIV
infection
HIV INFECTION
UNLIKELY
„ Treat, counsel and follow-up existing infections
„ Advise the mother about feeding and
about her own health
HIV status of
mother and child
unknown
HIV status of
mother and/or
child known
CLASSIFY
One or both of the
following:
• Mother HIV positive
and no
test result for child
OR
• Child less than
18 months with
positive antibody test
„ Treat, counsel and follow-up existing infection
„ Give co-trimoxazole prophylaxis
„ Give Vitamin A supplements
„ Refer/do PCR to confirm infant’s HIV with best
available test
„ Assess the child’s feeding and provide
appropriate counselling to the mother
„ Refer for further assessment including HIV
care/ART
„ Confirm HIV infzection status of child as soon as
possible with best available test
„ Follow up in 14 days, then monthly for 3 months
and then every 3 months
HIV EXPOSED:
POSSIBLE HIV
INFECTION*
8
• Deep or extensive ulcers of
mouth or gums or
• Not able to eat
SEVERE GUM
OR MOUTH
INFECTION
„ Refer URGENTLY to hospital
„ If possible, give first dose acyclovir pre-referral.
„ Start metronidazole if referral not possible
„ If child is on antiretroviral therapy this may be a drug
reaction so refer to second level for assessment.
• Ulcers of mouth or gums
GUM OR
MOUTH
ULCERS
„ Show mother how to clean the ulcers with saline or
peroxide or sodium bicarbonate.
„ If lips or anterior gums involved, give acyclovir, if
possible. If not possible, refer.
„ If child receiving cotrimoxazole or antiretroviral drugs
or isoniazid (INH) prophylaxis (for TB) within the last
month, this may be a drug rash, especially of the child
also has a skin rash, so refer.
„ Provide pain relief.
„ Follow up in 7 days.
• No ulcers of the mouth or
gums
NO GUM OR
MOUTH
ULCERS
„ Treat, counsel and follow up existing infections.
„ Advise the mother about feeding and about her own
health.
MOUTH or
Classify GUM
CONDITIONS
ASSESS MOUTH AND GUM CONDITIONS
(FOR CHILDREN ON ART OR CLASSIFIED FOR HIV INFECTION)
Look
• Deep or extensive ulcers of mouth or
gums
• Ulcers of mouth or gums
9
ASSESS MOTHER’S OWN HEALTH
ASSESS OTHER PROBLEMS:
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments.
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
Same protocol for HIV-exposed and infected
children
ROUTINE WORM TREATMENT
Give every child mebendazole every 6 months
from the age of one year. Record the dose on
the child’s card.
Same protocol for HIV exposed and infected
children
Age VACCINE HIV-EXPOSED HIV-INFECTED
Birth BCG OPV-0 BCG* NO BCG
6 weeks DPT+HIB-1 OPV-1 Hep B1 Same Same
10 weeks DPT+HIB-2 OPV-2 Hep B2 Same Same
14 weeks DPT+HIB-3 OPV-3 Hep B3 Same Same
9 months Measles** Measles at 6 months Same***
Repeat at or after 9 months Same***
*BCG should NOT be given any time after birth to infants known to be HIV infected or born to HIV infected women and HIV status unknown but who have
signs or reported symptoms suggestive of HIV infection
** 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..
*** Measles vaccine is at 6 and 9 months but NOT if child is severely immunocompromised due to HIV infection.
IMMUNIZATION SCHEDULE: Follow national guidelines
10
ESTABLISH HIV INFECTION STATUS
Interpreting the HIV antibody test results in a child < 18 months of age
Test result HIV antibody test is positive HIV antibody test is negative
Not breastfeeding or not breastfed
in last 6 weeks
HIV exposed and /or HIV infected
Manage as if they could be infected.
Repeat test at 18 months
HIV negative
Child is not HIV infected
Breast feeding HIV exposed and /or HIV infected
Manage as if they could be infected.
Repeat test at 18 months or once
breastfeeding has been discontinued
for more than 6 weeks
Child can still be infected by
breastfeeding. Repeat test once
breastfeeding has been discontinued
for more than 6 weeks.
RECOMMEND HIV testing for:
• All children born to an HIV positive mother
• All sick children with symptomatic suspected HIV infection
• All children brought for child health service in a generalized epidemic setting
For children > 18 months, a positive HIV antibody test result means the child is infected.
For HIV exposed children <18 months of age,
• If PCR or other virological test is available, test from 6 weeks of age
¾ A positive result means the child is infected
¾ A negative result means the child is not infected, but could become infected if they are still breastfeeding
• If PCR or other virological test not available, use HIV antibody test.
¾ A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected.
¾ A negative test usually means the child is not infected.
1. The older the child is the more likely the HIV antibody is due to their own infection and not due to maternal antibody
2. Very exceptionally a very severely sick child who is HIV infected will have HIV antibody test results that are negative. If the
clinical picture strongly suggests HIV, then virological testing will be needed.
If PCR or other virological test is not available, use HIV antibody test.
If the child becomes sick, recommend HIV antibody test.
If the child remains well, recommend HIV antibody test at 9–12 months.
If child > 12 month has not yet been tested, recommend HIV antibody test.
11
WHO PAEDIATRIC CLINICAL STAGING OF HIV
Has the child been confirmed HIV Infected?
(If yes, perform clinical staging: any one condition in the highest staging determines stage. If no, you cannot stage the patient)
WHO Paediatric Clinical
Stage 1- Asymptomatic
WHO Paediatric Clinical
Stage 2 - Mild Disease
WHO Paediatric Clinical
Stage 3 - Moderate Disease
WHO Paediatric Clinical Stage 4 -
Severe Disease (AIDS)
Growth - -
Moderate unexplained malnutrition not
responding to standard therapy
Severe unexplained wasting or stunting or
Severe malnutrition not responding to standard
therapy
Symptoms/signs No symptoms or only:
• Persistent Generalized
Lymphadenopathy
(PGL)
¾ Unexplained persistent enlarged
liver and/or spleen
¾ Unexplained persistent enlarged
parotid
¾ Skin conditions (prurigo,
seborrhoeic dermatitis, extensive
molluscum contagiosum or warts,
fungal nail infections, herpes
zoster)
¾ Mouth conditions (recurrent mouth
ulcerations, angular chelitis, lineal
gingival Erythema)Recurrent or
chronic upper RTI (sinusitis, ear
infections, otorrhoea)
¾ Oral thrush (outside neonatal period)
¾ Oral hairy leukoplakia
¾ Unexplained and unresponsive to
standard therapy:
• Diarrhoea >14 days
• Fever >1 month
• Thrombocytopenia*
(<50,000/mm3 for > 1 month)
• Neutropenia* (<500/mm
3
for 1 month)
• Anaemia for >1 month (haemoglobin
< 8 g/dl)*
¾ Recurrent severe bacterial pneumonia
¾ Pulmonary TB
¾ TB lymphadenopathy
¾ Symptomatic LIP*
¾ Acute necrotizing ulcerative
gingivitis/periodontitis
¾ Chronic HIV associated lung disease
including bronchiectasis*
¾ Oesophageal thrush
¾ More than one month of herpes simplex
ulcerations
¾ Severe multiple or recurrent bacterial
infections >2 episodes in a year (not including
pneumonia)
¾ Pneumocystis pneumonia (PCP)*
¾ Kaposi sarcoma
¾ Extrapulmonary tuberculosis
¾ Toxoplasma*
¾ cryptococcal meningitis*
¾ Acquired HIV-associated rectal fistula
¾ HIV encephalopathy*
ARV Therapy Indicated :
ƒ All infants below 12 mo
irrespective of CD4
ƒ 12- 35 mo and CD4 < 20%
(or £ 750 cells)
ƒ 36-59 mo and CD4<20%
(or £ 350 cells)
ƒ 5 yrs and CD4 <15%
(<cells/mm3)
Indicated:
Same as stage 1
ART is indicated:
• Child is over 12 months—usually
regardless of CD4 but if LIP/TB/oral
hairy leukoplakia—ART
Initiation may be delayed if CD4 above age
related threshold for advanced or severe
immunodeficiency
ART is indicated:
Irrespective of the CD4 count, and should be
started as soon as possible
NB
1
If HIV infection is NOT confirmed in
infants<18 months, presumptive diagnosis of
severe HIV disease can be made on the basis
of: **
¾ HIV antibody positive
AND
¾ One of the following:
o AIDS defining condition OR
o Symptomatic with two or more of :
•Oral thrush
•Severe pneumonia
•Severe sepsis
12
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON
THE ASSESS AND CLASSIFY CHART
¾ Give Co-trimoxazole to Children with Confirmed or
Suspected HIV Infection or Children who are HIV
Exposed
¾ Co-trimoxazole should be given starting at 4- 6 weeks of age to :
• All infants born to mothers who are HIV infected until HIV is definitively
ruled out
• All infants with confirmed HIV infection aged <12 months or those with stage 2,3
or 4 disease or
• Asymptomatic infants or children (stage 1) if CD4 <25%.
¾ Give co-trimoxazole once daily.
CO-TRIMOXAZOLE dosage—single dose per day
Age 5 ml syrup
40 mg / 200 mg
Single strength paediatric
tablet 20 mg / 100 mg
Single strength adult
tablet 80 mg / 400 mg
Less than 6 months 2.5 ml 1/4 tablet 1 tablet
6 months up to 5 years 5 ml 1/2 tablet 2 tablets
5 - 14 years 10 ml 1 tablet 4 tablets
> 15 years NIL 2 tablets -
¾ FOR DYSENTERY GIVE CIPROFLOXACIN
15mg/kg/day—2 times a day for 3 days
Second-line antibiotic for dysentery ____________________
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug’s dosage table.
¾ Determine the appropriate drugs and dosage for the child’s age or
weight
¾ Tell the mother the reason for giving the drug to the child
¾ Demonstrate how to measure a dose
¾ Watch the mother practise measuring a dose by herself
¾ Ask the mother to give the first dose to her child
¾ Explain carefully how to give the drug, then label and package the drug.
If more than one drug will be given, collect, count and package each
drug separately
¾ Explain that all the tablets or syrup must be used to finish the course of
treatment, even if the child gets better
¾ Check the mother’s understanding before she leaves the clinic
¾ Give an Appropriate Oral Antibiotic
¾FOR PNEUMONIA, ACUTE EAR INFECTION:
FIRST-LINE ANTIBIOTIC: ____________________________________________________
SECOND-LINE ANTIBIOTIC: __________________________________________________________
*Amoxycillin should be used if there is high co-trimoxazole resistance.
¾ FOR CHOLERA:
First-line antibiotic for cholera _________________________________________
Second-line antibiotic 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 5 days
AMOXYCILLIN*
Give two times daily for
5 days
AGE or
WEIGHT
ADULT
TABLET
(80/400mg)
PAEDIATRIC
TABLET
(20/100 mg)
SYRUP
(40/200 mg/
5 ml)
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 1 /2 15 ml
TETRACYCLINE
Give 4 times daily for
3 days
ERYTHROMYCIN
Give 4 times daily for
3 days
AGE or WEIGHT TABLET 250 mg TABLET 250 mg
2 years up to 5 years
(10-19 kg)
1 1
13
TEACH THE MOTHER
TO GIVE ORAL DRUGS AT HOME
¾Give pain relief
¾ Safe doses of paracetamol can be slightly higher for pain. Use the table and teach mother to measure
the right dose
¾ Give paracetamol every 6 hours if pain persists
¾ Stage 2 pain is chronic severe pain as might happen in illnesses such as AIDS:
• Start treating Stage 2 pain with regular paracetamol
• In older children, ½ paracetamol tablet can replace 10 ml syrup
• If the pain is not controlled, add regular codeine 4 hourly
• For severe pain, morphine syrup can be given
WEIGHT AGE
(If you do not know the
weight)
PARACETAMOL
120mg/5ml
Add CODEINE
30mg tablet
ORAL MORPHINE
5mg/5ml
4 - <6kg 2 months up to 4months 2 ml 1/4 0.5ml
6 - <10 kg 4 months up to 12
months
2.5 ml 1/4 2ml
10 - <12 kg 12 months up to 2 years 5 ml 1/2 3ml
12 - <14 kg 2 years up to 3 years 7.5 ml 1/2 4ml
14 - 19 kg 3 to 5 years 10 ml 3/4 5ml
¾ 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.
¾ From salbutamol metered dose inhaler (100μg/puff) give 2 puffs.
¾ Repeat up to 3 times every 15 minutes before classifying pneumonia.
Spacers can be made in the following way:
¾ Use a 500ml drink bottle or similar.
¾ 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.
¾ Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper
quarter of the bottle.
¾ 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.
¾ Flame the edge of the cut bottle with a candle or a lighter to soften it.
¾ In a small baby, a mask can be made by making a similar hole in a plastic (not
polystyrene) cup.
¾ Alternatively commercial spacers can be used if available.
To use an inhaler with a spacer:
¾ Remove the inhaler cap. Shake the inhaler well.
¾ Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
¾ The child should put the opening of the bottle into his mouth and breath in and out
through the mouth.
¾ A carer then presses down the inhaler and sprays into the bottle while the child
continues to breath normally.
¾ Wait for three to four breaths and repeat for total of five sprays.
¾ 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.
¾ Give Iron
¾ Give one dose daily for 14 days
¾ Give Oral Co-artemether
¾ Give the first dose of co-artemether in the clinic and observe for one hour. If
child vomits within an hour repeat the dose. 2nd dose at home after 8 hours.
¾ Then twice daily for further two days as shown below:
¾ Co-artemether should be taken with food
Co-artemether tablets
(20mg artemether and 120 mg lumefantrine)
WEIGHT (age) 0h 8h 24h 36h 48h 60h
5-15kg (2 mo <3 years) 1 1 1 1 1 1
15-24kg (4-8 years) 2 2 2 2 2 2
25-34 kg (9-14 years) 3 3 3 3 3 3
>34 kg (>14 years) 4 4 4 4 4 4
AGE or WEIGHT IRON/FOLATE TABLET
Ferrous sulfate 200 mg +
250 μg 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) kg)
1.25 ml (1/4 tsp)
12 months up to 3 years (10 - <14
kg) 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)
14
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
¾ Clear the Ear by Dry Wicking and Give Eardrops*
¾ Do the following 3 times daily
• Roll clean absorbent cloth or soft, strong tissue paper into a wick
• Place the wick in the child’s ear
• Remove the wick when wet
• Replace the wick with a clean one and repeat these steps until the ear is dry
• Instil quinolone eardrops for two weeks
¾ Treat Mouth Ulcers with Gentian Violet (GV)
¾Treat for mouth ulcers twice daily
• Wash hands
• Wash the child’s mouth with a clean soft cloth wrapped around the finger
and wet with salt water
• Paint the mouth with 1/2 strength gentian violet (0.25% dilution)
• Wash hands again
• Continue using GV for 48 hours after the ulcers have been cured
• Give paracetamol for pain relief
·
¾ Soothe the Throat, Relieve the Cough with a Safe Remedy
¾ Safe remedies to recommend:
- Breast milk for a breastfed infant
_______________________________________________________
_______________________________________________________
¾Harmful remedies to discourage:
_______________________________________________________
________________________________________________________
¾ Treat for Thrush with Nystatin
¾Treat for thrush four times daily for 7 days
• Wash hands
• Wet a clean soft cloth with salt water and use it to wash the child’s mouth
• Instill nystatin 1ml four times a day
• Avoid feeding for 20 minutes after medication
• If breastfed check mother’s breasts for thrush. If present treat with nystatin
• Advise mother to wash breasts after feeds. If bottle fed advise change to
cup and spoon
• If severe, recurrent or pharyngeal thrush consider symptomatic HIV (p. 7)
• Give paracetamol if needed for pain (p.12)
¾ Explain to the mother what the treatment is and why it should be given
¾ Describe the treatment steps listed in the appropriate box
¾ Watch the mother as she gives the first treatment in the clinic (except for remedy for cough or sore throat)
¾ Tell her how often to do the treatment at home
¾ If needed for treatment at home, give mother a tube of tetracycline ointment or a small bottle of gentian violet or
nystatin
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin
eardrops
¾Treat Eye Infection with Tetracycline Eye
Ointment
¾ Clean both eyes 4 times daily.
• Wash hands.
• Use clean cloth and water to gently wipe away pus.
¾Then apply tetracycline eye ointment in both eyes 4 times daily.
• Squirt a small amount of ointment on the inside of the lower
lid.
• Wash hands again.
¾Treat until there is no pus discharge.
¾Do not put anything else in the eye.
15
GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC
¾ Explain to the mother why the drug is given
¾ Determine the dose appropriate for the child’s weight (or age)
¾ Measure the dose accurately
¾ Give Vitamin A
VITAMIN A SUPPLEMENTATION:
¾Give Vitamin A first dose any time after 6 months of age
¾Thereafter give vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
¾ Give an extra dose of Vitamin A (same dose) for treatment if the child has
MEASLES or PERSISTENT DIARRHOEA. If the child has had
a dose of Vitamin A within the past month, DO NOT GIVE.
¾ Always record the dose of Vitamin A given on the child’s chart
Age VITAMIN A DOSE
6 up to 12 months 100 000 IU
One year and older 200 000 IU
¾ Give Mebendazole
¾ 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
16
GIVE THESE TREATMENTS IN THE CLINIC ONLY
¾ Explain to the mother why the drug is given
¾ Determine the dose appropriate for the child’s weight (or age)
¾ Use a sterile needle and sterile syringe when giving an injection
¾ Measure the dose accurately
¾ Give the drug as an intramuscular injection
¾ If the child cannot be referred, follow the instructions provided
¾ Give An Intramuscular Antibiotic
¾ GIVE TO CHILDREN BEING REFERRED URGENTLY
¾ Give Ampicillin (50 mg/kg) and Gentamicin (7.5mg/kg)
¾Give Quinine for Severe Malaria
FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
¾ Check which quinine formulation is available in your clinic
¾ Give first dose of intramuscular quinine and refer child urgently to hospital
IF REFERRAL IS NOT POSSIBLE:
¾Give first dose of intramuscular quinine
¾The child should remain lying down for one hour
¾Repeat 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
¾If low risk of malaria, do not give quinine to a child less than 4 months of age
¾ Give Diazepam to Stop a Convulsion
¾ Turn the child to his/her side and clear the airway. Avoid putting things in the
mouth
¾ Give 0.5mg/kg diazepam injection solution per rectum using a small syringe
without a needle (like a tuberculin syringe) or using a catheter
¾ Check for low blood sugar, then treat or prevent
¾ Give oxygen and REFER
¾ If convulsions have not stopped after 10 minutes repeat diazepam dose
WEIGHT AGE
DOSE OF DIAZEPAM
(10mg/2mls)
< 5kg <6 months 0.5 ml
5 - < 10kg 6 - < 12 months 1.0 ml
10 - < 15kg 1 - < 3 years 1.5ml
15 - 19 kg 4 - < 5years 2.0 ml
AGE or WEIGHT INTRAMUSCULAR QUININE
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
AMPICILLIN
¾ Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml)
¾ Where there is a strong suspicion of meningitis the dose of ampicillin
can be increased 4 times
AGE WEIGHT
AMPICILLIN 500
mg vial
Gentamicin 2ml
vial with 40 mg/ml
2 up to 4 months 4 – <6kg 1 ml 0.5 - 1.0 ml*
4 up to 12 months 6 – <10kg 2 ml 1.1 - 1.8 ml
1 up to 3 years 10 – <15kg 3 ml 1.9 - 2.7 ml
3 up to 5 years 15 – 20kg 5 ml 2.8 - 3.5 ml
*quinine salt
¾ IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin
injection every 6 hours and gentamicin once per day
¾ * Lower value for lower range of age and weight
17
¾ Treat the Child to Prevent Low Blood Sugar
¾ If the child is able to breastfeed:
Ask the mother to breastfeed the child
¾ If the child is not able to breastfeed but is able to swallow:
• Give expressed breast milk or breast-milk substitute
• If neither of these is available give sugar water
• Give 30-50 ml of milk or sugar water before departure
To make sugar water: Dissolve 4 level teaspoons
of sugar (20 grams) in a 200-ml cup of clean water
¾ If the child is not able to swallow:
• Give 50ml of milk or sugar water by nasogastric tube
18
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See FOOD advice on COUNSEL THE MOTHER chart)
Plan A: Treat for Diarrhoea at Home
Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid 2. Give Zinc Supplements (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)
¾ TELL THE MOTHER:
• Breastfeed frequently and for longer at each feed
• If the child is exclusively breastfed, give ORS or clean water in addition to breast
milk
• If the child is not exclusively breastfed, give one or more of the following:
food-based fluids (such as soup, rice water, and yoghurt drinks), or ORS
It is especially important to give ORS at home when:
• the child has been treated with Plan B or Plan C during this visit
• the child cannot return to a clinic if the diarrhoea gets worse
¾TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2
PACKETS OF ORS TO USE AT HOME.
¾SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL
FLUID INTAKE:
Up to 2 years: 50 to 100 ml after each loose stool
2 years or more: 100 to 200 ml after each loose stool
Tell the mother to:
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes then continue - but more slowly
• Continue giving extra fluid until the diarrhoea stops
2. GIVE ZINC (age 2 months up to 5 years)
¾ 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
¾ SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
• Infants—dissolve tablet in a small amount of expressed breast milk, ORS or
clean water in a cup
• Older children - tablets can be chewed or dissolved in a small amount of clean
water in a cup
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6
months)
4. WHEN TO RETURN
Plan B: Treat for Some Dehydration with ORS
In the clinic, give recommended amount of ORS over 4-hour period
¾DETERMINE 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.
• If the child wants more ORS than shown, give more
• For infants below 6 months who are not breastfed, also give 100-200ml clean
water during this period

¾ SHOW THE MOTHER HOW TO GIVE ORS SOLUTION:
• Give frequent small sips from a cup
• If the child vomits, wait 10 minutes then continue - but more slowly
• Continue breastfeeding whenever the child wants
¾ AFTER 4 HOURS:
• Reassess the child and classify the child for dehydration
• Select the appropriate plan to continue treatment
• Begin feeding the child in clinic
¾ IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
• Show her how to prepare ORS solution at home
• Show her how much ORS to give to finish 4-hour treatment at home
• Give her instructions how to prepare salt and sugar solution for use at home
• 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 fluid
(ml) over 4 hours
200 - 450 450 - 800 800 - 960 960 - 1600
19
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See FOOD advice on COUNSEL THE MOTHER chart)
Plan C: Treat for Severe Dehydration Quickly
FOLLOW THE ARROWS. IF
ANSWER IS “YES”, GO ACROSS.
IF “NO”, GO DOWN
• 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), divided as follows:
• Reassess the child every 1- 2 hours. If hydration status is not improving, give the IV drip more
rapidly.
• Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4(infants) or
1-2 hours (children).
• Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose
the appropriate plan (A, B, or C) to continue treatment.
• Refer URGENTLY to hospital for IV treatment.
• If 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.
• Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours
(total of 120 ml/kg).
• Reassess the child every 1-2 hours while waiting for transfer:
- If there is repeated vomiting or abdominal distension, give the fluid more slowly.
- If the hydration status is not improving after 3 hours, send the child for IV therapy.
• After 6 hours reassess the child. Classify dehydration. Then choose the appropriate plan
(A, B, or C) to continue treatment.
NOTE:
• If 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 IV or
NG treatment
Can you give
intravenous (IV)
fluid immediately?
Can the child drink?
AGE First give 30ml/kg in: Then give 70ml/kg in
Infants
(under 12 months)
1 hour 5 hours
Children
(12 months up to 5 years)
30 minutes 2½ hours
NO
YES
YES
NO
NO
YES
NO
NO
IMMUNIZE EVERY SICK
CHILD, AS NEEDED
Is IV treatment
available nearby
(within 30 minutes)?
Are you trained to use
a naso-gastric (NG) tube
for rehydration?
20
GIVE FOLLOW-UP CARE
¾ Care for the child who returns for follow-up using all the boxes that match the child’s previous classification
¾ If the child has any new problems, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart
¾ PNEUMONIA
After 2 days:
Check the child for general danger signs.
Assess the child for cough or difficult breathing.
Ask:
- Is the child breathing slower?
- Is there less fever?
- Is the child eating better?
Assess for HIV infection
Treatment:
¾ If chest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular chloramphenicol. Then refer URGENTLY to hospital.
¾ If 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. (If this child had measles within the
last 3 months or is known or suspected to have Symptomatic HIV Infection, refer.)
¾ If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.
See ASSESS & CLASSIFY chart.
}
¾ DYSENTERY:

After 2 days:
Assess the child for diarrhoea > See ASSESS & CLASSIFY chart

Ask:
- Are there fewer stools?
- Is there less blood in the stool?
- Is there less fever?
- Is there less abdominal pain?
- Is the child eating better?
Treatment:
¾ If the child is dehydrated, treat for dehydration.
¾ If number of stools, blood in the stools, fever, abdominal pain, or eating
is worse or the same
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 you do not have the
second line antibiotic, refer to hospital.
Exceptions: if the child is less than 12 months old or was dehydrated on the
first visit, or if he had measles within the last 3 months, REFER TO
HOSPITAL.
¾ If fewer stools, less fever, less abdominal pain, and eating better,
continue giving ciprofloxacin until finished.
Ensure that the mother understands the oral rehydration method fully
and that she also understands the need for an extra meal each day for a
week.
¾ PERSISTENT DIARRHOEA
After 5 days:
Ask:
- Has the diarrhoea stopped?
- How many loose stools is the child having per day?
Assess for HIV infection
Treatment:
¾ If 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 including for assessment for ART.
¾ If 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.
21
GIVE FOLLOW-UP CARE
¾Care for the child who returns for follow-up using all the boxes
that match the child’s previous classification
¾If the child has any new problems, assess, classify and treat
the new problem as on the ASSESS AND CLASSIFY chart
¾ MALARIA (Low or High Malaria 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:
¾ If the child has any general danger sign or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE.
¾ If the child has any cause of fever other than malaria, provide treatment.
¾ If 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.
- If fever has been present for 7 days, refer for assessment.

¾FEVER-MALARIA UNLIKELY (Low Malaria 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:
¾ If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
¾ If the child has any cause of fever other than malaria, provide treatment.
¾ If 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.
- If fever has been present for 7 days, refer for assessment.

¾ 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:
¾ If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If
treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct
treatment.
¾ If the pus is gone but redness remains, continue the treatment.
¾ If no pus or redness, stop the treatment.
Treatment for Mouth Ulcers:
¾If mouth ulcers are worse, or there is a very foul smell coming from the mouth, refer to hospital.
¾If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days.
22
GIVE FOLLOW-UP CARE
¾ Care for the child who returns for follow-up using all the boxes that match the child’s previous classification
¾ If the child has any new problems, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart

¾ EAR INFECTION
After 5 days:
Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
Check for HIV infection.
Treatment:
¾ If there is tender swelling behind the ear or high fever (38.5°C or above), refer URGENTLY to
hospital.
¾ 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.
¾ Chronic ear infection: Check that the mother is wicking the ear correctly. Encourage her to continue.
¾ If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the
5 days of antibiotic, tell her to use all of it before stopping.

¾ 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.
¾ Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make
significant changes in feeding, ask her to bring the child back again.
¾ If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure
the child's weight gain.

¾ ANAEMIA
After 14 days:
¾ Give iron. Advise mother to return in 14 days for more iron.
¾ Continue giving iron every 14 days for 2 months.
¾ If the child has palmar pallor after 2 months, refer for assessment.

¾ 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.
Check for HIV infection.
Treatment:
¾ If the child is no longer very low weight for age, praise the mother and encourage
her to continue.
¾ If 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:
If you do not think that feeding will improve, or if the child has lost weight, refer the
child.
23
IF SUSPECTED SYMPTOMATIC HIV INFECTION
¾ Follow-up in 14 days, monthly or as per national guidelines.
¾ Do a full assessment – classify for common childhood illnesses, for malnutrition and
feeding, skin and mouth conditions and for HIV on each visit
¾ Check if diagnostic HIV test has been done and if not, test for HIV as soon as possible
¾ Assess feeding and check weight and weight gain
¾ Encourage breastfeeding - mothers to continue exclusive breastfeeding
¾ Advise on any new or continuing feeding problems
¾ Initiate or follow up co-trimoxazole prophylaxis according to national guidelines
¾ Give immunizations according to schedule. Do not give BCG
¾ Give Vitamin A according to schedule
¾ Provide pain relief if needed
¾ Refer for confirmation of HIV infection and ART, if not yet confirmed
———————————————————————————————————————————————————————————————————————————
IF CHILD IS CONFIRMED HIV INFECTED*
¾ Follow-up in 14 days, monthly or as per national guidelines.
¾ Continue co-trimoxazole prophylaxis
¾ Follow-up on feeding
¾ Home care:
• Counsel the mother about any new or continuing problems
• If appropriate, put the family in touch with organizations or people who could
provide support
• Explain the importance of early treatment of infections or refer
• Advise the mother about hygiene in the home, in particular when preparing food
¾ Reassess for eligibility for ART or REFER
¾ Check mother’s health and advise on safe sexual practices and family planning
GENERAL PRINCIPLES OF GOOD CHRONIC CARE FOR
HIV-INFECTED CHILDREN
¾ Develop a treatment partnership with the mother and infant or child
¾ Focus on the mother and child’s concerns and priorities
¾ Use the ‘5 As’ : Assess, Advise, Agree, Assist, Arrange to guide you the
steps on chronic care consultation. Use the 5As at every patient consultation
¾ Support the mother and child’s self-management
¾ Organize proactive follow-up
¾ Involve “expert patients”, peer educators and support staff in your health
facility
¾ Link the mother and child to community-based resources and support
¾ Use written information – registers, Treatment Plan and treatment cards - to
document, monitor and remind
¾ Work as a clinical team
¾ Assure continuity of care
IF POSSIBLE HIV INFECTION / HIV EXPOSED
¾ Follow-up in 14 days, monthly or as per national guidelines.
¾ Do a full re-assessment at each follow-up visit and reclassify for HIV on each
follow-up visit
¾ Counsel about feeding practices (page 25 in chart booklet and according to
the recommendations in Module 3)
¾ Follow co-trimoxazole prophylaxis as per national guidelines
¾ Follow national immunization schedule
¾ Follow Vitamin A supplements from 6 months of age every 6 months
¾ Monitor growth and development
¾ Virological Testing for HIV infection as early as possible from 6 weeks of age
¾ Refer for ARVs if infant develops severe signs suggestive of HIV
¾ Counsel the mother about her own HIV status and arrange counselling and
testing for her if required
* Any child with confirmed HIV infection should be enrolled in chronic HIV care, including
assessment for eligibility of ART – refer to subsequent sections of the chart booklet.
GIVE FOLLOW-UP CARE FOR THE CHILD WITH POSSIBLE HIV INFECTION /
HIV EXPOSED OR SUSPECTED SYMPTOMATIC OR CONFIRMED HIV INFECTION
IF CHILD CONFIRMED UNINFECTED
¾ Stop co-trimoxazole only if no longer breastfeeding and more than 12 months of age
¾ Counsel mother on preventing HIV infection and about her own health
———————————————————————————————————————————————————————————————————————————
IF HIV TESTING HAS NOT BEEN DONE
¾ Re-discuss the benefits of HIV testing
¾ Identify where and when HIV testing including virological testing can be done
¾ If mother consents arrange HIV testing and follow-up visit
———————————————————————————————————————————————————————————————————————————
IF MOTHER REFUSES TESTING
¾ Provide ongoing care for the child, including routine monthly follow-up
¾ Discuss and provide co-trimoxazole prophylaxis
¾ On subsequent visits, re-counsel the mother on preventing HIV and on benefits of HIV
testing
24
COUNSEL THE MOTHER

¾Assess the Feeding of Sick Infants under 2 years
(or if child has very low weight for age)
Ask questions about the child’s usual feeding and feeding during this illness. Note whether the mother is HIV infected, uninfected,
or does not know her status. Compare the mother’s answers to the Feeding Recommendations for the child’s age.





If infant is receiving replacement milk, ASK:
- What replacement milk are you giving?
- How many times during the day and night?
- How much is given at each feed?
- How is the milk prepared?
- How is the milk being given? Cup or bottle?
- How are you cleaning the utensils?
- If still breastfeeding as well as giving replacement milk
could the mother give extra breast milk instead of
replacement milk (especially if the baby is below 6
months)
ASK — How are you feeding your child?
If the infant is receiving any breast milk,
ASK:
- How many times during the day?
- Do you also breastfeed during the night?
Does the infant take any other food or fluids?
- What food or fluids?
- How many times per day?
- What do you use to feed the child?
If low weight for age, ASK:
- How large are servings?
- Does the child receive his own serving?
- Who feeds the child and how?
During this illness, has the infant’s feeding changed?

- If yes, how?
25
FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH
Feeding Recommendations for a child who has PERSISTENT DIARRHOEA
• If still breastfeeding, give more frequent, longer breastfeeds, day and night.
• If taking other milk:
- replace with increased breastfeeding OR
- replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food
• Breastfeed as often as the child
wants, day and night, at least
8times in 24 hours.
• Do not give other foods or fluids.
Up to 6Months
of Age
• Breastfeed as often as the child wants.
• Give adequate servings of:
___________________________
___________________________
___________________________
___________________________
- 3 times per day if breastfed plus
snacks
- 5 times per day if not breastfed.
6 Months up
to 12Months
• Breastfeed as often as the child
wants.
• Give adequate servings of:
__________________________
__________________________
__________________________
__________________________
or family foods 3 or 4 times per day
plus snacks.
12 Months up to
2Years
• Give family foods at 3 meals
each day. Also, twice daily, give
nutritious food between meals,
such as:
__________________________
__________________________
__________________________
__________________________
__________________________
2 Years
and Older
NOTE: These feeding recommendations should be followed for infants of HIV negative mothers.
Mothers who DO NOT KNOW their HIV status should be advised to breastfeed but also
to be HIV tested so that they can make an informed choice about feeding
26
¾ Feeding advice for the mother of a child
with CONFIRMED HIV INFECTION
¾ The child with confirmed HIV infection needs the benefits of breastfeeding and
should be encouraged to breastfeed. S/he is already HIV infected therefore
there is no reason for stopping breastfeeding or using replacement feeding.
¾ The child should be fed according to the feeding recommendations for his
age.
¾ Children with confirmed HIV infection often suffer from poor appetite and
mouth sores, give appropriate advice.
¾ If the child is being fed with a bottle encourage the mother to use a clean cup
as this is more hygienic and will reduce episodes of diarrhoea.
¾ Inform the mother about the importance of hygiene when preparing food
because her child can easily get sick. She should wash her hands after going
to the toilet and before preparing food. If the child is not gaining weight well,
the child can be given an extra meal each day and the mother can encourage
him to eat more by offering him snacks that he likes if these are available.
Advise her about her own nutrition and the importance of a well balanced diet to
keep herself healthy. Encourage her to plant vegetables to feed her family.
COUNSEL THE MOTHER
¾Counsel the mother about Stopping Breastfeeding (for HIV exposed)
¾ While you are breastfeeding, teach your infant to drink expressed breast milk from a cup. This milk may be heat-treated to destroy HIV.
¾ Once the infant is drinking comfortably, replace one breastfeed with one cup feed using expressed breast milk.
¾ Increase the number of cup-feeds every few days and reduce the number of breastfeeds. Ask an adult family member to help with cup feeding.
¾ Stop putting your infant to your breast completely as soon as your baby is accustomed to frequent cup feeding. From this point on it is best to
heat-treat your breast milk.
¾ If your infant is receiving milk only check that your baby has at least 6 wet nappies in a 24 hour period. This means he is getting enough milk.
¾ Gradually replace the expressed breast milk with commercial infant formula or another milk after 6 months.
¾ If your infant needs to suck, give him / her one of your clean fingers instead of the breast.
¾ To avoid breast engorgement (swelling) express a little milk whenever your breasts feel full. This will help you feel more comfortable. Use cold
compresses to reduce inflammation. Wear a firm bra to prevent discomfort.
¾ Do not begin breastfeeding again once you have stopped. If you do you can increase the chances of passing HIV to your infant. If your breasts
become engorged,express breast milk by hand.
¾ Begin using a family planning method of your choice, if you have not already done so, as soon as you start reducing breastfeeds.
“AFASS” CRITERIA FOR STOPPING
BREASTFEEDING for HIV exposed
Acceptable:
Mother perceives no problem in replacement feeding.
Feasible:
Mother has adequate time, knowledge, skills, resources, and support to
correctly mix formula or milk and feed the infant up to 12 times in 24 hours.
Affordable:
Mother and family, with community can pay the cost of replacement feeding
without harming the health and nutrition of the family.
Sustainable:
Availability of a continuous supply of all ingredients needed for safe replacement
feeding for up to one year of age or longer.
Safe:
Replacement foods are correctly and hygienically prepared and stored.
27
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:
¾ If the mother reports difficulty with breastfeeding, assess breastfeeding (see YOUNG INFANT chart).
As needed, show the mother correct positioning and attachment for breastfeeding.
¾ If the child is less than 6 months old and is taking other milk or foods*:
- Build mother's confidence that she can produce all the breast milk that the child needs.
- Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk 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 breast milk substitute.
- Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
- Finish prepared milk within an hour.
¾ 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.
¾ If the child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and for longer if possible.
- Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer
frequent small feeds.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.
¾ If the child has a poor appetite:
- Plan small, frequent meals.
- Give milk rather than other fluids except where there is diarrhoea with some dehydration.
- Give snacks between meals.
- Give high energy foods.
- Check regularly.
¾ If the child has sore mouth or ulcers:
- Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
- Avoid spicy, salty or acid foods.
- Chop foods finely.
- Give cold drinks or ice, if available.
* if child is HIV exposed, counsel the mother about the importance of not mixing breastfeeding with replacement feeding.
28
Breastfeed exclusively as often as the child
wants, day and night.
Feed at least 8 times in 24 hours.
Do not give other foods or fluids (mixed feeding
increases the risk of HIV transmission from mother
to child when compared with exclusive
breastfeeding).
Stop breastfeeding as soon as this is AFASS.
OR (if feasible and safe)
Formula feed exclusively (no breast milk at all)
Give formula. Other foods or fluids are not
necessary.
Prepare correct strength and amount just before
use. Use milk within two hours and discard any left
over (a fridge can store formula for 24 hours)
Cup feeding is safer than bottle feeding
Clean the cup and utensils with hot soapy water
Give these amounts of formula 6 to 8 times per day
* Exception: heat-treated breast milk can
be given

l
If still breast feeding, breastfeed as often
as the child wants
Give 3 adequate servings of nutritious
complementary foods plus one snack per
day (to include protein, mashed fruit and
vegetables).
Each meal should be 3/4 cup*. If possible,
give an additional animal-source food, such
as liver or meat
___________________________
___________________________
___________________________
If an infant is not breastfeeding, give
about 1-2 cups (500 ml) of full cream milk
or infant formula per day
Give milk with a cup, not a bottle
If no milk is available, give 4-5 feeds per
day
* one cup= 250 ml
Up to 6 months of age 6 up to 12 months
Stopping breastfeeding
means changing from all breast milk to no
breast milk (over a period of 2-3 days to 2-
3 weeks). Plan in advance to have a safe
transition.
Stop breastfeeding as soon as this is
AFASS (see page 27). This would usually
be at the age of 6 months but some
women may have to continue longer.
Help mother prepare for stopping
breastfeeding:
• Mother should discuss and plan in
advance stopping breastfeeding with
her family if possible
• Express milk and give by cup
• Find a regular supply of formula or
other milk, e.g. full cream cows milk
• Learn how to prepare and store milk
safely at home
Help mother make the transition:
• Teach mother to cup feed her baby
• Clean all utensils with soap and water
• Start giving only formula or cows milk
once the baby takes all feeds by cup
Stop breastfeeding completely:
• Express and discard enough breast
milk to keep comfortable until lactation
stops
Stopping
breastfeeding
Age months Amount and times per day
0 up to 1 60 ml x 8
1 up to 2 90 ml x 7
2 up to 3 120 ml x 6
3 up to 4 120 ml x 6
4 up to 5 150 ml x 6
5 up to 6 150 ml x 6
FEEDING RECOMMENDATIONS: Child classified as HIV exposed
• If still breastfeeding, breastfeed as
often as the child wants.
• Give adequate servings of:
__________________________
__________________________
__________________________
__________________________
or family foods 5 times per day.
If breastfed, give adequate servings 3
times per day plus snacks
If an infant is not breastfeeding, give
about 1-2 cups* (500 ml) of full cream
milk or infant formula per day
Give milk with a cup, not a bottle
If no milk is available, give 4-5 feeds
per day
* one cup = 250 ml
12 months up to
2 years
29

COUNSEL THE MOTHER ABOUT HER OWN HEALTH

¾ If the mother is sick, provide care for her, or refer her for help.
¾ If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her
for help.
¾ Advise her to eat well to keep up her own strength and health.
¾ Check the mother's immunization status and give her tetanus toxoid if needed.
¾ Make sure she has access to:
• Family planning
• Counselling on STD and AIDS prevention.
¾Encourage every mother to be sure to know her own HIV status and to seek HIV testing if she does not know
her status or is concerned about the possibility of HIV in herself or her family.
30
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.
If the child has: Return for first follow-up in:
• PNEUMONIA
• DYSENTERY
• MALARIA, if fever persists
• FEVER-MALARIA UNLIKELY, if fever persists
• MEASLES WITH EYE OR MOUTH COMPLICATIONS
2 days
• PERSISTENT DIARRHOEA
• ACUTE EAR INFECTION
• CHRONIC EAR INFECTION
• FEEDING PROBLEM
• COUGH OR COLD, if not improving
5 days
• ANY OTHER ILLNESS, if not improving
• ANAEMIA
• CONFIRMED HIV INFECTION
• SUSPECTED SYMPTOMATIC HIV INFECTION
• HIV EXPOSED/ POSSIBLE HIV
14 days
• VERY LOW WEIGHT FOR AGE 30 days
Advise mother to return immediately if the child has any of these signs:
Any sick child • Not able to drink or breastfeed
• Becomes sicker
• Develops a fever
If child has NO PNEUMONIA:
COUGH OR COLD, also return if:
• Fast breathing
• Difficult breathing
If child has Diarrhoea, also return if: • Blood in stool
• Drinking poorly
Advise the Mother to Increase Fluid During Illness
FOR ANY SICK CHILD:
¾ If child is breastfed, breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount
of milk given
¾ Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.
FOR CHILD WITH DIARRHOEA:
¾ 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
31
CHECK FOR VERY SEVERE DISEASE AND
LOCAL INFECTION

¾ Give an appropriate oral antibiotic.
¾Teach mother to treat local infections at
home.
¾Advise mother to give home care
for the young infant.
¾Follow up in 2 days.
VERY
SEVERE
DISEASE

• Umbilicus red or draining pus
• Skin pustules
LOCAL
BACTERIAL
INFECTION
• None of the signs of very severe disease
or local bacterial infection
SEVERE DISEASE
OR LOCAL
INFECTION
UNLIKELY
¾ Advise mother to give home care for
the young infant.

¾ Give first dose of intramuscular
antibiotics.
¾ Treat to prevent low blood sugar.
¾Refer URGENTLY to hospital.**

¾Advise mother how to keep the infant
warm on the way to the hospital.
Any one of the following signs
• Not feeding well or
• Convulsions or
• Fast breathing (60 breaths per minute or
more) or
• Severe chest indrawing or
• Fever (37.5°C* or above) or
• Low body temperature (less than 35.5°C*)
or
• 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
• 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
TREATMENT
(Urgent pre-referral treatments are in bold print)
Classify
ALL
YOUNG
INFANTS
LOOK AND FEEL:
• Count the breaths in one minute.
Repeat the count if 60 or more
breaths per minute.
• Look for severe chest indrawing.

• Measure axillary temperature.

• Look at the umbilicus. Is it red or draining pus?

• Look for skin pustules.
• Look at the young infant's movements. If infant is
sleeping, ask the mother to wake him/her.
- Does the infant 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:
• Is the infant having
difficulty in feeding?
•Has the infant had
convulsions (fits)?
YOUNG
INFANT
MUST
BE
CALM
}
* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5°C 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”
32
THEN CHECK FOR JAUNDICE
ASK:
• When did jaundice first
appear?
LOOK AND FEEL:
• Look for jaundice (yellow eyes or
skin).
• Look at the young infant's palms
and soles. Are they yellow?
Classify
Jaundice

• Any jaundice if age less than 24
hours or
• Yellow palms and soles at any age
SEVERE
JAUNDICE

¾ Treat to prevent low blood sugar.
¾Refer URGENTLY to hospital.
¾Advise mother how to keep the infant warm
on the way to the hospital.

• Jaundice appearing after 24 hours of
age and
• Palms and soles not yellow
JAUNDICE

¾ Advise the mother to give home care for the
young infant

¾ Advise mother to return immediately if palms
and soles appear yellow.

¾ If the young infant is older than 3 weeks, refer
to a hospital for assessment.
¾ Follow-up in 1 day.
• No jaundice NO
JAUNDICE

¾ Advise the mother to give home care for the
young infant.

SIGNS
CLASSIFY AS
TREATMENT
(Urgent pre-referral treatments are in bold print)
33
THEN ASK: Does the young infant have diarrhoea*?
Classify
DIARRHOEA
FOR
DEHYDRATION
¾ If infant has no other severe classification:
- Give fluid for severe dehydration (Plan).
OR
¾If infant also has another severe
classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
- Advise mother to continue breastfeeding.
¾ Give fluid and breast milk for some
dehydration (Plan B).
OR
¾ If infant also has another severe
classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
- Advise mother to continue breastfeeding.
¾ Advise mother when to return immediately

¾Follow-up in 2 days if not improving
¾ Give fluids and breast milk to treat for
diarrhoea at home (Plan A)
¾ Advise mother when to return immediately
¾ Follow up in 2 days if not improving
Two of the following signs:
• Movement only when
stimulated or no movement
at all
• Sunken eyes
• Skin pinch goes back very
slowly.
SEVERE
DEHYDRATION
Two of the following signs:
• Restless, irritable
• Sunken eyes
• Skin pinch goes back
slowly.
SOME
DEHYDRATION

• 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:
• Look at the young infant's general condition:
- Infant’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 ?
- Is the infant restless and irritable?

• Look for sunken eyes.
• Pinch the skin of the abdomen.
Does it go back:
- Very slowly (longer than 2 seconds)?
- or slowly?
SIGNS
CLASSIFY AS
TREATMENT
(Urgent pre-referral treatments are in bold print)
34
THEN CHECK THE YOUNG INFANT FOR HIV INFECTION


ASK:
Has the mother or the
infant had an HIV test?
What was the result?
Classify
by test
result
¾ Give cotimoxazole prophylaxis from age
4-6 weeks
¾ Assess the child’s feeding and counsel as
necessary
¾ Refer for staging and assessment for ART
¾ Advise the mother on home care
¾ Follow-up in 14 days
¾ Give co-trimoxazole prophylaxis from age
4-6 weeks
¾ Assess the child’s feeding and give
appropriate feeding advice
¾ Refer/ do virological test to confirm infant’s
HIV status at least 6 weeks after
breastfeeding has stopped
¾ Consider presumptive severe HIV disease
¾ Follow-up in one month
• Child has positive
virological test
CONFIRMED HIV
INFECTION
One or both of the following
conditions:
• Mother HIV positive
• Child has positive HIV
antibody test (sero-
positive)
POSSIBLE HIV INFECTION/
HIV EXPOSED
Negative HIV test for
mother or child
HIV INFECTION UNLIKELY
¾ Treat, counsel and follow-up existing
infections
¾ Advise the mother about feeding and
about her own health
SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)
35
THEN CHECK FOR FEEDING PROBLEM OR
LOW WEIGHT FOR AGE IN BREASTFED INFANTS*
SIGNS
CLASSIFY AS
TREATMENT
(Urgent pre-referral treatments are in bold print)
Classify
FEEDING
• Not well attached to
breast or
• Not suckling effectively,
or
• Less than 8 breastfeeds
in 24hours, or
• Receives other foods or
drinks, or
• Low weight for age, or
• Thrush (ulcers or white
patches in mouth)
FEEDING
PROBLEM
OR
LOW WEIGHT
FOR AGE
¾ If not well attached or not suckling
effectively, teach correct positioning and
attachment.
• If not able to attach well immediately,
teach the mother to express breast milk
and feed by a cup
¾ If 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.
¾ If receiving other foods or drinks, counsel
mother about breastfeeding more,
reducing other foods or drinks, and using
a cup.
• If not breastfeeding at all:
- Refer for breastfeeding counselling
and possible relactation.
- Advise about correctly preparing
breast-milk substitutes and using a
cup.
¾ Advise the mother how to feed and keep
the low weight infant warm at home
¾ If thrush, teach the mother to treat thrush
at home.
¾ Advise mother to give home care for the
young infant.
¾ Follow up any feeding problem or thrush in
2days.
¾ Follow-up low weight for age in 14 days.
• Not low weight for age
and no other signs of
inadequate feeding.
NO FEEDING
PROBLEM
¾ Advise mother to give home care for
the young infant.
¾Praise the mother for feeding the
infant well.
ASK:
• Is the infant breastfed? If yes,
how many times in 24 hours?

• Does the infant usually receive
any other foods or drinks?
If yes, how often?
• If yes, what do you use to feed the infant?
LOOK AND FEEL:
• Determine weight for age.
• Look for ulcers or white patches in the
mouth (thrush).
• Has the infant breastfed in
the previous hour?
If the infant has not fed in the previous hour, ask the mother
to put her infant to the breast. Observe the breastfeed for
4minutes.
(If the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)
• Is the infant well attached?
not well attached good attachment
ASSESS BREASTFEEDING:




• Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
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 urgently to hospital
36
THEN CHECK FOR FEEDING PROBLEM OR
LOW WEIGHT FOR AGE IN INFANTS RECEIVING NO BREAST MILK
(use this chart when an HIV positive mother has chosen not to breastfeed)
ASK:
• What milk are you giving?
• How many times during the day and
night?
• How much is given at each feed?
• How are you preparing the milk?
− Let mother demonstrate or
explain how a feed is
prepared, and how it is given
to the infant.
• Are you giving any breast milk at
all?
• What foods and fluids in addition to
replacement feeds is given?
• How is the milk being given?
Cup or bottle?
• How are you cleaning the feeding
utensils?
LOOK, LISTEN, FEEL:
• Determine the weight for age.
• Look for ulcers or white patches in
the mouth (thrush).
• Milk incorrectly or
unhygienically prepared
Or
• Giving inappropriate
replacement feeds
Or
• Giving insufficient
replacement feeds
Or
• An HIV positive mother
mixing breast and other
feeds before 6 months
Or
• Using a feeding bottle
Or
• Thrush
Or
• Low weight for age
¾ Counsel about feeding
¾ Explain the guidelines for safe
replacement feeding
¾ Identify concerns of mother and family
about feeding.
¾ If mother is using a bottle, teach cup
feeding
¾ If thrush, teach the mother to treat it
at home
¾ Follow-up FEEDING PROBLEM or
THRUSH in 2 days
¾ Follow up LOW WEIGHT FOR AGE
in 7 days
• Not low weight for age
and no other signs of
inadequate feeding
FEEDING
PROBLEM
OR
LOW WEIGHT
FOR AGE
NO FEEDING
PROBLEM
¾ Advise mother to continue feeding, and
ensure good hygiene
¾Praise the mother for feeding the infant
well
Classify
FEEDING
SIGNS CLASSIFY AS
TREATMENT
(Urgent pre-referral treatments are in bold
i t)
37
THEN CHECK THE YOUNG INFANT’S IMMUNIZATION AND VITAMIN A STATUS:
¾ Give all missed doses on this visit.
¾ Immunize sick infants unless being referred.
¾ Advise the caretaker when to return for the next dose.
ASSESS OTHER PROBLEMS
IMMUNIZATION
SCHEDULE:
AGE
Birth
6 weeks
10 weeks
VACCINE VITAMIN A
BCG OPV-0 200 000 IU to the mother within 6 weeks of delivery
DPT+HIB-1 OPV-1 Hepatitis 1
DPT+HIB-2 OPV-2 Hepatitis 2
38
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
¾Give First Dose of Intramuscular Antibiotics
¾Give first dose of ampicillin intramuscularly and
¾Give first dose of Gentamicin intramuscularly.
*Avoid using undiluted 40 mg/ml gentamicin.

¾Referral is the best option for a young infant classified as VERY SEVERE DISEASE. If 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.
GENTAMICIN WEIGHT AMPICILLIN
Dose: 50 mg per kg
To a vial of 250 mg
Add 1.3 ml sterile water =
250 mg/1.5 ml
Undiluted 2 ml vial containing 20 mg= 2 ml at 10 mg/ml OR
Add 6 ml sterile water to 2 ml vial containing
80 mg* = 8 ml at 10 mg/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*
¾Treat the Young Infant to Prevent Low Blood Sugar
¾If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
¾If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breastmilk before departure. If not possible to give expressed breastmilk, 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).
¾If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric tube.
39
TREAT THE YOUNG INFANT
¾ Teach the Mother How to Keep the Young Infant Warm on the Way to the Hospital
¾ Provide skin to skin contact, OR
¾ 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.
¾Give 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)
¾ Give two times daily for 5 days
AMOXICILLIN
¾ 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
40
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

¾To Treat Diarrhoea, See TREAT THE CHILD CHART.

¾ Immunize Every Sick Young Infant, as needed.
¾ Teach the Mother How to Treat Local Infections at Home
¾ Explain how the treatment is given.
¾ Watch her as she does the first treatment in the clinic.
¾ Tell her to return to the clinic if the infection worsens.
To Treat Skin Pustules or Umbilical Infection
The mother should do the treatment twice daily for 5 days:

¾Wash hands
¾Gently wash off pus and crusts with soap and water

¾Dry the area

¾ Paint the skin or umbilicus/cord with full strength gentian
violet (0.5%)

¾Wash hands again
To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment 4 times daily for 7 days:

¾ Wash hands

¾ Paint the mouth with half-strength gentian violet (0.25%) using a
clean soft cloth wrapped around the finger

¾ Wash hands again
41
COUNSEL THE MOTHER
¾ Teach Correct Positioning and Attachment for Breastfeeding
¾ 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.
¾ 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.
¾ Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.
¾ Teach the Mother How to Express Breast Milk
Ask the mother to:
¾ Wash her hands thoroughly.
¾ Make herself comfortable.
¾ Hold a wide necked container under her nipple and areola.
¾ 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).
¾ Compress and release the breast tissue between her finger and thumb a few times.
¾ If 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.
¾ 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.
¾ Express one breast until the milk just drips, then express the other breast until the milk just drips.
¾ Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
¾ Stop expressing when the milk no longer flows but drips from the start.
42
COUNSEL THE MOTHER
Wash your hands before preparing the formula.
Make ____ ml for each feed. Feed the baby ____
times every 24 hours.
Always use the marked cup or glass to measure
water and the scoop to measure the formula
powder. Your baby needs ______ scoops.
Measure the exact amount of powder that you will
need for one feed.
Boil enough water vigorously for 1 or 2 seconds.
Add the hot water to the powdered formula. The
water should be added while it is still hot and not
after it has cooled down. Stir well.
Only make enough formula for one feed at a time.
Do not keep milk in a thermos flask because it will
become contaminated quickly.
Feed the baby using a cup. Discard any unused
formula, give it to an older child or drink it yourself.
Wash the utensils.
Come back to see me on _____.
HOW TO PREPARE COMMERCIAL FORMULA MILK
¾ Counsel the HIV-positive mother who has chosen
not to breastfeed (or the caretaker of a child who
cannot be breastfed)
The mother or caretaker should have received full counselling
before making this decision
¾ Ensure that the mother or caretaker has an adequate supply of
appropriate breast milk substitute replacement feed.
¾ Ensure that the mother or caretaker knows how to prepare milk correctly
and hygienically and has the facilities and resources to do so.
¾ Demonstrate how to feed with a cup and spoon rather than a bottle.
¾ Make sure that the mother or caretaker understands that prepared feed
must be finished within an hour after preparation.
¾ Make sure that the mother or caretaker understands that mixing
breastfeeding with replacement feeding may increase the risk of HIV
infection and should not be done.
¾ Teach the Mother How to Feed by a Cup
¾Put a cloth on the infant’s front to protect his clothes as some milk can spill
¾Hold the infant semi-upright on the lap.
¾Put a measured amount of milk in the cup.
¾Hold the cup so that it rests lightly on the infant’s lower lip.
¾Tip the cup so that the milk just reaches the infant’s lips.
¾Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
43
COUNSEL THE MOTHER
¾ 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 25°C) 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:
¾ Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
¾ 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
¾ 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. If cold, re-warm the baby using skin to skin contact.
- Breastfeed (or give expressed breast milk by cup) the infant frequently
44
COUNSEL THE MOTHER
¾ Advise the Mother to Give Home Care for the Young Infant

Advise the caretaker to return immediately if
the young infant has any of these signs:
¾ Breastfeeding poorly
¾ Reduced activity
¾ Becomes sicker
¾ Develops a fever
¾ Feels unusually cold
¾ Fast breathing
¾ Difficult breathing
¾ 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,
day or night, during sickness and health.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT
ALL TIMES
In cool weather cover the infant’s head and feet and dress the
infant with extra clothing.
3. WHEN TO RETURN:
WHEN TO RETURN IMMEDIATELY:
Follow up visit
If the infant has: Return for first follow-up in:
• JAUNDICE 1 day
• LOCAL BACTERIAL INFECTION
• FEEDING PROBLEM
• THRUSH
• DIARRHOEA
2 days
• LOW WEIGHT FOR AGE 14 days
• CONFIRMED HIV INFECTION or
POSSIBLE HIV INFECTION/HIV
EXPOSED
14 days
45
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
¾ LOCAL BACTERIAL INFECTION
After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.

Treatment:
¾ If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days
of antibiotic and continue treating the local infection at home.
¾ If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
¾DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped ?
Treatment:
¾If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE “Does the Young Infant Have Diarrhoea ?”
¾ If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
ASSESS EVERY YOUNG INFANT FOR “VERY SEVERE DISEASE” DURING FOLLOW UP VISIT.
¾JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?
¾If palms and soles are yellow, refer to hospital.
¾If 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.
¾ If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 3 weeks of age. If jaundice
continues beyond three weeks of age , refer the young infant to a hospital for further assessment.
46
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
¾ POSSIBLE HIV/HIV EXPOSED
¾ Follow-up after 14 days and then monthly or according to immunization programme.
¾ Counsel about feeding practices. Avoid giving both breast milk and formula milk (mixed feeding).
¾ Start co-trimoxazole prophylaxis at 4-6 weeks, if not started already and check compliance.
¾ Test for HIV infection as early as possible, if not already done so.
¾ Refer for ART if presumptive severe HIV infection as per definition above.
¾ Counsel the mother about her HIV status and arrange counselling and testing for her if required.
¾ 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.
¾Counsel 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.
¾ If 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:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to HOSPITAL.
47
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
¾ LOW WEIGHT FOR AGE
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.
¾ If the infant is no longer low weight for age, praise the mother and encourage her to continue.
¾ If 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.
¾ If 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:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
¾ 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.
¾ If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital.
¾ If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 7 days.
48
49
50
SIGNS CLASSIFY AS TREATMENT
Unique features in HIV
Itching rash with small
papules and scratch marks.
Dark spots with pale centres
PAPULAR
ITCHING RASH
(PRURIGO)
Treat itching:
- calamine lotion
- Antihistamine by mouth
- If not improved, 1%
hydrocortisone
Can be an early sign of HIV
and needs assessment for HIV
Is a Clinical stage 2
defining disease
An itchy circular lesion with
a raised edge and fine scaly
area in centre with loss of
hair. May also be found on
body or web of feet.
RINGWORM
(TINEA)
- Whitfield’s ointment or other
anti-fungal cream if few
patches
- If extensive Refer, if not give:
ketoconazole for 2 up to
12(6-10 kg) 40 mg per day.
For 12 up to 5give 60 mg per
day . Or give griseofulvin 10
mg/kg/day.
- If in hairline, shave hair
- Treat itching as above
Extensive : There is a high
incidence of coexisting nail
infection which has to be treated
adequately, to prevent recurrences of
tinea infection of skin
Fungal nail infection is a Clinical
stage 2 defining disease
Rash and excoriations on
torso; burrows in web space
and wrist. Face spared.
SCABIES
- Treat itching as above
- Manage with anti-scabies:
- 25% topical benzyl benzoate
at night , repeat for 3 days
after washing
- 1% topical lindane cream or
lotion once– wash off after 12
hours
In HIV positive individuals
scabies may manifest as crusted scabies.
Crusted scabies presents as
extensive areas of crusting mainly on
the scalp face, back, and feet. Patients
may not complain of itch but the scales
will be teeming with mites.
ANNEX A: SKIN AND MOUTH CONDITIONS*
Identify skin problem if skin is itching
* IMAI acute care module gives more information
51
Identify skin problem if skin has blisters / sores / pustules
SIGNS
CLASSIFY AS TREATMENT
Unique features in HIV
Vesicles over body. Vesicles
appear progressively over days
and form scabs after they rupture
Chicken pox Treat itching as aboveRefer
URGENTLY if pneumonia
orjaundice appear
Presentation atypical only if child is immunocompromised
Duration of disease longer
Complications more frequent
Chronic infection with continued appearance of new lesions for
>1 month; typical vesicles evolve into non-healing ulcers that
become necrotic, crusted, and hyperkeratotic.
Vesicles in one area on one side
of body with intense pain or
scars plus shooting pain.
Herpes zoster is uncommon in
children except where they are
immuno-compromised, for
example if infected with HIV
HERPES ZOSTER Keep lesions clean and dry. Use
local antiseptic
If eye involved give acyclovir– 20
mg /kg (max 800 mg) 4 times
daily for 5 days
Give pain relief
Follow-up in 7 days
Duration of disease longer
Hemorrhagic vesicles, necrotic ulceration
Rarely recurrent, disseminated or multidermatomal
Is a Clinical stage 2 defining disease
Vesicular lesion or sores, also
involving lips and / or mouth
HERPES SIMPLEX If child unable to feed, refer
If first episode or severe ulceration,
give acyclovir as above
Extensive area of involvement
Large ulcers
Delayed healing (often greater than a month)
Resistance to Acyclovir common. Therefore continue treatment
till complete healing of ulcer
Chronic HSV infection (>1) is a Clinical stage 4 defining
disease
Red, tender, warm crusts or
small lesions
IMPETIGO OR
FOLLICULITIS
Clean sores with antiseptic
Drain pus if fluctuant
Start cloxacillin if size >4cm or red
streaks or tender nodes or multiple
abscesses for 5 days ( 25-50 mg/kg
every 6 hours)
Refer URGENTLY if child has
fever and /or if infection extends to
the muscle
ANNEX A cont/d
52
Presenting signs & symptoms Classify Management & treatment Unique features in HIV
Skin colored pearly white papules
with a central umblication.
It is most commonly seen on the
face and trunk in children.
Molluscum
contagiosum
can be treated by various modalities:
Leave them alone unless
superinfected
Use of phenol: pricking each lesion
with a needle or sharpened orange
stick and dabbing the lesion with
phenol
Electrodesiccaton
Liquid nitrogen application (using
orange stick)Curettage
Incidence is higher
Giant molluscum (>1cm in
size), or coalescent double or
triple lesions may be seen
More than 100 lesions may be
seen.
Lesions often chronic and
difficult to eradicate
Extensive molluscum
contagiosum is a Clinical
stage 2 defining disease
The common wart appears as
papules or nodules with a rough
(verrucous) surface.
Warts Treatment:
Topical salicylic acid preparations
(eg. Duofilm).
Liquid nitrogen cryotherapy.
Electrocautery
Lesions more numerous and
recalcitrant to therapy.
Extensive viral warts is a
Clinical stage 2 defining
disease
Greasy scales and redness on
central face, body folds
Sebbhorrea Ketoconazole shampooIf severe, refer
or provide tropical steroids.For
seborrheic dermatitis: 1%
hyrdocortison cream X2 daily. If
severe, refer.
Seborrheic dermatitis may be
severe in HIV infection.
Secondary infection may be
common
IDENTIFY PAPULAR LESIONS: NON-ITCHY
ANNEX A cont/d
53
PRESENTING SIGNS CLASSIFY TREATMENTS
Not able to swallow SEVERE
OESOPHAGEAL
THRUSH
Refer URGENTLY to hospital. If not able to refer, give fluconazole.
If mother is breastfeeding check and treat the mother for breast thrush.
( Stage 4 disease)
Pain or difficulty swallowing OESOPHAGEAL
THRUSH
Give fluconazole.
Give oral care to young infant or child.
If mother is breastfeeding check and treat the mother for breast thrush.
Follow up in 2 days.
Tell the mother when to come back immediately.
Once stabilized, refer for ART initiation
( Stage 4 disease)
White patches in mouth, which
can be scraped off.
ORAL THRUSH Counsel the mother on home care for oral thrush. The mother should:
Wash her hands
Wash the young infant / child’s mouth with a soft clean cloth wrapped around her finger and wet with
salt water
Instill 1ml nystatin four times per day or paint the mouth with half strength gentian violet for 7 days
Wash her hands after providing treatment for the young infant or child
Avoid feeding for 20 minutes after medication
If breastfed, check mother’s breasts for thrush. If present (dry, shiny scales on nipple and areola), treat
with nystatin or GV
Advise the mother to wash breasts after feeds. If bottle fed, advise to change to cup and spoon
If severe, recurrent or pharyngeal thrush, consider symptomatic HIV
Give paracetamol if needed for pain
( Stage 3 disease)
Most frequently seen on the sides
of the tongue, a white plaque with
a corrugated appearance.
ORAL HAIRY
LEUCOPLAKIA
Does not independently require treatment, but resolve with ART and Acyclovir
( Stage 2 disease)
ANNEX A: ASSESS, CLASSIFY AND TREAT SKIN AND MOUTH
Mouth problems : Thrush
54
Pictures Signs CLASSIFY Treatment Unique features in HIV
Generalized red, widespread
with small bumps or blisters;
or one or more dark skin
areas (fixed drug reactions)
Fixed drug reactions Stop medications
Give oral antihistamines
If peeling rash refer
Could be a sign of reaction
to ARV’s
Wet, oozing sores or
excoriated, thick patches
ECZEMA Soak sores with clean water
to remove crusts (no soap)
Dry skin gently
Short-term use of topical
steroid cream not on face.
Treat itching
-
Severe reaction due to co-
trimoxazole or NVP
involving the skin as well as
the eyes and/mouth. Might
cause difficulty breathing
Steven-Johnson
syndrome
Stop medication
Refer Urgently
The most lethal reaction to
NVP, co-trimoxazole or
even efafirenz.
ANNEX A: ASSESS, CLASSIFY AND TREAT SKIN AND MOUTH CONDITIONS
DRUG /ALLERGIC REACTIONS
55
ANNEX B: PAEDIATRIC ART and dosages
RECOMMENDED FIRST LINE ARV REGIMENS FOR CHILDREN
The following regimens are recommended by WHO as first line ART for children. The choice of regimen at the country level will be determined by the
National ART guidelines.
AZT or d4T + 3TC + NVP or EFV1 :
AZT + 3TC + NVP
AZT + 3TC + EFV
d4T + 3TC + NVP
d4T + 3TC + EFV
ABC +3TC + NVP or EFV1:
ABC + 3TC + NVP
ABC + 3TC + EFV
* If <3 years or <10 kg, use NVP. EFV cannot be used in these children.
Nucleoside reverse
transcriptase
inhibitors (NsRTI)
Nucleotide
reverse
transcriptase
inhibitors
(NtRTI)
Non-nucleoside
reverse
transcriptase
inhibitors
(NNRTI)
Protease Inhibitors
(PI)
Stavudine (d4T)
lamivudine (3TC)
zidovudine
(ZDV/AZT)
didanosine (ddI)
abacavir (ABC)
tenofovir
disoproxil
fumarate
(TDF)
nevirapine (NVP)
efavirenz (EFV)
lopinavir (LPV)
saquinavir (SQV)
indinavir (IDV)
nelfinavir (NFV)
retonavir (RTV)*
COMMONLY USED ANTIRETROVIRAL DRUGS
POPULATION
Up to 12 months 1- 4 years > 5 years
START ART
PMTCT/NVP
exposure :
PI-regimen
NVP/EFV
+
2NRTI
NVP/EFV
+
2NRTI
*ritonavir is used as a ‘helper’ for one PI to make the effect of a
second PI stronger
56


ANNEX B: ARV DOSAGES
57
IMPORTANT POINTS TO REMEMBER ON ARV DOSAGES:
Lamivudine (3TC) - Give 4 mg/kg per dose twice daily
Weight Syrup 10 mg/ml 30 mg tablet 150 mg tablet
3-3.9 3 ml 1
4-5.9 3 ml 1
6-9.9 4 ml 1.5
10-13.9 6 ml 2
14-19.9 2.5 0.5
20-24.9
or
3
or
0.75
Zidovudine (AZT or ZDV) - Give 180-240 mg/m
2
per dose twice daily
Weight Syrup 10 mg/ml 30 mg tablet 150 mg tablet
3-3.9 6 ml 1
4-5.9 6 ml 1
6-9.9 9 ml 1.5
10-13.9 12 ml 2
14-19.9 2.5
20-24.9
or
3
or
Abacavir (ABC) - Give 8 mg/per dose twice daily
Weight Syrup 20 mg/ml 60 mg tablet 300 mg tablet
3-3.9 3 ml 1
4-5.9 3 ml 1
6-9.9 4 ml 1.5
10-13.9 6 ml 2
14-19.9 2.5 0.5
20-24.9
or
3
or
0.75
Stavudine (d4T) - Give 1 mg/kg per dose twice daily
Weight Syrup 10 mg/ml 6 mg tablet 15 mg tablet 20 mg tablet
3-3.9 6 ml 1
4-5.9 6 ml 1
6-9.9 9 ml 1.5
10-13.9 2 1
14-19.9 2.5 1
20-24.9
or
3
or or
1
• Give for children 6 weeks of age and above
• 0.75 Twice daily means 1 tablet AM and 0.5 (half) tablet PM
• 1.5 twice daily means 2 tablets AM and 1 tablet PM
58
Efavirenz (EFV) - Give 15 mg/kg/day if capsule or tablet once daily.
Weight Combinations of 200, 100 and 50 mg capsules 600 mg tablet
10-13.9 One 200 mg
14-19.9 One 200 mg + one 50 mg
20-24.9 One 200 mg + one 100 mg
or
ANNEX B: ARV DOSAGES cont/d
Nevirapine (NVP) - Give maintenance dose 160-200 mg/m
2
per dose
twice daily. Lead-in dose during week 1 and 2, give only AM dose
Weight Syrup 10 mg/ml 30 mg tablet 150 mg tablet
3-3.9 5 ml 1
4-5.9 5 ml 1
6-9.9 8 ml 1.5
10-13.9 10 ml 2
14-19.9 2.5 0.75
20-24.9
or
3
or
0.75
Lopinavir/ritonavir (lop/rit) - Give 230/75.5 mg/m
2
twice daily and
increase to 300/75 mg/m
2
if taken with nevirapine
Weight Syrup 80/20 mg/ml 100/25 mg tablet
3-3.9 1 ml
4-5.9 1.5 ml
6-9.9 1.5 ml
10-13.9 2 ml 1.5
14-19.9 2.5 ml 2
20-24.9 3 ml
or
2.5
59
ANNEX B: ARV DOSAGES cont/d
Weight 3-3.9 4-4.9 6-9.9 10-13.9 14-19.9 20-24.9
AZT/3TC 60/30 mg 1 1 1.5 2 2.5 3
AZT/3TC/NVP 60/30/50 mg 1 1 1.5 2 2.5 3
d4T/3TC 6/30 mg 1 1 1.5 2 2.5 3
d4T/3TC/NVP 6/30/50 mg 1 1 1.5 2 2.5 3
ABC/3TC 60/30 mg 1 1 1.5 2 2.5 3
ABC/3TC/NVP 60/30/50 mg 1 1 1.5 2 2.5 3
ABC/AZT/3TC 60/60/30 mg 1 1 1.5 2 2.5 3
Weight in kg 1-1.9 2-2.9 3-3.9 4-4.9
AM 0.4 ml 0.8 ml 1.2 ml 1.6 ml
PM 0.4 ml 0.8 ml 1.2 ml 1.6 ml
Zidovudine 10mg/ml syrup for PMTCT prophylaxis in newborns.
Give 4/kg/ twice daily
COMBINATION ARV
60
Very common side-effects: warn patients and
suggest ways patients can manage; also be prepared
to manage when patients seek care
Potentially serious side effects: warn
patients and tell them to seek care
Side effects occurring later during
treatment: discuss with patients
d4T
stavudine
NauseaDiarrhoea
Seek care urgently:
Severe abdominal pain
Fatigue AND shortness of breath
Seek advice soon:
Tingling, numb or painful feet or legs or
hands
Changes in fat distribution:
Arms, legs, buttocks, cheeks become
THIN
Breasts, belly, back of neck become FAT
3TC
lamivudine
NauseaDiarrhoea
NVP
nevirapine
NauseaDiarrhoea
Seek care urgently:
Yellow eyes
Severe Skin rash
Fatigue AND shortness of breath
Fever
ZDV
zidovudine
(also known as AZT)
Nausea
Diarrhoea
Headache
Fatigue
Muscle pain
Seek care urgently:Pallor (anaemia)
EFV
efavirenz
Nausea
Diarrhoea
Strange dreams
Difficulty sleeping
Memory problems
Headache
Dizziness
Seek care urgently:Yellow
eyesPsychosis or confusionSevere Skin
rash
Annex C : ARV side effects*
* for more guidance, refer to IMAI chronic care guideline module
61
ANNEX D: DRUG DOSAGES FOR OPPORTUNISTIC INFECTIONS
Recommended dosages for ketoconazole
Age of child
Weight Dose, frequency and duration
3 -<6kg 20 mg once daily 2 months up to
12 months 6 -<10kg 40 mg once daily
12 months up to
5 years
10-19kg 60 mg once daily
Recommended dosages for acyclovir
Age of child
Dose, frequency and duration
<2 years 200mg 8 hourly for 5 days
>2 years 400mg 8 hourly for 5 days
Fluconazole dosage
Weight of child
50mg/5ml oral
suspension
50 mg
capsule
3 -<6kg
6 -<10kg
10 -<15kg 5 ml once a day 1
15 -<20kg 7.5 ml once a day 1-2
20 -<29kg 12.5 ml once a day 2-3
Recommended dosages for cloxacillin / flucloxacillin
Weight of child
Form
Dose, every 6 hours for 5 days
3 -<6kg
250mg capsule ½ tablet
6 -<10kg 1
10 -<15kg 1
15 -<20kg 2
Nystatin oral suspension 100,000 units per ml
given 1-2 ml four times daily for all age groups
Recommended dosages for griseofulvin 10 mg per Kg per day
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
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
9
1

Integrated Management of Childhood Illness Chart booklet for high HIV settings
Process of updating the IMCI chart booklet for high HIV settings
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.
The chart booklet for high HIV settings is different because it includes sections on paediatric HIV care. The changes made in this edition are based on the new
recommendations for paediatric ART following a technical consultation " Report of the WHO Technical Reference Group, Paediatric HIV/ART Care Guideline
Group Meeting WHO Headquarters, Geneva, Switzerland,10-11 April 2008; as well as several meetings of the WHO paediatric ART Working Group.
Who was involved and their declaration of interests
The following experts were involved in the development of the updated newborn recommendations: Z. Bhutta, A. Blaise, W. Carlo, R. Cerezo, M. Omar, P.
Mazmanyan, MK Bhan, H.Taylor, G. Darmstadt, V. Paul, A. Rimoin, L. 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 A. Deorari, T. Desta, A. Kassie,
D.P. Hoa, H. Kumar, V. Paul and S. Ramzi.. Their contributions are acknowledged.
The experts involved in making new paediatric ART recommendations were E. Abrams, NE Ata Alla, G. Anabwani, S. Bhakeecheep, S. Benchekroun, M.F.
Bwakura-Dangarembizi, E. Capparelli R. DeLhomme, D. Clarke, M. Cotton, F. Dabis, B. Eley, S. Essajee, R. Ferris, L. Frigati, C. Giaquinto, D. Gibb, T.A.
Jacobs, D.N. El Hoda, R. Lodha, P. Humblet, A.Z. Kabore, A. Kekitiinwa, P.N. Kazembe, I.Kalyesubula, C. Luo, V. Leroy, T. Meyers, M. Mirochnick, L.
Mofenson, H. Moultrie, P. Msellati, J.S. Mukherjee, R. Nduati, T. Nunn, A. Mutiti, N.Z. Nyazema, L. Oguda, A Ojoo, R. Pierre, J. Pinto, A. Prendergast, E.
Rivadeneira, M. Schaefer, P. Vaz, U. Vibol, Catherine M. Wilfert, P. Weidle, Agnes Mahomva, Zhao Yan, Martina Penazzato & Sally Girvin as well as WHO
regional and HQ staff. 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.
68
WHO Library Cataloguing-in-Publication Data
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 2009
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.
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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.
Printed by the WHO Document Production Services, Geneva, Switzerland.
For further information, please contact:
Department of Child and Adolescent Health and Development (CAH)
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Tel: +41-22 791 3281 email: cah@who.int
Fax: +41-22 791 4853 http:/www.who.int/child-adolescent-health

ASSESS AND CLASSIFY THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
ASSESS
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE • 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:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS
ASK:
• Is the child able to drink or breastfeed? • Does the child vomit everything? • Has the child had convulsions?

LOOK:
• See if the child is lethargic or unconscious. • Is the child convulsing now?

A child with any general danger sign needs URGENT attention; complete the assessment and any prereferral treatment immediately so that referral is not delayed.

USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS.

THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
IF YES, ASK: For how long? LOOK, LISTEN, FEEL: Count the breaths in one minute. Look for chest indrawing. Look and listen for stridor. Look and listen for wheezing. Classify COUGH or DIFFICULT BREATHING

SIGNS • Any general danger sign or • Chest indrawing or • Stridor in calm child • Fast breathing

CLASSIFY AS SEVERE PNEUMONIA OR VERY SEVERE DISEASE

TREATMENT (Urgent pre-referral treatments are in bold print) Give first dose of an appropriate antibiotic Refer URGENTLY to hospital

If wheezing and either fast breathing or chest indrawing: Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again, and then classify. If the child is: 2 months up to 12 months 12 months up to 5 years Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more • No signs of pneumonia or very severe disease

}

CHILD MUST BE CALM

Give oral antibiotic for 5 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for five days* PNEUMONIA Soothe the throat and relieve the cough with a safe remedy If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise the mother when to return immediately Follow-up in 2 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days* Soothe the throat and relieve cough with a safe remedy COUGH OR COLD If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma

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

2

Does the child have diarrhoea?
IF YES, ASK : • For how long? • Is there blood in the stool? LOOK AND FEEL : • Look at the child’s general
condition.Is the child :

Two of the following signs: • • • •
Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly.

for DEHYDRATION

If child has no other severe classification: - Give fluid for severe dehydration (Plan C) OR If child also has another severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for cholera

SEVERE DEHYDRATION

− Lethargic or unconscious? − Restless and irritable? • Look for sunken eyes. • Offer the child fluid. Is the child: − Not able to drink or drinking poorly? − Drinking eagerly, thirsty? • Pinch the skin of the abdomen. Does it go back: − Very slowly (longer than 2 seconds)? − Slowly?
Not enough signs to classify as some or severe dehydration NO DEHYDRATION

Two of the following signs:

Classify DIARRHOEA

• • • •

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

SOME DEHYDRATION

Give fluid, zinc supplements and food for some dehydration (Plan B) If child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving. Give fluid, zinc supplements and food to treat diarrhoea at home (Plan A) Advise mother when to return immediately Follow-up in 5 days if not improving.

and if diarrhoea for 14 days or more

• Dehydration present

SEVERE PERSISTENT DIARRHOEA

Treat dehydration before referral unless the child has another severe classification Refer to hospital Check for HIV Infection Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamins and minerals including zinc for 14 days Follow up in 5 days

• No dehydration

PERSISTENT DIARRHOEA

and if blood in stool
• Blood in the stool DYSENTERY

Give ciprofloxacin for 3 days

* 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

diarrhoea.are classified in other tables. Rectal temperature readings are approximately 0.5°C or above) Refer URGENTLY to hospital Give oral co-artemether or other recommended antimalarial Give one dose of paracetamol in clinic for high fever (38.5°C or above) Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days. • Fever (by history or feels hot or temperature 37.pneumonia. refer for assessment High Malaria Risk IF YES: Decide Malaria Risk: high or low • Any general danger sign or • Stiff neck. • Look for clouding of the cornea.5°C or above) Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days. and malnutrition . refer for assessment Low Malaria Risk • Any general danger sign or • Stiff neck VERY SEVERE FEBRILE DISEASE • Look for mouth ulcers. has fever been present every day? • Has the child had measles within the last 3 months? LOOK AND FEEL: • Look or feel for stiff neck. Classify • Any general danger sign or • Clouding of cornea or • Deep or extensive mouth ulcers • Pus draining from the eye or • Mouth ulcers • Measles now or within the last 3 months SEVERE COMPLICATED MEASLES*** MEASLES WITH EYE OR MOUTH COMPLICATIONS*** MEASLES Give Vitamin A treatment Give first dose of an appropriate antibiotic If clouding of the cornea or pus draining from the eye. or red eyes. • Look for runny nose.Does the child have fever? (by history or feels hot or temperature 37. apply tetracycline eye ointment Refer URGENTLY to hospital Give Vitamin A treatment If pus draining from the eye.5°C or above) Refer URGENTLY to hospital Give oral co-artemether or other recommended antimalarial Give one dose of paracetamol in clinic for high fever (38.5°C** or above) MALARIA Classify FEVER LOW MALARIA RISK Give quinine for severe malaria (first dose) unless no malaria risk Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar Give one dose of paracetamol in clinic for high fever (38. runny nose. 4 . THEN ASK: • For how long? • If more than 7 days. Look for signs of MEASLES • Generalized rash and • One of these: cough. *** Other important complications of measles . Give Vitamin A treatment ** These temperatures are based on axillary temperature. refe for assessment Give one dose of paracetamol in clinic for high fever (38.5°C** or above) HIGH MALARIA RISK VERY SEVERE FEBRILE DISEASE Give quinine for severe malaria (first dose) Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar Give one dose of paracetamol in clinic for high fever (38. ear infection.5°C or above) Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days.5°C higher. stridor. If the child has measles now or within the last 3 months: Are they deep and extensive? • Look for pus draining from the eye. treat with gentian violet Follow-up in 2 days. • Runny nose PRESENT or • Measles PRESENT or • Other cause of fever PRESENT • NO runny nose and NO measles and NO other cause of fever MALARIA FEVER MALARIA UNLIKELY if MEASLES now or within last 3 months. treat eye infection with tetracycline eye ointment If mouth ulcers.

Does the child have an ear problem? IF YES. Refer URGENTLY to hospital. • Pus is seen draining from the ear and discharge is reported for 14 days or more. ASK: • Is there ear pain? • Is there ear discharge? If yes. check for HIV Infection Follow-up in 5 days. Give an antibiotic for 5 days. Dry the ear by wicking. for how long? LOOK AND FEEL: • Look for pus draining from the ear. Treat with topical quinolone eardrops for 2 weeks Check for HIV Infection Follow-up in 5 days No treatment. • No ear pain and No pus seen draining from the ear. ACUTE EAR INFECTION CHRONIC EAR INFECTION NO EAR 5 . Give first dose of paracetamol for pain. MASTOIDITIS • Pus is seen draining from the ear and discharge is reported for less than 14 days. Give paracetamol for pain. Give first dose of an appropriate antibiotic. Dry the ear by wicking. If ear discharge. or • Ear pain. Classify EAR PROBLEM • Tender swelling behind the ear. • Feel for tender swelling behind the ear.

THEN CHECK FOR MALNUTRITION AND ANAEMIA CHECK FOR MALNUTRITION LOOK AND FEEL: • • • Look for visible severe wasting Look for oedema of both feet Determine weight for age CLASSIFY NUTRITIONAL STATUS • • Visible severe wasting or Oedema of both feet SEVERE MALNUTRITION Treat the child to prevent low sugar Refer URGENTLY to a hospital • Very low weight for age VERY LOW WEIGHT Assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations . follow-up in 5 days • No palmar pallor NO ANAEMIA 6 . follow-up in 5 days Advise mother when to return immediately Follow up in 14 days If child is less than 2 years old. assess the child's feeding and counsel the mother on feeding according to the feeding recommendations . assess the child's feeding and counsel the mother on feeding according to the feeding recommendations . Is it: − Severe palmar pallor? − Some palmar pallor? CLASSIFY ANAEMIA • Some palmar pallor ANAEMIA Give iron Give oral antimalarial if high malaria risk Check for HIV infection Give mebendazole if child is 1 year or older and has not had a dose in the previous six months If child is less than 2 years old.If feeding problem.If feeding problem. follow-up in 5 days Check for HIV infection Advise mother when to return immediately Follow-up in 30 days If child is less than 2 years old. assess the child's feeding and counsel the mother on feeding according to the feeding recommendations .If feeding problem. follow-up in 5 days Advise mother when to return immediately · Not very low wight for age and no other signs of malnutrition NOT VERY LOW WEIGHT • Severe palmar pallor CHECK FOR ANAEMIA LOOK and FEEL: • SEVERE ANAEMIA Refer URGENTLY to hospital Look for palmar pallor.If feeding problem.

counsel and follow-up existing infection Give co-trimoxazole prophylaxis Check immunization status Give Vitamin A supplements Assess the child’s feeding and provide appropriate counselling to the mother Refer for further assessment including HIV care/ART Advise the mother on home care Follow up in 14 days. enter the box below and look for the following conditions suggesting HIV infection: SYMPTOMATIC HIV INFECTION UNLIKELY Advise the mother about feeding and about her own health Encourage HIV testing If the child also has a severe classification give appropriate pre referral treatment and refer urgently Treat. counsel and follow-up existing infection Give co-trimoxazole prophylaxis Give Vitamin A supplements Assess the child’s feeding and provide appropriate counselling to the mother Test to confirm HIV infection Refer for further assessment including HIV care/ART Advise the mother on home care Follow up in 14 days. complete assessment quickly and refer child URGENTLY. then monthly for 3 months and then every 3 months Treat. *A child with these classifications or on ART. then monthly for 3 months and then every 3 months Treat. counsel and follow-up existing infection Give co-trimoxazole prophylaxis Give Vitamin A supplements Refer/do PCR to confirm infant’s HIV with best available test Assess the child’s feeding and provide appropriate counselling to the mother Refer for further assessment including HIV care/ART Confirm HIV infzection status of child as soon as possible with best available test Follow up in 14 days. assess for mouth and gum conditions as in next page. counsel and follow-up existing infections Advise the mother about feeding and about her own health • Positive HIV antibody NOTE OR ASK: • • • • PNEUMONIA ? PERSISTENT DIARRHOEA? EAR DISCHARGE? VERY LOW WEIGHT? LOOK and FEEL: • Oral thrush • Parotid enlargement • Generalized persistent lymphadenopathy • test for child 18 months and above OR Positive HIV virological test CONFIRMED HIV INFECTION* CLASSIFY HIV test result available for mother/child? HIV status of mother and/or child known One or both of the following: • Mother HIV positive and no test result for child OR • Child less than 18 months with positive antibody test HIV EXPOSED: POSSIBLE HIV INFECTION* **A child who is on ART does not need to enter this HIV box. then monthly for 3 months and then every 3 months Treat. counsel and follow-up existing infection If yes to one of the two questions above. * Includes severe forms such as severe pneumonia. 7 • Negative HIV test in mother or child AND not enough signs to classify as suspected symptomatic HIV infection HIV INFECTION UNLIKELY .THEN ASSESS FOR HIV INFECTION** Has the mother or child had an HIV test? OR Does the child have one or more of the following conditions?: HIV status of mother and child unknown • • 2 or more conditions AND No test results for child or mother SUSPECTED SYMPTOMATIC HIV INFECTION • • • • Pneumonia * * Persistent diarrhoea * * Ear discharge (acute or chronic) Very low weight for age* * • Less than 2 conditions AND • No test result for child or mother If the child also has a severe classification give appropriate pre referral treatment and refer urgently Treat. In the case of severe forms.

so refer. Provide pain relief. If lips or anterior gums involved. Advise the mother about feeding and about her own health. Treat. If not possible. If child receiving cotrimoxazole or antiretroviral drugs or isoniazid (INH) prophylaxis (for TB) within the last month. Show mother how to clean the ulcers with saline or peroxide or sodium bicarbonate. give acyclovir. if possible. this may be a drug rash. counsel and follow up existing infections. especially of the child also has a skin rash. give first dose acyclovir pre-referral.ASSESS MOUTH AND GUM CONDITIONS (FOR CHILDREN ON ART OR CLASSIFIED FOR HIV INFECTION) Look • • Deep or extensive ulcers of mouth or gums or • Not able to eat • Ulcers of mouth or gums SEVERE GUM OR MOUTH INFECTION Deep or extensive ulcers of mouth or gums • Ulcers of mouth or gums Classify MOUTH or GUM CONDITIONS GUM OR MOUTH ULCERS • No ulcers of the mouth or gums NO GUM OR MOUTH ULCERS Refer URGENTLY to hospital If possible. 8 . refer. Start metronidazole if referral not possible If child is on antiretroviral therapy this may be a drug reaction so refer to second level for assessment. Follow up in 7 days.

Record the dose on the child’s card Same protocol for HIV-exposed and infected children ROUTINE WORM TREATMENT Give every child mebendazole every 6 months from the age of one year. VITAMIN A AND DEWORMING STATUS IMMUNIZATION SCHEDULE: Follow national guidelines Age Birth 6 weeks 10 weeks 14 weeks 9 months VACCINE BCG OPV-0 HIV-EXPOSED BCG* Same Same Same Measles at 6 months Repeat at or after 9 months HIV-INFECTED NO BCG Same Same Same Same*** Same*** VITAMIN A SUPPLEMENTATION Give every child a dose of Vitamin A every six months from the age of 6 months. MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. ASSESS MOTHER’S OWN HEALTH ASSESS OTHER PROBLEMS: 9 . Record the dose on the child’s card. Same protocol for HIV exposed and infected children DPT+HIB-1 OPV-1 Hep B1 DPT+HIB-2 OPV-2 Hep B2 DPT+HIB-3 OPV-3 Hep B3 Measles** *BCG should NOT be given any time after birth to infants known to be HIV infected or born to HIV infected women and HIV status unknown but who have signs or reported symptoms suggestive of HIV infection ** 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..CHILD’S IMMUNIZATION. *** Measles vaccine is at 6 and 9 months but NOT if child is severely immunocompromised due to HIV infection.

A negative test usually means the child is not infected. If the child becomes sick. If child > 12 month has not yet been tested. For HIV exposed children <18 months of age. test from 6 weeks of age A positive result means the child is infected A negative result means the child is not infected. A positive result is consistent with the fact that the child has been exposed to HIV. 10 . recommend HIV antibody test at 9–12 months. recommend HIV antibody test. Repeat test at 18 months or once breastfeeding has been discontinued for more than 6 weeks HIV antibody test is negative HIV negative Child is not HIV infected Child can still be infected by breastfeeding. The older the child is the more likely the HIV antibody is due to their own infection and not due to maternal antibody Very exceptionally a very severely sick child who is HIV infected will have HIV antibody test results that are negative. • If PCR or other virological test is not available. Repeat test once breastfeeding has been discontinued for more than 6 weeks. use HIV antibody test. but does not tell us if the child is definitely infected.ESTABLISH HIV INFECTION STATUS RECOMMEND HIV testing for: • All children born to an HIV positive mother • All sick children with symptomatic suspected HIV infection • All children brought for child health service in a generalized epidemic setting For children > 18 months. a positive HIV antibody test result means the child is infected. If PCR or other virological test is available. If the child remains well. 2. If the clinical picture strongly suggests HIV. then virological testing will be needed. recommend HIV antibody test. 1. but could become infected if they are still breastfeeding • If PCR or other virological test not available. Repeat test at 18 months HIV exposed and /or HIV infected Manage as if they could be infected. Interpreting the HIV antibody test results in a child < 18 months of age Test result Not breastfeeding or not breastfed in last 6 weeks Breast feeding HIV antibody test is positive HIV exposed and /or HIV infected Manage as if they could be infected. use HIV antibody test.

Asymptomatic Growth - WHO Paediatric Clinical Stage 2 . extensive molluscum contagiosum or warts.WHO PAEDIATRIC CLINICAL STAGING OF HIV Has the child been confirmed HIV Infected? (If yes. presumptive diagnosis of severe HIV disease can be made on the basis of: ** HIV antibody positive AND One of the following: o AIDS defining condition OR o Symptomatic with two or more of : • Oral thrush • Severe pneumonia • Severe sepsis 11 .000/mm3 for > 1 month) 3 • Neutropenia* (<500/mm for 1 month) • Anaemia for >1 month (haemoglobin < 8 g/dl)* Recurrent severe bacterial pneumonia Pulmonary TB TB lymphadenopathy Symptomatic LIP* Acute necrotizing ulcerative gingivitis/periodontitis Chronic HIV associated lung disease including bronchiectasis* ART is indicated: • Child is over 12 months—usually regardless of CD4 but if LIP/TB/oral hairy leukoplakia—ART Initiation may be delayed if CD4 above age related threshold for advanced or severe immunodeficiency WHO Paediatric Clinical Stage 4 Severe Disease (AIDS) Severe unexplained wasting or stunting or Severe malnutrition not responding to standard therapy Oesophageal thrush More than one month of herpes simplex ulcerations Severe multiple or recurrent bacterial infections >2 episodes in a year (not including pneumonia) Pneumocystis pneumonia (PCP)* Kaposi sarcoma Extrapulmonary tuberculosis Toxoplasma* cryptococcal meningitis* Acquired HIV-associated rectal fistula HIV encephalopathy* Symptoms/signs No symptoms or only: • Persistent Generalized Lymphadenopathy (PGL) ARV Therapy Indicated : All infants below 12 mo irrespective of CD4 12.Moderate Disease Moderate unexplained malnutrition not responding to standard therapy Oral thrush (outside neonatal period) Oral hairy leukoplakia Unexplained and unresponsive to standard therapy: • Diarrhoea >14 days • Fever >1 month • Thrombocytopenia* (<50. you cannot stage the patient) WHO Paediatric Clinical Stage 1. and should be started as soon as possible 1 NB If HIV infection is NOT confirmed in infants<18 months. perform clinical staging: any one condition in the highest staging determines stage. lineal gingival Erythema)Recurrent or chronic upper RTI (sinusitis. seborrhoeic dermatitis. If no. ear infections.35 mo and CD4 < 20% (or £ 750 cells) 36-59 mo and CD4<20% (or £ 350 cells) 5 yrs and CD4 <15% (<cells/mm3) Indicated: Same as stage 1 ART is indicated: Irrespective of the CD4 count. fungal nail infections. otorrhoea) WHO Paediatric Clinical Stage 3 . herpes zoster) Mouth conditions (recurrent mouth ulcerations. angular chelitis.Mild Disease Unexplained persistent enlarged liver and/or spleen Unexplained persistent enlarged parotid Skin conditions (prurigo.

Also follow the instructions listed with each drug’s dosage table.3 or 4 disease or • Asymptomatic infants or children (stage 1) if CD4 <25%. count and package each drug separately Explain that all the tablets or syrup must be used to finish the course of treatment.5 ml 1 1 /2 15 ml *Amoxycillin should be used if there is high co-trimoxazole resistance. ACUTE EAR INFECTION: FIRST-LINE ANTIBIOTIC: SECOND-LINE ANTIBIOTIC: ____________________________________________________ __________________________________________________________ Determine the appropriate drugs and dosage for the child’s age or weight Tell the mother the reason for giving the drug to the child Demonstrate how to measure a dose Watch the mother practise measuring a dose by herself Ask the mother to give the first dose to her child Explain carefully how to give the drug. Give an Appropriate Oral Antibiotic FOR PNEUMONIA.14 years > 15 years CO-TRIMOXAZOLE dosage—single dose per day 5 ml syrup Single strength paediatric 40 mg / 200 mg tablet 20 mg / 100 mg 2.6 weeks of age to : • All infants born to mothers who are HIV infected until HIV is definitively ruled out • All infants with confirmed HIV infection aged <12 months or those with stage 2.19 kg) CO-TRIMOXAZOLE (trimethoprim / sulphamethoxazole) Give two times daily for 5 days ADULT PAEDIATRIC SYRUP TABLET TABLET (40/200 mg/ (80/400mg) (20/100 mg) 5 ml) 1/2 2 5.0 ml AMOXYCILLIN* Give two times daily for 5 days TABLET (250 mg) 3/4 SYRUP (125 mg/5 ml) 7. Give co-trimoxazole once daily. Age Less than 6 months 6 months up to 5 years 5 . If more than one drug will be given.TREAT THE CHILD CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home.5 ml 1/4 tablet 5 ml 1/2 tablet 10 ml 1 tablet NIL 2 tablets Single strength adult tablet 80 mg / 400 mg 1 tablet 2 tablets 4 tablets - AGE or WEIGHT 2 years up to 5 years (10-19 kg) TETRACYCLINE Give 4 times daily for 3 days TABLET 250 mg 1 ERYTHROMYCIN Give 4 times daily for 3 days TABLET 250 mg 1 FOR DYSENTERY GIVE CIPROFLOXACIN 15mg/kg/day—2 times a day for 3 days Second-line antibiotic for dysentery ____________________ AGE Less than 6 months 6 months up to 5 years 250 mg TABLET DOSE/ tabs 1/2 tablet 1 tablet 500 mg TABLET DOSE/ tabs 1/4 tablet 1/2 tablet 12 . FOR CHOLERA: First-line antibiotic for cholera _________________________________________ Second-line antibiotic for cholera ______________________________________ Give Co-trimoxazole to Children with Confirmed or Suspected HIV Infection or Children who are HIV Exposed Co-trimoxazole should be given starting at 4. then label and package the drug. collect.5 ml 1 3 7.<10 kg) 12 months up to 5 years (10 . even if the child gets better Check the mother’s understanding before she leaves the clinic AGE or WEIGHT 2 months up to 12 months (4 .

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Give pain relief Safe doses of paracetamol can be slightly higher for pain.0 ml (<1/2 tsp) 2.5 ml (1/2 tsp) Give Oral Co-artemether Give the first dose of co-artemether in the clinic and observe for one hour. From salbutamol metered dose inhaler (100μg/puff) give 2 puffs.5 ml 10 ml 1/4 1/4 1/2 1/2 3/4 0. No child under 5 years should be given an inhaler without a spacer. Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. A carer then presses down the inhaler and sprays into the bottle while the child continues to breath normally.<14 kg 14 . add regular codeine 4 hourly • For severe pain. a mask can be made by making a similar hole in a plastic (not polystyrene) cup.19 kg 2 months up to 4months 4 months up to 12 months 12 months up to 2 years 2 years up to 3 years 3 to 5 years 2 ml 2. To use an inhaler with a spacer: Remove the inhaler cap. it should be primed by 4-5 extra puffs from the inhaler. morphine syrup can be given WEIGHT AGE (If you do not know the weight) PARACETAMOL 120mg/5ml Add CODEINE 30mg tablet ORAL MORPHINE 5mg/5ml GIVE INHALED SALBUTAMOL for WHEEZING USE OF A SPACER* A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. Spacers can be made in the following way: Use a 500ml drink bottle or similar. * If a spacer is being used for the first time. The child should put the opening of the bottle into his mouth and breath in and out through the mouth.<14 kg) kg) 3 years up to 5 years (14 .5ml 2ml 3ml 4ml 5ml Give Iron Give one dose daily for 14 days AGE or WEIGHT IRON/FOLATE TABLET Ferrous sulfate 200 mg + 250 μg Folate (60 mg elemental iron) 2 months up to 4 months (4 . This can be done using a sharp knife.<10 kg 10 .<12 kg 12 .<6 kg) 4 months up to 12 months (6 <10kg) kg) 12 months up to 3 years (10 . Flame the edge of the cut bottle with a candle or a lighter to soften it.25 ml (1/4 tsp) 1/2 tablet 1/2 tablet 2. In a small baby. Then twice daily for further two days as shown below: Co-artemether tablets (20mg artemether and 120 mg lumefantrine) 0h 8h 24h 36h 48h 60h 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 WEIGHT (age) 5-15kg (2 mo <3 years) 15-24kg (4-8 years) 25-34 kg (9-14 years) >34 kg (>14 years) Co-artemether should be taken with food 13 . ½ paracetamol tablet can replace 10 ml syrup • If the pain is not controlled. 4 .0 ml (< 1/4 tsp) 1. Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler.<6kg 6 . Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the bottle. For younger children place the cup over the child’s mouth and use as a spacer in the same way. Repeat up to 3 times every 15 minutes before classifying pneumonia. Alternatively commercial spacers can be used if available. Use the table and teach mother to measure the right dose Give paracetamol every 6 hours if pain persists Stage 2 pain is chronic severe pain as might happen in illnesses such as AIDS: • Start treating Stage 2 pain with regular paracetamol • In older children. A spacer works as well as a nebuliser if correctly used.19 kg) IRON SYRUP Ferrous fumarate 100 mg per 5 ml (20 mg elemental iron per ml) 1. 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. Wait for three to four breaths and repeat for total of five sprays. Shake the inhaler well.5 ml 5 ml 7. If child vomits within an hour repeat the dose. 2nd dose at home after 8 hours.

• Wash hands again. Relieve the Cough with a Safe Remedy Safe remedies to recommend: . strong tissue paper into a wick Place the wick in the child’s ear Remove the wick when wet Replace the wick with a clean one and repeat these steps until the ear is dry Instil quinolone eardrops for two weeks Soothe the Throat.Breast milk for a breastfed infant _______________________________________________________ _______________________________________________________ Harmful remedies to discourage: _______________________________________________________ ________________________________________________________ Treat for Thrush with Nystatin Treat for thrush four times daily for 7 days Wash hands Wet a clean soft cloth with salt water and use it to wash the child’s mouth Instill nystatin 1ml four times a day Avoid feeding for 20 minutes after medication If breastfed check mother’s breasts for thrush. Do not put anything else in the eye. Then apply tetracycline eye ointment in both eyes 4 times daily. * Quinolone eardrops may contain ciprofloxacin.TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME Explain to the mother what the treatment is and why it should be given Describe the treatment steps listed in the appropriate box Watch the mother as she gives the first treatment in the clinic (except for remedy for cough or sore throat) Tell her how often to do the treatment at home If needed for treatment at home. 7) • Give paracetamol if needed for pain (p. or ofloxacin eardrops 14 . If present treat with nystatin Advise mother to wash breasts after feeds. give mother a tube of tetracycline ointment or a small bottle of gentian violet or nystatin Clear the Ear by Dry Wicking and Give Eardrops* • • • • • Treat Mouth Ulcers with Gentian Violet (GV) Treat for mouth ulcers twice daily • Wash hands • Wash the child’s mouth with a clean soft cloth wrapped around the finger and wet with salt water • Paint the mouth with 1/2 strength gentian violet (0. norfloxacin. Treat until there is no pus discharge. • Wash hands.25% dilution) • Wash hands again • Continue using GV for 48 hours after the ulcers have been cured • Give paracetamol for pain relief · Do the following 3 times daily Roll clean absorbent cloth or soft. recurrent or pharyngeal thrush consider symptomatic HIV (p. • Squirt a small amount of ointment on the inside of the lower lid.12) • • • • • • Treat Eye Infection with Tetracycline Eye Ointment Clean both eyes 4 times daily. • Use clean cloth and water to gently wipe away pus. If bottle fed advise change to cup and spoon • If severe.

Always record the dose of Vitamin A given on the child’s chart Give Mebendazole 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. DO NOT GIVE. and − has not had a dose in the previous 6 months Age 6 up to 12 months One year and older VITAMIN A DOSE 100 000 IU 200 000 IU 15 .GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC Explain to the mother why the drug is given Determine the dose appropriate for the child’s weight (or age) Measure the dose accurately Give Vitamin A VITAMIN A SUPPLEMENTATION: Give Vitamin A first dose any time after 6 months of age Thereafter give vitamin A every six months to ALL CHILDREN VITAMIN A TREATMENT: Give an extra dose of Vitamin A (same dose) for treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of Vitamin A within the past month.

0 ml* 1.5ml) Where there is a strong suspicion of meningitis the dose of ampicillin can be increased 4 times AGE 2 up to 4 months 4 up to 12 months 1 up to 3 years 3 up to 5 years WEIGHT 4 – <6kg 6 – <10kg 10 – <15kg 15 – 20kg AMPICILLIN 500 mg vial 1 ml 2 ml 3 ml 5 ml Gentamicin 2ml vial with 40 mg/ml 0.2.0 ml Give An Intramuscular Antibiotic GIVE TO CHILDREN BEING REFERRED URGENTLY Give Ampicillin (50 mg/kg) and Gentamicin (7.1ml of sterile water (500mg/2.7 ml 2.5 ml 1.5 .5mg/kg) 10 . Avoid putting things in the mouth Give 0.5ml 2.2 ml 0.< 14 kg) 3 years up to 5 years (14 .8 ml 1.GIVE THESE TREATMENTS IN THE CLINIC ONLY Explain to the mother why the drug is given Determine the dose appropriate for the child’s weight (or age) Use a sterile needle and sterile syringe when giving an injection Measure the dose accurately Give the drug as an intramuscular injection If the child cannot be referred. do not give quinine to a child less than 4 months of age AGE or WEIGHT INTRAMUSCULAR QUININE 150 mg /ml* (in 2 ml) 2 months up to 4 months (4 . and then every 12 hours until the child is able to take an oral antimalarial.2 ml 300 mg /ml* (in 2 ml) 0.4 ml 0.1.6 ml 0.4 ml 0.< 10kg AGE <6 months 6 .< 3 years 4 . repeat the ampicillin injection every 6 hours and gentamicin once per day * Lower value for lower range of age and weight 2 years up to 3 years (12 .< 6 kg) 4 months up to 12 months (6 .< 12 months 1 .5 ml Give Quinine for Severe Malaria 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.6 ml IF REFERRAL IS NOT POSSIBLE OR DELAYED.1.8 .0 ml 1.8 ml 1.< 5years DOSE OF DIAZEPAM (10mg/2mls) 0.< 15kg 15 .9 . Do not continue quinine injections for more than 1 week If low risk of malaria.3. then treat or prevent Give oxygen and REFER If convulsions have not stopped after 10 minutes repeat diazepam dose WEIGHT < 5kg 5 .5 ml 0.1 .19 kg) *quinine salt 16 .< 12 kg) 0.3 ml 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a tuberculin syringe) or using a catheter Check for low blood sugar. follow the instructions provided Give Diazepam to Stop a Convulsion Turn the child to his/her side and clear the airway.0 ml 1.19 kg AMPICILLIN Dilute 500mg vial with 2.< 10 kg) 12 months up to 2 years (10 .

Treat the Child to Prevent Low Blood Sugar If the child is able to breastfeed: Ask the mother to breastfeed the child If the child is not able to breastfeed but is able to swallow: • • • Give expressed breast milk or breast-milk substitute If neither of these is available give sugar water Give 30-50 ml of milk or sugar water before departure To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water If the child is not able to swallow: • Give 50ml of milk or sugar water by nasogastric tube 17 .

WHEN TO RETURN 3. When to Return 1.450 4 months up to 12 months 6 . give one or more of the following: food-based fluids (such as soup. give more • For infants below 6 months who are not breastfed.960 2 years up to 5 years 12 .tablets can be chewed or dissolved in a small amount of clean water in a cup GIVE EXTRA FLUID GIVE ZINC (age 2 months up to 5 years) CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. Give Extra Fluid 2. also give 100-200ml clean water during this period SHOW THE MOTHER HOW TO GIVE ORS SOLUTION: • Give frequent small sips from a cup • If the child vomits. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT: Show her how to prepare ORS solution at home Show her how much ORS to give to finish 4-hour treatment at home Give her instructions how to prepare salt and sugar solution for use at home Explain the 4 Rules of Home Treatment: 2. ORS or clean water in a cup • Older children .GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING (See FOOD advice on COUNSEL THE MOTHER chart) Plan A: Treat for Diarrhoea at Home Counsel the mother on the 4 Rules of Home Treatment: 1. 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. 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 ——.< 10 kg 450 .1600 • If the child wants more ORS than shown.<20kg 960 . GIVE EXTRA FLUID (as much as the child will take) TELL THE MOTHER: • Breastfeed frequently and for longer at each feed • If the child is exclusively breastfed. SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: Up to 2 years: 50 to 100 ml after each loose stool 2 years or more: 100 to 200 ml after each loose stool Tell the mother to: • Give frequent small sips from a cup.1 tablet daily for 14 days SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS • Infants—dissolve tablet in a small amount of expressed breast milk. WHEN TO RETURN 18 .800 12 months up to 2 years 10 . rice water. wait 10 minutes then continue .but more slowly • Continue breastfeeding whenever the child wants AFTER 4 HOURS: • Reassess the child and classify the child for dehydration • Select the appropriate plan to continue treatment • Begin feeding the child in clinic • • • • 1. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. Continue Feeding 4. and yoghurt drinks). or ORS It is especially important to give ORS at home when: • the child has been treated with Plan B or Plan C during this visit • the child cannot return to a clinic if the diarrhoea gets worse TEACH THE MOTHER HOW TO MIX AND GIVE ORS.but more slowly • Continue giving extra fluid until the diarrhoea stops Plan B: Treat for Some Dehydration with ORS In the clinic. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME. 2. give ORS or clean water in addition to breast milk • If the child is not exclusively breastfed.1/2 tablet daily for 14 days 6 months or more ——. wait 10 minutes then continue . The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight in kg times 75.< 12 kg 800 . 3. AGE* WEIGHT Amount of fluid (ml) over 4 hours Up to 4 months < 6 kg 200 . • If the child vomits. Give Zinc Supplements (age 2 months up to 5 years) 3.

give the fluid more slowly. Then choose the appropriate plan (A. GO DOWN • Start IV fluid immediately. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4(infants) or 1-2 hours (children).If there is repeated vomiting or abdominal distension.2 hours. B. • If the child can drink. give the IV drip more rapidly. give ORS by mouth while the drip is set up.GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING (See FOOD advice on COUNSEL THE MOTHER chart) Plan C: Treat for Severe Dehydration Quickly FOLLOW THE ARROWS. If the child can drink. . AS NEEDED 19 . IF “NO”. Reassess the child every 1-2 hours while waiting for transfer: . If hydration status is not improving. B. or C) to continue treatment. GO ACROSS. normal saline). if not available. IMMUNIZE EVERY SICK CHILD. • Give 100 ml/kg Ringer’s Lactate Solution (or. divided as follows: AGE Infants (under 12 months) Children (12 months up to 5 years) • Can you give intravenous (IV) fluid immediately? YES First give 30ml/kg in: 1 hour 30 minutes Then give 70ml/kg in 5 hours 2½ hours NO • • Reassess the child every 1. Then choose the appropriate plan (A. Classify dehydration. send the child for IV therapy. or C) to continue treatment. • • NO YES • Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Classify dehydration. After 6 hours reassess the child. Can the child drink? NO NO Refer URGENTLY to hospital for IV or NG treatment NOTE: • If the child is not referred to hospital. provide the mother with ORS solution and show her how to give frequent sips during the trip or give ORS by naso-gastic tube. Reassess an infant after 6 hours and a child after 3 hours. Is IV treatment available nearby (within 30 minutes)? NO Are you trained to use a naso-gastric (NG) tube for rehydration? YES • • Refer URGENTLY to hospital for IV treatment. observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth. IF ANSWER IS “YES”.If the hydration status is not improving after 3 hours.

DYSENTERY: After 2 days: } Assess the child for diarrhoea > See ASSESS & CLASSIFY chart See ASSESS & CLASSIFY chart. If you do not have the second line antibiotic. abdominal pain.How many loose stools is the child having per day? Assess for HIV infection Treatment: If the diarrhoea has not stopped (child is still having 3 or more loose stools per day) do a full assessment of the child. or eating better. Ask: . Treat for dehydration if present. If the diarrhoea has stopped (child having less than 3 loose stools per day).GIVE FOLLOW-UP CARE Care for the child who returns for follow-up using all the boxes that match the child’s previous classification If the child has any new problems. or if he had measles within the last 3 months. fever and eating are the same. If number of stools. and eating better. REFER TO HOSPITAL. If breathing rate.) If breathing slower. fever. Ensure that the mother understands the oral rehydration method fully and that she also understands the need for an extra meal each day for a week. continue giving ciprofloxacin until finished. Then refer URGENTLY to hospital. less abdominal pain. (If this child had measles within the last 3 months or is known or suspected to have Symptomatic HIV Infection. Advise the mother to return in 2 days. Then REFER to hospital including for assessment for ART. If fewer stools.Is there less fever? . tell the mother to follow the usual feeding recommendations for the child’s age. Give it for 5 days. Assess the child for cough or difficult breathing. Ask: Treatment: If the child is dehydrated. less fever. classify and treat the new problem as on the ASSESS AND CLASSIFY chart PNEUMONIA After 2 days: Check the child for general danger signs. 20 . refer. complete the 5 days of antibiotic.Has the diarrhoea stopped? . or eating is worse or the same Change to second-line oral antibiotic recommended for shigella in your area. assess. blood in the stools. refer to hospital. less fever. change to the second-line antibiotic and advise the mother to return in 2 days or refer.Is the child breathing slower? . treat for dehydration. Are there fewer stools? Is there less blood in the stool? Is there less fever? Is there less abdominal pain? Is the child eating better? PERSISTENT DIARRHOEA After 5 days: Ask: . give a dose of second-line antibiotic or intramuscular chloramphenicol. Exceptions: if the child is less than 12 months old or was dehydrated on the first visit.Is the child eating better? Assess for HIV infection Treatment: If chest indrawing or a general danger sign.

If fever has been present for 7 days. 21 .If fever has been present for 7 days. refer to hospital. MALARIA (Low or High Malaria Risk) If fever persists after 2 days. continue the treatment. If the child has any cause of fever other than malaria. classify and treat the new problem as on the ASSESS AND CLASSIFY chart FEVER-MALARIA UNLIKELY (Low Malaria Risk) If fever persists after 2 days: Do a full reassessment of the child > See ASSESS & CLASSIFY chart. assess. MEASLES WITH EYE OR MOUTH COMPLICATIONS After 2 days: Look for red eyes and pus draining from the eyes. If malaria is the only apparent cause of fever: . Treatment: If the child has any general danger sign or stiff neck.) Advise the mother to return again in 2 days if the fever persists. Look at mouth ulcers. or there is a very foul smell coming from the mouth. teach mother correct treatment. Treatment for Mouth Ulcers: If mouth ulcers are worse. If no pus or redness. refer to hospital. .GIVE FOLLOW-UP CARE Care for the child who returns for follow-up using all the boxes that match the child’s previous classification If the child has any new problems. Advise the mother to return again in 2 days if the fever persists. If the child has any cause of fever other than malaria. Assess for other causes of fever. refer for assessment. provide treatment. Treatment: If the child has any general danger sign or stiff neck. treat as VERY SEVERE FEBRILE DISEASE. treat as VERY SEVERE FEBRILE DISEASE. If treatment has not been correct. refer for assessment. stop the treatment. continue using half-strength gentian violet for a total of 5 days. Treatment for Eye Infection: If pus is draining from the eye.Treat with the first-line oral antimalarial. ask the mother to describe how she has treated the eye infection. refer to hospital. or returns within 14 days: Do a full reassessment of the child > See ASSESS & CLASSIFY chart. Assess for other causes of fever. Smell the mouth. If treatment has been correct. . If the pus is gone but redness remains. provide treatment. If malaria is the only apparent cause of fever: . If mouth ulcers are the same or better.Treat with the second-line oral antimalarial (if no second-line antimalarial is available.

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. If you counsel the mother to make significant changes in feeding. Treatment: If there is tender swelling behind the ear or high fever (38. Chronic ear infection: Check that the mother is wicking the ear correctly. classify and treat the new problem as on the ASSESS AND CLASSIFY chart EAR INFECTION After 5 days: Reassess for ear problem. Counsel the mother about any new or continuing feeding problems. ANAEMIA After 14 days: Give iron. If the child is still very low weight for age. tell her to use all of it before stopping.GIVE FOLLOW-UP CARE Care for the child who returns for follow-up using all the boxes that match the child’s previous classification If the child has any new problems. praise the mother for her careful treatment. Encourage her to continue. counsel the mother about any feeding problem found. 22 . Exception: If you do not think that feeding will improve. treat with 5 more days of the same antibiotic. Advise mother to return in 14 days for more iron. refer URGENTLY to hospital. ask her to bring the child back again. Ask the mother to return again in one month. assess. If no ear pain or discharge. refer for assessment. ask the mother to return 30 days after the initial visit to measure the child's weight gain. If she has not yet finished the 5 days of antibiotic. If the child is very low weight for age. Ask about any feeding problems found on the initial visit. refer the child. Follow-up in 5 days. > See questions at the top of the COUNSEL chart. FEEDING PROBLEM After 5 days: Reassess feeding > See questions at the top of the COUNSEL chart. Treatment: If the child is no longer very low weight for age. praise the mother and encourage her to continue. Acute ear infection: if ear pain or discharge persists. > See ASSESS & CLASSIFY chart. Continue giving iron every 14 days for 2 months. Measure the child's temperature. Check for HIV infection. Reassess feeding. Continue wicking to dry the ear. or if the child has lost weight. If the child has palmar pallor after 2 months.5°C or above). Check for HIV infection. VERY LOW WEIGHT After 30 days: Weigh the child and determine if the child is still very low weight for age.

mothers to continue exclusive breastfeeding Advise on any new or continuing feeding problems Initiate or follow up co-trimoxazole prophylaxis according to national guidelines Give immunizations according to schedule. Agree. re-counsel the mother on preventing HIV and on benefits of HIV testing 23 . Arrange to guide you the steps on chronic care consultation. for malnutrition and feeding. if not yet confirmed ——————————————————————————————————————————————————————————————————————————— IF CHILD IS CONFIRMED HIV INFECTED* Follow-up in 14 days. skin and mouth conditions and for HIV on each visit Check if diagnostic HIV test has been done and if not. Assist. Treatment Plan and treatment cards . peer educators and support staff in your health facility Link the mother and child to community-based resources and support Use written information – registers. Do a full re-assessment at each follow-up visit and reclassify for HIV on each follow-up visit Counsel about feeding practices (page 25 in chart booklet and according to the recommendations in Module 3) Follow co-trimoxazole prophylaxis as per national guidelines Follow national immunization schedule Follow Vitamin A supplements from 6 months of age every 6 months Monitor growth and development Virological Testing for HIV infection as early as possible from 6 weeks of age Refer for ARVs if infant develops severe signs suggestive of HIV Counsel the mother about her own HIV status and arrange counselling and testing for her if required IF CHILD CONFIRMED UNINFECTED Stop co-trimoxazole only if no longer breastfeeding and more than 12 months of age Counsel mother on preventing HIV infection and about her own health ——————————————————————————————————————————————————————————————————————————— IF HIV TESTING HAS NOT BEEN DONE Re-discuss the benefits of HIV testing Identify where and when HIV testing including virological testing can be done If mother consents arrange HIV testing and follow-up visit ——————————————————————————————————————————————————————————————————————————— IF MOTHER REFUSES TESTING * Any child with confirmed HIV infection should be enrolled in chronic HIV care. monthly or as per national guidelines. monthly or as per national guidelines. Use the 5As at every patient consultation Support the mother and child’s self-management Organize proactive follow-up Involve “expert patients”. monthly or as per national guidelines. Provide ongoing care for the child. put the family in touch with organizations or people who could provide support • Explain the importance of early treatment of infections or refer • Advise the mother about hygiene in the home. Do not give BCG Give Vitamin A according to schedule Provide pain relief if needed Refer for confirmation of HIV infection and ART. including routine monthly follow-up Discuss and provide co-trimoxazole prophylaxis On subsequent visits. monitor and remind Work as a clinical team Assure continuity of care Follow-up in 14 days. Continue co-trimoxazole prophylaxis Follow-up on feeding Home care: • Counsel the mother about any new or continuing problems • If appropriate. in particular when preparing food Reassess for eligibility for ART or REFER Check mother’s health and advise on safe sexual practices and family planning IF POSSIBLE HIV INFECTION / HIV EXPOSED Follow-up in 14 days.to document. test for HIV as soon as possible Assess feeding and check weight and weight gain Encourage breastfeeding . Do a full assessment – classify for common childhood illnesses. including assessment for eligibility of ART – refer to subsequent sections of the chart booklet.GIVE FOLLOW-UP CARE FOR THE CHILD WITH POSSIBLE HIV INFECTION / HIV EXPOSED OR SUSPECTED SYMPTOMATIC OR CONFIRMED HIV INFECTION IF SUSPECTED SYMPTOMATIC HIV INFECTION GENERAL PRINCIPLES OF GOOD CHRONIC CARE FOR HIV-INFECTED CHILDREN Develop a treatment partnership with the mother and infant or child Focus on the mother and child’s concerns and priorities Use the ‘5 As’ : Assess. Advise.

COUNSEL THE MOTHER

Assess the Feeding of Sick Infants under 2 years (or if child has very low weight for age)
Ask questions about the child’s usual feeding and feeding during this illness. Note whether the mother is HIV infected, uninfected, or does not know her status. Compare the mother’s answers to the Feeding Recommendations for the child’s age.

ASK — How are you feeding your child?
If infant is receiving replacement milk, ASK:
What replacement milk are you giving? How many times during the day and night? How much is given at each feed? How is the milk prepared? How is the milk being given? Cup or bottle? How are you cleaning the utensils? If still breastfeeding as well as giving replacement milk could the mother give extra breast milk instead of replacement milk (especially if the baby is below 6 months)

If the infant is receiving any breast milk, ASK:
- How many times during the day? - Do you also breastfeed during the night?

Does the infant take any other food or fluids? - What food or fluids? - How many times per day? - What do you use to feed the child? If low weight for age, ASK: - How large are servings? - Does the child receive his own serving? - Who feeds the child and how? During this illness, has the infant’s feeding changed? - If yes, how?

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FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH
NOTE: These feeding recommendations should be followed for infants of HIV negative mothers. Mothers who DO NOT KNOW their HIV status should be advised to breastfeed but also to be HIV tested so that they can make an informed choice about feeding Up to 6Months of Age 6 Months up to 12Months 12 Months up to 2Years 2 Years and Older

• Breastfeed as often as the child wants, day and night, at least 8times in 24 hours. • Do not give other foods or fluids.

• Breastfeed as often as the child wants. • Give adequate servings of: ___________________________ ___________________________ ___________________________ ___________________________ 3 times per day if breastfed plus snacks 5 times per day if not breastfed.

• Breastfeed as often as the child wants. • Give adequate servings of: __________________________ __________________________ __________________________ __________________________ or family foods 3 or 4 times per day plus snacks.

• Give family foods at 3 meals each day. Also, twice daily, give nutritious food between meals, such as: __________________________ __________________________ __________________________ __________________________ __________________________

Feeding Recommendations for a child who has PERSISTENT DIARRHOEA
• • If still breastfeeding, give more frequent, longer breastfeeds, day and night. If taking other milk: replace with increased breastfeeding OR replace with fermented milk products, such as yoghurt OR replace half the milk with nutrient-rich semisolid food

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COUNSEL THE MOTHER
Feeding advice for the mother of a child with CONFIRMED HIV INFECTION
The child with confirmed HIV infection needs the benefits of breastfeeding and should be encouraged to breastfeed. S/he is already HIV infected therefore there is no reason for stopping breastfeeding or using replacement feeding. The child should be fed according to the feeding recommendations for his age. Children with confirmed HIV infection often suffer from poor appetite and mouth sores, give appropriate advice. If the child is being fed with a bottle encourage the mother to use a clean cup as this is more hygienic and will reduce episodes of diarrhoea. Inform the mother about the importance of hygiene when preparing food because her child can easily get sick. She should wash her hands after going to the toilet and before preparing food. If the child is not gaining weight well, the child can be given an extra meal each day and the mother can encourage him to eat more by offering him snacks that he likes if these are available. Advise her about her own nutrition and the importance of a well balanced diet to keep herself healthy. Encourage her to plant vegetables to feed her family.

“AFASS” CRITERIA FOR STOPPING BREASTFEEDING for HIV exposed
Acceptable: Mother perceives no problem in replacement feeding. Feasible: Mother has adequate time, knowledge, skills, resources, and support to correctly mix formula or milk and feed the infant up to 12 times in 24 hours. Affordable: Mother and family, with community can pay the cost of replacement feeding without harming the health and nutrition of the family. Sustainable: Availability of a continuous supply of all ingredients needed for safe replacement feeding for up to one year of age or longer. Safe: Replacement foods are correctly and hygienically prepared and stored.

Counsel the mother about Stopping Breastfeeding (for HIV exposed)
While you are breastfeeding, teach your infant to drink expressed breast milk from a cup. This milk may be heat-treated to destroy HIV. Once the infant is drinking comfortably, replace one breastfeed with one cup feed using expressed breast milk. Increase the number of cup-feeds every few days and reduce the number of breastfeeds. Ask an adult family member to help with cup feeding. Stop putting your infant to your breast completely as soon as your baby is accustomed to frequent cup feeding. From this point on it is best to heat-treat your breast milk. If your infant is receiving milk only check that your baby has at least 6 wet nappies in a 24 hour period. This means he is getting enough milk. Gradually replace the expressed breast milk with commercial infant formula or another milk after 6 months. If your infant needs to suck, give him / her one of your clean fingers instead of the breast. To avoid breast engorgement (swelling) express a little milk whenever your breasts feel full. This will help you feel more comfortable. Use cold compresses to reduce inflammation. Wear a firm bra to prevent discomfort. Do not begin breastfeeding again once you have stopped. If you do you can increase the chances of passing HIV to your infant. If your breasts become engorged,express breast milk by hand. Begin using a family planning method of your choice, if you have not already done so, as soon as you start reducing breastfeeds.

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. . salty or acid foods. appetizing. .Clear a blocked nose if it interferes with feeding. As needed.Make sure other milk is correctly and hygienically prepared and given in adequate amounts.Avoid spicy. . favourite foods to encourage the child to eat as much as possible. show the mother correct positioning and attachment for breastfeeding. counsel the mother to: . If the child is less than 6 months old and is taking other milk or foods*: . including at night. and gradually reducing other milk or foods. . assess breastfeeding (see YOUNG INFANT chart). .COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS If the child is not being fed as described in the above recommendations. If the child has a poor appetite: . counsel the mother about the importance of not mixing breastfeeding with replacement feeding. longer breastfeeds day or night. . .Make sure that other milk is a locally appropriate breast milk substitute. such as eggs. varied. and offer frequent small feeds.Plan small.Chop foods finely.Finish prepared milk within an hour.Expect that appetite will improve as child gets better.Build mother's confidence that she can produce all the breast milk that the child needs. 27 . If the child is not feeding well during illness. frequent meals.Breastfeed as much as possible. If other milk needs to be continued.Give milk rather than other fluids except where there is diarrhoea with some dehydration. . If the child has sore mouth or ulcers: .Check regularly. counsel the mother accordingly. . .Give soft foods that will not burn the mouth.Use soft. mashed potatoes.Suggest giving more frequent.Give snacks between meals. . .Give cold drinks or ice. In addition: If the mother reports difficulty with breastfeeding. pumpkin or avocado.Breastfeed more frequently and for longer if possible. counsel the mother to: .Recommend substituting a cup for bottle.Give high energy foods. . If the mother is using a bottle to feed the child: . . if available. * if child is HIV exposed.Show the mother how to feed the child with a cup.

give 4-5 feeds per day * one cup = 250 ml Stopping breastfeeding means changing from all breast milk to no breast milk (over a period of 2-3 days to 23 weeks). give 4-5 feeds per day * one cup= 250 ml • If still breastfeeding. breastfeed as often as the child wants Give 3 adequate servings of nutritious complementary foods plus one snack per day (to include protein. Stop breastfeeding as soon as this is AFASS. • Give adequate servings of: __________________________ __________________________ __________________________ __________________________ or family foods 5 times per day. If breastfed. give an additional animal-source food. give about 1-2 cups* (500 ml) of full cream milk or infant formula per day Give milk with a cup. Feed at least 8 times in 24 hours. Use milk within two hours and discard any left over (a fridge can store formula for 24 hours) Cup feeding is safer than bottle feeding Clean the cup and utensils with hot soapy water Give these amounts of formula 6 to 8 times per day * Exception: heat-treated breast milk can be given If still breast feeding. give about 1-2 cups (500 ml) of full cream milk or infant formula per day Give milk with a cup. such as liver or meat ___________________________ ___________________________ ___________________________ If an infant is not breastfeeding.FEEDING RECOMMENDATIONS: Child classified as HIV exposed Up to 6 months of age 6 up to 12 months l 12 months up to 2 years Stopping breastfeeding Breastfeed exclusively as often as the child wants.g. Each meal should be 3/4 cup*. e. Stop breastfeeding as soon as this is AFASS (see page 27). Prepare correct strength and amount just before use. not a bottle If no milk is available. If possible. day and night. full cream cows milk • Learn how to prepare and store milk safely at home Help mother make the transition: • Teach mother to cup feed her baby • Clean all utensils with soap and water • Start giving only formula or cows milk once the baby takes all feeds by cup Stop breastfeeding completely: • Express and discard enough breast milk to keep comfortable until lactation stops Age months 0 up to 1 1 up to 2 2 up to 3 3 up to 4 4 up to 5 5 up to 6 Amount and times per day 60 ml x 8 90 ml x 7 120 ml x 6 120 ml x 6 150 ml x 6 150 ml x 6 28 . Do not give other foods or fluids (mixed feeding increases the risk of HIV transmission from mother to child when compared with exclusive breastfeeding). Plan in advance to have a safe transition. breastfeed as often as the child wants. Help mother prepare for stopping breastfeeding: • Mother should discuss and plan in advance stopping breastfeeding with her family if possible • Express milk and give by cup • Find a regular supply of formula or other milk. Other foods or fluids are not necessary. OR (if feasible and safe) Formula feed exclusively (no breast milk at all) Give formula. This would usually be at the age of 6 months but some women may have to continue longer. mashed fruit and vegetables). give adequate servings 3 times per day plus snacks If an infant is not breastfeeding. not a bottle If no milk is available.

provide care for her. provide care for her or refer her for help. 29 . Advise her to eat well to keep up her own strength and health. breast infection). Make sure she has access to: • • Family planning Counselling on STD and AIDS prevention.COUNSEL THE MOTHER ABOUT HER OWN HEALTH If the mother is sick. or refer her for help. If she has a breast problem (such as engorgement. sore nipples. Encourage every mother to be sure to know her own HIV status and to seek HIV testing if she does not know her status or is concerned about the possibility of HIV in herself or her family. Check the mother's immunization status and give her tetanus toxoid if needed.

breastfeed more frequently and for longer at each feed. also return if: • Blood in stool • Drinking poorly 14 days • VERY LOW WEIGHT FOR AGE 30 days Advise the mother to come for follow-up at the earliest time listed for the child's problems. FOR CHILD WITH DIARRHOEA: Giving extra fluid can be lifesaving. give soup. If child is taking breast-milk substitutes. if not improving ANAEMIA CONFIRMED HIV INFECTION SUSPECTED SYMPTOMATIC HIV INFECTION HIV EXPOSED/ POSSIBLE HIV Return for first follow-up in: 2 days 5 days WHEN TO RETURN IMMEDIATELY Advise mother to return immediately if the child has any of these signs: Any sick child • Not able to drink or breastfeed • Becomes sicker • Develops a fever If child has NO PNEUMONIA: • Fast breathing COUGH OR COLD. also return if: • Difficult breathing If child has Diarrhoea. rice water. if fever persists • FEVER-MALARIA UNLIKELY. if not improving • • • • • ANY OTHER ILLNESS. if fever persists • MEASLES WITH EYE OR MOUTH COMPLICATIONS • PERSISTENT DIARRHOEA • ACUTE EAR INFECTION • CHRONIC EAR INFECTION • FEEDING PROBLEM • COUGH OR COLD. Give fluid according to Plan A or Plan B on the TREAT THE CHILD chart WHEN TO RETURN Advise the Mother When to Return to Health Worker FOLLOW-UP VISIT If the child has: • PNEUMONIA • DYSENTERY • MALARIA.FLUID Advise the Mother to Increase Fluid During Illness FOR ANY SICK CHILD: If child is breastfed. 30 . increase the amount of milk given Increase other fluids. For example. yoghurt drinks or clean water.

Does the infant move only when stimulated but then stops? .Does the infant not move at all ? • Not feeding well or • Convulsions or • Fast breathing (60 breaths per minute or more) or • Severe chest indrawing or • Fever (37. use the follow-up instructions . If infant is sleeping.5°C* or above) or • Low body temperature (less than 35. Is it red or draining pus? • Look for skin pustules. Follow up in 2 days. see Integrated Management of Childhood Illness.if follow-up visit. gently stimulate him/her. Repeat the count if 60 or more breaths per minute. Refer URGENTLY to hospital. Annex 2 “Where referral is not possible” 31 . • Look for severe chest indrawing. • 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. * These thresholds are based on axillary temperature. • Look at the young infant's movements. . ** If referral is not possible.5°C*) or • Movement only when stimulated or no movement at all Give first dose of intramuscular antibiotics. assess the young infant as follows: USE ALL BOXES THAT MATCH INFANT’S SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS. Teach mother to treat local infections at home. VERY SEVERE DISEASE Treat to prevent low blood sugar. 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 • Determine if this is an initial or follow-up visit for this problem.5°C higher. • Has the infant had convulsions (fits)? } YOUNG INFANT MUST BE CALM Classify ALL YOUNG INFANTS • Measure axillary temperature.if initial visit. . The thresholds for rectal temperature readings are approximately 0.** Advise mother how to keep the infant warm on the way to the hospital.Does the infant move on his/her own? If the infant is not moving. CHECK FOR VERY SEVERE DISEASE AND LOCAL INFECTION ASK: • Is the infant having difficulty in feeding? SIGNS Any one of the following signs CLASSIFY TREATMENT (Urgent pre-referral treatments are in bold print) LOOK AND FEEL: • Count the breaths in one minute. Management of the sick young infant module. ask the mother to wake him/her. . • Umbilicus red or draining pus • Skin pustules LOCAL BACTERIAL INFECTION Give an appropriate oral antibiotic. Advise mother to give home care for the young infant.ASSESS. • Look at the umbilicus.

32 . • Jaundice appearing after 24 hours of age and • 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. • No jaundice NO JAUNDICE Advise the mother to give home care for the young infant. Follow-up in 1 day. Refer URGENTLY to hospital. Advise mother how to keep the infant warm on the way to the hospital. If the young infant is older than 3 weeks. Are they yellow? Classify Jaundice • Any jaundice if age less than 24 hours or • Yellow palms and soles at any age Treat to prevent low blood sugar.THEN CHECK FOR JAUNDICE SIGNS ASK: appear? CLASSIFY AS SEVERE JAUNDICE TREATMENT (Urgent pre-referral treatments are in bold print) LOOK AND FEEL: skin). refer to a hospital for assessment. • When did jaundice first • Look for jaundice (yellow eyes or • Look at the young infant's palms and soles.

Give fluid for severe dehydration (Plan). NO DEHYDRATION Give fluids and breast milk to treat for diarrhoea at home (Plan A) Advise mother when to return immediately Follow up in 2 days if not improving * 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). OR SEVERE DEHYDRATION If infant also has another severe classification: . If infant has no other severe classification: . 33 . irritable • Sunken eyes • Skin pinch goes back slowly. Advise mother when to return immediately Follow-up in 2 days if not improving • Not enough signs to classify as some or severe dehydration. .Advise mother to continue breastfeeding. OR If infant also has another severe classification: .Does the infant not move at all ? .Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Very slowly (longer than 2 seconds)? .Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Is the infant restless and irritable? • Look for sunken eyes.Infant’s movements .Advise mother to continue breastfeeding. SOME DEHYDRATION Give fluid and breast milk for some dehydration (Plan B). Does it go back: .THEN ASK: Does the young infant have diarrhoea*? SIGNS Two of the following signs: CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print) IF YES.Does the infant move only when stimulated but then stops? . Two of the following signs: • Restless.or slowly? Classify DIARRHOEA FOR DEHYDRATION • Movement only when stimulated or no movement at all • Sunken eyes • Skin pinch goes back very slowly.Does the infant move on his/her own? . . • Pinch the skin of the abdomen. The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea. LOOK AND FEEL: • Look at the young infant's general condition: .

THEN CHECK THE YOUNG INFANT FOR HIV INFECTION SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print) • Child has positive virological test ASK: Has the mother or the infant had an HIV test? What was the result? Classify by test result One or both of the following conditions: • Mother HIV positive • Child has positive HIV antibody test (seropositive) CONFIRMED HIV INFECTION Give cotimoxazole prophylaxis from age 4-6 weeks Assess the child’s feeding and counsel as necessary Refer for staging and assessment for ART Advise the mother on home care Follow-up in 14 days POSSIBLE HIV INFECTION/ HIV EXPOSED Give co-trimoxazole prophylaxis from age 4-6 weeks Assess the child’s feeding and give appropriate feeding advice Refer/ do virological test to confirm infant’s HIV status at least 6 weeks after breastfeeding has stopped Consider presumptive severe HIV disease Follow-up in one month Negative HIV test for mother or child HIV INFECTION UNLIKELY Treat. counsel and follow-up existing infections Advise the mother about feeding and about her own health 34 .

• If not able to attach well immediately. • Is the infant suckling effectively (that is. NO FEEDING PROBLEM Advise mother to give home care for the young infant. or • Low weight for age. Clear a blocked nose if it interferes with breastfeeding. If receiving other foods or drinks.Chin touching breast (All of these signs should be present if the attachment is good). • If not breastfeeding at all: .Advise about correctly preparing breast-milk substitutes and using a cup. teach the mother to treat thrush at home. teach the mother to express breast milk and feed by a cup If breastfeeding less than 8 times in 24 hours. ask the mother to put her infant to the breast. day and night. slow deep sucks. and using a cup. Follow-up low weight for age in 14 days. Advise mother to give home care for the young infant. (If the infant was fed during the last hour.Refer for breastfeeding counselling and possible relactation. Observe the breastfeed for the previous hour? 4minutes. or If not well attached or not suckling effectively. counsel mother about breastfeeding more.More areola seen above infant’s top lip than below bottom lip . how often? • If yes. how many times in 24 hours? • Does the infant usually receive • Look for ulcers or white patches in the mouth (thrush). sometimes pausing)? not suckling effectively suckling effectively • Not low weight for age and no other signs of inadequate feeding. or • Thrush (ulcers or white patches in mouth) Advise the mother how to feed and keep the low weight infant warm at home If thrush.Lower lip turned outwards . advise to increase frequency of feeding. Classify FEEDING • Not well attached to breast or • Not suckling effectively. Advise her to breastfeed as often and for as long as the infant wants. or FEEDING PROBLEM OR LOW WEIGHT FOR AGE ASSESS BREASTFEEDING: • Has the infant breastfed in If the infant has not fed in the previous hour. ask the mother if she can wait and tell you when the infant is willing to feed again. LOOK AND FEEL: • Determine weight for age. Follow up any feeding problem or thrush in 2days. any other foods or drinks? If yes. LOOK FOR: . 35 .Mouth wide open . TO CHECK ATTACHMENT. reducing other foods or drinks.THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED INFANTS* If an infant has no indications to refer urgently to hospital SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print) ASK: • Is the infant breastfed? If yes. Praise the mother for feeding the infant well. teach correct positioning and attachment.) • Is the infant well attached? not well attached good attachment • Receives other foods or drinks. what do you use to feed the infant? • Less than 8 breastfeeds in 24hours. .

teach the mother to treat it at home Follow-up FEEDING PROBLEM or THRUSH in 2 days Follow up LOW WEIGHT FOR AGE in 7 days • Not low weight for age and no other signs of inadequate feeding NO FEEDING PROBLEM Advise mother to continue feeding. FEEDING PROBLEM OR LOW WEIGHT FOR AGE If mother is using a bottle. and how it is given to the infant. teach cup feeding If thrush. LISTEN. and ensure good hygiene Praise the mother for feeding the infant well 36 . FEEL: • • • Milk incorrectly or • • • • What milk are you giving? How many times during the day and night? How much is given at each feed? How are you preparing the milk? − Let mother demonstrate or explain how a feed is prepared. Look for ulcers or white patches in the mouth (thrush). Classify FEEDING unhygienically prepared Or • Giving inappropriate replacement feeds Or • Giving insufficient replacement feeds Or • An HIV positive mother mixing breast and other feeds before 6 months Or • Using a feeding bottle Or • Thrush Or • Low weight for age Counsel about feeding Explain the guidelines for safe replacement feeding Identify concerns of mother and family about feeding.THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN INFANTS RECEIVING NO BREAST MILK (use this chart when an HIV positive mother has chosen not to breastfeed) SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold i t) ASK: • • • • LOOK. Are you giving any breast milk at all? What foods and fluids in addition to replacement feeds is given? How is the milk being given? Cup or bottle? How are you cleaning the feeding utensils? Determine the weight for age.

Immunize sick infants unless being referred. Advise the caretaker when to return for the next dose.THEN CHECK THE YOUNG INFANT’S IMMUNIZATION AND VITAMIN A STATUS: AGE VACCINE BCG DPT+HIB-1 DPT+HIB-2 OPV-0 OPV-1 OPV-2 VITAMIN A 200 000 IU to the mother within 6 weeks of delivery Hepatitis 1 Hepatitis 2 IMMUNIZATION SCHEDULE: Birth 6 weeks 10 weeks Give all missed doses on this visit. ASSESS OTHER PROBLEMS 37 .

If the young infant is not able to swallow: Give 20-50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric tube.7 ml* 1.3 ml sterile water = 250 mg/1. 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.5 kg 0.1 ml* 3.4 ml* 2.0 ml 1. WEIGHT AMPICILLIN Dose: 50 mg per kg To a vial of 250 mg Add 1.8 ml 1. Give gentamicin once daily. continue to give ampicillin and gentamicin for at least 5 days.9 ml* 0.1 ml* 1. If the young infant is not able to breastfeed but is able to swallow: Give 20-50 ml (10 ml/kg) expressed breastmilk before departure.9 ml* 1.5 kg 2. Give ampicillin two times daily to infants less than one week of age and 3 times daily to infants one week or older.3 ml *Avoid using undiluted 40 mg/ml gentamicin.7 ml 0.3 ml* 1.0 ml* 1. If referral is not possible.5 ml GENTAMICIN Undiluted 2 ml vial containing 20 mg= 2 ml at 10 mg/ml OR Add 6 ml sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml AGE <7 days AGE>7 days Dose: 5 mg per kg Dose: 7.6 ml* 0. If not possible to give expressed breastmilk.5-<3 kg 3-<3.8 ml* 2.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.5 kg 3.5 mg per kg 0.5-<4 kg 4-<4.5 kg 1.2 ml* 1-<1. Referral is the best option for a young infant classified as VERY SEVERE DISEASE.6 ml* 2.1 ml 1. 38 .9 ml* 2. 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).5 ml 0.4 ml* 1.4 ml 0.5-<2 kg 2-<2.

gloves.5 ml AMOXICILLIN Give two times daily for 5 days Tablet 250 mg Syrup 125 mg in 5 ml Birth up to 1 month (<4 kg) 1/4 1/2 2. Dress the young infant with extra clothing including hat.5 ml 5 ml 1 month up to 2 months (4-<6 kg) 1/4 1 * Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.25 ml* 2. Give an Appropriate Oral Antibiotic for local infection For local bacterial infection: First-line antibiotic : Second-line antibiotic: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 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) 1/2* Syrup (40 mg trimethoprim +200 mg sulphamethoxazole) 1.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. 39 . socks and wrap the infant in a soft dry cloth and cover with a blanket.

Watch her as she does the first treatment in the clinic.TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER Teach the Mother How to Treat Local Infections at Home Explain how the treatment is given.25%) using a clean soft cloth wrapped around the finger Wash hands again To Treat Diarrhoea. Immunize Every Sick Young Infant. Tell her to return to the clinic if the infection worsens. as needed. 40 .5%) Wash hands again To Treat Thrush (ulcers or white patches in mouth) The mother should do the treatment 4 times daily for 7 days: Wash hands Paint the mouth with half-strength gentian violet (0. To Treat Skin Pustules or Umbilical 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. See TREAT THE CHILD CHART.

Look for signs of good attachment and effective suckling.wait until her infant's mouth is opening wide . aiming the infant's lower lip well below the nipple.with the infant approaching breast with nose opposite to the nipple . Show her how to help the infant to attach.COUNSEL THE MOTHER Teach Correct Positioning and Attachment for Breastfeeding Show the mother how to hold her infant . Teach the Mother How to Express Breast Milk Ask the mother to: Wash her hands thoroughly. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on the skin. not just neck and shoulders.move her infant quickly onto her breast. then express the other breast until the milk just drips. Compress and release all the way around the breast. Make herself comfortable.touch her infant's lips with her nipple .with the infant held close to the mother’s body . Compress and release the breast tissue between her finger and thumb a few times. Hold a wide necked container under her nipple and areola. If 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. keeping her fingers the same distance from the nipple. She should: . Alternate between breasts 5 or 6 times. If the attachment or suckling is not good. for at least 20 to 30 minutes. Express one breast until the milk just drips.with the infant's head and body in line . try again. Stop expressing when the milk no longer flows but drips from the start.with the infant's whole body supported. 41 . 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).

Feed the baby ____ times every 24 hours. Ensure that the mother or caretaker knows how to prepare milk correctly and hygienically and has the facilities and resources to do so. Make ____ ml for each feed. Make sure that the mother or caretaker understands that prepared feed must be finished within an hour after preparation. Stir well. Add the hot water to the powdered formula. Allow the infant to take the milk himself. Wash the utensils. 42 . Tip the cup so that the milk just reaches the infant’s lips. Demonstrate how to feed with a cup and spoon rather than a bottle. Hold the cup so that it rests lightly on the infant’s lower lip. DO NOT pour the milk into the infant's mouth. give it to an older child or drink it yourself. Discard any unused formula.COUNSEL THE MOTHER Counsel the HIV-positive mother who has chosen not to breastfeed (or the caretaker of a child who cannot be breastfed) The mother or caretaker should have received full counselling before making this decision Ensure that the mother or caretaker has an adequate supply of appropriate breast milk substitute replacement feed. Do not keep milk in a thermos flask because it will become contaminated quickly. Make sure that the mother or caretaker understands that mixing breastfeeding with replacement feeding may increase the risk of HIV infection and should not be done. Feed the baby using a cup. Always use the marked cup or glass to measure water and the scoop to measure the formula powder. Come back to see me on _____. Put a measured amount of milk in the cup. Measure the exact amount of powder that you will need for one feed. 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. Only make enough formula for one feed at a time. Your baby needs ______ scoops. HOW TO PREPARE COMMERCIAL FORMULA MILK Wash your hands before preparing the formula. The water should be added while it is still hot and not after it has cooled down. Boil enough water vigorously for 1 or 2 seconds.

nappies) whenever they are wet.g. Dress the young infant with extra clothing including hat and socks.Change clothes (e. re-warm the baby using skin to skin contact. do it in a very warm room with warm water. .Keep the room warm (at least 25°C) with home heating device and make sure that there is no draught of cold air. . Place the infant in skin to skin contact on the mother’s chest between the mother’s breasts. loosely wrap the young infant in a soft dry cloth and cover with a blanket. a nappy. .Keep the young infant in the same bed with the mother.Breastfeed (or give expressed breast milk by cup) the infant frequently 43 . . dry immediately and thoroughly after bathing and clothe the young infant immediately.Check frequently if the hands and feet are warm. keep the young infant clothed or covered as much as possible at all times.Avoid bathing the low weight infant. day and night. .Provide skin to skin contact as much as possible. hat and socks.When not in skin to skin contact. When washing or bathing. If cold. . Keep the infant’s head turned to one side Cover the infant with mother’s clothes (and an additional warm blanket in cold weather) . For skin to skin contact: Dress the infant in a warm shirt open at the front.COUNSEL THE MOTHER Teach the Mother How to Keep the Low Weight Infant Warm at Home .

MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES In cool weather cover the infant’s head and feet and dress the infant with extra clothing. EXCLUSIVELY BREASTFEED THE YOUNG INFANT Give only breastfeeds to the young infant Breastfeed frequently.COUNSEL THE MOTHER Advise the Mother to Give Home Care for the Young Infant 1. day or night. as often and for as long as the infant wants. during sickness and health. • • • • • Follow up visit If the infant has: Return for first follow-up in: JAUNDICE 1 day 2 days 14 days 14 days LOCAL BACTERIAL INFECTION FEEDING PROBLEM THRUSH DIARRHOEA • LOW WEIGHT FOR AGE • CONFIRMED HIV INFECTION or POSSIBLE HIV INFECTION/HIV EXPOSED 44 . WHEN TO RETURN: WHEN TO RETURN IMMEDIATELY: Advise the caretaker to return immediately 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 2. 3.

tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home. If improved. advise the mother home care and ask her to return for follow up in 1 day. If jaundice has started decreasing. but jaundice has not decreased. If pus and redness are improved. If jaundice continues beyond three weeks of age . assess and treat the young infant for diarrhoea. If skin pustules are same or worse. 45 . DIARRHOEA After 2 days: Ask: Has the diarrhoea stopped ? Treatment: If the diarrhoea has not stopped. reassure the mother and ask her to continue home care. If palms and soles are not yellow. refer to hospital. Are palms and soles yellow? If palms and soles are yellow. >SEE “Does the Young Infant Have Diarrhoea ?” If the diarrhoea has stopped. refer the young infant to a hospital for further assessment. Treatment: If umbilical pus or redness remains same or is worse. Ask her to return for follow up at 3 weeks of age. LOCAL BACTERIAL INFECTION After 2 days: Look at the umbilicus. tell the mother to continue exclusive breastfeeding. Is it red or draining pus? Look for skin pustules. refer to hospital. refer to hospital.GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT ASSESS EVERY YOUNG INFANT FOR “VERY SEVERE DISEASE” DURING FOLLOW UP VISIT. tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home. JAUNDICE After 1 day: Look for jaundice.

If you counsel the mother to make significant changes in feeding. or if the young infant has lost weight. Refer for ART if presumptive severe HIV infection as per definition above. ask the mother to return 14 days after the initial visit to measure the young infant's weight gain. ask her to bring the young infant back again. Counsel about feeding practices. FEEDING PROBLEM After 2 days: Reassess feeding. Counsel the mother about her HIV status and arrange counselling and testing for her if required. 46 . Exception: If you do not think that feeding will improve. if not already done so. > See "Then Check for Feeding Problem or Low Weight" above. Counsel the mother about any new or continuing feeding problems. Test for HIV infection as early as possible. Ask about any feeding problems found on the initial visit. Start co-trimoxazole prophylaxis at 4-6 weeks. If the young infant is low weight for age. if not started already and check compliance. Avoid giving both breast milk and formula milk (mixed feeding). refer to HOSPITAL.GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT POSSIBLE HIV/HIV EXPOSED Follow-up after 14 days and then monthly or according to immunization programme.

47 . If thrush is worse. continue half-strength gentian violet for a total of 7 days. Reassess feeding. If the infant is still low weight for age. but is feeding well. or if the young infant has lost weight. Ask the mother to return again in 14 days (or when she returns for immunization. refer to hospital. Exception: If you do not think that feeding will improve. Ask her to have her infant weighed again within a month or when she returns for immunization. or the infant has problems with attachment or suckling. If the infant is still low weight for age and still has a feeding problem. refer to hospital. 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. If thrush is the same or better. praise the mother. and if the infant is feeding well. If the infant is no longer low weight for age. praise the mother and encourage her to continue. THRUSH After 2 days: Look for ulcers or white patches in the mouth (thrush). > See "Then Check for Feeding Problem or Low Weight" above. if this is within 14 days).GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT LOW WEIGHT FOR AGE After 14 days: Weigh the young infant and determine if the infant is still low weight for age. counsel the mother about the feeding problem. Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above.

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SCABIES . * IMAI acute care module gives more information 50 .If extensive Refer. RINGWORM (TINEA) . and feet. to prevent recurrences of tinea infection of skin Fungal nail infection is a Clinical stage 2 defining disease Rash and excoriations on torso. . Or give griseofulvin 10 mg/kg/day.Manage with anti-scabies: .If not improved.ANNEX A: SKIN AND MOUTH CONDITIONS* Identify skin problem if skin is itching SIGNS Itching rash with small papules and scratch marks.calamine lotion . May also be found on body or web of feet. For 12 up to 5give 60 mg per day .25% topical benzyl benzoate at night . shave hair . burrows in web space and wrist. Crusted scabies presents as extensive areas of crusting mainly on the scalp face.Whitfield’s ointment or other anti-fungal cream if few patches .Treat itching as above Extensive : There is a high incidence of coexisting nail infection which has to be treated adequately. repeat for 3 days after washing .Treat itching as above .Antihistamine by mouth (PRURIGO) . 1% hydrocortisone Can be an early sign of HIV and needs assessment for HIV Unique features in HIV Is a Clinical stage 2 defining disease An itchy circular lesion with a raised edge and fine scaly area in centre with loss of hair.1% topical lindane cream or lotion once– wash off after 12 hours In HIV positive individuals scabies may manifest as crusted scabies. if not give: ketoconazole for 2 up to 12(6-10 kg) 40 mg per day. back.If in hairline. Dark spots with pale centres CLASSIFY AS TREATMENT Treat itching: PAPULAR ITCHING RASH . Face spared. Patients may not complain of itch but the scales will be teeming with mites.

also involving lips and / or mouth HERPES SIMPLEX If child unable to feed. Herpes zoster is uncommon in children except where they are immuno-compromised. typical vesicles evolve into non-healing ulcers that become necrotic. disseminated or multidermatomal Is a Clinical stage 2 defining disease Vesicular lesion or sores. crusted. necrotic ulceration Rarely recurrent. warm crusts or small lesions IMPETIGO OR FOLLICULITIS Clean sores with antiseptic Drain pus if fluctuant Start cloxacillin if size >4cm or red streaks or tender nodes or multiple abscesses for 5 days ( 25-50 mg/kg every 6 hours) Refer URGENTLY if child has fever and /or if infection extends to the muscle 51 .ANNEX A cont/d Identify skin problem if skin has blisters / sores / pustules SIGNS Vesicles over body. tender. and hyperkeratotic. Vesicles appear progressively over days and form scabs after they rupture CLASSIFY AS Chicken pox TREATMENT Treat itching as aboveRefer URGENTLY if pneumonia orjaundice appear Unique features in HIV Presentation atypical only if child is immunocompromised Duration of disease longer Complications more frequent Chronic infection with continued appearance of new lesions for >1 month. Therefore continue treatment till complete healing of ulcer Chronic HSV infection (>1) is a Clinical stage 4 defining disease Red. Vesicles in one area on one side of body with intense pain or scars plus shooting pain. give acyclovir as above Extensive area of involvement Large ulcers Delayed healing (often greater than a month) Resistance to Acyclovir common. for example if infected with HIV HERPES ZOSTER Keep lesions clean and dry. Use local antiseptic If eye involved give acyclovir– 20 mg /kg (max 800 mg) 4 times daily for 5 days Give pain relief Follow-up in 7 days Duration of disease longer Hemorrhagic vesicles. refer If first episode or severe ulceration.

Liquid nitrogen cryotherapy.For seborrheic dermatitis: 1% hyrdocortison cream X2 daily. Warts Treatment: Topical salicylic acid preparations (eg. Electrocautery Lesions more numerous and recalcitrant to therapy. Classify Molluscum contagiosum Management & treatment can be treated by various modalities: Leave them alone unless superinfected Use of phenol: pricking each lesion with a needle or sharpened orange stick and dabbing the lesion with phenol Electrodesiccaton Liquid nitrogen application (using orange stick)Curettage Unique features in HIV Incidence is higher Giant molluscum (>1cm in size). Seborrheic dermatitis may be severe in HIV infection. refer. or coalescent double or triple lesions may be seen More than 100 lesions may be seen. Secondary infection may be common 52 . body folds Sebbhorrea Ketoconazole shampooIf severe. refer or provide tropical steroids.ANNEX A cont/d IDENTIFY PAPULAR LESIONS: NON-ITCHY Presenting signs & symptoms Skin colored pearly white papules with a central umblication. Duofilm). If severe. It is most commonly seen on the face and trunk in children. Extensive viral warts is a Clinical stage 2 defining disease Greasy scales and redness on central face. Lesions often chronic and difficult to eradicate Extensive molluscum contagiosum is a Clinical stage 2 defining disease The common wart appears as papules or nodules with a rough (verrucous) surface.

Give oral care to young infant or child. If not able to refer. refer for ART initiation ( Stage 4 disease) Counsel the mother on home care for oral thrush. ORAL HAIRY LEUCOPLAKIA 53 . shiny scales on nipple and areola). consider symptomatic HIV Give paracetamol if needed for pain ( Stage 3 disease) Does not independently require treatment. If present (dry. ORAL THRUSH Most frequently seen on the sides of the tongue. Tell the mother when to come back immediately.ANNEX A: ASSESS. but resolve with ART and Acyclovir ( Stage 2 disease) White patches in mouth. The mother should: Wash her hands Wash the young infant / child’s mouth with a soft clean cloth wrapped around her finger and wet with salt water Instill 1ml nystatin four times per day or paint the mouth with half strength gentian violet for 7 days Wash her hands after providing treatment for the young infant or child Avoid feeding for 20 minutes after medication If breastfed. ( Stage 4 disease) Pain or difficulty swallowing Give fluconazole. recurrent or pharyngeal thrush. treat with nystatin or GV Advise the mother to wash breasts after feeds. which can be scraped off. advise to change to cup and spoon If severe. Once stabilized. Follow up in 2 days. check mother’s breasts for thrush. a white plaque with a corrugated appearance. If mother is breastfeeding check and treat the mother for breast thrush. If bottle fed. CLASSIFY AND TREAT SKIN AND MOUTH Mouth problems : Thrush PRESENTING SIGNS Not able to swallow CLASSIFY SEVERE OESOPHAGEAL THRUSH OESOPHAGEAL THRUSH TREATMENTS Refer URGENTLY to hospital. If mother is breastfeeding check and treat the mother for breast thrush. give fluconazole.

or one or more dark skin areas (fixed drug reactions) CLASSIFY Fixed drug reactions Treatment Stop medications Give oral antihistamines If peeling rash refer Unique features in HIV Could be a sign of reaction to ARV’s Wet. Treat itching - Severe reaction due to cotrimoxazole or NVP involving the skin as well as the eyes and/mouth. widespread with small bumps or blisters. co-trimoxazole or even efafirenz.ANNEX A: ASSESS. 54 . thick patches ECZEMA Soak sores with clean water to remove crusts (no soap) Dry skin gently Short-term use of topical steroid cream not on face. oozing sores or excoriated. CLASSIFY AND TREAT SKIN AND MOUTH CONDITIONS DRUG /ALLERGIC REACTIONS Pictures Signs Generalized red. Might cause difficulty breathing Steven-Johnson syndrome Stop medication Refer Urgently The most lethal reaction to NVP.

AZT or d4T + 3TC + NVP or EFV1 : AZT + 3TC + NVP AZT + 3TC + EFV d4T + 3TC + NVP d4T + 3TC + EFV ABC +3TC + NVP or EFV1: ABC + 3TC + NVP ABC + 3TC + EFV * If <3 years or <10 kg. use NVP. The choice of regimen at the country level will be determined by the National ART guidelines.ANNEX B: PAEDIATRIC ART and dosages RECOMMENDED FIRST LINE ARV REGIMENS FOR CHILDREN The following regimens are recommended by WHO as first line ART for children. EFV cannot be used in these children. COMMONLY USED ANTIRETROVIRAL DRUGS Nucleoside reverse transcriptase inhibitors (NsRTI) Nucleotide reverse transcriptase inhibitors (NtRTI) tenofovir disoproxil fumarate (TDF) Non-nucleoside reverse transcriptase inhibitors (NNRTI) nevirapine (NVP) efavirenz (EFV) Protease Inhibitors (PI) Up to 12 months POPULATION 1.4 years > 5 years Stavudine (d4T) lamivudine (3TC) zidovudine (ZDV/AZT) didanosine (ddI) abacavir (ABC) lopinavir (LPV) saquinavir (SQV) indinavir (IDV) nelfinavir (NFV) retonavir (RTV)* START ART PMTCT/NVP exposure : PI-regimen NVP/EFV + 2NRTI NVP/EFV + 2NRTI *ritonavir is used as a ‘helper’ for one PI to make the effect of a second PI stronger 55 .

ANNEX B: ARV DOSAGES 56 .

75 Twice daily means 1 tablet AM and 0.5 2 2.9 4-5.9 14-19.9 Syrup 10 mg/ml 3 ml 3 ml 4 ml 6 ml or 30 mg tablet 1 1 1.9 Syrup 10 mg/ml 6 ml 6 ml 9 ml or 6 mg tablet 1 1 1.9 20-24.Give 4 mg/kg per dose twice daily Weight 3-3.9 4-5.9 14-19.5 twice daily means 2 tablets AM and 1 tablet PM Lamivudine (3TC) .9 Syrup 20 mg/ml 3 ml 3 ml 4 ml 6 ml or 60 mg tablet 1 1 1.75 Abacavir (ABC) .9 20-24.Give 8 mg/per dose twice daily Weight 3-3.9 14-19.5 3 or 300 mg tablet Stavudine (d4T) .9 10-13.9 20-24.5 3 or 150 mg tablet Zidovudine (AZT or ZDV) .9 6-9.5 3 or 150 mg tablet 0.9 20-24.IMPORTANT POINTS TO REMEMBER ON ARV DOSAGES: • • • Give for children 6 weeks of age and above 0.9 6-9.9 Syrup 10 mg/ml 6 ml 6 ml 9 ml 12 ml or 30 mg tablet 1 1 1.5 2 2.9 4-5.9 4-5.9 6-9.75 57 .9 10-13.Give 180-240 mg/m2 per dose twice daily Weight 3-3.5 3 or 15 mg tablet or 20 mg tablet 1 1 1 0.5 (half) tablet PM 1.5 2 2.9 6-9.5 2 2.9 10-13.5 0.5 0.9 14-19.9 10-13.Give 1 mg/kg per dose twice daily Weight 3-3.

5 Efavirenz (EFV) .75 0. give only AM dose Weight 3-3.9 6-9.5 ml 3 ml or 100/25 mg tablet 0.9 14-19.9 14-19.5 ml 1.9 Syrup 10 mg/ml 5 ml 5 ml 8 ml 10 ml or 30 mg tablet 1 1 1. Lead-in dose during week 1 and 2.9 10-13.75 1.9 Syrup 80/20 mg/ml 1 ml 1.9 20-24.9 4-5. Weight 10-13.9 20-24.5 2 2.5 ml 2 ml 2.Give 230/75.ANNEX B: ARV DOSAGES cont/d Nevirapine (NVP) .Give maintenance dose 160-200 mg/m2 per dose twice daily.5 3 or 150 mg tablet Lopinavir/ritonavir (lop/rit) .5 mg/m2 twice daily and increase to 300/75 mg/m2 if taken with nevirapine Weight 3-3.9 10-13.9 6-9.Give 15 mg/kg/day if capsule or tablet once daily.9 Combinations of 200.9 4-5.9 20-24.9 14-19. 100 and 50 mg capsules One 200 mg One 200 mg + one 50 mg One 200 mg + one 100 mg or 600 mg tablet 58 .5 2 2.

5 1.5 2.9 2.9 1.6 ml 1.9 3 3 3 3 3 3 3 59 .9 AM 0.5 1.5 1.9 1.5 2.5 2.9 0.ANNEX B: ARV DOSAGES cont/d Zidovudine 10mg/ml syrup for PMTCT prophylaxis in newborns.5 10-13.5 20-24.2 ml 4-4.9 2 2 2 2 2 2 2 14-19.5 2.5 1.8 ml 3-3.5 2.8 ml 0.5 1. Give 4/kg/ twice daily Weight in kg 1-1.5 2.9 1 1 1 1 1 1 1 4-4.5 1.2 ml 1.9 1.4 ml 2-2.6 ml COMBINATION ARV Weight AZT/3TC 60/30 mg AZT/3TC/NVP 60/30/50 mg d4T/3TC 6/30 mg d4T/3TC/NVP 6/30/50 mg ABC/3TC 60/30 mg ABC/3TC/NVP 60/30/50 mg ABC/AZT/3TC 60/60/30 mg 3-3.9 1 1 1 1 1 1 1 6-9.4 ml PM 0.

refer to IMAI chronic care guideline module 60 . back of neck become FAT Potentially serious side effects: warn patients and tell them to seek care Side effects occurring later during treatment: discuss with patients NauseaDiarrhoea NVP nevirapine Seek care urgently: Yellow eyes Severe Skin rash Fatigue AND shortness of breath Fever Nausea Diarrhoea Headache Fatigue Muscle pain Nausea Diarrhoea Strange dreams Difficulty sleeping Memory problems Headache Dizziness Seek care urgently:Pallor (anaemia) ZDV zidovudine (also known as AZT) EFV efavirenz Seek care urgently:Yellow eyesPsychosis or confusionSevere Skin rash * for more guidance. belly. buttocks. numb or painful feet or legs or hands NauseaDiarrhoea 3TC lamivudine Changes in fat distribution: Arms. legs. also be prepared to manage when patients seek care NauseaDiarrhoea d4T stavudine Seek care urgently: Severe abdominal pain Fatigue AND shortness of breath Seek advice soon: Tingling. cheeks become THIN Breasts.Annex C : ARV side effects* Very common side-effects: warn patients and suggest ways patients can manage.

frequency and duration <2 years >2 years 200mg 8 hourly for 5 days 400mg 8 hourly for 5 days Recommended dosages for cloxacillin / flucloxacillin Weight of child 3 -<6kg 6 -<10kg 10 -<15kg 15 -<20kg Form 250mg capsule Dose. every 6 hours for 5 days ½ tablet 1 1 2 61 .5 ml once a day 12. frequency and duration 2 months up to 3 -<6kg 12 months 6 -<10kg 12 months up to 10-19kg 5 years 20 mg once daily 40 mg once daily 60 mg once daily 5 ml once a day 7.ANNEX D: DRUG DOSAGES FOR OPPORTUNISTIC INFECTIONS Fluconazole dosage Weight of child 3 -<6kg 6 -<10kg 10 -<15kg 15 -<20kg 20 -<29kg 50mg/5ml oral suspension 50 mg capsule Recommended dosages for ketoconazole Age of child Weight Dose.000 units per ml given 1-2 ml four times daily for all age groups Recommended dosages for acyclovir Age of child Dose.5 ml once a day 1 1-2 2-3 Recommended dosages for griseofulvin 10 mg per Kg per day Nystatin oral suspension 100.

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M.Kalyesubula. as well as several meetings of the WHO paediatric ART Working Group. Mofenson. L. Pierre. W. was summarized in the document "Technical updates of the guidelines on IMCI : evidence and recommendations for further adaptations. L. Benchekroun. D. Rimoin. R. El Hoda. Abrams. Deorari. Jacobs. Similarly. N. Kabore. Bhakeecheep. Bwakura-Dangarembizi. Their contributions are acknowledged. Other persons who reviewed the draft chart booklet and provided comments include A. R. ear infections and infant feeding. 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". Rivadeneira. J. 1998). B. Dr Antonio Pio did the technical editing of the draft IMCI chart booklet. . Gul Rehman and a team of CAH staff members drafted the updated chart booklet based on the above. Darmstadt. C. Pinto.P. U. T. Vaz. Luo. Vibol. 2005". M. Wright and WHO staff from Regional and Headquarter offices. V. Gibb. findings of a multi-centre study (Lancet. Mutiti. Nunn. Carlo. Paediatric HIV/ART Care Guideline Group Meeting WHO Headquarters. Reviews were usually followed by technical consultations where the recommendations and their technical bases were discussed and consensus reached. A Ojoo. Msellati. Prendergast. D. H. Humblet. Bhutta. S. Anabwani. L. G.Taylor. Desta. Clarke.N. C.F. M. Zhao Yan. diarrhoeal diseases. Geneva. DeLhomme. I. Catherine M. Dr. R.S. D. S. A. Kekitiinwa. A.10-11 April 2008.N. P. Capparelli R. G. T. Leroy. Agnes Mahomva. H. Schaefer. P. Meyers. L. A. Cotton. P. Oguda. J. Mukherjee. H.. V. M. Lodha. P. Paul and S. R. Kazembe. A. The chart booklet for high HIV settings is different because it includes sections on paediatric HIV care. More recently. Wilfert. Dabis. E. Cerezo. Switzerland. 2008) led to the development of simplified recommendations for the assessment of severe infections in the newborn. E. Martina Penazzato & Sally Girvin as well as WHO regional and HQ staff. The changes made in this edition are based on the new recommendations for paediatric ART following a technical consultation " Report of the WHO Technical Reference Group. D. F. New evidence on the management of acute respiratory infections. S. M. Ramzi. P. T. Nduati. Evidence reviews supported the formulation of recommendations in each of these areas (see document and the references). Kumar.A. Omar. Eley. Hoa. MK Bhan. malaria. published between 1995 and 2004. Mirochnick. P.Z. Ferris. Blaise. Weidle. R. Paul. in addition to participating in its peer-review. Technical basis for adapting clinical guidelines. None of the above experts declared any conflict of interest. Essajee. Their contributions are acknowledged. Frigati. Kassie. A. A. The Department plans to review the need for an update of this chart booklet by 2011. NE Ata Alla. Nyazema. Giaquinto. Who was involved and their declaration of interests The following experts were involved in the development of the updated newborn recommendations: Z.Z. A. T. V. Mazmanyan. Moultrie.Integrated Management of Childhood Illness Chart booklet for high HIV settings Process of updating the IMCI chart booklet for high HIV settings 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. The experts involved in making new paediatric ART recommendations were E.

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