INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
SICK CHILD
AGE 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 sore throat? .......................................... 4
Does the child have an ear problem? ................................... 4
Does the child have fever? ................................................... 5
Classify malaria ............................................................. 5
Classify measles ............................................................ 5
Then Check for Malnutrition............................................. 6
Then Check for Anaemia ................................................ 6
Then Check the Child's Immunization Status ................. 6
Then Check the Child's Vitamin A Supplementation Status6
Then Check the Child's Deworming Status .................... 6
Assess Other Problems .................................................. 6
TREAT THE CHILD
Teach the Mother to Give Oral Drugs at Home
Oral Antibiotic ............................................................ 7
Oral Antimalarial ....................................................... 8
Paracetamol............................................................... 8
Multi Vitamin / Mineral Supplement ........................... 8
Vitamin A ................................................................... 8
Iron ............................................................................ 8
Medendazole ............................................................ 8
Teach the Mother to Treat
Local Infections at Home
Treat Eye Infection with
Chloramphenicol Eye Ointment................... 9
Dry the Ear by Wicking.............................................. 9
Treat Mouth Ulcers with Gentian Violet .................... 9
Soothe the Throat, Relieve the Cough with
a Safe Remedy............................................ 9
Give These Treatments in Clinic Only
Treat Convulsions with Diazepam .......................... 10
Intramuscular Antibiotic .......................................... 10
Quinine for Severe Malaria ..................................... 10
Treat Wheezing ...................................................... 11
Prevent Low Blood Sugar ...................................... 11
antibiotic for Streptococcal Sore Throat ................. 11
TREAT THE CHILD, continued
Give Extra Fluid for Diarrhoea
and Continue Feeding
Plan A: Treat Diarrhoea at Home......................................... 12
Plan B: Treat Some Dehydration with ORS......................... 12
Plan C: Treat Severe Dehydration Quickly........................... 13
Immunize Every Sick Child, As Needed..........................13
Give Follow-up-Care
Pneumonia............................................................................14
No Pneumonia - Wheeze......................................................14
Dysentery..............................................................................14
Persistent Diarrhoea.............................................................15
Ear Infection..........................................................................15
Malaria (Low or High Malaria Endemic Area)........................15
Fever-Malaria Unlikely (Malaria non Endemic Area).............15
Fever No Malaria (No Malaria Risk)......................................15
Measles with Eye or Mouth Complications............................16
Measles.................................................................................16
Feeding Problems.................................................................16
Anaemia................................................................................16
Very Low Weight...................................................................16
COUNCEL THE MOTHER
Food
Assess the Child's Feeding...................................................17
Feeding Recommendations..................................................18
Counsel About Feeding Problems.........................................19
Fluid
Increase Fluid During Illness.................................................20
When to Return
Advise the Mother When to Return to
Health Worker ...............................................................20
Counsel the Mother About
Her Own Health.......................................................................21
Ministry of Health World Health UNICEF
Pakistan Ogranization
SICK YOUNG INFANT
AGE LESS THEN 2 MONTHS
ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
Assess, Classify and Identify Treatment
Check for Possible Infection ............................................................22
Check for Possible Neonatal Tetanus ..............................................22
Then Check for Jaundice .................................................................22
Then ask: Does the young infant have diarrhoea?...........................23
Then Check for Feeding Problem,Low Birth Weight,Low Weight.....24
Then Check the Young Infant's Immunization Status ......................25
Assess Other Problems....................................................................25
Treat the Young Infant and Counsel the Mother
Intramuscular Antibiotics .................................................................26
To Treat Diarrhoea, See TREAT THE CHILD Chart................... 12-13
Immunize Every Sick Young Infant ..................................................27
Traat Local Infections at Home ........................................................27
To Treat Eye Infection, See TREAT THE CHILD Chart .....................9
Correct Positioning and Attachment for Breastfeeding....................28
Home Care for Young Infant ............................................................28
Give Follow-up Care for the Sick Young Infant
Local Bacterial Infection...................................................................29
Diarrhoea.........................................................................................29
Feeding Problem..............................................................................30
Low Weight, Low Birth Weight.........................................................30
Thrush..............................................................................................30
RECORDING FORMS
SICK YOUNG INFANT ..........................................................31
SICK CHILD ...............................................................................33
WEIGHT FOR AGE CHART ...................................................... on back cover
February 2010
 2

ASSESS AND CLASSIFY THE SICK CHILD

AGE 2 MONTHS UP TO 5 YEARS
ASSESS CLASSIFY IDENTIFY
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE TREATMENT
Determineif thisis an initiao l r follow-upvisitforthisproblem. USE ALL BOXES THAT MATCH THE
- if follow-up visit,use thefollow-up instructionosn FOLLOW-UP chart. CHILD'S SYMPTOMS AND PROBLEMS
- if initialvisit,assess the childas follows: TO CLASSIFY THE ILLNESS.

CHECK FOR GENERAL DANGER SIGNS SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold and italic print.)

ASK: LOOK: Treat convulsions if present now.

Is thechildnotable to drinkor breastfeed?
Does the childvomiteverything?
Has the childhad convulsions?
See if the childis lethargicor Complete assessment immediately
Any generaldangersign VERY
unconscious. Give first dose of an appropriate antibiotic.
SEVERE DISEASE Treat the child to prevent low blood sugar.
See if thechildis convulsingnow
Refer URGENTLY to hospital.

Give first dose of an appropriate antibiotic.

Any general danger sign
THEN ASK ABOUT MAIN SYMPTOMS: or VERY SEVERE
DISEASE
Treat wheezing if present
Treat the child to prevent low blood sugar.
Stridor in calm child
Does the child have cough or difficult breathing? Refer URGENTLY to hospital.*
Give an appropriate Oral antibiotic for 5 days
IF YES, ASK: LOOK, LISTEN: Classify Ifwheezing(evenif it disappearedafterrapidlyacting
bronchodilator)give oral bronchodilatorfor5 days
Countthe breathsin one COUGH or FastBreathingand/or Soothe thethroatand relievethecough witha safe remedy
For howlong?
minute. CHILD DIFFICULT LowerChestIndrawing PNEUMONIA Ifcoughingformore than 3 weeks or if havingrecurrent
Look forchestindrawing. MUST BE BREATHING wheezing,refer for assessment forTB or Asthma
Look and listenforstridor CALM Advise mother when to return immediately.
Look and listenforwheeze. Follow-upin 3 days.
Ifwheezing(evenif it disappearedafterrapidly
If the child is: Fast breathing is: If wheezing and either fast
actingbronchodilator)give a oralbronchodilato
r
breathing or chest indrawing: No signsofpneumonia for5 days.
2 monthsup 50 breathsper Give a trialof rapidactinginhaled orveryseveredisease. Ifcoughingmorethan3 weeks or if having recurrent
NO PNEUMONIA:
to 12 months minuteor more bronchodilatofrorup to threetimes15-20 (if wheeze go directlyto treat COUGH OR COLD wheezing refer for assessment forTB or Asthma.
minutesapart.Countthebreathsand Soothe thethroatand relievethecoughwith
12 monthsup 40 breathsper lookforchestindrawing again,and wheezing)
to 5 years minuteor more thenclassify .
a safe remedy.
Advise mother when to return immediately.
Followup in 3 days if not improving.
Does the child have diarrhoea? If childhas no other severe classification:
- Give fluidfor severe dehydration(Plan C).
Two of the followingsigns: - Give appropriatedose of Zinc Suspensionfor 10 days.
IF YES, ASK: LOOK AND FEEL:
for OR
DEHYDRATION Lethargicor unconscious SEVERE If child also has another severe classification:
For how long? Look at the child'sgeneral condition. - Refer URGENTLY to hospital with mother
Sunken eyes DEHYDRATION
Is the child: giving frequent sips of ORS on the way.
Not able to drinkor drinkingpoorly
Is there bloodin the Advise the mother to continue breastfeeding.
Lethargicor unconscious? Skin pinchgoes back very slowly.
stool? If child is 2 years or older and there is cholera in your area,
Restlessand irritable?
give antibiotic for cholera.
Look for sunkeneyes. Give fluidand food for some dehydration(Plan B).
Two of the followingsigns: Give appropriatedose of Zinc Suspensionfor 10 days.
Offer the childfluid.Is the child:
If child also has any other severe classification:
Restless,irritable SOME - Refer URGENTLY to hospital with mother
Not able to drinkor drinkingpoorly? Classify giving frequent sips of ORS on the way.
Drinkingeagerly, thirsty? Sunken eyes DEHYDRATION
DIARRHOEA Drinkseagerly, thirsty Advise the mother to continue breastfeeding.
Pinch the skin of the abdomen. Skin pinchgoes back slowly. Advisemotherwhen to returnimmediatel.y
Does it go back: Follow-upin 2 days if not improving.

Very slowly(longerthan 2 seconds)? Give fluidand food to treat diarrhoeaat home (Plan A).
Slowly? Not enoughsignsto classifyas some NO Give appropriatedose of Zinc Suspensionfor 10 days.
or severe dehydration. DEHYDRATION Advisemotherwhen to returnimmediatel.y
Follow-upin 2 days if not improving.

Treat dehydrationbefore referralunlessthe childhas any other

SEVERE
severe classification.
Dehydrationpresent. PERSISTENT Give appropriatedose of Zinc Suspensionfor 10 days.
DIARRHOEA Refer to hospital.
if diarrhoea is for
14 days or more Advisethe motheron feedinga childwho has
PERSISTENT DIARRHOEA.
No dehydration.
PERSISTENT Give appropriatedose of Zinc Suspensionfor 10 days.
DIARRHOEA Give multivitaminm , ineralsupplementfor two weeks
Advisemotherwhen to returnimmediately
Follow-upin 5 days.

Treat for 3 days with an oral antibiotic recommended for

Shigella.
and if blood Bloodin the stool. DYSENTERY Give appropriatedose of Zinc Suspensionfor 10 days.
in stool Advisemotherwhen to returnimmediately
Follow-upin 2 days.

* I f refer ral is n ot p ossib le, m an ag e t h e ch ild as d escr ib ed in In te g ra te d M a n a g e m e n t o f C h ild h o o d Illn e ss, Treat t h e Ch ild ,
An n ex: W h ere Refer ral I s Not Possib le, an d W HO g u id elin es for in p at ien t care.

DANGERSIGNS, COUGH
DIARRHOEA
ASSESS AND CLASSIFY

Does the child have throat problem:
IF YES, ASK:
Does the child have sore
throat?
Is the child not able to drink?
Does the child have fever?
Does the child have an ear problem?
IF YES, ASK:
Is there severe ear pain?
Is there ear discharge?
If yes, for how long?
LOOK AND FEEL:
Fever (temperature 37.5o C or above)
Feel the front of the neck for tender
enlarged lymph nodes.
Look for red, enlarged tonsils
Look for exudate on the throat.
LOOK AND FEEL:
Look for pus draining from the ear.
Feel for tender swelling behind the ear.
4
Classify
SORE THROAT Sore throat AND not able to drink
Fever and/ or sore throat AND
at least two of the following signs.
Tender, enlarged lymph nodes on
neck.
Red, enlarged tonsils.
White exudate on throat.
Not enough signs to classify as
throat abscess or streptococcal
sore throat.
No signs present (with or without
fever)
Classify
Tender swelling behind the ear.
EAR PROBLEM
Pus is seen draining from the ear
and/or discharge is reported for
less than 14 days, OR
Severe ear pain.
Discharge is reported for 14 or
more days (pus is seen or not seen
draining from the ear).
No ear pain and
No pus draining from the ear.
Give first does of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
THROAT ABSCESS Give first dose of paracetamol for high fever or pain.
Refer URGENTLY to hospital.
Give benzathine penicillin or Amoxycillin.
Give paracetamol for high fever or pain.
STREPTOCOCCAL Give safe, soothing remedy for sore throat.
SORE THROAT Advice mother when to return immediately
Follow-up in 5 days if not improving
Give safe, soothing remedy for sore throat.
VIRAL SORE Give paracetamol for high fever or pain.
Advice mother when to return immediately
THROAT
Follow-up in 5 days, if not improving.
NO THROAT
No additional treatment.
PROBLESM
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
MASTOIDITIS
Give first dose of paracetamol for high fever or pain.
Refer URGENTLY to hospital.
Give an appropriate oral antibiotic for 5 days.
Give paracetamol for high fever or pain.
ACUTE EAR Dry the ear by wicking.
INFECTION Advise mother when to return immediately.
Follow-up in 5 days.
Dry the ear by wicking if pus seen draining from the ear
Give appropriate topical quinolone ear drops for 2 weeks
CHRONIC EAR Give paracetamol for high fever or pain
INFECTION Refer to Ear Nose & Throat specialist.
Follow-up in 5 days.
NO EAR If any other ear problem present give appropriate treatment or
INFECTION refer to Ear Nose & Throat specialist.
 Does the child have fever?
(by historyor feels hot or temperature37.5OC *** or above)

A patient presenting with fever
(continuous or intermittent)
(temp=or >more then 37.5 C)
o In non or low endemicareas travel
or history of fever with in the
last 3 days associated with
rigors, with no features of
other diseases and have one
or more of the following:
headache, nausea vomiting.
THEN ASK:
Fever For how long?
If more than 7 days, has fever
been presentevery day?
Has the childhad measles within
the last 3 months?
IF YES:
Malaria transmissionin the area = Yes
Transmissionseason = Yes
historywithinthe last 15-days to an area
where malaria transmissionoccurs= Yes
Yes_____ No_____
(if yes, use the treatmentinstructions
for the relevantmalaria risk area)
CLASSIFY
FEVER
LOOK AND FEEL
Look or feel for stiff neck.
Look for runnynose.
Look for signsof MEASLES
Generalizedrash of measles AND
One of these: cough,runnynose,
or red eyes.
IF YES Any general danger sign or
Stiff neck.
Fever (by history or feels hot or
O (CLINICAL)
temperature 37.5 C*** or above).
Any general danger sign or
IF NO
Stiff neck.
Fever for more than two days.
AND
- Runny nose PRESENT or
- Measles PRESENT or
- Other cause of fever PRESENT
Take the slide (thick and thin) immediately before giving IM artimether or
quinine and send it with the patient.
Give first dose of IM artimether or quinine for suspected severe or
VERY SEVERE complicated malaria.
FEBRILE
Give first dose of an appropriate antibiotic.
DISEASE Treat the child to prevent low blood sugar.
o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Refer URGENTLY to hospital.
Confirm through RDTs or Microscopy if available.
Treat the child with appropriate antimalarial.
SUSPECTED o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Advisemotherwhen to returnimmediatel.y
MALARIA**** Follow-upin 3 days if fever persists.
If fever is presentevery day for more than 7 days, refer for assessment.
Take the slide (thick and thin) immediately before giving IM artimether or
quinine and send it with the patient.
Give first dose of IM artimether or quinine for suspected severe or
VERY SEVERE complicated malaria.
FEBRILE Give first dose of an appropriate antibiotic.
DISEASE Treat the child to prevent low blood sugar.
o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Refer URGENTLY to hospital.
Give one dose of paracetamol in clinic for high fever (38.5o C or above).
FEVER - Treat other cause of fever accordingly.
MALARIA Advise mother when to return immediately.
UNLIKELY Follow-up in 3 days if fever persists.
If fever is present every day for more than 7 days, refer for assessment.

If the child has measles now Look for mouthulcers. Give first dose of an appropriate antibiotic.
o
or within the last 3 months: Any general danger sign or Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Are they deep and extensive?
MEASLES NOW Clouding of cornea or SEVERE If clouding of the cornea or pus draining from the eye, apply
Look for pus drainingfrom the eye. OR WITH IN THE COMPLICATED chloramphenicol eye ointment.
Deep or extensive mouth MEASLES***** Treat the child to prevent low blood sugar.
Look for cloudingof the cornea. LAST 3 MONTHS ulcers. Give Vitamin A.
Refer URGENTLY to hospital.
Give one dose of paracetamol in clinic for high fever (38.5o C or above).
MEASLES WITH If pus draining from the eye, treat eye infection with chloramphenicol eye
Pus draining from the eye EYE AND / OR ointment. If mouth ulcers, treat with gentain violet
or MOUTH Give Vitamin A.
Mouth ulcers. COMPLICATIONS
Advice mother when to return immediately.
****
Follow-up in 2 days.
Give one dose of paracetamol in clinic for high fever (38.5o C or above).
Measles now or within the Give Vitamin A.
MEASLES
last 3 months. Advice mother when to return immediately.
Follow-up in 2 days if not improving or if measles now follow-up in 2 days

* ACT Artemesinine based Combination Therapy. ** RDT is Rapid Diagnostic Test.

*** These temperatures are based on axillary temperature. **** All Suspected (Clinical) Malaria cases may be confirmed through RDTs or Microscopy for determining wether it is a Vivax or Falciparum Malaria and then treat appropriately
***** Other important complications of measles - pneumonia, stridor, diarrhoea, (Give Chloroquine for Vivax Malaria and ACT for Falciparum Malaria).
ear infection, and malnutrition - are classified in other tables.

SORE THROAT EAR PROBLEM FEVER, MALARIA, MEASLES,

5
 6

THEN CHECK FOR MALNUTRITION

Give Vitamin A.
Classify Visiblesevere wastingor SEVERE Treat the child to prevent low blood sugar
Oedema of both feet. MALNUTRITION
LOOK AND FEEL: NUTRITIONAL Refer URGENTLY to hospital.
STATUS
Look for visiblesevere wasting. Assessthe child'sfeedingand counselthe motheron feeding
accordingto the FOOD box on the COUNSEL THE MOTHER
Look and feel for oedema of both feet. Very low weightfor age. VERY chart.
LOW WEIGHT Advisemotherwhen to returnimmediatel.y
If feedingproblem,follow-upin 5 days.
Determineweightfor age. Follow-upin 30 days.
If child is less than 2 years old, assess the child'sfeeding and
counselthe motheron feedingaccordingto the FOOD box on the
Not very low weightfor age AND NOT VERY COUNSEL THE MOTHER chart.
no other signsof malnutrition/. LOW WEIGHT Advisemotherwhento returnimmediatel.y
If feedingproblem,follow-upin 5 days.
THEN CHECK FOR ANAEMIA
Treat the child to prevent low blood sugar
LOOK Severe palmar pallor SEVERE ANAEMIA Refer URGENTLY to hospital.
Classify
Look for palmar pallor. Is it: ANAEMIA Assess the child's feeding and counsel the mother on feeding
according to the FOOD box on the COUNSEL THE MOTHER
Severe palmar pallor? chart.
Some palmar pallor? Give iron.
Some palmar pallor ANAEMIA Give oral antimalarial if high malaria risk.
Deworm if child is two years or older & has not had a dose in
previoussixmonths,or has evidenceor worminfestation
Advisemotherwhento returnimmediatel.y

No palmar pallor NO ANAEMIA No additionaltreatment.

THEN CHECK CHILD'S IMMUNIZATION, VITAMIN A SUPPLEMENTATION, AND DEWORMING STATUS

AGE VACCINE
Birth BCG OPV-0 VITAMINA if childis 6 monthsor older and has if childis 1 year or older and has
6 weeks PENTAVLENT-1 OPV-1
IMMUNIZA
TION 10 weeks SUPPLEMENTATION not receiveda dose in the last 6 DEWORMING not receiveddewormingdose in
PENTAVLENT-2 OPV-2 months,give a dose of vitaminA in the last 6 months,give a dose of
SCHEDULE: 14 weeks PENTAVLENT-3 OPV-3 STATUS: the clinic
STATUS: Mebendazole500mg (singledose)
9 months MEASLES-1
15 months MEASLES-2
of age

ASSESS OTHER PROBLEMS

MAKE SURE CHILD WITHANY GENERAL DANGER SIGN IS REFERRED after firstdose of an appropriateantibioticand other urgenttreatments.
Exception: Rehydrationof the childaccordingto Plan C may resolvedanger signsso that referralis no longerneeded.
 TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIEDON
THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE

ORAL DRUGS AT HOME Give an Appropriate Oral Antibiotic
FOR PNEUMONIAAND ACUTE EAR INFECTION:
Follow the instructions below for every oral drug to be given at home. FIRST-LINE ANTIBIOTIC: A MOXYCILLIN
Also follow the instructions listed with each drug's dosage table. SECOND-LINE ANTIBIOTIC: C EPHRADINE
AMOXYCILLIN
Give two times CEPHRADINE
daily for 5 days Give three times daily for 5 days
Determine the appropriate drugs and dosage for the child's age SYRUP SYRUP SYRUP SYRUP
or weight. AGE or WEIGHT 125 mg 250 mg 125 mg 250 mg
per 5 ml per 5 ml per 5 ml per 5 ml
Tell the mother the reason for giving the drug to the child.
2 months up to 12 months
5 ml 2.5 ml 5 ml 2.5 ml
(4 - <10 kg)
Demonstrate how to measure a dose. 12 months up to 5 years
10 ml 5 ml 10 ml 5 ml
(10 - 19 kg)
Watch the mother practice measuring a dose by herself.
FOR DYSENTERY AND CHOLERA:
Give recommendedantibioticfor 5 days.
Ask the mother to give the first dose to her child. FIRTS-LINE ANTIBIOTIC C IPROFLOXCIN
SECOND-LINE DRUG METRONIDAZOLE (REFE R TO FOLLOW UP B OX)
Explain carefully how to give the drug, then label and package C IPROFLOXCIN METRONIDAZOLE
Give two times daily for 3 days Give three times daily for 5 days
the drug. AGE or WEIGHT TABLET SYRUP TABLET SYRUP
500 mg 250 mg per 5 ml 200 mg 200 mg per 5 ml
2 months up to 4 months
If more than one drug will be given, collect, count and package (4 - <6 kg)
each drug separately. 4 months up to 12 months
1/5 1.5ml
(6 - <10 kg)
12 months up to 3 years
1/3 3.5 ml
Explain that all the oral drug tablets or syrups must be used to (10 -< 14 kg) 1/2 2.5 ml
3 years up to 5 years
finish the course of treatment, even if the child gets better. (14 - 19 kg) 1/2 5 ml 1 5 ml

Check the mother's understanding before she leaves the clinic.

ANTIBIOTICS

MALNUTRITION and ANAEMIA

IMMUNIZATION STATUS TREAT
 8

TEACH THE MOTHER TO GIVE Give Zinc Suspension

ORAL DRUGS AT HOME Along with increased fluids and continued feeding, all children with diarrhoea should be given
Zinc Suspension for 10 days
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table. AGE Zinc Sulphate (20mg /5ml)

Give an Oral Antimalarial Up to 6 months

6 months up to 5 years
2.5ml

5ml
ANTIMALARIAL FOR FALCIPARUM MALARIA : ACT (Artemesinine based Combination Therapy) ,
ANTIMALARIAL FOR VIVAX MALARIA: CHLOROQUINE

IF Artemesinine based Combination Therapy (ACT), which is Artesunate + SULFADOXINE - PYRIMETHAMINE:

Give the first dose as directly observed therapy in the clinic. Give Multivitamin / Mineral Supplement
If the child vomits the drug with in 30 minutes of intake, repeat the dose. For persistent diarrhoea, give 5 ml (one tea spoon) once daily of multivitamin minerals for 2 weeks
each 5 ml contains
IF CHLOROQUINE: Vitamin-A: 8000 IU (800 micrograms)
Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of Folate: 100 micrograms
chloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the clinic for Magnesium: 150 mg
additional tablets. Iron: 20 mg
Explain that itching is a possible side effect of the drug, but is not dangerous. Zinc: 20 mg
Copper: 2 mg

Dose in mg (No. of tablets)

Artesunate (50 mg) Sulfadoxine-Pyrimethamine (500/25mg) Give Vitamin A
AGE Give two doses.
DAY 1 DAY 2 DAY 3 DAY 1 DAY 2 DAY 3 Give first dose in clinic.
5 months up to 12 months 25 (½) 25 (½) 25 (½) 250 / 12.5 (½) Give mother one dose to give at home the next day.

1 year to 5 years 50 (1) 50 (1) 50 (1) 500/25 (1) AGE VITAMINA CAPSULE S

200 000 IU 100 000 IU

CHLOROQUINE Up to 6 months 50 000 IU

Give for 3 days
6 months up to 12 months 1/2 capsule 1 capsule
TAB LE T TAB LE T SYRUP
(150 mg base) (100 mg base) (50 mg base per 5 ml) 12 months up to 5 years 1 capsule 2 capsules
AGE or WEIGHT
DAY 1 DAY 2 DAY 3 DAY 1 DAY 2 DAY 3 DAY 1 DAY 2 DAY 3
2 months up to 12 months
(4 - <10 kg)
12 months up to 3 years
1/2 1/2 1/2 1 1 1/2 7.5 ml 7.5 ml 5.0 ml
Give Iron
(10 - <14 kg)
1 1 1/2 1 1/2 1 1/2 1/2 15.0 ml 15.0 ml 5.0 ml Give one dose daily for 14 days.
3 years up to 5 years IRON/FOLATE TAB LE T IRON SYRUP
1 1/2 1 1/2 1 1/2 2 2 1
(14 - 19 kg) AGE or WEIGHT Ferrous sulfate 200 mg + Ferrous Fumarate 100 mg
250 mcg Folate per 5 ml
(60 mg elemental iron) (20 mg elemental iron per ml)
2 months up to 4 months (4 - <6 kg) 1.00 ml

O 4 months up to 12 months (6 - <10 kg) 1.25 ml

Give Paracetamol for High Fever (> 38.5 C) or 12 months up to 3 years (10 - <14 kg) 1/2 2.00 ml

Sore Throat or Ear Pain 3 years up to 5 years (14 - 19 kg) 1/2 2.5 ml

Give paracetamol every 6 hours until high fever or sore throat or ear pain is relieved.

PARAC ETAMOL Give Mebendazole

F OR TREATMENT OF A NEMIA A ND IF S TOOLS POSITIVE FOR WORMS OR:
AGE or WEIGHT TAB LE T (500 mg) SYRUP (120 mg per 5 ml)
If the child is 1 year or older and has not had a dose in the previous 6 months or
2 months up to 6 months (4- <7 kg) 2.5 ml If child is less then 12 months of age and has evidence of worm infestation, such cases should be referred
and managed on case by case basis.
6 months up to 3 years (7- <14 kg) 1/4 5 ml G IVE MEB ENDAZOLE AS A SINGLE DOSE IN CL INIC.
3 years up to 5 years (14 - 19 kg) 1/2 10 ml AGE or WEIGHT MEBE NDAZOLE (500 mg) AL BE NDAZOLE (200 mg)

Above 12 months (10 - <19 kg) 1 1

TEACH THE MOTHER TO TREAT LOCAL INFECTIONSAT HOME
Explain to the motherwhatthe treatmentis and why it should be given.
Dry the Ear by Wicking
Describe the treatmentsteps listed in the appropriatebox.
Dry the ear at least 3 times daily.

Watch the motheras she doses the first treatmentin the clinic (exceptremedy Roll clean absorbentclothor soft, strongtissuepaper into a wick.
for cough or sore throat). Place the wick in the child'sear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps untilthe ear is dry.
Tell her how often to do the treatmentat home.

If needed for treatment at home, give mother the tube of chloramphenicol

ointmentor a small bottleof gentianviolet.
Treat Mouth Ulcers with Gentian Violet
Check the mother'sunderstandingbefore she leaves the clinic.
Treat the mouthulcerstwice daily.
Wash hands.
Wash the child'smouthwith clean soft clothwrappedaroundthe fingerand wet with salt water.
Treat Eye Infection with Chloramphenicol Paint the mouthwith half-strengthgentianviolet(0.25 %).
Wash hands again.

Eye Ointment
Clean both eyes 3 times daily.

Wash hands Soothe the Throat, Relieve the Cough

Ask childto close the eye.
Use clean clothand water to gentlywipe away pus. with a Safe Remedy
Then apply Chloramphenicoelye ointmentin both eyes 3 times daily. Safe remediesto recommend:
Breast milk for exclusivelybreastfedinfant.
Ask the childto look up. Honey with water : one tea spoonhoney in half cup of luke warm water.
Squirta small amountof ointmenton the insideof the lower lid. Green tea, Soup etc.
Wash hands again.
Harmfulremediesto discourage:
Treat untilrednessis gone. Cough syrupcontainingcodeine,antihistaminesa
, lcohol,atropineand expectorants.
Do not use other eye ointmentsor drops,or put anythingelse in the eye. Oral and nasal decongestants
Return to clinicimmediatel,yif infectionbecomesworse. Do not massage or bind the chest
Do not give opium,alcoholetc.

ORAL DRUGS
LOCAL INFECTIONS
 10

GIVE THESE TREATMENTS IN Give Intramuscular Antibiotics

CLINIC ONLY FOR CHILDREN BEING REFERRED URGENTLY:

Explain to the motherwhy the drug is given. Give firstdose of IntramuscularAmpicillinand Gentamicinand refer childurgentlyto hospital.
IF REFERRAL IS NOT POSSIBLE:
Determinethe dose appropriatefor the child's weight(or age). Repeat the Ampicillinand Gentamicinor Chloramphenicoilnjectionin divideddoses every
12 hoursfor 7 and 5 days respectivel.y
Use a sterile needle and sterile syringe. Measure the dose accurately. Then change to an appropriateoral antibioticto complete10 days of treatment.
AMPICILLIN CHLORAMPHENICOL
Give the drug as an Intramuscularinjection. Dose: 50 mg per kg
GENTAMICIN
Dose: 7.5 mg per kg
Dose: 40 mg per kg
AGE or WEIGHT Add 3 ml sterilewater to vial containing Add 5.0 ml sterilewater to vial containing
1 vial = 40mg/2ml
500 mg = 3.5ml at 143 mg/ml 1000 mg = 5.6 ml at 180 mg/ml
Ifchild cannot be referred,follow the instructions provided.
2 monthsup to 4 months (4 - < 6 kg) 1.5 ml = 214 mg 1.5 ml = 30 mg 1.0 ml = 180 mg

4 monthsup to 9 months (6 - < 8 kg) 2 ml = 286 mg 2.5 ml = 50 mg 1.5 ml = 270 mg

Treat the convulsing Child with 9 monthsup to 12 months (8 - < 10 kg) 3 ml = 429 mg 3 ml = 60 mg 2.0 ml = 360 mg

Diazepam 12 monthsup to 3 years (10 - < 14 kg)

3 years up to 5 years (14 - 19 kg)

3.5 ml = 500 mg

5 ml = 715 mg
4 ml = 80 mg

5 ml = 100 mg
2.5 ml = 450 mg

3.5 ml = 630 mg
Manage the Airway:
Turn the childon the side to avoid aspiration
Do not insertany thingin the mouth
If lips and tongueare blue, open the mouthand make sure the airway is
clear. Give Quinine HCL/ARTEMETHER INJ. for Severe Malaria
If necessaryremove secretionsfrom the throatthrougha catheterinserted FOR CHILDREN BEING REFERRED WITHVERY SEVERE FEBRILE DISEASE:
throughthe nose Check whichquinine*/artemethefrormulationis availablein your clinic.
Give DiazepamRectally: Give firstdose of intramuscularquinine/artemethea r nd refer childurgentlyto hospital.
Draw up the dose of diazepam into a small syringe If low risk of malaria, do not give quinine/artemethetro a childless than 4 monthsof age.
Add 2-3 ml water Then remove the needle IF REFERRAL IS NOT POSSIBLE:
Attacha piece of nasogastrictube to the syringeif possible. Give firstdose of intramuscularquinine/artemether.
Insert 4 to 5 cm of the tube or tip of the syringeinto the rectumand inject The childshouldremain lyingdown for one hour.
the diazepam solution. Repeat the quinineinjectionat 4 and 8 hourslater, and then every 12 hoursuntilthe childis able to take an oral
Hold buttockstogetherfor a few minutes antimalarial.Do not continuequinineinjectionsfor more than 1 week.
In case of intramuscularartemetherinjectiongive 1.6mg/kg body weightevery day for 7 days.
AGE or WEIGHT Diazepam Given Rectally (10 mg=2ml) If low risk of malaria, do not give quinineto a childless than 4 monthsof age.
Dose 0.5mg/kg
INTRAMUSCULAR QUININE HCL (in 2 ml ampoules) INTRAMUSCULAR ARTEMETHER
Less then 7 days (If weight< 2.5 kg) 0.25 ml (1ml ampoules)
AMPOULES (300 mg/ml) AMPOULES (40 & 80 mg/ml)
Less then 7 days (If weight> 2.5 kg) 0.5 ml AGE or WEIGHT
Draw up this dose of Add this Total diluted
7 days up to 4 months(3 - < 6 kg) 0.5 ml undiluted quinine amount of solution to 40 mg/ml 80 mg/ml
in syringe normal saline administer (60 mg/ml)
4 monthsup to 12 months (6- < 10 kg) 1 ml
2 monthsup to 4 months (4 - < 6 kg) 0.2 ml 0.8 ml 1.0 ml 0.2 ml 0.1 ml

12 monthsup to 3 years (10- < 14 kg) 1.25 ml 4 monthsup to 12 months (6 - < 10 kg) 0.3 ml 1.2 ml 1.5 ml 0.4 ml 0.2 ml

3 years up to 5 years (14 - 19 kg) 1.5 ml 12 monthsup to 2 years (10 - < 12 kg) 0.4 ml 1.6 ml 2.0 ml 0.5 ml 0.25 ml

2 years up to 3 years (12 - < 14 kg) 0.5 ml 2.0 ml 2.5 ml 0.5 ml 0.25 ml
IfHigh Fever, Lower the Fever:
Sponge the childwith tap water 3 years up to 5 years (14 - 19 kg) 0.6 ml 2.4 ml 3.0 ml 0.5 ml 0.3 ml
Give antipyretic
Treat the child to preventlow blood suger. * In Pakistan Quinine HCL is available in ampoules of 300mg / ml.
 Treat the Child
Treat Wheezing: to Prevent Low Blood Sugar
CHILDREN WITH WHEEZING AND GENERAL DANGER SIGN OR STRIDOR
Give one dose of rapid acting bronchodilator and REFER immediately If the child is able to breastfeed:

Ask the mother to breastfeed the child.

CHILDREN WITH WHEEZING AND CHEST INDRAWING AND/OR FAST BREATHING
Give a rapid acting bronchodilator and reassess the child 30 minutes later
If the child is not able to breastfeed but is able to swallow:

IF: THEN: Give expressed breast milk or a breast milk substitute.

CHEST INDRAWING OR Treat for PNEUMONIA If neither of these is available, give sugar water.
FAST BREATHING PERSISTS Give oral salbutamol for 5 days. Give 30-50 ml of milk or sugar water before departure.

NO FAST BREATHING Treat for NO PNEUMONIA COUGH OR COLD To make sugar water: Dissolve 4 level teaspoons of sugar
Give oral salbutamol for 5 dats, (20 grams) in a 200-ml cup of clean water.

If the child is not able to swallow:

CHILDREN WITH WHEEZING AND NO DANGER SIGNS, NO STRIDOR,NO CHEST Give 50 ml of milk or sugar water by nasogastric tube.
INDRAWING NO FAST BREATHING
Treat for no pneumonia: cough or cold
Give oral salbutamol for 5 days

RAPID ACTING BRONCHODILATOR ORAL SALBUTAMOL

Three times daily for five days
Give An Antibiotic for Streptococcal
AGE or WEIGHT
Nebulized Salbutamol Metered dose inhaler
with spacer device TABLETS SYRUP
Sore Throat
(5mg/ml) (100mcg/dose) AGE or WEIGHT (2 mg) (2 mg/5ml) Give a single dose of Intramuscular Benzathine Penicillin
2 months up to 6 months 0.25 ml 2 months up to 6 months
(4- <7 kg) (plus 2.0 ml sterile water) 1 puff 1/4 1.25 ml Age Benzathine Penicillin
(4- <7 kg)
(600,000 units add 5 ml sterile water)
6 months up to 12 months 0.5 ml 6 months up to 12 months
(7- <10 kg) (plus 2.0 ml sterile water) 1 to 2 puffs (7- <10 kg) 1/2 2.5 ml < 5 years 600,000 unit

12 months up to 5 years 0.5 ml 12 months up to 5 years

(10- 19 kg) (plus 2.0 ml sterile water) 2 to 3 puffs (10- 19 kg) 1 5 ml OR
Give Amoxycillin for 10 days (see "Appropriate Oral Antibiotic" box
for dose of Amoxycillin)

11

CONVULSIONS
INTRAMUSCULARANTIBIOTIC
INTRAMUSCULAR QUININE
WHEEZING, LOW BLOOD SUGAR
STREPTOCOSCAL SORE THROAT
 12

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home Plan B: Treat Some Dehydration with ORS
Counsel the mother on the 3 Rules of Home Treatment: Give in clinic recommended amount of ORS over 4-hour period
Give Extra Fluid, Continue Feeding, When to Return
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.
1. GIVE EXTRA FLUID (as much as the child will take) 4 months up to 12 months up to 2 yearsup to
AGE* Up to 4 months
12 months 2 years 5 years
TELL THE MOTHER:
- Breastfeed frequently and for longer time at each feed. WEIGHT < 6 kg 6 - < 10 kg 10 - < 12 kg 12 - 19 kg
- If the child is exclusively breastfed, give ORS or clean water in addition to breast milk
In ml 200 - 400 400 - 700 700 - 900 900 - 1400
- If the child is not exclusively breastfed, give one or more of the following: ORS solution,
food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water. * Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can
also be caluclated by multiplying the child's weight (in kg) times 75.
It is especially important to give ORS at home when:
- the child has been treated with Plan B or Plan C during this visit. If the child wants more ORS than shown, give more.
- the child cannot return to a clinic if the diarrhoea gets worse. For infants under 6 months who are not breastfed, also give
100-200 ml clean water during this period.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS, GIVE THE MOTHER 2 PACKETS
OF ORS (1000 ml) TO USE AT HOME. 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.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL
FLUID INTAKE: Continue breastfeeding whenever the child wants.
Up to 2 years 50 to 100 ml after each loose stool
2 years or more 100 to 200 ml after each loose stool AFTER 4 HOURS:
Reassess the child and classify the child for dehydration.
Tell the mother to: Select the appropriate plan to continue treatment.
- Give frequent small sips from a cup. Begin feeding the child in clinic.
- If the child vomits, wait 10 minutes. Then continue, but more slowly.
- Continue giving extra fluid until the diarrhoea stops. 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 ZINC SUSPENSION Give her enough ORS packets to complete rehydration. Also give her 2 packets
- Along with increased fluids and continued feeding, all children with diarrhoea should as recommended in Plan A.
be given Zinc Suspension for 10 days Explain the 3 Rules of Home Treatment:

AGE Zinc Suspension (20mg / 5ml) GIVE ZINC SUSPENSION

- Along with increased fluids and continued feeding, all children with diarrhoea should
Up to 6 months 2.5ml
be given Zinc Suspension for 10 days
6 months up to 5 years 5ml
AGE Zinc Suspension (20mg / 5ml)

Up to 6 months 2.5ml

6 months up to 5 years 5ml

2. CONTINUE FEEDING
See COUNSEL THE MOTHER chart 1. GIVE EXTRA FLUID
3. WHEN TO RETURN See Plan A for recommended fluids
2. CONTINUE FEEDING and
See COUNSEL THE MOTHER chart
3. WHEN TO RETURN
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See FOOD advice on COUNSEL THE MOTHER chart)

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO DOWN. GIVE ZINC SUSPENSION
- Along with increased fluids and continued feeding, all children with diarrhoea should
START HERE Start IV fluidimmediatel.yIf the childcan drink,give ORS by mouthwhile the drip is be given Zinc Suspension for 10 days
set up. Give 100 ml/kg Ringer'sLactate Solution(or, if not available,normalsaline), AGE Zinc Suspension (20mg / 5ml)
Can you give dividedas follows:
Up to 6 months 2.5ml
intravenous(IV) fluid YES
immediately? AGE First give Then give 6 monthsup to 5 years 5ml
30 ml/kg in: 70 ml/kg in:
Infants
(under 12 months) 1 hour* 5 hours
Children
(12 monthsup to 5 years) 30 minutes* 2 1/2 hours

* Repeat once if radial pulse is still very weak or not detectable. GIVE VITAMIN-A SUPPLEMENTATION, AS
Reassess the child every 1- 2 hours. If hydrationstatusis not improving,give the IV
NO drip more rapidly. NEEDED
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after
3-4 hours (infants) or 1-2 hours(children.)
Reassess an infant after 6 hoursand a child after 3 hours.Classifydehydration. Then
choosethe appropriateplan (A, B, or C) to continue treatment.

Is IV treatment
availablenearby
(within30 minutes)? YES Refer URGENTLY to hospital for IV treatment.
If the child can drink, provide the motherwith ORS solution and show her how to give GIVE MEBENDAZOLE, AS NEEDED
frequentsips during the trip.
NO

Are you trainedto

use a naso-gastric
Start rehydration by tube (or mouth) with ORS solution:give 20 ml/kg/hour for 6 hours
(NG) tube for
rehydration? (total of 120 ml/kg).
Reassess the child every 1-2 hours:

NO YES
- If there is repeated vomitingor increasing abdominal distension,give the fluid move
slowly.
IMMUNIZE EVERY SICK CHILD, AS NEEDED
- If hydrationstatus is not improving after 3 hours, send the childfor IV therapy.
After 6 hours,reassess the child. Classify dehydration.Then choose the appropriate
Can the childdrink? plan (A, B, or C) to continue treatment.

NO
NOTE:
If possible, observe the childat least 6 hours after rehydrationto be sure the mother
can maintain hydrationgivingthe childORS solution by mouth.
Refer URGENTLY to
hospitalfor IV or NG
treatment

13

PLAN A, PLAN B
PLAN C
 14

NO PNEUMONIA: COUGH OR COLD- WHEEZE

GIVE FOLLOW-UP CARE After 3 days:

Check the childfor general danger signs.

Assessthe childfor coughor difficultbreathing. See ASSESS & CLASSIFY chart.
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications. Treatment:
If any general danger sign or stridor -, treat as VERY SEVERE DISEASE, give a dose of
If the child has any new problem, assess, classify and treat the new problem pre-referralintramuscularantibioticsI.f wheezingnow, give one dose of rapid acting
as on the ASSESS AND CLASSIFY chart. bronchodilatoa r nd refer URGENTLY to hospital.
If fast breathing or chest indrawing, with wheeze also give a dose of rapid actingbronchodilator
and reassessaccordingto "treatwheezing"box.
If child is wheezing but has no general danger signs, no stridor, no chest indrawing or no
fast breathing
- if this is the firstepisodeof wheezingor if the childhad previousepisodesbut has not been
referred,give salbutamoland refer for assessment.
- If the childhas already been referredfor a previousepisodeof wheezingadvise the motherto
continuewith treatmentprescribedby the referralhospital.Advisethe motherto returnif the
child'sbreathingbecomesmore difficult.If this childreturnsbecause conditionhas worsened,
PNEUMONIA refer URGENTLY to hospitalfor furthertreatment.
If had wheeze and now no wheezing- complete5 days of oral salbutamol.
After 3 days:

Check the childfor general danger signs.

Assessthe childfor coughor difficultbreathing. See ASSESS & CLASSIFY chart.
Ask:
DYSENTERY
- Is the childbreathingslower? After 2 days:
- Is there less fever?
- Is the childeating better? Assessthe childfor diarrhoea. > See ASSESS & CLASSIFY chart.
- Is the childwheezing? Ask:
- Are there fewer stools?
Treatment: - Is there less bloodin the stool?
- Is there less fever?
If child has chest indrawing or has fast breathing - Is there less abdominalpain?
and with or without wheeze, give a dose of intramusculaAr mpicillinand Gentamicin. - Is the childeating better?
If wheezingalso give three cyclesof rapidlyactingbronchodilato.r Treatment:
If the childis dehydrated, treat dehydration.
If breathing rate, fever and eating are the same, with or without wheeze, change to the second- If numberof stools,amountof bloodin stools,fever, abdominalpain, or eating is worse-referto
line antibioticand advise the motherto returnin 3 days. If wheezingnow or had wheezingon first hospital.
visitgive/continueoral salbutamol.(If this childhad measles withinthe last 3 months,refer). If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same:
Add metronidazole.Give for 5 days.Advisethe motherto returnin 2 days.
If breathing rate slower, less fever, or eating better, with or without wheezing, completethe 5 Exceptions - if the child:
days of antibiotic.If wheezingnow or had wheezingon firstvisitgive/continueoral salbutamolfor - is less than 12 monthsold, or
five days. - was dehydratedon the firstvisit,or Refer to hospital.
- had measles withinthe last 3 months
If child had no wheeze on the first visit but has wheeze now and had no general danger signs
or stridor, or chest indrawing or fast breathing, treat as in "No Pneumonia:Cough or Cold - If fewer stools, less blood in the stools, less fever, less abdominal pain, and
Wheeze" box. eating better, continuegivingthe same antibioticuntilfinished.
GIVE FOLLOW-UP CARE
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications.
If the child has any new problem, assess, classify and treat the new problem as
on the ASSESS AND CLASSIFY chart.

PERSISTENT DIARRHOEA
After 5 days:
MALARIA (Low or High Malaria Endemic Area)
Ask:
- Has the diarrhoeastopped? If fever persistsafter 3 days, or returnsimmediatelyif the same symptomsreappear within28 days:
- How many loose stoolsis the childhavingper day? Do a full reassessmentof the child. Assessfor other causes of fever. > See ASSESS & CLASSIFY chart.

Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per
day), do a full reassessmentof the child.Give any treatmentneeded. Then refer to
hospital.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the
motherto followthe usual feedingrecommendationsfor the child'sage.
Tell the motherto continuegivingmultivitaminmineralssupplementfor two weeks.
Treatment:
If the childhas any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the childhas any cause of fever other than malaria, providetreatment.
If malaria is the only apparent cause of fever:
- Treat with the second-lineoral antimalarial.(If no second-lineantimalarialis available,refer to
hospital.)Advisethe motherto returnagain in 2 days if the fever persists
- If fever has been presentfor 7 days, refer for assessment.

EAR INFEC TION FEVER-MALARIA UNLIKELY (Malaria non endemic Area)

After 5 days: If fever persistsafter 2 days:
Reassess for ear problem. > See ASSESS & CLASSIFY chart. Do a full reassessmentof the child. Assessfor other causes of fever. > See ASSESS & CLASSIFY chart.
Measure the child'stemperature.
Treatment:
Treatment: If the childhas any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If there is tender swelling behind the ear or high fever (38.5oC or above), refer
If the childhas any cause of fever other than malaria, providetreatment.
URGENTLY to hospital.
Acute ear infection: if ear pain or discharge persists,treat for 5 more days with the If malaria is the only apparent cause of fever:
same antibiotic.Continuewickingto dry the ear. Follow-upin 5 days.
Chronic ear infection: Check that the motheris wickingthe ear correctl,yencourageher - Treat with the first-lineoral antimalarial.Advisethe motherto returnagain in 2 days if the fever persists.
to continue.Check for complianceof treatmentprescribedby the Ear Nose & Throat - If fever has been presentfor 7 days, refer for assessment.
specialist
If no ear pain or discharge, praise the motherfor her carefultreatment.If she has not
yet finishedthe 5 days of antibiotic,tell her to use all of it before stopping.

15

PNEUMONIA, NO PNEUMONA, WHEEZE DYSENTERY, PERSISTENT

DIARRHOEA, EAR INFECTION, MALARIA, FEVER,

FOLLOW-UP
 16

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the child's FEEDING PROBLEM
previous classifications.
After 5 days:
If the child has any new problem, assess, classify and treat the new problem as on the Reassess feeding. > See questions at the top of the COUNSEL Chart
ASSESS AND CLASSIFY chart. Ask about any feedingproblemsfoundon the initialvisit.
Counselthe motherabout any new or continuingfeedingproblems.If you counselthe
motherto make significantchangesin feeding,ask her to bringthe childback again.
MEASLES WITHEYE OR MOUTH COMPLICATIONS If the childis very low weightfor age, ask the motherto return30 days after the initial
visitto measure the child'sweightgain.
After 2 days:

Look for red eyes and pus drainingfrom the eyes. ANAEMIA
Look at mouthulcers.
Smell the mouth. After 14 days:
Give iron.Advisemotherto returnin 14 days for more iron.
Treatmentfor Eye Infection:
Continuegivingiron every 14 days for 2 months.

If pus is draining from the eye, ask the motherto describehow she has treated the eye infection. If the childhas palmar pallorafter 2 months,refer for assessment.
If treatmenthas been correct,refer to hospital.If treatmenthas not been correct,teach mothercorrect
treatment.
VERY LOW WEIGHT
If the pus is gone but redness remains, continuethe treatment. After 30 days:
If no pus or redness, stop the treatment.
Weigh the childand determineif the childis stillvery low weightfor age.
Treatmentfor Mouth Ulcers: Reassess feeding. > See questions at the top of the COUNSEL chart
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Treatment:
If mouth ulcers are the same or better, continueusinghalf-strengthgentianviolet(0.25 %) for a If the childis no longer very low weight for age, praise the motherand encourageher
to continue.
total of 5 days.
If the childis stillvery low weight for age, counselthe motherabout any feeding
problemfound.Ask the motherto returnagain in one month.Continueto see the child
monthlyuntilthe childis feedingwell and gainingweightregularlyor is no longervery
MEASLES low weightfor age.
After 2 days:
Exception:
Do a full reassessmentof the child.> See ASSESS & CLASSIFY Chart. If you do not thinkthat feedingwill improve,or if the childhas lost weight, refer the
child.
Treatment:
If general danger sign or clouding of the corrnea or deep extensive mouth ulcers or pneumonia,
treat as SEVERE COMPLICATED MEASLES. IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE
If pus draining from the eye or mouth ulcers, treat as MEASLES WITH EYE OR MOUTH INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER FOR THE
COMPLICATIONS. NEXT FOLLOW-UP VISIT
If none of the above signs, advise the motherwhen to returnimmediatel.y
Followup in two days if not improving.
ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.
If the childreceivedalready the dose of vitaminA in the previousvisit,do not repeat. (SEE COUNSEL CHART.)
 COUNSEL THE MOTHER

FOOD
Assess the Child's Feeding
Ask questionsaboutthe child'susualfeedingand feedingduringthisillness,Comparethe mother'sanswersto the Feeding Recommendations
forthechild'sage in thebox below.

ASK
Do you breastfeedyourchild?
- Howmanytimesduringtheday?
- Do you also breastfeedduringthenight?

Does thechildtakeany otherfoodor fluids?

- Whatfoodor fluids?
- Howmanytimesper day?
- Whatdo you use to feedthechild?
- Ifverylowweightforage: Howlargeare servings?

Duringthisillness,has thechild'sfeedingchanged?Ifyes, how?

17

MEASELS
FEEDING PROBLEM ASSESS FEEDING
PALLOR, VERY LOW WEIGHT COUNSEL
 18

Feeding Recommendations During Sickness and Health

Up to 6 Months 6 Months 12 Months 2 Years
of Age up to up to and Older
12 Months 2 Years

Breastfeedas often as the child

Breast feed as often as the child
wants, day and night,at least 8 times
in 24 hours.
Breast feed at least for 10 minuteson
each breast every time
Do not give other foods
water.
Do not use bottlesor pacifiers
Breastfeedas often as the childwants.
Give adequate servingsof:
Khichri*,Rice (Bhatt)* with seasonal
vegetables(Carrot, Spinach,Potatoes
etc.), or Minced Meat. Rice Kheer, Suji
ka Halwa or Kheer*, Dalia*,
Vermicellis’*, Choori*,Mashed Potato
or vegetables*,Egg, Banana and
othersSeasonal fruits.
(upto 9 monthsfood shouldbe
mashed)
- 3 times per day if breastfed;
- 5 times per day if not breastfed.
- Each servingshouldbe equivalentto
1/2-3/4 or a cup.
wants. Give familyfoodsat 3 meals each
Give adequate servingsof: day. Also, twice daily, give nutritious
food between meals, such as:
Roti, Parattha, Khichrior Rice, Curry,
Minced Meat, Chicken,Egg,
Seasonal Vegetables,Choori, Seasonal fruit(Banana,Apple,
Mango, Orange etc.) Biscuit,Rusk,
Vermicellis’, and/or any foodslisted
Chips, Pakora, Samosa, Lassi,
for 6-12 monthschild
Give food at least 3 times per day Yoghurt,Bread with Eggs, Halwa etc.
AND
Give also snacks2 times per day
between meals such as seasonalfruit
(Banana,Apple, Mango, Orange etc.)
Biscuit,home made Pakora or
Samosa, Lassi,Yoghurt,Bread with
Egg, Halwa etc.
OR
Family foods5 times per day.

Wash your hands before preparing the child's food and use clean cooking utensils.
* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil / Ghee / Butter); meat, fish, eggs, or pulses; and fruits and vegetables.

Feeding RecommendationsFor a Child Who Has PERSISTENT DIARRHOEA

If stillbreastfeeding,give more frequent,longerbreastfeeds,day and night.
If takingother milk:
- replace with increasedbreastfeedingOR
- replace with fermentedmilk products,such as yoghurtOR
- replace half the milk with nutrient-richsemisolidfood.
For other foods,followfeedingrecommendationsfor the child'sage.
Counsel the MotherAbout Feeding Problems
If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.)
As needed, show the mother correct positioning and attachment for breastfeeding.
If the child is less than 6 months old and is taking other milk or foods OR:
If the mother thinks she does not have enough milk:
- Buildmother'sconfidencethat she can produceall the breast milk that the childneeds.
- Suggestgivingmore frequent,longerbreastfeedsday or night,and graduallyreducingother milk or foods.

If other milk needs to be continued,counselthe motherto:

- Breastfeedas much as possible,includingat night.
- Make sure that other milk is a locallyappropriatebreast milk substitute.
- Make sure other milk is correctlyand hygienicallypreparedand given in adequate amounts.
- Prepare only an amountof milk whichchildcan consumewithinone hour. If their is some left over milk, discard.

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

- Recommendsubstitutinga cup for bottle.
- Show the motherhow to feed the childwith a cup.

If the child is being fed too small amounts

- Recommendincreasingthe frequencyand portionsize for each meal day by day. untilrecommendedportionsize achieved.
- Recommendthat the motherencouragesthe childto eat more.
If the child is not being fed actively, counsel the mother to:
- Sit with the childand encourageeating.
- Give the childan adequate servingin a separate plate or bowl.
- Observe what the childlikes and considerthese for preparingthe food.(considerenergy rich, high densityfood).

If the child is not feeding well during illness, counsel the mother to:
- Breastfeedmore frequentlyand for longerif possible.
- Use soft, varied, appetizing,favoritefoodsto encouragethe childto eat as much as possible,and offer frequentsmall feedings.
- Add oil/ghee/butterto prepare foods.Also give green leafy and yellowvegetablesand fruitsto the child.
- Clear a blockednose if it interfereswith feeding.
- Expect that appetitewill improveas childgets better.
- Give expressedbreast milk if necessary.

Follow-up any feeding problem in 5 days.

Advise mother not to give her child, harmful, contaminated and unhygienicaly prepared junk foods from vendors e.g. kulfi, ice cream, sodas/
sherbet/drinks etc., paparrs, pakoras, samosas, nimkos etc.

19

FEEDING RECOMMENDATION
FEEDING PROBLEMS
 20

FLUID AND FOOD

Advise the Mother to Increase Fluid and Continue Feeding During Illness
FOR ANY SICK CHILD:

Breastfeed more frequently and for longer at each feed.

Increase fluid. For example, give soup, rice water, yoghurt drinks or clean water.
Give small frequent meals of energy rich food.

FOR CHILD WITH DIARRHOEA:

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

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
thechild's
he child’s problems.
problems.

Return for
If the child has: follow-up in:

PNEUMONIA 3 days
NO PNEUMONIA WITH WHEEZE if no improvement
MALARIA, if fever persists
FEVER-MALARIA UNLIKELY, if fever persists
DYSENTERY 3 days
MEASLES WITH EYE OR MOUTH COMPLICATIONS 2 days
MEASLES (if measles now)
PERSISTENT DIARRHOEA WHEN TO RETURN IMMEDIATELY
ACUTE EAR INFECTION
CHRONIC EAR INFECTION 5 days Advise mother to return immediately if the child has any of these signs:
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving Any sick child Not able to drink or breastfeed
Becomes sicker
ANAEMIA 14 days
Develops a fever
VERY LOW WEIGHT FOR AGE 30 days
If child has NO PNEUMONIA: Chest indrawing
COUGH OR COLD, also return if: Fast breathing
NEXT WELL-CHILD VISIT Difficult breathing
Advise mother when to return for next immunization according to
immunization schedule. If child has Diarrhoea, also return if: Blood in stool
Drinking poorly
Counsel the MotherAbout Her Own Health
If the mother is sick, provide care for her, or refer her for help.

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

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

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

Make sure she has access to:

- Family planning

- Counseling on STD and AIDS prevention

21

FLUID
WHEN TO RETURN
MOTHER'S HEALTH
 22

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

AGE LESS THEN 2 MONTHS
ASSESS CLASSIFY IDENTIFYTREATMENT
ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE USE ALL BOXES THAT MATCH INFANT'S SYMPTOMS
Determineif this is an initialor follow-upvisitfor this problem. AND PROBLEMS TO CLASSIFY THE ILLNESS.
- if follow-upvisit,use the follow-upinstructionson the FOLLOW-UP chart.
- if initialvisit,assess the younginfantas follows:

SIGNS CLASSIFY AS TREATMENT

CHECK FOR POSSIBLE INFECTION (Urgentpre-referraltreatmentsare in bold

ASK: LOOK, LISTEN, FEEL: Any one of the following signs

Classify ConvulsionsOR Give first dose of Intramuscular

Has the infanthad Count the breaths in one minute. ALL Not feedingwell OR antibiotics.
convulsions(fits)? Repeat the count if elevated. YOUNG Fast breathing(60 breathsper minuteor more) OR Treat to prevent low blood sugar.
INFANT YOUNG Severe chest indrawingOR VERY Advise mother how to keep the infant
Look for severe chest indrawing.
Is the infanthaving Look and listen for grunting.
MUST BE INFANTS GruntingOR SEVERE warm on the way to the hospital.
CALM Fever (37.5oC* or above) OR DISEASE Refer URGENTLY to hospital.**
difficultyin feeding?
low body temperature(less than 35.5oC*) OR
Measure axillary temperature. Movementsonly when stimulatedor
no movementseven when stimulated
Look at the umbilicus. Is it red or draining pus? Umbilicusred or drainingpus Give an appropriateoral antibiotic.
Look for skin pustules. Skin pustules Teach the motherto treat local infections
LOCAL at home.
Look at the young infant’s movements. BACTERIAL Advisemotherto give home care for the
INFECTION younginfant.
Does the infant move only when stimulated?
Does the infant not move even when stimulated? Follow-upin 2 days.

BACTERIAL
None of the signsof very severe disease Advisemotherto give home care for
or bacterialinfection INFECTION younginfant.
local
UNLIKELY

THEN CHECK FOR JAUNDICE

Classify Any jaundiceif age less than 24 hoursor Treat to prevent low blood sugar.
ASK LOOK, LISTEN, FEEL: JAUNDICE SEVERE
Refer URGENTLY to hospital.
Yellow palms and soles at any age Advise the mother how to keep the
JAUNDICE young infant warm on the way to the
Look for jaundice
Look at the younginfantsplams and soles. hospital.
Are they yellow? Jaundiceappearingafter 24 hoursof age and Advisethe motherto give home care
for the younginfant
JAUNDICE Advisemotherto returnimmediatelyif
Palms and soles not yellow palms and soles appear yellow.
Follow-upin 1 day.
No jaundice Advisethe motherto give home care for
NO JAUNDICE the younginfant.
THEN ASK: Two of the followingsigns: If infantdoes not have VERY SEVERE
DISEASE:
Does the young infanthave diarrhoea? Movement only when - Give fluidfor severe dehydration
stimulaetd or no movement (Plan C). OR
even when stimulated
Sunken eyes SEVERE If infant also has VERY SEVERE
Skin pinch goes back very DEHYDRATION DISEASE:
slowly. - Refer URGENTLY to hospital with
IF YES, ASK LOOK AND FEEL: mother giving frequent sips of ORS
for on the way.
DEHYDRATION Advise the mother to continue
For how long ? Look at the younginfants’ general condition. breastfeeding.
Is there blood Does the infantmove only when stimulated?
in the stool? Does the infantnot move even when stimulated?

Two of the following signs: Give fluid and food for some dehydration
Is the infantrestlessand irritable?
(Plan B).
Restless, irritable If infant also has VERY SEVERE
Look for sunkeneyes. DISEASE:
Sunken eyes
Classify - Refer URGENTLY to hospital
Pinch the skin of the abdomen. Skin pinch goes back slowly. SOME with mother giving frequent sips of
Does it go back:
DIARRHOEA DEHYDRATION ORS on the way.
- Advise mother to continue
Very slowly(longerthan 2 seconds)?
breastfeeding.
Slowly?
Advisemotherwhen to return
immediately.
Follow-up in 2 days if not improving.
Not enough signs to Give fluids to treat diarrhoea at home
classify as some or (Plan A).
severe dehydration. NO DEHYDRATION Advisemotherwhen to return
immediately.
Follow-up in 2 days if not improving.

Diarrhoea lasting 14 If the young infant is dehydrated, treat

days or more. dehydration before referral unless the
and if diarrhoea SEVERE infanthas also VERY SEVERE
PERSISTENT DISEASE OR SEVERE JAUNDICE
14 days or more
DIARRHOEA
Refer to hospital.

and if blood in Bloodin the stool. Treat to prevent low blood sugar
stool Advise mother how to keep the infant
BLOOD INSTOOL warm on the way to hospital
Refer URGENTLY to hospital

* These thresholds are based on axillary temperature.

** If referral is not possible, see Integrated Management of Childhood Illness, Treat the Child, Annex: "Where Referral is Not Possible."

23

BACTERIALINFECTION
DIARRHOEA
ASSESS AND CLASSIFY
 24

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT:

Not well attached to breast or If not well attached or not suckling effectively,
ASK: LOOK, LISTEN, FEEL: Classify not suckling effectively, teach correct positioning and attachment.
Is the infant breastfeed? If yes, Determine weight for age. OR If not able to attach well immediately, teach the
FEEDING mother to express breast milk and feed by a cup.
how many times in 24 hours?
Less than 8 breastfeeds
in 24 hours, If breastfeeding less than 8 times in 24 hours,
Does the infant usually receive advise to increase frequency of feeding. Advise
any other foods or drinks? OR
her to breastfeed as often and for as long as the
If yes, how often? infant wants, day and night.
Receive other foods or drinks,
If an infant has no indications to refer urgently to hospital: OR If receiving other foods or drinks, counsel mother
ASSESS BREASTFEEDING: If the infant has not fed in the previous hour, ask the about breastfeeding more, reducing other foods
Low weight for age, FEEDING or drinks, and using a cup.
Has the infant mother to put her infant to the breast. Observe the OR PROBLEM If not breastfeeding at all:
breastfeeding breastfeed for 4 minutes. OR - Refer for breastfeeding counseling and
previous hour? Thrush (Ulcers or white patches LOW possible relactation
(If the infant was fed during the last hour, ask the in month) WEIGHT - Advise about correctly preparing breastmilk
mother if she can wait and tell you when the infant is substitutes and using a cup.
willing to feed again).
Advise the mother how to feed and keep the low
weight young infant warm at home.
Is the infant able to attache well?
not well attached good attachment If thrush, teach the mother to treat thrush at home.

TO CHECK ATTACHMENT, LOOK FOR: Advise mother to give home care for the young
- More areola visible above than below the mouth infant.
- Mouth wide open
- Lower lip turned outward Fellow-up any feeding problems or thrush in 2
days.
- Chin touching breast
Not low weight and no other Advise mother to give home care for the
(All of these signs should be present if the attachment is good.) signs of inadequate feeding. NO FEEDING young infant.
PROBLEM
Is the infant suckling effectively (that is, slow deep Praise the mother for feeding the infant well.
sucks, sometimes pausing)?
not suckling effectively suckling effectively

Clear a blocked nose if it interferes with

breastfeeding.

Look for ulcers or white patches in the mouth

(thrush).
THEN CHECK THE YOUNG INFANT'S IMMUNIZA
TION STATUS:
AGE VACCINE

Birth BCG OPV-0

IMMUNIZA
TIONSCHEDULE: 6 weeks PENTAVLENT-1 OPV-1

ASSESS OTHER PROBLEMS

25

CHECK FOR FEEDING PROBLEMS

 26

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

TO TREAT CONVULSIONS, SEE TREAT THE CHILD CHART

Give First Dose of Intramuscular Antibiotics

Give first dose of Ampicillin or benzylpenicillin intramuscularly.
Give first dose of Gentamicin intramuscularly.

AMPICILLIN
Dose: 50 mg per kg
To a vial of 250 mg
WEIGHT
Add 1.3 ml sterile water =
250 mg / 1.5 ml
BENZYLPENICILLIN
Dose: 50.000 mg per kg GENTAMICIN
To a vial of 600 mg
(1000000 units) Undiluted 2 ml vial Add 6 ml sterile water to 2 ml
containing OR vial containing
Add 1.6 ml sterile water =
20 mg = 2 ml at 10 mg/ml 80 mg* = 8 ml at 10 mg/ml
500000 units / ml
Age < 7 days Age > 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg

1 - 1.5 kg 0.4 ml 0.2 ml 0.6 ml 0.9 ml

1.5 - 2 kg 0.5 ml 0.2 ml 0.9 ml 1.3 ml

2 - 2.5 kg 0.7 ml 0.3 ml 1.1 ml 1.7 ml

2.5 - 3 kg 0.8 ml 0.5 ml 1.4 ml 2.0 ml

3 - 3.5 kg 1.0 ml 0.5 ml 1.6 ml 2.4 ml

3.5 - 4 kg 1.1 ml 0.6 ml 1.9 ml 2.8 ml

4 - 4.5 kg 1.3 ml 0.7 ml 2.1 ml 3.2 ml

* Avoid using undiluted 40 mg/ml gentamicin. The dose is 1/4 of that listed.

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, give ampicillin
and gentamicin for at least 5 days. Give ampicillin every 2 times daily to infants less than one week of age and 3 times daily
to infants one week or older. Give gentamicin once daily.

Give an Appropriate Oral Antibiotic for local infection

FIRST-LINE ANTIBIOTIC: AMOXYCILLIN
SECOND-LINE ANTIBIOTIC: CEPHRADINE
AMOXYCILLIN SYRUP CEPHRADINE SYRUP
AGE or WEIGHT (125 mg / 5 ml) (125 mg / 5 ml)
Give two times daily for 5 days Give three times daily for 5 days

Birth up to 1 month 2.5 ml

1.25 ml
( <3 kg)
1 month up to 2 months
2.5 ml 5 ml
(3 - 4 kg)
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

To Treat Diarrhoea, See TREAT THE CHILD Chart.

Immunize Every Sick Young Infant, as Needed.

Teach the Mother to Treat Local Infections at Home

Explainhow the treatmentis given.
Watch her as she does the firsttreatmentin the clinic.
Tell her to do the treatmenttwice daily. She shouldreturnto the clinicif the infectionworsens.

To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or whitepatches in mouth)

The mothershould: The mothershould:

Wash hands Wash hands
Gently wash off pus and crustswith soap and water Wash mouthwith clean soft clothwrappedaroundthe finger
Dry the area and wet with salt water
Paint with gentianviolet Paint the mouthwith half-strengthgentainviolet(0.25 %)
Wash hands Wash hands

To Treat Eye Infection, See Treat the Child Chart

27

ANTIBIOTICS
LOCALINFECTIONS
TREAT AND COUNSEL
 28

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding
Show the mother how to hold her infant
- with the infant's head and body straight
- facing her breast, with infant's nose opposite her nipple
- with infant's body close to her body
- supporting infant's whole body, not just neck and shoulders.

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

- touch her infant's lips with her nipple
- wait until her infant's mouth is opening wide
- move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple.

Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Advise Mother to Give Home Care for the Young Infant

EXCLUSIVELY BREATFEED 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.

MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.

In cool weather cover the infant’s head and feet and dress the infant with extra clothing.

WHEN TO RETURNED
Follow-up Visit When to Return Immediately:
If the infant has: Return for follow-up in: Advise the mother to return immediately if the
young infant has any of these signs:
LOCAL BACTERIAL INFECTION
DIARRHOEA 2 days Breastfeeding or drinking poorly
ANY FEEDING PROBLEM Becomes sicker
THRUSH Develops a fever
LOW WEIGHT FOR AGE 14 days Fast breathing
LOW BIRTH WEIGHT Difficult breathing
Depressed breathing
GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT
LOCAL BACTERIAL INFECTION
After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.

Treatment:
Ifumbilical pus or redness remains 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.
Ifskin 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.

DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped?

Treatment:
Ifthe diarrhoea has not stopped, assess and treat theyoung infant fordiarrhoea. >SEE “Does the Young Infant Have Diarrhoea?”

Ifthe diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.

29
LOCAL INFECTIONS
BREASTFEEDING
HOME CARE FOLLOW-UP
 30

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or low birth weight" above.
Ask about any feeding problems found on the initial visit.

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

If the young infant is low weight for age, ask 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 the child.

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

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

If the 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.

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 2 weeks). 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.

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or low birth weight or Low Weight" above.

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

If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.
I.D-No

MANAGEMENT OF THE SICK YOUNG INFANT AGE LESS THEN 2 MONTHS

Name: Age: days Present weight: kg Birth weight kg (for baby less then 7 days, if birth weight not know use present weight as birth
weight)
o o
Temperature: C F

ASK: What are the infant's problems? Initial visit? Follow-up Visit?

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Has the infant had convulsions (fits)?
Is the infant having difficultly in feeding?
Count the breaths in one minute. ________ breaths per minutes.
Repeat if elevated the count if elevated ________Fast breathing?
Look for severe chest indrawing.
Look and listen for grunting.
o
Fever (temperature 37.5 C or above)?
o
Low body temperature (less than 35.5 C)
Look at the young infant's movements.
Does the young infant move only when stimulated?
Does the young infant not moved even when stimulated?
Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.

THEN CHECK FOR JAUNDICE

ASK: LOOK, LISTEN, FEEL:
Look for jaundice
Look at the young infant’s palms and soles.
Are they yellow?

DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes ______ No ______

Look at the young infant’s general condition.
Does the infant move only when stimulated?
Does the infant not move even when stimulated?

Is the infant restless or imitable?

Look for sunken eyes.

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

Very slowly (longer than 2 seconds)?
Slowly?

31
 32
ASSESS (Circle all signs present) CLASSIFY TREAT
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
Is the infant breastfed? Yes _____ No _____ Determine wight for age. Low _____ Not Low _____.
If Yes, how many times in 24 hours?____ Times

Does the infnat usually receive any

other foods or drinks? Yes _____ No _____
If Yes, how often?

If the infant has no indications to refer urgently to hospital:

ASSESS BREASTFEEDING:
Has the infant breastfeed in the previous hour? If infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.

Is the infant able to attach? To check attachment, look for:

- Mouth wide open Yes ___ No ___
- Lower lip turned outward Yes ___ No ___
- More areola above than
below the mouth Yes ___ No ___
- Chin touching breast Yes ___ No ___

not well attached good attachment

Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?

not suckling effectively suckling effectively

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

CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS: Circle immunization needed today
Return for next immunization on: immunization to given today
BCG OPV-0

PENTAVLENT-1 OPV-1
(Date)

ASSESS OTHER PROBLEMS

Advice mother when to return immediately
Return for follow-up in ........................ days

Name:
ASK: What are the child's problems?
ASSESS (Circle all signs present)
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINKOR BREASTFE ED
VOMITS EVERYTHING
CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
For how long? ____ Days
DOES THE CHILD HAVE DIARRHOEA?
For how long? _____ Days
Is there blood in the stools?
DOES THE CHILD HAVE THROAT PROBLEM:
Does the child have sore throat?
Is the child not able to drink?
Does the child have fever?
DOES THE CHILD HAVE AN EAR PROBLEM?
Is there severe ear pain?
Is there ear discharge?
IfYes, for how long? ___ Days
DOES THE CHILD HAVE FEVER? (byhistory/feels hot/t
A patient presentingwithfever
(continuous or interm ittent)
(temp= or >more then37.5 C)
o
or history of feverwithin the
last3 days associated with
rigors,withno features of
otherdiseases and have one
or more of the follow
ing:
headache, nausea vomitin g.
If the child has measles now
or within the last 3 months:
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
o o
Age: months Weight: kg Temperature: C F
Initial visit? Follow-up Visit?
CLASSIFY TREAT
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
ANY DANGER SIGN PRESENT
Yes _____ No _____
Yes _____ No _____
Count the breaths in one minute. (childmust be calm)
_______ breaths per minute. Fast breathing?
Look for chest indrawing.
Look and listen for stridor.
Look and listen for wheeze
Yes _____ No _____
Look at the child's general condition. Is the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offerthe 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?
Yes ___ No___
o
Fever (temperature 37.5 C or above).
Feel for tender enlarged lymph nodes on the neck.
Look for red, enlarged tonsils.
Look for white exudate on the throat.
Yes ___ No___
Look for pus draining fromthe ear.
Feel for tender swelling behind the ear.
o
emperature 37.5 C or above) Yes ___ No___
Malaria transmission in the area = Yes
Transmission season = Yes
Innon or low endemic areas travel history within the last 15-days to an area
where malaria transmission occurs = Yes___ No___
(ifyes, use the relevant treatment instructions)
Fever For how long? ______ days Look or feel for stiffneck.
Ifmore than 7 days, has fever Look for runny nose.
been present every day? Look for signs of MEASLES
Has the childhad measles within Generalized rash of measles AND
the last 3 months? One of these: cough, runny nose,
or red eyes.
Look for mouth ulcers.
Are they deep and extensive?
Look for pus draining fromthe eye.
Look for clouding of the cornea.
33
 34
Remember to refer any childwho has danger sign or severe classification
ASSESS (Circle all signspresent) CLASSIFY TREAT
THEN CHECK FOR MALNUTRITION

Look for visiblesevere wasting.

Look and feel for oedema of both feet.
Determineweightfor age. Very Low ___ Not Very Low ____

THEN CHECK FOR ANAEMIA

Look for palmar pallor

Severe palmar pallor?
Some palmar pallor?
CHECK THE CHILD'S IMMUNIZA
TION STATUS Circle immunizationsneeded today.
Return for next immunizationon: Immunizationto be given today?

BCG PENTAVALENT - 1 PENTAVALENT - 2 PENTAVALENT - 3 Measles-1

OPV 0 OPV 1 OPV 2 OPV 3 Measles-2 (Date)

FOR CHILDREN 6 MONTHS OR ABOVE Vitamin-Ato be given today?

CHECK THE CHILD'S VITAMINA Has the childreceivedvitaminA in the last 6 months Vitamin-A needed Yes____ No ____
SUPPLEMENTATION STATUS Yes____ No ____
Yes___ No ___
FOR CHILDREN 1 YEARS OR ABOVE Mebendazole needed Mebendazoleto be given today?
CHECK THE CHILD'S DEWORMINGSTATUS Has the childreceived Mebendazole in the last 6 months Yes____ No ____ Yes____ No ____
Yes___ No ___
ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old.
FEEDING PROBLEMS FEEDING ADVICE

Do you breastfeedyour child? Yes____ No ____

If Yes, how many times in 24 hours?___ times.
Do you breastfeedduringthe night? Yes____ No ____

Does the childtake any other food or fluids? Yes____ No ____

If Yes, what food or fluids?

How many times per day? ___ times What do you use to feed the child?

If very low weightfor age: How large are servings?

Does the childreceive his/herown servings?____Who feeds the childand how?

Duringthe illness,has the child'sfeedingchanged? Yes____ No ____

If Yes, how?

ASSESS OTHER PROBLEMS

Advice motherwhen to returnimmediately
Return for follow-upin ........................d.ays
 Malaria Endemic Areas (Districts)
Temperature H igh M alar ia Endemic A r eas L ow M alar ia Endemic A r eas
M alar ia Non

ConversionTable endemic A r eas

o o
C /F
o o
F to C
0 = -17.7
95 = 35.0
97 = 36.1
98 = 36.6
98.6 = 37.0
99 = 37.2
100 = 37.7
101 = 38.3
102 = 38.8
103 = 39.4
104 = 40.0

NOTES
105 = 40.5
106 = 41.1

35
 36

WEIGHT FOR AGE CHART

Low weight
for age

Very Low
weight for
age

Low weight for age

Very Low
weight for age

AGE IN MONTHS