OSCE REVIEW - BSN  Benefits of IMCI

▪ Addresses major child health problems

THE IMCI STRATEGY ▪ Responds to demand
▪ Promotes preventive as well as curative care
 Integrated Management of Childhood Illness ▪ Cost-effective
▪ An integrated approach to child health that ▪ Promotes cost saving
focuses on the well-being of the whole child. ▪ Improves equity
▪ Aims to reduce death, illness & disability, and
to promote growth and development among  The IMCI Case Management Process
under under 5 children. 1. Assess
▪ It combines improved management of childhood 2.Classify
illness with aspects of Nutrition, VAC 3.Identify Treatment
supplementation, deworming, immunization, and 4.Treat
other factors influencing child and maternal 5.Counsel the Mother
health. 6.Follow-Up

▪ A strategy for reducing mortality and morbidity COLOR CODED TRIAGE SYSTEM:
associated with major causes of childhood illness.  PINK
▪ A joint WHO/UNICEF initiative since 1992
give pre-referral treatment
▪ Currently focused on first level health facilities
▪ Comes as a generic guidelines for management - advice the parents
which have been adapted to each country - refer the child URGENTLY

 Diseases comprising 70% of deaths among under

5 children
▪ Pneumonia
▪ Diarrhea
▪ Dengue hemorrhagic fever
▪ Malaria
▪ Measles
▪ Malnutrition

 GREEN
 Objectives of IMCI
SIMPLE ADVICE ON HOME MANAGEMENT
▪ To reduce significantly global mortality and
morbidity associated with the major causes of - teach the mother or caregiver how to give oral
disease in children. drugs and treat local infections at home
▪ To contribute to healthy growth and development
- counseling the mother or other caregiver about
of children.
food (feeding problems), fluids, when to return to the
▪ Assess for “General Danger Signs”
health facility, and her own health
▪ Routinely assess for major symptoms.
▪ Use limited number of carefully selected
 Age groups
clinical signs.
▪ Sick Child Aged 2 months up to 5 years
▪ Address most, if not all of the major reasons a
▪ Young Infants Aged Up to 2 months
child is brought to the clinic.
▪ Use a limited number of essential drugs and
 The IMCI Case Management Process
encourage participation of caretakers in
the treatment.
ASSESS AND CLASSIFY
▪ Counseling of caretakers.

 Check for GENERAL DANGER SIGNS

Components of IMCI
▪ not able to drink or breastfeed
▪ Improving case management skills of health
▪ vomits everything
workers.
▪ convulsions
o Standard guidelines
▪ abnormally sleepy or difficult to awaken
o Training (pre-service and in-service)
o Follow-up after training
 Not able to drink or breastfeed
▪ Improving the health system to deliver IMCI:
▪ Not able to suck or swallow when offered a drink
o Essential drug supply and management
or breast milk because he/she is too weak or
o Organization of work in health facilities
cannot swallow
o Management and supervision
▪ Ask: Is the child able to take fluid into his/her
▪ Improving family and community practices
mouth and swallow it?

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 OSCE REVIEW - BSN Chest Indrawing – the lower chest wall goes IN as the
child breaths IN
IMCI Stridor – a harsh noise as the child breaths IN
Wheeze – soft musical noise made when the child
 Check for GENERAL DANGER SIGNS breaths OUT

 Vomits everything Classify the illness

▪ Not able to hold anything down Urgent pre-referral treatment and referral
▪ What goes down comes back up Specific medical treatment and advice
▪ Check: offer the child fluid – water or Simple advice on home management
expressed breast milk
Classify coUgh or difficUlt breathing
 Convulsion Any general danger sign Severe pneumonia
▪ Arms and legs stiffen because the muscles are Chest indrawing or Very Severe
contracting Stridor in calm child Disease
▪ The child may lose consciousness or not able to Fast breathing Pneumonia
respond to spoken directions or handling, even if (If wheezing go directly to
the eyes are open treat wheezing)
▪ May be due to fever or associated with No signs of pneumonia or No Pneumonia:
meningitis, cerebral malaria or other life very severe disease Cough or Cold
threatening conditions (If wheezing go directly to
treat wheezing)
 Abnormally sleepy or difficult to awaken
▪ Drowsy and does not take notice of Assess diarrhea
his/her surroundings ▪ For how long?
▪ Does not respond normally to sounds or movement ▪ Is there blood in the stool?
▪ Stares blankly and appear not to notice what ▪ Look at the child’s gen. condition.
is going on ▪ Look for sunken eyes.
▪ Cannot be wakened. Does not respond when ▪ Offer the child fluid – drinking
touched, shaken, or spoken to normally/poorly/eagerly? Not able to drink?
▪ Pinch the skin of the abdomen.
 Assess & Classify THE 4 MAIN SYMPTOMS o Look for sunken eyes
▪ Cough or difficult breathing o Skin Pinch that goes back Very Slowly
▪ Diarrhea
▪ Fever Classify diarrhea for dehydration
▪ Ear problem Two of the following Severe
signs: Abnormally sleepy Dehydration
 Assess and classify cough or difficult breathing or difficult to awaken
▪ How long? Sunken eyes
▪ Count the breaths in one minute. Decide if fast Not able to drink or
breathing is present drinking poorly
▪ Look for chest indrawing Skin pinch goes back very
▪ Look and listen for stridor slowly
▪ Look and listen for wheeze Two of the following signs: Some Dehydration
o If wheeZing and either fast breathing or Restless, irritable
chest indrawing: Sunken eyes
- Give a trial rapid acting inhaled Drinks eagerly, thirsty
bronchodilator for up to three times 15-20 Skin pinch goes back slowly
minutes apart. Count the breaths and look Not enough signs to classify No Dehydration
for chest indrawing again, then classify. as some or severe
- 0.5 ml salbutamol diluted in 2.0 ml of dehydration
sterile water per dose nebulization
should be used. If diarrhea is 14 days or more
▪ Assess and Classify Cough or Difficult breathing Dehydration present. Severe persistent
If child is: Fast Breathing is: diarrhea
2 months up to 12 50 breaths per minute or No Dehydration. Persistent Diarrhea
months more
12 months up to 5 40 breaths per minute or
If there is blood in stoo
years more
Blood in the stool Dysentery
 OSCE REVIEW - BSN ▪ Cold and clammy extremities
▪ Capillary refill more than 3 seconds
IMCI ▪ Persistent abdominal pain
▪ Persistent vomiting
Assess Fever ▪ Tourniquet test positive
▪ Decide malaria risk
▪ If malaria risk, obtain a blood smear Assess DHF
▪ For how long? ▪ Skin petechiae – dark red spots or patches in the
▪ If more than 7 days, has fever been present skin. When skin is streached, they do not disappear
every day? ▪ Persistent abdominal pain – continuous, without
▪ Has the child had measles within the last 3 months relief
▪ Look or feel for stiff neck. ▪ Persistent vomiting – not associated with food
▪ Look for runny nose. intake
▪ Look for signs of measles. ▪ Positive toUrniqUet test – 20 or more petechiae
▪ If child has measles now or within the last in one square inch
3 months:
o Look for mouth ulcers Assess/Classify Dengue Hemorrhagic Fever
o Look for pus draining from the eyes. ▪ Any one sign present: Severe Dengue Hemorrhagic
o Look for clouding of the Fever
▪ No sign present - Fever: Dengue Hemorrhagic
cornea Generalized Rash of Measles Fever Unlikely

Measles Complications: Assess Ear Problem

▪ Mouth Ulcer ▪ Is there ear pain?
▪ Pus Draining from Eye ▪ Is there ear discharge? For how long?
▪ Clouding of the Cornea ▪ Look for pus draining from the ear.
Classify fever (Malaria Risk) ▪ Feel for tender swelling behind the ear.
Any general danger sign Very Severe
Stiff neck Febrile Classify ear problem
Disease/Malaria Tender swelling behind the Mastoiditis
Blood smear (+) Malaria ear
If no blood smear: no runny Ear Pain Acute Ear
nose and no measles and no Pus is seen draining from Infection
other causes of fever the ear and discharge is
Blood smear (-) or runny Fever: Malaria reported for less than 14
nose or measles or other Unlikely days
causes of fever Pus is seen draining from Chronic Ear
the ear and discharge is Infaction
Classify fever (No Malaria Risk) reported for 14 days or
Any general danger sign Very Severe more
Stiff neck Febrile Disease No ear pain No Ear Infection
No signs of very severe Fever: No Malaria No pus seen draining from
febrile disease the ear

Classify Measles Check for malnUtrition and anemia

Clouding of the cornea
Deep or extensive mouth
ulcers
Any general danger sign
Pus draining from the eye,
or Mouth ulcers
Measles now or within the
last 3 months
Assess/Classify Dengue Hemorrhagic Fever
▪ Bleeding from nose or gums
▪ Bleeding in stools/vomitus
▪ Black stools/vomitus 4
Severe For all Children:
Complicated ▪ Determine weight for age.
Measles ▪ Look for edema of both feet.
▪ Look for visible severe wasting.
Measles with Eye For children aged 6 months or more, determine if
or Mouth MUAC is less than 115 mm
Complications
Measles Signs of Severe Malnutrition
▪ Edema of Both Feet
▪ Visible Severe Wasting
OSCE REVIEW - BSN Duration of antibiotic treatment from 5 days to 3 days
Frequency of administration of antibiotics from 3x to
IMCI 2x a day

Classify NUtritional StatUs: Management for non-severe pneUmonia therefore:

If age up to 6 months SEVERE First line - Oral amoxicillin to be given in 25mg/kg dose
- and visible severe MALNUTRITIO twice daily in children 2-59 months of age for 3 days
wasting N Second line - Oral Cotrimoxazole to be given 2x daily
- and edema of both feet for 3 days

If age 6 months and above Technical basis:

and: ▪ 3 days treatment is equally effective as the 5 day
- MUAC less than 115mm treatment
or edema of both feet ▪ Reduces cost of treatment
or visible severe ▪ Improves compliance
wasting ▪ Reduces antimicrobial resistance in the community
Very low weight for age VERY ▪ Use of oral Amoxicillin vs injectable penicillin in
LOWWEIGHT children with severe pneumonia
Not very low weight for age NOT VERY LOW o Where referral is difficult and injection is
and no other signs of WEIGHT not available, oral Amoxicillin in 45
malnutrition mg/kg/dose 2x daily should be given to
children with severe
pneumonia for 5 days
Check for Anemia Technical basis: Clinical oUtcome with
LOOK AND FEEL: oral amoxicillin was comparable to injectable
▪ Look for palmar pallor. Is it penicillin in hospitaliZed children with severe
▪ Severe palmar pallor? pneUmonia
▪ Some palmar pallor ▪ Gentamicin plus ampicillin vs chloramphenicol for
very severe pneumonia
Check for Signs of Anemia o Injectable ampicillin plus injectable gentamicin
▪ No palmar pallor is a better choice than injectable
▪ Some palmar pallor o chloramphenicol for very severe pneumonia in
▪ Severe palmar pallor children 2-59 months of age.
o A pre-referral dose of 7.5mg/kg intramuscular
Classify for Anemia: injection gentamicin and 50 mg/kg injection
Severe palmar pallor SEVERE ANEMIA ampicillin can be used
Some palmar pallor ANEMIA ▪ Use of oral Amoxicillin vs injectable penicillin in
No palmar pallor NO ANEMIA children with severe pneumonia
o Where referral is difficult and injection is not
Check for: available, oral Amoxicillin in 45 mg/kg/dose 2x
daily should be given to children with severe
▪ Immunization Status
▪ Vitamin A Supplementation Status pneumonia for 5 days
▪ Deworming Status Technical basis: Clinical oUtcome with
▪ Assess for Other Problems oral amoxicillin was comparable to injectable
penicillin in hospitaliZed children with severe
Identify Treatment pneUmonia
▪ Determine if urgent referral is needed.
Give Extra Fluid for Diarrhea and Continue Feeding
▪ Identify treatment for patient who do not need
urgent referral. Treatment Plan A for No Dehydration
▪ For patients who need urgent referral, identify 1. Give Extra Fluid:
urgent pre-referral treatment. a. Up to 2 yrs. : 50-100 ml after each loose stool
▪ Give pre-referral treatment. b.2 yrs. Or more: 100-200 ml after each loose
▪ Refer the child with a referral note. stool
2. Give Zinc Supplements (for 10-14 days):

Acute respiratory infection a. < 6 mos. : 10 mg/day

First-line/second line antibiotic for non-severe b.6 mos. – 5 yrs: 20 mg/day
pneumonia 3.Continue feeding
PREVIOUS UPDATED 4.When to Return
First line Cotrimaxazole Amoxicillin
Second Amoxicillin Cotrimaxazole
line

SN RMPB 5
OSCE REVIEW - BSN ▪ Continue breastfeeding whenever the child wants
▪ After 4 hours: Reassess, classify, select
IMCI appropriate treatment plan; begin feeding the child
in the clinic.
Diarrheal diseases
Use or oral osmolarity oral rehydration salt Treatment Plan C for Severe Dehydration
Technical basis: ▪ Can you give IV fluid? If yes, give IV fluid
▪ Efficacy of ORS solUtion for tx of acUte immediately.
non-cholera in children is improved by redUcing ▪ If No: Is IV treatment available nearby (within 30
its sodiUm concentration to 75 mEq/l, its minutes)? If yes, refer immediately to hospital for
glUcose concentration to 75 mmol/l, and its total IV treatment.
osmolarity to 245mOsm/l. ▪ If No: Are you trained to use NG tube for
▪ The need for UnschedUled sUpplemental IV is rehydration? If yes, start rehydration by NG
redUced by 33%, stool oUtpUt is redUced by ▪ If No: Can the child drink? If yes, give ORS by
aboUt 20% and the incidence of vomiting by mouth
aboUt 30%. ▪ If No, refer URGENTLY to hospital for IV or NG
treatment.
Composition
mmol/liter Diarrheal Diseases
New Old Use of antibiotics in the management of bloody diarrhea
Sodium 75 90 (shigella dysentery)
Chloride 65 80 ▪ Ciprofloxacin is the most appropriate drug in place
Glucose, 75 111 of nalidixic acid which leads to rapid development
anhydrous of resistance
Potassium 20 20 ▪ Dose: 15 mg/kg body weight 2x a day for 3 days
Citrate 10 10 ▪ Treat the Child: Oral Antibiotics/Antimalarial
Total 245 311
Osmolarity For Cholera:
▪ First Line: Tetracycline
▪ Second Line: Erythromycin
Benefits of Zinc Supplementation
▪ Reduces the severity of diarrhea
▪ Shortens the duration of diarrhea Oral Antimalarial:
▪ First Line: Artemether-Lumefantrine
▪ Lowers the number of diarrhea episodes – protects
▪ Second Line: Chloroquine, Primaquine, Sulfadoxine
the child from diarrhea for the next 2 – 3 months. and Pyrimethamine
Treatment Plan B for Some Dehydration
Give recommended amount of Reformulated ORS: Fever
AGE Up to 4 months 12 2 Treatment of drug-resistant malaria
▪ In case of parasitological or clinical failure to a
4 up to 12 months years
given drug, refer patient to the next level with
month months up to 2 up to 5
proper documentation (blood smear result incl.
s years years
parasite count on day7, 14, 21, & 28
WEIG Less 6 6 to less 10 to 12 to
o Quinine sulfate(300 or 600 mg/tab)
HT kg than 10 kg less less
o 10 mg/kg/dose every 8 hours for 7 days +
than 12 than
Clindamycin 10 mg/kg 2x a day for 3 days
kg 20 kg
Pre-referral treatment:
Amoun 200-4 450-800 800-96 960-16
▪ Artesunate suppository for uncomplicated P.
t of 50 0 00
falciparUm malaria in infants or young children
fluid
who cannot swallow.
(ml)
over 4
EAR INFECTIONS
hours Chronic ear infection

The approximate amount of ORS required can also ▪ Chronic ear infection should be treated with otical
▪
be calculated by multiplying child’s weight by 75 quinolone ear drops for at least 2 weeks in addition
to dry ear by wicking
▪
If the child wants more ORS, give more
▪
For infants below 6 months who are not breastfed,
also give 100-200 ml clean water during this period.
▪
Give frequent small sips from a cup.
▪
If child vomits, wait 10 minutes then continue –
more slowly

SN RMPB 6
OSCE REVIEW - BSN Routinely Check for Deworming Status
Give MebendaZOle/AlbendaZOle
IMCI - Give 500 mg. Mebndazole/400mg Albendazole as a
single dose in the health center if the child is 12
Acute ear infection months up to 59 months and has not received a dose
▪ Oral amoxicillin is a better choice for the in the previous 6 months
management of suppurative otitis media in
countries where antimicrobial resistance to MebendaZOle/AlbendaZOle Dose:
cotrimoxazole is high AGE OR Albendaz Mebendaz
▪ Dry the Ear by Wicking and Instill WEIGHT ole 400 ole 500 mg
Quinolone Eardrops mg tab. tab.
▪ Dry the ear using wick of clean absorbent cloth or 12 months up to ½ tablet 1 tablet
soft, strong tissue paper. 23 months
▪ Instill quinolone eardrops after wicking 3 times 24 months up to 1 tablet 1 tablet
daily for 2 weeks 59 months
▪ Quinolone eardrops may include: ciprofloxacin,
norfloxacin, or ofloxacin Vitamin A Treatment/Supplementation
▪ Follow the “Rule of Three” : 3 drops, tilt head for 3 AGE Vitamin A Capsules
minutes, instill 3 times a day 100,000 200,000
IU IU
Other Treatments 6 months up to 12 1 capsule ½ capsule
▪ Vitamin A for sick children months
▪ Iron for anemia 12 months up to 5 1 capsule
▪ Paracetamol for high fever (38.5 C or more) and yrs
for ear pain.
▪ Mebendazole/Albendazole for deworming. ▪ Counsel the Mother on Infant Feeding
▪ Multivitamins and minerals for Persistent Diarrhea 1. Exclusive breastfeeding up to 6 mos.
(with at least 2 of Recommended Energy and ▪ Breastfeed as often as the child wants, day and
Nutrient Intake: folate, Vitamin A, zinc, night at least 8 times in 24 hours
magnesium, copper) ▪ Breastfeed when the child shows signs of hunger,
▪ Tetracycline Eye Ointment for eye infection (TID) beginning to fuss, sucking fingers, or moving the
▪ Quinolone Eardrops & Ear Wicking for ear lips
discharge (TID). ▪ Do not give other foods or fluids
▪ Half-strength Gentian Violet for mouth ulcers
( BID). 2.Complementary feeding 6 mos. up to 23 mos.
▪ Cough Remedies: breastmilk ▪ Breastfeed as often as the child wants
▪ tamarind, calamansi, ginger (SKL) ▪ Give adequate serving of complementary foods: 3
▪ Given at Health Center Only: times per day if breastfed, with 1-2 nutritious
o IM Antibiotic for children being referred snacks as desired from 9-23 mos.
who cannot take oral antibiotic : ▪ Give foods 5 times per day if not breastfed with 1
- Give Gentamicin (7.5 mg/kg) AND Ampicillin 50 or 2 cups of milk
mg/kg ▪ Give small chewable items to eat with fingers.
Let the child try to feed itself, but provide help
Treat to Prevent Low Blood Sugar
▪ Breastfeed more frequently 3.Management of severe malnutrition where referral is
▪ Give sugar 30-50 ml of milk or sugar water before not possible
departure (for referral) ▪ Where a child is classified as having severe
▪ To make sugar water: Dissolve 4 level teaspoon malnutrition and referral is not possible, the IMCI
(20 grams) of sugar in 200 ml cup of clean water guidelines should be adapted to include
▪ If unconscious, give D10 5ml/kg over a few management at first-level facilities
minutes or give D50 1ml/kg by slow push. ▪ modified milk diet is given
Revised Immunization Schedule
Age Vaccine
Birth BCG, HepB1
6 weeks DPT1, OPV1, HepB2
10 weeks DPT2, OPV2
14 weeks DPT3, OPV3, HepB3
9 months Anti – measles
12 – 15 MMR
months
OSCE REVIEW - BSN Signs to look for in assessment:
PrevioUs: 12 signs
IMCI Updated: 7 signs
Classify: Aged Up to 2 months (Updated)
4.HIV and Infant Feeding ▪ Not feeding well, or
▪ In areas where HIV is a public health problem all ▪ Convulsions, or
women should be encouraged to receive HIV ▪ Fast breathing (60 bpm or more), or
testing and counseling ▪ Severe chest indrawing, or
▪ If a mother is HIV-infected and replacement ▪ Fever (37.5 C or above), or
feeding is acceptable, feasible, affordable, ▪ Low body temp. (less than 35.5 C), or
sustainable and safe for her and her infant, ▪ Movement only when stimulated or no movement at
avoidance of all breastfeeding is recommended. all
Otherwise, exclusive breastfeeding is
recommended during the first months of life Classify, Identify Treatment
▪ The child of HIV-infected mother who is not Red Local • Give an appropriate
breastfed should receive complementary foods umbilic Bacteri oral antibiotic.
▪ Care for Development – communication and play us al • Teach the mother to
▪ Increase fluids during illness Skin Infecti treat local infections
▪ When to Return: pustule on at home.
o for follow-up s • Advise mother how
o immediately to give home care
o for immunization for the young infant.
• Follow-up in 2 days.
When to Return Immediately
Any sick child Not able to drink or Checking for jaundice is added in the protocol
breastfeed
Becomes sicker Classification: Severe jaundice (pink), Jaundice (yellow),
Develops fever No jaundice (green)
No Pneumonia: Cough Fast breathing ▪ Any jaundice if age SEVERE
or cold Difficult breathing less than 24 hrs, or JAUNDICE
Diarrhea Blood in stool ▪ Yellow palms and
Drinking poorly soles at any age
Fever: DHF Unlikely Any sign of bleeding ▪ Jaundice appearing JAUNDICE
Persistent abdominal after 24 hrs of age,
pain and
Persistent vomiting ▪ Palms and soles not
Skin petechiae/ Skin yellow
rash ▪ No Jaundice NO
JAUNDICE
Give Follow-Up Care: Persistent Diarrhea
▪ After 5 days: Assess and Classify diarrhea
▪ Ask: Has the diarrhea stopped? ▪ For dehydration ( severe, some or no dehydration)
▪ How many loose stools is the child having per day? ▪ If diarrhea is 14 days or more: Severe Persistent
Diarrhea
Treatment ▪ If blood in stool: Dysentery
▪ If diarrhea has not stopped (3 or more/day), do a
full reassessment. Give any treatment needed. Check for feeding Problem or Low Weight
Refer to hospital.
▪ If diarrhea has stopped, tell the mother to follow
the feeding recommendation for child’s age.

Assess: Age up to 2 months

Previous Updated
Age: 1 week up to 2 Birth up to 2
months months

Main symptom:
PrevioUs: Possible serious bacterial infection
Updated: Very severe disease and local bacterial
infection
Not well attached to Feeding
breast Problem or Low
Not suckling Weight
effectively
Less than 8 feeds in 24
hrs.
Receives other foods or
drinks
Low weight for age
Thrush
Not low weight for age No feeding
and no other signs of Problem
inadequate feeding
OSCE REVIEW - BSN o For Immunization
▪ Make sure the young infant stays warm at all times.
IMCI
When to Return Immediately
Assess: Age up to 2 months ▪ Breastfeeding or drinking poorly.
▪ Check for the young infant’s immunization status ▪ Becomes sicker.
▪ Assess other problems ▪ Develops fever.
▪ Fast breathing.
Treat the Young Infant ▪ Difficult breathing.
▪ Give an appropriate oral antibiotic: ▪ Blood in stool.
▪ First Line: Amoxycillin
▪ Second Line: Cotrimoxazole ( Not given in
infants less than 1month of age who are Follow-Up Care: Oral Thrush
premature or jaundiced). ▪ After 2 days:
▪ Injectable Antibiotic (for referred patients unable ▪ Look for ulcers or white patches in the mouth.
to take oral antibiotic or for cases where referral ▪ Reassess feeding
is not possible): Ampicillin and Gentamicin ▪ If thrush is worse, or if the infant has problems
with attachment or suckling, refer to hospital.
Treat Skin Pustules ▪ If thrush is the same or better, and the infant is
▪ Wash hands. feeding well, continue half-strength Gentian Violet
▪ Gently wash off pus and crusts with soap and water. for a total of 5 days.
▪ Dry the area.
▪ Paint with full-strength Gentian Violet. Technical updates adapted in Philippine IMCI
▪ Wash hands. ▪ Antibiotic treatment of non-severe and severe
Treat Umbilical Infection pneumonia
▪ Wash hands. ▪ Low osmolarity ORS and antibiotic treatment for
▪ Paint with full-strength Gentian Violet. bloody diarrhea
▪ Wash hands. ▪ Treatment of fever/malaria
▪ Treatment of ear infections
Treat Oral Thrush ▪ Infant feeding
▪ Wash hands. ▪ Treatment of helminthiasis
▪ Wash mouth with clean soft cloth wrapped ▪ Management of sick young infant aged up to 2
around the finger and wet with salt water. months
▪ Paint the mouth with half-strength Gentian Violet.
▪ Wash hands.

Teach Correct Positioning and Attachment for

Breastfeeding
▪ 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 opening wide,
▪ Move her infant quickly onto breast, aiming the
infant’s lower lip well below the nipple.
▪ Look for signs of good attachment and effective
suckling. If the attachment or suckling is not good,
try again.

Signs of Good Attachment

▪ Chin touching the breast
▪ Mouth wide open.
▪ Lower lip turned outward.
▪ More areola visible above the top lip than below
the lower lip.