WEEK 17: INTEGRATED MANAGEMENT OF (+) general Severe

CHILDHOOD ILLNESSES danger signs Complicated

1 step – ask the mother: (about the child’s
st (+) red eyes Measles
(+) stiffed neck
problem) (+) fever
Initial or follow up? (+) mouth sores Measles With
General Danger signs: (+) conjunctivitis Eye Or Mouth
1. C- Convulsion Complications
2. A- Abnormally sleepy (-) danger signs Measles
(-) mouth and
3. N- Not able to drink
eye
4. S- Severe Vomiting (vomits everything) complications
(+) danger signs Severe
Main Symptoms (+) rashes Dengue
CDEF (cough, diarrhea, fever, ear infection) (+) Hemorrhagic
S/Sx Diagnosis Fever
COUGH (-) danger signs Fever
1. Respiratory (+) danger signs Severe (+) fever (Unlikely
rate? (+) signs and Pneumonia Dengue
2. Chest symptoms Hemorrhagic
indrawing? (-) danger signs Pneumonia Fever)
3. Stridor? (+) signs and EAR INFECTION
symptoms 1. Pus? (+) Swelling Mastoiditis
(-) danger signs No 2. Swelling Behind Behind The Ear
(-) signs and Pneumonia/ The Ear Chronic Ear
symptoms Cough Or Infection
Cold. Acute Ear
DIARRHEA Infection
1. How long? (+) danger signs Severe No Ear
2. Blood in the Dehydration Infection
stool? (Only Pink MALNUTRITION
3. Sleepy or That Doesn’t 1. Weight for Age Severe
irritable? Need Urgent 2. Edema (On The Malnutrition
4. Sunken eyes? Referral) Feet) Very Low
(-) danger signs Some 3. Severe Muscle Weight
Dehydration Wasting Not Very Low
(-) danger signs No 4. Mid Upper Arm Weight
(-) signs and Dehydration Circumference (+) Palmar Severe
symptoms MUAC (<115 Pallor Anemia
Long term Severe mm) Anemia
diarrhea Persistent No anemia
Diarrhea 29 diagnosis IMCI
Persistent What is IMCI?
Diarrhea  Is a systematic approach to children’s
Dysentery
health which focuses on the whole child.
FEVER
1. Malaria Risk? (+) danger signs Very Severe  It is a strategy for reducing mortality and
2. Stiffed Neck? (+) malaria risk Febrile morbidity associated with major causes of
3. Runny Nose? Disease childhood illness
4. Generalize Malaria  Developed by UNICEF and WHO in 1992.
Rash? (-) danger signs Malaria
History of IMCI
5. Cough? (+) malaria risk
6. Red Eyes? (+) fever Fever (Malaria  Every year, almost 11 million children
(-) malaria Unlikely) under the age of five around the world die
unlikely from preventable illnesses.
(+) danger signs Very Severe  Most common causes of these deaths are:
(+) fever Febrile
o Acute Respiratory Infection (ARI)
(-) malaria risk Disease
(-) danger signs Fever (No (Pneumonia mostly)
(+) fever Malaria) o Diarrhea
(-) malaria o Malaria
 o Measles  Mild, Moderate, Severe
o Malnutrition TREAT THE  Curative method of
INDICATIONS FOR IMCI PATIENT treating the disease
QUALITY OF CARE:  Vary on the condition of
Every day, millions of parents bring their sick child the patient
to:  2 months – 5 years
 Hospitals COUNSEL  Health education
 Health Centers
THE  Important for
PATIENT parents/caregivers who
 Pharmacists
lack knowledge
 Doctors
 Traditional Healers
MANAGEMENT OF SICK CHILD
CAUSE OF THE PROBLEM:
2 MONTHS – 5 YEARS
 Surveys reveal that many sick children:
At The Start of the Management:
o Are not properly assessed and
 Ask the mother what the child’s problems
treated
are
o Parents are poorly advised
 Determine if this is an initial or follow-up visit
OTHER CAUSES
for this problem
 Minimal or non-existent diagnostic support
CHECK FOR GENERAL DANGER SIGNS
 Scarce drugs and equipment ASK (subjective):
 Irregular flow of patients  Is the baby NOT ABLE TO DRINK or
THEREFORE:
BREASTFEED?
 Doctors have few opportunities to practice  Does the child VOMITS EVERYTHING?
complicated procedures
 Has the child had CONVULSIONS?
 Rely on signs and symptoms for
LOOK (objective):
management and makes the best use of
 If the child is ABNORMALLY SLEEPY OR
available resources
DIFFICULT TO AWAKEN?
OBJECTIVES OF IMCI
GENERAL DANGER SIGNS
 To significantly reduce the global mortality 1. CONVULSIONS ABNORMALLY SLEEPY
and morbidity associated with the major 2. NOT ABLE TO DRINK
cause of diseases in children 3. SEVERE VOMITING (Vomits Everything)
 To contribute to health growth and CONVULSIONS
development of children
 May be the result of fever
INTEGRATED CASE MANAGEMENT PROCESS
 Do little harm beyond frightening the mother
 Presented in a series of charts that show
 Life threatening convulsions: MENINGITIS,
the sequence of steps and provide
CEREBRAL MALARIA
information for performing them.
 All children with convulsions should be
INTEGRATED CASE MANAGEMENT PROCESS
considered SERIOUSLY ILL!
1. Assess the child or young infant
 Referral is a must!
2. Classify the Illness
ABNORMALLY SLEEPY
3. Identify treatment
4. Treat the child/refer  unconscious/lethargic
5. Counsel the mother  Does not take notice any of his
6. Give follow-up care surroundings
ASSESS  History taking  Does not respond normally to sounds or
THE CHILD  Asking and observing the environment
OR YOUNG patient’s  Associated with many conditions
INFANT
 condition NOT ABLE TO DRINK/BREASTFEED
 Explore possible causes  Too weak or can’t swallow
CLASSIFY  Based on thorough  Do not rely completely on mother’s
THE assessment  evidence
ILLNESS  Supported with laboratory  Observe while she gives the child
results something to drink
 SEVERE VOMITING  Chest indrawing + Wheeze, treat
 VOMITING is important because: wheezing
 It is a sign of a serious illness  Treat the child to prevent low blood sugar
 Child will not be able to take in medications  REFER URGENTLY TO THE HOSPITAL
or fluids for rehydration
 NEEDS REFERRAL! (except in severe PNEUMONIA
dehydration)  Fast breathing
CHECK FOR THE MAIN SYMPTOMS  Give Antibiotic for 3 DAYS
C Cough or Difficulty in breathing  If still wheezing, give INHALED
D Diarrhea BRONCHODILATOR for 5 DAYS
E Ear problem  Soothe the throat and relieve cough with
F Fever a safe remedy
 Advise mother when to return
COUGH OR DIFFICULTY IN BREATHING immediately
ASK:  Follow up in 2 DAYS
 For how long?
NO PNEUMONIA: COUGH OR COLD
LOOK, LISTEN (the child must be CALM)
 No signs of pneumonia or very severe
 Respiratory Rate (ONE MINUTE)
disease
 Chest Indrawing  If still wheezing, give INHALED
 Stridor BRONCHODILATOR for 5 DAYS
 Wheeze  Soothe the throat and relieve cough with
FAST BREATHING a safe remedy
2 Months – 12 Months 12 Months – 60  If with cough for 30 days, REFER
Months  Advise mother when to return
50 Breaths Per Minute 40 Breaths Per Minute immediately
Or More Or More  Follow up in 5 DAYS if not improving, 2
CHEST INDRAWING DAYS if treated for wheeze
 The lower chest wall goes IN when the child
breaths IN APPROPRIATE ANTIBIOTIC
STRIDOR AMOXICILLIN - 1st Line
 A harsh noise made when the child breaths COTRIMOXAZOLE – 2nd Line
IN.  Determine the appropriate drug and
 Happens when there is a swelling of the  dosage for the child’s age or weight
larynx, trachea, or epiglottis.  Tell the mother the reason for giving the
 Considered life-threatening because airway drugs to the child
maybe blocked  Demonstrate how to measure a dose
WHEEZE  Watch the mother practice how to measure
 Wheezing noise when the child breaths a dose by herself
OUT  Explain carefully how to give the drug, then
 Not considered a stridor label and package the drug
 If present during assessment, give a trial of  If more than one drug to be given, collect,
RAPID-ACTING BRONCHODILATOR for count, and package each drug separately
up to THREE TIMES 15-20 minutes apart.  Explain that all the tablets and/or syrup
Recheck breaths and chest indrawing must be used to finish the course of
again, then classify treatment, even if the child feels better
SEVERE PNEUMONIA / VERY SEVERE  Check the mother’s understanding before
DISEASE she leaves the health center
 Any General Danger Sign AMOXICILLIN
 Chest Indrawing Adult Tablet Syrup
 Stridor in a calm child (500 mg) (100 Mg Per
 Give 1st dose of Antibiotic 5 mL)
 Give Vitamin A 2 mos. – 6 mos. ¼ 1.5 mL
 (3-5 kgs.)  Is the child drinking poorly or drinking
6 mos. – 12 mos. ½ 2.5 mL eagerly?
(6-9 kgs.)  Pinch the abdomen, does it goes back
12 mos. – 3 yrs. ¾ 3.5 mL longer than 2 seconds? Or less than 2
(10-14 kgs.) seconds?
3 yrs. – 5 yrs. 1 5 mL
 Two of the following signs:
(15-19 kgs.)
 Abnormally sleepy or difficult to awaken
 Sunken eyes
COTRIMOXAZOLE
 Not able to drink/drinking poorly
Adult Tablet Syrup
 Skin goes back VERY SLOWLY
(500 mg) (100 Mg Per
SEVERE DEHYDRATION
5 mL)
PLAN C
2 mos. – 6 mos. ½ 5 mL
(3-5 kgs.)  If with other severe classification, Refer
6 mos. – 12 mos. URGENTLY with mother giving frequent
sips of ORS on the way, advise to
(6-9 kgs.)
continue BF
12 mos. – 3 yrs. 1 10 mL
(10-14 kgs.)  If child is 2 yrs and with cholera in the
area, give antibiotic for cholera
3 yrs. – 5 yrs.
(15-19 kgs.)
Two of the following signs:
VITAMIN A  Restless, irritable
100,000 IU 200,000 IU  Sunken eyes
6 mos. – 12 1  Drinking EAGERLY
mos.  Skin goes back SLOWLY
12 mos. – 5 1 SOME DEHYDRATION
yrs.  If with other severe classification, Refer
GIVE: URGENTLY with mother giving frequent
 1 CAPSULE TODAY (Day 1) sips of ORS on the way, advise to
continue BF
 1 CAPSULE TOMORROW (Day 2)
 Advise mother when to return
 1 CAPSULE 2 WEEKS AFTER Day 2 immediately
TREAT TO PREVENT LOW BLOOD SUGAR  Follow up in 5 days if not improving
 If able to breastfeed, ASK MOTHER TO
BREASTFEED CHILD Not enough signs to classify
 If not able to breastfeed but can swallow: NO DEHYDRATION
o Give expressed milk, or breastmilk PLAN A
substitute Advise the mother when to return immediately
o If not available, give 30-50 cc of Follow up in 5 days if not improving
SUGAR WATER or MILK.
 If child is not able to swallow, 50 mL of TETRACYCLINE
MILK or SUGAR WATER thru NGT  Drug of choice for cholera
 If child is unconscious, START IV Infusion,  Give two times daily for 3 days
Give 5mL/kg of 10% Dextrose solution over  1 tablet (250 mg)
a few minutes or 1 mL/kg of 50% Dextrose  ALTERNATIVE - ERYTHROMYCIN
solution slow push
DIARRHEA PLAN A REHYDRATION
ASK: GIVE EXTRA FLUIDS:
 For how long?  Breastfeed frequently and longer per
 Is there any blood in the stools? feeding
LOOK, LISTEN  For exclusively breastfed babies, give ORS
 Is the child abnormally sleepy? Irritable or or clean water together with BM.
restless?  For non-exclusively breastfed babies, give
 Look for sunken eyes one or more of the following-food based
 liquids (soup, rice water, buko juice), or  Also give ORS (5 mL/kg/hr) as soon as child
ORS can drink
 Teach the mother how to mix and give  Reassess, then RE-CLASSIFY
ORS, give the mother 2 PACKETS of ORS IS IV TREATEMENT AVAILABLE NEARBY?
to use at home (WITHIN 30 MINS)
 Show the mother how to give additional  Refer URGENTLY to the Hospital for
fluids other than usual intake Treatment
GIVE ZINC SUPPLEMENTS  If the child can drink, provide the mother
 Tell the mother how much zinc to give (20 with ORS solution and show her how to give
mg tab) frequent sips during the trip
 2 MOS. – 6 MOS. ARE YOU TRAINED TO USE NGT FOR
 6 MOS. Above REHYDRATION? CAN THE CHILD DRINK?
 ½ tab OD for 14 days 1 tab OD for 14 days  Start rehydration through NGT: 20mL/kg/hr
 Demonstrate how to give the supplement for 6 hours
CONTINUE FEEDING  Reassess every 1-2 hrs:
WHEN TO RETURN  If there is vomiting or increasing abdominal
PLAN B REHYDRATION distention, give more fluid SLOWLY
DETERMINE AMOUNT OF ORS TO BE GIVEN  If hydration is not improving for 3 hrs, SEND
FOR 4 HOURS FOR IV THERAPY
AGE WEIGHT AMOUNT  After 6 hours, REASSESS and
Up to 4 mos. < 6 kgs. 200 – 450 RECLASSIFY
4 – 12 mos. 6 - <10 kgs. 450 – 800
12 mos. – 2 10 - < 12 kgs. 800 – 960  Diarrhea for 14 days or more
yrs.  Dehydration PRESENT
2 yrs – 5 yrs 12 - < 20 kgs. 960 - 1600 SEVERE, PERSISTENT DIARRHEA
 Treat Dehydration before referral unless
SHOW HOW TO PREPARE ORS SOLUTION child has another severe classification
AFTER 4 hours:  Give VITAMIN A
 Reassess and Reclassify  REFER to the HOSPITAL
 Select appropriate plan for treatment
 Begin feeding the child in the HC  Diarrhea for 14 days or more
 Give zinc supplements  Dehydration ABSENT
IF THE MOTHER MUST LEAVE BEFORE PERSISTENT DIARRHEA
COMPLETING TREATMENT:  Advise on feeding for child with
 Show her how to prepare the ORS at home PERSISTENT DIARRHEA
 Show her how much ORS to give her child  Give VITAMIN A
to finish the 4-hour treatment at home  Give MULTIVITAMINS and MINERALS
 Give her instruction on how to prepare salt (including Zinc) for 14 days
and sugar solution for use at home  Follow up in 5 days
 Explain 4 RULES OF HOME TREATMENT  Advise the mother when to return
immediately
 HMSS (homemade salt sugar): 1L of water
= 8 tsp of sugar + 1 tsp of salt
 Blood In The Stool
o Good for only 24 hours
DYSENTERY
PLAN C REHYDRATION
 Give CIPROFLOXACIN for 3 days
 Lactate → liver → HCO3 → combats
 Follow up in 2 days
metabolic acidosis
 Advise the mother when to return
CAN YOU GIVE IV FLUID IMMEDIATELY? immediately
 GIVE IV FLUID IMMEDIATELY.
 100 mL/kg LRS (or NSS if not available) CIPROFLOXACIN
 Reassess every 1-2 hrs. If not improving, Age or Weight Give 2 times daily for 3 days
give fluids rapidly 100 mg tablet 250 mg tablet
 2-6 mos. ½ tab ¼ tab  Send blood smear with the patient
(3-5 kg)  REFER URGENTLY TO THE HOSPITAL!
6-12mos. 1 tab ½ tab
(6-9 kg)  Positive Blood Smear
1-3 yrs. 1 ½ tab ½ tab MALARIA
(10-14 kg)  ORAL ANTIMALARIAL
3-5 yrs. 2 tab 1 tab  Paracetamol if with fever
(15-19 kg)
 Advise the mother when to return
immediately
FEVER (Malaria Risk)  Follow up in 2 days if fever persists
DECIDE MALARIA RISK!  If fever is present for more than 7 days,
Ask: refer for assessment
 Does the child live in a malaria area?
 Has the child visited/ travelled or stayed in a  Blood smear (-)
malaria risk area for the past 4 weeks?  Runny nose
DECIDE MALARIA RISK!  Measles
 If YES, OBTAIN BLOOD SMEAR  Other causes of fever
 Blood smear: FEVER: MALARIA UNLIKELY
o Thin smear – identify the causative  Give Paracetamol if with fever
agent  Advise when to return immediately
o Thick smear – used to quantify  Follow up in 2 days if fever persists
o Obtained at the peak of the fever  If fever is present every day for 7 days,
Then ask: refer for assessment
 How long is the fever?
 If more than 7 days, has the fever been PARACETAMOL
present every day? Age or weight TABLET SYRUP
 Has the child has measles within the last 3 (500 mg) (120 mg/5 mL)
months? 2 mos – 3 yrs ¼ 5 mL
(4 - <14 kgs.)
DECIDE MALARIA RISK!
3 yrs – 5 yrs ½ 10 mL
Look and Feel:
(14 - <19 kgs)
 STIFF NECK
 RUNNY NOSE QUININE
 Look for signs of measles: Age or Weight Intramuscular
 Generalized rash and cough or runny nose 150 mg/mL 300 mg/mL
or red eye (in 2 mL) (in 3 mL)
 Rash of measles: 2-4 mos 0.4 mL 0.2 mL
o Maculopapular rash – flat-elevated (4 - <6 kg)
rash 4-12 mos 0.6 mL 0.3 mL
o Rubeola – blue specs opposite the (6 - <10 kg)
molar or buccal mucosa (Koplic 12 mos – 2 yrs 0.8 mL 0.4 mL
spots) (10 - <12 kg)
o Rubella (German measles) – post 2-3 yrs 1.0 mL 0.5 mL
(12 - <14 kg)
orricular, sub occipital, post cervical
3-5 yrs 1.2 mL 0.6 mL
lymphadenopathy
(14 - <19 kg)

 General danger sign QUININE

 Stiff neck
VERY SEVERE FEBRILE DISEASE / MALARIA
 First dose of quinine!
 First dose of appropriate antibiotic
 Treat to prevent low blood sugar
 Give Paracetamol if with fever (38.5)
 GIVE QUININE THEN REFER URGENTLY TO
THE HOSPITAL!
 REFERRAL NOT POSSIBLE:
 Give first dose of quinine
 Child should remain lying down for one hour
  Repeat quinine at 4 and 8 hrs later, then MEASLES
every 12 hrs until child can take oral  Vitamin A
antimalarial. Do not give for more than 1  Advise mother when to return
week immediately
 If no malaria risk, do not give to child less
than 4 months of age TETRACYCLINE
 Clean both eyes 3 times daily
 General danger sign
 Wash hands
 Stiff neck
 Use clean cloth and water to gently wipe
VERY SEVERE FEBRILE DISEASE
away pus
 First dose of appropriate antibiotic
 Apply Tetracycline
 Treat to prevent low blood sugar
 Give Paracetamol if with fever (38.5)  Ask the child to look up
 REFER URGENTLY TO THE HOSPITAL!  Small amount on the inside of lower lid
 Wash hands again
 No signs of very severe febrile disease GENTIAN VIOLET
FEVER: NO MALARIA  Treat twice daily
 Give Paracetamol if with fever  Wash hands
 Advise when to return immediately  Wash child’s mouth with a clean soft cloth
 Follow up in 2 days if fever persists wrapped
 If fever is present every day for 7 days,  around the finger and wet with salt water
refer for assessment  Paint mouth with half-strength Gentian
 Treat other causes of fever Violet (0.25% dilution)
 Wash hands again
FEVER (Measles Risk)  Continue using for 38 hours until ulcers
If child has measles now or within the last 3 months have been cured
LOOK:  Give paracetamol for pain relief.
 For mouth ulcers
 Pus draining from the eyes FEVER (Dengue Hemorrhagic Fever)
 Clouding of cornea  Assess Dengue Hemorrhagic Fever
 General danger sign ASK:
 CLOUDING OF CORNEA  Did the child have:
 Deep or extensive mouth ulcers  Bleeding from the nose or gums, or in the
SEVERE COMPLICATED MEASLES vomitus or stools?
 Give Vitamin A  Black vomitus
 Give first dose of appropriate antibiotic  Black stools
 CLOUDING OF CORNEA/PUS
 Persistent abdominal pain
– tetracycline ointment
 REFER URGENTLY TO THE HOSPITAL  Persistent vomiting
LOOK AND FEEL:
 Pus draining from the eye  Bleeding from nose or gums
 Mouth ulcers  Skin petechiae
MEASLES WITH EYE OR MOUTH  Cold and clammy extremities
COMPLICATIONS  Slow capillary refill
 Give Vitamin A  Any sign of bleeding
 If with pus draining from the eye –  Capillary refill for more than 3 secs
TETRACYCLINE  Persistent abdominal pain
 Mouth ulcers – GENTIAN VIOLET  Persistent vomiting
 Follow up in 2 days  (+) tourniquet rest
 Advise when to return immediately SEVERE DENGUE HEMORRHAGIC FEVER
 PLAN B – vomiting, abd pain, (+)
 Measles now or within the last 3 mos. tourniquet
 PLAN C – if with signs of bleeding
  Treat to prevent low blood sugar
 REFER URGENTLY!
 DO NOT GIVE ASPIRIN!
 No signs of severe DHF
FEVER: DENGUE HEMORRHAGIC FEVER
UNLIKELY
 Advise mother when to return
immediately
 Follow up in 2 days if fever persists or
child shows signs of bleeding
 DO NOT GIVE ASPIRIN!
 Rempel leads test (tourniquet test or
capillary fragility test) – presumptive
diagnosis for DHF
o >20 petechiae in 1 square inch (+)
 Do not give aspirin (NSAID) → blocks
thromboxane → lead to more bleeding
EAR PROBLEM
IF YES,
 Is there ear pain?
 Is there ear discharge?
If Yes, for how long?
LOOK AND FEEL:
 Pus draining from the ear
 Feel for tender swelling behind the ear
 Tender swelling behind the ear
MASTOIDITIS
 Give first dose of an appropriate antibiotic
 Giver first dose of paracetamol for pain
 REFER URGENTLY TO THE HOSPITAL
 Ear pain
 Pus draining from the ear and discharge
Is reported for less than 14 days
ACUTE EAR INFECTION
 Give antibiotic for 5 days
 Give paracetamol for pain
 Dry the ear by wicking
 Follow-up in 5 days
 Advise the mother when to return
immediately
 Pus draining from the ear and discharge
Is reported for more than 14 days
CHRONIC EAR INFECTION
 Dry the ear by wicking
 Instill quinolone otic drops for 2 weeks
 Follow up in 5 days
 Advise the mother when to return
immediately
 No ear pain and pus from ear
NO EAR INFECTION
 No additional treatment
 Advise mother when to return
immediately
Dry the ear by WICKING and Instillation of
QUINOLONE Otic Drops
 Dry the ear at least 3 times daily
o Roll clean absorbent cloth or soft,
strong tissue paper into a wick
o Place the wick in the child’s ear
o Remove the wick when wet
o Replace the wick with a clean one
and repeat steps until ear is dry
 Instill QUINOLONE OTIC DROPS after
wicking, 2 to 3 drops three times daily for 2
weeks
MALNUTRITION
LOOK AND FEEL
 Determine weight for age
 Look for edema of both feet
 Look for visible severe wasting
 For children 6 months older, check if MUAC
is less than 115 mm.
 6 months below:
o Visible severe wasting
o Edema of both feet
 6 months above:
o MUAC less than 115 mm
o Edema of both feet
o Visible severe wasting
SEVERE MALNUTRITION
 Treat the child to prevent low blood sugar
 Give vitamin A
 REFER URGENTLY TO THE HOSPITAL
 Very low weight for age
VERY LOW WEIGHT
 Assess the child’s feeding and counsel
mother on feeding according to the
feeding recommendations and care for
development
 If feeding is a problem, follow up in 5 days
 GIVE VITAMIN A
 Advise the mother when to return
immediately
 Follow up in 30 days
 Not very low weight for age and No signs
of malnutrition
NOT VERY LOW WEIGHT
  Assess the child’s feeding and counsel
mother on feeding according to the
feeding recommendations and care for
development
 If feeding is the problem, follow up in 5
days
 Advise mother when to return
immediately

ANEMIA
LOOK AND FEEL
Look for palmar pallor,
 Severe palmar pallor?
 Some palmar pallor?

 SEVERE PALMAR PALLOR

SEVERE ANEMIA
 REFER URGENTLY TO THE HOSPITAL!

 SOME PALMAR PALLOR

ANEMIA
 Assess the child’s feeding and counsel
mother on feeding according to the
feeding recommendations and care for
development
 GIVE IRON
 GIVE ALBENDAZOLE/MEBENDAZOLE if
child is 1 year or older and has not had a
dose in the previous 6 months
 Advise the mother when to return
immediately
 Follow-up in 14 days

 No palmar pallor
NO ANEMIA
 If the child is less than 2 years old,
Assess the child’s feeding and counsel
mother on feeding according to the
feeding recommendations and care for
development
 Advise mother when to return
immediately