Revised IMNCI CHART BOOKLET-1-1

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
SICK CHILD SICK YOUNG INFANT THE REPUBLIC OF UGANDA, 2017

Age: 2 Months Up To 5 Years Age: Birth Up To 2 Months
ASSESS AND CLASSIFY THE SICK Start The Child With TB Exposure On Isoniazid Preventive IMNCI PROCESS FOR THE SICK
Therapy ...........................................................................20
CHILD Dosage of Isoniazid by weight band...............................20 YOUNG INFANT.................................................31 WHO MOH UNICEF
Check For General Danger Signs.........................................1 Signs of Severe Disease.................................................32
Then Ask About Main Symptoms........................................2 Give Ready-To-Use Therapeutic Food.............................21
Does the child have cough or difficult breathing?........2 Give Ready-To-Use Therapeutic Food For Severe ASSESS, CLASSIFY AND TREAT THE
Acute Malnutrition .....................................................21
Does The Child Have Diarrhoea?.......................................3 Recommended Amounts of Ready-to-Use
YOUNG INFANT Give Follow-Up Care continued
Does The Child Have Fever?..............................................4 Check For Possible Serious Bacterial Infection ..............33 Pneumonia Or Severe Pneumonia..............................48
Therapeutic Food .....................................................21 Then Check For Jaundice................................................34
Does The Child Have Ear Problem?...................................5 Local Infection..............................................................48
Then Check For Malnutrition .............................................6 Then Assess For Diarrhoea ...........................................35 Jaundice.......................................................................48
Check For Anaemia............................................................7 GIVE FOLLOW-UP CARE FOR ACUTE Then Check For HIV Infection ........................................36 Diarrhoea......................................................................49
Then Check For HIV Infection............................................8 CONDITIONS Then Check For TB .........................................................37 Feeding Problem..........................................................49
Then Check For TB............................................................9 Give Follow-Up Care .......................................................22 Then Check For Feeding Problem Or Low Weight .........38 Low Weight For Age....................................................49
Check The Child’s Immunisation & Vitamin A Status ......10 Pneumonia .................................................................22 Check Young Infant‘s Immunization Status .....................39 Thrush..........................................................................49
Persistent diarrhoea ...................................................22 Assess Young Infant For Other Problems .......................39
TREAT THE CHILD
Pre-referral treatment ......................................................11
Dysentery ...................................................................22
Malaria ........................................................................23
Assess The Mother’s Health Needs ................................39
ANNEX
Give diazepam to Stop Convulsions..........................11 Fever- No malaria .......................................................23 TREAT THE YOUNG INFANT Annex1: Assess Child Development Milestones.............50
Annex2: Weight-For-Height Boys ...................................51
Give Artesunate Suppositories Or Intramuscular.......11 Measles with eye or mouth complications...................23 Give First Doses Of Intramuscular Gentamicin ..........40
Ear infection ...............................................................23 Prevent Low Blood Sugar ..........................................40 Annex3: Weight-For-Length Boys ..................................52
Artesunate Or Quinine For Severe Malaria................11
Give an Intramuscular Antibiotic.................................11 Feeding problem .......................................................23 Keep The Young Infant Warm ....................................40 Annex4: Growth Chart Boys............................................53
Treat The Child To Prevent Low Blood Sugar ...........12 Anaemia .....................................................................24 Refer Urgently ............................................................40 Annex5: Weight-For-Height Girls.....................................54
Refer Urgently............................................................12 Very low weight ..........................................................24 Plan C: Treat Severe Dehydration ..............................41 Annex6: Weight-For-Length Girls....................................55
Plan C: Treat For Severe Dehydration Quickly .........13 Give Oral Amoxicillin ..................................................42 Annex7: Growth Chart Girls.............................................56
Moderate Acute Malnutrition.............................................24 Plan A: Treat Diarrhoea at home ...............................43
Carry Out The Treatment Steps Identified On The Assess Uncomplicated Severe Acute Malnutrition........................24 Plan B: Treat some dehydration with ORS.................43
And Classify Chart ...........................................................14 How To Treat Local Infections.....................................44
Teach The Mother To Give Oral Medicines................14 COUNSEL THE MOTHER Immunize Every Sick Young Infant, As Needed .........44
Give An Appropriate Oral Antibiotic............................14 Assess The Feeding Of Sick Infants Under 2 Years........25
Give Oral Anti Malarial For Malaria ...........................15 COUNSEL THE MOTHER
Give Paracetamol for High fever................................15 Feeding Recommendations..............................................26 Correct Positioning And Attachment For
Give Extra Fluids For Diarrhoea And continue Feeding recommendation for all children.....................26 Breastfeeding .............................................................45
Feeding (Plan A and Plan B).....................................16 Consel The Mother About Feeding Problems..............27 How To Express Breastmilk.........................................45
Give Iron....................................................................17 Feeding Advice For The Mother .................................28 How To Feed By A Cup...............................................46
Give Salbutamol For Wheezing.................................17 “AFASS” criteria for stopping breastfeeding ..............28 How To Keep The Low Weight Infant Warm..............47
Teach The Mother To Treat Local Infections..............18 Counsel The Mother About Responsive Care Giving How To Give Home Care ...........................................47
Treat the child for Tb ................................................19 And Stimulating The Child’s Brain ..............................29
Give Vitamin A And Mebendazole In Clinic...............20 Counsel The Mother About Her Own Health ..............30
Recommmended Tb Treatment Regimen.................20 Fluids...........................................................................30 GIVE FOLLOW-UP CARE
Dosage of anti-TB medicines by weight band..........20 Very Severe Disease Where Referral Was Refused
When To Return ..............................................................30
Or Not Possible...........................................................48

1
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD
ASSESS CLASSIFY AS IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE USE ALL BOXES THAT MATCH
Determine if this is an initial or follow-up visit for this problem. CHILD’S SYMPTOMS AND
• If follow-up visit, use the follow-up instructions on
PROBLEMS TO CLASSIFY THE
TREAT THE CHILD chart. ILLNESS
• If initial visit, assess the child as follows:
CHECK FOR GENERAL DANGER SIGNS

ASK: • Any general signs VERY SEVERE • Give diazepam if convulsing now
LOOK AND FEEL
URGENT DISEASE • Quickly complete the assessment
- Is the child able to drink or - See if the child attention • Give any pre-referral treatment immediately
breastfeed? is lethargic or • Treat to prevent low blood sugar
unconscious.
- Does the child vomit • Keep the child warm
everything? - Is the child convulsing • Refer URGENTLY
now?
- Has the child had convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
1
ASSESS AND CLASSIFY THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS
ASSESS CLASSIFY IDENTIFY TREATMENT
THEN ASK ABOUT MAIN SYMPTOMS: USE ALL BOXES THAT MATCH CHILD’S SYMPTOMS AND PROBLEMS
USE ALL BOXESTO CLASSIFY THE ILLNESS
THAT MATCH THE CHILD’S SYMPTOMS
Does the child have cough or difficult breathing?
SIGN AND PROBLEMS
CLASSIFY AS TO CLASSIFY THE TREATMENT
IDENTIFY ILLNESS.
(Urgent pre-referral treatments are in bold print)
Ask the mother what the child’s problems are, determine whether this is an initial or follow-
up visit for this problem. If follow-up visit, use the follow-up instructions on TREAT THE SIGNS
• Any general SEVERECLASSIFY AS
• Give TREATMENT
first dose of an appropriate antibiotic
Classify
ASK:
CHILD LOOK,
chart if initial LISTEN,
visit, assess the childFEEL:
as follows: danger sign PNEUMONIA (Urgent to
• Refer URGENTLY pre-referral
hospitaltreatments are in bold print)
COUGH or
• Count the breaths in one minute. Child OR OR VERY
DIFFICULT
•CHECK
For how FOR
• LookGENERAL DANGER
for chest indrawing. SIGNS
must • Any in
• Stridor general
a danger SEVERE
sign SEVERE • Give first dose of an appropriate
BREATHING
long? • Look and listen for stridor be OR child
calm DISEASEPNEUMONIA OR antibiotic
ASK: • Look and listen for wheezingLOOK: calm • Chest indrawing VERY SEVERE • Refer URGENTLY to hospital
- OR
Chest indrawing PNEUMONIA • Give oral Amoxicillin for 5 days
• Is the child able to drink or breastfeed? • See if the child is lethargic or DISEASE
OR • If wheezing (or wheezing has disappeared after
• Does the child vomit everything? unconscious. • Stridor in calm child
• Has the child had convulsions • Is the child convulsing now? - Fast breathing rapidly acting bronchodilator) give an inhaled
• Fast breathing • Give
bronchodilator for 5oral
daysantibiotic for 5 days
If wheezing and either fast breathing or chest
A child with any general danger sign needs URGENT attention; complete the • If wheezing (even if it disappeared
assessment, anyindrawing:
pre-referralGive a trial
treatment of rapid acting
immediately inhaledis not delayed.
so that referral
• If recurrent wheeze, refer for asthma assessment
after rapidly acting bronchodilator)
bronchodilator for up to three times 15–20 • If chest indrawing
giveinanHIV exposed/infected
inhaled child,forgive
bronchodilator
minutes apart. Count the breaths and look for 5 days* and refer.
first dose of amoxicillin
chest indrawing again, and then classify. • Soothe the • Soothe
throat the throat
and relieve and relieve
the cough with athe
safe
THEN ASK ABOUT MAIN SYMPTOMS: PNEUMONIA
cough with a safe remedy
remedy
• If coughing for more than 2 weeks or
Does the child have cough or difficult breathing? • If coughing for 14 days or more, check for TB
if having recurrent wheezing, refer for
(See page 9) assessment for TB or asthma
ASK: OOK, LISTEN, FEEL: • Advise mother when tothe
• Advise return immediately
mother when to return
• Count the breaths in one minute. (See page 30) immediately
For how long? • Look for chest indrawing. Child must • Follow-up in• 3 Follow
days up in 3 days
• Look and listen for stridor be calm Classify
• Look and listen for wheezing. • No
COUGH or • No signsigns
of of pneumonia
COUGH OR • If wheezing•(orIfwheezing
wheezinghas give oral salbutamol
disappeared after for
DIFFICULT OR
Pneumonia COLD 5 days*
rapidly acting bronchodilator) give an inhaled
If wheezing and either fast breathing or chest indrawing: Breathing very severe disease
OR • Soothe the throat and relieve cough
Give a trial of rapid acting inhaled bronchodilator for up to bronchodilator for 5 days
with a safe remedy
three times 15–20 minutes apart. Count the breaths and • Very severe • If recurrent wheezing, referfor
formore
asthma assessment
disease COUGH OR COLD • If coughing than 2 weeks or
look for chest indrawing again, and then classify.
if having recurrent wheezing,
• Soothe the throat and relieve the cough with arefer
safe for
remedy assessment for TB or asthma
If the child is: Fast breathing is: • If coughing •forAdvise
14 daysmother
or more,when
checktofor
return
TB
immediately
2 months up to 12 months 50 breaths per minute or more (see page 9)
12 months up to 5 years 40 breaths per minute or more
• Follow up in 5 days if not improving
• Advise mother when to return immediately
• Follow-up in 5 days if not improving
2
DOES THE CHILD HAVE DIARRHOEA? SIGN CLASSIFY AS IDENTIFY TREATMENT
Two of the following signs: • If child has no other severe classification:
IF YES, ASK: LOOK AND FEEL: → Give fluid for severe dehydration (Plan C) OR
for • Lethargic or unconscious
If child also has another severe classification:
• For how long? • Look at the child’s general DEHYDRATION • Sunken eyes → Refer URGENTLY to hospital with mother
• Is there blood condition. Is the child: • Not able to drink or drinking SEVERE giving frequent sips of ORS on the way
in the stool? → Lethargic or poorly DEHYDRATION Advise the mother to continue breastfeeding
unconscious? • Skin pinch goes back very • If child is 2 years or older and there is cholera in your
→ Restless and irritable? slowly.
area, give antibiotic for cholera
• Look for sunken eyes. Classify Two of the following signs: • Give fluid, zinc supplements and food for some
• Offer the child fluid. Is the Diarrhoea • Restless, irritable dehydration (Plan B)
SOME • If child also has a severe classification:
child: • Sunken eyes DEHYDRATION
→ Not able to drink or → Refer URGENTLY to hospital with mother
• Drinks eagerly, thirsty giving frequent sips of ORS on the way
drinking poorly?
• Skin pinch goes back slowly Advise the mother to continue breastfeeding
→ Drinking eagerly, thirsty?
• Follow-up in 5 days if not improving.
• Pinch the skin of the
abdomen. Not enough signs to classify as NO DEHYDRATION • Give fluid, zinc supplements and food to treat diarrhoea at
Does it go back: some or severe dehydration home (Plan A)
→ Very slowly (longer than • Advise mother when to return immediately
2 seconds)? • Follow-up in 5 days if not improving.
→ Slowly?
SEVERE • Treat dehydration before referral unless the child has

and if diarrhoea PERSISTENT another severe classification
• Dehydration present
for 14 days or DIARRHOEA → Refer to hospital
* If referral is not possible, manage the child as more
described in Integrated Management of Childhood • Check for HIV Infection
Illness, Treat the Child, Where Referral Is Not • No dehydration • Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
Possible. DIARRHOEA
• Give multivitamins and minerals including zinc for 10 days
• Follow up in 5 days
If dysentry present with severe dehydration or and if blood in • Blood in the stool • Give ciprofloxacin for 3 days
some dehydration, treat with plan C and plan B stool DYSENTERY • Follow-up in 2 days
respectively.
3
DOESTHE
DOES THECHILD
CHILDHAVE
HAVEFEVER?
FEVER?
(by history or feels hot or temperature 37.5°C** or above)
SIGN SIGNS
CLASSIFY AS CLASSIFY AS TREATMENT
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold
(Urgent pre-referral print)are in bold print)
treatments
IF
IFYES:
YES, ASK: LOOK AND FEEL:
• Any general VERY • Give 1st dose of rectal artesunate (10 mg/kg) or IM/IV artesunate
• Any general
danger sign ordanger sign or
SEVERE • Give
(3 mg/kg if < 20 kg, 2.4 mg/kg first
if >dose of Artesunate or quinine
20 kg)
Classify
Then ask: Look and feel: •• Stiffneck
Stiff neck FEBRILE for severe
• Give 1st dose of appropriate malaria
antibiotic
• For how long? • Look or feel for stiff neck. FEVER VERY SEVERE • Give first dose of an appropriate antibiotic
•
• For howthan
If more long?7 • Look or feel for stiff neck DISEASE • Treat child to prevent low blood sugar (breastfeed or give
expressed breast milk• orTreat the child
breastmilk to prevent
substitute or low blood
sugar sugar
water by
days, has fever • Look for runny nose. • Give one dose of paracetamol in clinic for
• Ifbeen
more than 7 days, • Look for runny nose cup or NGT)
present high fever (38.5°C or above)
has
everyfever been pres- Look for signs of MEASLES • Give one dose of paracetamol 10 mg/kg for high fever (38.5°C)
• Refer URGENTLY to hospital
• ent
Hasevery
the child
day?had • Look forrash
• Generalized any bacterial
and • Refer URGENTLY to hospital
cause of fever Classify
measles within
FEVER •• Malaria
Malariatest
test POSITIVE • Give Artemether-Lumefantrine(AL)
• Give Artemether-Lumefantrine/Artemether-Amodiaquine
• Has the3child
the last had
months? • One of these: cough, runny POSITIVE • Give one dose of paracetamol in clinic for
measles within the • Look
nose, foreyes.
or red any other • Advise mother when to return immediately
MALARIA FEBRILE DISEASE high fever (38.5°C or above)
last 3 months? cause of fever • Follow-up in 3 days if•fever persists
Advise mother when to return immediately
MALARIA
Do a Malaria Test IF • Look for mouth ulcers. Are • day
• If fever is present every Follow-up
for more in than
2 days if fever
7 days, persists
refer for
NO general danger • Generalized
they rash and
deep and extensive? further assessment • If fever is present every day for more than
sign or severe • Lookonefor of
pusthese:
draining from
cough, 7 days,inrefer for assessment
• Malaria test • Give one dose of paracetamol the clinic for high fever
classification the runny
eye. nose, or red eyes. FEVER (38.5 degree C or above)
Negative
• Look for clouding of the NO
cornea. • Give appropriate antibiotic treatment for an identified bacterial
• Other causes of MALARIA cause of fever
Do a malaria test for all children with fever: • Any general
fever PRESENTdanger sign or • Give Vitamin A treatment
If NO severe classification • Clouding of cornea or • Advise mother when•to Give
SEVERE
returnfirst
immediately
dose of an appropriate antibiotic
If the child has measles now or within the last 3 months. • Deep or extensive mouth • Follow-up in 3 days if•fever
COMPLICATED If clouding
persists of the cornea or pus draining
ulcers If fever is present every from
• MEASLES*** the
day for eye,than
more apply tetracycline
7 days, refer foreye
If the child has measles • Look for mouth ulcers assessment ointment
now or within the last 3 • Check for TB if fever is• present
Refer URGENTLY
for 14 days ortomorehospital
(see page 9)
months • Are they deep and ex-
tensive? • Pus draining from the eye or • Give Vitamin A treatment
• Mouth ulcers MEASLES WITH • If pus draining from the eye, treat eye
• Look for pus draining Classify • Any general SEVERE • Give Vitamin A treatment
danger sign or EYE OR MOUTH infection with tetracycline eye ointment
from the eye MEASLES COMPLICATEDCOMPLICA
• Give first dose of an appropriate
TIONS*** • If mouth antibiotic
ulcers, treat with gentian violet
• Clouding of MEASLES*** • Follow-up in 3 days.
• If clouding of the cornea or pus draining from the eye, apply
• Look for clouding of the cornea or tetracycline eye ointment
cornea •• Deep extensive
Measles now or within the last • Give Vitamin A treatment
• MEASLES
Refer URGENTLY to hospital
mouth ulcers
3 months
• Pus draining from MEASLES • Give Vitamin A treatment
** These temperatures are based on axillary temperature. the eye or WITH EYE • If pus draining from the eye, treat eye infection with tetracycline eye
Rectal temperature readings are approximately 0.5°C • Mouth ulcers ointment
** These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C higher.]
higher. OR MOUTH
*** Other important complications of measles — pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables. • If mouth ulcers, treat with gentian violet
COMPLICA
*** Other important complications of measles — TIONS *** • Follow-up in 3 days.
pneumonia, stridor, diarrhoea, ear infection, and
malnutrition - are classified in other tables. • Measles now or MEASLES • Give Vitamin A treatment
within the last 3
months
4
DOESTHE
DOES THECHILD
CHILDHAVE
HAVEEAR
EARPROBLEM?
PROBLEM?
SIGN SIGNS CLASSIFY
CLASSIFY AS AS TREATMENT
IDENTIFY TREATMENT
(Urgent pre-referral
(Urgent treatments
pre-referral treatmentsare
arein
in bold print)
bold print)
• Tender swelling behind • Give first dose of an appropriate antibiotic

IF YES, ASK: LOOK AND FEEL: Classify • the
Tender
ear swelling behind the ear. MASTOIDITIS • Give first dose of an appropriate antibiotic.
• Give first dose of paracetamol for pain
EAR PROBLEM MASTOIDITIS • Give first dose of paracetamol for pain.
• Is there ear pain? • Look for pus draining from • Refer• • URGENTLY to hospital
Refer URGENTLY
URGENTLY to to hospital.
hospital
• Is there ear the ear.
discharge? If yes, • Pus is seen draining from • Give Amoxicillin for 5 days
• the
Pusearis seen draining from
and discharge is the ACUTE EAR • Give Amoxicillin for 5 days.
for how long? • Feel for tender swelling ear and discharge is reported • Give paracetamol for pain for pain.
• Give paracetamol
reported for less than 14 ACUTEINFECTION
EAR
behind the ear cornea. for less than 14 days, or
days, INFECTION • Dry the• ear
Dry by
thewicking
ear by wicking.
• OR
Ear pain. • If ear discharge, check for HIV Infection.
• If ear discharge, check for HIV Infection
• Follow-up in 5 days.
• Ear pain • Follow-up in 5 days
.
• Pus is seen draining from the CHRONIC EAR • Dry the ear by wicking.
• Pus is seen
ear and drainingisfrom
discharge reported • Dry the
• ear bywith
Treat wicking
topical quinolone eardrops for
the ear and discharge is INFECTION
for 14 days or more. • Treat with
2 topical quinolone eardrops for 2 weeks
weeks.
reported for 14 days or CHRONIC EAR
more INFECTION • Check• for
Check for HIV Infection.
HIV Infection (See page
(See 8)
pageand
8) and TB (see page 9)
• Follow-up
TB (see page 9) in 5 days.
• No ear pain and No pus seen • Follow-up in 5 days

NO EAR INFECTION • No treatment.
draining
• No from
ear pain theNo
and ear.
pus NO EAR • No treatment
seen draining from the ear INFECTION
5
THEN CHECK FOR MALNUTRITION
Check for Malnutrition SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Oedema of both feet • Give first dose of an appropriate antibiotic
CHECK FOR ACUTE MALNUTRITION OR
Classify COMPLICATED • Keep the child warm
LOOK AND FEEL: • WFH/L less than -3 zscores
NUTRITIONAL SEVERE ACUTE • Refer URGENTLY to hospital
OR MUAC less than 115 mm AND any
Look for signs of acute malnutrition one of the following: MALNUTRITION
STATUS
• Look for oedema of both feet. • Medical complication present
OR
• Determine WFH/L* ___ z-score.
• Not able to finish RUTF
• Measure MUAC**____ mm in a child OR
6 months or older. • Breastfeeding problem
If WFH/L less than -3 z-scores or MUAC less • WFH/L less than -3 zscores • Give oral antibiotics for 5 days
than 115mm, then: OR UNCOMPLICATED • Give ready-to-use therapeutic food for a child aged 6 months
• MUAC less than 115 mm SEVERE ACUTE or more
AND MALNUTRITION • Counsel the mother on how to feed the child.
Check for any medical complication present: • Able to finish RUTF • Check for TB (see page 9)
• Any general danger signs • Advise mother when to return immediately
• Follow up in 7 days
• Any severe classification
• Pneumonia with chest indrawing
• WFH/L between -3 and -2 z-scores • Assess the child’s feeding and counsel the mother on the feeding
OR MODERATE ACUTE recommendations
If no medical complications present: • If feeding problem, follow up in 7 days
• MUAC 115 up to 125 mm MALNUTRITION
• Child is 6 months or older, offer RUTF*** • Check for TB (see page 9)
to eat. Is the child: • Advise mother when to return immediately (See page 16)
- Not able to finish RUTF portion? • Follow-up in 30 days
- Able to finish RUTF portion?
• Child is less than 6 months, assess • WFH/L - 2 z-scores or more • Give mebendazole if child is 1 year or older and has not had a dose
breastfeeding: OR NO ACUTE in the previous 6 months.
• MUAC 125 mm or more MALNUTRITION • If child is less than 2 years old, assess the child’s feeding and
Does the child have a breastfeeding
problem? counsel the mother on feeding according to the FOOD box on the
COUNSEL THE MOTHER chart.
• If feeding problem, follow-up in 7 days.
• Advise mother when to return immediately. (See page 30)
* WFH/L is Weight-for-Height or Weight-for-Length
determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using

MUAC tape in all children 6 months or older.
*** RUTF is Ready-to-Use Therapeutic Food for conducting

the appetite test and feeding children with severe acute
malnutrition.
6
CHECK FOR ANAEMIA
SIGNS CLASSIFY AS IDENTIFY TREATMENT
Look and Feel for palmar pallor • Severe palmar • Refer URGENTLY to hospital
Classify pallor SEVERE
Is it: • If child has any history or symptoms suggestive of SCD
• Severe palmar pallor?
ANAEMIA ANAEMIA recommend testing for SCD
• Some palmar pallor?
• Some • Give iron**
If palmar pallor present, assess for history and pallor
symptoms of Sickle Cell Disease(SCD); • Give mebendazole if child is 1 year or older and has not had a dose in
the previous 6 months
ANAEMIA • Advise mother when to return immediately
Ask: Look and Feel for
• Follow-up in 14 days
• Family history of SCD • Swelling of hands &
OR feet with persistent
• If child has any history or symptoms suggestive of SCD recommend
crying in infants due
testing for HbS
• Death of sibling from to pain • If child is already confirmed with SCD refer
anaemia • No palmar • If child is less than 2 years old, assess the child’s feeding and counsel
• Features suggestive
• Painful joints and bones of a stroke i.e. pallor the mother according to the feeding recommendations
weakness of one side NO ANAEMIA
• History of previous of the body • If feeding problem, follow-up in 5 days
blood transfusion more
than once • Bossing skull
• History of unexplained
episodes of severe pain,
such as pain in the
abdomen, chest, bones **If child has confirmed sickle disease and or severe acute malnutrition and is receiving RUTF, DO NOT give iron.
or joints
7
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care. If already in HIV care, go to the next step and assess for TB.

ASK: • Positive DNA PCR test in child • Give cotrimoxazole prophylaxis*
Classify ALL OR
Has the mother or child had an HIV test? CONFIRMED • Check for TB (see page 9)
YOUNG • Positive HIV rapid test in a HIV INFECTION
Then note mother’s and/or child’s HIV status:- child18 months or older • Link child to Early Infant Diagnosis (EID) /ART
INFANTS
IF YES: Clinic for follow up care
• Mother: • Assess the child’s feeding and provide
appropriate counselling to the mother
-- POSITIVE or NEGATIVE
• Child: • Advise the mother on home care
-- DNA PCR test POSITIVE or NEGATIVE • Mother HIV-positive AND HIV EXPOSED • Give cotrimoxazole prophylaxis
-- Rapid HIV test POSITIVE or NEGATIVE negative DNA PCR test in a
breastfeeding child or if only • Check for TB (see page 9)
IF MOTHER IS HIV POSITIVE AND CHILD’S stopped less than 6 weeks ago • Link child to ART/Mother Baby care point to start
STATUS IS NEGATIVE OR UNKNOWN, OR or continue ARV prophylaxis
ASK: • Mother HIV-positive, child not
yet tested • Do DNA PCR test to confirm HIV status**
• Was the child breastfeeding at the time or 6
weeks before the test? • Positive serological test in a • Assess the child’s feeding and provide
infant less than 16 months appropriate counselling to the mother
• Is the child breastfeeding now?
• Advise the mother on home care
• If breastfeeding ASK: Is the mother on ART and
child on ARV Prophylaxis?
• HIV test not done for mother HIV INFECTION • Encourage mother to go for HIV counseling and
IF NO: Mother & child HIV status unknown:- or infant child less than 18 STATUS testing in a health facility
• Then TEST mother months old.
UNKNOWN
• If positive, then test the child
• Negative HIV test in mother HIV INFECTION • Treat, counsel and follow-up existing infections
or child. UNLIKELY
* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children until confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breastfeeding has stopped; if serological test is positive, do a virological test
as soon as possible.
8
THEN CHECK FOR TB
ASSESS SIGNS CLASSIFY IDENTIFY TREATMENT
• Initiate TB treatment
ASK:- LOOK AND FEEL Two or more of the following in HIV Negative
Classify child AND one or more of the following in HIV TB • Treat, counsel, and follow up any
For symptoms Look or feel for Positive child: co- infections
TB Status
suggestive of TB physical signs of TB
• At least two symptoms suggestive of TB • Ask about the caregiver’s health and
treat as necessary
• Has the child been - Swellings in the neck • Positive history of contact with a TB case
coughing for 14 days or or armpit • Link the child to the nearest TB clinic
more? • Any physical signs suggestive of TB for further assessment and ongoing
- Swelling on the back follow-up
OR
• Has the child had • If GeneXpert or smear microscopy
persistent fever for 14 - Stiff neck A positive GeneXpert or smear microscopy test test is not available or negative,
days or more? refer for further assessment
- Persistent wheeze
• Has the child had poor not responding to Positive history of contact with a TB case and TB • Start Isoniazid at 10mg/kg for 6
weight gain in the last brochodilaters NO other TB symptoms or signs listed above months
EXPOSURE
one month?* • Treat, counsel, and follow up
existing infections
ASK: History of contact • Ask about the caregiver’s health and
Has the child had contact with a person with Pulmonary treat as necessary
Tuberculosis or chronic cough?
• Link child to the nearest TB clinic
Collect sample for GeneXpert or smear microscopy
If available, send the child for laboratory tests (GeneXpert or NO TB symptoms or signs NO TB • Treat, counsel, and follow up
smear microscopy) and/ or Chest X-Ray. existing infections
• Start Isoniazid in HIV positive child

above 1 year at 10mg/kg for 6
* Poor weight gain (Weight loss, or very low weight (weight-for-age months
less than -3 z-score), or underweight (weight-for age less than
-2 z-score), or confirmed weight loss (>5%) since the last visit, or
growth curve flattening), yellow and red MUAC colour code. * Refer the TB case that the child was in contact with to the nearest TB clinic for comprehensive contact tracing
9
THEN CHECK THE CHILD‘S IMMUNIZATION AND VITAMIN A STATUS
Immunization Schedule:
• Follow National Guidelines:
AGE VACCINE VITAMIN A SUPPLEMENTATION
Give every child a dose of Vitamin A every
Birth BCG* OPV-O six months from the age of 6 months.
Record the dose on the child’s chart.
6 weeks DPT+HepB+HIB OPV-1 RTV1 PCV1
10 weeks DPT+HepB+HIB OPV-2 RTV2 PCV2 ROUTINE DEWORMING
TREATMENT
14 weeks DPT+HepB+HIB OPV-3 IPV RTV3 PCV3 Give every child mabendazole every six
months from the age of 1 year. Record the
9 months Measles dose on the child’s chart.
*Children confirmed to be HIV positive should not be given BCG due to associated BCG disease among HIV infected children.
Assess the child’s growth and Assess the Child for other Assess the Mother’s Health Needs
development milestones problems including Congenital • Check if had full course of tetanus toxid, if not,
• Plot the child’s weight on his/her growth Malformations give an appointment.
card (immunization or mother baby • Ask mother for any other problem or • Ask if pregnant , if so give antenatal
passport) identified external malformations appointment. If not, ask if interested to talk
• Ask mother about what the child is now • Check child for any external malformations about family planning.
able to do in terms of physical movement, and abnormal signs • Ask if RCT has been done and the results.
communication and interaction.
• Refer infant to hospital, if they have any • If mother is an adolescent, link to appropriate
• See annex 1 for details of expected external malformations clinic or service provider for support.
milestones for various age groups
10
2 years up to 3
For children being referred with very severe febrile disease: 2(12 - <14
years up kg)
to 3 y
For children
Check being referred
which pre-referral treatmentwith very severe
is available febrile
in your clinic disease:
(rectal artesunate (12 - <14 kg)
3 years up to 5
Check which pre-referral
suppositories, artesunatetreatment
injection is
oravailable
quinine). in your clinic (rectal artesunate 3(14 - 19upkg)
years to 5 y
TREATTHE
TREAT THE CHILD
TREAT THESICK
SICKCHILD
CHILDAND
ANDsuppositories,
COUNSEL
COUNSEL
Artesunate THE
artesunate
THE
suppository: Insert firstMOTHER
injection ordose
quinine).
MOTHER of the suppository and refer child urgently (14 - 19 kg)
Artesunate suppository: Insert first dose
Intramuscular artesunate or quinine: Give of first
the suppository andchild
dose and refer referurgently
child urgently
to
If the child is classified as severe disease, give pre-referal treatment
Intramuscular
hospital. and refer urgently
artesunate or quinine: Give first dose and refer child urgently to
Treat th
PRE-REFERRAL TREATMENT
If the child is classified as severe disease, give pre-referal treatment and refer urgently
hospital.
Treat the
• Explain to the mother why the drug is given If referral is not possible:
• • Explain to the mother why the drug is given If the chil
If the child is classified as severe disease, give
Determine the dose appropriate for the child’s weight (or age) If referral
pre-referral treatment
For isand
artesunatenot possible:
refer urgently
injection: IfAsk
the the
child
• • Determine the dose appropriate for the child’s weight (or age) m
Use a sterile needle and sterile syringe when giving an injection For
→ artesunate
Give first doseinjection:
of artesunate intramuscular injection Ask the m
• • Use a sterile needle and sterile syringe when giving an injection
Measure the dose accurately If the chil
• Explain to the mother why the drug is given →
For Give first
→ artesunate dose of artesunate
Repeat doseinjection:
after 12 hrs andintramuscular
daily until theinjection
child can take orally If→ the child
• • Measure the dose accurately
Give the drug as an intramuscular injection Give
• Determine the dose appropriate for the child’s weight (or age)
• • Give the drug as an intramuscular injection
→→→Repeat
Give
Givefulldose
first after
dose
dose 12
ofoforal hrs and daily
artesunate asuntil
soonthe
intramuscular
antimlarial aschild can take
injection
the child orally
is able to take orally. → → GiveIf ne
• UseIf the child cannot be referred follow the instructions provided
a sterile needle and sterile syringe when giving an injection → →Give
Repeat doseof
full dose after
oral12 hrs and every
antimlarial 24 hours
as soon as theuntil
childthe child to
is able can take
take orally
orally.
• If the child cannot be referred follow the instructions provided → If
→ Give nei
• Measure the dose accurately → Give full dose of oral antimalarial as soon as the child is able to take orally.
For artesunate suppository: → Give
• Give the drug as an intramuscular injection For
Give diazepam to Stop Convulsions → artesunate suppository:
Give first dose of suppository
For Give
artesunate
first dosesuppository:
Give diazepam to Stop Convulsions
• If the child cannot be referred, follow the instructions provided → of suppository
→ Repeat the same dose of suppository every 24 hours until the child can take If the chil
→ →Repeat
Give first thedosesameofdose suppository
of suppository oralevery 24 hours asuntil the
aschild can take If→the child
Turn the child to his/her side and clear the airway. Avoid putting things in the oral
→ quinine:
For Repeatantimalarial.
the sameGive dosefull dose
after 12 of
hours, antimalarial
then every 24 soon
hours until thethechild
childis able
can take Give
Give
Give diazepam
Turn the diazepam toside
child to his/her Stop
to Convulsions
and Stop Convulsions
clear the airway. Avoid putting things in the For
oral
to antimalarial.
take
quinine:
oral orally
antimalarial.
Give
Give
full
full
dose
dose
of
of
oral
oral
antimalarial
antimalarial
as
as
soon
soon
as
as
the
the
child
child
is able
is able to → Give
Give diazepam to Stop Convulsions
mouth
• mouth
Position the child appropriately and clear the airway. Avoid putting things in the
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe →
→ to Givetake first
takefirst
Give orally
dose of intramuscular quinine.
orally
dose of intramuscular quinine.
→ The child should remain lying down for one hour.
mouth0.5mg/kg diazepam injection solution per rectum using a small syringe
Give
Turn thea child
without to his/her
needle side and clear
(like a tuberculin the or
syringe) airway.
usingAvoid putting things in the
a catheter →ForThe
→ Repeatchildthe
quinine: should
quinineremain lying at
injection down
4 andfor8one hour.
hours later, and then every 12 hours until the
• without
Give
Turn 0.5mg/kg
the a child
needle diazepam
to his/her
(like a injection
side and
tuberculin solution
clear the
syringe) per
or rectum
airway.
using Avoid
a using a small
putting
catheter syringe
things in the For
→ quinine:
Repeat the quinine injection at 4 and 8 hours later, and then everyinjections
12 hoursfor until the
mouth for low blood sugar, then treat or prevent
Check Giveisfirst
→ child able dose of intramuscular
to take quinine.Do not
an oral antimalarial. continue quinine more
without
mouth
Check a
for needle
low (like
blood a tuberculin
sugar, then syringe)
treat or or using
prevent a catheter → → Give
Give
child is first
first
able dose
dose
to ofofintramuscular
take intramuscular
an oral quinine.
quinine.
antimalarial. Do not continue quinine injections for more
Give oxygen
Give 0.5mg/kg diazepam
and REFER injection solution per rectum using a small syringe → thanThe 1child week. should remain lying down for one hour.
• Give
Check
Give for lowand
0.5mg/kg
oxygen blood
diazepam
REFERsugar,injection
then treat or prevent
solution per rectum using a small syringe → → The
The child
1child shouldremain
should remainlying lyingdown
downfor forone
onehour.
hour.
Ifwithout a needle
convulsions have(like
nota stopped
tuberculin syringe)
after or using
10 minutes a catheter
repeat diazepam dose → thanRepeat week.the quinine injection at 4 and 8 hours later, and then every 12 hours until the
• If
Ifwithout
convulsions
a have
needle not
(like a stopped
tuberculinafter 10
syringe)minutes,
or repeat
using a diazepam dose
catheter → Repeat
→ Repeat the
the quinine
quinine 8 hours
injection later,
RECTAL
at 4 and
and 8 then
hoursevery
later,8and
hours
INTRAMUSCULAR thenuntil theINTRAMUSCULAR
every child is able
12 hours to the
until
convulsions
Check for lowhave
blood not stopped
sugar, thenafter
treat10orminutes
prevent repeat diazepam dose AGE or
child
WEIGHT
isanable
Check for low and
blood sugar, then treat AGE or prevent AGE ortake
WEIGHT oraltoantimalarial.
take an oral Doantimalarial.
RECTAL
ARTESUNATE
not continue DoINTRAMUSCULAR
not
quinine continue
ARTESUNATE quinine
injections injections
more than 1for
for INTRAMUSCULAR
QUININE more
week.
WEIGHT
Give oxygen REFER DOSE OF DIAZEPAM child
thanis1 able week. to take an oral antimalarial. Do not
ARTESUNATE
SUPPOSITORY continue quinine injections
ARTESUNATE QUININE for more
Give WEIGHT
oxygen and REFER AGE DOSE(10mg/2mls
OF DIAZEPAM
If convulsions have not stopped after 10 minutes repeat diazepam dose than 1 week. SUPPOSITORY
50 mg 200 mg 60 mg 150 mg/ml* 300 mg/ml*
(10mg/2mls RECTAL INTRAMUSCULAR INTRAMUSCULAR
If convulsions < 6 months
< 5kg have not stopped after 10 minutes repeat diazepam0.5 dose
ml AGE or WEIGHT suppositories
50 mg suppositories
200 mg vial60(20mg/ml)
mg 150(in 2 ml
mg/ml* 300(in 2 ml
mg/ml*
< 5kg < 6 months RECTAL
ARTESUNATE INTRAMUSCULAR
ARTESUNATE INTRAMUSCULAR
(in 2 ml QUININE
DOSE 0.5 ml AGE or WEIGHT Dosage
suppositories Dosage
suppositories vial 2.4 mg/kg
(20mg/ml) ampoules) ampoules)
(in 2 ml
5WEIGHT
– < 10kg 6 – < 12 AGEmonths OF
1.0DIAZEPAM
ml ARTESUNATE
SUPPOSITORY ARTESUNATE QUININE
AGE DOSE OF DIAZEPAM 10 mg/kg
Dosage 10 mg/kg
Dosage 2.4 mg/kg ampoules) ampoules)
5WEIGHT
– < 10kg 6 – < 12 months (10mg/2mls
1.0 ml SUPPOSITORY
10 – < 15kg 1 – < 3 years 1.5ml
(10mg/2mls 10 50
mg/kg
mg 10200
mg/kg mg 60 mg 150 mg/ml* 300 mg/ml*
10 – << 5kg
15kg 1 –< <6 3months
years 0.5 ml
1.5ml 2 months up to 4 months suppositories
50 mg
1 suppositories
200 mg vial60 (20mg/ml)
1/2mgml 0.4
150(in 2ml
ml
mg/ml* 300(in 2ml
ml
mg/ml*
0.2
15<–5kg
19 kg 4< –6 < 5years
months 2.0
0.5 mlml Dosage Dosage vial2.4 mg/kg 0.42ml
ampoules) ampoules)
(in
64 –– << 12 months 2(4 - <6 kg)
months up to 4 months suppositories
1 suppositories (20mg/ml)
1/2 ml (in ml 0.22mlml
155–– 19
< 10kg
kg 5years 1.0mlml
2.0 (4 - <6 kg) 10 mg/kg
Dosage 10 mg/kg
Dosage 2.4 mg/kg ampoules) ampoules)
5 – < 10kg 6 – < 12 months 1.0 ml 4 months up to 12 months 10 mg/kg
10 – < 15kg 1 – < 3 years 1.5ml 2 10 mg/kg
- 1 ml 0.6 ml 0.3 ml
4(6 - <10 kg)
months up to 12 months
10 – < 15kg 1 – < 3 years 1.5ml 2 months up to 4 months 21 11/2
ml ml 0.6
0.4mlml 0.3
0.2mlml
GIVE ARTESUNATE SUPPOSITORIES
4 – < OR
5years INTRAMUSCULAR (6 - <10 kg) -
Give Artesunate Suppositories Or Intramuscular
GIVE
15 – 19 kg
ARTESUNATE
ARTESUNATE SUPPOSITORIES
15 – 19 kg OR QUININE FOR4 – <SEVERE OR INTRAMUSCULAR
5years MALARIA
2.0 ml
2.0 ml (4
(4
212 -months
months<6 kg)
-months
<6
upup
kg)kg)
toto4 months
2 years 1
2
1/2 ml
1.5 ml
0.4 ml
0.8 ml
0.2 ml
0.4 ml
12(10 - <12 up to 2 years
Artesunate Or QUININE
ARTESUNATE OR QuinineFOR
ForSEVERE
Severe Malaria
MALARIA 4 months up to 12 months
(10 - <12 kg)
42(6 - <10up
months kg)
uptoto312 months
22
-
1.51mlml 0.8
0.6mlml 0.4
0.3mlml
years years 23 1 ml 0.6
1.0ml
ml 0.3
GIVE 0.5ml
For ARTESUNATE
children beingSUPPOSITORIES
referred with veryOR INTRAMUSCULAR
severe febrile disease: 2(6
(12- <10
years - <14kg)
up kg)
to 3 years
-1 1.5 ml
1.0 ml
ml
GIVE
For ARTESUNATE
children
ARTESUNATE being
OR SUPPOSITORIES
referred
QUININE with
FOR very OR
SEVERE INTRAMUSCULAR
severe febrile
MALARIA disease: 12 months up to 2 years
(12 - <14 kg)
3 1 1.5 ml 0.5 ml
Check which pre-referral treatment is available in your clinic (rectal artesunate 3(10
12 years- <12
months upkg)
up
to to 2 years
5 years
2 1.5 ml 0.8 ml 0.4 ml
ARTESUNATE
Check OR QUININE
which pre-referral treatmentFOR SEVERE
is available MALARIA
in your clinic (rectal artesunate (10 - <12 kg) 23 1 1.5 ml
2 ml 1.2ml
0.8 ml 0.6ml
0.4 ml
suppositories, artesunate injection or quinine). 3(14
years - 19upkg)
to 5 years
1.2
suppositories, artesunate injection
2 years up to 3 years 33 11 21.5
ml ml 1.0mlml 0.6 ml
firstordose
quinine). 0.5 ml
For children
Artesunate beingInsert
suppository: referred with ofvery severe febrile
the suppository disease:
and refer child urgently (14 - 19 kg)
2(12
years - <14
up kg)
to 3 years 1.0 ml
3 1 1.5 ml 0.5 ml
For
Artesunate children being
suppository:
Check which pre-referral referred
Insert first with
dose ofvery severe
the suppository febrile
and disease:
refer child
childurgently
urgently (12 - <14 kg)
Intramuscular artesunate treatment
or quinine:isGive available
first in your
dose andclinic
refer(rectal
child artesunate
urgently to 3 years up to 5 years
Check which
Intramuscular pre-referral
artesunate treatment
or quinine: is available
Give first in
dose your
andclinic
refer
refer (rectal
child
child artesunate
urgently
urgently to to 3 1 2 ml 1.2 ml 0.6 ml
suppositories,
hospital. artesunate injection or quinine).
Treat the child to prevent low blood sugar
3(14
years - 19upkg)
to 5 years
3 1 2 ml 1.2 ml 0.6 ml
suppositories,
hospital.
Artesunate
artesunateInsert
Artesunate suppository:
suppository:
injection
Insert
firstordose
first dose
quinine).
of the suppository and refer child urgently
of first
the suppository andchild
referurgently
child urgently
Treat the child to prevent low blood sugar
(14 - 19 kg)
Intramuscular
If referral is artesunate or quinine:
not possible: Give dose and refer to
Intramuscular artesunate or quinine: Give first dose and refer child urgently to If the child is able to breastfeed:
If referral is not possible:
hospital.
For artesunate injection: Treat
IfAsk the
the the
child child
is able
mother to prevent
totobreastfeed
breastfeed:
the child low blood sugar
hospital.
For
→ artesunate
Give first doseinjection:
of artesunate intramuscular injection Treat
11
If the child is not able toto
Ask the
the mother child
to breastfeed prevent
the child
breastfeed low
but is able blood sugar
to swallow:
→ Give
If first
referral dose
is of
not artesunate
possible: intramuscular
daily until theinjection IfIfthe
→ Repeat dose after 12 hrs and child can take orally thechild
childisisnot able
able to breastfeed but is able to swallow:
to breastfeed:
(10 - <12 kg)
Determine the dose appropriate for the child’s weight (or age)
2 years up to 3 years 1.0 ml
3 1 1.5 ml 0.5 ml
UseFor children
a sterile needlebeing referred
and sterile with
syringe very
when severe
giving febrile disease:
an injection (12 - <14 kg)
Check which
Measure pre-referral
the dose treatment is available in your clinic (rectal artesunate
accurately 3 years up to 5 years
suppositories,
Give the drug as
IfArtesunate
the child cannot
artesunate TREAT THE SICK CHILD AND COUNSEL THE MOTHER
injectioninjection
an intramuscular
be referred
or quinine). (14 - 19 kg)
3 1 2 ml 1.2 ml 0.6 ml
suppository: Insertfollow the instructions

first dose providedand refer child urgently
of the suppository
Intramuscular artesunate or quinine: Give first dose and refer child urgently to
GiveGive ananIntramuscular
Intramuscular Antibiotic Antibiotic
hospital.
Give to children being referred urgently
Treatthe
Treat the child
child to prevent
to prevent low blood
low blood sugar sugar
Give If Ampicillin
referral is(50not possible:
mg/kg) and Gentamicin (7.5mg/kg)
If the child is able to breastfeed:
For artesunate injection: Ask the mother to breastfeed the child
→ Give first dose of artesunate intramuscular injection If the child is not able to breastfeed, but is able to swallow:
Ampicillin
→ Repeat dose after 12 hrs and daily until the child can take orally → Give expressed breast milk or breast-milk substitute
breastmilk substitute
→ Dilute
→ Give 500mg vialofwith
full dose oral2.1ml of sterile
antimlarial aswater
soon (500mg/2.5ml)
as the child is able to take orally. → If neither of these is available, give sugar water
→ Give 30–50 ml of milk or sugar water before departure
Gentamicin
For artesunate suppository: To make sugar water: Dissolve 4 level teaspoons of sugar
→ 7.5mg/kg/day
→ once
Give first dose of daily
suppository
age (20 grams) in a 200ml cup of clean water
→ IF REFERRAL
→ Repeat the same IS NOT
dosePOSSIBLE OR DELAYED,
of suppository every 24 repeat the ampicillin
hours until the child can take
EN If the child is not able to swallow:
injection every 6 hours
oral antimalarial. Give full dose of oral antimalarial as soon as the child is able → Give 50ml of milk or sugar water by nasogastric tube
→ Where there is a strong suspicion of meningitis the dose of ampicillin can be
to take orally
increased 4 times
ld
A
te
AGE WEIGHT Ampicillin 500 mg vial Gentamicin 2ml vial/40
mg/ml*
Refer Urgently
ReferUrgently
Urgently
2 up to 4 months 4 – <6kg 1 ml 0.5 – 1.0 ml
•• Write a referal
referralnote
notefor
forthe
themother
mothertototake
taketotothe
thehospital.
hospital.
4 up to 12 months 6 – <10kg 2 ml 1.1 – 1.8 ml
•• If the infant also has SOME DEHYDRATION OR SEVERE DEHYDRATION
1 up to 3 years 10 – <15kg 3 ml 1.9 – 2.7 ml and is able to drink:
3 up to 5 years 15 – 20kg 5 ml 2.8 – 3.5 ml -- Give
Give thethe mother
mother some
some prepared
prepared ORSORS
andandaskask
herher to give
to give frequent
frequent
sips
sips of
of ORS
ORS on
on the
the way.
way
* Lower value for lower range of age/weight. -- Advise
Advise mother
mother to continue
to continue breastfeeding
breastfeeding
12
Plan C:C:Treat
Plan Treat for Severe
for Severe dehydration
dehydration Quickly
Quickly
Follow the arrows. If answer is “yes”, go across. If “no”, go down
Start IV
Iv fluid immediately.
If the child can drink, give ORS by mouth while the drip is set up.
Can you give Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided
intravenous (IV) fluid
IV fluid YES as follows:
immediately?
AGE First give 30ml/kg in Then give 70ml/kg in
Infants (under 12 months) 1 hour 5 hours
Children (12 months up to 5 years) 30 minutes 2½ hours
NO
Reassess the child every 1–2 hours. If hydration status is not improving, give the IV
drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3–4
hours (infants) or 1–2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration.
Then choose the appropriate plan (A, B, or C) to continue treatment.
Is IV treatment available
nearby (within 30
Refer URGENTLY to hospital for IV treatment.
minutes)?
YES If the child can drink, provide the mother with ORS solution and show her how to give
frequent sips during the trip or give ORS by nasogastic
naso-gastictube.
tube.
NO
Are you trained to use

a Naso-Gastric (NG)
Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours
tube for rehydration?
(total of 120 ml/kg).
Reassess the child every 1–2 hours while waiting for transfer:
→ If there is repeated vomiting or abdominal distension, give the fluid more slowly.
NO YES
→ If the hydration status is not improving after 3 hours, send the child for IV
Therapy.
After 6 hours reassess the child. Classify dehydration. Then choose the appropriate
plan (A, B, or C) to continue treatment.
Can the child drink?
NOTE:
NO If the child is not referred to hospital, observe the child at least 6 hours after rehydration
to be sure the mother can maintain hydration giving the child ORS solution by mouth.
Refer URGENTLYtoto
Refer URGENTLY
IMMUNIZE EVERY SICK CHILD, AS NEEDED
hospital for IV or NG
treatment
13
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
Teach the mother to give oral medicines at home
1. Give an appropriate oral antibiotic
Follow the instructions below for every oral medicine to be given at For pneumonia, acute ear infection:
home. Also follow the instructions listed with each medicine’s dosage First-line antibiotic: Oral Amoxicillin
table. AMOXYCILLIN*
Give two times daily for 5 days
• Determine the appropriate medicine s and dosage for the child’s age or weight AGE or WEIGHT DISPERSIBLE SYRUP (250 mg /5ml)
TABLET (250 mg)
• Tell the mother the reason for giving the medicine to the child
2 months up to 12 months (4 - <10 kg) 1 5 ml
• Demonstrate how to measure a dose 12 months up to 5 years (10 - <19 kg) 2 10 ml
• Watch the mother practice measuring a dose by herself

For prophylaxis, confirmed HIV or HIV exposed child:
• Ask the mother to give the first dose to her child ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
CO-TRIMOXAZOLE
• Explain carefully how to give the drug, then label and package the medicine. Give once a day starting at 6 weeks of age to:
→ All infants HIV Exposed until HIV is definitively ruled
out
→ All infants and children with confirmed HIV infection.
• If more than one medicine will be given, collect, count and package each
medicine separately 5 ml syrup Single strength Single strength
AGE 40/200 mg Dispersible tablet adult tablet
• Explain that all the tablets or syrup must be used to finish the course of 20/ 100 mg 80/400 mg
treatment, even if the child gets better Less than 6 months 2.5 ml 1 tablet -
• Check the mother’s understanding before she leaves the clinic 6 months up to 5 years 5 ml 2 tablets 1/2 tablet
For dysentery give ciprofloxacin 15mg/kg/day ---

2 times a day for 3 days:
250 mg TABLET 500 mg TABLET
AGE or WEIGHT DOSE/tabs DOSE/ tabs
Less than 6 months 1/2 tablet 1/4 tablet
6 months up to 5 years 1 tablet 1/2 tablet
14
2. Give oral Antimalarial for Malaria 3. Give Paracetamol for High fever
If Artemether-Lumefantrine (AL) (> 38.50) or Ear pain
• Give the first dose of Artemether-Lumefantrine (AL) in the clinic and observe for one hour
, Give Paracetamol every 6 hours until high fever or ear pain is gone
• If child vomits within an hour repeat the dose. Give the 2nd dose at home after 8 hours
• Then twice daily for further two days as shown below
AGE OR WEIGHT PARACETAMOL TABLET (500mg)
• Artemether-Lumefantrine (AL) should be taken with food
2 months up to 4 months (4 - <6kg) 1/4
Coartem tablets
4 months up to 12 months (6 - <10 kg) 1/2
(20mg artemether and 120mg lumefantrine)
12 months up to 5 years (10 - 19 kg) 1
WEIGHT Age 0hr 8hr 24hr 36hr 48hr 60hr
5–15 kg 4 months - <3 yrs 1 1 1 1 1 1

15–24 kg 4–8 years 2 2 2 2 2 2
25–34 kg 9–14 years 3 3 3 3 3 3
>34 kg >14 years 4 4 4 4 4 4
Artesunate Amodiaquine (AS + AQ)

If AL is not available:
• Give the first dose of Artemether- amodiaquine (AS+AQ) in the clinic and observe for one hour.
If child vomits within an hour repeat the dose.
• Then daily for 2 days as per the table below using the fixed dose combination
Dose in mg (No. of tablets)

Artesunate (50mg) Amodiaquine (153 mg)
WEIGHT Age Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
5–15 kg 4 months - 25 (½ tab) 25(½ tab) 25 (½ tab) 76 (½ tab) 76 (½ tab) 76 (½ tab)
<3 years
15–24 kg 4–8 years 50 (1) 50 (1) 50 (1) 153 (1) 153 (1) 153 (1)
25–34 kg 9–14 years 100 (2) 100 (2) 100 (2) 306 (2) 306 (2) 306 (2)
>34 kg >14 years 200 (4) 200 (4) 200 (4) 612 (4) 612 (4) 612 (4)
Note: Do not use amodiaquine alone, use with artesunate tablets
15
4.Give
Giveextra fluidfor
extra fluid fordiarrhoea
diarrhoeaandand continue
continue feeding
feeding
Plan A: Treat for diarrhoea at Home Plan B: Treat for Some dehydration with ORS
Counsel the mother on the 4 rules of Home Treatment: In the clinic, give recommended amount of ORS over-hour period
1. Give Extra Fluid 2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding 4. When to return Determine amount of ORS to give during first hours
1. Give extra fluid (as much as the child will take) AGE* Up to 6 6 months up 12 months 2 years up to
Tell the mother: months to 12 months up to 2 yrs 5 years
→ Breastfeed frequently and for longer at each feed
→ If the child is exclusively breastfed, give ORS or clean water in addition to WEIGHT < 6 kg 6–< 10 kg 10–< 12 kg 12–<20kg
breastmilk
breast milk Amount of fluid 200–450 450–800 800–960 960–1600
→ If the child is not exclusively breastfed, give one or more of the following: (ml) over hours
Food-based fluids (such as soup, rice water, and yoghurt drinks), or ORS
It is especially important to give ORS at home when: * Use the child’s age only when you do not know the weight. The approximate amount of
→ The child has been treated with Plan B or Plan C during this visit ORS required (in ml) can also be calculated by multiplying the child’s weight in kg times 75.
→ The child cannot return to a clinic if the diarrhoea gets worse
Teach the mother how to mix and give ORS. Give the mother 2 packets of → If the child wants more ORS than shown, give more
ORS to use at home. → For infants below 6 months who are not breastfed, also give 100–200ml clean water
Show the mother how much fluid to give in addition to the usual fluid intake: during this period
→ Up to 2 years: 50–100 ml after each loose stool
→ 2 years or more: 100–200 ml after each loose stool Show the mother how to give ORS solution:
Tell the mother to: → Give frequent small sips from a cup
→ Give frequent small sips from a cup. → If the child vomits, wait 10 minutes then continue - but more slowly
breastfeeding
→ Continue breast feeding whenever the child wants
→ If the child vomits, wait 10 minutes then continue - but more slowly
→ Continue giving extra fluid until the diarrhoea stops
After 4 hours:
2. Give zinc (age 2 months up to 5 years) → Reassess the child and classify the child for dehydration
→ Select the appropriate plan to continue treatment
Tell the mother how much zinc to give (20 mg tab): → Begin feeding the child in clinic
→ 2 months up to 6 months —— 1/2 tablet daily for 10 days
→ 6 months or more —— 1 tablet daily for 10 days If the mother must leave before completing treatment:
Show the mother how to give zinc supplements → Show her how to prepare ORS solution at home
→ Infants—dissolve tablet in a small amount of expressed breast milk, ORS
breastmilk, → Show her how much ORS to give to finish 4-hour treatment at home
or clean water in a cup → Give her instructions how to prepare salt and sugar solution for use at home
→ Older children—tablets can be chewed or dissolved in a small amount of → Explain the 4 Rules of Home Treatment:
clean water in a cup 1. Give extra fluid
2. Give zinc (age 2 months up to 5 years)
3. Continue feeding (exclusive breastfeeding if age less than 6 months) breastfeeding
3. Continue feeding (exclusive breast feeding if age less than 6 months)
4. When to return
4. When to return : Tell mother to return if;
- Child has blood in stool
- and OR is drinking poorly
16
5. GiveIron
Give Iron
Give one dose daily for 14 days
IRON/FOLATE TABLET IRON SYRUP
FOLIC ACID TABLET
AGE or WEIGHT Ferrous sulfate200 mg + 250 µg Ferrous fumarate 100 mg per 5
5mg
Folate (60 mg elemental\ iron) ml (20 mg elemental iron per ml)
2 months up to 4 months (4 – <6 kg) 1.0 ml (< 1/4 tsp) 1/2
4 months up to 12 months (6 – <10kg) 1.25 ml (1/4 tsp) 1
12 months up to 3 years (10 – <14 kg) 1/2 tablet 2.0 ml (<1/2 tsp) 1
3 years up to 5 years (14 – 19 kg) 1/2 tablet 2.5 ml (1/2 tsp) 1
6. Give salbutamol for wheezing

Dosaging for Salbutamol For a small baby:
AGE OR WEIGHT Salbutamol Three times daily for 5 days • Use a 500ml drink bottle or similar.
• Cut a hole using a sharp knife in the bottle base in the same shape as the
2 mg 4 mg Inhaler (preferably
Syrup mouth piece of the inhaler.
tablet tablet use a spacer)
2 months up to 12 months • Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper
1/2 1/4 2.5ml Give 2 doses (200 µg) quarter of the bottle.
(Less than 10 kg)
• Cut a small V in the border of the large open part of the bottle to fit to the child’s nose
12 months up to 5 years and be used as a mask.
1 1/2 5.0ml Give 2 doses (200 µg)
(10 – 19 kg)
• Flame the edge of the cut bottle with a candle or a lighter to soften it.
• From salbutamol metered dose inhaler (100µg/puff ) give 2 puffs.
• Repeat up to 3 times every 15 minutes before classifying pneumonia Alternatively commercial spacers can be used if available.
To use an inhaler with a spacer:
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child
• Remove the inhaler cap. Shake the inhaler well.
under 5 years should be given an inhaler without a spacer. A spacer works as well as a
nebuliser if correctly used. • Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
• The child should put the opening of the bottle into his mouth and breathe in and out
Spacers can be made in the following way: through the mouth.
For older children: • A carer then presses down the inhaler and sprays into the bottle while the child
continues to breathe normally.
• Use a 500ml drink bottle or similar.
• Wait for three to four breaths and repeat for total of five sprays.
• Cut a hole using a sharp knife in the bottle base in the same shape as the Mouth piece
of the inhaler. • For younger children place the cup over the child’s mouth and use as a spacer in the
same way.
• Flame the edge of the cut bottle with a candle or a lighter to soften it.
* If a spacer is being used for the first time, it should be primed by 4–5 extra puffs from
the inhaler.
17
Teach
7. Teachthe
themother totreat
mother to treatlocal
local infections
infections at home
at home
Treat eye infection with tetracycline eye ointment

• Explain
Explain to the
to the mother
mother what what the treatment
the treatment is and
is and why why itbeshould
it should given be
given the treatment steps listed in the appropriate box
Describe Clean both eyes 4 times daily.
• Describe
Watch the treatment
the mother steps
as she gives thelisted in the appropriate
first treatment box
in the clinic (except for remedy → Wash hands.
• Watch the mother as she gives the first treatment in the clinic (except for → Use clean cloth and water to gently wipe away pus.
for cough or sore throat)
remedy for cough or sore throat) Then apply tetracycline eye ointment in both eyes 4 times daily.
Tell her how often to do the treatment at home
• Tell her how often to do the treatment at home
If needed for for
treatment at home, give give
mother a tube → Squirt a small amount of ointment on the inside of the lower lid.
• If needed treatment at home, mother a of tetracycline
tube ointment
of tetracycline or a
oint-
small bottle of gentian violet or Nystatin
ment or a small bottle of gentian violet or Nystatin → Wash hands again.
Check
• Checkthethe
mother’s understanding
mother’s understanding before she leaves
before the clinic
she leaves the clinic Treat until there is no pus discharge.
Do not put anything else in the eye.
Clear the ear by dry wicking and give eardrops*
Treat mouth ulcers with gentian violet (GV)
Do the following 3 times daily
→ Roll clean absorbent cloth or soft, strong tissue paper into a wick
Treat for mouth ulcers twice daily
→ Wash hands
→ Place the wick in the child’s ear
→ Wash the child’s mouth with a clean soft cloth wrapped around the inger and
→ Remove the wick when wet
wet with salt water
→ Replace the wick with a clean one and repeat these steps until the ear is dry
→ Paint the mouth with 1/2 strength gentian violet (0.25% dilution)
→ Instil quinolone eardrops for two weeks
→ Wash hands again
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin → Continue using GV for 48 hours after the ulcers have been cured
→ Give Paracetamol for pain relief
Soothe the throat, relieve the cough with a safe remedy

Treat
Treat Oral Thrush
Thrush with with Nystatin
Nystatin
Safe remedies to recommend: Treat thrush four times daily for 7 days
→ Breast milk for a breastfed infant → Wash hands
→ Simple linctus → Wet a clean soft cloth with salt water and use it to wash the child’s mouth
→ Tea with lemon → Instill Nystatin 1ml four times a day
→ Avoid feeding for 20 minutes after medication
Harmful remedies to discourage: → If breastfed, check mother’s breasts for thrush. If present treat with Nystatin
→ Ipecacuaanna → Advise mother to wash breasts after feeds. If bottle fed advise change to cup
→ Phenergan and spoon
→ Codeine → If severe, recurrent or pharyngeal thrush consider symptomatic HIV
→ Piriton → Give paracetamol if needed for pain
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin on clear the ear
18
.
Initiate Treatment for The Child with TB Start Isoniazid preventive therapy for the Child with TB Exposure and HIV
All TB medicines should be taken under direct observation by a treatment supporter (Directly positive child above 1 year with no TB
Observed Therapy – DOT). TB treatment is divided into 2 phases: an initial (intensive) phase for
2 months and a continuation phase for 4 or 10 months depending on the type of TB disease. Isoniazid reduces the risk of TB development among children with a history of
TB treatment regimen is documented in a standard format, e.g. 2RHZE/4RH where:- TB exposure as well as children living with HIV. Isoniazid is given at a dose of
• Letters represent abbreviated anti-TB medicine names (R - Rifampicin; H – Isoniazid; 10mg/kg/ day for 6 months
• Z – Pyrazinamide; E – Ethambutol)
• Numbers represent the duration in months / (forward slash sign) division between Dosage of Isoniazid by weight band
treatment phases Weight band
Tablet
strength 14–19.9
TB treatment regimen for a child who is diagnosed with TB 3–5.9 kg 6–9.9 kg 10–13.9 kg 20–24.9 kg
kg
REGIMEN Isoniazid 1½ 2½
Types of disease ½ Tablet 1 Tablet 2 Tablet
100 mg Tablets Tablets
Intensive phase Continuation phase
All forms of TB (excluding TB * If available, give pyridoxine at a dose of 12.5 mg/day for children < 5 years in addition to Isoniazid.
2RHZE 4RH
meningitis and Bone TB) However, absence of pyridoxine should not stop a health worker from initiating TB treatment.
TB meningitis Bone
2RHZE 10RH
(Osteoarticular) TB
* Ethambutol is safe for use in children provided the dose is within the recommended range.
* Streptomycin is no longer recommended for use in the treatment of susceptible TB.
* Children with TB meningitis or airway obstruction due to TB adenopathy should be referred to hospital.
* Children diagnosed with drug resistant TB should be referred to the nearest MDR TB treatment site for
further management.
Dosage of anti-TB medicines by weight band

Number of tablets
Weight Intensive Phase(2 months) Continuation Phase (4 months)
bands RHZ
E100 RH 75/50
75/50/150
4-7 kg 1 1 1
8-11 kg 2 2 2
12-15 kg 3 3 3
16-24 kg 4 4 4
* Continuation phase: 4 months for all forms of TB (excluding TB meningitis and Bone TB) and 10 months for TB
meningitis and Bone TB.
* If available, give pyridoxine at a dose of 12.5 mg/day for children < 5 years in addition to anti-TB medicines.
However, absence of pyridoxine should not stop a health worker from initiating TB treatment.
19
8. Give Vitamin A and mebendazole in clinic
1. Explain to the mother why the drug is given
2. Determine the dose appropriate for the child’s weight (or age)
3. Measure the dose accurately
Give Vitamin A
Vitamin A Supplementation: Give Mebendazole
Give Vitamin A to all children to prevent severe illness:
Give 500 mg mebendazole as a single dose in clinic if:
- First dose in breastfed children to be given any time after 6 months of age
→ Hookworm/whipworm is a problem in your area
- Hereafter Vitamin A should be given every six months to ALL CHILDREN
→ The child is 1 year of age or older, and
→ Has not had a dose in the previous 6 months
Vitamin A Treatment:
- Give an extra dose of Vitamin A (same dose) for treatment if the child has
measles or PERSISTENT DIARRHOEA. If the child has had a dose of
Vitamin A within the past month or if the child is on RUTF for treatment
of severe acute malnutrition, DO NOT GIVE VITAMIN A
- Always record the dose of Vitamin A given on the child’s chart
Age VITAMIN A DOSE

6 up to 12 months 100 000IU
One year and older 200 000IU
20
GIVE READY-TO-USE THERAPEUTIC FOOD
Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

- Wash hands before giving the ready-to-use therapeutic food (RUTF).
- Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
- Encourage the child to eat the RUTF without forced feeding.
- Give small, regular meals of RUTF and encourage the child to eat often 5-6 meals per day
- If still breastfeeding, continue by offering breast milk first before every RUTF feed.
- Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended
for the age (See Feeding recommendations in COUNSEL THE MOTHER chart).
- When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
- Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.
Recommended Amounts of Ready-to-Use Therapeutic Food

CHILD'S Packets per day Packets per
WEIGHT (kg) (92 g Packets Week Supply
Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
21
GIVE FOLLOW-UP
FOLLOW-UPCARE
CAREFOR
FORACUTE
ACUTECONDITIONS
CONDITIONS
Give follow-up care
Care for the child who returns for follow-up using all the boxes that match the child’s Dysentery
previous classification
If the child has any new problems, assess, classify and treat the new problem as on the
ASSESS AND CLASSIFY chart
After 2 days:
3. Dysentery
Assess the child for diarrhoea > See ASSESS & CLASSIFY chart
1. Pneumonia
Pneumonia Ask:
After
→ Are2 there
days:fewer stools?
→ Is there
Assess lessfor
the child blood in the stool?
diarrhoea > See ASSESS & CLASSIFY chart
After 3 days: → Is there less fever?
→ Check the child for general danger signs. See ASSESS & → Is there less abdominal pain?
→ Assess the child for cough or difficult breathing. CLASSIFY chart Ask:
→ Is the child eating better?
→ Are there fewer stools?
Ask: Treatment:
→ Is there less blood in the stool?
→ Is the child breathing slower? → If there
→ Is the child
lessisfever?
dehydrated, treat for dehydration.
→ Is there less fever? → If there
number
→ Is lessofabdominal
stools, blood in the stools, fever, abdominal pain, or eating is worse or
pain?
→ Is the child eating better? the same
Assess for HIV infection → IsChange
the childtoeating better?oral antibiotic recommended for shigella in your area. Give
second-line
it for 5 days. Advise the mother to return in 2 days. If you do not have the second
Treatment: line antibiotic, REFER TO HOSPITAL.
Treatment:
→ If chest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular chloramphenicol. Then referreferURGENTLY
URGENTLY to hospital.
to hospital. → If the child is dehydrated, treat for dehydration.
Exceptions:
→ If breathing rate, fever and eating are the same, change to the second-line antibiotic → If
If thenumber of stools,
child is less than 12blood in theold
months stools, fever,
or was abdominal
dehydrated on pain, or eating
the first visit, orisifworse or
he had
and advise the mother to return in 2 days or refer.
refer. (If this child had measles within the same:
measles within the last 3 months, REFER TO HOSPITAL.
the last 3 months or is known or suspected to have Symptomatic HIV Infection,refer.)
refer.) - Change to second-line oral antibiotic recommended for shigella in your area.
→ If breathing slower, less fever, or eating better, complete the 5 days of antibiotic. → IfGive fewer stools,
it for less fever, less abdominal pain, and eating better, continue giving
5 days.
- ciprofloxacin
Advise the motheruntil finished.
to return in 2 days.
Ensure that the mother understands the oral rehydration method fully and that she
- also
If youunderstands
do not havethe theneed
second lineextra
antibiotic, REFER
dayTOforHOSPITAL.
2. Persistent
Persistentdiarrhoea
Diarrhoea for an meal each a week.
→ Care for the child who returns for follow-up using all the boxes that match the child’s
Exceptions:
After 5 days: → If the child has any new problems, assess, classify and treat the new problem as on
If the the
child is less than
ASSESS AND12 months old
CLASSIFY or was dehydrated on the first visit, or if he had
chart
Ask:
→ Has the diarrhoea stopped? measles within the last 3 months, REFER TO HOSPITAL.
→ How many loose stools is the child having per day? → If fewer stools, less fever, less abdominal pain, and eating better, continue giving
Assess for HIV infection ciprofloxacin until finished.
Ensure that the mother understands the oral rehydration method fully and that she
Treatment: also understands the need for an extra meal each day for a week.
→ If the diarrhoea has not stopped (child is still having 3 or more loose stools per day) → Care for the child who returns for follow-up using all the boxes that match the child’s
do a full assessment of the child. Treat for dehydration if present. Then refer to
refer to
hospital including for assessment for ART.
→ If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the → If the child has any new problems, assess, classify and treat the new problem as on
mother to follow the usual feeding recommendations for the child’s age. the ASSESS AND CLASSIFY chart
22
4. Malaria 7. Ear infection
If fever persists after 3 days, or returns within 7 days: After 5 days:
→ Do a full reassessment of the child > See ASSESS & CLASSIFY chart. → Reassess for ear problem. > See ASSESS & CLASSIFY chart.
→ Assess for other causes of fever. → Measure the child’s temperature.
→ Check for HIV infection.
Treatment:
Treatment:
→ If the child has any general danger sign or stiff neck, treat as VERY SEVERE
→ If there is tender swelling behind the ear or high fever (38.5°C or above), refer
FEBRILE DISEASE. URGENTLY to hospital.
→ If the child has any cause of fever other than malaria, provide treatment. → Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the
→ If malaria is the only apparent cause of fever: same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.
- Treat with the second-line oral antimalarial (if no second-line antimalarial is → Chronic ear infection: Check that the mother is wicking the ear correctly.
available, refer to hospital.) Encourage her to continue.
- Advise the mother to return again in 2 days if the fever persists. → If no ear pain or discharge, praise the mother for her careful treatment. If
→ If fever has been present for 7 days, refer for assessment. she has not yet finished the 5 days of antibiotic, tell her to use all of it before stopping.
5. Fever - No Malaria
8. Feeding Problem
If fever persists after 3 days:
→ Do a full reassessment of the child > See ASSESS & CLASSIFY chart. After 5 days:
Assess for other causes of fever. → Reassess feeding > See questions at the top of the COUNSEL chart.
→ Ask about any feeding problems found on the initial visit.
Treatment:
→ If the child has any general danger sign or stiff neck, treat as VERY SEVERE Counsel the mother about any new or continuing feeding problems. If you counsel
FEBRILE DISEASE. the mother to make significant changes in feeding, ask her to bring the child back
→ If the child has any cause of fever other than malaria, provide treatment. again.
→ If malaria is the only apparent cause of fever:
- Treat with the first-line oral antimalarial. If the child is very low weight for age, ask the mother to return 30 days after the
initial visit to measure the child’s weight gain.
- Advise the mother to return again in 2 days if the fever persists.
→ If fever has been present for 7 days, refer for assessment.
6. Measles with eye or mouth complications

After 3 days: Treatment for Mouth Ulcers:
→ Look for red eyes and pus draining from the eyes.
→ If mouth ulcers are worse, or there is a very foul smell coming from the mouth,
→ Look at mouth ulcers.
→ Smell the mouth. refer to hospital.
→ If mouth ulcers are the same or better, continue using half-strength gentian violet for
Treatment for Eye Infection: a total of 5 days.
→ If pus is draining from the eye, ask the mother to describe how she has treated the
eye infection. If treatment has been correct, refer to hospital. If treatment has not → Care for the child who returns for follow-up using all the boxes that match the
been correct, teach mother correct treatment. child’s previous classification
→ If the pus is gone but redness remains, continue the treatment. → If the child has any new problems, assess, classify and treat the new
problem as on the ASSESS AND CLASSIFY chart
→ If no pus or redness, stop the treatment.
23
9. Anaemia 11. Moderate Acute Malnutrition
After 14 days: After 30 days:
• Give iron. Advise mother to return in 14 days for more iron.
Assess the child using the same measurement (WFH/L or MUAC)
• Continue giving iron every 14 days for 2 months. used on the initial visit: If WFH/L, weigh the child, measure height
refer
• If the child has palmar pallor after 2 months, refer for assessment. or length and determine if WFH/L.
- If MUAC, measure using MUAC tape.
10. Very low weight for age - Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER
chart.
After 3 days:
Weigh the child and determine if the child is still very low weight for age. Reassess
Treatment:
feeding. See questions at the top of the COUNSEL chart.
- If the child is no longer classified as MODERATE ACUTE
Check for HIV infection. MALNUTRITION, praise the mother and encourage her to
continue.
Treatment: - If the child is still classified as MODERATE ACUTE
• If the child is no longer very low weight for age, praise the mother and encourage her to continue. MALNUTRITION, counsel the mother about any feeding
• If the child is still very low weight for age, counsel the mother about any feeding problem found. Ask the mother problem found. Ask the mother to return again in one month.
to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weight Continue to see the child monthly until the child is feeding well
regularly or is no longer very low weight for age. and gaining weight regularly or his or her WFH/L is -2 z-scores
or more or MUAC is 125 mm. or more.
Exception:
If you think
If youthat feeding
think will notwill
that feeding improve, or if the
not improve, or ifchild has lost
the child has weight or his
lost weight or or
hisher MUAC has diminished, refer the
or her Exception:
child. refer
MUAC has diminished, refer the child. If you think that feeding will not improve, or if the child has lost
weight or his or her MUAC has diminished, refer the child.
12. Uncomplicated Severe Acute Malnutrition
After 7 days or during regular follow up: -3 z-scores or MUAC is less than 115 mm or oedema of both feet but NO medical
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. complication and passes appetite test), counsel the mother and encourage her to
continue with appropriate RUTF feeding. Ask mother to return again in 7 days.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit. Check for
oedema of both feet. - If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and
Check the child’s appetite by offering ready-to use therapeutic food if the child is 6 months or older. -2 z-scores or MUAC between 115 and 125 mm), advise the mother to continue
RUTF. Counsel her to start other foods according to the age appropriate feeding
Treatment: recommendations (see COUNSEL THE MOTHER chart). Tell her to return again in 14
- If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 days. Continue to see the child every 14 days until the child’s WFH/L is -2 z-scores or
z-scores or more, and/or MUAC is 125 mm or more.
- MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication - If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC
or oedema, or fails the appetite test), refer URGENTLY to hospital. is 125 mm or more), praise the mother, STOP RUTF and counsel her about the age
- If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than appropriate feeding recommendations (see COUNSEL THE MOTHER chart).
24
COUNSEL THE MOTHER
ASSESS THE FEEDING OF SICK CHILD UNDER 2 YEARS
(or if child has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED)
Ask questions about the child’s usual feeding and feeding during this illness. Note whether the mother is HIV infected, uninfected, or does not
know her status. Compare the mother’s answers to the Feeding Recommendations for the child’s age
ASK — How are you feeding your child?

If the child is receiving any breastmilk, ASK: Does the child take any other food or fluids?
→ How many times during the day? → What food or fluids?
→ Do you also breastfeed during the night? → How many times per day?
→ What do you use to feed the child?
If low weight for age, ASK:

If child is receiving replacement milk, ASK: → How large are servings?
→ What replacement milk are you giving? → Does the child receive his own serving?
→ How many times during the day and night?
→ Who feeds the child and how?
→ How much is given at each feed?
→ How is the milk prepared? During this illness, has
has the
the child’s
child’s feeding
feeding changed?
changed?
→ How is the milk being given? Cup or bottle?
→ If yes, how?
→ How are you cleaning the utensils?
→ If still breastfeeding
breastfeedingas well as giving replacement milk could the mother give extra
breastmilk instead of replacement milk (especially if the baby is below 6 months)
25
FEEDING RECOMMENDATIONS
Feeding recommendation for all children during sickness and health, and including children on ARV or HIV exposed
Up to 6 Months 6 Months up to 12 Months 12 Months up to 2 Years 2 Years and Older
of Age
• Give family foods at least 3

• Breastfeed as often as the child wants
meals each day. Also give a
• Breastfeed as often as and breastfed child atleast for 24
• Breastfeed as often as the child wants nutritious snack twice daily such
the child wants, day months
as banana/eggs/bread.
and night at least 8 • Introduce child to some soft foods such as:
• In addition, give three to five feeds:
times in 24 hours - Thick porridge made out of either
maize or cassava/millet/soya flour. Add - Mixtures of mashed foods made
• Do not give other foods sugar and oil mixed with wither milk or out of either matooke/potatoes/
or fluids pounded ground nut. cassava/posho (maize/millet/rice. Feeding Recommendations
• If a child between 4 Mix with fish/beans/pounded for a child who has PERSISTENT
- Mixture of mashed foods made out
and 6 months appears groundnuts. Add green vegeta- DIARRHOEA
of either matooke/potatoes/cassava/
hungry after breast- bles. If still breastfeeding, give more
posho (maize/beans/pounded ground-
feeding or is not gain- frequent, longer breastfeeds, day
nuts. Add green vegetables
ing weight adequately, - Thick porridge made out of either and night. If taking other milk:
add complimentary - Start with 2-3 heaped tablespoons per maize/cassava/millet/soya flour. • Replace with increased
foods (listed under feed and gradually increase to atleast Add sugar and oil mix with wither breastfeeding OR
6 months up to 12 one third of a nice plastic cup milk or pounded groundnuts • Replace with fermented milk
months) • Feed child with soft foods three times a products, such as yoghurt OR
• Give a nutritious snack in between
day if breastfeeding; and five times if child • Replace half the milk with
• Give those foods 1 or feeds
is not breastfeeding • If child is HIV exposed, mother nutrient-rich semisolid food
2 times per day after
breastfeeding • Give a snack like egg/banana/bread in should be encouraged to discontinue
between the feeds breastfeeding at 12 months
26
Counsel themother
Counsel the mother about
about feeding
feeding problems
problems
If the mother reports difficulty with breastfeeding, assess breast-feeding (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*:
→ Build mother’s confidence that she can produce all the breast milk that the child needs.
→ Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother to:

→ Breastfeed as much as possible, including at night.
→ Make sure that other milk is a locally appropriate breast milk substitute.
→ Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
→ Finish prepared milk within an hour.
If the mother is using a bottle to feed the child:

→ Recommend substituting a cup for bottle.
→ Show the mother how to feed the child with a cup.
If the child is not feeding well during illness, counsel the mother to:
→ Breastfeed more frequently and for longer if possible.
→ Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feeds.
→ Clear a blocked nose if it interferes with feeding.
→ Expect that appetite will improve as child gets better.
If the child has a poor appetite:

→ Plan small, frequent meals.
→ Give milk rather than other fluids except where there is diarrhoea with some dehydration.
→ Give snacks between meals.
→ Give high energy foods.
→ Check regularly.
If the child has sore mouth or ulcers:

→ Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
→ Avoid spicy, salty or acid foods.
→ Chop foods finely.
→ Give cold drinks or ice, if available.
* if child is HIV exposed, counsel the mother about the importance of not mixing breast-feeding with replacement feeding.
27
Feeding advice for the mother of a child with confirmed “AFASS” criteria for stopping breastfeeding for HIV
HIV infection exposed
• The child should be fed according to the feeding recommendations for his/her age. Acceptable:
• Mothers should be encouraged to breastfeed up to 12 months and discontinue Mother perceives no problem in replacement feeding.
thereafter
Feasible:
• Children with confirmed HIV infection often suffer from poor appetite and mouth sores, Mother has adequate time, knowledge, skills, resources, and support to correctly mix
give appropriate advice. formula or milk and feed the infant up to 12 times in 24 hours.
• If the child is being fed with a bottle, encourage the mother to use a clean cup as this is
Affordable:
more hygienic and will reduce episodes of diarrhoea.
Mother and family, with community can pay the cost of replacement feeding without
• Inform the mother about the importance of hygiene when preparing food because her harming the health and nutrition of the family.
child can easily get sick. She should wash her hands after going to the toilet and before
preparing food. If the child is not gaining weight well, the child can be given an extra Sustainable:
meal each day and the mother can encourage him to eat more by offering him snacks Availability of a continuous supply of all ingredients needed for safe replacement feeding
that he likes if these are available. for up to one year of age or longer.
• Advise mother about her own nutrition and the importance of a well balanced diet to Safe:
keep herself healthy. Encourage mother to plant vegetables to feed her family
Replacement foods are correctly and hygienically prepared and stored.
28
Counsel
Counselthe
themother CARE
motherabout FOR
aboutresponsive
early CHILD DEVELOPMENT
care giving
childhood and stimulating
development: AND
the
Responsive STIMULATION
child’s
care giving brain
and stimulating the child’s brain
Newborn
Newborn birth up 11 week
weekup to 6 months 6 months up to12
6 months 12months
12 months up to 2 22 years
years and older
Birthtoup to
1week up to 6 months
up to 12 up to years and older
1 week months months 2 years
Play: Play:Give
Play: Giveyour
your child
child things
things to to
Your Play: Play:Give
Giveyour
yourchild
childclean safe
clean safe Play: Help your child count,
Yourbaby
babylearns
learnsfrom
frombirth.
birth. Provide ways for your
Play: provide ways for your household things to handle, bang stuckup.
stack up.
Play: Provide ways for your child household things to handle, Play: and
child tosee,
to see,hear, feel
hear, and
feel and and
bangdrop.
and drop.
name helpcompare things.
your child count,
baby
Play:toprovide
see ,hear, move
ways forarms
your move,
move, show
showcolorful
colorfulthings
thingsfor namesimple
Make and compare
colorful things.
toys
Communicate: Ask your child Make
baby
and to freely,
legs see ,hear,
Gentlymove
stroke your child.child.
for your Communicate:
simple questions, Ask yourtochild
respond for yoursimple
child. colorful toys
arms
and andyour
hold legsbaby.
freely, for your child.
simple questions, respond to
your child’s attempt to talk. Show
Gently stroke and hold your your child’s attempt to talk.
baby. and talk about nature, picture
Communicate: Look into Show and talk about nature,
Communicate:
baby’s Look
eyes and talk into
to your and things
picture and things.
baby’s
baby, eyesbreast
when and talk to your
feeding.
baby,a when
Even breast
new born babyfeeding.
sees
Even a new born baby sees
your face and hears your voice.
your face and hears your
voice.
Communicate:
Communicate: Respond
Respondtoto your
your
child’s soundsandand interests. Communicate: Encourage
Communicate: Encourage
Communicate: Smile child’s sounds interests.
Communicate: smileand
and Tell your child the name of the your child to talk and answer
laugh with your child to talk and answer
laugh withyour
yourchild, get
child, get a your
things
Tell yourand people,
child sample
the name of thetoys yourchild
childquestions,
questions, teach
teach
a conversation
conversion going
going by by
copying your
yourchild
childstories,
stories,songs and
songs and
your child
copying sounds
your and
child sounds things and people, sample toys games.
games.
gestures.
and gestures.
29
Counsel
Counsel thethe mother
mother aboutabout
her ownher own health
health WHEN
WHEN TO TO RETURN
RETURN
• If Ifthe
themother
motherisissick,
sick,provide
providecare
careforforher,
her,ororrefer
referher
refer herfor
forhelp.
help. Advise the mother when to return to health worker
• If Ifshe
shehas
hasa abreast
breastproblem
problem(such(suchasasengorgement,
engorgement,sore sorenipples,
nipples,breast
breastinfection),
infection),
provide
provide care
care forfor her
her oror referher
refer
refer herfor
forhelp.
help.
Follow-up visit
• Adviseher
Advise hertotoeateatwell
welltotokeep
keepupupherherown
ownstrength
strengthandandhealth.
health.
• Checkthe
Check themother’s
mother’simmunization
immunizationstatusstatusandandgivegiveher
hertetanus
tetanustoxoid
toxoidif ifneeded.
needed. If the child has Return for first follow-up in3
• Makesure
Make suresheshehas hasaccess
accessto:to: • Pneumonia
-Family
Familyplanning
- Family planning
planning
• Dysentery 2 days
-Counselling
Counsellingon
- Counselling ononSTD
STDand
STD and AIDS
andAIDS
HIV prevention.
prevention.
prevention.
• Malaria, if fever persists 3 days
• Encourage
Encourageevery everymother
mothertotobe besure
suretotoknow
knowher herown
ownHIV
HIVstatus
statusand
andtotoseekseekHIV
HIVtesting
if testing
she does not does
if she knownot herknow
status or status
her is concerned about theabout
or is concerned possibility of HIV in of
the possibility herself
HIV inor • Fever-malaria unlikely, if fever persists
her family.
herself or her family. • Measles with eye or mouth complications
• Persistent diarrhoea
• Acute ear infection
Fluids
Fluid • Chronic ear infection 5 days
• Feeding problem
Advise the
Advise the Mother
Mother to
to Increase
Increase Fluid
Fluid During
During Illness
Illness • Cough or cold, if not improving
For any
For any sick
sickchild:
child: • Anaemia
IfIfchild
childisisbreastfed,
breastfed,breastfeed
breastfeedmore
morefrequently
frequentlyand
andfor
forlonger
longeratateach
eachfeed.
feed. • Confirmed HIV
hiv infection
If Ifchild
childisistaking
takingbreast-milk
breast-milksubstitutes,
substitutes,increase
increasethe
theamount
amountof ofmilkmilk given
given Increase
Increase other • Suspected symptomatic HIVhiv infection
infection 14 days
otherFor
fluids. fluids. For example,
example, giverice
give soup, soup, riceyoghurt
water, water, yoghurt
drinks ordrinks
cleanorwater.
clean water.
• HIV exposed/ possible HIV
hiv infection
For
For child withdiarrhoea:
child with diarrhoea:
Givingextra
extrafluid
fluidcan
canbe
belifesaving.
lifesaving.Give
Givefluid
fluidaccording
accordingtotoPlan
PlanAAororPlan
PlanBB • Very low weight for age 30 days
Giving
ononthe
theTREAT
TREATTHE THECHILD
CHILDchart
chart
Advise the mother to come for follow-up at the earliest time listed for the child’s problems.
When to return immediately

Advise mother to return immediately if the child
has any of these signs:
Any sick child → Not able to drink or

breastfeed
→ Becomes sicker
→ Develops a fever
If child has NO PNEUMONIA: → Fast breathing
COUGH OR COLD, also → Difficult breathing
return if:
→ If child has Diarrhoea, also → Blood in stool
return if: → Drinking poorly
30
SICK YOUNG INFANT AGE: BIRTH UP TO 2 MONTHS
IMNCI PROCESS FOR THE SICK YOUNG INFANT
GREET THE CAREGIVER
ASK: Child’s age ASK: Initial or follow-up visit for problems?

ASK : What are the infant’s problems? MEASURE: Weight and temperature
ASSESS FOR MAIN SYMPTOMS

Jaundice
ASSESS FOR Diarrhea
SIGNS OF SEVERE DISEASE Feeding problem or LOW WEIGHT FOR AGE
Possible HIV INFECTION,
TB EXPOSURE
All with severe

disease require
URGENT
referral CLASSIFY
TREAT IN CLINIC TREAT AT HOME

URGENT REFERRAL REFERRAL NOT REQUIRED
URGENT REFERRAL REQUIRED REFERRAL NOT REQUIRED
• IDENTIFY TREATMENT • IDENTIFY TREATMENT
• IDENTIFY pre-referral treatment • TREAT
• URGENTLY REFER • COUNSEL caretaker on home treatment
• COUNSEL caretaker • FOLLOW-UP CARE
• FOLLOW-UP CARE
31
SIGNS
SIGNSOF
SIGNS OFSEVERE
OF SEVERE DISEASE
SEVERE DISEASE
Assess for signs of severe disease

Assess for signs of severe disease
Severe chest indrawing or

fast breathing
32
ASSESS, CLASSIFY AND TREAT THE YOUNG INFANT
AGE: BIRTH UP TO 2 MONTHS
DO QUICK ASSESSMENT OF ALL YOUNG INFANTS BIRTH UP TO 2 MONTHS
ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE
- Determine if this is an initial or follow-up visit for this problem USE ALL BOXES THAT MATCH INFANT’S SYMPTOMS AND PROBLEMS TO CLASSIFY
- If initial visit, assess the child and classify as follows:
CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY
SEVERE DISEASE, PNEUMONIA AND LOCAL INFECTION SIGNS CLASSIFY AS IDENTIFY TREATMENT
Any one or more of the following • Give first dose of intramuscular
}
ASK: LOOK AND FEEL:
Classify ALL signs: antibiotic
• Is the infant • Count the breaths in one YOUNG POSSIBLE
minute INFANT YOUNG • Not able to feed since birth, stopped
having difficulty SERIOUS • Treat to prevent low blood sugar
in feeding? Repeat the count if 60 or INFANTS feeding well or not feeding at all or
MUST BACTERIAL • Refer URGENTLY to hospital **
more breaths per minute. • Convulsions or
• Has the infant BE CALM INFECTION • Teach the mother how to keep
had convulsions • Look for severe chest • Severe chest indrawing or OR VERY the infant warm on the way to
(fits)? indrawing. • Fever (38°C* or above) or SEVERE
• Measure axillary temperature. • Low body temperature (less than the hospital
DISEASE
35.5°C*) or
• Look at the young infant’s movements. If
infant is sleeping, ask the mother to wake • Movement only when stimulated or
him/her: no movement at all, or
• Fast breathing (60 breaths per minute
- Does the infant move on his/her own? or more) in infants less than 7 days old
If the infant is not moving, gently
stimulate him/her.
• Fast breathing (60 breaths per minute • Give amoxicillin for 7 days
- Does the infant move only when or more) in infants 7 to 59 days old PNEUMONIA • Advise mother to give home
stimulated but then stops? care for the young infant
- Does the infant not move at all?
• Follow up on day 4 of treatment
• Look at the umbilicus. Is it red or draining
pus? • Also treat per any others
• Look for skin pustules • Umbilicus red or draining pus LOCAL • Give amoxicillin for 5 days
• Skin pustules INFECTION • Teach mother to treat local
infections at home
• Advise mother to give home
care for the young infant
• Follow up on day 3
• No signs of bacterial infection or very SEVERE • Advise mother to give home
* These thresholds are based on axillary temperature. severe disease DISEASE OR care for the young infant
INFECTION
** If referral is refused or not possible, see page 12.
UNLIKELY
33
THEN CHECK FOR JAUNDICE
USE ALL BOXES THAT MATCH INFANT’S SYMPTOMS AND PROBLEMS TO CLASSIFY

- Any jaundice if age less SEVERE • Treat to prevent low blood sugar
If jaundice LOOK AND FEEL Classify
than 24 hours or JAUNDICE • Refer URGENTLY to hospital
present , ASK: ALL
- Look for jaundice (yellow - Yellow palms and soles at
YOUNG
- When did eyes or skin) INFANTS
any age
the jaundice
appear first? - Look at the young infant’s - Jaundice appearing after JAUNDICE • Advise mother to give home care
palm and soles. Are they 24 hours of age and for the young infant
yellow? - Palms and soles not • Advise mother to return
yellow immediately if palms and soles
appear yellow
• If young infant is older than 14
days, refer to a hospital for
assessment
• Follow up in 1 day
No Jaundice NO JAUNDICE Advise mother to give homecare for

the young infant
34
THEN ASSESS FOR DIARRHOEA
ASK: Does the young infant have diarrhoea*?
Two of the following signs: Infant has no other severe classification:
• Movement only when
IF YES, LOOK AND FEEL: stimulated or no • Give fluid for severe dehydration (Plan C)
Look at the young infant’s general condition: movement at all
• Start IV fluid immediately, or Refer
- Infant’s movements • Sunken eyes. URGENTLY for IV fluid. If that is not possible,
• Does the infant move on his/her own? • Skin pinch goes back very SEVERE start rehydration by NG tube OR
Classify slowly. DEHYDRATION
• Does the infant not move even when stimulated but • If infant also has another severe
then stops? DIARRHOEA for classification:
DEHYDRATION
• Does the infant not move at all? • Refer URGENTLY to hospital with mother
• Is the infant restless and irritable? giving frequent sips of ORS on the way
- Look for sunken eyes. • Advise the mother to continue breastfeeding
- Pinch the skin of the abdomen. Does it go back: • Teach the mother how to keep the infant
• Very slowly (longer than 2 seconds)? warm on the way to the hospital
• or slowly?
Two of the following signs: • Give fluid and breastmilk for some
• Restless, irritable. dehydration (Plan B)
• Sunken eyes. If infant has any severe classification:
• Skin pinch goes back •• Refer URGENTLY to hospital with mother
slowly. giving frequent sips of ORS on the way
SOME
DEHYDRATION
• Advise the mother to continue breastfeeding
• Follow-up in 2 days if not improving
Not enough signs to • Give fluids to treat diarrhoea at home and

classify as some or severe continue breastfeeding (Plan A)
dehydration. NO
DEHYDRATION
* What is diarrhoea in a young infant? • Follow-up in 2 days if not improving
A young infant has diarrhoea if the stools have changed from usual
pattern and are many and watery (more water than faecal matter).
The normally frequent or semi-solid stools of a breastfed baby are
not diarrhoea.
35
THEN CHECK FOR HIV INFECTION
ASK: • Infant has positive virological CONFIRMED HIV • Give cotrimoxazole prophylaxis from age 6 weeks
Classify HIV test
• Has the mother had an HIV test? INFECTION • Check for TB (see page 37)
INFECTION by
If yes:
– Serological test POSITIVE or NEGATIVE? test results • Link infant to Early infant Diagnosis (EID)/Mother
Baby Care point for follow up
– Has the infant had an HIV test?
• Assess the infant’s feeding and counsel as
necessary
If yes:
– Virological test POSITIVE or NEGATIVE? • Advise the mother on home care
– Serological test POSITIVE or NEGATIVE?
• Mother HIV positive AND HIV EXPOSED: • Give cotrimoxazole prophylaxis from age 6 weeks
If mother is HIV positive and there is NO positive negative virological test POSSIBLE HIV
INFECTION • Start or continue ARV’s for prophylaxis
virological test in infant, in young infant who is
ASK: breastfeeding or stopped less • Check for TB (see page 37)
• Is the young infant breastfeeding now? than 6 weeks ago
• Assess the infant’s feeding and give appropriate
• Was the young infant breastfeeding at the time OR feeding advice
of test or before it?
• Mother HIV positive, young • Do virological test at age 6 weeks or repeat 6
• Are the mother and young infant on ePMTCT infant not yet tested weeks after the infant stops breastfeeding
ARV prophylaxis?
OR • Advise the mother on home care
IF NO test: Mother and young infant status • Infant has positive serological • Follow-up regularly
unknown test (HIV antibody test)
• Perform HIV test for the mother. If positive,
perform virological test for the young infant
• HIV test not done for mother HIV INFECTION • Encourage HIV testing where it is available
or infant STATUS
UNKNOWN
• Negative HIV test for mother HIV UNLIKELY • Treat, counsel and follow-up existing infections
or infant
• Advise the mother about feeding and about her
own health
36
THEN CHECK FOR TB
ASSESS SIGNS CLASSIFY IDENTIFY TREATMENT
• Refer to hospital for further
ASK:- LOOK AND FEEL assessment and management
Presence of ANY of the symptoms suggestive
Classify PRESUMPTIVE
For symptoms Look or feel for of TB OR weight less than 1.5kg or -3Z score • Ask about the caregiver’s health
TB Status with any symptom. TB and treat as necessary
suggestive of TB physical signs of TB
• Has the young infant • Determine weight for

had contact with a age A sick young infant with no TB symptoms or NO
person with Pulmonary signs • Treat, counsel, and follow up
- Weight less than PRESUMPTIVE existing infections
Tuberculosis or chronic
cough? 1.5kg? TB • Ask about the caregiver’s health
- Weight for age less and treat as necessary
• Has the young infant
had persistent fevers for than -3 Z score?
14 days or more?
• Does the young infant

have pneumonia which * Refer young infants with dangers signs as well as those where TB treatment is not available.
is not responding to
standard therapy?
• Has the young infant

been coughing for 14
days or more?
* Poor weight gain (Weight loss, or very low weight (weight-forage

less than -3 z-score), or underweight (weight-for age less
than -2 z-score), or confirmed weight loss (>5%) since the last
visit, or growth curve flattening), yellow and red MUAC colour codes.
37
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED INFANTS
ASK: LOOK AND FEEL: • Weight • Treat to prevent low blood sugar.
Classify < 1.5 kg, or • Refer URGENTLY to hospital.
• Is the infant breastfed? If yes, • Determine weight for age. • Weight VERY LOW
ALL • Teach the mother to keep the young infant warm on the
how many times in 24 hours? – Weight less than 1.5 kg? < -3 Z score WEIGHT
FEEDING way to hospital
– Weight for age less than
• Does the infant usually receive -3 Z score? • Not well attached • If not well attached or not suckling effectively, teach
any other foods or drinks?
• Look for ulcers or white to breast or correct positioning and attachment.
– If yes, how often? patches in the mouth FEEDING
(thrush). - If not able to attach well immediately, teach the mother
– If yes, what do you use to • Not suckling PROBLEM
feed the infant? to express breastmilk and feed by a cup
and/or
effectively, or • If breastfeeding less than 8 times in 24 hours, advise to
LOW
WEIGHT increase frequency of feeding. Advise the mother to
ASSESS BREASTFEEDING: • Less than 8
FOR AGE breastfeed as often and for as long as the infant wants, day
• Has the If the infant has not fed in the previous hour, ask breastfeeds in 24 and night.
infant the mother to put her infant to the breast. Observe hours, or
breastfed in the breastfeed for 4 minutes. • If receiving other foods or drinks, counsel mother about
the previous breastfeeding more, reducing other foods or drinks, and
(If the infant was fed during the last hour, ask the • Receives other
hour? mother if she can wait and tell you when the infant using a cup.
foods or drinks, or
is willing to feed again.) • If not breastfeeding at all:
• Is the infant well attached? • Low weight for - Refer for breastfeeding counselling and possible
not well attached good attachment age, or relactation.
- Advise about correctly preparing breastmilk substitutes
TO CHECK ATTACHMENT, LOOK FOR: • Thrush (ulcers or
- More areola seen above infant’s top lip than below and using a cup.
bottom lip
white patches in
mouth) • Check for TB (See card 37)
- Mouth wide open
- Lower lip turned outwards • Advise the mother how to feed and keep the low weight
- Chin touching breast infant warm at home
(All of these signs should be present if the attachment • If thrush, teach the mother how to treat thrush at home.
is good). • Advise mother to give home care for the young infant.
• Follow up FEEDING PROBLEM or thrush on day 3.
• Is the infant suckling effectively (that is, slow
deep sucks, sometimes pausing)? • Follow up LOW WEIGHT FOR AGE on day 14.
not suckling effectively suckling effectively • Not low weight NO • Advise mother to give home care for the young infant.
• Clear a blocked nose if it interferes with
for age and FEEDING • Praise the mother for feeding the infant well.
breastfeeding. no other signs PROBLEM
of inadequate
feeding
38
THEN CHECK THE YOUNG INFANT ‘S IMMUNIZATION STATUS
THEN CHECK YOUNG INFANT ‘S IMMUNIZATION

VACCINES*
AND VITAMIN A STATUS:
BCG** OPVO
DPT1 + HepB + HIB OPV1 RTV1 PCV1
DPT2 + HepB + HIB OPV2 RTV2 PCV2
3rd Dose at 14 weeks
* Vaccines should be provided in line with the national immunization policy.

** Young infants who are HIV positive or unknown are HIV status with symptoms
consistent with HIV should not be given BCG
ASSESS
ASSESS YOUNG
YOUNG INFANT
INFANT FOR
FOR OTHER
OTHER PROBLEMS
PROBLEMS INCLUDING
INCLUDING CONGENITAL
CONGENITAL MALFORMATIONS
MALFORMATIONS
• Ask mother for any other problem or identified external malformations
•• Ask mother
Check for any
child for any external
other problem or identified
malformations and external
abnormal malformations
signs
•• Check child for any external malformations and abnormal signs or problems that you cannot handle
Refer infant to hospital if they have any external malformations
• Refer infant to hospital if they have any external malformations or problems that you cannot handle
ASSESS THE MOTHER’S HEALTH NEEDS

Ask and check for any postpartum complications such as bleeding and infections. Ask if mother has identified and has been counselled about
ASSESS
family THE ifMOTHER’S
planning; not link to FP HEALTH NEEDS
clinic. If mother is an adolescent, link to appropriate clinic or service provider for support.
Ask and check for any postpartum complications such as bleeding and infections. Ask if mother has identified and has been counselled about
family planning; if not link to FP clinic. If mother is an adolescent, link to appropriate clinic or service provider for support.
39
39
TREAT THE YOUNG INFANT
IF THE YOUNG INFANT IS CLASSIFIED AS POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE
DISEASE, GIVE PRE-REFERRAL TREATMENTS AND Refer URGENTLY
1. Give First Doses of Intramuscular Gentamicin 3. Keep the Young Infant Warm on the Way
and Intramuscular Ampicillin to the Hospital
Gentamicin: Give 5 mg/kg/day in once daily injection. In low birth weight  Provide skin to skin contact, OR
infants, give 4 mg/kg/day in once daily injection. To prepare the injection:
From a 2 ml vial containing 40 mg/ml, remove 1 ml gentamicin from the  Keep the young infant clothed or covered as much as possible
vial and add 1 ml distilled water to make the required strength of 20 mg/ all the time, especially in a cold environment. Dress the young
ml. infant with extra clothing including hat, gloves, and socks.
Wrap the infant in a soft dry cloth and cover with a blanket.
Ampicillin: Give 50mg/kg IM
* If refferal is not possible, continue treatment for seven days
4. Refer Urgently
2. Prevent Low Blood Sugar
 Write a referral note for the mother to take to the
 If the young infant is able to breastfeed:
hospital.
Ask the mother to breastfeed the young infant.
 If the infant also has SOME DEHYDRATION OR
 If the young infant is not able to breastfeed but is able to swallow: SEVERE DEHYDRATION and is able to drink:
Give 20–50 ml (10 ml/kg) expressed breastmilk before departure. If not
possible to give expressed breastmilk, give 20–50 ml (10 ml/kg) sugar Give the mother some prepared ORS and ask her to give
water. (To make sugar water: Dissolve 4 level teaspoons of sugar (20 frequent sips of ORS on the way. Advise mother to continue
grams) in a 200-ml cup of clean water.) breastfeeding.
 If the young infant is not able to swallow:
Give 20–50 ml (10 ml/kg) of expressed breastmilk or sugar water by

nasogastric tube.
40
PLAN C : TREAT SEVERE DEHYDRATION QUICKLY
TREAT THE YOUNG INFANT WITH SEVERE DEHYDRATION QUICKLY WITH PLAN C
Follow the arrows. If answer is Yes, go across. If No, go down.
Can you give • Start IV fluid immediately.

intravenous (IV)
IV • If the young infant can drink, give ORS by mouth while the drip is set up.
YES
fluid • Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows:
immediately? AGE First give 30 ml/kg in : Then give 70 ml/kg in :
Infants (under 12 months) 1 hour 5 hours
• Reassess the young infant every 1–2 hours. If hydration status is not improving, give the IV drip more
rapidly.
NO
• Also give ORS (about 5 ml/kg/hour) as soon as the young infant can drink: usually after 3–4 hours.
• Reassess a young infant after 6 hours. Classify dehydration. Then choose the appropriate plan (A, B or C)
to continue treatment.
Is IV treatment
available nearby
(within 30 minutes)?
• Refer URGENTLY to hospital for IV treatment.
YES
• If the infant can drink, provide the mother with ORS solution and show her how to give frequent sips
NO
during the trip or give ORS by nasogastric tube.
Are you trained to use

a nasogastric (NG) • Start rehydration by tube (or mouth) with ORS solution: Give 20 ml/kg/hour for 6 hours (total of 120
tube for rehydration? ml/kg).
• Reassess the young infant every 1–2 hours while waiting for transfer:
NO
YES – If there is repeated vomiting or abdominal distension, give the fluid more slowly.
– If the hydration status is not improving after 3 hours, send the young infant for IV therapy.
Can the young infant • After 6 hours reassess the young infant. Classify dehydration. Then choose the appropriate plan (A, B or C)
drink? to continue treatment.
NO
NOTE:
Refer URGENTLY to hospital
hospital • If the young infant is not referred to hospital, observe the young infant at least 6 hours after rehydration
for IV or NG treatment. to be sure the mother can maintain hydration giving the young infant ORS solution by mouth.
11
41
6. How to Give Oral Medicines at Home 7. Give Oral Amoxicillin

• Local Infection: Give oral amoxicillin twice daily for 5 days
Follow the instructions below to teach the mother about each oral
• Pneumonia (fast breathing alone) in infant 7–59 days old: Give
medicine to be given at home. Also follow the instructions listed with
oral amoxicillin twice daily for 7 days
each medicine’s dosage table.
• Determine the appropriate medicines and dosage for the infant’s age or AMOXICILLIN
weight. Desired range is 75 to 100 mg/kg/day divided into 2
daily oral doses. Give twice daily
• Tell the mother the reason for giving the medicine to the infant.
Dispersible Dispersible Syrup
• Demonstrate how to measure a dose.
Tablet Tablet (125 mg in 5
• Watch the mother practise measuring a dose by herself. WEIGHT
(250 mg) Per (125 mg) Per ml)
• Ask the mother to give the first dose to her infant. dose dose Per dose
• Explain carefully how to give the medicine, then label and package the 1.5 to 2.4 kg 1/2 tablet 1 tablet 5 ml
medicine.
2.5 to 3.9 kg 1/2 tablet 1 tablet 5 ml
• If more than one medicine will be given, collect, count and package each
4.0 to 5.9 kg 1 tablet 2 tablets 10 ml
medicine separately.
• Explain that all the tablets or syrups must be used to finish the course of
treatment, even if the infant gets better.
• Check the mother’s understanding before she leaves the clinic.
42
To Treat the Young Infant with Diarrhoea, Give Extra Fluids and Continue Feeding
If the young infant has NO DEHYDRATION, use Plan A. If the young infant has SOME DEHYDRATION, use Plan B.
PLAN A: TREAT DIARRHOEA AT HOME PLAN B: TREAT SOME DEHYDRATION WITH ORS
Counsel the mother on the Rules of Home Treatment In the clinic, give recommended amount of ORS over 4-hour period
for Young Infant: DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
1. Give Extra Fluids
2. When to Return WEIGHT < 6 kg
AGE* Up to 4 months
1. GIVE EXTRA FLUID (as much as the young infant will
take) TELL THE MOTHER: ORS 200 – 450 ml
* Use the age only when you do not know the weight. The approximate amount of ORS required
- Breastfeed frequently and for longer at each feed.
- Also give ORS or clean water in addition to breastmilk. (in ml) can also be calculated by multiplying the young infant’s weight (in kg) times 75.
- If the young infant wants more ORS than shown, give more.
- For young infants who are not breastfed, also give 100 - 200 ml clean water during this
It is especially important to give ORS at home when: period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
- The young infant has been treated with Plan B or Plan C during this
visit. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
- The young infant cannot return to a clinic if the diarrhoea gets worse. - Give frequent small sips from a cup.
- If the young infant vomits, wait 10 minutes. Then continue, but more slowly.
- Continue breastfeeding whenever the young infant wants.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE
MOTHER 2 PACKETS OF ORS TO USE AT HOME.
AFTER 4 HOURS:
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO
THE USUAL FLUID INTAKE:
- Reassess the young infant and classify the infant for dehydration.
Up to 2 years, 50 to 100 ml after each loose stool
- Select the appropriate plan to continue treatment.
- Continue breastfeeding the young infant in clinic.
Tell the mother to:
- Give frequent small sips from a cup. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
- Show her how to prepare ORS solution at home.
- If the infant vomits, wait 10 minutes. Then continue, but more slowly.
- Show her how much ORS to give to finish 4-hour treatment at home.
- Continue giving extra fluid until the diarrhoea stops. Give her enough ORS packets to complete rehydration. Also give her 2 packets as
recommended in Plan A.
2. WHEN TO RETURN
Explain the Rules of Home Treatment for Young Infant:
1. GIVE EXTRA FLUIDS. Breastfeed frequently and for longer at each feed.
2. WHEN TO RETURN
43
How to Treat Local Infections at Home
 Explain how the treatment is given.
 Watch her as she does the first treatment in the clinic. To Treat Thrush (ulcers or white patches in mouth)
 Tell her to return to the clinic if the infection worsens.
The mother should do the treatment 4 times daily for 7 days:
 Wash hands
 Paint the mouth with half-strength gentian violet (0.25%)

To Treat Skin Pustules or Umbilical Infection using a clean soft cloth wrapped around the finger
The mother should do the treatment twice daily for 5 days:  Wash hands again
 Wash hands
 Gently wash off pus and crusts with soap and water
 Dry the area
 Paint the skin or umbilicus/cord with full strength gentian violet (0.5%)
 Wash hands again
44
COUNSEL THE MOTHER
1. Correct Positioning and Attachment for Breastfeeding 2. How to Express Breastmilk

 Show the mother how to hold her infant: Ask the mother to:
- With the infant’s head and body in line
 Wash her hands thoroughly.
- With the infant approaching breast with nose opposite to the nipple
 Make herself comfortable.
- With the infant held close to the mother’s body
 Hold a wide necked container under her nipple and
- With the infant’s whole body supported, not just neck and shoulders.
areola.
 Show her how to help the infant to attach. She should:  Place her thumb on top of the breast and the first finger
- Touch her infant’s lips with her nipple on the under side of the breast so they are opposite
each other (at least 4 cm from the tip of the nipple).
- Wait until her infant’s mouth is opening wide
- Move her infant quickly onto her breast, aiming the infant’s lower lip  Compress and release the breast tissue between her
well below the nipple. finger and thumb a few times.
 Look for signs of good attachment and effective suckling. If the  If the milk does not appear she should re-position her
attachment or suckling is not good, try again. thumb and finger closer to the nipple and compress and
release the breast as before.
 Compress and release all the way around the breast,

keeping her fingers the same distance from the nipple.
3. How to Feed by a Cup Be careful not to squeeze the nipple or to rub the skin
or move her thumb or finger on the skin.
 Put a cloth on the infant’s front to protect his clothes as some milk  Express one breast until the milk just drips, then express
can spill the other breast until the milk just drips.
 Hold the infant semi-upright on the lap.
 Alternate between breasts 5 or 6 times, for at least 20 to
 Hold the cup so that it rests lightly on the infant’s lower lip. 30 minutes.
 Tip the cup so that the milk just reaches the infant’s lips.
 Stop expressing when the milk no longer flows but drips
 Allow the infant to take the milk himself. DO NOT pour the milk from the start.
into the infant’s mouth.
45
COUNSEL THE MOTHER
4. How to Keep the Low Weight Infant 5. How to Give Home Care for the Young Infant
Warm at Home  Advise 1.
theEXCLUSIVELY
Mother to BREASTFEED
Give HomeTHE
Care forINFANT
YOUNG the Young Infant
(for breastfeeding
mothers)
 Keep the young infant in the same bed with the mother. 1. – GiveBREASTFEED
EXCLUSIVELY only breastfeeds
THE to the young
YOUNG infant.
INFANT (for breastfeeding mothers)
 Keep the room warm (at least 25°C) with home heating – Breastfeed
– Give frequently,
only breastfeeds to theas often
young and for as long as the infant wants, day or night,
infant.
device and make sure that there is no draught of cold air. during sickness and health.
– Breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and healt
 Avoid bathing the low weight infant. When washing or 2.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
bathing, do it in a very warm room with warm water, In cool weather
–
– In cool weather covercover the infant’s
the infant’s head
head and feetand
and feet
dressand
thedress the infant
infant with with extra
extra clothing.
dry immediately and thoroughly after bathing and clothing.
clothe the young infant immediately. 3. WHEN
3. TO RETURN:
WHEN TO RETURN:
 Change clothes (e.g. nappies) whenever they are wet. Follow up visit
WHEN TO RETUR
 Provide skin to skin contact as much as possible, day If the infant has: Return for first follow-up on:
and night. For skin to skin contact: • JAUNDICE Day 2 of treatment Advise the car
immediately if t
• Dress the infant in a warm shirt open at the front, a • DIARRHOEA
has any of t
nappy, hat and socks. • FEEDING PROBLEM
Day 3
• THRUSH  Breastfeedin
• Place the infant in skin to skin contact on the • LOCAL INFECTION  Reduced ac
mother’s chest between the mother’s breasts. Keep • PNEUMONIA  Becomes sic
the infant’s head turned to one side. • SEVERE PNEUMONIA where referral is refused Day 4  Develops a f
or not possible
• Cover the infant with mother’s clothes (and an  Feels unusu
additional warm blanket in cold weather). • LOW WEIGHT FOR AGE in infant receiving no  Develops fas
Day 7
breastmilk
 Develops dif
 When not in skin to skin contact, keep the young
• LOW WEIGHT FOR AGE in breastfed infant Day 14  Palms or sol
infant clothed or covered as much as possible at
all times. Dress the young infant with extra clothing • CONFIRMED HIV INFECTION or HIV EXPOSED:
Per national guidelines
including hat and socks, loosely wrap the young POSSIBLE HIV INFECTION
infant in a soft dry cloth and cover with a blanket.
WHEN TO RETURN IMMEDIATELY:
 Check frequently if the hands and feet are warm. If cold,
re-warm the baby using skin to skin contact. Advise the caretaker to return immediately if the young infant has any of these signs:
 Breastfeeding poorly  Develops a fever
 Breastfeed the infant frequently (or give expressed
breastmilk by cup).  Reduced activity  Feels unusually cold  Develops difficult breathing
 Becomes sicker  Develops fast breathing 21  Palms or soles appear yellow
46
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
1. Pneumonia or Severe Disease

Follow up on day 4 of treatment.
→ Reassess the young infant for POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE, PNEUMONIA AND
LOCAL INFECTION as on page 2.
→ Refer young infant if:
• Infant becomes worse after treatment is started or
• Any new sign of VERY SEVERE DISEASE appears while on treatment
→ If the young infant is improving, ask the mother to continue giving the oral amoxicillin twice daily until all the tablets are finished.
→ Ask the mother to bring the young infant back in 4 more days.
→ Young infants with fast breathing alone should be checked as often as possible but it is mandatory to do so on day 4 of treatment.
2. Local Infection 3. Jaundice
On day 3 of treatment: On day 2: LOOK for jaundice. Are palms or

soles yellow?
• Look at the umbilicus. Is it red or draining pus?
• Look for skin pustules. → If palms or soles are yellow, refer to hospital.
→ If palms or soles are not yellow, but jaundice has not
Treatment:
decreased, advise the mother about home care and ask her
→ If umbilical pus or redness remains same or is worse, to return for follow up again tomorrow.
refer to hospital. If pus and redness are improved, tell
→ If jaundice has started decreasing, reassure the mother and
the mother to continue giving the 5 days of antibiotic and
ask her to continue home care. Ask her to return for follow up
continue treating the local infection at home.
at 3 weeks of age.
→ If skin pustules are same or worse, refer to hospital. If After 3 weeks of age: If jaundice continues beyond 3
improved, tell the mother to continue giving the 5 days of weeks, refer the young infant to hospital for further
antibiotic and continue treating he local infection at home. assessment.
47
4. Diarrhoea 6. Low Weight For Age
On day 3, On day 14 (or on day 7 if the infant is receiving no breastmilk):
ASK: Has the diarrhoea stopped? Weigh the young infant and determine if the infant is still low weight for age.
• If the diarrhoea has not stopped, assess and treat Reassess feeding. Use “Then Check for Feeding Problem or Low Weight for Age”
the young infant for diarrhoea (see page 4) on page 6 or 7.
• If the diarrhoea has stopped, tell the mother to • If the infant is no longer low weight for age, praise the mother and encourage her
continue exclusive breastfeeding. 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
5. Feeding Problem immunization.
• If the infant is still low weight for age and still has a feeding problem, counsel the
On day 3: mother about the feeding problem. Ask the mother to return again in 14 days (or
when she returns for immunization, if this is within 14 days). Continue to see the
Reassess feeding. Use “Then Check for Feeding young infant every few weeks until the infant is feeding well and gaining weight
Problem or Low Weight for Age” above (page 6 or 7). regularly or is no longer low weight for age.
Ask about any feeding problems found on the initial
visit.
Exception:
• Counsel the mother about any new or continuing • If you think that feeding will not improve or if the young infant has lost weight,
feeding problems. If you counsel the mother to refer to hospital.
make significant changes in feeding, ask her to
bring the young infant back again. 7. Thrush
• If the young infant is low weight for age, ask the On day 3 of treatment:
mother to return 14 days after the initial visit to
Look for ulcers or white patches in the mouth (thrush).
measure the young infant’s weight gain.
Reassess feeding. Use “Then Check for Feeding Problem or Low Weight for Age”
(page 6 or 7).
Exception:
• If you think that feeding will not improve or if the • If thrush is worse, or the infant has problems with attachment or suckling, refer to
young infant has lost weight, refer to HOSPITAL. hospital.
• If thrush is the same or better, and if the infant is feeding well, continue half-
strength gentian violet for a total of 7 days.
48
ANNEX
ANNEX1
Assess child development milestones

AGE GROSS MOTOR FINE MOTOR SPEECH AND LANGUAGE ADAPTIVE AND SOCIAL SKILLS
6 weeks Prone-lifts-chin intermittently
10 weeks Prone- arms extended forward Pulls at clothes Coos
Prone-raises head and chest, rolls Reach and grasp, objects to

14 weeks rolls over front to back, no head Responds to voice
mouth
lag
Begins to babble, responds to

6 months Prone-weight on hands, tripod sit Ulnar grasp Stranger anxiety
name
9 months Pulls to stand Finger-thumb grasp Mama, dada, imitates one word Plays games, separation anxiety
2 other words with meaning

12 months Walks with support, “cruises” Pincer grasp, throws Plays peek-a-boo, drinks with cup
besides mama or dada
15 months Walks without support Draws a line Jargon Points to needs
10 words, follows simple

18 months Up steps with help Piles up to three levels, scribbling Uses spoon, points to body parts
commands
Piles things up to six levels, 2–3 word phrases, uses I, me, you,
24 months Up 2 feet per step, runs, kicks ball Parallel play, helps to undress
undresses 25% intelligible
49
w
Weight-for-height BOYS
2 to 5 years (z-scores)
30 3 30
28 28
2
26 26
1
24 24
0
22 22
-1
20 20
Weight (kg)
-2
18 18
-3
16 16
14 14
12 12
10 10
8 8
6 6
65 70 75 80 85 90 95 100 105 110 115 120
Height (cm)
WHO Child Growth Standards
50
ANNEX3
Weight-for-length BOYS
Birth to 2 years (z-scores)
24 3 24
22 2 22
20 1 20
18
0 18
-1
16 16
-2
Weight (kg)
14
-3 14
12 12
10 10
8 8
6 6
4 4
2 2
45 50 55 60 65 70 75 80 85 90 95 100 105 110
Length (cm)
51
ANNEX4
GROWTH CHART
Weight for age: BOY (Birth to 2 years)
IMPORTANT: Give your baby only breast milk for

the first 16 months
Add foods and other liquids only at 6 months
13 14 15 16 17 18 19 20 21 22 23 24
1 2 3 4 5 6 7 8 9 10 11 12 Months 2nd Year
Months 1st Year

Weight the child during each visit, properly record on the card and interpret to the mother or caretaker
18
52
ANNEX5
Weight-for-Height GIRLS
2 to 5 years (z-scores)
32 32
3
30 30
28 2 28
26 26
1
24 24
0
22 22
-1
Weight (kg)
20 20
-2
18 18
-3
16 16
14 14
12 12
10 10
8 8
6 6
65 70 75 80 85 90 95 100 105 110 115 120
Height (cm)
53
ANNEX6
Weight-for-length GIRLS
Birth to 2 years (z-scores)
3
24 24
22
2 22
20
1 20
0
18 18
-1
16 16
-2
Weight (kg)
14 -3 14
12 12
10 10
8 8
6 6
4 4
2 2
45 50 55 60 65 70 75 80 85 90 95 100 105 110
Length (cm)
54
ANNEX7
GROWTH CHART
Weight
Weight for
Weightfor age:GIRL
for age:
age: GIRL
GIRL (Birth
(Birth
(Birth to 22 years)
to
to 2 years) years)
IMPORTANT: Give your baby only breast milk for

the first 16 months
Add foods and other liquids only at 6 months
13
13 14 15
13 14
14 15 16
15 16 17
16 17 18
17 18 19
18 19 20 21
19 20
20 21 22
21 22 23
22 2323 24
24
24
11 22 33 44 55 66 77 88 99 10 11
10 11 12
12 Months
Months
Months 2nd Year
1 2 3 4 5 6 7 8 9 10 11 12
2ndYear
2nd Year
Months 1st Year
Weight the child during each visit, properly record on the card and interpret to the mother or caretaker
17
55
2017 Revision and updates with support from
56

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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

SICK CHILD SICK YOUNG INFANT THE REPUBLIC OF UGANDA, 2017

CHECK FOR GENERAL DANGER SIGNS

SEVERE • Treat dehydration before referral unless the child has

• Tender swelling behind • Give first dose of an appropriate antibiotic

• No ear pain and No pus seen • Follow-up in 5 days

** MUAC is Mid-Upper Arm Circumference measured using

*** RUTF is Ready-to-Use Therapeutic Food for conducting

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Start Isoniazid in HIV positive child

suppository: Insertfollow the instructions

Are you trained to use

• Demonstrate how to measure a dose 12 months up to 5 years (10 - <19 kg) 2 10 ml

• Watch the mother practice measuring a dose by herself

For dysentery give ciprofloxacin 15mg/kg/day ---

5–15 kg 4 months - <3 yrs 1 1 1 1 1 1

25–34 kg 9–14 years 3 3 3 3 3 3

>34 kg >14 years 4 4 4 4 4 4

Artesunate Amodiaquine (AS + AQ)

Dose in mg (No. of tablets)

Note: Do not use amodiaquine alone, use with artesunate tablets

2 months up to 4 months (4 – <6 kg) 1.0 ml (< 1/4 tsp) 1/2

4 months up to 12 months (6 – <10kg) 1.25 ml (1/4 tsp) 1

3 years up to 5 years (14 – 19 kg) 1/2 tablet 2.5 ml (1/2 tsp) 1

6. Give salbutamol for wheezing

Treat eye infection with tetracycline eye ointment

Soothe the throat, relieve the cough with a safe remedy

Dosage of anti-TB medicines by weight band

Age VITAMIN A DOSE

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Recommended Amounts of Ready-to-Use Therapeutic Food

6. Measles with eye or mouth complications

12. Uncomplicated Severe Acute Malnutrition

ASK — How are you feeding your child?

If low weight for age, ASK:

• Give family foods at least 3

If other milk needs to be continued, counsel the mother to:

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

If the child has a poor appetite:

If the child has sore mouth or ulcers:

When to return immediately

Any sick child → Not able to drink or

ASK: Child’s age ASK: Initial or follow-up visit for problems?

ASSESS FOR MAIN SYMPTOMS

All with severe

TREAT IN CLINIC TREAT AT HOME

Assess for signs of severe disease

Severe chest indrawing or

SIGNS CLASSIFY AS IDENTIFY TREATMENT

No Jaundice NO JAUNDICE Advise mother to give homecare for

- Look for sunken eyes. • Advise the mother to continue breastfeeding

Not enough signs to • Give fluids to treat diarrhoea at home and

• Has the young infant • Determine weight for

• Does the young infant

• Has the young infant

* Poor weight gain (Weight loss, or very low weight (weight-forage

SIGNS CLASSIFY AS IDENTIFY TREATMENT

THEN CHECK YOUNG INFANT ‘S IMMUNIZATION

* Vaccines should be provided in line with the national immunization policy.

ASSESS THE MOTHER’S HEALTH NEEDS

 If the young infant is not able to swallow:

Give 20–50 ml (10 ml/kg) of expressed breastmilk or sugar water by