St.

Anne College Lucena Incorporated COLLEGE OF NURSING and ALLIED HEALTH SCIENCES

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Introduction

 

1999 World Health Report shows that children in low-to middle-income countries are ten times more likely to die before reaching the age of five than children living in the industrial world 70% of these deaths are due to acute respiratory infections, diarrhea, measles, malaria, malnutrition or often a combination of these Sick children are not properly assessed and treated Diagnostic facilities, drugs, and equipment are minimal or non-existent

Introduction

Improvement of child health is dependent on effective strategies that are based on holistic approach, availability, capacity of the health system, and acceptability During mid-1990s, WHO, together with UNICEF and other agencies developed IMCI Intended to give curative care, and address disease prevention and health promotion The objectives are to reduce death and the frequency of illness and disability, and contribute to improved growth and development

The Integrated Case Management Process

 

Can be used by any health care professionals who see sick infants and children aged 1 week to 5 years For first level facility Routine assessment of child for general danger signs, common illnesses, malnutrition, anemia, et. al.

Three Components of the IMCI
Upgrading the case management skills of the health care providers  Strengthening the health system for effective management of childhood illness  Improving family and community practices related to child health and nutrition The IMCI involves the following elements:

Assess a child by checking first for danger signs (or possible bacterial infection in a young infant) and common conditions

Three Components of the IMCI

Classify using color-coded triage system
 Urgent

pre-referral treatment and referral (pink)  Specific medical treatment and advice (yellow)  Simple advice on home management (green)
 Identify

treatments for the child  Provide practical treatment instructions  Assess feeding, including breastfeeding practices. Counsel to solve any problems found in the child and the mother  Give follow-up care

Principles of Integrated Care
 

Must be examined for “general danger signs” Must be assessed for major symptoms
2 months to 5 years: cough or difficulty of breathing, diarrhea, fever, ear problem  1 week to 2 months: bacterial infection and diarrhea

Must also be assessed for nutrition and immunization status, feeding problems and other potential problems Only a limited number of carefully-selected clinical signs are used

Principles of Integrated Care
 

Combination of individual signs leads to a classification rather than a diagnosis Addresses most, but not all, major reasons a sick child is brought for consult Uses a limited number of drugs and encourage active participation of caretakers in the treatment Includes counselling about home management, feeding, fluids and when to return to a health facility

ASSESS AND CLASSIFY THE SICK CHILD
Aged 2 Months Up to 5 Years

Objectives
  

Asking the mother about the child’s problem Checking for general danger signs Asking the mother about the four main symptoms:
Cough or difficulty breathing  Diarrhea  Fever  Ear problem

Checking when a main symptom is present
 Assessing

for related signs  Classifying the illness according to presence or absence of signs

Objectives

 

Checking for signs of malnutrition and anemia and classifying the child’s nutritional status Checking the child’s immunization status Checking the child’s Vitamin A supplementation status Assessing any other problems

Ask the Mother what the Child’s Problems are
 

Greet the mother appropriately Use good communication and reassure the mother
Listen carefully  Use words that are easily understandable  Give time to answer the questions  Ask additional questions when the mother is not sure about her answer

Check for General Danger Signs
Check ALL sick children for general danger signs. A child with ANY of the danger signs has a serious problem and needs URGENT referral to the hospital  The child is not able to drink or breastfeed  The child vomits everything  The child has convulsions\  The child is abnormally sleepy or difficult to awaken

Check for General Danger Signs
ASK: Is the child able to drink or breastfeed?  If you are not sure about the mother’s answer, ask her to offer the child a drink and observe the child’s response  Breastfeeding children may have difficulty sucking when their nose is blocked ASK: Does the child vomit everything? ASK: Has the child had convulsions?  Use also other terms like “fits”, “spasms”, or “jerky movements”

Check for General Danger Signs
LOOK: See if the child is abnormally sleepy or difficult to awaken  An abnormally sleepy child is drowsy  Does not show interest in what is happening around  Does not look at his/her mother or watch your face when you talk  May stare blankly  Does not respond when touched, shaken, or spoken to

Check for the Four Main Symptoms
1. Cough or Difficult Breathing  Assess cough or difficult breathing
 The

child may have pneumonia or another severe respiratory infection  Pneumonia is easily identified by checking for these two clinical signs: FAST BREATHING and CHEST INDRAWING  A child with cough or difficult breathing is assessed for
How long has the child had these symptoms  Fast breathing  Chest indrawing  Stridor in a calm child

Check for the Four Main Symptoms

The cut-off for fast breathing in a calm child depends on the child’s age
2

months to 12 months: ≥ 50 bpm  12 months to 5 years: ≥ 40 bpm
 LOOK
 If

for chest indrawing

you are not sure, change the child’s position so that he/she is lying flat  Chest indrawing must be present all the time and not only during feeding or crying  Intercostal indrawing is NOT chest indrawing

Check for the Four Main Symptoms

LOOK and LISTEN for stridor
 Stridor

is a harsh noise when the child breathes IN.  May be caused by swollen larynx, trachea or epiglottis  Listen only when the child is calm  If the sound is heard when the child breathes out, this is wheezing and NOT stridor

Classify cough or difficult breathing
 CLASSIFY

means to make a decision about the severity of illness. They are not exact disease diagnoses. Instead, they are categories that are used to determine the appropriate action or treatment

Check for the Four Main Symptoms

The classification table is color-coded to tell quickly if the child has a serious illness
 PINK

row needs urgent attention and referral or admission for in-patient care. This is a SEVERE classification  YELLOW row means the child needs an appropriate antibiotic, an oral antimalarial, or another treatment  GREEN row means the child does not need specific medical treatment. The health worker teaches the mother how to care for her child at home
 The

child is classified only ONCE. If the child has signs from more than one row, always select the more serious classification

Check for the Four Main Symptoms
SIGNS CLASSIFY AS TREATMENT - Any general danger SEVERE PNEUMONIA sign OR VERY SEVERE - Chest indrawing DISEASE - Stridor in a calm child - Fast breathing - No signs of pneumonia or very severe disease PNEUMONIA NO PNEUMONIA; COUGH, OR COLD

Check for the Four Main Symptoms
2. Diarrhea  Assess diarrhea

Diarrhea is assessed for
 How

long  Blood in the stool  Signs of dehydration
 ASK

about diarrhea in all children  ASK: For how long?
 Diarrhea

lasting for 14 days or more is PERSISTENT DIARRHEA

Check for the Four Main Symptoms
ASK: Is there blood in the stool? If yes, consider this a case of DYSENTERY  LOOK and FEEL for the following signs of dehydration

 Abnormally

sleepy or difficult to awaken  Restless and irritable  Sunken eyes  Offer the child water. Is the child not able to drink or drinks poorly?  Pinch the skin of the abdomen. Does it go back: very slowly (longer than two seconds)? Slowly? Immediately?

Check for the Four Main Symptoms

Classify dehydration

There are three classifications
 SEVERE

DEHYDRATION  SOME DEHYDRATION  NO DEHYDRATION
 If

there is one sign present in the PINK row and one in the YELLOW, classify him/her on the YELLOW row

Check for the Four Main Symptoms
Two of the following signs: SEVERE DEHYDRATION - Abnormally sleepy or difficult to awaken - Sunken eyes - Not able to drink or drinks poorly - Skin pinch goes back very slowly Two of the following signs: -Restless and irritable - Sunken eyes - Drinks eagerly, thirstily - Skin pinch goes back slowly SOME DEHYDRATION

Not enough signs to classify as NO DEHYDRATION having some or severe dehydration

Check for the Four Main Symptoms

Classify persistent diarrhea
 PERSISTENT

DIARRHEA is diarrhea for14 days or more, which has no signs of dehydration  SEVERE PERSISTENT DIARRHEA is diarrhea for 14 days or more with severe dehydration

Classify dysentery
 Diarrhea

and blood in the stool

Check for the Four Main Symptoms
3. Fever  Assess and classify fever

Malaria
 Deciding

malaria risk: Per AO No. 129-S, dated June 12, 2002, all the provinces in the Philippines are categorized according to the malaria situation  Category of provinces:

Category A: Provinces with no significant improvement in malaria situation in the last ten years or the situation worsened in the last five years, the average number cases of is more than 1,000 in the last ten years

Check for the Four Main Symptoms
Agusan del Sur Agusan del Norte Apayao Basilan Bukidnon Cagayan Compostela Valley (Pilot) Davao del Sur Davao del Norte Ifugao Isabela Kalinga (pilot area) Misamis Oriental Mindoro Occidental Palawan Quezon Quirino Saranggani Sulu Surigao del Sur Tawi-tawi Zambales Zamboanga del Sur

Check for the Four Main Symptoms
Category B: Provinces where the situation has improved in the last five years or the average number of cases is 100 – 1,000 per year Abra North Cotabato Aurora Nueva Ecija Bataan Nueva Viscaya Bulacan Pangasinan Camarines Norte Rizal Camarines Sur Romblon Ilocos Norte Sultan Kudarat Lanao del Sur Tarlac Maguindanao Zamboanga del Norte Mindoro Oriental

Check for the Four Main Symptoms
Category C: Provinces with a significant reduction in cases in the last five years Albay Masbate Antique Negros Oriental Batanes Negros Occidental Batangas Misamis Occidental Benguet Pampanga Cavite Samar (Eastern) Ilocos Sur Samar (Western) La Union Sorsogon Marinduque Surigao del Norte

Check for the Four Main Symptoms
Category D: Provinces that are malaria-free, although some are still potentially malarious due to vectors Aklan Cebu Biliran Guimaras Camiguin Leyte, Norte and Sur Capiz Northern Samar Catanduanes Siquijor

A

child who lives in these areas or who has visited and stayed overnight in any of these areas in the past FOUR weeks or who has had blood transfusion during the past six months should be considered to be at RISK for malaria.

Check for the Four Main Symptoms

Measles
 Fever

and generalized rash are the main symptoms of measles. The measles virus can also damage the immune system for many weeks after the onset of measles  Complications include:
    

Diarrhea (including dysentery and persistent diarrhea) Pneumonia Mouth ulcers Ear infection Severe eye infection (which may lead to corneal ulceration and blindness) Encephalitis

Check for the Four Main Symptoms

Dengue Hemorrhagic Fever
 You

must know the Dengue risk in your area  All regions in the country are endemic for dengue. The NCR is highly endemic all year round usually peaking two months after rainfall

A child has the main symptom fever if -The child has history of fever, or -The child feels hot, or -The child has an axillary temperature of 37.5˚C or above

Check for the Four Main Symptoms
 If

the child had fever, determine

 How

long?  History of measles  Stiff neck  Runny nose  Signs suggesting measles  If the child has measles now or within the last three months, assess for signs of complications such as mouth ulcers, pus draining from the eyes and clouding of the cornea

Check for the Four Main Symptoms

Then, for all children with fever
 Decide
     

the Dengue fever risk  If with risk, assess for signs suggesting dengue
Bleeding from the nose or gums or in vomitus or stools Black vomitus or black stools Petechiae in the skin Signs of shock Persistent abdominal pain Persistent vomiting

 If

all signs are negative and the child is six months or older, with fever in a dengue risk area, perform a torniquet test

Check for the Four Main Symptoms

Classify Fever
 There

are three possible classifications of fever when there is malaria risk:
 VERY

SEVERE FEBRILE DISEASE/MALARIA  MALARIA  FEVER: MALARIA UNLIKELY
 VERY
 If

SEVERE FEBRILE DISEASE/ MALARIA

the child has any general danger sign or  Stiff neck

Check for the Four Main Symptoms

MALARIA
 If

there is a risk of malaria  Has fever but no runny nose  No measles and no other causes of fever, or  Positive blood smear
 FEVER:
 Does

MALARIA UNLIKELY

not have signs of very severe febrile disease  Has runny nose  Has measles or other causes of fever, or  Negative blood smear

Check for the Four Main Symptoms

Other causes of fever:
 Severe

pneumonia  Very severe disease  Cough or cold  Dysentery  Measles  Measles with eye/mouth complication  Dengue hemorrhagic fever  Ear infection  Mastoiditis

UTI  Osteomyelitis  Erysepelas  Abcess  Impetigo/ Pyoderma  Tonsilopharyngitis  Infected wounds  Nephritis  Typhoid fever  Diarrhea

Check for the Four Main Symptoms

Classify Measles

There are three possible classifications
 SEVERE

COMPLICATED MEASLES  MEASLES WITH EYE OR MOUTH COMPLICATIONS  MEASLES
 SEVERE
 With

COMPLICATED MEASLES WITH EYE OR MOUTH COMPLICATIONS

clouding of the cornea or deep or extensive mouth ulcers pus draining from the eyes or mouth ulcers, which are not deep or extensive

 MEASLES
 With

Check for the Four Main Symptoms

MEASLES
 Measles

now or within the last three months and with none of the complications listed in the PINK or YELLOW row

Classify dengue hemorrhagic fever (DHF)
 There

are two possible classifications

 SEVERE

DENGUE HEMORRHAGIC FEVER  FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

Check for the Four Main Symptoms

SEVERE DENGUE HEMORRHAGIC FEVER
 Bleeding

from the nose or gums or in the vomitus or stool  Skin petechiae  Shock  Persistent abdominal pain and vomiting  Positive torniquet test
 FEVER:
 None

DENGUE HEMORRHAGIC FEVER UNLIKELY
of the signs needed for classification of severe DHF

Check for the Four Main Symptoms
4. Ear problems  A child with an ear problem is assessed for
Ear pain  Ear discharge  If ear discharge is present, the duration  Tender swelling behind the ear

Check for the Four Main Symptoms

There are four classifications

MASTOIDITIS
 Tender

swelling behind the ear

 ACUTE
 Pus

EAR INFECTION ear infection

draining from the ear for less than two weeks or  Ear pain
 Chronic
 Pus

draining from the ear for two weeks or more

 NO

EAR INFECTION

 No

ear pain  No ear discharge

Check for Malnutrition and Anemia

Check ALL sick children for signs suggesting malnutrition and anemia by

Looking for VISIBLE SEVERE WASTING
 Very

thin, has no fat, and looks like skin and bones

Looking for PALMAR PALLOR
 SOME

palmar pallor if skin of the palm is pale  SEVERE palmar pallor is the skin of the palm is very pale so that it appears white
 Looking
 Use

and feeling for EDEMA OF BOTH FEET  Determining weight for age
the weight for age chart

Check for Malnutrition and Anemia

Classify nutritional status

There are three classifications
 SEVERE
  

MALNUTRITION OR SEVERE ANEMIA

Visible severe wasting Severe palmar pallor, or Edema on both feet

 ANEMIA
 

OR VERY LOW WEIGHT

Some palmar pallor, or Very low weight for age

 NO
 

ANEMIA OR NOT VERY LOW WEIGHT
Not very low weight for age No other signs of malnutrition

Check the Child’s Immunization Status

Check the immunization status of all sick children. Determine if they are up to date and if they need any immunization today Use the recommended schedule
AGE Birth 6 weeks 10 weeks 14 weeks 9 months VACCINE BCG DPT1, OPV1, HEP B1 DPT2, OPV2, HEP B2 DPT3, OPV3, HEP B3 MEASLES

Check for Malnutrition and Anemia
 

Observe contraindications to immunization If the child is going to be referred, do not immunize the child before referral Children with diarrhea who are due for OPV should receive the dose but it is NOT counted. The child should return when the next dose of OPV is due for an extra dose of OPV

Check the Child’s Vitamin A Status
 

Check the Vitamin A status of all sick children Use the recommended Vitamin A schedule
 The

first dose is six months or above (100,000 IU)  Subsequent doses every six months (200,000 IU) up to the age of 59 months (4 years and 11 months)

Assess Other Problems

Since the ASSESS and CLASSFIY chart does not address all of a sick child’s problems, the health worker must now assess the other problems the mother says. Refer if the child cannot be managed in the health center

IDENTIFY TREATMENT
Aged 2 Months Up to 5 Years

Introduction

If condition is under more than one classification, look in more than one place in the ASSESS and CLASSIFY chart for the treatments listed. Some treatments may be the same “Refer urgently to a hospital” means health facility with expertise and resources to treat a very sick child If the child must be referred urgently, decide which treatment to do before the referral. Refer only if you expect that the child will actually receive better care. In some instances, giving your best care is better than sending a child on a long trip to a hospital

Introduction

If referral is not possible or if the parents refuse to take the child, the health worker should help the family take care of the child.

Objectives
  

Determine if urgent referral is needed Determine treatments needed For patients who need urgent referral
 Identify

the urgent pre-referral treatment  Explaining the need for referral to the mother, and  Writing the referral note

Referral for Severe Classification
        

SEVERE PNEUMONIA OR VERY SEVERE DISEASE SEVERE DEHYDRATION SEVERE PERSISTENT DIARRHEA VERY SEVERE FEBRILE DISEASE/ MALARIA VERY SEVERE FEBRILE DISEASE SEVERE COMPLICATED MEASLES SEVERE DENGUE HEMORRHAGIC FEVER MASTOIDITIS SEVERE MALNUTRITION OR SEVERE ANEMIA

Referral for Severe Classification

Do not give treatments that would unnecessarily delay the referral except in

SEVERE PERSISTENT DIARRHEA
 Referral

is needed, but not as urgent

 If

the child’s only severe classification is SEVERE DEHYDRATION
 Keep

and treat the child if the health center has the ability to do so (Plan C)  If the child has another severe classification in addition to SEVERE DEHYDRATION, referral is needed

Referral for General Danger Signs
MAKE SURE SHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after the first dose of an appropriate antibiotic and other urgent treatments. Exception: Rehydration of the child according to Plan C may resolve danger signs so that referral is no longer needed.

Referral for Other Severe Problems

Since the ASSESS and CLASSIFY chart does not include all problems that the child may have, ask the mother for any other problem that the child may have. You will need to refer them if you cannot treat a severe problem

Identify Treatments for Patients Who Do Not Need Urgent Referral
 

Write treatments at the back of the SICK CHILD RECORDING FORM Include items that begin with the words “Follow up.” if several times are specified for follow-up, look for the earliest definite time Some treatments, like Vitamin A, are listed for more than one problem. List it only once. However, each specific antibiotic must be listed

When to Return Immediately

Return immediately if the child
Is not able to drink or breastfeed  Becomes sicker  Develops fever

Watch for the following signs in a child with a simple cough or cold
 Fast

breathing  Difficult breathing

Watch for the following in a child with diarrhea
 Blood

in the stool  Drinking poorly

When to Return Immediately

Watch for the following in a child with FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
 Any

signs of bleeding  Abdominal pain  Vomiting

Identify Urgent Pre-referral Treatment Needed

When needing urgent referral, quickly identify and begin the most urgent treatment. Give just the first dose of the drugs before referral
Give an appropriate antibiotic  Give quinine for severe malaria  Give Vitamin A  Treat the child to prevent low blood sugar  Start IV fluids according to Plan C for a child with SEVERE DENGUE HEMORRHAGIC FEVER with bleeding, cold clammy skin, capillary refill of more than three seconds

Identify Urgent Pre-referral Treatment Needed
 Give

ORS according to Plan B for a child with SEVERE DENGUE HEMORRHAGIC FEVER with only petechiae, positive torniquet test, or abdominal pain or vomiting but without cold clammy skin and with a normal capillary refill time  Give an oral antimalarial  Give paracetamol for high fever (38.5˚C or above) or pain from mastoiditis  Apply tetracycline eye ointment if pus is draining from the eye  Provide ORS so that the mother can give frequent sips on the way

Identify Urgent Pre-referral Treatment Needed

The first five treatments are urgent because they can prevent serious consequences
Bacterial meningitis or cerebral malaria  Corneal rupture  Brain damage  Death

Do not delay referral to give non-urgent treatments If immunizations are needed, do not give them before the referral

Give Urgent Pre-referral Treatment
 

If the child with danger signs will not be able to take anything orally, he/she will need to be given an intramuscular injection of chloramphenicol If the child needs treatment to prevent low blood sugar, and NGT can be inserted, give sugar water or breastmilk substitute by NG before referral Four steps to refer a child

Explain to the mother the need for a referral and get her agreement to take the child. If you suspect that she does not want to take the child, find out why

Give Urgent Pre-referral Treatment
Calm the mother’s fears and help her resolve any problems  Write a referral note for the mother to take with her to the hospital. Tell her to give it to the health worker there  Give the mother supplies and instructions needed to care for the child on the way to the hospital

TREAT THE CHILD
Aged 2 Months Up to 5 Years

Objectives
 

   

Determining appropriate oral drugs and dosages Giving oral drugs and teaching how and when to give oral drugs at home Treating local infections and teaching how and when to give treatments at home Checking the mother’s understanding Giving injectable pre-referral drugs Preventing low blood sugar Treating different classifications of dehydration and teaching about extra fluids to give at home Immunizing children

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give an appropriate antibiotic
 The

following needs antibiotic

 General

danger signs  Severe pneumonia or very severe disease  Pneumonia  Severe dehydration with cholera in the area  Dysentery  Very severe febrile disease/malaria  Severe complicated measles  Mastoiditis  Acute ear infection

Select an Appropriate Oral Drug and Determine the Dose and the Schedule
 Give

first-line oral antibiotic if it is available. Second-line antibiotic is given only if the first-line is unavailable, or the illness does not respond to the first-line antibiotic  Sometimes, one antibiotic can be given for several illnesses. Do not double the dose or prolong the duration of giving the drug  To determine the correct dose, choose the row for the weight or age. Weight is better used in choosing the right dose

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

For PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS
 First-line

antibiotic: Cotrimoxazole  Second-line antibiotic: Amoxycillin
AGE OR WEIGHT COTRIMOXAZOLE AMOXYCILLIN - Give two times daily for 5 - Give three times daily for days 5 days ADULT TABLET SYRUP 80 mg/ 400/mg 40 mg/ 200 mg/ 5 mL 2 months up to 12 months (4-10 kg) 12 months up to 5 years (10-19 kg) 1/2 1 5 mL 10 mL TABLET 250 mg SYRUP 125 mg/ 5 mL

1/2 1

5 mL 10 mL

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

For DYSENTERY: Give antibiotic recommended for Shigella in your area for 5 days
 First-line

antibiotic: Cotrimoxazole  Second-line antibiotic: Nalidixic Acid COTRIMOXAZOLE NALIDIXIC ACID
- Give two times daily for 5 days AGE OR WEIGHT See above dosage 2 months up to 4 months (4-6 kg) 4 months up to 12 months (6-10 kg)

- Give four times daily for 5 days SYRUP 250 mg/ 5 mL 1.25 mL (1/4 tsp)

2.5 mL (1/2 tsp)

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

For CHOLERA: Give an antibiotic recommended for Cholera in your area for 3 days
 First-line

antibiotic: Tetracycline TETRACYCLINE COTRIMOXAZOLE  Second-line antibiotic: Cotrimoxazole - Give four times daily - Give two times daily
for 3 days for 5 days AGE OR WEIGHT 2 months up to 4 months (4-6 kg) 4 months up to 12 months 1/2 (6-10 kg) 12 months up to 5 years (10-19 kg) 1 CAPSULE (250 mg) See above dosage

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give an Oral Antimalarial

Treatment with Chloroquine assumes that the child has not yet been treated with that drug before. Confirm this with the mother. Use instructions in the GIVE FOLLOW-UP CARE MALARIA on the TREAT THE CHILD chart if it is a follow-up visit  Reduce the dose for the three-day treatment of Chloroquine  Explain the possible itching as a side effect of the drug  If (+) for P. Falciparum, a single dose of Sulfadoxine/Primaquine is given. Then the first dose of Chloroquine is given after two hours to minimize gastric irritation. A single dose of Primaquine will be given on Day 4 at the health center

Select an Appropriate Oral Drug and Determine the Dose and the Schedule
 If

(+) P. Vivax, a first dose of Primaquine and Chloroquine is given in the center, the, one dose each day for another 13 days  For mixed infections, treat as P. Falciparum and start Primaquine as in P. Vivax  If no blood smear test done, treat as P. Falciparum  DO NOT give Primaquine to children under 12 months of age

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give an oral antimalarial
 First-line:

Chloroquine, Primaquine, Sulfadoxine and Pyrimethamine  Second-line: Artemeter-Lumefrantine

If Chloroquine
 Explain

to watch child carefully for 30 minutes after giving a dose of Chloroquine. Repeat ifthe child vomits after 30 minutes  Itching is a possible side-effect of the drug

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

If Sulfadoxine + Pyrimethamine
 Give

single dose in the health center 2 hours before intake of Chloroquine single dose on Day 4 for P. Falciparum for three days

If Primaquine
 Give

If Artemeter-Lumefrantine
 Give

Select an Appropriate Oral Drug and Determine the Dose and the Schedule
CHLOROQUINE - Give for 3 days PRIMAQUINE PRIMAQUIN - Give single E dose in health - Give daily center for P. for 14 days falciparum for p. vivax SULFADOXINE + PYRIMETHAMINE - Give single dose in health center

AGE

TABLET (150 mg) DAY 1 DAY 2 1/2 DAY 3 1/2

TABLET (15 mg)

TABLET (15 mg)

TABLET (500 mg/ 25 mg) 1/4

2 months up 1/2 to 5 months (4-7 kg) 5 months up 1/2 to 12 months (710 kg) 12 months 1 up to 3 years (10-14 kg)

1/2

1/2

1/2

1

1/2

1/2

1/4

3/4

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give Paracetamol for High Fever (38.5˚ or higher) or Ear Pain
 Give

one dose Paracetamol in the center then give enough for one day

PARACETAMOL AGE OR WEIGHT TABLET (500 mg) SYRUP (120 mg/ 5 mL) 5 mL (1 tsp) 10 mL (2 tsp)

2 months up to 3 years 1/4 (4-14 kg) 3 to 5 years (14-19 kg) 1/2

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give Vitamin A
Vitamin A is given in SEVERE PNEUMONIA or VERY SEVERE DISEASE, SEVERE PERSISTENT DIARRHEA or PERSISTENT DIARRHEA, or MEASLES, or SEVERE MALNUTRITION or VERY LOW WEIGHT  For both treatment and supplementation, a single dose is given in the health center  Should be given only

 Age

six months and older  Children who have not had a dose in the past six months

Select an Appropriate Oral Drug and Determine the Dose and the Schedule
AGE VITAMIN A CAPSULES

100,000 IU 6 months up to 12 months 1

200,000 IU 1/2 1

12 months up to years -

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give Iron
Some palmar pallor  Give syrup to a child under 12 months old. Iron/folate tablet for children above 12 months  Give mother enough iron for 14 days and tell to give one dose daily. Teach how to give and what to observe  If receiving antimalarial sulfadozine pyrimethamine (Fansidar), do not give Iron/Folate tablet yet until a follow-up visit in two weeks. If the Iron available does not contain Folate, it may be given

Select an Appropriate Oral Drug and Determine the Dose and the Schedule
AGE OR WEIGHT IRON/FOLATE IRON SYRUP TABLET Ferrous sulfate Ferrous sulfate 150 mg/ 5mL 200 mg + 250 (6 mg mcg folate elemental iron (60 mg per mL) elemental iron) IRON DROPS Ferrous sulfate 25 mg (25 mg elemental iron/ mL)

3 months up to 4 months (4-6 kg) 4 months up to 12 months (6-10 kg) 12 months up to 1/2 3 years (10-14

2.5 mL (1/2 tsp) 0.6 mL

4 mL (3/4 tsp)

1 mL

5 mL

1.5 mL

Select an Appropriate Oral Drug and Determine the Dose and the Schedule

Give Mebendazole

A one-year old child who is anemic and with hookworms or whipworms needs to be given this drug  Mebendazole 500 mg or Albendazole 400 mg as single dose is given at the center if the child has not been given one in the AGE OR WEIGHT ALBENDAZOLE 400 MEBENDAZOLE 500 previous six mg Tablet months mg Tablet
12 months up to 23 months 24 months up to 59 months 1/2 1 1 1

Use Good Communication Skills

Success of home treatment depends on how well the health care worker communicated. The mother needs to know how to give the treatment and understand the importance of the treament Skills in communication include the following
ASK questions and LISTEN to find out what the mother is already doing for the child  PRAISE for what she has done well  ADVISE how to treat at home  CHECK the understanding

Use Good Communication Skills

ADVISE THE MOTHER HOW TO TREAT HER CHILD AT HOME

Three basic steps in teaching
Give information – explain how to do the task  Show an example – show how to do the task  Let her practice – ask to do the task while you watch

 When

teaching

Use words easily understood  Use teaching aids that are familiar, such as common containers  Give feedback  Encourage to ask questions

Use Good Communication Skills

CHECK THE MOTHER’S UNDERSTANDING
 Use

good checking questions to help make sure that the mother learns and remembers how to treat her child  Good checking questions require that she GOOD CHECKING QUESTIONS POOR CHECKING QUESTIONS describe WHY, HOW, or WHEN
How will you prepare the ORS? Do you remember how to mix How often should you breastfeed your the ORS? child? Should you breastfeed your On what part of the eye do you apply child? the ointment? Have you used ointment on your How much extra fluid should you give child before? after each loose stool? Do you know how to give extra Why is it important for you to wash your fluids?

Teach the Mother to Give Oral Drugs at Home

Follow these instructions
Determine the appropriate drugs and dosage for age and weight  Tell the reason for giving the drug including why and what problem it is treating  Demonstrate how to measure a dose  If the drug is in syrup form, show how to measure using common household teaspoon

 1.25

mL – ¼ tsp  2.5 mL – ½ tsp  5 mL – 1 tsp

Teach the Mother to Give Oral Drugs at Home

 

Show how to give Vitamin A capsule

Watch the mother practice measuring a dose Ask the mother to give the first dose. If the child vomits within 30 minutes, give another dose. If the child is dehydrated and vomiting, wait until the child is rehydrated before giving the dose again Explain carefully, then label and package the drug
 To

write information on a drug label

 Full

name of the drug and the total amount to complete the treatment

Teach the Mother to Give Oral Drugs at Home
Write the correct dose and when to give  Write the daily dose and schedule

Write clearly  Put the drug in its own labelled container, keeping it clean and dry  Ask questions to make sure the mother understands  If more than one drug will be given, package each drug separately  Explain that all oral drugs must be used to finish the course of treatment even if the child gets better  Advise to store drugs properly  Check mother’s understanding before she leaves

Teach the Mother to Treat Local Infections at Home

Treat eye infection with Tetracycline eye ointment
If the child will be referred, clean eye gently and squirt a small amount  If the child will not be referred, teach how to apply drug at home  Treat both eyes until redness is gone from the infected eye  Do not use any other eye ointments, drops, or alternative treatments  Bring the child to health center after two days

Teach the Mother to Give Oral Drugs at Home

Dry the ear by wicking
Use clean, absorbent cotton cloth or soft strong tissue paper for making a wick  Done three times daily until wick no longer gets wet  Do not place anything in the ear between wicking treatments. Do not allow water to get in the ear

Teach the Mother to Give Oral Drugs at Home

Treat mouth ulcers with gentian violet
 Use

half-strength gentian violet  Use clean soft cloth dipped in salt water  Use cotton-tipped stick to paint the gentian violet on the mouth ulcers. Do not allow child to drink the gentian violet  Treat mouth ulcers two times per day for five days

Teach the Mother to Give Oral Drugs at Home

Soothe the throat and relieve cough with safe remedy
 Should

not contain atropine (oral and nasal decongestants), codeine derivatives or alcohol  Safe remedies to recommend
 Breastmilk

for exclusively breastfed infants  Tamarind, calamansi, or ginger

Determine Priority of Advice

When the child has several problems, the instructions to the mother can be quite complex. In this case, instructions will have to be limited to what is most important
How much likely can this mother understand and remember?  Is she likely to come back for follow-up treatment? If so, some advice can wait until then  What advice is most important

Determine Priority of Advice

Essential treatments include giving antibiotics or antimalarial drugs, and giving fluids to a child with diarrhea If necessary, OMIT or DELAY
 Feeding

assessment and couselling  Soothing remedy for cough and cold  Paracetamol  Iron treatment  Wicking the ear

Give These Treatments in Health Center Only

May need to be given in the health center
Intramuscular antibiotic if the child cannot take oral antibiotic  Quinine for severe malaria  Breastmilk or sugar water to prevent low blood sugar

Intramuscular Chloramphenicol may need to be given before leaving for the hospital if
 Not

able to drink or breastfeed  Vomits everything  Has convulsions  Abnormally sleepy or difficult to awaken  Cannot take oral antibiotic

Give These Treatments in Health Center Only

Give an intramuscular antibiotic
 First

dose is given then refer urgently to hospital  If referral is not possible
AGE OR  Repeat injection every 12 hours for 5 days WEIGHT CHLORAMPHENICOL 40 mg/ kg  Change to appropriate antibiotic to complete Add 5 mL sterile water to vial 10 days of treatment containing 1,000 mg = 5.6 mL at 180 mg/ mL 2 months up to 4 months (4- 1 mL = 180 mg 6 kg) 4 months up to 9 months (6- 1.5 mL = 270 mg 8 kg) 9 months up to 12 months (8-10 kg) 2 mL = 360 mg

Give These Treatments in Health Center Only

Quinine injection is given to a child with VERY SEVERE FEBRILE DISEASE/ MALARIA if there is going to be any delay in the child reaching the referral hospital. It is given intramuscularly ONLY because of these possible side effects
Sudden drop in blood pressure  Dizziness  Ringing of the ears  Sterile abscess

Should remain lying down for one hour

Give These Treatments in Health Center Only

Give first dose of intramuscular Quinine then refer urgently to hospital If referral is not possible
 Repeat

Quinine injection at 4 to 8 hours later, then 12 hours until child is able to take oral antimalarial. Do not continue injections for more than 1 week  DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE

Give These Treatments in Health Center Only

AGE OR WEIGHT

INTRAMUSCULAR QUININE 300 mg/ mL (in ampules)

4 months up to 12 months (6-10 kg)

0.3 mL

12 months up to 2 years (10-12 kg)0.4 mL 2 years up to 3 years (12-14 kg) 3 years up to 5 years 914-19 kg) 0.5 mL 0.6 mL

Give These Treatments in Health Center Only

Treat the child to prevent low blood sugar
Low blood sugar occurs in serious infections such as severe malaria or meningitis, or when the child is not able to eat for many hours  Giving some breastmilk, breastmilk substitute, or sugar water is done before the child is referred  Give 30-50 mL of milk or sugar water before departure

 To

make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in 200-mL cup of clean water

Give These Treatments in Health Center Only
 If

the child is not able to swallow
50 mL of milk or sugar water by nasogastric tube

 Give

 If

the child is difficult to awaken or unconscious, start IV infusion
 Give

5 mL/ kg of 10% of dextrose solution (D10) over a few minutes  Or give 1 ml/ kg of 50% (D50) by slow push

Give Extra Fluid for Diarrhea and DHF and Continue Feeding

Plan A: Treat diarrhea at home
 Treatment

plan for child with diarrhea with NO DEHYDRATION  Three rules of home treatment
 Give

extra fluids (as much as the child will take)  Continue feeding  When to return

Give Extra Fluid for Diarrhea and DHF and Continue Feeding

GIVE EXTRA FLUIDS
 Tell

the mother

For exclusively breastfed babies, breastfeed frequently and longer, and give ORS or clean water. For children over six months, no food-based fluids For children not exclusively breastfed, give one or more of the following: ORS, food-based fluids, and/or clean water

 Teach

how to mix and give ORS. Give two packets of ORS to use at home  Show how much fluid to give in addition to the usual fluid intake
 

Up to 2 years – 50 to 100 mL after each loose stool 2 years or older – 100 to 200 mL after each loose stool

Give Extra Fluid for Diarrhea and DHF and Continue Feeding
CONTINUE FEEDING  WHEN TO RETURN

 The
  

following signs indicate that the child should be returned immediately
Not able to drink of breastfeed Becomes weaker Develops fever

 If

the child has diarrhea, also tell the mother to return if the child
 

Has blood in the stool Drinking poorly

Give Extra Fluid for Diarrhea and DHF and Continue Feeding

Plan B: Treat some dehydration with ORS
Initial treatment for four hours in the health center  If the child is for referral, do not try to rehydrate before leaving. The child will be given frequent sips of ORS on the way  After four hours, reassess and classify  DETERMINE THE AMOUNT OF ORS TO GIVE DURING THE FIRST FOUR HOURS

 The

age or weight, degree of dehydration, and number of stools passed during rehydration will affect the amount of ORS needed

Give Extra Fluid for Diarrhea and DHF and Continue Feeding
 To

determine the amount needed
Multiply child’s weight (in kilograms) by 75

 Giving

ORS should not interfere with breastfeeding. For infants under six months who are not breastfed, 100-200 mL clean water should be given during the first four hours in addition to the ORS

 SHOW
 Food

MOTHER HOW TO GIVE ORS

should not be given within the first four hours of treatment

Give Extra Fluid for Diarrhea and DHF and Continue Feeding

AFTER FOUR HOURS
Reassess using the ASSESS and CLASSIFY chart  Reassess child BEFORE four hours if child is not taking ORS or seems to be getting worse  If child’s eyes are puffy, it is a sign of overhydration. Stop ORS and give clean water or breastmilk. ORS is resumed when puffiness is gone

 IF

THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT
Show how to prepare ORS  Show how much to give to complete the 4-hour treatment  Give enough packets to complete rehydration plus two more packets as recommended in Plan A  Explain the three Rules of Home Treatment

Give Extra Fluid for Diarrhea and DHF and Continue Feeding

Plan C: Treat severe dehydration quickly

Treatment depends on
 Type

of equipment available  Training of the health worker  Whether the child can drink

Treat persistent diarrhea
 Requires

special feeding

Treat dysentery
 Oral

antibiotic recommended for Shigella is given and mother is told to return in two days for follow-up

Immunize Every Sick Child as Needed

If the child is well enough to go home, give the necessary immunization before he/she leaves the center Immunization is given even if only one child needs the immunization Reconstituted vaccines must be discarded after six hours Opened vials of OPV may be kept if
Not yet expired  Stored between 0 to 8 degrees Celsius  Not taken out of the health center

OPV vials with vaccine vial monitors that changed in color indicate expiration

Immunize Every Sick Child as Needed
 

Record all immunizations on the child’s immunization card If the child has diarrhea and needs OPV, give it but do not record the dose. Tell the mother to return in four weeks for an extra dose Tell the possible side effects of each vaccine
BCG: ulceration  OPV: none  DPT: fever, irritability and soreness  Measles: fever and mild rash a week after lasting for oneto three days  Hepatitis B: none

COUNSEL THE MOTHER

Objectives
       

Assess the child’s feeding Identifying feeding problems Counselling about feeding problems Assessing the child’s care for development Identifying problems in care for development Counselling about care for development problems Advising to increase fluid intake during illness Advising
When to return for follow-up visits  When to return immediately  When to return for immunizations

Feeding Recommendations

Ages from birth up to six months
Breastfeed exclusively  Breastmilk contains protein, fat, lactose, Vitamins A and C, iron, fatty acids needed for the infant’s growing brain, eyes, and blood vessels and all the water an infant needs  Breastmilk protect an infant against infection and help to develop a loving relationship

Ages six months to 12 months
 Breastfeeding

should still be continued

Feeding Recommendations
Complementary foods are increased gradually asthe child nears 12 months. By then, complementary foods are the main source of energy  If a child is breastfed, give complementary foods three times daily; if a child is not breastfed, give complementary foods five times daily  It is important to ACTIVELY feed the child. Child should be encouraged to eat, not having to compete with siblings from a common plate  Child should get adequate serving

Feeding Recommendations

Good complementary foods
 Energy

and nutrient-rich and locally affordable foods  Examples are thick cereal with added oil or milk, fruits, vegetables, legumes, beans, meat, eggs, fish, and milk products  When giving complementary food to a child between four and six months old, introduce them one at a time at least three days apart to rule out any allergic reaction  If the child receives cow’s milk or any other breastmilk substitute, these and any other drinks should be given by cup, NOT by feeding bottle

Feeding Recommendations

Ages 12 months up to two years
 Continue

breastfeeding as often as the child wants and also give nutritious complementary foods  Family food should become an important part of the child’s diet  By 12 months, the child should share the family rice

Ages two years and older
 Child

should be taking variety of family foods in three meals per day plus two extra meals or snacks per day

Special Recommendations for Children with Persistent Diarrhea
 

May have difficulty digesting milk other than breastmilk Temporarily reduce the amount of other milks in their diet and take more breastmilk or replace half the milk with nutrient-rich, semi-solid foods DO NOT USE CONDENSED OR EVAPORATED MILK For other foods, follow the feeding recommendation for the child’s age

Assess the Child’s Feeding

Assess the feeding of children who
Classified as having ANEMIA or VERY LOW WEIGHT, or  Less than 2 years old

Ask questions about usual feeding and during this illness. Compare mother’s answers to the FEEDING RECOMMENDATIONS chart Ask:
 Do

you breastfeed your child?

How many times during the day?  Do you also breastfeed during the night?

Assess the Child’s Feeding

Does the child take any other food or fluids?
 What

food or fluids?  How many times per day?  What do you use to feed the child?  If very low weight for age: How large are servings? Does the child receive his/ her own serving? Who feeds the child and how?
 During

this illness, has the child’s feeding changed? If yes, how?

Identify Feeding Problems
 

Identify differences between actual feeding and the recommendations Examples of feeding problems
Difficulty in breastfeeding – check the mother’s reason. Show correct positioning and attachment  Use of feeding bottle – often dirty. Demonstrate the use of spoon or cups  Lack of active feeding – child not encouraged to eat, is not given own serving, has to compete with other siblings  Not feeding well during illness – offer favorite food to encourage eating. Breastfeed more frequently, offer nutritious, varied, and appetizing foods. Clear blocked nose

Identify Feeding Problems
 Not

giving protein source of food in lugaw or rice – add or mix protein-rich sources of food such as flaked fish, chicken, pulverized roasted dilis, chopped meat, egg yolk, steamed tokwa, and munggo  Improper handling and use of breastmilk substitute - counsel on proper preparation and handling of breastmilk substitute

Counsel the Mother About Feeding Problems

If mother reports difficulty with breastfeeding, assess breastfeeding. As needed, show correct positioning and attachment for breastfeeding If child is less than 6 months old and is taking other milk or foods
Build mother’s confidence that she can produce all the breastmilk that the child needs  Suggest giving more frequent, longer breastfeeding, day and night, and gradually reducing other milk or foods

Counsel the Mother About Feeding Problems
If other milk needs to be continued, counsel to breastfeed as much as possible, including night.  Make sure that other milk is locally appropriate breastmilk substitute and give only when necessary  Make sure other milk is correctly and hygienically prepared and given in adequate amounts  Prepare only an amount of milk which the child can consume within an hour. Discard left-overs

If mother is using a bottle to feed the child
 Recommend

substituting a cup for bottle  Show how to feed with a cup. Do NOT pour the milk into the baby’s mouth

Counsel the Mother About Feeding Problems

If the child is not being fed actively, counsel to
Sit with child and encourage eating  Give child an adequate serving in a separate bowl  Observe what the child likes and consider this in the preparation of his/her food

If the child is not feeding well during illness, counsel to
 Breastfeed

more frequently and longer  Use soft, varied, appetizing, favorite foods and offer frequent small feedings  Clear blocked nose  Expect that appetite will improve as child gets better

Follow up any feeding problem in 5 days

Use Good Communication Skills (ALPAC)

Ask and Listen

Find out what the mother is already doing for her child then you will know what practice needs to be changed praise that is genuine and only for actions that are helpful to the child

Praise
 Give

Advise
 Limit

to what is relevant  Use language that the mother will understand. Use pictures or real objects if possible

Use Good Communication Skills (ALPAC)

Advise against any harmful practice. Be clear but be careful not to make the mother feel guilty or incompetent. Explain why the practice is harmful

Check understanding
 Ask

questions to find out what the mother understands and what needs further explanation  Avoid asking leading questions (which suggest the right answer) and questions answerable with yes or no

Use of Mother’s Card
A mother’s card can be given to help remember appropriate foods and fluids, and when to return to health worker. It has words and pictures that illustrate the main points of advice  There are many reasons why a Mother’s Card is helpful
 It

will remind you or other health care workers of important points to cover when counselling  It will remind the mother what to do  The mother may show the card to other family members

Use of Mother’s Card
The mother will appreciate being given something during the visit  Multivisit cards can be used as a record of treatments and immunizations given

When reviewing a Mother’s Card with a mother
Hold the card so the mother can easily see the pictures or allow her to hold it herself  Explain and point to each picture  Circle or record relevant information  Watch to see if the mother seems worried or puzzled  Ask the mother to tell what she should do at home using the card

Advise the Mother to Increase Fluids During the Illness

For any sick child
Breastfeed more frequently and longer at each feed  Increase fluid. For example giving soup, rice water, buko juice or clean water

For child with diarrhea
 Give

according to Plan A or Plan B on the TREAT THE CHILD CHART

Advise the Mother When to Return to a Health Center

Follow-up visit
Return for follow-up in 2 days

If the child has PNEUMONIA DYSENTERY MALARIA, if the fever persists FEVER-MALARIA UNLIKELY, if fever persists FEVER (NO MALARIA), if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS DENDUE HEMORRHAGIC FEVER UNLIKELY, if fever persists PERSISTENT DIARRHEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEMS MANY OTHER ILLNESSES, if not improving ANEMIA VERY LOW WEIGHT FOR AGE

5 days

14 days 30 days

Advise the Mother When to Return to a Health Center

When to return immediately
-Not able to drink or breastfeed -Becomes sicker -Develops fever -Fast breathing -Difficult breathing -Blood in stool -Any sign of bleeding -Persistent abdominal pain -Persistent vomiting -Skin petechiae -Skin rash

Any sick child

If the child has NO PNEUMONIA: COUGH OR COLD If the child has diarrhea If the child has FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

Counsel the Mother About Her Own Health
 

 

If mother is sick, provide care for her, or refer for help If she has breast problem (engorgement, sore nipples, breast infection) provide care for her or refer for help Advise her to eat well Check mother’s immunization status and give her Tetanus toxoid if needed Make sure she has access to
Family planning  Counselling on STD and AIDS prevention

Care for Development
Children who are poorly nourished often have difficulty learning. They may be timid and easily upset, harder to feed, and less likely to play and communicate. They have special needs for care. Their mothers may also need help to understand how their children communicate their needs Children are different at birth and this affect how they learn. Early care also affects their learning.

Care for Development

 

Much of what children learn, they learn when they are very young Children need a safe environment as they learn Children need consistent loving attention from at least one person Mothers can help their children learn by responding to their words, actions, and interests Children learn by playing and trying things out, and by observing and copying what others do

Recommendation By Age Group

Birth to 4 months
Play: Learning is through seeing, hearing, feeling, and moving.  Communicate: Crying.

4 months up to 6 months
 Play:

Reaching for objects and putting things in mouth. Have clean, large, colorful things to see and reach  Communicate: New sounds like squeals and laughter. Smile at the child and communicate with sounds and gestures

Recommendation By Age Group

6 months up to 12 months
Play: Making noise like banging objects together or dropping them. Give them clean things to handle  Communicate: Imitation of sounds and actions. Children understand words before they learn to say them. Begin telling the names of things and people

12 months up to 2 years
 Play:

More active and wants to move around and explore. They like to stack things up and put things into containers

Recommendation By Age Group
 Communicate:

Learning to speak. Can answer simple questions.

2 years and older
 Play:

Help your child count, name and compare things  Communicate: Encourage to talk, and answer child’s questions. Teach stories, games, and songs. Should be corrected gently so that they will not be discouraged or feel ashamed

Assess the Child’s Care for Development
Observe the mother and the child from the beginning of the consultation  How does the mother respond when the child reaches for her?  How does she get the child’s attention?  How does she comfort the child?  Does the mother look at the child and smile?  How does the child respond to the mother?  Does the child follow the mother’s sounds and movements?  Does the child look to the mother for comfort?

Identify Problems in Care for Development

Identify the difference between the actual care provided and the recommendations for care and give some recommendations. Examples of common problems are:
 Mother

cannot breastfeed  Mother does not know what her child does to play and communicate  Mother feels she does not have enough time to provide care for development. She feels she needs extra time because of the many household chores

Identify Problems in Care for Development
Mother has no toys for her child to play with. She may think that all toys must be bought  Child is not responding or seems “slow”. Some children may have learning disabilities but they can learn more with special care  Child is being raised by someone other than the mother

Counsel the mother about care for development
 Give

relevant advice  Use good communication skills (ALPAC)

Counsel the mother about her own health

FOLLOW-UP
Aged 2 Months Up to 5 Years

Objectives
 

 

Deciding if the child’s visit is for follow-up Assessing signs specified in the follow-up box for the child’s previous classification Selecting treatments based on the child’s signs If the child has any new problems, assessing and classifying them as in an initial visit
Ask the mother about the child’s problem. Determine if this is a follow-up or an initial visit for this illness  If for follow-up, ask if the child has developed any new problem. This requires a full assessment

Objectives
If no new problem, follow the instructions in the FOLLOWUP box that matches the child’s previous classification  If the child has any kind of diarrhea, classify and treat the dehydration as in an initial assessment  Children with repeatedly chronic problems should be referred to a hospital when they do not improve  If with several problems, showing signs of shock, or is getting worse, refer the child to a hospital  Refer if a second-line drug is unavailable  If a child has not improved with the treatment, he/she may have an illness different from that suggested by the chart. He/she may need other treatments provided in a hospital

Pneumonia

After 2 days
Check for general danger signs  Assess for cough or difficult breathing

Ask
Is the child breathing slower?  Is there less fever?  Is the child eating better?

Treatment

If chest indrawing or a general danger sign, give a dose of second-line antibiotic or intramuscular chloramphenicol, then refer urgently to hospital

Pneumonia
 If

breathing rate, fever, and eating are the same, change to the second-line antibiotic and advise mother to return in 2 days or refer. If the child had measles within the last 3 months, refer  If breathing rate slower, less fever, or eating better, complete the 5 days of antibiotic  If cough is more than 30 days, refer

Persistent Diarrhea

After 5 days, ask
Has the diarrhea stopped?  How many loose stools is the child having per day?

Treatment
 If

the diarrhea has not stopped (child is still having less than 3 or more loose stools per day), do a full reassessment. Give any treatment needed, then refer to a hospital  If diarrhea has stopped (child having less than 3 loose stools per day), tell to follow the usual recommendations for the child’s age

Dysentery

After 2 days

Assess the child for diarrhea there fewer stools? there less blood in the stool? there less fever? there less abdominal pain? the child eating better?

Ask
 Are  Is  Is  Is  Is

Treatment
 If

the child is dehydrated, treat dehydration

Dysentery
 If

number of stools, amount of blood of stools, fever, abdominal pain, or eating is the same or worse, change to second-line oral antibiotic recommended for Shigella. Give for 5 days. Advise to return in 2 days
 Except
  

if the child

Less than 12 months old, or Was dehydrated on the first visit, or Had measles within the last 3 months, REFER to hospital

 If

fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving antibiotic until finished

Malaria

If fever persists after 2 days, or returns within 14 days, do a full assessment Treatment
If with any general danger sign or stiff neck, treat as VERY SEVER FEBRILE DISEASE/ MALARIA  If with any cause of fever other than malaria, provide treatment  If malaria is the only apparent cause of fever

 Take

blood smear  Give second-line oral antimalarial without waiting for result of blood smear

Malaria
 Advise

to return if fever persists  If fever persists after 2 days treatment with second-line oral antimalarial, refer with blood smear for reassessment  If fever has been present for 7 days, refer for assessment

Fever: Malaria Unlikely
  

If fever persists after 2 days, do full assessment Assess for other causes of fever Treatment
If with any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE/ MALARIA  If malaria is the only apparent cause of fever

 Take

blood smear  Treat with first-line oral antimalarial. Advise to return in 2 days if fever persists  If fever has been present for 7 days, refer for assessment

Fever (No Malaria)

If fever persists after 2 days, do a full assessment Make sure there has been no travel to malarious area and overnight stay in malaria area. If there has been travel and overnight stay, do blood smear if possible Treatment

If there has been travel and overnight stay to a malarious area and the blood smear is positive or there is no blood smear, classify and treat as FEVER with MALARIA RISK

Fever (No Malaria)

If there has been no travel to malarious area and blood smear is negative
 If

with any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE  If with any apparent cause of fever, provide treatment  If no apparent cause of fever, advise to return in 2 days if fever persists  If fever has been present for 7 days, refer for assessment

Fever: Dengue Hemorrhagic Fever Unlikely

If fever persists after 2 days
Do full assessment  Do torniquet test  Assess for other causes of fever

Treatment
 If

with any signs of bleeding, including skin petechiae or a positive torniquet test, or signs of shock, or persistent abdominal pain or persistent vomiting, treat as DENGUE HEMORRHAGIC FEVER

Fever: Dengue Hemorrhagic Fever Unlikely
If with any other apparent cause of fever, provide treatment  If fever has been present for 7 days, refer for assessment  If no apparent cause of fever, advise to return daily until the child has had no fever for at least 48 hours  Advise to make sure child is given more fluids and is eating

Measles With Eye or Mouth Complications

After 2 days
Look for red eyes and pus draining from the eyes  Look at mouth ulcers  Smell the mouth

Treatment for eye infection
 If

pus draining from the eye, ask how mother treated the infection. If correct, refer to hospital. If incorrect, teach the correct treatment  If pus is gone but redness remains, continue treatment  If no pus or redness, stop treatment

Measles With Eye or Mouth Complications

Treatment for mouth ulcers
 If

mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital  If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days

Ear Infection

After 5 days
Reassess for ear problem  Measure the child’s temperature

Treatment
 If

there is tender swelling behind the ear or high fever (38.5˚C or above), treat as MASTOIDITIS  Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking ear. Follow-up in 5 days

Ear Infection
 Chronic

ear infection: Check if the mother is wicking the ear correctly and encourage to continue  If no ear pain or discharge, praise the mother for her careful treatment. Tell to use up all the antibiotic for 5 days before stopping

Feeding Problem

After 5 days
Reassess feeding  Ask about any feeding problems found on the initial visit

Counsel about any new or continuing feeding problems. If you advise significant changes in feeding, ask to return If child has very low weight for age, ask to return in 30 days after initial visit to measure weight gain

Anemia

After 14 days
 Give

iron. Advise to return in 14 days for more iron  Continue giving iron every day for 2 months with follow-up every 14 days  If with palmar pallor after 2 months, refer for assessment

Very Low Weight

After 30 days
Weigh and determine if still with very low weight for age  Reassess feeding

Treatment
 If

no longer very low weight for age, praise and encourage to continue  If still very low weight for age, counsel about any feeding problem found. Continue to see child monthly until child is feeding well and gaining weight regularly or is no longer very low weight for age

Except if you do not think feeding will improve or if the child has lost weight, refer

MANAGEMENT OF THE SICK YOUNG INFANT
Aged 1 Week to 2 Months

Introduction

Young infants have special characteristics that must be considered when classifying their illness They can become sick and die very quickly from serious bacterial infections. They frequently have only general signs such as few movements, fever, or low body temperature

Objectives
  

   

Assessing and classifying for possible bacterial infection Assessing and classifying for diarrhea Checking for feeding problem or low weight, assessing breastfeeding, and classifying feeding Treating with oral or intramuscular antibiotics Giving fluids for treatment of diarrhea Teaching mother to treat local infections Teaching correct positioning and attachment for breastfeeding Advising how to give home care

Assess and Classify the Sick, Young Infant

Check the young infant for possible bacterial infection
The infant must be calm while assessing the first four signs  Ask: Has the infant had any convulsions?  Look and listen

 Fast

breathing(>60 bpm), repeat count if elevated  Severe chest indrawing  Nasal flaring  Grunting

Assess and Classify the Sick, Young Infant
 Bulging

fontanels  Pus draining from the ear  Umbilicus: Red or draining pus? Does the redness extend to the skin?  Feel or measure body temperature. Fever = Axillary temperature of >37.5˚C or rectal temperature of >38˚C  Skin pustules: Are there many or severe pustules?  Abnormally sleepy or difficult to awaken  Movements: Are they less than normal?

Assess and Classify the Sick, Young Infant

Classify all sick, young infants for bacterial infection
Any sign classifies the infant as having POSSIBLE SERIOUS BACTERIAL INFECTION and needs urgent referral to the hospital  Classified as LOCAL BACTERIAL INFECTION if only red umbilicus or draining pus or skin pustules

Assess diarrhea
 Normally

frequent or loose stool of a breastfed baby is not diarrhea  Thirst is not assessed because it is not possible to distinguish thirst from hunger

Assess and Classify the Sick, Young Infant

Classify diarrhea
Classified in the same way as older child  Classify status of dehydration  Classify if with diarrhea for more than 14 days

 There

is only one classification for persistent diarrhea  Refer immediately
 Classify
 Refer

if with blood in the stool

immediately  Do not start antibiotic but give frequent sips of ORS on the way

Assess and Classify the Sick, Young Infant

Check for feeding problem or low birth weight
 Growth

is assessed by determining weight for age  Best way to feed infant is through exclusive breastfeeding  ASK: Is there any difficulty feeding?  ASK: Is the infant breastfed? If yes, how many times in 24 hours?  ASK: Does the young infant usually receive any other food or drink? If yes, how often?

Assess and Classify the Sick, Young Infant
ASK: What do you use to feed your infant?  LOOK: Determine the weight for age

Assess breastfeeding
 Do

not assess if

 Exclusively

breastfed without difficulty and is not low weight for age  Not breastfed at all  With serious problem requiring urgent referral

Assess and Classify the Sick, Young Infant

Assess breastfeeding if an infant
Has any difficulty feeding  Is breastfeeding less than eight times in 24 hours  Is taking any other foods or drinks  Is low weight for age  Has no indications for urgent referral

 ASK:

Has the infant breastfed in the previous hour? If not, ask to put infant to the breast and observe for 4 minutes  If infant was fed during the last hour, ask if mother can wait and tell you when the infant is willing to feed again

Assess and Classify the Sick, Young Infant

Is the infant able to attach?
 No

attachment at all  Not well attached  Good attachment
 To

check attachment, LOOK for all of these signs
 Chin

touching breast  Mouth wide open  Lower lip turned outward  More areola visible above than below the mouth

Assess and Classify the Sick, Young Infant
 Is

the infant sucking effectively? not sucking at all? Not sucking effectively?
A

satisfied infant releases the breast spontaneously

 Clear

blocked nose  Look for ulcers or white patches in the mouth (thrush)

Assess and Classify the Sick, Young Infant

Classify feeding

NOT ABLE TO FEED: POSSIBLE SERIOUS BACTERIAL INFECTION
 Give

first dose of intramuscular antibiotics  Treat to prevent low blood sugar level  Advise how to keep warm  Refer URGENTLY
 FEEDING
 Advise

PROBLEM OR LOW WEIGHT

to breastfeed as often and for as long as the infant wants, day and night

Assess and Classify the Sick, Young Infant
 If

receiving other foods or drinks, counsel about breastfeeding more, reducing other foods and drinks and using a cup  If thrush, teach how to treat  Advise to give home care  Follow-up any feeding problem or thrush in 2 days  Follow up low weight for age in 14 days
 NO

FEEDING PROBLEM

 Advise

to give home care  Praise for feeding well

Assess and Classify the Sick, Young Infant
 

Check the infant’s immunization status Assess other problems

Identify Appropriate Treatment

Determine if the young infant needs urgent referral
If infant has POSSIBLE SERIOUS BACTERIAL INFECTION  If infant has SEVERE DEHYDRATION, and needs rehydration with IV fluids according to Plan C. If you can give IV therapy, you can treat the infant in health center. Otherwise, refer urgently  If both with SEVERE DEHYDRATION and POSSIBLE SEVERE BACTERIAL INFECTION, refer urgently. Mother should give frequent sips and continue breastfeeding

Identify Appropriate Treatment

Identify treatments for a young infant who does not need urgent referral

Record treatments, advice, and when to return for follow-up procedures as in referring a young

Refer the young infant
 Same

child
 Referral

note  Explain why to refer  Teach what she needs to do along the way

Identify Appropriate Treatment
 Explain

that young infants are particularly vulnerable  If mother will not take the infant to the hospital, follow guidelines WHEN REFERRAL IS NOT POSSIBLE

Treat the Sick Young Infant and Counsel the Mother

Give an appropriate antibiotic
 First-line:

Cotrimoxazole  Second-line: Amoxicillin
COTRIMOXAZOLE AMOXICILLIN Give two times daily for Give three times daily 5 days for 5 days AGE OR WEIGHT ADULT SYRUP TABLET (40 mg/ 200 (80 mg/ 400 mg/ 5 mL) mg) 1.25 mL TABLET (250 mg) SYRUP (125 mg/ 5 mL) 1.25 mL

Birth up to 1 month (<3 kg) 1 to 2 months 1/4 (3-4 kg)

2.5 mL

1/4

2.5 mL

Treat the Sick Young Infant and Counsel the Mother

Avoid giving Cotrimoxazole to young infant less than one month of age who is premature or jaundiced. Give Amoxicillin or Benzylpenicillin instead

Give first dose of intramuscular antibiotics
 Gentamicin

and Benzylpenicillin. Combination is effective against broader range of bacteria  Referral is best option for infant with POSSIBLE BACTERIAL INFECTION. If not possible, give Benzylpenicillin every 6 hours and Gentamicin one dose daily for at least five days.

Treat the Sick Young Infant and Counsel the Mother
WEIGH GENTAMICIN T 5 mg per kg Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml Add 6 ml sterile water to 2 ml vial containing 80 mg = 8 ml at 10 mg/ml BENZYLPENICILLIN 50,000 units per kg To a vial of 600 mg (1,000,000 units) Add 2.1 ml sterile water = 2.5 ml at 400,000 units/ ml 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml Add 3.6 ml sterile water = 4.0 ml at 250,000 units/ ml 0.2 ml 0.4 ml 0.6 ml 0.8 ml 1.0 ml

1 kg 2 kg 3 kg 4 kg 5 kg

0.5 ml 1.0 ml 1.5 ml 2.0 ml 2.5 ml

Treat the Sick Young Infant and Counsel the Mother
  

Treat diarrhea according to TREAT THE CHILD chart Immunize every sick, young infant, as needed Treat the mother to treat local infections at home
Local infections treated the same way that mouth ulcers are treated in an older child  Clean the infected area twice a day with gentian violet. Half strength used in the mouth  Explain and demonstrate the treatment. Watch and guide her.  Return for follow-up in two days or sooner if infection worsens

Treat the Sick Young Infant and Counsel the Mother
Stop gentian violet after five days  To treat skin pustules

Wash hands  Wash off pus and crusts with soap and water  Dry the area  Paint with gentian violet  Wash hands

 To

treat umbilical infection

Wash hands  Clean with 70% ethyl alcohol  Pain with gentian violet  Wash hands

Treat the Sick Young Infant and Counsel the Mother

To treat oral thrush
 Wash

hands  Wash mouth with clean soft cloth wrapped around finger and wet with salt water  Paint the mouth with half-strength gentian violet  Wash hands

Teach correct positioning and attachment for breastfeeding
 Show
 With

how to hold infant
the infant’s head and body straight

Treat the Sick Young Infant and Counsel the Mother
 Facing

mother’s breast, with infant’s nose opposite her nipples  With infant’s body close to her body  Supporting infant’s whole body, not just neck and shoulders
 Show

her how to help the infant to attach.

 Touch

infant’s lips with mother’s nipple  Wait until infant’s mouth is opening wide  Move infant quickly onto breast, aiming infant’s lower lip well below the nipple

Treat the Sick Young Infant and Counsel the Mother

Counselling the mother about feeding problems Advise the mother to give home care for the young infant
 Foods

and fluids

 Frequent

breastfeeding will give nourishment and help prevent dehydration

 When

to return

 Follow-up

LOCAL BACTERIAL INFECTION, ANY FEEDING PROBLEM, THRUSH: 2 days

Treat the Sick Young Infant and Counsel the Mother

LOW WEIGHT FOR AGE: 14 days

 When
     

to return immediately

Breastfeeding or drinking poorly Becomes sicker Develops fever Fast breathing Difficult breathing Blood in stool

Make sure the young infant stays warm at all times
 Keeping

a sick young infant warm is very important. Low temperature alone can kill

FOLLOW-UP
Sick Young Infant

Local Bacterial Infection

After 2 days
Look at the umbilicus. Is it red or draining pus? Does redness extend to the skin?  Look at the skin pustules. Are there many or severe pustules?

Treatment
 If

the pus or redness remains or is worse, refer  If improved, continue giving the 5 days of antibiotic and continue treating the local infection at home

Feeding Problem

After 2 days
Reassess feeding  Ask about any feeding problems found on the initial visit

 Counsel

about any new or continuing problems. If you counsel to make significant changes in feeding, ask to bring the infant back again  If infant is low weight for age, ask to return in 14 days after initial visit to measure weight gain
 Exception:

if you think that feeding will not improve, or young infant has lost weight, refer

Low Weight

After 14 days
Weigh and determine if still low weight for age  Reassess feeding

If no longer low weight for age, praise the mother and encourage to continue  If still low weight for age, but feeding well, praise mother. Ask to return within a month or when she returns for immunization  If still low weight for age, and still with feeding problem, counsel about feeding problem. Ask to return within 14 days or when she returns for immunization, if this is within 2 weeks

Low Weight

Exception: if you think that feeding will not improve, or young infant has lost weight, refer

Oral Thrush

After 2 days
 Look

for ulcers or white patches in the mouth  Reassess feeding
 If

thrush is worse, or if with problems with attachment or sucking, refer  If thrush is the same or better, and is feeding well, continue half-strength gentian violet for a total of 5 days