Integrated Management of Childhood Illness1 | Measles | Pneumonia

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

Under five mortality: Estimated trend and MDG goal Philippines 1980-2004 .

Under-five Mortality Rates. by Country Type and by Region. 20076 .

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4. 3.DOH Essential Package of Child Survival Interventions 1. Skilled attendance during pregnancy. childbirth and the immediate post partum Care of the Newborn Breastfeeding and complementary feeding Micronutrient supplementation Immunization of children and mothers IMCI Use of insecticide treated bed nets . 6. 7. 5. 2.

wo objectives of IMCI: 1. To contribute a healthy growth and development of children. To significantly reduce global mortality and morbidity associated with the major causes of disease in children 2. .

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 .

anemia. al. common illnesses.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. et. malnutrition. .

I. IV. II. Assess the child or young infant Classify the illness Identify the treatment Treat the child/Refer Counsel the mother Give follow-up care . III. VI. V.

Principles of Integrated Care Must be examined for ´general danger signsµ Must be assessed for major symptoms 2 months to 5 years: cough or difficulty of breathing. 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 . fever. diarrhea.

feeding. but not all.Principles of Integrated Care Combination of individual signs leads to a classification rather than a diagnosis Addresses most. 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. fluids and when to return to a health facility .

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

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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 .

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 Check ALL sick children for general danger signs.

´spasmsµ. 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 ´fitsµ. or ´jerky movementsµ .Check for General Danger Signs ASK: Is the child able to drink or breastfeed? If you are not sure about the mother·s answer.

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. or spoken to . shaken.

5 kg. What are the child s problems? The mother said. and she is not eating well. Her temperature is 35. This is Maya's initial visit for this problem. The health worker asked. .5°C.Exercises: Case 1 Maya is 15 months old. She weighs 8. Maya has been coughing for 4 days.

d. Write Maya's name.Answer the following: a. Does Maya have general danger signs? If yes. circle the signs on the Recording Form. and temperature in the spaces provided on top of the line form. Tick (¥) whether this is the initial or follow-up visit. b. weight. Then tick(¥) ´yesµ or ´noµ after the question. age. ´General danger signs present?µ . Write Maya's problem on the line after the question ´Ask: What are the child·s problems?µ c.

Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO___ .MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg.

Is she vomiting? The mother said No. The health worker looked to see if Maya was abnormally sleepy or difficult to awaken . Then he asked. Next. He asked. She was not abnormally sleepy or difficult to awaken. . Is Maya able to drink or Breastfeed? The mother said No. The health worker gave Maya some water. Has she had convulsions? The mother said No. Maya does not want to breastfeed. he asked the mother.Exercises: Case 1 continuation The health worker checked Maya for general danger signs. She was too weak to lift her head. She was not able to drink from a cup. Maya watched them and looked around the room. When the health worker and the mother were talking.

Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO___ .MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES_¥__NO__ _ .

The health worker asked about the child s problems. . he is coughing and has ear pain. Is your child able to drink? The parents answered. Does Niño vomit everything? he asked. The health worker asked. The health worker looked at Niño. He weighs 10 kg. The parent said No. Niño's parents said. Has he had convulsions? they said No. This is the initial visit for this problem. The health worker asked. the child was not abnormally sleepy or difficult to awaken. Yes. His temperature is 38 °C.Case 2: Niño is 4 years old.

Then tick ´yesµ or ´noµ after the question. and temperature in the spaces provided on top of the line form. ´General danger signs present?µ . Tick whether this is the initial or follow-up visit. Write Niño's problem on the line after the question ´Ask: What are the child·s problems?µ c. b. weight. age.Answer the following: a. circle the signs on the Recording Form. Does Niño have general danger signs? If yes. d. Write Niño's name.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:_____Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?____Initial Visit?_follow-up visit?___ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__¥ _ .

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 1.

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  for chest indrawing If 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 .

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Instead.  May be caused by swollen larynx. They are not exact disease diagnoses. they are categories that are used to determine the appropriate action or treatment . trachea or epiglottis  Listen only when the child is calm  If the sound is heard when the child breathes out.Check for the Four Main Symptoms † LOOK  and LISTEN for stridor Stridor is a harsh noise when the child breathes IN. this is wheezing and NOT stridor Classify cough or difficult breathing † CLASSIFY means to make a decision about the severity of illness.

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. If the child has signs from more than one row. 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. always select the more serious classification .

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

The health worker checked for general danger signs. Her father told the worker. You have done the right thing to bring your child today. Lucite will not breastfeed. He saw chest indrawing. The health worker counted 55 breaths/min. The health worker said. I will examine her now. Lucite has had cough for 3 days. She is very weak. The mother said.Exercises: Case 1 Lucite is 8 months old. She will not take any other drinks I offer her. She weighs 6kg. She did not look at the health worker or her parents when they talked. Lucite is abnormally sleepy. He decided Lucite had stridor because he heard a harsh noise when she breathed in. Lucite does not vomit everything and not had convulsions. . She is having trouble breathing. Her temperature is 39°C.

Fast breathing? Look for chest indrawing Look and listen for stridor . Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO___ DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ______days YES____ NO____ Count the breaths in one minute ____breaths per minute.MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg.

Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES_¥__NO__ _ DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ____3__days YES__ __ NO____ Count the breaths in one minute __55__breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Severe Pneumonia or Very Severe Disease .MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg.

He weighs 5. He did not see chest indrawing. The health worker said to the mother. He has not had convulsions. His temperature is 38°C.Case 2 Beanie is 6months old. . He has not vomited during this illness. You said he has had cough for 2 days now. ´I want to check Beanie's cough. The health worker checked for general danger signs. He will need to remain calm while I do this. His mother said he has had cough for 2 days. He did not hear stridor.µ The health worker counted 58 breathes/min. The mother said that Beanie is able to breastfeed . Beanie is not abnormally sleepy or difficult to awaken.5kg. I am going to count his breathes.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Fast breathing? Look for chest indrawing Look and listen for stridor Pneumonia . Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__¥ _ DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long? ___2___days YES_ ___ NO____ Count the breaths in one minute __58__breaths per minute.

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 2.

Does it go back: very slowly (longer than two seconds)? Slowly? Immediately?  . Is the child not able to drink or drinks poorly?  Pinch the skin of the abdomen. 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.Check for the Four Main Symptoms † ASK: Is there blood in the stool? If yes.

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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 .

Skin pinch goes back slowly Not enough signs to classify as having some or severe dehydration SOME DEHYDRATION NO DEHYDRATION .Skin pinch goes back very slowly Two of the following signs: -Restless and irritable .Abnormally sleepy or difficult to awaken .Drinks eagerly.Not able to drink or drinks poorly .Check for the Four Main Symptoms SIGNS CLASSIFY AS TREATMENT Two of the following signs: SEVERE DEHYDRATION .Sunken eyes . thirstily .Sunken eyes .

He has no blood in the stool. . His eyes is sunken.Case 1: Joel Joel has had diarrhea for five days. The health worker offers Joel some water. and the child drinks eagerly. it goes back slowly. When the health worker pinches the skin on the child·s abdomen. His father and mother also think that Joel·s eyes are sunken. He is irritable.

Record Joel·s signs of dehydration and classify DOES THE CHILD HAVE DIARRHEA ‡For how long?______days ‡Is there blood in the stool? YES____ NO____ Look at the child s general condition. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly? . Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid.

Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid.Record Joel·s signs of dehydration and classify DOES THE CHILD HAVE DIARRHEA ‡For how long?___5___days ‡Is there blood in the stool? YES__ _ NO____ Look at the child s general condition. Does it go back : Very slowly? (longer than 2 seconds) Slowly? Some Dehydration . Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen .

2 Classify Persistent Diarrhea ‡ Dehydration present SEVERE PERSISTENT DIARRHEA ‡No dehydration PERSISTENT DIARRHEA .2 Classify Diarrhea 4.2.Check for the Four Main Symptoms 4.

´No. The mother said. She does not have cough or difficult breathing.5°C. Her eyes are not sunken. She weighs 12 kg. He noted she has had diarrhea for 21 days.µ The health worker checked Farida for signs of dehydration. . The health worker assessed her diarrhea. The skin pinch goes back immediately. Farida does not have any general danger signs. The child is irritable throughout the visit. Her temperature is 37. Farida·s mother said the child has had diarrhea for 3 weeks. He asked if there had been blood in the stool.Case 2: Farida Farida is 14 months old.

Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen .Record Farida·s signs of and classify Persistent Diarrhea DOES THE CHILD HAVE DIARRHEA ‡For how long?___21___days ‡Is there blood in the stool? YES__ __ NO____ Look at the child s general condition. Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Does it go back : Very slowly? (longer than 2 seconds) Slowly? Persistent Diarrhea .

2 Classify Diarrhea 4.2.3 Classify Dysentery ‡ Blood in the stool DYSENTERY .Check for the Four Main Symptoms 4.

5 °C. Carlo does not have any general danger signs.Case 3: Carlo Carlo is 10 months old He weighs 8 kg. I will checked for signs of dehydration. . He does not have cough or difficult breathing. Her temperature is 38. The health worker assesses the child for diarrhea. The skin pinch goes back immediately. ´You said Carlo has had blood in the stool. He is not restless nor irritable. The child drank normally when offered some water and does not seem thirsty. He is here today because he has had diarrhea for 3 days. He does not have a sunken eyes.µ The child is not abnormally sleepy or difficult to awaken.

Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid.Record Carlo·s signs and classify DOES THE CHILD HAVE DIARRHEA ‡For how long?____3__days ‡Is there blood in the stool? YES__ __ NO____ Look at the child s general condition. Does it go back : Very slowly? (longer than 2 seconds) Slowly? Dysentery .

129-S. all the provinces in the Philippines are categorized according to the malaria situation . dated June 12.Check for the Four Main Symptoms 3. Fever Assess and classify fever † Malaria  Deciding malaria risk: Per AO No. 2002.

Category of provinces: .

CATEGORY A 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 .

CATEGORY B Abra Aurora Bataan Bulacan Camarines Norte Camarines Sur Ilocos Norte Lanao del Sur Maguindanao Mindoro Oriental North Cotabato Nueva Ecija Nueva Viscaya Pangasinan Rizal Romblon Sultan Kudarat Tarlac Zamboanga del Norte .

CATEGORY C Albay Antique Batanes Batangas Benguet Cavite Ilocos Sur La Union Marinduque Masbate Negros Oriental Negros Occidental Misamis Occidental Pampanga Samar (Eastern) Samar (Western) Sorsogon Surigao del Norte .

Norte and Sur Northern Samar 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.CATEGORY D Aklan Biliran Camiguin Capiz Catanduanes Cebu Guimaras Leyte. .

HIGH MALARIA RISK ASSESS CLASSIFY TREATMENT ‡ANY DANGER VERY SEVERE SIGNS OR FEBRILE ‡STIFF NECK DISEASE ‡FEVER MALARIA .

LOW MALARIA RISK ‡Any general danger sign or ‡Stiff neck ‡NO runny nose and ‡NO measles and ‡NO other cause of fever ‡Runny nose OR ‡Measles OR ‡Other causes of fever VERY SEVERE FEBRILE DISEASE MALARIA FEVER: MALARIA UNLIKELY .

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The child observed to have runny nose.Example: A 2 year old-boy is brought to the health center because he has felt hot for 2 days. A blood smear was done with negative result. . he recorded this signs. He does not have cough or difficult breathing or diarrhea. When the health worker assessed the child·s fever. There is Malaria risk. He does not have general danger signs.

37. Generalized rash and ‡If more than 7 days. has fever been present everyday? One of these: cough. runny nose ‡Has the child had measles with the last 3 months? Or red eyes.‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp. obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days. Fever: Malaria Unlikely .5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk.

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 † 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 ‡Any general danger sign or ‡Clouding of the cornea or ‡Deep or extensive mouth ulcers ‡Pus draining from the eye or ‡Mouth ulcers ‡Measles now or within the last 3 months SEVERE COMPLICATED MEASLES MEASLES WITH EYE AND MOUTH COMPLICATIONS MEASLES .

DOES THE CHILD HAS MOUTH ULCER? ANSWER: NORMAL MOUTH .

DOES THE CHILD HAS MOUTH ULCER? ANSWER: NO STOMATITIS .

IS THE GENERALIZED RASH OF MEASLES PRESENT? ANSWER: YES .

IS THE GENERALIZED RASH OF MEASLES PRESENT? ANSWER: NO (PRICKLY HEAT) .

IS THERE AN EYE COMPLICATION? ANSWER: YES .

5ÝC or above .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. or -The child feels hot. or -The child has an axillary temperature of 37. 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.

 for all children with fever Decide the Dengue fever risk  If with risk. perform a torniquet test . with fever in a dengue risk area.Check for the Four Main Symptoms † Then. 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.

PETECHIAE .

AEDES AEGYPTI .

Classify Dengue Hemorrhagic Fever ‡Bleeding from nose or gums ‡Bleeding in stools or vomitus ‡Skin petechiae ‡Cold and clammy extremities ‡Capillary refill more than 3 seconds ‡Persistent abdominal pain ‡Persistent vomiting ‡Torniquet test positive SEVERE DENGUE HEMORRHAGIC FEVER ‡No signs of severe dengue hemorrhagic fever FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY .

Check for the Four Main Symptoms † Other  causes of fever: UTI  Osteomyelitis  Erysepelas  Abcess  Impetigo/ Pyoderma  Tonsilopharyngitis  Infected wounds  Nephritis  Typhoid fever  Diarrhea  Severe pneumonia  Very severe disease  Cough or cold  Dysentery  Measles  Measles with eye/mouth complication  Dengue hemorrhagic fever  Ear infection  Mastoiditis .

5°C. Next. The health worker did not have the facilities for examination of a blood smear. Fidel did not have diarrhea. and was not abnormally sleepy or difficult to awaken. The health worker checked the child for complications of measles. There were no pus draining from the eye and no clouding of the cornea. The mother said Fidel has felt hot for 2 days. His temperature is 37. He weighs 8. Fidel was able to drink. Fidel did not have a stiff neck. The mother said Fidel had been coughing for 5 days. Fidel has rash covering his whole body. His mother says he has a rash and cough. The health worker asked about Fidel·s cough. There have been no cases of dengue in their area. . There is Malaria risk. The health worker asked about Fidel·s fever. He did not see chest indrawing. Was not vomiting.2 kg.Example: Case of Fidel Fidel is 10 months old. The health worker checked Fidel for general danger signs. Fidel·s eyes were red. He counted 43 breaths per minute. He did not hear stridor when Fidel was calm. He had a runny nose with this illness.

Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__¥ _ DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long?__5_days YES__ __ NO____ Count the breaths in one minute __43__breaths per minute.MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Fast breathing? Look for chest indrawing Look and listen for stridor ‡No Pneumonia ‡Cough or cold .

Is the child: Abnormally sleepy or difficult to awaken Restless and irritable? Look for sunken eyes Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly and thirsty? Pinch the skin of the abdomen . Does it go back : Very slowly? (longer than 2 seconds) Slowly? .DOES THE CHILD HAVE DIARRHEA ‡For how long?______days ‡Is there blood in the stool? YES____ NO__ __ Look at the child s general condition.

‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp. runny nose ‡Has the child had measles with the last 3 months? Or red eyes. Fever: Malaria Unlikely .37. Generalized rash and ‡If more than 7 days. has fever been present everyday? One of these: cough.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk. obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days.

are they deep and extensive? Look for pus draining from the eye Look for clouding of the cornea Measles .If the child has measles now or within last 3months Look for mouth ulcers If yes.

Assess Dengue Hemorrhagic Fever ASK: ‡Has the child had any bleeding from the nose or gums or in the vomitus or stool? ‡Has the child has black vomitus or black stool? ‡Has the child had persistent abdominal pain? ‡Has the child had persistent vomiting? LOOK AND FEEL Look for bleeding from nose or gums Look for skin petechiea Feels for cold and clammy extremities Check for capillary refill Perform torniquet test .

5°C and feels hot. There is no dengue risk. has not vomited.Exercises: Case of Nestor Nestor is 5 months old. and is not abnormally sleepy or difficult to awaken. The blood smear for malaria was positive. and there is a risk of malaria. His mother said he is not eating well. She said he feels hot. Nestor is able to drink. the health worker assessed Nestor further for signs related to fever. Record·s Nestor sign·s and classify them in the recording form. and she want a health worker to help him. his nose is Not runny. .2 kg. It is rainy season. Because Nestor·s temperature is 37. The mother said Nestor·s fever began 2 days ago. He has not had measles within the last 3 months. His axillary temperature is 37.5°C. He weighs 5. He does not have stiff neck. and there are no signs suggesting measles. does not have convulsions. Nestor does not have cough and diarrhea.

Generalized rash and ‡If more than 7 days.37.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk. has fever been present everyday? One of these: cough.‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp. obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__2__days. Malaria . runny nose ‡Has the child had measles with the last 3 months? Or red eyes.

ASSESS AND CLASSIFY EAR PROBLEM A child with ear problem may have ear infection Sometimes the infection can spread from the ear to the bone behind the ear (the mastoid) causing mastoiditis. Infection can also spread from the ear to the brain causing meningitis .Check for the Four Main Symptoms 6.

1 ASSESS EAR INFECTION A child with ear problem is assessed for:  Ear pain  Ear discharge-if yes. a sign of mastoiditis .present for more than 2 weeks is treated as chronic ear infection -present for less than 2 weeks is treated as an acute ear infection  Tender swelling behind the ear.Check for the Four Main Symptoms 6. how long? .

Check for the Four Main Symptoms ‡Tender swelling behind the ear MASTOIDITIS ‡Ear pain ACUTE EAR ‡Pus is seen draining from the ear. and discharge is reported for 14 days or more CHRONIC EAR INFECTION ‡No ear pain and NO EAR ‡No pus is seen draining from the ear INFECTION . INFECTION and discharge is reported for less than 14 days ‡Pus is seen draining from the ear.

She does not have diarrhea and fever. The mother said she is sure Sally has ear pain. The child cried most of the night because her ear hurts.4°C. Her mother came to the health center today because Sally is sick for the last 2 days. She was crying last night and complained that her ear is hurting. He felt behind the child·s ears and felt tender swelling behind one ear. Next the health worker asked about Sally·s ear problem. . The health worker did not see any pus draining from the child·s ear. The health worker checked and found no general danger signs. Her temperature is 37.Case I:Sally Sally is 3 years old. Sally does not have cough or difficult breathing. She weighs 13 kg. said the mother. There has been discharge coming from Sally·s ear on and off for about a year.

Record Sally·s sign of ear problem and classify them on the Recording form. DOES THE CHILD HAVE AN EAR PROBLEM? YES__ NO__ ‡Is there ear pain? ‡Is there ear discharge? If yes. for how long____days Look for pus draining from the ear Feel for tender swelling behind the ear .

for how long? On and off about a year . DOES THE CHILD HAVE AN EAR PROBLEM? YES__ __ NO____ ‡Is there ear pain? ‡Is there ear discharge? Look for pus draining from the ear Feel for tender swelling behind the ear Mastoiditis If yes.Record Sally·s sign of ear problem and classify them on the Recording form.

She does not have diarrhea and fever. She does not have cough or difficult breathing. but the discharge has been coming from the ear for 3 or 4 days. The health worker asked about Susan·s ear problem.Case 2: Susan Susan is 18 months old. The mother said that Susan does not have ear pain. She weighs 9 kg. He did not feel any tender swelling behind the ear. Her mother said Susan had discharge coming from ear for the last 3 days. . The health worker saw pus draining from the child·s right ear. Her temperature is 37°C. Susan does not have any general danger signs.

Record Susan·s sign of ear problem and classify them on the Recording form. DOES THE CHILD HAVE AN EAR PROBLEM? YES__ __ NO____ ‡Is there ear pain? ‡Is there ear discharge? Look for pus draining from the ear Feel for tender swelling behind the ear ACUTE EAR INFECTION If yes. for how long? _3 or 4 days .

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or Very low weight for age Not very low weight for age No other signs of malnutrition  ANEMIA OR VERY LOW WEIGHT    NO ANEMIA OR NOT VERY LOW WEIGHT   .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 Some palmar pallor.

Check for Malnutrition ‡Visible severe wasting or ‡Edema of both feet SEVERE MALNUTRITION ‡Very low weight for age VERY LOW WEIGHT ‡Not very low weight for age and no other signs of malnutrition NOT VERY LOW WEIGHT .

CHECK ANEMIA SEVERE PALMAR SEVERE ANEMIA PALLOR SOME PALMAR PALLOR ANEMIA NO PALMAR PALLOR NO ANEMIA .

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She weighs 7kg. has not had convulsions. Her mother brought her today because the child has felt hot and has a rash.Her temperature is 38. and is not abnormally sleepy or difficult to awaken. has not vomited.5°C. Case 1: Ana Ana is 18 months old. . The health worker saw that Ana looks like skin and bones. Ana is able to drink.. The health worker checked for general danger signs.

and because her temperature is 38. Ana lives where there is a malaria risk. Her blood smear was positive for Plasmodium vivax.5°C. . She does not have a runny nose. the health worker assessed her for fever. Her rash is generalized rash. She does not have diarrhea. There is no dengue risk in the area. and she has red eyes. She does not have a stiff neck. She has had fever for 5 days.Case 1: Ana She does not have cough or difficult breathing. She has measles. Because Ana s mother said the child felt hot.

Case 1: Ana The health worker assessed her for signs of measles complications. She does not have edema on both feet. The health worker next checked her for malnutrition and anemia. There is no palmar pallor. The health worker determined her weight for age . Ana does not have mouth ulcers. Ana has visible wasting. There is no pus draining from the eye and no clouding of the cornea. Ana does not have an ear problem.

MALARIA . obtain a blood smear: (+) (Pf) (Pv) (-) NOT DONE THEN ASK: Look for signs of MEASLES ‡For how long has the child has fever?__5__days. Generalized rash and ‡If more than 7 days. runny nose ‡Has the child had measles with the last 3 months? Or red eyes.‡DOES THE CHILD HAVE FEVER ?(By history/feels hot/temp.5°C or above YES_ _NO____ Decide MALARIA risk: ‡Does the child live in malaria area? LOOK AND FEEL: ‡Has the visited or stayed overnight Look and feel for stiff neck in a malaria area for the past 4 weeks? Look for runny nose If Malaria risk.37. has fever been present everyday? One of these: cough.

are they deep and extensive? Look for pus draining from the eye Look for clouding of the cornea Measles .If the child has measles now or within last 3months Look for mouth ulcers If yes.

CHECK FOR MALNUTRITION AND ANEMIA Look for visible severe wasting Look for edema of both feet Look for palmar pallor Severe palmar pallor? Some palmar pallor? Determine weight for age Very low? SEVERE MALNUTRITION OR SEVERE ANEMIA .

It has been present for 21 days.Case 2: David David is 11 months old.5°C. His mother says he has had a dry cough for the last 3 weeks. His palms are very pale and appear almost white. David does not have any general danger signs. He counted 41 breathes/min. There is no edema of both feet. The health worker checked David for malnutrition and anemia. David does not have visible severe wasting. He has not had a fever during this illness. . The health worker determined David weight for age. The health worker assessed his cough. The health worker does not see chest indrawing. There is no stridor when the child is calm. He does not have an ear problem. David does not have diarrhea. He weighs 8kg. His temperature is 36.

Fast breathing? Look for chest indrawing Look and listen for stridor ‡No Pneumonia ‡Cough or cold .MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child s Name:________________Age:_____ Weight______kg. Temperature_______ ASK:What are the child s problems?______________Initial Visit_______follow-up visit__________ Assess(Circle all signs present) Classify CHECK FOR DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN General Danger Signs Present? YES___NO__¥ _ DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING ‡For how long?__21 days YES__ __ NO____ Count the breaths in one minute __41__breaths per minute.

CHECK FOR MALNUTRITION AND ANEMIA Look for visible severe wasting Look for edema of both feet Look for palmar pallor Severe palmar pallor? Some palmar pallor? Determine weight for age Very low? SEVERE MALNUTRITION OR SEVERE ANEMIA .

OPV1.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. HEP B1 DPT2. HEP B3 MEASLES . HEP B2 DPT3. OPV2. OPV3.

The child should return when the next dose of OPV is due for an extra dose of OPV .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.

OPV1. No Anemia and No Very Low Weight Immunization history: BCG. 6 months old. DPT1. Classified as Diarrhea with no Dehydration and also Anemia. Metro.CHECK IMMUNIZATION STATUS OF THE FOLLOWING CHILDREN: 1. OPV1. 3 months old. he received OPV2. No general danger signs. HEP B1 at birth. and HEP B1 given 5 weeks ago. When Mark was 7 months old. Classified as No Pneumonia: Cough or Cold and No Anemia and Not Very Low Weight for Age. 9 months old. Mark. OPV1. 3. DPT1 and HEP B1. No general danger signs. Immunization history: BCG. DPT2 and HEP B2.HEPB2. Victor has diarrhea. DPT1. No general danger signs. Malaria. OPV2 and DPT2 given 6 weeks ago. Classified as Pneumonia. . Immunization history: BCG. 2. Victor.

When should he return for his next immunization Metro Victor Mark . What immunizations. does the child need today? 3.CHECK IMMUNIZATION STATUS OF THE FOLLOWING QUESTIONS 1. if any. Is the child up to date with his immunization? 2.

000 IU) up to the age of 59 months (4 years and 11 months) .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.

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

ASSESS THE YOUNG INFANT ASK? †IS THE INFANT HAVING DIFFICULTY OF BREATHING? †HAS THE INFANT HAD CONVULSIONS? .

LISTEN & FEEL † COUNT THE NUMBER OF BREATHS † SEVERE CHEST INDRAWING † MEASURE AXILLARY TEMPERATURE † LOOK AT THE UMBILICUS † LOOK FOR SKIN PUSTULES † LOOK AT THE YOUNG INFANT MOVEMENT .ASSESS THE YOUNG INFANT LOOK.

LOCAL BACTERIAL INFECTION ‡ NOT FEEDING WELL OR ‡CONVULSION ‡FAST BREATHING ‡SEVERE CHEST INDRAWING ‡FEVER ‡LOW BODY TEMPERATURE ‡MOVEMENT ONLY WHEN STIMULATED OR NO MOVEMENT AT ALL VERY SEVERE DISEASE ‡UMBILICAL IS RED OR DRAINING PUS ‡SKIN PUSTULE ‡NO SIGNS OF VERY SEVERE DISEASE LOCAL BACTERIAL INFECTION SEVERE DISEASE OR LOCAL INFECTION UNLIKELY .

Anselmo is calm and awake. There is no pus in his ears. He is brought to the health center because he is having difficulty in breathing. His mother says that Anselmo has not had convulsions.ASSESS & CLASSIFY Anselmo is a 3 week old infant. there are no skin pustules.50C. and his movements are normal. The health worker first checks the young infant for signs of possible bacteria infection. He does not have diarrhea. The health worker counts 74 breath per minute. the umbilicus is normal. His axillary temperature is 36. He finds Anselmo has severe chest indrawing . His weight is 3. .6 kg.

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CHECK FOR JAUNDICE ‡ANY JAUNDICE IF AGE LESS THAN 24 HOURS ‡YELLOW SOLES AND PALM AT ANY AGE SEVERE JAUNDICE ‡JAUNDICE AFTER 24 HOURS OF ANY AGE ‡SOLES AND PALMS ARE NOT YELLO NO JAUNDICE JAUNDICE NO JAUNDICE .

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE ASK: ‡ Is the infant breastfed? If yes. what do you use to feed the infant? . how often? ‡ If yes. how many times in 24 hours? ‡ Does the infant usually receive any other foods or drinks? If yes.

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE LOOK. LISTEN.FEEL: .

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
‡Not well attached to breast or Not suckling effectively, or Less than 8 breastfeeds in 24 hours, or Receives other foods or drinks, or Low weight for age, or Thrush (ulcers or white patches in mouth)
FEEDING PROBLEM OR LOW WEIGHT FOR AGE
If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. Advise her to breastfeed as often and for as long as the infant wants, day and night. If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup. If not breastfeeding at all: - Refer for breastfeeding counselling and possible relactation. - Advise about correctly preparing breastmilk substitutes and using a cup. Advise the mother how to feed and keep the low weight infant warm at home If thrush, teach the mother to treat thrush at home. Advise mother to give home care for the young infant. Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days.

‡Not low weight for age and no other signs of inadequate feeding

NO FEEDING PROBLEM

Advise mother to give home care for the young infant. Praise the mother for feeding the infant well

IDENTIFY TREATMENT
Aged 2 Months Up to 5 Years

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 hospitalµ 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.

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

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 for Severe Classification Do not give treatments that would unnecessarily delay the referral except in † SEVERE  PERSISTENT DIARRHEA Referral is needed. 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. .

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 When needing urgent referral. quickly identify and begin the most urgent treatment.

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 (38.5ÝC 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 † . positive torniquet test.Identify Urgent Pre-referral Treatment Needed Give ORS according to Plan B for a child with SEVERE DENGUE HEMORRHAGIC FEVER with only petechiae.

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. and NGT can be inserted. If you suspect that she does not want to take the child. he/she will need to be given an intramuscular injection of chloramphenicol If the child needs treatment to prevent low blood sugar. find out why . 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.

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 .

2010 9:30 am Urgent Referral to Aliaga District Hospital Venus Canalita. age 20 months Referred for: Severe Dehydration Severe Malnutrition Also has a cough ²no fast breathing no chest indrawing Treatment given at Rural Health Station: Vitamin A 200. Aliaga . Mendoza Mauway Brgy. Health Station San Carlos.000 IU ORS mother to give sip on way to hospital Needs measles immunization ² not given Roberta C.Example of Referral Note August 25.

TREAT THE CHILD Aged 2 Months Up to 5 Years .

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

VERY SEVERE DISEASE.Select an Appropriate Oral Drug and Determine the Dose and the Schedule For PNEUMONIA.Give three times daily for 5 days TABLET 250 mg 1/2 1 SYRUP 125 mg/ 5 mL 5 mL 10 mL . ACUTE EAR INFECTION. MASTOIDITIS † First-line antibiotic: Cotrimoxazole † Second-line antibiotic: Amoxycillin AGE OR WEIGHT COTRIMOXAZOLE .Give two times daily for 5 days ADULT TABLET 80 mg/ 400/mg 2 months up to 12 months (4-10 kg) 12 months up to 5 years (10-19 kg) 1/2 1 SYRUP 40 mg/ 200 mg/ 5 mL 5 mL 10 mL AMOXYCILLIN .

25 mL (1/4 tsp) 2.Give two times daily for 5 days AGE OR WEIGHT 2 months up to 4 months (4-6 kg) 4 months up to 12 months (6-10 kg) 12 months up to 5 years (10-19 kg) See above dosage NALIDIXIC ACID .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 .5 mL (1/2 tsp) 5 mL (1 tsp) .Give four times daily for 5 days SYRUP 250 mg/ 5 mL 1.

Give two times daily for 5 days See above dosage .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 † Second-line antibiotic: Cotrimoxazole TETRACYCLINE .Give four times daily for 3 days AGE OR WEIGHT 2 months up to 4 months (4-6 kg) 4 months up to 12 months (610 kg) 12 months up to 5 years (1019 kg) 1/2 1 CAPSULE (250 mg) COTRIMOXAZOLE .

Falciparum. a single dose of Sulfadoxine/Primaquine is given. 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.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. 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 † .

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

Sulfadoxine and Pyrimethamine † Second-line: Artemeter-Lumefrantine If Chloroquine † Explain to watch child carefully for 30 minutes after giving a dose of Chloroquine.Select an Appropriate Oral Drug and Determine the Dose and the Schedule Give an oral antimalarial † First-line: Chloroquine. Primaquine. 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 .

Give daily for 14 days for p. vivax TABLET (15 mg) SULFADOXINE + PYRIMETHAMINE .Select an Appropriate Oral Drug and Determine the Dose and the Schedule CHLOROQUINE .Give for 3 days PRIMAQUINE . falciparum TABLET (15 mg) DAY 2 1/2 DAY 3 1/2 1/4 PRIMAQUINE .Give single dose in health center for P.Give single dose in health center TABLET (500 mg/ 25 mg) AGE TABLET (150 mg) DAY 1 1/2 2 months up to 5 months (4-7 kg) 5 months up to 12 months (7-10 kg) 12 months up to 3 years (10-14 kg) 3 years up to 5 years (1419 kg) 1/2 1/2 1/2 1/2 1 1 1/2 1/2 1/4 3/4 1 1/2 1 1/2 1 3/4 1/2 1 .

Select an Appropriate Oral Drug and Determine the Dose and the Schedule Give Paracetamol for High Fever (38.5Ý or higher) or Ear Pain † Give one dose Paracetamol in the center then give enough for one day PARACETAMOL AGE OR WEIGHT 2 months up to 3 years (414 kg) 3 to 5 years (14-19 kg) TABLET (500 mg) 1/4 1/2 SYRUP (120 mg/ 5 mL) 5 mL (1 tsp) 10 mL (2 tsp) .

or SEVERE MALNUTRITION or VERY LOW WEIGHT † For both treatment and supplementation.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. 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  . or MEASLES.

000 IU 1/2 1 .000 IU 6 months up to 12 months 12 months up to years 1 - 200.Select an Appropriate Oral Drug and Determine the Dose and the Schedule AGE VITAMIN A CAPSULES 100.

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). it may be given . If the Iron available does not contain Folate. do not give Iron/Folate tablet yet until a follow-up visit in two weeks.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.

6 mL 1 mL 1.5 mL 2 mL .Select an Appropriate Oral Drug and Determine the Dose and the Schedule AGE OR WEIGHT IRON/FOLATE TABLET Ferrous sulfate 200 mg + 250 mcg folate (60 mg elemental iron) IRON SYRUP Ferrous sulfate 150 mg/ 5mL (6 mg elemental iron per mL) 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 3 years (10-14 kg) 3 years up to 5 years (14-19 kg) 1/2 1 2.5 mL (1/2 tsp) 4 mL (3/4 tsp) 5 mL 10 mL (1 ½ tsp) 0.

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 previous six months AGE OR WEIGHT 12 months up to 23 months 24 months up to 59 months ALBENDAZOLE 400 mg Tablet 1/2 1 MEBENDAZOLE 500 mg Tablet 1 1 .

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 Success of home treatment depends on how well the health care worker communicated.

such as common containers  Give feedback  Encourage to ask questions  .Use Good Communication Skills ADVISE THE MOTHER HOW TO TREAT HER CHILD AT HOME † Three basic steps in teaching Give information ² explain how to do the task  Show an example ² show how to do the task  Let her practice ² ask to do the task while you watch  † When teaching Use words easily understood  Use teaching aids that are familiar.

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 describe WHY. or WHEN GOOD CHECKING QUESTIONS How will you prepare the ORS? How often should you breastfeed your child? On what part of the eye do you apply the ointment? How much extra fluid should you give after each loose stool? Why is it important for you to wash your hands? POOR CHECKING QUESTIONS Do you remember how to mix the ORS? Should you breastfeed your child? Have you used ointment on your child before? Do you know how to give extra fluids? Will you remember to wash your hands? . HOW.

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.25 mL ² ¼ tsp  2.5 mL ² ½ tsp  5 mL ² 1 tsp  . show how to measure using common household teaspoon 1.

If the child vomits within 30 minutes. give another dose. 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 . wait until the child is rehydrated before giving the dose again Explain carefully. If the child is dehydrated and vomiting.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.

keeping it clean and dry † Ask questions to make sure the mother understands † If more than one drug will be given.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. 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

OMIT or DELAY † Feeding assessment and couselling † Soothing remedy for cough and cold † Paracetamol † Iron treatment † Wicking the ear .Determine Priority of Advice Essential treatments include giving antibiotics or antimalarial drugs. and giving fluids to a child with diarrhea If necessary.

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 † .

5 mL = 630 mg 9 months up to 12 months (8-10 kg) 2 mL = 360 mg .5 mL = 450 mg 3.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 Repeat injection every 12 hours for 5 days  Change to appropriate antibiotic to complete 10 days of AGE OR WEIGHT CHLORAMPHENICOL 40 mg/ kg treatment  Add 5 mL sterile water to vial containing 1.000 mg = 5.5 mL = 270 mg 2.6 mL at 180 mg/ mL 2 months up to 4 months (4-6 kg) 4 months up to 9 months (6-8 kg) 12 months to 3 years (10-14 kg) 3 to 5 years (14-19 kg) 1 mL = 180 mg 1.

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 .

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

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) 12 months up to 2 years (10-12 kg) 2 years up to 3 years (12-14 kg) 3 years up to 5 years 914-19 kg) 0.4 mL 0.5 mL 0.3 mL 0.6 mL .

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 . or when the child is not able to eat for many hours † Giving some breastmilk. breastmilk substitute.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.

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 These Treatments in Health Center Only † If  the child is not able to swallow Give 50 mL of milk or sugar water by nasogastric tube † If the child is difficult to awaken or unconscious.

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  .

no food-based fluids For children not exclusively breastfed. breastfeed frequently and longer. 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 ² 50 to 100 mL after each loose stool 2 years or older ² 100 to 200 mL after each loose stool . give one or more of the following: ORS.Give Extra Fluid for Diarrhea and DHF and Continue Feeding † GIVE   EXTRA FLUIDS For exclusively breastfed babies. and/or clean water Tell the mother  Teach how to mix and give ORS. food-based fluids. For children over six months. and give ORS or clean water.

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 † 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.

and number of stools passed during rehydration will affect the amount of ORS needed . do not try to rehydrate before leaving. reassess and classify † DETERMINE THE AMOUNT OF ORS TO GIVE DURING THE FIRST FOUR HOURS  The age or weight.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. The child will be given frequent sips of ORS on the way † After four hours. degree of dehydration.

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  MOTHER HOW TO GIVE ORS Food should not be given within the first four hours of treatment .

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 † 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. Stop ORS and give clean water or breastmilk. it is a sign of overhydration.

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 † Oral special feeding Treat dysentery 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 .

irritability and soreness † Measles: fever and mild rash a week after lasting for oneto three days † Hepatitis B: none † . 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.Immunize Every Sick Child as Needed Record all immunizations on the child·s immunization card If the child has diarrhea and needs OPV.

COUNSEL THE MOTHER .

fatty acids needed for the infant·s growing brain. eyes. lactose. fat.Feeding Recommendations Ages from birth up to six months † Breastfeed exclusively † Breastmilk contains protein. iron. 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 . Vitamins A and C.

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

Feeding Recommendations † Good  complementary foods Energy and nutrient-rich and locally affordable foods  Examples are thick cereal with added oil or milk. and milk products  When giving complementary food to a child between four and six months old. legumes. meat. fruits. beans. 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. vegetables. these and any other drinks should be given by cup. NOT by feeding bottle . fish. eggs.

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 .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.

semi-solid foods DO NOT USE CONDENSED OR EVAPORATED MILK For other foods. follow the feeding recommendation for the child·s age .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.

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?  . or † Less than 2 years old † Ask questions about usual feeding and during this illness.Assess the Child·s Feeding Assess the feeding of children who Classified as having ANEMIA or VERY LOW WEIGHT.

how? .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.

Show correct positioning and attachment † Use of feeding bottle ² often dirty. is not given own serving. varied. Demonstrate the use of spoon or cups † Lack of active feeding ² child not encouraged to eat. offer nutritious. Clear blocked nose † . Breastfeed more frequently. and appetizing foods.Identify Feeding Problems Identify differences between actual feeding and the recommendations Examples of feeding problems Difficulty in breastfeeding ² check the mother·s reason. has to compete with other siblings † Not feeding well during illness ² offer favorite food to encourage eating.

egg yolk. steamed tokwa. chopped meat. chicken. pulverized roasted dilis. and munggo † Improper handling and use of breastmilk substitute counsel on proper preparation and handling of breastmilk substitute .Identify Feeding Problems † Not giving protein source of food in lugaw or rice ² add or mix protein-rich sources of food such as flaked fish.

assess breastfeeding. and gradually reducing other milk or foods . day and night. 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.Counsel the Mother About Feeding Problems If mother reports difficulty with breastfeeding.

Do NOT pour the milk into the baby·s mouth † . including night. counsel to breastfeed as much as possible.Counsel the Mother About Feeding Problems If other milk needs to be continued. † 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.

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 .Counsel the Mother About Feeding Problems If the child is not being fed actively. appetizing. counsel to Breastfeed more frequently and longer † Use soft. 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. varied.

Use pictures or real objects if possible .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 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 .

and when to return to health worker.Use of Mother·s Card A mother·s card can be given to help remember appropriate foods and fluids. 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 † .

rice water. For example giving soup.Advise the Mother to Increase Fluids During the Illness For any sick child † Breastfeed more frequently and longer at each feed † Increase fluid. buko juice or clean water For child with diarrhea † Give according to Plan A or Plan B on the TREAT THE CHILD CHART .

if fever persists PERSISTENT DIARRHEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEMS MANY OTHER ILLNESSES. if fever persists FEVER (NO MALARIA). if not improving ANEMIA VERY LOW WEIGHT FOR AGE Return for follow-up in 2 days 5 days 14 days 30 days . if the fever persists FEVER-MALARIA UNLIKELY.Advise the Mother When to Return to a Health Center Follow-up visit If the child has PNEUMONIA DYSENTERY MALARIA. if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS DENDUE HEMORRHAGIC FEVER UNLIKELY.

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

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

4 months up to 6 months † Play: Reaching for objects and putting things in mouth. large. † Communicate: Crying. feeling.Recommendation By Age Group Birth to 4 months † Play: Learning is through seeing. Have clean. and moving. hearing. colorful things to see and reach † Communicate: New sounds like squeals and laughter. Smile at the child and communicate with sounds and gestures .

Give them clean things to handle † Communicate: Imitation of sounds and actions.Recommendation By Age Group 6 months up to 12 months † Play: Making noise like banging objects together or dropping them. They like to stack things up and put things into containers . Begin telling the names of things and people 12 months up to 2 years † Play: More active and wants to move around and explore. Children understand words before they learn to say them.

Teach stories. games.Recommendation By Age Group † Communicate: Learning to speak. 2 years and older † Play: Help your child count. and songs. Should be corrected gently so that they will not be discouraged or feel ashamed . Can answer simple questions. name and compare things † Communicate: Encourage to talk. and answer child·s questions.

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? .

She feels she needs extra time because of the many household chores . 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.Identify Problems in Care for Development Identify the difference between the actual care provided and the recommendations for care and give some recommendations.

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 ´slowµ. 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 .

assessing and classifying them as in an initial visit † Ask the mother about the child·s problem. ask if the child has developed any new problem. This requires a full assessment .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. Determine if this is a follow-up or an initial visit for this illness † If for follow-up.

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.Objectives If no new problem. 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. he/she may have an illness different from that suggested by the chart. follow the instructions in the FOLLOW-UP box that matches the child·s previous classification † If the child has any kind of diarrhea. He/she may need other treatments provided in a hospital † . showing signs of shock.

then refer urgently to 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.

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

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). Give any treatment needed. tell to follow the usual recommendations for the child·s age . then refer to a hospital † If diarrhea has stopped (child having less than 3 loose stools per day). do a full reassessment.

treat dehydration .Dysentery After 2 days † Assess the child for diarrhea Ask Are there fewer stools? † Is there less blood in the stool? † Is there less fever? † Is there less abdominal pain? † Is the child eating better? † Treatment † If the child is dehydrated.

REFER to hospital † If fewer stools. abdominal pain.Dysentery † If number of stools. and eating better. less fever. Advise to return in 2 days  Except if the child    Less than 12 months old. change to second-line oral antibiotic recommended for Shigella. Give for 5 days. or eating is the same or worse. continue giving antibiotic until finished . less abdominal pain. amount of blood of stools. or Had measles within the last 3 months. or Was dehydrated on the first visit. less blood in the stools. fever.

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  . 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. or returns within 14 days.Malaria If fever persists after 2 days.

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

Advise to return in 2 days if fever persists  If fever has been present for 7 days. 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.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. refer for assessment  .

If there has been travel and overnight stay. classify and treat as FEVER with MALARIA RISK . 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. do a full assessment Make sure there has been no travel to malarious area and overnight stay in malaria area.Fever (No Malaria) If fever persists after 2 days.

advise to return in 2 days if fever persists  If fever has been present for 7 days. refer for assessment  . provide treatment  If no apparent cause of fever.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.

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

refer for assessment † If no apparent cause of fever.Fever: Dengue Hemorrhagic Fever Unlikely † If with any other 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 . provide treatment † If fever has been present for 7 days.

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

or there is a very foul smell from the mouth.Measles With Eye or Mouth Complications Treatment for mouth ulcers † If mouth ulcers are worse. refer to hospital † If mouth ulcers are the same or better. continue using half-strength gentian violet for a total of 5 days .

treat with 5 more days of the same antibiotic.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. Continue wicking ear. Follow-up in 5 days . treat as MASTOIDITIS † Acute ear infection: if ear pain or discharge persists.5ÝC or above).

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

ask to return If child has very low weight for age. If you advise significant changes in feeding.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. ask to return in 30 days after initial visit to measure weight gain .

refer for assessment .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 . praise and encourage to continue † If still very low weight for age.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. 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.

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

fever. or low body temperature . They frequently have only general signs such as few movements.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.

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 .Objectives Assessing and classifying for possible bacterial infection Assessing and classifying for diarrhea Checking for feeding problem or low weight.

repeat count if elevated  Severe chest indrawing  Nasal flaring  Grunting  . 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).Assess and Classify the Sick.

Fever = Axillary temperature of >37.5ÝC or rectal temperature of >38ÝC  Skin pustules: Are there many or severe pustules?  Abnormally sleepy or difficult to awaken  Movements: Are they less than normal?  . 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.Assess and Classify the Sick.

Assess and Classify the 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 . Young Infant Classify all sick.

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  if with blood in the stool Refer immediately  Do not start antibiotic but give frequent sips of ORS on the way .

how often? . how many times in 24 hours? † ASK: Does the young infant usually receive any other food or drink? If yes. 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.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.

ask if mother can wait and tell you when the infant is willing to feed again † . ask to put infant to the breast and observe for 4 minutes † If infant was fed during the last hour.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.

Young Infant † Is  the infant able to attach? No attachment at all  Not well attached  Good attachment † To  check attachment.Assess and Classify the Sick. 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) .

.

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  PROBLEM OR LOW WEIGHT Advise to breastfeed as often and for as long as the infant wants.Assess and Classify the Sick. day and night .

reducing other foods and drinks and using a cup  If thrush. counsel about breastfeeding more. 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 If receiving other foods or drinks.

Young Infant Check the infant·s immunization status Assess other problems .Assess and Classify the Sick.

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

advice.Identify Appropriate Treatment Identify treatments for a young infant who does not need urgent referral † Record treatments. and when to return for follow-up procedures as in referring a young child Refer the young infant † Same  Referral note  Explain why to refer  Teach what she needs to do along the way .

Identify Appropriate Treatment that young infants are particularly vulnerable If mother will not take the infant to the hospital. follow guidelines WHEN REFERRAL IS NOT POSSIBLE Explain .

25 mL 2.25 mL 2.5 mL 1/4 AMOXICILLIN Give three times daily for 5 days TABLET (250 mg) SYRUP (125 mg/ 5 mL) 1.5 mL .Treat the Sick Young Infant and Counsel the Mother Give an appropriate antibiotic † First-line: Amoxicillin † Second-line: Cotrimoxazole COTRIMOXAZOLE Give two times daily for 5 days AGE OR WEIGHT Birth up to 1 month (<3 kg) 1 to 2 months (3-4 kg) 1/4 ADULT TABLET (80 mg/ 400 mg) SYRUP (40 mg/ 200 mg/ 5 mL) 1.

. Combination is effective against broader range of bacteria † Referral is best option for infant with POSSIBLE BACTERIAL INFECTION. If not possible. Give Amoxicillin or Benzylpenicillin instead Give first dose of intramuscular antibiotics † Gentamicin and Benzylpenicillin. give Benzylpenicillin every 6 hours and Gentamicin one dose daily for at least five days.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.

000.4 ml 0.5 ml at 400.5 ml 0.0 ml at 250.000 units/ ml 0.Treat the Sick Young Infant and Counsel the Mother WEIGHT GENTAMICIN 5 mg per kg Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml 1 kg 2 kg 3 kg 4 kg 5 kg Add 6 ml sterile water to 2 ml vial containing 80 mg = 8 ml at 10 mg/ml BENZYLPENICILLIN 50.1 ml 0.6 ml 0.6 ml Add 3.2 ml 0.2 ml 0.5 ml 2.000 units) Add 2.0 ml 2.000 units per kg To a vial of 600 mg (1.5 ml .000 units/ ml 0.1 ml sterile water = 2.0 ml 1.5 ml 1.4 ml 0.6 ml sterile water = 4.8 ml 1.0 ml 0.

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. † Return for follow-up in two days or sooner if infection worsens † . Watch and guide her. Half strength used in the mouth † Explain and demonstrate the treatment. young infant.Treat the Sick Young Infant and Counsel the Mother Treat diarrhea according to TREAT THE CHILD chart Immunize every sick.

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  how to hold infant With the infant·s head and body straight .

Touch infant·s lips with mother·s nipple  Wait until infant·s mouth is opening wide  Move infant quickly onto breast. with infant·s nose opposite her nipples  With infant·s body close to her body  Supporting infant·s whole body. aiming infant·s lower lip well below the nipple .Treat the Sick Young Infant and Counsel the Mother Facing mother·s breast. not just neck and shoulders  † Show  her how to help the infant to attach.

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 Breastfeeding or drinking poorly Becomes sicker Develops fever Fast breathing Difficult breathing Blood in stool  When to return immediately       † 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 .

continue giving the 5 days of antibiotic and continue treating the local infection at home . Are there many or severe pustules? Treatment † If the pus or redness remains or is worse. refer † If improved.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.

ask to bring the infant back again  If infant is low weight for age. or young infant has lost weight. ask to return in 14 days after initial visit to measure weight gain  † Exception: if you think that feeding will not improve. refer .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 return within a month or when she returns for immunization  If still low weight for age. praise mother. but feeding well. praise the mother and encourage to continue  If still low weight for age. Ask to return within 14 days or when she returns for immunization. if this is within 2 weeks  .Low Weight After 14 days † Weigh and determine if still low weight for age † Reassess feeding If no longer low weight for age. counsel about feeding problem. and still with feeding problem.

or young infant has lost weight.Low Weight † Exception: if you think that feeding will not improve. refer .

and is feeding well. or if with problems with attachment or sucking. refer  If thrush is the same or better.Oral Thrush After 2 days † Look for ulcers or white patches in the mouth † Reassess feeding If thrush is worse. continue half-strength gentian violet for a total of 5 days  .

irritability and soreness † Measles: fever and mild rash a week after lasting for oneto three days † Hepatitis B: none † . 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.Immunize Every Sick Child as Needed Record all immunizations on the child·s immunization card If the child has diarrhea and needs OPV.

RN. MAN . MESDE.JENNIFER H.

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