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Childhood Illness1
 

Childhood Illness1

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    Childhood Illness1 Childhood Illness1 Document Transcript

    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age Management of Childhood Illness up to 5 years age
    • © 2007 MKFC Stockholm College Management of Childhood Illness contents up to 5 years age 3 1. the health Worker 14 2.7. checking immunization status and childhood illnesses 14 2.7.1. Vaccinations (Immunizations) – simple, sure protection 14 2.7.2. The most important vaccines 3 1.1. hoW to Work – a good strategy 15 2.8. assessing other problems 3 1.2. the health status of children is important 15 2.9. if the children age 2 months 3 1.3. good communication is important up to 5 years needs urgent medical care 4 1.3.1. The steps to good communication 16 2.9.1. Urgent pre–referral treatments 16 2.10. counselling a mother or caretaker 5 2. children age 2 months 17 2.11. the advices health Worker can give up to 5 years 17 2.11.1. Advise to continue feeding and increase fluids 17 2.11.2. Teach how to give oral drugs or to treat local infection at home 5 2.2. general danger signs 18 2.11.3. Advice when to return 5 2.2.1. The following danger signs should be checked in all children 18 2.12. folloW–up care 6 2.3. checking main symptoms 6 2.3.1. Cough or difficult breathing – Controll 19 3. young infants 7 2.3.2. Diarrhoea age 1 Week up to 2 months 7 2.3.2.1. How severe diarrhoea – dehydration 9 2.3.2.2. Recommended drinks for a child with diarrhoea 19 3.1. assessment of sick young infants 10 2.3.2.3. Classification of dysentery 19 3.2. checking for main symptoms 10 2.4. fever 19 3.2.1. Bacterial infection 10 2.4.1. A child having fever should be controlled for 19 3.2.2. Important to check 11 2.4.2. Measles 20 3.2.3. Diarrhoea 12 2.5. ear problems 20 3.3. feeding problems or loW Weight 12 2.5.1. Important to check 20 3.3.1. Important to check 12 2.5.2. Treatment 21 3.3.2. Feeding Problems or Low Weight? 13 2.5.3. Prevention 21 3.4. checking immunization status 13 2.5.4. Infection in the ear canal 21 3.5. assessing other problems 13 2.6. the nutritional status – 22 3.6. counselling a mother or caretaker malnutrition and anaemia 22 3.7. folloW–up care 13 2.6.1. Poor nutrition can result in the following health problems: 13 2.6.2. Assessing the child’s feeding 13 2.6.3. Council the mother or the caretaker Sources: http://www.who.int/child-adolescent-health/integr.htm http://www.hesperian.org/publications_download_wtnd.php 2
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 1. the health Worker and childhood illnesses 1.1. How to work – a good strategy The strategy • preventive and curative health care • to improve and get better practices in the health system and specially at homes The goals are • improvment in family and community health care practices • to reduce death and the frequency and severity of illness and disability • to contribute to improved growth and development in the country Principles • To get to know what are the general danger signs. • To assess, check the persons major symptoms. • To classify how severe the person´s condition is. • Councelling the caretakers about home care, for example about feeding, fluids and when to return to a health facility. 1.2. The health status of children is important Children´s health – things that affect positively • Good mother and childcare • Improvements in breastfeeding • Childhood vaccinations • Oral rehydration therapy; the child can get enough food and fluid –> re- duction in diarrhoea deaths • Effective antibiotics 1.3. Good communication is important A good communication It is important to communicate effectively, in a good way with the child>s mother or caretaker. Good communication techniques and an ability to as- sess, to observe, to notice and judge the common problems or signs of dis- ease or malnutrition are needed. Using good communication helps the mother or caretaker to be sure that the child will receive good care. For example if the mother or caretaker knows how to give the treatment and understands its importance – it can be a suc- cesful home treatment. 3
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 1.3.1. The steps to good communication • Listen carefully to what the caretaker says. This will show them that you take their concerns, problems seriously. • Use words the caretaker understands. Try to use local words and avoid medical terminology. • Give the caretaker time to answer questions. S/he may need time to reflect, to think and decide. • Ask additional questions when the caretaker is not sure about the answer. A caretaker may not be sure if a symptom is not so obvious. Ask additional, more questions to help her/him give clear answers. 4
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2. children age 2 months up to 5 years 2.1. Assessment of sick children includes • communicate with the caretaker – get the history; who is the child, how old, when did the child get sick etc. • check the general danger signs; • check the main symptoms; • check the nutritional status; • assess the child’s feeding; • check the immunization status; and • assess the other problems. 2.2. General Danger Signs A sick child may have signs that clearly indicate a specific problem. For exam- ple, a child may have chest indrawing and cyanosis (cyanosis means that the child gets bluish), which indicate severe pneumonia. 2.2.1. The following danger signs should be checked in all children The child has had convulsions during the present illness Convulsions may be the result of fever. Convulsions are when a person’s body shakes rapidly and uncontrollably. All children who have had convulsions during the present illness should be considered seriously ill. The child is unconscious or lethargic An unconscious child is likely to be seriously ill. A lethargic child, who is awake but does not take any notice of his or her surroundings or does not respond normally to sounds or movement, may also be very sick. The child is unable to drink or breastfeed A child may be unable to drink either because s/he is too weak or because s/ he cannot swallow. Do not rely completely on the mother’s evidence for this, but observe while she tries to breastfeed or to give the child something to drink. The child vomits everything The vomiting itself may be a sign of serious illness, but it is also important to note because such a child will not be able to take medication or fluids for rehydration. 5
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age If a child has one or more of these signs, s/he must be considered seriously ill and will almost always need to be controlled if it is – acute respiratory infection (ARI), diarrhoea, and fever (especially associated with malaria and measles). – A checking of nutritional status is also important, as malnutrition is an- other main cause of death. 2.3. Checking main symptoms After checking for general danger signs, the health care worker must check for main symptoms. 1) cough or difficult breathing; 2) diarrhoea; 3) fever; and 4) ear problems. The first three symptoms are included because they often result in death. Ear problems are included because they can cause disabilities if not treated. 2.3.1. Cough or difficult breathing – Controll Three signs are used to assess a sick child with cough or difficult breathing: • Respiratory rate, how many times the child breaths per minute, which dis- tinguishes children who have pneumonia from those who do not; • Lower chest wall indrawing, which indicates severe pneumonia; and • Stridor (noisy breathing in children when child breathes in) which indi- cates those with severe pneumonia who require hospital care. The point at which fast breathing is considered to be fast depend on the child’s age. Normal breathing rates are higher in children age 2 months up to 12 months than in children age 12 months up to 5 years. Child’s Age Rate for Fast Breathing 2 months up to 12 months 50 breaths per minute or more 12 months up to 5 years 40 breaths per minute or more Lower chest wall indrawing, defined as the inward movement of the bony struc- ture of the chest wall with inspiration, is a useful indicator of severe pneu- monia. 6
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age Stridor is a harsh noise made when the child inhales (breathes in). Sometimes a wheezing noise is heard when the child exhales (breathes out). This is not stridor. A wheezing sound is most often associated with asthma. 2.3.2. Diarrhoea When a person has loose or watery stools, he has a diarrhoea. Diarrhoea can be mild or serious. Diarrhoea is more common and more dangerous in young children, especially those who are poorly nourished. Although diarrhoea has many different causes, the most common are infec- tion and poor nutrition. With good hygiene and good food, most diarrhoea could be prevented. And if treated correctly by giving lots of drink and food, fewer children who get diarrhoea would die. Most children who die from diarrhoea die because they do not have enough water left in their body. This lack of water is called dehydration. Diarrhoea is a symptom that should be checked in every child that is not feel- ing well. The caretaker of a child with diarrhoea should be asked how long the child has had diarrhoea and if there is blood in the stool. This will allow identifica- tion of children with persistent diarrhoea and dysentery. All children with diarrhoea for 14 days or more with signs of dehydration should get to the hospital. 2.3.2.1. How severe diarrhoea – dehydration All children with diarrhoea should be checked how long time they have had diarrhoea, if blood is present in the stool and if dehydration is present. Signs of how severe the dehydration is: – Child’s general condition. If the child with diarrhoea is lethargic or unconscious or look restless/irri- table. – Sunken eyes. The eyes of a dehydrated child may look sunken. – Child’s reaction when offered to drink. A child is not able to drink if s/he is not able to take fluid in his/her mouth and swallow it. 7
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age For example, a child may not be able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the child is weak and cannot drink without help. S/he may be able to swallow only if fluid is put in his/her mouth – this is a bad sign. If the child is drinking eagerly, thirsty that is good. Notice if the child reach- es out for the cup or spoon when you offer him/her water. When the water is taken away, see if the child is unhappy because s/he wants to drink more – this is a good sign. – Elasticity of skin. Check elasticity of skin using the skin pinch test. When released, the skin pinch goes back eit er very slowly (longer than 2 seconds), or slowly (skin h stays up even for a brief instant), or immediately. How to do Skin Pinch Test • Locate the area on the child’s abdomen halfway between the umbili- cus and the side of the abdomen; then pinch the skin using the thumb and first finger. • It is important to firmly pick up all of the layers of skin and the tissue under them for one second and then release it. 8
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.3.2.2. Recommended drinks for a child with diarrhoea – breastmilk more often than usual – soups – rice water – fresh fruit juices – weak tea with a little sugar – clean water from a safe source. If there is a possibility the water is not clean, it should be purified by boiling or filtering. – oral rehydration salts (ORS) mixed with the proper amount of clean water. Drinks should be given from a clean cup. A feeding bottle should never be used because it is harder to keep clean and more likely to cause an infection. If the child vomits, the caregiver should wait for 10 minutes and then begin again to give the drink to the child slowly, small sips at a time. Diarrhoea usually stops after three or four days. If it lasts longer than one week, caregivers should seek help from a trained health worker. Foods for a person with diarhhoea When the person is womit- As soon as the child will accept food, give ing or feels too sick to eat, food he likes and accepts. Following foods or he should drink similar ones: – watery mush or broth of rice, maize powder, or Energy foods Body–building foods potato – ripe or cooked – chicken (boiled or – rice water (with some bananas roasted) mashed rice) – crackers – eggs (boiled) – chicken, meat, egg, or – rice, oatmeal, or – meat (well cooked, bean broth other well–cooked without much fat – Kool–Aid or similar grain or grease) sweetened drinks – fresh maize (well – beans, lentils, or – rehydration drink cooked or mashed) peas (well cooked – breast milk (small babies) – potatoes or mashed) – applesauce – fish (well cooked) (cooked) – papaya (It helps to add a little sugar or vegeta- ble oil to the cereal foods.) 9
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.3.2.3. Classification of dysentery A child is having dysentery if the mother or caretaker reports blood and mucus in the child’s stool. Dysentery is especially severe in infants and in children who are undernourished, who develop a dehydration during their illness, or who are not breast–fed. All children with dysentery (bloody diarrhoea) should be treated promptly with an antibiotic and that is why they have to visit a doctor. 2.4. Fever All sick children should be checked for fever. It may be caused by minor infec- tions, but may also be a sign of specific illness, particularly malaria or other severe infections, including meningitis, typhoid fever, or measles. Important to check Body temperature should be checked in all sick children. Children are considered to have fever if their body temperature is above 37.5°C axil- lary (38°C rectal). If you don’t have a thermometer, children are consid- ered to have fever if they feel hot. 2.4.1. A child having fever should be controlled for Stiff neck. A stiff neck may be a sign of meningitis, cerebral malaria or another very severe febrile disease. If the child is conscious and alert, check stuffiness by tickling the feet, asking the child to bend his/her neck to look down or by very gently bending the child’s head forward. It should move freely. Risk of malaria and other infections. Malaria risk can vary by season or places. The national malaria control pro- gramme normally defines areas of malaria risk in a country. Runny nose. When malaria risk is low, a child with fever and a runny nose does not need an antimalarial. This child’s fever is probably due to a common cold. Duration of fever. Most fevers go away within a few days. A fever that has lasted every day for more than five days can mean that the child has a more severe disease such as typhoid fever. 10
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.4.2. Measles Children with fever should be assessed for signs of current or previous measles (within the last three months). Measles is a serious virus infection. The usual signs are fever with a generalised rash, plus at least one of the following signs: red eyes, runny nose, or cough. The mother should be asked about if somebody near the family/child has had measles during the last three months. The child ususally becomes increasingly ill. The mouth may become very sore and he may develop diarrhoea. After 2 or 3 days a few tiny white spots like salt grains appear in the mouth. A day or 2 later the rash appears—first behind the ears and on the neck, then on the face and body, and last on the arms and legs. After the rash appears, the child usually begins to get better. The rash lasts about 5 days. Sometimes there are scattered black spots caused by bleeding into the skin (‘black mea- sles’). This means the attack is very severe. Get medical help. Treatment: – The child should stay in bed, drink lots of liquids, and be given nutritious food. If he cannot swallow solid food, give her liquids like soup. If a baby cannot breast feed, give breast milk in a spoon. – If possible, give vitamin A to prevent eye damage. – For fever and discomfort, give acetaminophen (or ibuprofen). – If earache develops, give an antibiotic. – If signs of pneumonia, meningitis, or severe pain in the ear or stomach develop, get medical help. Prevention of measles: Children with measles should keep far away from other children, even from brothers and sisters. Especially try to protect children who are poorly nour- ished or who have tuberculosis or other chronic illnesses. Children from other families should not go into a house where there is measles. If children in a family where there is measles have not yet had measles themselves, they should not go to school or into stores or other public places for 10 days. To prevent measles from killing children, make sure all children are well- nourished. Have your children vaccinated against measles when they are 12 to 15 months of age. 11
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.5. Ear problems Ear problems are common in small children and should be checked in all children brought to the outpatient health facility. The infection often begins after a few days with a cold or a stuffy or plugged nose. The fever may rise, and the child often cries or rubs the side of his head. Sometimes pus can be seen in the ear. In small children an ear infection sometimes causes vomiting or diarrhoea. So when a child has diarrhoea and fever be sure to check his ears. 2.5.1. Important to check When otoscopy (an instrument used to look into the ear) is not available, look for the following simple clinical signs: Tender swelling behind the ear. The most serious complication of an ear infection is a deep infection in the mastoid bone (the bone directly behind the ear). It can be tender swelling behind one of the child’s ears. In infants, this tender swelling also may be above the ear. Ear pain. In the early stages of acute otitis, a child may have ear pain, which usually causes the child to become irritable and rub, touch the ear frequently. Ear discharge or pus. This is another important sign of an ear infection. When a mother reports an ear discharge, the health care pro- vider should check for pus drainage from the ears and find out how long the discharge has been present. 2.5.2. Treatment • It is important to treat ear infections early • Carefully clean pus out of the ear with cotton, but do not put a plug of cot- ton, a stick, leaves, or anything else in the ear. • Children with pus coming from an ear should bathe regularly but should not swim or dive for at least 2 weeks after they are well. 12
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.5.3. Prevention • Teach children to wipe but not to blow their noses when they have a cold. • Do not bottle feed babies – or if you do, do not let baby feed lying on his back, as the milk can go up his nose and lead to an ear infection. • When children’s noses are plugged up, use salt drops and suck the mucus out of the nose. 2.5.4. Infection in the ear canal To find out whether the canal or tube going into the ear is infected, gently pull the ear. If this causes pain, the canal is infected. Put drops of water with vinegar in the ear 3 or 4 times a day. (Mix 1 spoon of vinegar with 1 spoon of boiled water.) If there is fever or pus, get medical help. 2.6. The nutritional status – malnutrition and anaemia Good food is needed for a person to grow well, work hard, and stay healthy. Many common sicknesses come from not eating enough. A person who is weak or sick because he does not eat enough, or does not eat the foods his body needs, is said to be poorly nourished – or malnourished. He suffers from malnutrition. 2.6.1. Poor nutrition can result in the following health problems: • the child is not growing or gaining weight normally • slowness in walking, talking, or thinking • big bellies, thin arms and legs • lack of energy, child is sad and does not play • swelling of feet, face, and hands, often with sores or marks on the skin 2.6.2. Assessing the child’s feeding A good food does not only help prevent disease, it helps the sick body fight disease and become well again. So when a person is sick, eating enough nu- tritious food is especially important. Unfortunately, some mothers stop feeding a child or stop giving certain nu- tritious foods when he is sick or has diarrhoea – so the child becomes weaker, cannot fight off the illness, and may die. Sick children need food! If a sick child will not eat, encourage him to do so. 2.6.3. Council the mother or the caretaker All children less than 2 years old and all children classified as anaemia or low (or very low) weight need to be assessed for feeding. 13
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age Council the mother or the caretaker to feed the child as much as he will eat and drink. And be patient. A sick child often does not want to eat much. So council to feed him something many times during the day. Also, try to make sure that he drinks a lot of liquid so that he pees (passes urine) several times a day. If the child will not take solid foods, council to mash the food and give them as a mush or gruel. Often the signs of poor nutrition first appear when a person has some other sickness. For example, a child who has had diarrhoea for several days may de- velop swollen hands and feet, a swollen face, dark spots, or peeling sores on his legs. These are signs of severe malnutrition. The child needs more good food! And more often. Feed the child many times during the day. During and after any sickness, it is very important to eat well. 2.7. Checking immunization status The immunization status of every sick child brought to a health facility should be checked. 2.7.1. Vaccinations (Immunizations) – simple, sure protection Vaccines give protection against many dangerous diseases. Each country has its own schedule of vaccinations. Vaccinations are usually given free. If health workers do not vaccinate in your village, take your children to the nearest health center to be vaccinated. It is better to take them for vaccina- tions while they are healthy than to take them for treatment when they are sick or dying. 2.7.2. The most important vaccines 1. DPT, for diphtheria, whooping cough (pertussis), and tetanus. For full pro- tection, a child needs 4 or 5 injections. Usually the injections are given at 2 months, 4 months, 6 months, and 18 months old. In some countries one more injection is given when a child is between 4 and 6 years old. 2. Polio (infantile paralysis). The child needs drops in the mouth 4 or 5 times. In some countries the first vaccination is given at birth and the other 3 doses are given at the same time as the DPT injections. In other countries, the first 3 doses are given at the same time as the DPT injections, the fourth dose is given between 12 and 18 months of age, and a fifth dose is given when the child is 4 years old. 3. BCG, for tuberculosis. A single injection is given under the skin of the left arm. Children can be vaccinated at birth or anytime afterwards. If any 14
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age member of the household has tuberculosis, it is important to vaccinate ba- bies in the first few weeks or months after birth. The vaccine makes a sore and leaves a scar. 4. Measles. A child needs 1 injection given no younger than 9 months of age, and often a second injection at 15 months or older. But in many coun- tries a ‘3 in 1’ vaccine called MMR is given, that protects against measles, mumps, and rubella (German measles). One injection is given when the child is between 12 and 15 months old, and then a second injection is given between 4 and 6 years of age. 5. HepB (Hepatitis B). This vaccine is given in a series of 3 injections at inter- vals of about 4 weeks after each other. Generally these injections are given at the same time as DPT injections. In some countries the first HepB is given at birth, the second at 2 months old, and the third when the baby is 6 months old. 6. Td or TT (Tetanus toxoid), for tetanus (lockjaw) for adults and children over 12 years old. Throughout the world, tetanus vaccination is recommended with 1 injection every 10 years. In some countries a Td injection is given between 9 and 11 years of age (5 years after the last DPT vaccination), and then every 10 years. Pregnant women should be vaccinated during each pregnancy so that their babies will be protected against tetanus of the newborn. Vaccinate your children on time. Be sure they get the complete series of each vaccine they need. 2.8. Assessing other problems We have talked about main symptoms. Nevertheless, health care providers still need to consider other causes of severe or acute illness. It is important to controll also the child’s other complaints and to ask questions about the caretaker’s health (usually, the mother’s). 2.9. If the children age 2 months up to 5 years needs urgent medical care All infants and children with a severe problems shall be taken to a hospital as soon as assessment is completed and necessary pre–referral treatment is done. It is important to counsel the caretaker effectively if the child is obviously severely ill. If the mother or caretaker does not accept referral, available options (to treat the child by repeated clinic or home visits) should be consid- 15
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age ered. If the caretaker accepts referral, s/he should be given a short, clear refer- ral note, and should get information on what to do during referral transport, particularly if the hospital is distant. 2.9.1. Urgent pre–referral treatments for children age 2 months up to 5 years • Appropriate antibiotic • Quinine (for severe malaria) • Vitamin A • Prevention of hypoglycemia with breastmilk or sugar water • Oral antimalarial • Paracetamol for high fever (38.5°C or above) or pain • ORS solution so that the mother can give frequent sips on the way to the hospital Note: The first four treatments above are urgent because they can prevent serious consequences such as progression of bacterial meningitis or cerebral malaria, corneal rupture due to lack of vitamin A, or brain damage from low blood sugar. The other listed treatments are also important to prevent wors- ening of the illness. If a child does not need urgent referral, check to see if the child needs non– urgent referral for further assessment; for example, for a cough that has lasted more than 30 days, or for fever that has lasted five days or more. These referrals are not as urgent, and other necessary treatments may be done before transporting for referral. 2.10. Counselling a mother or caretaker A child who is seen at the clinic needs to continue treatment, feeding and fluids at home. The child’s mother or caretaker also needs to recognize when the child is not improving, or is becoming sicker. When you teach a mother how to treat a child, use three basic teaching steps: • give information; • show an example; • let her practice. When teaching the mother or caretaker: • use words that s/he understands; • use teaching aids that are familiar; 16
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age • give feedback when s/he practices, praise what was done well and make corrections; • allow more practice, if needed; and • encourage the mother or caretaker to ask questions and then answer all questions. Finally, it is important to check the mother’s or caretaker’s understanding. 2.11. The advices health worker can give What you as a health worker give as advice will depend on the child’s condi- tion. Below some basic things that should be considered when counselling a mother or caretaker: • Advise to continue feeding and increase fluids during illness; • Teach how to give oral drugs or to treat local infection; • Counsel to solve feeding problems (if any); • Advise when to return. 2.11.1. Advise to continue feeding and increase fluids During illness, children’s appetites and thirst may be decreased. However, mothers and caretakers should be counselled to increase fluids and to offer the types of food recommended for the child’s age, as often as recommended, even though a child may take small amounts at each feeding. After illness, good feeding helps make up for weight loss and helps prevent malnutrition. When the child is well, good feeding helps prevent future illness. 2.11.2. Teach how to give oral drugs or to treat local infection at home Simple steps should be followed when teaching a mother or caretaker how to give oral drugs or treat local infections. These steps include: – what is the right drugs and dosage for the child’s age or weight; – tell the mother or caretaker what the treatment is and why it should be given; – show how to measure a dose; – watch the mother or caretaker practise measuring a dose; – ask the mother or caretaker to give the dose to the child; – explain carefully how, and how often, to do the treatment at home; – explain that All oral drug tablets or syrups must be used to finish the course of treatment, even if the child gets better; – check the mother’s or caretaker’s understanding. 17
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 2.11.3. Advice when to return Every mother or caretaker who is taking a sick child home needs to be advised about when to return to a health facility. – teach signs that mean to return immediately for further care; – advise when to return for a follow–up visit; and – tell when the next well–child or immunization visit shall be done. Advise a mother or caretaker to return to a health facility: Any sick child – Not able to drink or drink or breastfeed – Becomes sicker – Develops a fever If child has no pneumonia: cough or cold, also return if: – Fast breathing – Difficult breathing If child has diarrhoea, also return if: – Blood in stool – Drinking poorly 2.12. Follow–up care Some sick children will need to return for follow–up care. At a follow–up visit, see if the child is improving, getting better on the drug or other treat- ment that was prescribed. Some children may not respond to a particular antibiotic or antimalarial, and may need to try an another drug. Children with persistent diarrhoea also need follow–up to be sure that the diarrhoea has stopped. Children with fever or eye infection need to be seen if they are not improving. Follow–up is especially important for children with a feeding problem to ensure they are being fed adequately and are gaining weight. When a child comes for follow–up of an illness, ask the mother or caretaker if the child has developed any new problems. If she answers yes, the child requires a full assessment: check for general danger signs and assess all the main symptoms and the child’s nutritional status. 18
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 3. young infants age 1 Week up to 2 months 3.1. Assessment of sick young infants While there are similarities in the care taking of sick young infants (age 1 week up to 2 months) and children (age 2 months up to 5 years), some signs observed in infants differ from those in older children. Assessment includes the following steps: • Checking for possible bacterial infection; • Assessing if the young infant has diarrhoea; • Checking for feeding problems or low weight; • Checking the young infant’s immunization status; • Assessing other problems. It is important to remember that the guidelines above are not used for a sick new–born who is less than 1 week old. In the first week of life, new–born infants are often sick from conditions related to labour and delivery, or have conditions that require special management. 3.2. Checking for Main Symptoms 3.2.1. Bacterial infection While the signs of pneumonia and other serious bacterial infections cannot be easily seen in this age group, it is recommended that all sick young in- fants be assessed first for signs of possible bacterial infection. 3.2.2. Important to check Many signs point to possible bacterial infection in sick young infants. The most informative and easy to check signs are: Convulsions (as part of the current illness). Assess the same as for older children. Fast breathing. Young infants usually breathe faster than older children do. The breathing rate of a healthy young infant is commonly more than 50 breaths per minute. Therefore, 60 breaths per minute is the cut–off rate to identify fast breathing in this age group. If the count is 60 breaths or more, the count should be repeated, because the breathing rate of a young infant is often irregular. The young infant will occasionally stop breathing for a few seconds, followed by a period of faster breathing. If the second count is also 60 breaths or more, the young infant has fast breathing. 19
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age Severe chest indrawing. Mild chest indrawing is normal in a young infant because of softness of the chest wall. Severe chest indrawing is very deep and easy to see. It is a sign of pneumonia or other serious bacterial infection in a young infant. Nasal flaring (when an infant breathes in) and grunting (when an infant breathes out) are an indication of troubled breathing and possible pneumo- nia. A bulging fontanel (when an infant is not crying), skin pustules, umbilical redness or pus draining from the ear are other signs that indicate possible bacterial infection. Lethargy or unconsciousness, or less than normal movement also indicate a serious condition. Temperature (fever or hypothermia) may also indicate bacterial infection. Fever (axillary temperature more than 37.5°C or rectal temperature more than 38°C) is uncommon in the first two months of life. Fever in a young infant may indicate a serious bacterial infec- tion, and may be the only sign of a serious bacterial infection. Young infants can also respond to infection by dropping their body temperature to below 35.5°C (36°C rectal). 3.2.3. Diarrhoea All sick young infants should be checked for diarrhoea. 3.3. Feeding problems or low weight All sick young infants seen in health facilities should be assessed for weight and adequate feeding, as well as for breast–feeding technique. 3.3.1. Important to check • Determine weight for age. Assess the same as for older children. • Assessment of feeding. Assessment of feeding in young infants is similar to that in older children. The health worker should ask about: – breastfeeding frequency and night feeds; – what other types foods or fluids the child has eaten, how often and if the child has eaten lately; and – how the child has eaten now during this illness. 20
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age Breastfeeding - Signs that the baby is feeding well – the baby’s whole body is turned towards the mother – the baby is close to the mother – the baby is relaxed and happy – the baby’s mouth is wide open – the baby takes long, deep sucks If an infant has difficulty feeding, or is breastfed less than 8 times in 24 hours, or taking other foods or drinks, or low weight for age, then breast- feeding should be assessed. Assessment of breastfeeding in young infants includes checking if the infant is able to attach, if the infant is suckling effec- tively (slow, deep sucks, with some pausing), and if there are ulcers or white patches in the mouth (thrush). 3.3.2. Feeding Problems or Low Weight? – Not able to feed – possible serious bacterial infection. The young infant who is not able to feed, or not attaching to the breast or not suckling effectively, has a life–threatening problem. This could be caused by a bacterial infec- tion or another illness. The infant should be taken to a doctor. – Infants with feeding problems or low weight are those infants who have feed- ing problems like not attaching well to the breast, not suckling effectively, getting breastmilk fewer than eight times in 24 hours, receiving other foods or drinks than breastmilk, or those who have low weight for age or thrush (ulcers/white patches in mouth). – Infants with no feeding problems are those who are breastfed exclusively at least eight times in 24 hours and whose weight is not classified as low weight for age according to standard measures. 3.4. Checking immunization status As for older children, immunization status should be checked in all sick young infants. Equally, illness is not a contraindication to immunization. 3.5. Assessing other problems As for older children, all sick young infants need to be assessed for other potential problems mentioned by the mother or observed during the exami- nation. If a potentially serious problem is found or there is no means in the clinic to help the infant, s/he should be referred to hospital. 21
    • © 2007 MKFC Stockholm College Management of Childhood Illness up to 5 years age 3.6. Counselling a mother or caretaker As with older children, the success of home treatment depends on how well the mother or caretaker knows how to give the treatment, understands its importance, and knows when to return to a health care provider. Counselling the mother or caretaker of a sick young infant includes the fol- lowing essential elements: • Teach how to give oral drugs or to treat local infection. • Teach correct positioning and attachment for breastfeeding: – show the mother how to hold her infant – with the infant’s head and body straight – facing her breast, with infant’s nose opposite her nipple – with infant’s body close to her body – supporting infant’s whole body, not just neck and shoulders. • Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again. • Advise about food and fluids: advise to breastfeed frequently, as often as possible and for as long as the infant wants, day and night, during sickness and health. Advice when to return • teach signs that mean to return immediately for further care; • advise when to return for a follow-up visit; and • tell when the next well-child or immunization visit shall be done. Advise to return immediately if the infant has any of these signs: • Breastfeeding or drinking poorly • Becomes sicker • Develops a fever • Fast breathing • Difficult breathing • Blood in stool 3.7. Follow–up care If the child does not have a new problem • Assess the child according to the instructions; • Use the information about the child’s signs to select the appropriate treat- ment; • Give the treatment. 22