CME

4. INTRODUCTION
423
207
506
428
1570
429 737
383
48 19
96
30
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 - 6 DAYS 7 - 17 DAYS 28 DAYS - < 1 YEAR 1 YEAR - < 5 YEARS
PREVENTABLE NOT PREVENTABLE UNDETERMINED UNKNOWN

5. IMCI & ATUCU5
Integrated Management of Childhood
Illness (IMCI)
 Developed by WHO & UNICEF
 Implemented in Malaysia since 2002
 Implemented in states (Sabah, Sarawak,
Pahang, N.Sembilan, Kelantan )
 Intensive course, includes theory and
clinical (11 day)
 Target to clinics :
i. In rural area (pendalaman) – LOGISTIC
issues
ii. Difficulty in referring patient to hospital
iii. Limited resources (clinical and non-clinical)
iv. Clinic without doctors
 Target group : paramedics
 An accredited course
Approach to Unwell Children under
5 years (ATUCU5)
 Adapted programme from IMCI and
Common Childhood Illness (CCI) JKN
Sarawak
 More in classroom style (2-3hari)
 Objective is to increase the knowledge
and skills of all healthcare providers in:
i. Detecting early danger signs in
children under 5
ii. Giving early care to children before
referring
 Target group : all healthcare provider
(FMS, MO,HO, nurses, MA, JM)
 Refresher course

6. ATUCU-5
APPROACH TO UNWELL CHILDREN UNDER 5 YEARS

10. Counsel & General Danger Sign

12. All sick children should be routinely checked
for general danger signs
• If you have found during the assessment that the child has a general danger sign, complete the rest of the
assessment IMMEDIATELY.
• Remember that a child with any general danger sign has a severe problem. There must be NO DELAY IN
TREATMENT.
• A child with any general danger sign needs urgent attention and pre-referral treatment.
• You should complete the rest of assessment immediately and give urgent pre-referral treatment then
referred urgently.
• Do not give treatments that would unnecessarily delay referral
• Most children who have a general danger sign also have a severe classification. They are referred for their
severe classification

13. CONVULSING CHILD
1. AIRWAY MANAGEMENT
o Turn the child to the side
o Extend the neck slightly to open the airway
o Clear the airway -remove secretions by suction or manually
o Give oxygen
o Do not insert anything in the mouth
2. RECTAL DIAZEPAM

14. LOW BLOOD SUGAR
• If the child is able to breastfeed:
o Ask the mother to breastfeed the child
• If the child is not able to breastfeed but is able to
swallow:
o Give 30-50 ml of expressed breastmilk or a breastmilk
substitute.
o If neither of these is available, give 30-50 ml of 10%
dextrose orally before departure
• If the child is not able to swallow and you know
how to use a nasogastric (NG) tube
o Give 30-50 ml of milk or 10% dextrose solution by
nasogastric tube
• If not able to swallow and able to insert IV line
o Give IV Dextrose 10% 2-3 ml/kg

15. Assessment & treat main
symptoms

16. Pneumonia
COUGH OR DIFFICULT
BREATHING

17. COUGH OR DIFFICULT BREATHING
Age 2 Months up to 5 Years
• Cough is the most common complaint
• Cough can be due to airway, lung or heart
problems
• Respiratory infection can occur at any part
of respiratory tract.
• Pneumonia can cause death due to hypoxia
or sepsis and is one of the common cause of
preventable death in Under 5.

21. Pneumonia

22. Criteria for hospitalization OUTPATIENT MANAGEMENT
• Children aged 3 months and below,
whatever the severity of pneumonia.
• Fever ( more than 38.5 ⁰C ), refusal to
feed and vomiting
• Fast breathing with or without
cyanosis
• Associated systemic manifestation
• Failure of previous antibiotic therapy
• Recurrent pneumonia
• Severe underlying disorder, e.g.
Immunodeficiency
• In children with mild pneumonia, their
breathing is fast but there is no chest
indrawing.
• Oral antibiotics can be prescribed.
• Educate parents/caregivers about
management of fever, preventing
dehydration and identifying signs of
deterioration.
• The child should return in two days
for reassessment, or earlier if the
condition

23. DIARRHOEA

24. DIARRHOEA
Definition
• Loose or watery stools ≥ 3 x in a 24-hour period
• Common in age 6 months- 2yrs old
• More common in babies aged < 6 months who are drinking infant formulas
• Frequent passing of normal stools is not diarrhoea.
• Babies who are exclusively breast fed often have soft stools; this is not diarrhoea.
Types Of Diarrhoea
• Diarrhoea less than 14 days is acute diarrhoea
• Diarrhoea 14 days or more is persistent diarrhoea
• Diarrhoea with blood in stool with or without mucus is called dysentery
Complications of Dehydration
• Seizures
• Shock with tachycardia, fast
breathing
• Kidney failure (no urination)
• Brain oedema
• Coma and death

25. Assessment of diarrhoea

26. First assess the state of
perfusion of the child.
• Is the child in shock?
• tachycardia,
• weak peripheral pulses
• delayed capillary refill
time > 2 seconds
• Cold peripheries
• Depressed mental
state with or without
hypotension.
• Any child with shock go
straight to treatment Plan
C.

27. Plan C

28. Plan B

31. HFMD
DF
Measles
Fever

32. Fever

33. Fever assessment
•Eg : Dengue, Meningococcaemia

34. • Measles,
• Other viral
exanthems, HFMD

35. Other causes of fever with rashes
Eg :
• Heat rash is a maculopapular rash, can be
localise or generalise and usually child is well
with no fever.
• Chicken pox present with fever and vesicular
papular rashes. The vesicles are on a red base
(“Dew drop on a rose petal”) and pruritic.

37. Examine for other causes of fever
✔General examinations-cellulitis,
abscesses, skin infection,septic arthritis
osteomyelitis
✔Ear-Ear infection
✔Throat-Pharyngitis, Tonsillitis
✔Lung-Pneumonia
✔Abdomen Acute Appendicitis
✔Other causes: Diarrhoea, URTI, UTI, TB,
Viral fever, Dengue, Malaria

38. CCTVR

39. Check ear, nose and throat

40. Assessment of Ear
Problem
Ask
• Any ear pain
• Any ear discharge
• Duration of ear
discharge
•Look & Feel :
• Pus draining from ear
• Tender swelling behind
the ear

41. Fever Management
• If no indication for urgent referral, allow home with Sy.Paracetamol
• 1st dose at clinic if temp ≥ 38.5 °C
• Follow up in 2/7 if fever persist
• Fever > 7 days - refer for further assessment

42. HFMD
HFMD VS Herpangina (painful mouth ulcer associated with sore throat & fever,
caused by Coxsakie Group A virus)
IMPORTANT HISTORY-To assess severity of disease
• Date of onset Fever, mouth ulcer, rash/vesicles
• Vomiting, poor feeding, lethargy, drowsiness, fits
• Repeated Startling during sleep/awake (myoclonus seizure)
• History of travelling within last 1 week & any contact with other children with
HFMD

43. Criteria for admission
CLINICAL MANAGEMENT OF HFMD
• HFMD is usually a mild and self limiting. In general, most
cases of HFMD do not require admission but can be
managed as outpatients
• Mild HFMD cases only need symptomatic treatment.
• Treatment of fever and relief of symptoms, adequate
hydration and rest are important.
• Parents and care takers should be educated on hygiene
and measures that they should take to prevent
transmission to other children.
ADVICE GIVEN UPON PATIENT’S DISCHARGE
“Your child has been diagnosed to have hand-foot-mouth
disease. This disease is normally not dangerous but in the
light of recent events, we advise that you bring back your
child to this hospital if he / she has any of the following
symptoms:
• High fever. • Lethargy and weakness.
• Refusing feeds and passing less urine. • Rapid breathing. •
Vomiting. • Drowsiness or irritably. • Fits.”
• When the child is unable to tolerate oral feeds and there is a need
for intravenous hydration;
• When the child is clinically very ill or toxic-looking
• When some other more serious disease cannot be excluded
• When there is persistent hyperpyrexia (e.g >38ºC) for >48 hours;
• When there is a suspicion of neurological complications, e.g
increased lethargy, myoclonus, increased drowsiness, change in
sensorium and/or seizures;
• When there is a suspicion of cardiac complications (myocarditis),
e.g low blood pressure, low pulse volume, heart rhythm
abnormalities, murmurs, gallop rhythm, displaced apex beat;
• When parents are unable to cope with child’s illness; and
• When there is inadequate family or social support in looking after
the child at home.

44. Clinical staging and management of enterovirus 71 infection

45. Dengue fever in children
Dengue rash (island of white in the sea of red)

52. Measles
Diagnosis of Measles
• History of measles for past 3 months or
currently having measles?
• Progression of Measles Rash:
• Within 3/7-maculopapular rash begins
behind ears and neck then spreads to
face and whole body
• Next 3/7-fading of the rashes
• Last 3 days, peeling of skin and
brownish discoloration
• Rash lasted 7-9 days (not itchy)
• Rash with 3C's either
cough/conjunctivitis /coryza (running
nose)

53. Measles Assessment
• Severity of the disease -
Conjunctivitis, mouth ulcer
• Complications of disease eg -
clouding of cornea, may be
worse in children with Vitamin A
deficiency. Therefore in severe
measles - Vitamin A is given to
prevent severe complications.
Complication of measles:
❑ Clouding of cornea
❑ Pus draining from the eye
❑ Extensive mouth ulcers (>5 deep
extensive mouth ulcers affecting
feeding)
❑ Other complications eg: stridor,
pneumonia, diarrhoea,
malnutrition and ear infection

54. ASSESSMENT OF
NUTRITIONAL STATUS

55. MALNUTRITION

57. SEVERE ACUTE MALNUTRITION - SAM
• Severely wasted (sign of marasmus)
• Oedema (sign of kwashiorkor)
MALNUTRITION
Lacks of:
• Essential vitamins
• Minerals
Causes of Acute Malnutrition
(Appetite↓ & food consumed not efficiently)
• - Frequent illness
• - HIV infection
• - Tuberculosis

58. SEVERE ACUTE
MALNUTRITION - SAM

62. • Remove all the child’s clothes to check for wasting
Look for visible severe wasting

63. • Wasting of the muscles of the
shoulder and arms
The buttocks are wasted and there
skin folds (baggy pants).
Abdomen may be large or distended. Face may still looks
normal.

64. Check for oedema of both feet

65. ANAEMIA

66. • Look for palmar pallor
• Reduced Hb or Hct below level
normal for that of Age & Sex
• Normal Hb level-11g/dL
• WHO Hb threshold used to define
anaemia:
ANAEMIA

67. ANAEMIA:PREVENTION BY DEWORMING
For every child > 1 y/o:
• To give Albendazole 400 mg single dose every 6 months (WHO)
• Usual dosage :
• 1-2 y/o : 200 mg stat ≥ 2 y/o : 400 mg stat

69. For WHOM & WHEN to do?
1. All Children 2 years old
2. Very low weight for age
3. Anaemia
FEEDING ASSESSMENT

70. Identifying Feeding Problem

71. • The four signs of good
attachment are:
• more areola seen above
infant's top lip than below
bottom lip
• mouth wide open
• lower lip turned outward
• chin touching breast

76. CHILD'S IMMUNIZATION
STATUS

79. CONTRAINDICATION
A contraindication is a condition when the
vaccine is not advised due to some
potential and serious adverse effects.
First, it is important to note that common
illnesses are not a contraindication to
vaccination. Therefore no sick child,
including the malnourished child, should
miss vaccination.
A child should only miss the vaccination if
there is a clear contraindication
ABSOLUTE CONTRAINDICATION
1. Do not give to children with history of
severe anaphylaxis following vaccination
2. Do not give live attenuated vaccine to
severely immunocompromise child. Eg: Do
not give BCG to a child with AIDS
3. Do not give whole cell pertussis to a child
who has had convulsions or shock within 7
days of the last dose of the vaccine.
4. Do not give pertussis vaccination to a
child with recurrent convulsions or another
active/ progressive neurological disease of
the central nervous system

80. IMMUNISATION POSTPONEMENT -
ACUTE ILLNESS
1. Temperature >38.5 C.
2. Malnourished child with
complications
3. Baby who are suspected
to have congenital TB
should delay BCG
vaccination and refer
paediatrician
IMMUNISATION POSTPONEMENTCHRONIC ILLNES
1. Children who have received IvIg or blood products should have
their live vaccine (MMR, IMOJEV, BCG) given 3 months after their
treatment.
2. Children who have received steroids (Eg: Nephrotic syndrome, ITP,
Immune haemolytic anaemia) with a dose of Predinisolone
>2mg/kg/day for >7 days or lower dose for >2 weeks, vaccination
should be given after 6 months only.
3. Child born to mother with active TB, BCG vaccination is delayed for
6 months to allow completion of isoniazide prophylaxis therapy (IPT)
***Child with bleeding tendency vaccination should consult
paediatrician

81. HOW WILL YOU HANDLE
IMMUNIZATIONS IN A
SICK CHILD?
•Before giving a child any
vaccination use 'senarai semak
buku rekod kesihatan' that is in
the clinic copy of BRKK
•There are two good rules to
remember:
1.If a sick child is well enough to
go home, there are no
contraindications to vaccination.
2.If a child require referral for
admission, to postpone the
immunisation until after discharge

82. HOW DO YOU MANAGE FEVER FOLLOWING
VACCINATION?
❏ If a child develops fever of over 38.5 °C following vaccination, give
oral paracetamol at a dose of 10-15 mg/kg/dose given 4-6 hourly.
This can be given for up to 2 days if child is still with high fever
❏ DO NOT GIVE PARACETAMOL IF FEVER < 38.5 °C
❏ ROUTINE PROPHYLACTIC PARACETAMOL IS NO LONGER
RECOMMENDED
❏ DO NOT OVER WRAP THE CHILD

83. CATCH UP IMMUNIZATION
Rule No.1: Immunization must be at
least 4/52 apart
Rule No.2: Practice Opportunistic
Immunization
Rule No.3: (DTaP-IPV//Hib 1 can be
given at 7/52 old if Opportunistic
Immunization is indicated*
Rule No.4: Many vaccines can be
given together simultaneously but
must be given at different sites

92. TREATING LOCAL INFECTION
a. Eye or Ear infection
b. Mouth ulcers
c. Oral Thrush
d. Skin pustules
e. Umbilical infection

93. EYE INFECTION
(pus discharge from the eyes, conjunctivitis)
Home treatment
1.Clean both eyes 4 times daily •Wash hands
•Use clean cloth and water to gently wipe away pus
2. The apply Chloramphenicol eye ointment in both
eyes 4 times daily
•Squirt a small amount of ointment on the inside of
the lower
•Wash hands again
3. Treat until there is no pus discharge
•Do not put anything else in the eyes

94. EAR INFECTION
(ear discharge, ear pain)
Home treatment
1. Dry the ear at least 3 times daily
• Roll clean absorbent cloth or soft,
strong tissue into a wick
• Place the wick in the child's ear •
Remove the wick when wet
• Replace the wick with a clean one
and repeat these steps until the ear
is dry
• Do not use cotton buds

95. MOUTH ULCERS
Home treatment
1. Treat for mouth ulcers twice daily
• Wash hands
• Wash the child's mouth with clean soft
cloth wrapped around the finger and wet
with sodium bicarbonate solution (if
available), if not available use salt water
• Wash hands again
• Give paracetamol for pain relief

96. ORAL TRUSH
Home treatment
1.Treat thrush four times daily for 7 days
• Wash hands
• Wet a clean soft cloth with salt water and use
it to wash the child's mouth.
• Instill nystatin 1ml four times a day
• Avoid feeding for 20 minutes after medication
• If breastfed check mother's breasts for
thrush. If present treat with nystatin
• Advise mother to wash breasts after feeds. If
bottle fed advice change to cup and spoon •
Give paracetamol if needed for pain.

97. SKIN PUSTULES
Home treatment
1. Wash hands
2. Gently wash pus and crusts with
soap and water
3. Dry the area
4.Wash hands
• To do the treatment twice daily for
5 days
• Do not rupture any pustules
• Depends on local setting, may use normal saline or potassium
permanganate solution
• Preparation for potassium permanganates solution:
o 1 part potassium to 9 part of water OR until solution is light pink
in colour o Stop using once the pustules have scabbed

98. UMBILICAL INFECTION
Home treatment
1.Wash hands
2.Gently wash off pus and crusts with
soap and water
3.Dry the area
4.Wash hands
• To do the treatment twice daily for 5
days

99. ASSESSMENT OF YOUNG
INFANTS
• All young infants must be checked for very severe disease and local
bacterial infection
• Young infants can become sick and die very quickly from bacterial
infection. Therefore, they require urgent referral.

101. CHECK FOR VERY SEVERE
DISEASE
• Not feeding well • Greenish vomitus • Convulsions
• Fast breathing 60 breath/min or more • Severe chest indrawing
• Fever (37.5 C or above) • Low body temperature (less than 35.5 C)
• Movement only when stimulated or no movement at all

102. HISTORY (MUST ASK)
• Is the infant not feeding well?
❏ A young infant who was feeding well earlier but
is not feeding well now may have a serious
infection.
❏ A newborn that has not been able to feed since
birth may be premature or may have
complications such as birth asphyxia. These
infants who are either not able to feed or are
not feeding well should be referred urgently to
hospital.
❏ Poor suckling effort is assessed by asking
duration of each suckling effort and the ability
to maintain suckling
• ASK: ABOUT GREENISH VOMITUS
❏ Greenish (bilious) vomiting is a sign of
intestinal obstruction in a young
infant.
❏ It is an urgent condition that requires
immediate referral to exclude
conditions such as Duodenal Atresia,
midgut malrotation and volvulus,
meconium ileus and necrotizing
enterocolitis.

103. ASK: HAS YOUR BABY HAD
CONVULSIONS [FITS]?
• spasms(kejang)
• arms & legs become stiff
• stop breathing & become blue
(cyanosed)
• rhythmic movement any part of
body eg: twitching of mouth or
blinking of eyes
• loss of consciousness

104. Thing to look for
LOOK: DOES THE SICK INFANT HAVE
FAST BREATHING?
• Count Respiratory rate for 1 minute.
• Child must be calm and not feeding when
counting the respiration rate.
• Healthy young infant : Resp. rate = 50-59/min.
• If Resp. rate ≥ 60/min, the respiration rate is
counted for a second time because it is normal
for young infants to have irregular breathing.
• If the second respiration rate is also ≥ 60/
min, the young infant has FAST BREATHING. •
Remark: episodic breathing in young infant is
usual
DOES THE INFANT HAVE SEVERE CHEST
INDRAWING?
• The infant has chest
indrawing if the lower
chest wall (lower ribs)
goes IN when breath in
• Severe chest
indrawing very deep and
easy to see
• Present all the time
when child is calm

105. MEASURE TEMPERATURE: FEVER OR
LOW BODY TEMPERATURE?
• Fever is defined as 37.5°C or above (axillary/
forehead) or 38.5°C (tympanic)
• Low body temperature is below 35.5°C
(axillary/ forehead) or 36.5°C (tympanic)
Fever is uncommon in the first two months of
life. If a young infant has fever, this may mean
the infant has very severe disease. Fever may
be the only sign of a serious bacterial infection
Young infants can also respond to infection by
dropping their body temperature. This is called
hypothermia.
LOOK AT THE YOUNG INFANT'S
MOVEMENTS
• Does the young infant move on his /her
own?
• Does the young infant moves only when
stimulated then stops? (by tapping the infant
soles with your 2 fingers)
• Infant does not move at all ○ no movement
despite being stimulated ○ cannot be woken
up even after stimulation

106. CHECK FOR LOCAL BACTERIAL INFECTION

107. • The umbilical cord usually separates one to two weeks after birth. The wound heals within 15
days. Redness of the end of the umbilicus, or pus draining from the umbilicus, is a sign of umbilical
infection. Recognizing and treating an infected umbilicus early are essential to prevent sepsis.
• Explain on technique on how to examine the umbilicus by using thumb and forefinger to separate
the umbilicus at 3 – 9 o’clock and 6 – 12 o’clock. If umbilicus is dirty, to clean it first

109. CHECK FOR JAUNDICE
Jaundice can be detected clinically when the level of bilirubin in the serum rises
above 85 μmol/l (5mg/dl).

110. Approach to an infant with jaundice
Causes of neonatal jaundice
➢ Haemolysis due to ABO or Rh-
isoimmunisation, G6PD deficiency,
microspherocytosis, drugs.
➢ Physiological jaundice.
➢ Cephalhaematoma, subaponeurotic
haemorrhage.
➢ Polycythaemia.
➢ Sepsis septicaemia, meningitis, urinary
tract infection, intra-uterine infection.
➢ Breastfeeding and breastmilk jaundice.
➢ Gastrointestinal tract obstruction:
increase in enterohepatic circulatio
History
❖ Age of onset
❖ Risk factor
❖ Presence of
abnormal
symptoms such
as apnoea,
difficulty in
feeding, feed
intolerance and
temperature
instabilit

111. Physical
examination
★ General condition, gestation and
weight, signs of sepsis, hydration
status.
★ Signs of acute bilirubin
encephalopathy (ABE) should be
assessed for in all babies with severe
NNJ (see BIND score)
★ Pallor, plethora, cephalhaematoma,
subaponeurotic haemorrhage.
★ Signs of intrauterine infection e.g.
petechiae, hepatosplenomegaly.
★ Cephalo-caudal progression of
severity of jaundice
★ The adequacy of breastfeeding
★ Babies with weight loss > 7% should
be referred for further evaluation and
closely monitored

112. TOTAL BIND SCORE
• Advanced ABE (score 7 - 9):
urgent bilirubin reduction intervention is
needed to prevent further brain damage and
reduce the severity of sequelae
• Moderate ABE (score 4 - 6):
urgent bilirubin reduction intervention is likely
to reverse this acute damage
• Mild ABE (score 1 - 3):
subtle signs of ABE
Note: An abnormal or ‘referred’ Auditory
Brainstem Response (ABR) is indicative of
moderate ABE. Serial ABR may be used to
monitor progression and reversal of acute
auditory damage and could be indicative of the
effectiveness of bilirubin reduction strategy

113. • Look for jaundice under natural sunlight
• Press infant skin over the forehead with your
fingers to blanch and look for yellow
discoloration
• If jaundice present: Ask did jaundice first
appear before 24H of life or at Day 1 of life? If
jaundice is prolonged more than 14 days?
• Check level of jaundice:
• palms and soles
• below umbilicus
• above umbilicus
Methods of Detecting
Jaundice
• Transcutaneous Bilirubinometer
(TcB) –
if TcB levels are more than 200umol/l
(12mg/dl), total serum bilirubin (TSB)
should be obtained. TcB is not to be
used for patients on phototherapy

114. Total Serum Bilirubin

115. Prolonged Neonatal Jaundice
aundice (SB >85 μmol/L or 5 mg/dL) that persists beyond 14 days of life in a term baby (≥ 37 weeks) or 21 days in a
baby (≥35 weeks to < 37 weeks).
of Prolonged Jaundice
ugated Hyperbilirubinaemia Conjugated Hyperbilirubinaemia
Defined as the direct (conjugated) fraction of bilirubin more than 34 μmol/L (2mg/dL), or more than
15% of the total bilirubin
All babies with conjugated hyperbilirubinaemia must be referred to a paediatric department
urgently to exclude biliary atresia
aemia
y tract infection
milk jaundice
yroidism
ysis:
deficiency
enital spherocytosis
osaemia
yndrome
Biliary tree abnormalities:
• Biliary atresia - extra, intra-hepatic • Choledochal cyst • Paucity of bile ducts
• Alagille syndrome, non-syndromic Idiopathic neonatal hepatitis syndrome
Septicaemia
Urinary tract infection
Congenital infection (TORCHES)
Metabolic disorders
• Citrin deficiency • Galactosaemia • Progressive familial intrahepatic cholestasis (PFIC)
• Alpha-1 antitrypsin deficiency
Total Parenteral Nutrition

118. Diarrhoea in young infant

119. Diarrhoea in young infant
• If the mother or caregiver says that the
young infant has diarrhea, assess and
classify for diarrhoea.
• Diarrhoea in young infant:
- Change in pattern from usual stool
pattern
- More frequent stool
- More watery stool (more water than
faecal matter)
• It is normal for breastfed young infant
to have frequent, loose or semi-solid
stool

120. • Examine for hydration status
• Look for infant movements move on his/her own
move only when stimulated then stops does not move
at all
• Is the infant restless/irritable
• Look for sunken eyes
• Skin pinch : goes back very slowly (>2 sec)/slowly

121. ASSESS FEEDING PROBLEM &
CHECK FOR LOW WEIGHT

122. ASSESS BREASTFEEDING
Has the infant breastfeed in the previous hour?
• If not, observe breastfeeding for 4 minutes
Check for signs of good positioning
•⌧ Baby's head and body in line •⌧ Baby's held close to mother's body
•⌧ Baby's whole body supported •⌧ Baby approaches breast, nose to nipple
Check for signs of good attachment
•⌧ More areola seen above baby's top lip •⌧ Baby's mouth open wide
•⌧ Lower lip turn outwards •⌧ Baby's chin touches breast
Check for effective suckling (slow deep sucks, sometimes pausing)
•⌧ Slow deep sucks with pauses • ⌧Cheeks round when suckling
•⌧Baby releases breast when finished •⌧Mother notices signs of oxytocin reflex
Correct Positioning and Attachment

123. MOTHER’S CARD

126. Reference
Under-5 Mortality Review 2016: Looking into The Preventable Deaths
Training Manual On Approach To Unwell Children Under 5 Years
Paediatric Protocols 4th Edition
CPG: Dengue in children, HFMD
Handbook of Integrated Management of Childhood Illness (IMCI)