BASIC-PEDIA-Lec-IMCI-Version-4.pdf

Far Eastern University – Nicanor Reyes Medical Foundation
BASIC PEDIATRICS: INTERGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) – NOVEMBER 2021
Ma. Angela Hernando-Mallari, MD, DPPS; Tricia May V. Viernes-Geli, MD, DPPS
OVERVIEW
• Introduction
• Integrated Case Management Process
• Selecting the Appropriate Case
Management Chart
• General Danger Signs
• Main Symptoms
• Counsel and Follow-Up Care
• Management of the Sick Young Infant
Aged Up to 2 Months
INTRODUCTION
- Every day, millions of parents take children with potentially fatal illnesses to first-level health facilities such
as clinics, health centers, outpatient departments of hospitals.
- Surveys of the management of sick children at these facilities reveal that many are not properly assessed
and treated and that their parents are poorly advised.
- Providing quality care to sick children in these conditions is a serious challenge. In response to this
challenge, WHO and UNICEF developed a strategy known as Integrated Management of Childhood
Illness (IMCI).
What is IMCI?
- An integrated approach to child health that focuses on the well-being of the whole child
- It aims to reduce death, illness and disability, and to promote improved growth and development among
children under five years of age
- It includes both preventive and curative elements that are implemented by families and communities
as well as by health facilities
Who are the children covered by the IMCI protocol?
• Sick children from birth up to 2 months (Sick young infant)
• Sick children 2 months up to 5 years (Sick child)
What does IMCI offer?
- It offers simple and effective methods to prevent and manage the leading causes of serious illness and
mortality in young children.
- The guidelines promote evidence-based assessment and treatment, using a syndromic approach that
supports the rational, effective, and affordable use of drugs.
Where is it intended to be used?
- The approach is designed for use in OUTPATIENT clinical settings with limited diagnostic tools, limited
medications, and limited opportunities to practice complicated procedures.
- Therefore, the management may differ in hospital setting and in areas with immediate access to diagnostic
and treatment modalities.
STRATEGY INCLUDES THREE MAIN COMPONENTS:
• Improvements in the case-management skills of health worker through the provision of locally adapted
guidelines on IMCI and through activities to promote their use
• Improvements in the health system required for effective management of childhood Illness
• Improvements in family and community practices
Why IMCI?
- 10M children die each year in developing countries BEFORE they reach their 5th birthday
- 7 in 10 deaths are due to acute respiratory infections (mostly pneumonia), diarrhea, measles, malaria, or
malnutrition often in combination.
- Many are not properly assessed and treated and that their parents are poorly advised
Based on data taken from The Global Burden of Disease 1996, edited by Murray CJL and Lopez AD, and
Epidemiological evidence for a potentiating effect of malnutrition on child mortality, Pelletier DL, Frongillo
EA and Habicht JP, American Journal of Public Health 1993.
Rationale for the integrated approach in the management of sick children
• Majority of deaths are caused by 5 preventable and treatable conditions namely:
o Pneumonia, Diarrhea, Measles, Malaria, and Malnutrition
• 3 out of 4 episodes of childhood illness are caused by this condition
• Most children have more than one illness at one time
• Single diagnosis may not be possible or appropriate
In the Western Pacific Region
• 527,000 children die before their 5th birthday
• 97% occurred in six countries:
o Cambodia
o China
o Lao People's Democratic Republic
o Papua New Guinea
o Philippines
o Vietnam
NOTE �
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Read ALL THE CHARTS. There are minor changes
(details added) on the chart to make it similar on the
uploaded PPT. But as much as I can, I based this trans in
the handbook kasi di po pwede reference ang PPT nila
kapag may correction(s) sa exams.
USE AT YOUR OWN RISK �
�
�
� You can email me at
vdmed2b@gmail.com for corrections/questions. Happy aral!
REFERENCES:
• Lecture & PPT
• Handbook: https://doh.gov.ph/faqs/Integrated-
Management-of-Childhood-Illness-IMCI
• Chartbook
TE A M ROBREDO PANGILINAN
# LEN I KIKO 2022
Causes of' death iu children under :;, World. 2017
Annualnum~ rofdeathsbyle.iding cauSl"'sin childrenunder 5year.;old
;:!: Change country
Lowerrespir;;itoryinfections
Neonatalpretermcomplic;itions
Diarrhe.oldise.ises
Neonatal asphy)cfa & trauma
Congenltalbirthdefects
Malaria
Other neonat.11 disorders
Nl!Onatal sepsis& infections 203,013
Nutrition.ild~~'/~i~: ~ 1~~~#,'t
Whooping cough - 86,091
Musles - 83,439
HIV/AIDS ~ 77,485
Tu£;~:~= i;:~;g
Cancers - 49.916
R~ ;accidents - 49,068
Digesttvediseues - 40.177
C..rdiovaKYh1r diseF)~ =-t~•~l
H~t,tls . 13,943
KidMYdisuse 1 12,980
Homicide l 11,815
Live.-dise.ise I 7.808
Heat·relatedde;iths(hotorcoldexposurell 3.133
Dlabetesmellltus 1.714
Naturaldis.asttrs 649
649.439
FIGURE1:DISTRIBUTION OF 11.6MILLION DEATHS
AMONGCHILDRENLESSTHAN5YEARS OLDINALL
DEVELOPINGCOUNTRIES, 1995
0 100,000 200,000 300,000 400,000 500,000 600,000 700,000
OurWoddlnData.orgkau:on·ol-dealh • CC BY
Figure 1 : Major causes of death In neonates and chlldren under-5
In the Western Pacific Region • 2008
Deaths among children under-5
00.,
""
""''""""
disoas~
(pmtneon11tal)
"'
Neonatal deaths
l
Olhes26%
Congenial anorreies 10%
Neonataltetarus l %
Cial'rhoealdiseases 19'.
Neona1a1 necoons 8%
Bi1h asphyxia and
bifthtraooia
,.,.
Rer:~~~KlYr
,..
Source: WHO. The World Health Statistics 2011 _J

Topic: INTERGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)
2
IMCI IN THE PHILIPPINES
- Started as a pilot basis in 1996
- Intended for health workers and hospital
staff were capacitated to implement the
strategy at the frontline level
ACCELERATING IMPLEMENTATION OF
IMCI IN THE PHILIPPINES 2015-2025
General objective:
- To accelerate IMCI implementation all
over the country.
Specific objectives, by 2025:
• To establish IMCI ICATT training units
and core trainers in all regions of the
country
• To implement IMCI in at least 80% of
primary health care facilities (barangay health centers and BHSs)
• To integrate IMCI in all medical, nursing and midwifery schools
• To establish IMCI referral hospitals in all provinces and cities
• To establish core IMCI activities in the barangays. (to be identified)
INTEGRATED CASE MANAGEMENT PROCESS
Complete IMCI case management process involves the following elements:
• Assess a child and ask questions.
• Classify a child’s illnesses using a colour-coded triage system.
• Identify specific treatments for the child
• Provide practical treatment instructions.
• Assess feeding practices and counsel to solve any feeding problems
found
• Give follow-up care
(1a) ASSESS
- By checking first for danger signs (or possible bacterial infection in a young infant)
- Asking questions about common conditions
- Examining the child
- Checking nutrition and immunization status.
- Checking the child for other health problems.
(1b) CLASSIFY ILLNESS
- Using a color-coded triage system.
- Many children have more than one condition, each illness is classified according to whether it requires:
o Urgent pre-referral treatment and referral (red), or
o Specific medical treatment and advice (yellow), or
o Simple advice on home management (green).
(2) TREAT THE CHILD
IDENTIFY SPECIFIC TREATMENTS
- If a child requires urgent referral, give essential treatment before the patient is transferred.
- If a child needs treatment at home, develop an integrated treatment plan for the child and give the first
dose of drugs in the clinic.
- If a child should be immunized, give immunizations.
PROVIDE PRACTICAL TREATMENT INSTRUCTIONS
- Teach the caretaker/mother:
o How to give oral drugs
o How to feed and give fluids during illness
o How to treat local infections at home.
- Ask to return for follow-up on a specific date
- Teach her how to recognize signs that indicate the child should return immediately to the health facility.
(3) COUNSEL
ASSESS FEEDING
- This includes assessment of breastfeeding practices, and counsel to solve any feeding problems found.
- Then counsel the mother about her own health.
(4) FOLLOW-UP
GIVE FOLLOW-UP CARE
- When a child is brought back to the clinic as requested
- If necessary, reassess the child for new problems.
LECTURE
1. Assess and classify the
sick child
2. Treat the child
3. Counsel
4. Follow-up
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SUMMARYOF THE INTEGRATED CASEMANAGEMENTPROCESS
For all sick children age 1 week up to 5 years who are brought to a first-level health facility
ASSESS the child:Check for danger signs (or possible bacterial infection). Askabout main symptoms. If a main symptom
is reported,assess further. Check nutrition and immunization status.Check for other problems.
CLASSIFYthe child's illnesses: Use a colour-coded triage system to classify the child's main symptoms
and his or her nutrition or feeding status.
is needed and possible
IDENTIFY URGENT
PRE-REFERRAL TREATMENT(S)
needed forthe child's classifications.
TREAT THE CHILD: Give urgent pre-referral
treatment(s) needed.
REFER THE CHILD: Explain to the child's
caretakerthe need for referral.
Calm the caretaker's fears and help resolve any
problems.Write a referral note.
Give instructions and supplies needed to care
for the child on the way to the hospital.
needed or possible
IDENTIFY TREATM ENT needed for the child's
classifications: Identify specific medical
treatments and/oradvice.
TREAT THE CHILD: Give the first dose of oral
drugs in the clinic and/or advise the child's
caretaker.Teach the caretaker how to give oral
drugs and how to treat local infections at home.
If needed,give immunizations.
COUN SEL THE MOTHER: Assess the child's
feeding,including breastfeeding practices, and
solve feeding problems, if present.Advise about
feeding and fluids during illness and about
when to return to a health facility. Counsel the
mother about her own health.
FOLLOW-UP care:Give follow-up care when the child returns to the clinic and,
if necessary, reassess the child for new problems.

3
FROM IMCI HANDBOOK
- If a child’s illness does not respond to the standard treatments described in this handbook, or if a
child becomes severely malnourished, or returns to the clinic repeatedly, the child is referred to a
hospital for special care.
- Case management can only be effective to the extent that families bring their sick children to a trained
health worker for care in a timely way. If a family waits to bring a child to a clinic until the child is
extremely sick, or takes the child to an untrained provider, the child is more likely to die from the illness.
Therefore, teaching families when to seek care for a sick child is an important part of the case
management process.
SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS
Decide which age group the child is in:
• Age 1 week up to 2 months, or
• Age 2 months up to 5 years.
Up to 5 years means the child has NOT YET had his or her fifth birthday.
- Group includes a child who is 4 years 11 months but not a child who is 5 years old
- 2 months old would be in the group 2 months up to 5 years, not in the group 1 week up to 2 months
- If the child is NOT YET 2 months of age, the child is considered a young infant.
o Management of the young infant age 1 week up to 2 months is somewhat different from older.
SICK CHILD (2 months to 5 years)
FROM IMCI HANDBOOK
- A mother or other caretaker brings a sick child to the clinic for a particular problem or symptom. If you
ONLY assess the child for that PARTICULAR problem or symptom, you might overlook other signs
of disease. The child might have pneumonia, diarrhoea, malaria, measles, or malnutrition. These
diseases can cause death or disability in young children if they are not treated.
- The chart ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS describes
how to assess and classify sick children so that signs of disease are not overlooked. According to the
chart, you should ask the mother about the child’s problem and check the child for general danger signs.
Assess for the following MAIN symptoms:
• Cough or difficulty of breathing
• Diarrhea
• Fever
• Ear problem
• Malnutrition and feedling
• Immunization status
GENERAL DANGER SIGNS
A child with a general danger sign has a serious problem. Most children with a general danger sign need
URGENT referral to hospital. They may need lifesaving treatment with injectable antibiotics, oxygen or other
treatments that may not be available in a first-level health facility. Complete the rest of the assessment
immediately.
••
FOR ALL SICK CHILDREN age 1 week up to Syears who are brought to the clinic
IFthe child is from 1 week up to 2 months
I
USE THE CHART:
• ASSESS, CLASSIFY AND TREATTHE SICK
YOUNG INFANT
/ickil,i Bottom
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ASK THE CHILD'SAGE
I
I
IF the child is from 2 months upto 5 years
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USE THE CHARTS:
• ASSESS AND CLASSIFYTHE SICK CHILD
• TREAT THE CHILD
• COUNSEL THE MOTHER
FOR ALL SICK CHILDREN AGE 2 MONTHS UPTO SYEARS WHO ARE BROUGHT TO THE CLINIC
GREET the mother appropriately and
ask about her child.
LOOK to see if the child's weight and
temperature have been recorded
ASK the mother what the child's problems are
Use Good Communication Skills:
(see also Chapter 25)
• Listen carefully to what the mother tells you
• Use words the mother understands
• Give the mother time to answer the questions
• Ask additional questions when the mother is not sure
about her answer
Record Important Information
DETERMINE if this is an initial visit or a follow-up visit for this problem
IF this isan INITIAL VISIT for the problem
ASSESS and CLASSIFY the child following
the guidelines in this part of the handbook (PART 1
1)
IFthis is a FOLLOW-UP VISIT for the problem
GIVE FOLLOW-UP CARE according to t he guidelines
in PART VII of this handbook
For ALL sick children ask the mother about the child's problem, then
CHECKFORGENERALDANGERS~NS
CHECK FOR GENERAL DANGER SIGNS Make sure
that a child
with any
danger sign
is referred
after
receiving
urgent pre-
referral
treatment.
ASK: LOOK:
• Is the child able to drink or breastfeed? • See if the child is lethargic or unconscious.
• Does the child vomit everything? • Is the child convulsing now?
• Hs the child had convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and
any pre-referral treatment immediately so referral is not delayed
Then ASK about main symptoms:coug h and difficult breathing.diarrhoea, fever,ear problems.
CHECK for malnutrition and anaemia, immunization status and for other problems_

4
FROM CHARTBOOK + LECTURE
MANAGEMENT
Convulsion is a danger sign only when:
• Occurs in less than 6 months
• More than one episode
• Occurring for more than 15 minutes
• This definition EXCLUDES SIMPLE FEBRILE CONVULSIONS
MAIN SYMPTOMS
(a) COUGH OR DIFFICULTY OF BREATHING
FROM IMCI HANDBOOK
- Respiratory infections can occur in any part of the respiratory tract. In developing countries, pneumonia
is often due to bacteria. The most common are Streptococcus pneumoniae and Hemophilus influenzae.
Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized
infection).
- You can identify almost all cases of pneumonia by checking for these two clinical signs: fast breathing
and chest indrawing.
- When children develop pneumonia, their lungs become stiff. One of the body’s responses to stiff
lungs and hypoxia (too little oxygen) is fast breathing. When the pneumonia becomes more severe,
the lungs become even stiffer. Chest indrawing may develop. Chest indrawing is a sign of severe
pneumonia. (In chartbook, it is classified as yellow, pneumonia only)
Look for chest indrawing when the child breathes IN. Look at the lower chest wall (lower ribs). The child
has chest indrawing if the lower chest wall goes IN when the child breathes IN. Chest indrawing occurs
when the effort the child needs to breathe in is much greater than normal. In normal breathing, the
whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN.
- If the child’s body is bent at the waist, it is hard to see the lower chest wall move. Ask the mother to
change the child’s position so he is lying flat in her lap.
- For chest indrawing to be present, it must be clearly visible and present all the time.
- If you only see chest indrawing when the child is crying or feeding, the child does not have chest
indrawing.
- If only the soft tissue between the ribs goes in when the child breathes in (also called intercostal
indrawing or intercostal retractions), the child does not have chest indrawing.
- In this assessment, chest indrawing is lower chest wall indrawing. This is the same as “subcostal
indrawing” or “subcostal retractions.” It DOES NOT include “intercostal indrawing.”
Stridor is a harsh noise made when the child breathes IN.
- Stridor happens when there is a swelling of the larynx, trachea or epiglottis. These conditions are often
called croup. This swelling interferes with air entering the lungs. It can be life-threatening when the
swelling causes the child’s airway to be blocked. A child who has stridor when calm has a dangerous
condition.
I• Any general danger sign Pink: ■ Give diazepam if convulsing now
VERY SEVERE ■ Quickly complete the assessment
> DISEASE ■ Give any pre-referal treatment immediately
I
■ Treat to prevent low blood sugar
■ Keep the child warm
■ Refer URGENTLY.
L
Give Diazepam to Stop Convulsions
■ Turn the child to his/her side and clear the airway. Avoid putting things in the mouth.
■ Give 0.5mg/kg diazepam injection solution per rectum using a small syringe withOut a needle (like a
tuberculin syringe} or using a catheter.
■ Check for low blood sugar, then treat or prevent.
■ Give oxygen and REFER
■ If convulsions have not stopped after 10 minutes repeat diazepam dose
AGE or WEIGHT
DIAZEPAM
10mQ/2mls
2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
12 months up to 3 years (10 - <14 kg ) 1.5ml
3 years up to 5 years (14-19 kg) 2.0 ml
Treat the Child to Prevent Low Blood Sugar
■ If the child is able to breastfeed:
• Ask the mother to breastfeed the child.
■ If the child is not able to breastfeed but is able to swallow:
• Give expressed breast milk or a breast-milk substitute.
• If nerther of these is available, give sugar water· .
• Give 30 - 50 ml of milk or sugar water• before departure.
■ If the child is not able to swallow:
• Give 50 ml of milk or sugar water" by nasogastric tube.
• If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
• • To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
water.
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5
If the pulse oximeter is available, determine oxygen saturation and refer if it is less than 90%.
MANAGEMENT: Give Intramuscular Antibiotics
Rationale for management of children with wheeze
• Wheeze can cause fast breathing and or chest indrawing
• Good response to inhaled bronchodilator may cause fast breathing or chest indrawing to disappear
• Only children with wheeze and signs of pneumonia (fast breathing and/or chest indrawing) need
antimicrobials
• Wheezing without signs of pneumonia only need bronchodilator treatment
MANEGEMENT: Give Inhaled Salbutamol for Wheezing
Antibiotic treatment for Pneumonia
• Children aged 2 – 59 months with pneumonia (with chest enrobing and high RR)
• Oral amoxicillin - at least 40mg/kg per dose BID for 5 days
For ALL sick ch ildren ask t he mother about the ch ild's problem,check for general danger signs
and then
ASK: DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
G 9)
IFYES, ASK: LOOK, LISTEN, FEEL: Classify
• For how long? • Count the breathsin one minute.
COUGH or
} CHILD MUST DIFFICULT
• Look for chest indrawing
BE CALM BREATHING
• Look and listen for stridor
• Look and listen for wheezing
Ifthe ch ild is: Fast breathing is:
If wheezing with either fast breathing or chest indrawing: 2 months up 50 breaths per
Give utrialof rupid acting inhaledd bronchodikitor for up to three times 15-20 to 12 months minute or more
minutes apart. Count the breathsand look forchest indra•Ning again,and then 12 monthsup 40 breaths per
classify. to 5 years minute or more
I
CLASSIFY t he ch ild's illness using t he co lour-coded classificat ion table for cough or difficu lt breat hing.
I
Then ASK about t he next main symptoms: diarrhoea, fever, ear problems.CHECK for malnutrition and anaemia,
immunization status and for other problems
I • Any general danger sign Pink: .Give first dose of an appropriate antibiotic
or SEVERE .Refer URGENTLY to hospita1••
>• Stridor in calm child. PNEUMOIIIAOR
VERY SEVERE
DISEASE
.Chest indrawing or Yellow: • Give oral Amoxicillin for 5 doys..4
.Fast breathing PNEUMONIA • If wheezing (or disappeared after rapidly
acting bronchodilator) give an inhaled
bronchodilator for 5 days.....,.
.If chest indrawing in HIV exposed/infected child,
give first dose of amoxicillin and refer.
.Soothe the throat and relieve the cough with a
safe remedy
.If coughing for more than 14 days or recurrent
wheeze, refer for possible TB or asthma
assessment
.Advise mother when to return immediately
.Follow-up in 3 days
.No signs of pneumonia or Green: .If wheezing (or disappeared after rapidly acting
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
5 days""
.Soothe the throat and relieve the cough with a
safe remedy
.If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
assessment
.Advise mother when to return immediatety
.Follow-up in 5 days rt not improving
••/ickil,i Bottom
GIVE TO CHILDREN BEING REFERRED URGENTLY
■ Give Ampicillin (50 mg/kg) and Gentamicin (7_
5 mg/kg).
AMPICILLIN
■ Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
• IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
■ Where there is a st rong suspicion of meningitis, the dose of ampicillin can be increased 4
times.
GENTAMICIN
■ 7.5 mg/kg/day once daily
AGE or WEIGHT
AMPICILLIN GENTAMICIN
500 mg vial 2ml/40 mg/ml vial
2 up to 4 months (4 - <6 kg) 1 m 0_
5-1.0 ml
4 up to 12 months (6 - <10 kg) 2ml 1-1 -1.8ml
12 months up to 3 years (10 - <14 kg) 3ml 1_
9-2.7 ml
3 years up to 5 years (14 - 19 kg) 5m 2_
8-3.5 ml
USE OF A SPACER*
A spacer is a way of delivering the bronchod ilator drugs effectively into the lungs. No child under 5 years
should be given an inhaler without a spacer A spacer works as well as a nebuliser if correctly used.
• From salbutamol metered dose inhaler (100 µg/puff) give 2 puffs.
■ Repeat up to 3 times every 15 minutes before classifying pneumonia.
• If a spacer is being used for tl1e first time, it should be primed by 4-5 extra puffs from the inl1aler.
I
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6
DIARRHEA
FROM IMCI HANDBOOK
- Diarrhea occurs when stools contain more water than normal. Diarrhoea is also called loose or
watery stools; these often cause dehydration.
- It is common in children, especially those between 6 months and 2 years of age. It is more common in
babies under 6 months who are drinking cow’s milk or infant formulas.
- Frequent passing of normal stools is not diarrhoea. The number of stools normally passed in a day varies
with the diet and age of the child. Diarrhea is defined as three or more loose or watery stools in a 24-
hour period.
- Cholera is one example of loose or watery diarrhoea.
• Sporadic cholera outbreak in the Philippines are usually seen after a massive flood (e.g., aftermath of
Typhoon Yolanda)  Drug of choice: Tetracycline or Erythromycin
PLAN A: TREAT DIARRHEA AT HOME
For ALL sick children ask the mother about the child's problem, check for general danger signs,
ask about cough or difficult breathing and then
ASK: DOES THE CHILD HAVE DIARRHOEA?
a ~
Does the child have diarrhoea?
IFYES, ASK: LOOK, LISTEN, FEEL:
• For how long? • Look at the child's general condition.
Isthe child:
• Is there blood in the
stool Lethargic or unconscious?
Restless or irritable?
• Look for sunken eyes.
e Offer the child fluid. lsthe child:
Not able to drink or drinking poorly? Classify
I
Drinking eagerly, thirsty?
DIARRHOEA
• Pinch the skin of the abdomen.
Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
I
I CLASSIFY the child's illness using the colour-coded classification tables for diarrhoea.
I
Then ASK about the next main symptoms: fever, ear problem,and CHECK for malnutrition and
anaemia, immunization status and for other problems.
•• /ickil,i Bottom
SIGNS CLASSIFY AS IDENTIFY TREATMENT
(Urgent pre-referral treatmentsare in bold print.)
Two of the following signs: ► If child has no other severe classification:
• Lethargic or unconscious - Give fluid for severe dehydration (Plan C).
• Su nken eyes SEVERE OR
• Not able to drink or DEHYDRATION If child also has another severe classification:
drinking poorly - Refer URGENTLY to hospital with mother giving
• Skin pinch goes back frequent sips of ORS on the way.
very slowly Advise the mother to continue breastfeeding
► If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera.
Two of the following signs: ► Give fluid and food for some dehydration (Plan B).
• Restless, irritable
• Sunken eyes SOME ► If child also has a severe classification:
• Drinks eagerly, thirsty DEHYDRATION - Refer URGENTLY to hospital with mother
• Skin pinch goes back giving frequent sips of ORS on the way.
slowly Advise the mother to continue breastfeeding
► Advise mother when to return immediately.
► Fol low-up in 5 days if not improving.
Not enough signs to ► Give fluid and food to treat diarrhoea at home
classify as some or NO (Plan A).
severe dehydration. DEHYDRATION ► Advise mother when to return immediately.
► Follow-up in 5 days if not improving.
r---------------------------------------------------------1
ERYTHROMYCIN TETRACYCLINE
AGE or WEIGHT
Give four times daily for 3 days Give four times daily for 3 days
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1
Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid
2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding
4. When to Return.
1. GIVE EXTRA FLUID (as much as the child will take)
■ TELL TH E MOTHER:
• Breastfeed frequently and for longer at each feed .
• If the child is exclusively breastfed , give ORS or clean water in addition to breast milk.
• If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fiuids (such as soup, rice water, and yoghurt drinks), or clean
water.
■ It is especially important to give ORS at home when:
• the child has been treated with Plan B or Plan C during this visit.
• the child cannot return to a clinic if the diarrhoea gets worse.

7
PLAN B: TREAT SOME DEHYDRATION WITH ORS
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
r--- ■ TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ------
ORS TO USE AT HOME.
■ SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID
INTAKE:
Up to 2 years 50 to 100 ml after each loose stool
2 ears or more 100 to 200 ml after each loose stool
Tell the mother to :
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then continue, but more slowly.
• Continue giving extra fiuid until the diarrhoea stops.
2. GIVE ZINC (age 2 m onths up to 5 years>
■ TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
2 months u to 6 months 1/2 tablet dail for 14 da s
6 months or more 1 tablet dail for 14 da s
■ SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
• Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
• Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months>
4. WHEN TO RETURN
In the clinic, give recommended amount of ORS over 4-hour period
■ DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
WEIGHT < 6 kci 6 · <10 kci 10 - <12 kci 12 - 19 kci
AGE' Upto 4 4 months up to 12 12 months up to 2 2 years up to 5
months months years years
ln ml 200 - 450 450 - 800 800 - 960 960 - 1600
• Use the child's age only when you do not know the weight. The approximate amount of ORS
required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
• If the child wants more ORS than shown, give more.
• For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
■ SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
• Give frequent small sips from a cup.
• If the child vomits, wait 1O minutes. Then continue, but more slowly.
• Continue breastfeeding whenever the child wants.
■ AFTER 4 HOURS:
• Reassess the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.
■ IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
in Plan A.
• Explain the 4 Rules of Home Treatment:
1. GIVE EXTRA FLUID
2. GIVE ZINC (age 2 months up to 5 years>
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
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~ 023
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FOLLow THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
START HERE ■ Start IV fluid immediately. If the child can drink, give ORS by
Can you give mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid YES-> Solution (or, if not available, normal saline , divided as follows
immediately? AGE First give Then give
NO
30 ml/kci in: 70 ml/kci in:
l Infants (under 12 1 hour* 5 hours
months)
Children (12 months up 30 minutes* 2 1/2 hours
to 5 vears)
• Repeat once if radial pulse is still very weak or not
detectable.
■ Reassess the child every 1-2 hours. If hydration status is
not improving, give the IV drip more rapidly.
■ Also give ORS (about 5 ml/kg/hour) as soon as the child can
drink: usually after 3-4 hours (infants) or 1-2 hours (children).
■ Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B,
or C) to continue treatment.
Is IV treatment ■ Refer URGENTLY to hospital for IV treatment.
available nearby (within YES-> ■ If the child can drink, provide the mother with ORS solution and
30 minutes)? show her how to give frequent sips during the trip or give ORS
NO by naso-gastric tube.
l
Are you trained to use ■ Start rehydration by tube (or mouth> with ORS solution:
a naso-gastric (NG) YES-> give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
tube for rehydration? ■ Reassess the child every 1-2 hours while waiting for
NO transfer:
l • If there is repeated vomiting or increasing abdominal
Can the child drink? YES->
distension, give the fluid more slowly.
• If hydration status is not improving after 3 hours, send the
NO child for IV therapy.
l ■ After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.
Refer URGENTLY to NOTE:
hospital for IV or NG ■ If the child is not referred to hospital, observe the child at least
treatment 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
w_ - - - - - - - - - - - - - - - - - - - - - - - - - - - .i

8
FROM IMCI HANDBOOK + LECTURE
TYPES OF DIARRHEA [REFER TO TABLE BELOW]
• If an episode of diarrhea lasts <14 days, it is acute diarrhea. Acute watery diarrhoea causes
dehydration and contributes to malnutrition. The death of a child with acute diarrhoea is usually due to
dehydration.
• If the diarrhea lasts ≥14 days, it is persistent diarrhea (without dehydration). Up to 20% of episodes of
diarrhea become persistent. Persistent diarrhoea often causes nutritional problems that contribute to
deaths in children who have diarrhea. If there is dehydration, classify it as severe persistent diarrhea.
o Advise the mother on feeding give multivitamins and minerals including ZINC for 14 days and follow
up in five days.
• Diarrhea with blood in the stool, with or without mucus, is called dysentery. The most common
cause of dysentery is Shigella bacteria. Amoebic dysentery is not common in young children. A child
may have both watery diarrhoea and dysentery.
o Management: Ciprofloxacin for three days and advice to follow up in three days.
Treatment for Diarrhea
• Use of low/reduced osmolarity Oral Rehydration
Salts (ORS)
• Providing children with zinc for 14 days
− Children > 6 months 20 mg zinc
− Children < 6 months 10 mg of zinc
• Ciprofloxacin as first line drug for bloody diarrhea
Composition of the old and reformulated ORS
- New/reformulated has low or reduced osmolarity.
FEVER
LECTURE
• Fever is defined by history of ‘feels hot’ or a temperature of ≥37.5° C based on axillary temperature.
• Rectal temperature is approximately 0.5° C higher
• Decide if the child is high risk or low risk for malaria. There’s separate table for HIGH malaria risk.
• Also, look for bacterial cause of fever (e.g., local tenderness, oral sores, refusal to use a limb, hot tender
swelling, red tender skin or boils, lower abdominal pain or pain in passing urine in older children.
• If no malaria test is available in a HIGH risk area, classify it as malaria. In low malaria risk and no obvious
cause of fever classify as malaria.
MALARIA RISK AREA: Palawan, Davao Del Sur, Davao Del Norte, Sultan Kudarat, Sulu archipelago
NOTE
In Vitamins and Minerals lecture:
• WHO recommends zinc supplementation to
all cases of diarrhea and dysentery
• Given for 10-14 days
I I
.FOR DYSENTERY give Ciprofloxacine
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
CIPROFLOXACINE
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet I 500 mg tablet
Less than 6 months 1/2 I 1/4
6 months uo to 5 vears 1 I 1/2
SIGNS CLASSIFY AS IDENTIFYTREATMENT
(Urgent pre-referral treatments are in bold print.)
• Dehydration present SEVERE ► Treat dehydration before referral unless the child has
PERSISTENT another severe classification.
DIARRHOEA ► Refer to hospital.
• No dehydration PERSISTENT ► Advise the mother on feeding a ch ild who has
DIARRHOEA PERSISTENT DIARRHOEA.
► Follow-up in 5 days.
• Blood in the stool DYSENTERY ► Treat for 5 days with an oral antibiotic
recommended for Shigella in your area.
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OLD WHO- Rebnnulated
ORS (meq ORS (meqor
ormmol/I) mmol/I)
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245
••/ickil,i Bottom
For ALL sick children ask the mother about the child's problem, check for general danger signs, ask
about cough or difficult breathing, diarrhoea and then
ASK: DOES THE CHILD HAVE FEVER?
Does the child have fever?
(by history or feels hot or temperature 37.5 °C** or above)
IF YES:
Decide the Malaria Risk: high or low
THEN ASK:
• For how long?
• If more than 7 days, has
fever been present every day?
• Has the ch ild had measles within
the last 3 months?
If the child has measles now or
within the last 3 months:
LOOKAND FEEL:
• Look or feel for stiff neck.
• Look for runny nose.
Look for signs of MEASLES
• Generalized rash and
• One of these: cough, runny nose,
or red eyes.
• Look for mouth ulcers.
Are they deep and extensive?
• Look for pus draining from the eye.
• Look for clouding of the cornea.
Do malaria test: If no severe
classification
• In all fever cases with
HIGH MALARIA RISK
• In LOW malaria risk if no
obvious cause of fever
present.
CLASSIFY the child's illness using the colour-coded classification tables for fever.
Then ASKabout the next main symptom: ear problem, and CHECK for malnutrition and anaemia,
immunization status and for other problems.
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9
FROM IMCI HANDBOOK
• Malaria is caused by parasites in the blood called “plasmodia.” They are transmitted through the bite
of anopheline mosquitoes. Four species of plasmodia can cause malaria, but the most dangerous one
is Plasmodium falciparum.
• Fever is the main symptom of malaria. It can be present all the time or go away and return at regular
intervals. Other signs of falciparum malaria are shivering, sweating and vomiting. A child with malaria
may have chronic anemia (with no fever) as the only sign of illness.
• Signs of malaria can overlap with signs of other illnesses. For example, a child may have malaria and
cough with fast breathing, a sign of pneumonia. This child needs treatment for BOTH falciparum malaria
and pneumonia. Children with malaria may also have diarrhea. They need an antimalarial and treatment
for the diarrhoea.
• In areas with very high malaria transmission, malaria is a major cause of death in children. A case of
uncomplicated malaria can develop into severe malaria as soon as 24 hours after the fever first appears.
Severe malaria is malaria with complications such as cerebral malaria or severe anemia. The child
can die if he does not receive urgent treatment.
(a) MALARIA
For High or Low Malaria Risk:
LECTURE
MANAGEMENT: Give Oral Antimalarial for MALARIA
.Any general danger sign or Pink: ■ Give first dose of artesunate or quinine for severe malaria
.Stiff neck. VERY SEVERE FEBRILE ■ Give first dose of an appropriate antibiotic
: DISEASE ■ Treat the child to prevent low blood sugar
■ Give one dose of paracetamol in clinic for high fever (38.5°C
or above>
■ Reier URGENTLY to hospital
.Malaria test POSITIVE Yellow: ■ Give recommended first line oral antimalarial
MALARIA ■ Give one dose of paracetamol in clinic for high fever (38.5°C
or above>
■ Give appropriate antibiotic treatment for an identified bJcterial cause
of fever
■ Advise mother when to return immediately
■ Follow-up in 3 days if fever persists
■ If fever is present every day for more than 7 days, refer for
assessment
.Malaria test NEGATIVE Green: ■ Give one dose of paracetamol in clinic for high fever (38.5°C
.Other cause of fever PRESENT FEVER: o r above>
NO MALARIA ■ Give appropriate ant ibiotic treatment for an identified bacterial
cause of fever
■ Follow-up in 3 days if fever persists
■ If fever is present every day for more than 7 days, refer for
assessment
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Give Artesunate Suppositories or Intramuscular Artesunate or
Quinine for Severe Malaria
i FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
, ■ Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
I artesunate injection or quinine).
I
I ■ Artesunate suppository: Insert first dose of the suppository and refer child urgently
L ■ Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital.___________ _
r 1F REFERRAL IS NOT POSSIBLE:_____________________________________ _
■ For artesunate iniection:
• Give first dose of artesunate intramuscular injection
• Repeat dose after 12 hrs and daily until the child can take orally
• Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
• Give first dose of suppository
• Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
• Give full dose of oral antimalarial as soon as the child is able to take orally
■ For quinine:
• Give first dose of intramuscular quinine.
• The child should remain lying down for one hour.
• Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able
to take an oral antimalarial. Do not continue quinine injections for more than 1 week.
If low risk of malaria, do not give quinine to a child less than 4 months of age.
RECTALARTESUNATE INTRAMUSCULAR INTRAMUSCULAR
SUPPOSITORY ARTESUNATE QUININE
AGE or WEIGHT 50 mg 200 mg
60mg 150 mg/ml* 300 mg/ml*
suppositories suppositories
vial (20mg/ml) 2.4 (in 2 ml (in 2 ml
Dosage 10 Dosage 10 mg/kg ampoules) ampoules)
mg/kg mg/kg
2 months up to 4
1 112ml 0.4ml 0.2ml
months (4 - <6 kg)
4 months up to 12
2 1 ml 0.6ml 0.3ml
months (6 - <10 kg)
12 months up to 2
2 - 1.5ml 0.8ml 0.4ml
years (10 - <12 kg)
2 years up to 3
3 1 1.5 ml 1.0ml 0.5ml
years (12 - <14 kg)
3 years up to 5
3 1 2ml 1.2ml 0.6ml
years (14 - 19 kg )
• quinine salt
■ If Artemether-Lumefantrine (AL)
• Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child
vomits within an hour repeat the dose.
• Give second dose at home after 8 hours.
• Then twice daily for further two days as shown below.
• Artemether-lumefantrine should be taken with food.
■ If Artesunate Amodiaquine (AS+AQ)
• Give first dose in the clinic and observe for an hour, if a child vomits within an hour repeat the
dose.
• Then daily for two days as per table below using the fixed dose combination.
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10
MALARIA DIAGNOSIS
- Prompt parasitological confirmation by microscopy or alternatively by Rapid
Diagnostic Tests (RDTs) is recommended in ALL patients suspected of
malaria before treatment is started.
TREATMENT OF VERY SEVERE DISEASE IN MALARIA RISK AREA
- Pre-referral treatment includes rectal Artesunate suppository or oral Quinine and
IM Ampicillin and Gentamicin
TREATMENT OF UNCOMPLICATED FALCIPARUM MALARIA
- Artemisinin based combination therapies (ACTs) should be used in
the treatment of uncomplicated P. falciparum malaria
- ACTs should include at least 3 days of treatment with an artemisinin
derivative
For No Malaria Risk and No Travel to Malaria-Risk Area
Same management antibiotics given in child (+) cough/DOB = Pneumonia/Severe Pneumonia
MANAGEMENT: Give Intramuscular Antibiotics
rr-------------------------------------------------------
Artemether-Lumefantrine Artesunate plus Amodiaquine tablets
tablets Give Once a day for 3 days
(20 mg artemether and 120
mg lumefantrine)
(25 mg AS/67.5 (50 mg AS/135 mg
WEIGHT (age) Give two times daily for 3 mgAQ) AQ)
days
Day 1 Day 2 day 3
Day
Day 2 Day 3
Day
Day 2 Day 3
1 1
5 - <10 kg (2 months up
1 1 1 1 1 1 . . .
to 12 months)
10 - <14 kg (12 months
1 1 1 - - - 1 1 1
up to 3 years)
14 - <19 kg (3 years up to
2 2 2 - - - 1 1 1
5 years)
.Any general danger sign Pink: ■ Give first dose of an appropriate antibiotic.
.Stiff neck. VERY SEVERE FEBRILE .Treat the child to prevent low blood sugar.
' DISEASE .Give one dose of paracetamol in clinic for high fever (38.5°C
or above>
.
.Reier URGENTLY to hospital.
.No general danger signs Green: .Give one dose of paracetamol in clinic for high fever (38.5°C
.No stiff neck. FEVER or above>
.Give appropriate antibiotic treatment for any identified bacterial
cause of fever
.Advise mother when to return immediately
.Follow-up in 2 days if fever persists
.If fever is present every day for more than 7 days, refer for
assessment
• /ickil,i Bottom
GIVE TO CHILDREN BEING REFERRED URGENTLV
■ Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg).
AMPICILLIN
■ Dilute 500mg vial with 2.1 ml of sterile water (500mg/2.5ml).
• IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
■ Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times.
GENTAMICIN
■ 7.5 mg/kg/day once daily
AGE or WEIGHT
AMPICILLIN GENTAMICIN
500 mg vial 2ml/40 mg/ml vial
2 up to 4 months (4 - <6 kg) 1 m 0.5-1.0 ml
4 up to 12 months (6 - <10 kg) 2ml 1.1 -1.8 ml
12 months up to 3 years (10 - <14 kg) 3ml 1.9-2.7 ml
3 years up to 5 years (1 4 - 19 kg) 5m 2.8-3.5 ml

11
(b) MEASLES
LECTURE
• Symptomatology of measles:
o High fever up to 105°F (>40°C)
o 3Cs/ Triad: Cough, runny nose (Coryza) and conjunctivitis
• 2-3 days after the symptoms begin, tiny white spots also known as complex spots may appear inside
the mouth, which also appear 1-2 days before the onset of the rash. And these spots are
pathognomonic for measles.
• Other complications of measles are pneumonia, stridor, diarrhea, ear infection and acute malnutrition.
These are classified in other tables.
FROM IMCI HANDBOOK
- Children with measles may have other serious complications of measles. These include stridor in a
calm child, severe pneumonia, severe dehydration, or severe malnutrition.
- Vitamin A deficiency contributes to some of the complications such as corneal ulcer. Any vitamin A
deficiency is made worse by the measles infection.
MANAGEMENT: Treat Eye Infection with Tetracycline Eye Ointment
MANAGEMENT: Treatment for Mouth Ulcers with Gentian Violet (GV)
EAR PROBLEM
If the child has measles now or
within the last 3 months:
• Look for mouth ulcers.
Are they deep and extensive?
• Look for pus draining from the eye.
• Look for clouding of the cornea.
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EXAMPLE 13: CLASSIFICATION TABLE FOR MEASLES (IFMEASLES NOWOR WITHIN THE LASTJMONTHS)
(Urgent pre-referral treatmentsare in bold print.)
• Any general danger sign SEVERE ► Give vitamin A.
or COMPLICATED ► Give first dose of an appropriate antibiotic.
• Clouding of cornea or MEASLES*** ► If clouding of the cornea or pus draining from the
• Deep or extensive eye, apply tetracycline eye ointment.
mouth ulcers. ► Refer URGENTLY to hospital.
• Pus draining from the MEASLES WITH ► Give vitamin A.
eye or EYE OR MOUTH ► If pus draining from the eye, treat eye infection
• Mouth ulcers COMPLICATIONS*** with tetracycline eye ointment.
► If mouth ulcers, treat with gentian violet.
• Measles now or within MEASLES ► Give vitamin A.
the last 3 months.
••• Other important complicationsof measles-pneumonia, stridor, diarrhoea, ear infection,and malnutrition-are
classified in other tables.
• /ickil,i Bottom
■ Clean both eyes 4 times daily.
• Wash hands.
• Use clean cloth and water to gently wipe away pus.
■ Then apply tetracycline eye ointment in both eyes 4 times daily.
• Squirt a small amount of ointment on the inside of the lower lid.
• Wash hands again.
■ Treat until there is no pus discharge.
■ Do not put anything else in the eye.
L I
■ Treat for mouth ulcers twice daily.
• Wash hands.
• Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
• Paint the mouth with half-strength gentian violet (0.25% dilution).
• Wash hands again.
• Continue using GV for 48 hours after the ulcers have been cured.
• Give paracetamol for pain relief.
For ALL sick children ask the mother about the child's problem, check for general danger signs,
ask about cough or difficult breathing,diarrhoea, fever and then
ASK: DOES THE CHILD HAVE AN EAR PROBLEM?
G C$
Does the child have an ear problem?
If YES ASK: LOOKAND FEEL:
• Is the re ear pain? • Look for pus draining from the ear.
• Is the r ear discha rge? • Fee lfo r tender swelling behind the ear.
If yes,for how long?
I
I CLASSIFY the child's illness using the colou r-coded classification table for ear problem.
I
Then CHECK for malnutrition and anaemia, immunization status and for other problems.
KOPLIK SPOTS

12
FROM IMCI HANDBOOK
• When a child has an ear infection, pus collects behind the ear drum and causes pain and often fever.
o If the infection is not treated, the ear drum may burst. The pus discharges, and the child feels less
pain. The fever and other symptoms may stop, but the child suffers from poor hearing because the
ear drum has a hole in it. Usually the ear drum heals by itself.
o At other times the discharge continues, the ear drum does not heal and the child becomes deaf in
that ear.
• 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. These are severe
diseases. They need urgent attention and referral.
• Acute Ear Infection DOC: Amoxicillin BID for five days, give Paracetamol for pain every six hours.
• Chronic ear infection DOC: treat with topical quinolone drops for 14 days and advise them to follow up
in five days.
MANAGEMENT: Clear the Ear by Dry Wicking and Give Eardrops
ACUTE MALNUTRITION
APPETITE TEST
- Offer appropriate amount of RUTF to the child to eat:
o After 30 minutes check if the child was able to finish the amount of RUTF given and decide:
 Child ABLE to finish at least one third of a packet of RUTF portion (92 g) or 3 teaspoons
from a pot within 30 minutes.
 Child NOT ABLE to eat one third of a packet of RUTF portion (92 g) or 3 teaspoons from a
pot within 30 minutes.
EXAMPLE 15:CLASSIFICATION TABLE FOR EAR PROBLEM
(Urgent pre-referral treatments are in bold print.)
• Tender swelling behind MASTOIDITIS ► Give first dose of an appropriate antibiotic.
the ear. ► Give first dose of paracetamol for pain.
► Refer URGENTLY to hospital.
• Pus is seen draining ► Give an oral antibiotic for 5 days.
from the ear and ACUTE EAR ► Give paracetamol for pain.
discharge is reported INFECTION ► Dry the ear by wicking.
for less than 14 days, ► Follow-up in Sdays.
or
• Ear pain.
• Pus is seen draining ► Dry the ear by wicking.
from the ear and CHRONIC EAR ► Follow-up in Sdays.
discharge is reported INFECTION
for 14 days or more.
• No ear pain and No NO EAR No additional treatment.
pus seen draining INFECTION
from the ear.
■ Dry the ear at least 3 times daily.
• Roll clean absorbent cloth or soft, strong tissue paper 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.
• Instill quinolone eardrops after dry wicking three times daily for two weeks.
• Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.
CHECK FOR ACUTE MALNUTRITION
LOOK AND FEEL:
Look for signs of acute malnutrition
• Look for edema of both feet.
• Determine WFH/L' _ z-score.
• Measure MUAC" __ mm in a child 6 months or older.
If WFH/L less than -3 z-scores or MUAC less than 115
mm, then:
• Check for any medical complication present:
o Any general danger signs
o Any severe classification
o Pneumonia with chest indrawing
• If no medical compl ications present:
o Child is 6 months or older, offer RUTF"" to
eat. Is the child:
Not able to finish RUTF portion?
Able to finish RUTF portion?
o Child is less than 6 months, assess
breastfeeding:
Does the child have a breastfeeding
problem?
Cla::::ify
NUTRITIONAL
STATUS
' WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
" MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
'"RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.

13
LECTURE
• Give small regular meals of RUTF and encourage the child to eat more than or at least as often as five
to six meals per day.
• If still breastfeeding continue by offering breast milk first before every RUTF feed. Give only RUTF for
at least two weeks. If breastfeeding, continue to breastfeed and gradually introduce foods recommended
for the age. See the feeding recommendations in counsel mother chart.
• When introducing recommended foods ensure that the child completes his daily ratio of RUTF before
giving other foods. Offer plenty of clean water from a cup when the child is eating the RUTF.
• The recommended amounts are listed in your charts and is based on weight.
Red – PPT based. Black – based on chart booklet & recording.
MICRONUTRIENT POWDER SUPPLEMENT (MMP) is given daily to children
six to 23 months old.
- Use this at 6 months of age during the introduction of complementary
feeding
- Mix MNP into complementary food preferably soft or semi-solid before
feeding it to the child
- Do not add MNP to foof before or during cooking
o For 6-11 months infant, give a total of 60 sachets over a period of
6 months
o For 12-23 months children, give 60 sachets every 6 months for a
total fo 120 sachest in a year.
ANEMIA
*Assess for sickle cell anaemia if common in your area.
LECTURE
• Some pallor: give iron give one dose daily for 14 days, use specific doses for age are in your charts.
o If that child has severe acute malnutrition and receiving RUTF, do not give iron because there is
already adequate amount of iron in the RUTF
• Oedema of both feet Pink: • Give first dose appropriate antibiotic
OR COMPLICATED • Treat the child to prevent low blood
• WFH/L less than -3 z- SEVERE ACUTE sugar
scores OR MUAC less MALNUTRITION
• Keep the child warm
than 115 mm AND any • Refer URGENTLV to hospital
one of the following:
9 Medical
complication present
or
9 Not able to finish RUTF
or
9 Breastfeeding
problem.
• WFH/L less than -3 z- Yellow: • Give oral antibiotics for 5 days
scores UNCOMPLICATED • Give ready-to-use therapeutic food for a child
OR SEVERE ACUTE aged 6 months or more
• MUAC less than 115 mm MALNUTRITION • Counsel the mother on how to feed the child.
AND • Assess for possible TB infection
• Advise mother when to return immediately
• Able to finish RUTF.
Follow up in 7 days
•
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• WFH/L between -3 and - Yellow:
2 z-scores MODERATE ACUTE
OR MALNUTRITION
• MUAC 115 up to 125 mm.
• WFH/L - 2 z-scores or
more
OR
• MUAC 125 mm or more.
Green:
NO ACUTE
MALNUTRITION
• /ickil,i Bottom
■ Assess the child's feeding and counsel the
mother on the feeding recommendations
■ If feeding problem, follow up in 7 days (5 days)
■ Assess for possible TB infection.
■ Follow-up in 30 days
■ If child is less than 2 years old, assess the
child's feeding and counsel the mother on
feeding according to the feeding
recommendations
Give micronutrient powder supplement.
■ lffeeding problem, follow-up in 7 days (5 days)
•
.
.
Composition per 1g serving:
Jron. ··--- _ _12.smg
(,s«111e<1rerr01.1$tJ"'Ji1~teN1re[DTAor
r«IDI.ISb~)
V1taminA_ -·-- ~
(.,l,dlyC.WS,;urronA;Ki:"f~ll!Olp,l~lafnbedl'tll
Zinc._ •..Smg
la5Zn:~te.CllkleorglUCONt~
Vitamin(. ....-30mg
(.i;ald~morlOd..mlSCOlb.,teJ
FolleaclCL_ - - - - - -1~
Storage:
2 years under cool and dry itoraQe conditions,
minimum 1year under tropic.al conditions..
Package weight: 0. 14 ouncu
l- •, .~::l.
~ _. ,,.,
.; 41,..J
. " . ~<L
THEN CHECK FOR ANAEMIA
Check for :m:iemi:I
I
.Look for palmar pallor. Is it:
0 Severe palmar pallor*? Cfo==ily
0 Some palmar pallor? ANAEMIA Classification
arrow
I
Severe palmar pallor Pink: ■ Refer URGENTLy to hopsltal
SEVERE ANAEMIA
Some pallor Yellow: ■ Give iron'"*
ANAEMIA • Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
• Advise mother when to return immediately
• Follow-up in 14 days
No palmar pallor Green: • • If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according
to the feeding recommendations
~ If feeding problem, follow-up in 5 days
Give micronutrient powder (MNP) I
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14
IMMUNIZATION STATUS
Check the child’s immunization, Vitamin A, Deworming Status, and Oral Health.
IMMUNIZATION SCHEDULE:
LECTURE + CHARTBOOK
*Children who are HIV or unknown HIV status symptoms consistent with HIV should not be
vaccinated with BCG. Infant born to mother with TB disease, do not give BCG first, instead give Isoniazid
Preventive therapy (IPT) for 3 months. If TST negative after 3 months, give BCG.
**DPT+HHIB+HepB is available as pentavalent vaccine
***Second dose of measles vaccine may be given at any opportunistic moment during periodic
supplementary immunization activities as early as one month following the first dose
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months
of age may benefit from a booster dose in the second year of life.
****Rotavirus vaccine is given to childern in selected areas due to limited supplies; Rotavirus vaccine is
avaialble as 2 dose or 3 dose schedule
*****Pneumococcal Conjugate Vaccine (PCV) is given to children in selected areas only due to limited
supplies.
Give Vitamin A Supplementation and Treatment
VITAMIN A SUPPLEMENTATION:
• Give first dose any time after 6 months of age to ALL CHILDREN
• Thereafter vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
• Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has
MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A within the past
month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
• Always record the dose of Vitamin A given on the child's card.
• For routine worm treatment or deworming, give every child Mebendazole every six months from the
age of one year. Record the dose on the child’s chart.
• Give 500mg Mebendazole as a single dose in clinic if:
o Hookworm or whip worm is a common problem in your area
o Child is >1 and had a dose in the previous six months.
Then we assess for other problems. Make sure a child with any general danger sign is referred after the first
dose of an appropriate antibiotic and other urgent treatments. Feed all children with a general danger sign
to prevent low blood sugar.
FROM IMCI HANDBOOK
• Give the recommended vaccine only when the child is the appropriate age for each dose. If the child
receives an immunization when he or she is too young, the child’s body will not be able to fight the
disease very well. Also, if the child does not receive an immunization as soon as he is old enough,
his risk of getting the disease increases.
• In exceptional situation where measles morbidity and mortality before nine months of age represent a
significant problem (more than 15% of cases and deaths), an extra dose of measles vaccine is given
at 6 months of age. This is in addition to the scheduled dose given as soon as possible after 9
months of age. This schedule is also recommended for groups at high risk of measles death, such as
infants in refugee camps, infants admitted to hospitals, infants affected by disasters and during
outbreaks.
• All children should receive all the recommended immunizations before their first birthday. If the
child does not come for an immunization at the recommended age, give the necessary immunizations
any time after the child reaches that age. For each vaccine, give the remaining doses at least 4 weeks
apart. You do not need to repeat the whole schedule.
• There are only three situations at present that are contraindications to immunization:
o Do not give BCG to a child known to have AIDS.
o Do not give DPT 2 or DPT 3 to a child who has had convulsions or shock within 3 days of the most
recent dose.
o Do not give DPT to a child with recurrent convulsions or another active neurological disease of the
central nervous system.
• In all other situations, here is a good rule to follow: There are no contraindications to immunization
of a sick child if the child is well enough to go home.
• Children with diarrhoea who are due for OPV should receive a dose of OPV (oral polio vaccine) during
this visit. However, do not count the dose. The child should return when the next dose of OPV is due for
an extra dose of OPV.
Follownational guidelines
N:;E_ VACCINE VITAMIN ASUPPLEMENTATION
Giveevery childa dose of Vitamin Aevery six
months from the age of 6 months.Record the
dose on the child's chart.
Binh BCG' Hep BO ROUTNE 05QRMNG
6 weeks CPT+HIB-1" Hep B1 0Pv1 R1V1"" PCV1-
Giveevery child Mebendazoleor Albendazole
every 6 months from the age of one year.
Re<:ordthe dose on the chikfs carcl.
10 weeks CPT-IHIB-2 Hep B2 OPv2 R
1V2 PCV2
14 weeks CPTtHIB-3 Hep B3 OPv3 RM PCV3 ORAL HEALTH
9 months Measles'"
Advise mother tobring the child lo adentist
every 6monthsfor dental check-up from the
age of 6 months
12 months - M,fl
15 months
r-------------------------------------------------------1
AGE VITAMIN A DOSE
6 up to 12 months 100 000 IU
One year and older 200 000 IU
L-------------------------------------------------------
~ 0
2
3
r-------------------------------------------------------
AGE VACCINE
IMMUNIZATION SCHEDULE: Birth BCG OPV-0
6 weeks DPT-1 OPV-1
1Oweeks DPT-2 OPV-2
14 weeks DPT-3 OPV-3
9 months Measles
CONTRAINDICATIONS TO IMMUNIZATION
DPT ■ Do not give DPT2 or DPT 3 to a ch ild who had convulsions, shock or any other
adverse reaction after the most recent dose.Instead,give DT.
■ Do not give ta a child with recurrent convulsions or another active neurological
disease of the central nervous system.
OPV ■ If the child has diarrhoea, give a dose of OPV,but do not count the dose.Ask the
mother to return in 4 weeks for the missing dose of OPV.

15
HIV INFECTIONS
LECTURE
• Ask about the breastfeeding status of the child.
• If no test has been done, request for the test.
• HIV testing is recommended for all children with unknown HIV status, especially those born HIV
positive mothers. If you do not know the mother's status, that's the mother first if possible.
LECTURE
• Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative
after cessation of breastfeeding.
• If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test
is positive, do a virological test as soon as possible.
COUNSEL AND FOLLOW-UP CARE (WHEN TO RETURN)
Use this chart if the child is NOT enrolled in HIV care.
ASK
H;i: the mother or child h;id ;in HIV te:t?
IF YES:
Decide HIV status:
• Mother: POSITIVE or NEGATIVE
• Child:
o Virological test POSITIVE or NEGATIVE
o Serological test POSITIVE or NEGATIVE
If mother i:. HIV po:.itive :md child fa neg.1tive or
unknown, ASK:
• Was the child breastfeeding at the time or 6 weeks before
the test?
• Is the child breastfeeding now?
• If breastfeeding ASK: Is the mother and child on ARV
prophylaxis?
IF NO, THEN TEST:
• Mother and child status unknown: TEST mother.
• Mother HIV positive and child status unknown: TEST child.
C/J::ify
HIV
: tatu:
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'--------------------------------------------------------'
• Positive virological test in Yellow:
• Initiate ART treatment and HIV care
child CONFIRMED HIV • Give cotrimoxazole prophylaxis•
CR INFECTION • Assess the child's feeding and provide appropriate
• Positive serological test in a counselling to the mother
child 18 months or older • Advise the mother on home care
• Asess or refer for TB assessment and INH
preventive therapy
• Follow-up regularly as per national guidelines
-- ---------- -------------- ----------------- ---------------------------------------------
• Mother HIV-positive AND Yellow:
• Give cotrimoxazole prophylaxis
negative virological test in HIV EXPOSED
• Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
stopped less than 6 weeks
• Do virological test to confirm HIV status"
ago
• Assess the child's feeding and provide appropriate
OR counselling to the mother
• Mother HIV-positive, child • Advise the mother on home care
not yet tested • Follow-up regularly as per national guidelines
OR
• Positive serological test in a
child less than 18 months
old
• Negative HIV test in mother Green:
• Treat, counsel and follow-up existing infections
or child HIV INFECTION
UNLIKELY
. . . .
~ 0
2
3
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'--------------------------------------------------------'
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the ch
problems.
If t he chi ld has: Ret urn fo r
fo llow -up in :
■ PNEUMONIA 3 days
■ DYSENTERY
■ MALARIA, if fever persists
• FEVER: NO MALARIA, if fever persists
■ MEASLES WITH EYE OR MOUTH
COMPLICATIONS
■ MOUTH OR GUM ULCERS OR THRUSH
■ PERSISTENT DIARRHOEA 5 days
■ ACUTE EAR INFECTION
■ CHRONIC EAR INFECTION
■ COUGH OR COLD, if not improving
■ UNCOMPLICATED SEVERE ACUTE 14 days
MALNUTRITION
■ FEEDING PROBLEM
■ ANAEMIA 14 days
■ MODERATE ACUTE MALNUTRITION 30 days
■ CONFIRMED HIV INFECTION According to national
■ HIV EXPOSED recommendations
NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
WHEN TO RETURN IMMEDIATELY
Advise mother to return immediately if the ch ild has any of these signs :
Any sick child ■ Not able to drink or breastfeed
• Becomes sicker
• Develops a fever
If child has COUGH OR COLD, also return if:
• Fast breathing
• Difficult breathing
If child has diarrhoea, also return if: • Blood in stool
• Drinking poorly

16
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
FROM IMCI HANDBOOK
SUMMARY OF ASSESS AND CLASSIFY:
• Young infants have special characteristics that must be considered when classifying their illnesses. They
can become sick and die very quickly from serious bacterial infections such as pneumonia, sepsis and
meningitis.
• The chart is not used for a sick newborn, that is a young infant who is less than 1 week of age. In the
first week of life, newborn infants are often sick from conditions related to labour and delivery, or have
conditions which require special management.
• For all these reasons, management of a sick newborn is somewhat different from caring for a young
infant age 1 week up to 2 months.
LECTURE
• DO A RAPID APRAISAL OF ALL WAITING INFANTS.
• First, ask the mother what the young infants problems are. Determine whether this is an initial or follow-
up visit for this problem. If it's a follow up visit, use the follow up instructions. But if it's an initial visit,
assess the young infant as follows.
• It is important to note all the signs and symptoms of the infants to classify the illness.
• Check for possible serious bacterial infection very severe disease, pneumonia or local bacterial infection.
• Amoxicillin is also identified as treatment for local bacterial infection
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
••
Name
Ask: What are the child's problems?
We~ht (kg),
Initial Visit?
Hajht/Length (an)
Follow-up Visit?
ASSESS (Cirde all signs present)
CHECK FOR GENERAL DANGER SIGN
• NOT ABLE TO DRINK OR BREASTFEED • LETHARGIC OR UNCONSCIOUS
• VOMITS EVERYTHING • CONVULSING NOW
• CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
• For how long? _ Days • Count the breaths in one minute: _ breaths per minute. Fast breathing?
• l ook for chest indrawing
• look and listen for stridor
• look and listen for wheezing
DOES THE CHILD HAVE DIARRHO EA?
• For how long?_ Days • Look at the childs general condition. Is the child
• Is there blood in the stool? o Lethargic or unconscious? Restless and irritable?
• l ook for sunken eyes.
• Offer the child fluid. Is the child:
o Not able to drink or drinking poorly? Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back
o Verv slowtv (lonaer then 2 seconds? S1.-....Av?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)
Decide malaria risk: High_ Low _ No_ • Look or feel for stiff neck
• For how long? _Days • Look for runny nose
• If more than 7 days, has fever been present every day? • Look for signs of MEASLES
• Has child had measles within the last 3 months? o Generalized rash and
Do a malaria test, if NO general danger sign in all cases in
o One of these: cough, runny nose, or red eyes
high malaria risk or NO obOOUs cause of fever in low
• Look for any other cause of fever.
malaria risk.:
Test POSITIVE? P. falciparum P. viva,c NEGATJVE?
If the child has measles now or within the • Look for mouth ulcers. If yes, are they deep and extensive?
last 3 months: • Look for pus draining from the eye
• Look for cloudina of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM?
• Is there ear pain? • Look for pus draining from the ear
• Is there ear discharqe? If Yes, for how IQn!:l? Davs • Feel for tender swellin~ behind the ear
THEN CHECK FOR ACUTE MALNUTRITION • Look for oedema of both feet.
AND ANAEMIA • Determine WFH/l z-score:
◊ Less than -3? Between -3 and -2? -2ormore?
• Child 6 months or older measure MUAC mm.
-
• Look for palmar pallor.
................................................................ - .... o . Severe_
pa)mar pallor? Sorne_
pa)mar pallor? ............................
If child has MUAC less than 115 mm or • Is there any medical complication: General danger sign?
WFH/L less than -3 Z scores: M y severe classification? Pneumonia with chest indrawing?
• 0-.ild 6 months or older. Offer RUTF to eat. Is the child·
o Not able to finish? Able to finish?
• Child less than 6 months: Is there a breastfeedina oroblem?
CHECK FOR HIV INFECTION
• Note mother's and/or child's HIV status
o Mother's HIV test: NEGATIVE POSrTIVE NOT DONEJKNOWN
o Child's virological test NEGATIVE POSITIVE NOT DONE
o Child's serological test NEGATIVE POSITIVE NOT DONE
• If mother is HIV-positive and NO positive virological test in child:
o Is the child breastfeeding now?
o Was the child breastfeeding at the time of test or 6 weeks before it?
o If breastfeedinc:r Is lhe mother and child on AFN oroahvlaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today)
BCG DPT+HIB--1 DPT+HIB--2 DPT+HIB--3 Measles1 Measles 2 VrtaminA
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazoie
Hep BO HepB1 HepB2 HepB3
RTV-1 RTV-2 RTV-3
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION,
ANAEMIA , or is HIV exposed or infected
• Do you breastfeed your child? Yes_ No_
o If yes, how many times in 24 hours? _ times. Do you breastfeed during the night? Yes_ No_
• Does the child take any other foods or fluids? Yes _ No _
o If Yes, what food or fluids?
o How many times per day? _ times. What do you use to feed the child?
o If MOOERATE ACUTE MALNUTRITIOO: How large are servings?
o Does the child receive his own serving?_ Who feeds the child and how?
• During this illness, has the child's feeding changed? Yes_ No _
o If Yes, how?
ASSESS OTHER PROBLEMS: Ask about mother's own health
/ickil,i Bottom
Temperature (°C)
CLASSIFY
General danger sign
present?
Yes No I
Ask t he mot her or careta ker about the young infant's problem.
I
- -
Remember to use
D.inger sign when I
selectlng
classlflc.i.tlons
Yes - No
- I
If this is an INITIAL VISIT for the problem,follow the steps below.
I
(If this is a follow-up visit for the problem, give follow-up care according to PART VII)
I
Yes - No
- I
Check for POSSIBLE BACTERIAL INFECTION and classify the illness.
I
I
Ask the mother or caretaker about If diarrhoea is present:
DIARRHOEA: • assess the infant further for signs
Yes - No
-
related to diarrhoea, and
• classify the illness according to the
signs which are present or absent.
I
Check for FEEDING PROBLEM OR LOW WEIGHT and cla ssify the infant's nutritional status.
............. .........
I
Yes - No
- I
Check the infant's immunization status and decide if the infant needs any immunizations today.
I
I
I
Assess any other problems.
I
I
.......................
I
Th en: Identify Treatment (PART IV), Treat the Infant (PART V), and
I
Counsel the Mother (PART VI)
Return for next
immunization oo:
(Date)
FEEDING r-------------------------------------------------------1
PROBLEMS
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17
LECTURE
• Once the illness is classified, identify the treatment and treat accordingly.
For possible serious bacterial infection or very severe disease:
• Give the first dose of intramuscular gentamicin 5 – 7.5 mg/kg milligram per kilogram AND intramuscular
ampicillin at 50 mg/kg
• Referral is the best option for this infant. If referral is not possible, continue to give IM gentamicin OD
or IM ampicillin BID until referral is feasible or for seven days if still not feasible.
TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR
• If the young infant is able to breastfeed: Ask the mother to breastfeed the young infant/Do breastfeed
to prevent low blood sugar.
• If the young infant is not able to breastfeed, but is able to swallow give 20 to 50 ML about 10ml/kg of
expressed breastmilk befere departure.
• If not possible to to give expressed breast milk (EBM), give 20 to 50 ml of sugar water (To make sugar
water: 4 levels of teaspoon of sugar about 20 grams in a 200 ML cup of clean water)
• If the infant is not able to swallow, give 20-50 mg of expressed best milk (EBM) or sugar water by
nasogastric tube (NGT).
o Then, refer urgently and write a referal note for the mother to take to the hospital.
• If the infant have some dehydration or severe dehydration, give them mother's unrpepared ORS and
ask her to give frequent sips of ORS on the way to the hospital. Advise the mother to continue
breastfeeding.
For those classified with pneumonia
• Give oral amoxicillin BID for seven days based on the weight
• Classified with local bacterial infection give amoxicillin BID for five days based on weight.
• Teach the mother how to treat local infections at home. Explain how the treatment is given and watch
her as she gives the first treatment in the clinic. Tell her to return to the clinic if the infection persist.
•
To treat skin pustules or umbilical infection:
• Put around the umbilicus with full strength Gentian Violet which is about 0.5%.
• The mother should give the treatment BID for five days to treat the rash or ulcers or white patches in the
mouth with half strength Gentian Violet about 0.25%.
• Using a clean soft cloth wrapped around the finger, then the mother should give the treatment QID daily
for 7 days.
Giving home care such as:
• Exclusively breastfeeding young infant.
• Kept warm at home at all times.
• Know when to return and know when to return immediately (i.e., breastfeeding poorly, reduced activity,
develops a fever, feels unusually cold, fast breathing, and palms or soles appear yellow.
ASK:
• Is the infant having
diffirulty in feeding?
• Hasthe infant had
COllVUlsioos (fits)?
SIGNS
Any one or more ofthe following signs:
LOOKM41> FEEl:
• Count the breaths in }
I minute. The young
R
epeat thecount if it is inrt must be
60 or more breaths per ca m.
minute.
• Look for severe chest indrawing.
• Measure axmary temperature.
• Look at theyoung infant'smovements..
'if the infant is sleeping, ask the mother
to wake him/her.
- Does the infant moveon his/her
own1 If the infant is not moving,
genlly stimulate himorher.
- Does the infant moveonly when
stimulated but then stops?
- Does the infant not move at all?
• 'Look at theumbilkus. Is it red or
draining pus?
• Look for skin pustules.
I
Classify
AU YOUNG
INFM4TS
IDENTIFY TREATMENT
(Urgentpre-refenaltreatment is shown in bold.)
-+ Give first dose of intramuscularantibiotics..
• Not able to feed at all,or not feeding welll or
CI.AS.SIFY
POSSIBLE
SERIOUS
BACTERIAL
INFKTION
-+ Treatto prevent low blood sugar.
• Coo11Ulsions or
• Severe chest indrawing or
• High body t~ture (38•c•or above) or
• Low body temperature (less than 35.S-C•) or
• Movement only when stimulated or no
movement at all or
• Fast breathing (60 breaths per minute or more)
in infants less than 7 days old
• Fast breathing (60 breaths per minute or more)
in infants 7-59 days old
• Umbilicus red or draining pus
• Skin pustules
• No signs of bacterial infec:tioo or very severe
disease
• /ickil,i Bottom
or
VERY SEVERE
DtSEASE
PNEUMONIA
LOCAL
BACTERIAL
INFECTION
-+ Advise the mother how to keep the infant
wann on the w.y to the hospital.
-+ Refer URGENTLY to hospital.
OR
-+ Hreferral is REJUSED or NOT FEASIBLE,, treat
inthe clinicuntil referral is feasible. (See
mart on p. 13)
-+ Give oral amoxicillin for 7days.
-+ Advise the mother to give home care.
-+ Follow up in 3days.
-+ Give amoxicillin for 5days.
-+ T
each the mother how to treat local infections
at home.
-+ Advise the mother to give home care.
-+ Fol ow up in 2days
INFECTION -+ Advise the mother on giving home care to the
UNLIKELY young infant.
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18
JAUNDICE
To Treat Diarrhea/dehydration, See TREAT THE CHILD Chart/pg 17.
DIARRHEA
What is diarrhea in young infant?
- A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery
(more water than faecal matter).
- The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
-
The sick young infant has any one of lhe lollowing:
• (OflYUlsions
•Not able 10 feed atal
•No l110Yeflle01 on ~inulalion
•Wei(Jhl< 1kg
The sick young infant has any one of lhe lollowing:
•Not feeding w~I on obseMtion
•Temperature J8 •cor more
•Temperature less than JS.I'(
•Severechestioorawing
•Movementon~11i1enstimulated
The sick young infant ha~
•fa~ breatt-ong (60 breaths per minu1e or more) in infants
Jessthan7daysold
CIAIIII
CRITICAL ILLNESS
C
LINICAL SEVERE
INFECTIO
N
IBIR1IEllal'
◄ Reinforce URGENT referral. Expl,in lo the caregivtrthat the infant is Vff'/ sick and must be
urgently referred for hospital care.
◄ Krefenal is stilnot feasible, givt once-daily intramu1CUlargent.,mkin and twke-daily
intramu1CUlar ampkimn unb1 referral is feasible or for 7days Kreferral Is still not lwi'ble.
◄ Treat ID prevent low blood sugar.
◄ Teach the mother how lo leep lhe young infant warm at hOll'E.
◄ Advise the motherto return daiyfor the injections
◄ Treatanyotherc~sificalion of ilness in lhe young infant
◄ Reassesstheyoung infant al each visit
◄ Givt on<e-dailyintrarnu!<ular gentamicin' and oral amoxi<ilin for 7day,.
◄ Treat ID prevent low blood sugar.
◄ Teach the mother how lo leep the young infant warm at hOll'E.
◄ Advise the motherto return for lhe next injection lhe following da'f.
◄ Treat any other classification of ilness in the young infant
◄ Reassesstheyoung infant at each visit
SMRE PNEUMONIA ◄ Givt oral amoxi<ilin for 7dayi.
◄ Teach the mother how lo gwe oral amoxicilintwice daiy.
◄ Treat any other c~sification of ilness in the young infant
◄ Advise the motherto return for follow-up in Jday,.
CHECK FOR JAUNDICE
•
) •
•
•
•
If jaundice present, ASK: LOOK AND FEEL:
• When did the jaundice
appear first?
Any jaundice if age less
than 24 hours 2!:
Yellow palms and soles at
any age
Jaundice appearing after 24
hours of age and
Palms and soles not yellow
No jaundice
• Look for jaundice (yellow
eyes or skin)
CLASSIFY JAUNDICE )
• Look at the young infant's
palms and soles. Are they
yellow?
0-----------~
Pink: • Treat to prevent low blood sugar
SEVEREJALM>ICE ■ Refer URGENTLY to hospital
• Advise mother how to keep the infant warm
on the way to the hospital
Yellow: • Advise the mother to give home care for the
JAUNDICE young infant
• Advise mother to return immediately if palms and
soles appear yellow.
• If the young infant is older than 14 days, refer to a
hospital for assessment
Follow-up in 1 day
Green: ■ Advise the mother to give home care for the
NO JAUNDICE young infant
• /ickil,i Bottom
THEN ASK: Does the young infant have diarrhoea*?
IF YES, LOOK AND FEEL:
• Look at the young infant's general condition:
Infant's movements Classify
o Does the infant move on his/her own?
o Does the infant not move even when stimulated but
then stops?
DIARRHOEA for /
DEHYDRATION
_______,
o Does the infant not move at all?
o Is the infant restless and irritable?
• Look for sunken eyes.
• Pinch the skin of the abdomen. Does it go back:
o Very slowly (longer than 2 seconds)?
o or slowly?
Two of the following signs: Pink : ■ If infant has no other severe classification:
• Movement only when SEVERE 0 Give fluid for severe dehydration (Plan C)
stimulated or no movement DEHYDRATION CR
at all If infant also has another severe
• Sunken eyes classification:
• Skin pinch goes back very 0 Refer URGENTLY to hospital with
slowly. mother giving frequent sips of ORS on
the way
Advise the mother to continue
breastfeeding
Two of the following signs: Yellow: ■ Give fiuid and breast milk for some dehydration
• Restless and irritable SOME (Plan B)
• Sunken eyes DEHYDRATION ■ If infant has any :;evere cl;,:;:;ification:
• Skin pinch goes back 0 Refer URGENTLY to ho:;pit;,I with
slowly. mother giving frequent sip:; of ORS on
the way
0 Advise the mother to continue
brea:;tfeeding
■ Follow-up in 2 days if not improving
Not enough signs to classify Green: ■ Give fiuids to treat diarrhoea at home and
as some or severe NO DEHYDRATION continue breastfeeding (Plan A)
dehydration. ■ Advise mother when to return immediately
■ Follow-up in 2 days if not improving
I

19
HIV INFECTION
THEN CHECK FOR HIV INFECTION
ASK
• Has the mother and/or young infant had an HIV test?
IFYES:
• What is the mother's HIV status?:
• What is the young infant's HIV status?:
o Virological test POSITIVE or NEGATIVE
If mother is HIV positive and NO positive virological test
in child ASK:
• Is the young infant breastfeeding now?
• Was the young infant breastfeeding at the time of test
or before it?
• Is the mother and young infant on PMTCT ARV
prophylaxis?*
IF NO test: Mother and young infant status unknown
• Perform HIV test for the mother; if positive, perform
virological test for the young infant
Classify >
,_~t_
1
:_tuc..:s:...._________,,
• Infant has positJve virologlcal test
• Infant has positwe serologteal test
or
• Mother is HIV posnrve AND infant
who 1s breastfeeding or stopped less
than 6weeks ago has anegative
v1rological test
or
• Mother is HIV positive, and young
Infant not yet tested.
• HIV test not done for mo her or
infant
• Negati<e HIV test b- the mother or
negative virological test for the infant
CONARMEO HIV
INFECTION
HIV ElCPOSED:
POSSIBLE HIV
INFECTION
HIV I FECTION
STATUS UNKNOWN
HIV INFECTION
UNLlmY
➔ Give cotrimccazole prophylaxis from age 4-6 weeks.
➔ Refer or give antiretroviral treatment and HIV care.
➔ Refer or start the mother on aooretrovirals if not on
treatment.
➔ Advise the mother on home care.
➔ Follow-up as per national guidelines.
➔ Give cotrimoxazole prophylaxis from age 4-6 ks.
➔ Start or continue antiretroviral prophylaxis according
to nsk assessment
➔ Conduct av,rological test for the infant
➔ Refer or start the mother oo ant1retrovirals if not on
treatment
➔ Advise the mother on home care.
➔ Follow up regularly as per national guidelines
➔ I · ia e HIV tesmg and counseling.
➔ Conduct HIV test for the mother and if positive, a
YJrologJCal leSt for the infant
➔ Conduct virological test for the infant if the mother is
not available.
➔ Treat. counsel and follow up any infections.
➔ Advise the mother about feeding and about her own
health.
• FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:
ANTIBIOTIC FOR PROPHYLAXIS Oral Cotrimoxazole
COTRIMOXAZOLE
(trimethoprun +rulfum,ihoxazole)
AGE Give once a day starting at 4-6 weeks of age
Syrup Paediatric tablet Adult tablet
(40/200 mg/5ml) (Single strength 20/100 mg) (Single strength 80/400 mg)
Less than 6 months 2.5ml 1
6 months up to 5 years 5ml 2 1/2

20
LOW BIRTH WEIGHT
A.SK: LOOK AND FEEL:
• Is the infant breastfed? Uyes, how many • 0eterm· weight for age.
times in 24 hours? - Weight less than 2kg?
• Does the infant receive artt o er foods - Weight for acJe less than
or drink? -2 zscore
- If yes, how often? • Look for ukers or wh· e
- What do you use to eed the infant? pa ches inthe mouth (thrush).
ASSESS BREASTFEEDING:
• Has the in nt breastfed in the previous hour?
If the infant has not red in the previous hour, ask the mother to put the infant
ro her breast Observe the breastfeed for 4 minutes.
(If the infant sfed during the previous hour,as the mo her whether she
can wait and tell you when the infant iswilling to feed again.)
• Is the infant well attached?
Goodattachment Poor attachment Noattachmentat all
TO CHECK ATTACHME T. LOOK FOR:
--,
- Moreareola seen above infant's top lipthan belowbottom lip
- Mouth ·de open
- LowerJ,p turned outwards
- Chin touching breast
(All of these signs should be p,ese ifthe attachmen is good).
• Is the · fant sucking effectively(that is, slow deep sucks,sometimes pausing)?
Sucking effectively Not sucking effectively ot sucking at all
-t Oear a blodced nose if it interferes with breastfeeding.
Classify
FEEDING
SIGNS
• Weight < 2kg in
infants less than 7days
• Not wel attached to
breast or
• Not sucking effectively
or
• Less than 8 breastfeeds
in 24 hours, or
• Receives other foods or
dnnk, or
• Weight < -2Zscore, or
• Thrush (ulcers or white
patches in mouth)
• Weight ~ -2Zscore
and no other sign of
inadequate feeding.
CLASSIFY
VERY LOW
WEIGHT
FORAGE
FEEDING
PROBLEM
lilld/or
LOW
WEJGHT
FORAGE
NO FEEDING
PROBLEM
IDEHTIFY TREATMENT
-+ REFER to hospital for Kangaroo mother CMe.
-+ Treat to prevent low blood sugar.
-+ Advise the mother to lrNp tt. young Infant warm on tt. way
to hosplta
-+ If not well attached or not sucking effectJvely, teach correct
positioning and attachment
-+ If not ableto attach wellimmediately, teach the mother to express
breastrnilk and feed from acup.
-+ If breastfeeding less than 8times in 24 hours, advise the mother
to increase the frequency and to breastfeed as often and for as
long as the infant wants, day and night
-+ If the ·nfant IS receiving other foods or dnnks, counsel the mother to
increase breastfeed1119, reduce other foods and dnnk and use acup.
-+ If not breastfeeding at all
- Refer for breastfeeding counselling and possible relactallon.
- Advise about correct preparation of breastrnilk substitutes and
use of acup.
-+ Advise the mother on how 10 feed and keep the low-we,ght infant
warm at home.
-+ If the infant has thrush, teach the mother to treat thrush at home.
-+ Advise the mother on gMng home care to the young infant
-+ Follow up any FEIOI GPROBLEM or thrush in 2days.
-+ Follow up infants who have LOW WEIGHT FOR AGE within
14 days.
-+ Advise mother on giving home care to the young infan
-+ Praise the mother for feeding the infant well.

21
IN INFANTS NOT RECEIVING BREASTMILK (Use this chart in HIV-positive mother who has chosen not to
breastfeed)
IMMUNIZATION SCHEDULE
ASK:
a mi areyougiving?
• How many imes dur g eday
nd mgh?
• How m dl oyou g ch
feed?
• How do you prepare the ?
- ll't the mother demonstrate
or expla11 how she prepares
and how she g 1t to
• H IS n? Cup or
bo e?
• How do you dean the ding
utensils?
• Do you g arrt astmtl at I?
foods and · sdo
Ill addition to
LOO LISTEN, FEEL:
• Determine the
i't'aght or age.
- ei h less than
Hg?
- ei t for age
les.s than -2 Z
score?
• Look ulcers or
epatches in the
mou C rush).
Classify
FEEDI G
• Weight < 2tg in infants less than
7days
VERY LOW WBGHT
FORAGE
➔ REFERto hospital for Kaingaroo moth« are.
➔ Trat to prevent low blood 51191r.
• GMrig lllal)propnate replacement
feeds, Of
• Givlrig 1nsuffioeot replacement feeds.
Of
• Mikincorrectly or unhyg,erncally
prepared. Of
• Usirig afeed,rig bonle. o,
• An HIV-posill'YI! mother givlrig both
breasttru and other feeds before
6 months. or
• Weight for age < •2Zscore
• Weight ~ -2Zscores and no other
sign of inadequate feed1rig
• /ickil,i Bottom
FEWING PROBlEM
~nd/or
LOW WEIGHT FOR AGE
NO FEEDING PROBLEM
➔ Advise the mother on kHplng the young inbnt
Wlrm on the W'f to hosplul.
➔ Counsel about feedtrig
➔ Explain the guidelines for safe replacement
feedmg
➔ Identify coocems of mother and family about
feedtrig.
➔ If mother is usirig a bottle. teach cup feedmg.
➔ If thrush. teach the mother how to treat 11 at
home.
➔ Follow-up FEEDING PROBLEM or thrush m2days.
➔ Follow up LOW WEIGHT FOR AGE 11 7days.
➔ Advise mo her to cont11ue feeding. and ensure
good hygiene.
➔ Praise the mother tor feeding the infant we
AGE
Birt h
6 weeks
VACCINE
BCG
DPT+HIB-1
OPV-0 Hep BO
OPV-1 Hep B1 RTV1 PCV1
ASSESS THE MOTHER'S HEAL TH NEEDS
Nutritional status and anaemia, cont raception. Check hygienic practices.
VITAMIN
A
200 000
IUtothe
mother
w ithin 6
w eeks of
delivery
ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG
INFANT
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT
Give only breastfeeds to the young infant Breastfeed frequently, as often and for as long as the
infant wants.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
Follow uo visit
If the infant has: Return for first follow.up in:
■ JAUNDICE 1 day
• LOCAL BACTERIAL INFECTION 2 days
■ FEEDING PROBLEM
■ THRUSH
• DIARRHOEA
■ LOW WEIGHT FOR AGE 14 days
■ CONFIRMED HIV INFECTION According to national recommendations
• HIV EXPOSED
WHEN TO RETURN IMMEDIATELY:
Advise the mother to return immediately if the young infant has any of these
signs:
■ Breastfeeding poorly
• Reduced activity
■ Becomes sicker
■ Develops a fever
• Feels unusually cold
■ Fast breathing
■ Difficult breathing
■ Palms and soles appear yellow

22
GIVING FOLLOW-UP CARE
ASSESS EVERY YOUNG INFANT FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR SEVERE
DISEASE, PNEUMONIA OR LOCAL BACTERIAL INFECTION DURING FOLLOW-UP VISITS.
➔ PNEUMONIA OR SEVERE PNEUMONIA
After 3days•:
---
Reassess the young infant lo, POSSIBLE SERIOUS BACTERIAL INFECTION or PNEUMONIA or LOCAL BACTERIAL INFECTION as described on p. 1.
Treatment
➔ Refer urgentlyto hospital it.
- The infant becomes worse or
- Any new sign of POSSIBLE SERIOUS BACTERIAL INFECTION or VERY SEVERE OISEASE appears while on treatment
➔ Ifthe young infant is improving, ask the mother to continue giving the oral amoxicillin twice daily until all the tablets are firished.
➔ Ask the mother to bring the young infant back in 4more days.
➔ LOCAL BACTERIAL INFECTION
After 2 days:
• Look at the umbilicus. Is it red or draining pus?
• look for skin pustules.
Treatment
➔ If umbilical pus or redness remains tho sarno or is worso, refer the infant to hospital. If pus and rvdnoss a111 improved,tell the mother to
complete Sdays of antibiotic treatment and to continue treatment of the local infection at home.
➔ If skin pustules are the same or worse,refer the infant to hospital. If they are improved,tell the mother to complete 5 days of antibiotic
treatment and to continue treating the local infection at home.
➔ JAUNDICE
After 1 day:
LOOK for jaundice. Are the palms or soles yellow?
➔ If the palms or soles are yellow, refer the infant urgently to hospital.
➔ If the palms or soles are not yellow but jaundice has not decreased, advise the mother about home care and
ask her to return for follow-up again the next day.
-+ If the jaundice has started to decrease, reassure the mother, and ask her to continue home care. Ask her to
return for follow-up when the infant is 3weeks of age.
-+ After 3weeks of age: Ifjaundice continues beyond 3weeks of age, refer the young infant to hospital for
further assessment
'=
1
➔ DIARRHOEA
After 2 days:
ASK: Has the diarrhoea stopped?
I
➔ If the diarrhoea has not stopped, assess, classify and treat the young infant for diarrhoea (see p. 3).
-+ If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
I ➔ CONFIRMED HIV INFECTION OR HIV EXPOSED
I
• A young infant classified as having CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits
regularly as per national guidelines. Follow the instructions for follow-up care of children aged 2 months to 5years.
• /ickil,i Bottom
I
➔ FEEDING PROBLEM
After 2days:
Reassess feeding. Check for a feeding problem or low weight for age as described on pp. 5 and 6.
-+ Ask about any feeding problems found on the initial visit
-+ Counsel the mother about any new or continuing feeding problems. If you advise the mother to make significant
changes in feeding, ask her to bring the young infant back again.
➔ If the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young
infant's weight gain.
Exceptions:
If you think that feeding will not improve or if the young infant has lost weight, refer the infant to hospital.
➔ LOW WEIGHT FOR AGE
After 14 days (or 7days if the infant is not receiving breastmilk):
Weigh the young infant and detennine whether he or she sbll has alow weight for age.
Reassess feeding (pp. Sand 6).
➔ If the infant no longer has alow weight for age, praise the motherand encourage her to continue.
➔ If the infant still has a low -ight for age but is feeding well, praise the mother, and ask her to have her infant weighed again
within l month or when she returns for immunization.
➔ If the infant still has a low - ight for age and still has afeeding problem, counsel the mother about feeding, and ask her to
return again in 14 days (or when she returns for immunization, if within 14 days). Continue to see the young infant every few
weeks until he or she is feeding well and gaining weight regularly or no longer has a low weight for age.
Exceptions:
➔ If you think that feeding will not improve or if the young infant has lost weight, refer the infant to hospital.
➔ THRUSH
After 2 or 3 days:
Look lo, ulcers or white patches in the mouth (thrush).
Reassess feeding (pp. Sand 6).
➔ If the thrush isworse or the infant has problems with attachment or sucking, refer to hospital.
➔ If the thrush is the same or hotter and the infant is feeding well,continue half-strength gentian violet for atotal of 7days.
@>) GCash
TE A M ROIREDO ,ANGILIN&N
# LEN ll l l0 2022
~encfin5 love
at Christ,...as

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