Here are the answers to the questions:a) Write Gyatsu's name, age, weight and temperature in the spaces provided: Gyatsu, 6 months, 5.5 kg, 38°Cb) Gyatsu's problem is cough c) Tick for initial visit d) No, Gyatsu does not have a general danger signIn the 'Classify' column, tick 'No' for 'General danger sign present?'The health worker found that Gyatsu's breathing rate was 50 breaths per minute. According to the classification table, this indicates pneumonia

INTERGRATED MANAGEMENT OF
CHILDHOOD ILLNESS(IMCI)

GOAL OF IMCI
• Reduce child/infant mortality rate by 2/3 by 2015
OBJECTIVES
• To contribute to healthy growth and development
of children
• To reduce the incidence and seriousness of illness
and serious problems that affect children below 5
years
• To reduce global infant and child mortality rate

3. Causes of Child Mortality (Contd)- Kenya
3
Source: World Health Statistics 2011, WHO
16%
20%
9%
11%
1%
10%
10%
8%
3%
19%
3%
Pneumonia Diarrhoeal Causes HIV/AIDS Malaria
Measles Prematurity Birth Asphyxia Neonatal Sepsis
Congential Anomalies Other diseases Injuries
Cause Deaths
Total Deaths 188,928
Diarrhoea 38,802
Pneumonia 30,406
Malaria 20,666
Neonatal
causes =
31% of
under 5
mortality

IMCI Clinical Guidelines
2 months 5 years
IMCI Guidelines
Sick Child
Birth
Sick Young infant

Important to note:
• IMCI does not cover all symptoms
• IMCI strategy is not reviewing all pediatric medicine
• Emphasis is how to deal more effectively with the
most common problems in sick children brought to
the clinic
• IMCI strategy takes into consideration the
overlapping of these symptoms and conditions

Important to note…..
• The core interventions is integrated management of five
most important causes of death, namely:
1. Acute Respiratory Infections
2. Diarrhoea
3. Measles
4. Malaria
5. Malnutrition and Anemia, HIV
6. Young infant infection
 IMCI also addresses the common signs/symptoms that
make the mother to bring the child to hospital

The IMCI Case Management Process
This must be performed on all sick children
The IMCI Case Management Process includes;
– Assessing and classifying the sick child from birth
up to 5 years
– Identifying treatment and treating the child
– Counseling the caregiver
– Follow up care
This process is detailed in the IMCI chart booklet
26/05/2020 7

The Chart Booklet and the Recording form
Chart Booklet
• The chart booklet is a IMCI case management job aid which
gives a step by step guide on the case management process
• Health care providers need to continuously refer to this
document throughout the case management process
• Many mistakes service providers make in assessment,
classification and management of sick children and young
infants is due to failing to use this job aid
Recording Form ( Chart booklet pages 43 -46)
• There is sick child recording form and a sick young infant
recording form
• Each is used for the corresponding age group
• The assessment findings, Classifications and management
options for the child should be recorded on this form
26/05/2020 8

Colour codes in IMCI
• Pink -danger meaning that the child has
severe illness and needs emergency referral
• Yellow -the child has moderate illness and can
be managed at the health centre.
• Green- the child has mild illness and can go
home.

ASSESSING AND CLASSIFYING A
SICK CHILD AGED 2 MONTHS UPTO
5 YEARS
26/05/2020 10

ASSESSING AND CLASSIFYING THE SICK CHILD
• A sick child is often brought to clinic due to a
particular problem/ symptom
• However, the illness may be due to more than
one disease condition
• The assessment process therefore should not be
limited to the presenting problem alone
26/05/2020 11

PROCESS OF ASSESSING AND CLASSIFYING THE
SICK CHILD
This must be performed when assessing all sick children
1. Ask what the child’s problem is
2. Check for the 5 General Danger signs
3. Assess for the 4 main symptoms
4. Check for malnutrition and anaemia
5. Check for HIV Exposure and infection
6. Check for immunization, Vitamin A & Deworming
status
7. Assess if the child has any other problems
26/05/2020 12

1. Ask about the child’s problem
• Greet the caregiver, make her/ him feel comfortable
• Ask the caregiver what the child’s problems are and
record them as the caregiver tells you
• Take the child’s bio data and basic vital signs
• Remember to use good communication skills i.e.
– Use words the mother understands
– Give mother time to answer questions
– Listen carefully to what the mother says
– Ask additional questions / probe if answers not clear
26/05/2020 13

2. Check for the 5 General Danger signs
• Not able to drink or breastfeed
• Vomits everything
• History of convulsions in the current illness
• Lethargic or unconscious
• Convulsing now
Child with any General Danger sign needs URGENT
attention: complete assessment , give any pre referral
treatment immediately and refer.
26/05/2020 14

Not able to drink or breastfeed:
26/05/2020 15
“Not able to drink or breast-feed” means that
the child is not able to suck or swallow when
offered a drink or breast milk.
NB: if not sure of the mother’s answer, offer the
child clean water/ breastmilk

Vomiting everything:
 Vomiting everything” means;
child is not able to hold anything down at all.
What goes down comes back up.
 NB: if not sure of the mother’s answer, offer
the child clean water/ breastmilk. Observe if
the child vomits
26/05/2020 16

convulsions:
A convulsion is any involuntary movement in any
part of the body
• A child can have this danger sign if there is
history of convulsions or convulsing during the
visit.
• A history of convulsions only counts as a
danger sign if the convulsions happened
during the present illness.
• Use words for convulsions that caregivers
understand. eg fits or spasms
26/05/2020 17

Lethargic or unconscious:
“Lethargic or unconscious" means that:
• the child is not awake and alert when he
should be
• He is drowsy and does not show interest in
what is happening around him.
• the child may stare blankly and appears not to
notice what is going on around him.; or
• Unconscious child cannot be awakened. He
does not respond when touched, shaken or
spoken to
26/05/2020 18

Exercise A ( General Danger signs)
26/05/2020 19
Case 1: Salina
Salina is 15 months old. She weighs 8.5 kg. Her temperature is 38.5o
C.
The health worker asked, "What are the child's problems?" The mother said, "Salina
has been coughing for 4 days, and she is not eating well." This is Salina's initial visit
for this problem.
The health worker checked Salina for general danger signs. He asked, "Is Salina able
to drink or breastfeed?" The mother said, "No. Salina does not want to breastfeed."
The health worker gave Salina some water. She was too weak to lift her head. She
was not able to drink from a cup.
Next he asked the mother, "Is she vomiting?" The mother said, "No." Then he asked,
"Has she had convulsions?" The mother said, "No."
The health worker looked to see if Salina was lethargic or unconscious. When the
health worker and the mother were talking, Salina watched them and looked around
the room. She was not lethargic or unconscious.
Now answer the questions

Exercise A ( General Danger signs)….
26/05/2020 20
Write Salina's name, age, weight and temperature in the spaces provided on the top
line of the form.
b. Write Salina's problem on the line after the question "Ask -- What are the
child's problems?"
c. Tick () whether this is the initial or follow-up visit for this problem.
d. Does Salina have a general danger sign? If yes, circle her general danger sign
in the box with the question, "Check for general danger signs."
In the top row of the "Classify" column, tick () either "Yes" or "No" after the
words, "General danger sign present?"

3. Four main symptoms
The health worker attending to a sick child
MUST ask about all the four main symptoms
below.
• Cough or difficult breathing
• Diarrhoea
• Fever
• Ear problem
When a symptom is present, assess further on
that symptom.
26/05/2020 21

Cough or Difficult breathing
 Pneumonia is among the leading causes of
death in children under five years
 In Kenya, it is currently responsible for 16% of
under five deaths
 Most children with cough or difficult breathing
have only a cough or a cold
 A few children with cough or difficult breathing
may also have pneumonia
26/05/2020 22

A
musical
sound
heard
during
expirati
on
ASSESSING FOR COUGH OR DIFFICULT BREATHING - THE
CHILD MUST BE CALM
IF YES, ASK
• For how long?
• Count the breaths in
one minute
• Look for chest in
drawing
• Look and listen for
stridor
• Look and listen for
wheeze
26/05/2020 23
2 months up to 12
months
12 months up to 5
years
50 breaths per minute
or more
40 breaths per minute
or more
If the child is: Fast breathing is:
LOOK, LISTEN, FEEL
Present
if
the
lower
chest
wall
moves
IN
during
inspiration
A
harsh
sound
heard
during
inspiration
Does the child have cough or difficult breathing?

Introduction to the classification tables
- Chart booklet page2
• Classification tables contain signs of illness and their
classifications on the ASSESS & CLASSIFY chart.
• Most classification tables have three rows with distinct colours.
• The colour of the rows tells you quickly if the child has a serious
illness.
• You can also quickly choose the appropriate treatment.
Colour coding
– Pink = Severe Classification needing admission or urgent
referral
– Yellow = A classification needing treatment/ intervention with
drugs
– Green = Not serious and in most cases no drugs are needed
26/05/2020 24

CLASSIFICATION TABLES FOR COUGH OR
DIFFICULT BREATHING
26/05/2020 25
SIGNS CLASSIFY AS
• Any general danger signs
OR
•Chest indrawing in calm child
OR
•Stridor in calm child
SEVERE PNEUMONIA
OR VERY SEVERE
DISEASE
Fast breathing PNEUMONIA
No signs of very severe
disease or pneumonia
NO PNEUMONIA:
COUGH OR COLD

Exercise B – General Danger Signs and Cough
26/05/2020 26
Case 1: Gyatsu
Gyatsu is 6 months old. He weighs 5.5 kg. His temperature is 38
C. His mother said
he has had cough for 2 days. The health worker checked for general danger signs.
The mother said that Gyatsu is able to breastfeed. He has not vomited during this
illness. He has not had convulsions and is not convulsing now. Gyatsu is not
lethargic or unconscious.
The health worker said to the mother, "I want to check Gyatsu's cough. You said he
has had cough for 2 days now. I am going to count his breaths. He will need to
remain calm while I do this."
The health worker counted 58 breaths per minute. He did not see chest indrawing.
He did not hear stridor nor wheeze.

Exercise B – General Danger Signs and Cough…
26/05/2020 27
a. Record Gyatsu's signs on the Recording Form given
b. To classify Gyatsu's illness, look at the classification table for cough or
difficult breathing in your chart booklet. Look at the pink (or top) row.
Decide: Does Gyatsu have a general danger sign? Yes___ No ___
- Does he have chest indrawing or stridor when calm? Yes __ No __
- Does he have the severe classification SEVERE PNEUMONIA OR VERY
SEVERE DISEASE? Yes___ No___
c. If he does not have the severe classification, look at the yellow (or middle) row.
- Does Gyatsu have fast breathing? Yes___ No___
d. How would you classify Gyatsu's illness? Write the classification on the Recording
Form.

Diarrhoea
Def..
Diarrhoea is passage of three or more watery
stools in 24 hours
It is common in children, especially those between 6
months and 2 years of age
It is the 2nd leading cause of mortality in under-fives.
Most of these deaths are usually due to dehydration.
If an episode of diarrhoea lasts less than 14 days, it is
an acute diarrhoea and if 14 days or more, it is
persistent diarrhoea. Diarrhoea with blood in the
stool, with or without mucus, is called dysentery
Frequent passage of normal stool is not diarrhoea
26/05/2020 28

Child
reaches
out
for
the
container
when
withdrawn
Child
too
weak
to
swallow
• Look at the child’s general condition
-Lethargic or unconscious?
-Restless or irritable?
• Look for sunken eyes
• Offer the child fluid. Is the child:
-Not able to drink or drinking poorly?
-Drinking eagerly, thirsty?
• Pinch the skin of the abdomen.
Does it go back;
-Very slowly (longer than 2 seconds?
-Slowly
-Immediately
Child
cannot
be
calmed
ASSESSING FOR DIARRHOEA
IF YES, ASK
• For how
long?
• Is there
blood in
the
stool?
26/05/2020 29
LOOK AND FEEL
Does the child have diarrhea?

Classifying a child with diarrhoea
• Children with diarrhoea die as a result of
dehydration.
• ALL children with diarrhoea MUST first be
classified for dehydration
26/05/2020 30

CLASSIFICATION OF DEHYDRATION
SIGNS CLASSIFY AS
26/05/2020 31
Two or more of the
following signs
 Lethargic or unconscious
 Sunken eyes
 Not able to drink or
drinking poorly
 Skin pinch goes back
very slowly (> 2 seconds)
SEVERE DEHYDRATION

CLASSIFICATION OF DEHYDRATION cont’d
SIGNS CLASSIFY AS
26/05/2020 32
Two or more of the following
signs
 Restless or irritable
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back slowly
(within 2 seconds)
SOME DEHYDRATION
• Not enough signs to classify as
some or severe dehydration
NO DEHYDRATION

IF DIARRHOEA LASTS 14 DAYS OR MORE OR
THERE IS BLOOD IN STOOL
SIGNS CLASSIFY AS
• Dehydration present SEVERE PERSISTENT
DIARRHOEA
26/05/2020 33
• No Dehydration PERSISTENT DIARRHOEA
• Blood in the stool DYSENTERY

EXERCISE E
In this exercise, you will practice assessing and classifying dehydration in
children with diarrhea. Read the following case studies of children with
diarrhea. Use the dehydration classification table in the chart.
1. Pano has had diarrhea for five days. He has no blood in the stool. He is
irritable. His eyes are sunken. His father and mother also think that
Pano's eyes are sunken. The health worker offers Pano some water, and
the child drinks eagerly. When the health worker pinches the skin on the
child's abdomen, it goes back slowly
Record the child's signs and classification for dehydration on the Recording
Form.
2. Jane has had diarrhea for 3 days. There was no blood in the stool. The
child was not lethargic or unconscious. She was not irritable or restless.
Her eyes were sunken. She was able to drink, but she was not thirsty. The
skin pinch went back immediately.
Record the signs of dehydration and classify them on the Recording Form
26/05/2020 34

Fever
• Fever is present if :-
– There is history from parent/caregiver or
– Child feels hot or
– Child has temperature 37.50
c or above
• A child with fever may have malaria, measles or another severe
disease. Malaria currently causes 11% of under five deaths
• Fever may also be due to a simple cough, cold or other viral
infection.
• To classify and treat fever, you must know malaria risk in your
area
– High Malaria risk; > 5% of fever cases in children are due to
malaria
– Low Malaria risk; 5% or less of fever cases in children are
due to malaria
26/05/2020 35

DOES THE CHILD HAVE FEVER?
THEN ASK:
• For how long?
• If more than 7 days, has fever been
present everyday?
• Has the child had signs of measles
within the last 3 months?
LOOK AND FEEL
• Look or feel for stiff neck
• Look for running nose
Look for signs of MEASLES
• Generalized rash and One of
these: cough, runny nose, or red
eyes
Look for any other cause of fever
26/05/2020 36
IF YES
Decide malaria risk: high, low or no risk
NOTE: If you can’t test, don’t withhold treatment
TEST NEGATIVE
•P. falciparum or P. vivax
absent
TEST POSITIVE
•P. falciparum PRESENT
•P. vivax PRESENT
DO A MALARIA TEST:
If NO general danger sign or stiff neck
• High Malaria risk: Do a malaria test in
all fever cases
• Low malaria risk: Do a malaria test if
no obvious cause of fever
• No malaria risk: Do a malaria test if
no obvious cause of fever

DOES THE CHILD HAVE FEVER?.....
If the child has signs of measles now or within the last 3
months
• Look for mouth ulcers, are they deep or extensive?
• Look for pus draining from the eye
• Look for clouding of the corner
26/05/2020 37
Check for Complications of MEASLES

CLASSIFY FOR FEVER – High Malaria Risk
SIGNS CLASSIFY AS
• Any general danger sign OR
• Stiff neck
VERY SEVERE FEBRILE
DISEASE
26/05/2020 38
Malaria test positive* MALARIA
• Malaria test NEGATIVE or
• Runny nose PRESENT or
• Measles PRESENT or
• Other cause of fever
PRESENT**
FEVER-NO MALARIA
*If malaria test is not available, classify as malaria
** Other possible causes of bacterial infection may include
urinary tract infection, typhoid, cellulitis and osteomyelitis.

CLASSIFY FOR FEVER – Low and No Malaria Risk
SIGNS CLASSIFY AS
• Any general danger sign OR
• Stiff neck
VERY SEVERE FEBRILE
DISEASE
26/05/2020 39
Malaria test positive* MALARIA
• No general danger signs
• No stiff Neck
• Malaria test Negative
FEVER-NO MALARIA

Classify Measles- If signs of MEASLES now or within the last 3
months
26/05/2020 40
***Other important complications of measles-pneumonia, stridor, diarrhoea, ear
infection and malnutrition are classified in other tables
SIGNS CLASSIFY AS
• Generalized rash of measles and one
of: Cough, runny nose or red eyes
SUSPECTED MEASLES
• Any general danger sign or
• Clouding of the cornea or
• Deep or extensive mouth ulcers
SEVERE COMPLICATIONS
OF MEASLES***
• Pus draining from the eye or
• Mouth ulcers
EYE OR MOUTH
COMPLICATIONS OF
MEASLES***
• No pus draining from the eye and no
mouth ulcers
NO EYE OR MOUTH
COMPLICATIONS OF
MEASLES

Exercise K – Classify illness in children with signs of fever
26/05/2020 41
Case : Atika
Atika is 5 months old. She weighs 5 kg. Her temperature is 36.50C.The risk of Malaria is
high. Her family brought her to the clinic because she feels hot and has had cough for 2
days.
She is able to drink. She has not vomited or had convulsions, and is not lethargic or
unconscious.
The health worker said, "I am going to check her cough now." The health worker counted
43 breaths per minute. There was no chest indrawing and no stridor when Atika was calm.
Atika did not have diarrhea.
"Now, I will check her fever," said the health worker. Atika lives in an area where many cases
of malaria occur all year long (high malaria risk). Her mother said, "Atika has felt hot off and
on for 2 days." She has not had measles within the last 3 months. She does not have stiff
neck or runny nose.
Atika has a generalized rash. Her eyes are red. She has mouth ulcers. They are not deep
and extensive. She does not have pus draining from the eye. She does not have clouding
of the cornea.
Record the child's signs and classify them on the Recording Form on this page.

EAR PROBLEM
26/05/2020 42
• A child with an ear problem may have an ear infection.
• Ear infection may cause pus to collect behind the ear drum
causing pain and often fever.
• If not treated, the ear drum may burst ,discharge pus and the
child feels less pain.
• However, the child may suffer poor hearing or worse deafness
• Ear infection may lead to Mastoiditis or Meningitis

ASSESS for EAR PROBLEM
If the child has ear
problem-ASK
• Is there ear pain?
• Is there ear discharge?
if yes, for how long?
LOOK AND FEEL
• Pus draining from the ear
• Feel for tender swelling behind
the ear
26/05/2020 43
Does the child have an ear problem?

CLASSIFY CHILD EAR PROBLEM
26/05/2020 44
SIGNS CLASSIFY AS
• Tender swelling behind the ear MASTOIDITIS
• Pus seen draining from the ear or
• discharge is reported for less than
14 days or
• Ear pain
ACUTE EAR INFECTION
• Pus is seen draining from the ear or
• discharge is reported for more than
14 days
CHRONIC EAR INFECTION
• No ear pain and
• No pus seen or reported draining
from the ear
NO EAR INFECTION

Good Nutrition and Malnutrition
Components of Nutrition
 Good nutrition results from the adequate intake of
macronutrients, micronutrients and water to supply the
metabolic (anabolic and catabolic) processes in the
body.
 There are two components of nutrition;
1. Macronutrients
2. Micronutrients

What is Malnutrition?
• Malnutrition is defined as a state when the body does not have
enough of the required nutrients (under-nutrition) or has excess
of required nutrients (over-nutrition).
• Inadequacies of macro or micro nutrients may result in failure to
thrive, poor growth or wasting.
• These processes are often measured by their anthropometrical
consequences (weight for age, height for age or weight for
height).
• Under nutrition is the most common form of malnutrition in
developing countries.

ASSESS FOR MALNUTRITION
Ask: Is there history of TB contact?
26/05/2020 47
LOOK AND FEEL:
• Take the child’s weight for age and plot on mother/ child health booklet to determine
the z-score
• Take the child’s length/height for age and plot on mother/child health booklet to
determine the z-score
• Determine the growth pattern; Is the growth faltering? (Weight curve is flattening or
dropping for at least 2 consecutive months?)
• Look for oedema of both feet
• Look for visible severe wasting
For children aged 6 months up to 59 months, determine MUAC:
• < 11.5cm
• 11.5 -12.5cm
• 12.5 - 13.5cm
For children aged 6 month sup to 59 months,
determine Z Score􀀝
• < -3
• -3 to < -2
• -2 to < -1

CLASSIFY NUTRITIONAL STATUS
26/05/2020 48
SIGNS CLASSIFY AS
For all children:
• With visible severe wasting
• Oedema of both feet,
• <-3 Z Score ( weight for age or weight for height/Length)
For children 6 months upto 59 months: MUAC <11.5 cm
SEVERE
ACUTE
MALNUTRITION
For all age groups:
• Static weight or losing weight
• 3 to <-2 Z- Score
If age 6 months upto 59 months MUAC 11.5 to 12.5 cms
MODERATE
ACUTE
MALNUTRITION
For all age groups:
• Static weight or losing weight
• -2 to <-1 Z- Score
If age 6 months upto 59 months MUAC 12.5 to 13.5cms
AT RISK OF
ACUTE
MALNUTRITION
Weight between
• -1 to +2
NO
MALNUTRITION

Anemia
• The condition of having a lower-than-normal number of red
blood cells or quantity of hemoglobin. Anemia diminishes the
capacity of the blood to carry oxygen.
Common Causes
• Iron deficiency; may result from a diet deficient in iron
• Intestinal parasites
• Repeated nose bleeds
• Haemolysis, due to: Malaria and other Inherited blood
disorders like sickle cell disease)
• Chronic illness, such as tuberculosis and AIDS
• Severe malnutrition (due to lack of protein to produce
haemoglobin)
26/05/2020 49

ASSESS for ANAEMIA
26/05/2020 50
Look for palmar pallor. Is it:
• Severe palmar pallor?
• Some palmar pallor?
• No palmar pallor?

CLASSIFY ANAEMIA
26/05/2020 51
SIGNS CLASSIFY AS
• Severe palmar pallor SEVERE
ANAEMIA
• Some palmar pallor ANAEMIA
• No palmar pallor NO ANAEMIA

CHECK FOR HIV EXPOSURE AND INFECTION
26/05/2020 52
 Children may acquire HIV infection from an infected mother
through vertical transmission in utero, during delivery or while
breastfeeding.
 Without any intervention, 30 – 40% babies born to infected
mothers will themselves be infected.
 Most children born with HIV die before they reach their fifth
birthday, with most not surviving beyond two years
 Good treatment can make a big difference to children with HIV
and their families.
 The child’s status may also be the first indicator that their parents
are infected too

ASSESS FOR HIV EXPOSURE AND INFECTION
26/05/2020 53
ASK
• Ask for mother’s
HIV status to
establish child’s HIV
exposure*.Is it:
- Reactive
- Non reactive
- Unknown
• Ask if child has had
any TB
Contact.
LOOK, FEEL AND DIAGNOSE:
Child ≤18 months
• If Mother’s HIV status is unknown,
conduct an antibody test (rapid test)
on mother or child to determine HIV
exposure
• If mother’s or child’s antibody test is
POSITIVE the child is HIV exposed.
Take DBS for DNA PCR testing at 6 weeks or
earliest contact thereafter
Child ≥18 months
If mother’s antibody test is POSITIVE, the
child is exposed. Conduct an antibody test
on the child.

ASSESS FOR HIV EXPOSURE AND INFECTION…
26/05/2020 54
PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV
INFECTION IN CHILDREN <18 MONTHS
LOOK and FEEL:
• Pneumonia ***
• Oral Candidiasis /thrush
• Severe sepsis
• Other AIDS defining
conditions**
Presumptive HIV diagnosis should be confirmed at the earliest opportunity.

CLASSIFY HIV STATUS
26/05/2020 55
SIGNS CLASSIFY AS
• Child<18 months and DNA PCR test POSITIVE
• Child>18 months and Antibody test POSITIVE
CONFIRMED
HIV
INFECTION
Children <18months
• If mother’s HIV status is POSITIVE and no test result for child
OR
• If Child with antibody test POSITIVE
OR
• If DNA PCR test is NEGATIVE
HIV EXPOSED
• No test results for child or mother
• 2 or more of the following conditions:
• Severe pneumonia
• Oral candidiasis/thrush
• Severe Sepsis
OR
• An AIDS defining condition
SUSPECTED
SYMPTOMATIC
HIV
INFECTION
• Mother or child test HIV negative HIV
INFECTION
UNLIKELY

CHECK THE CHILD’SIMMUNIZATION, VITAMIN A &
DEWORMING STATUS
• Immunization is one of the most cost effective health
intervention for disease control.
• It targets children under the age of 5 years.
• It needs tremendous inputs and effort to make it
happen.
• Immunization coverage can be enhanced through;
– Routine Immunization
– Supplemental Immunizations
– Surveillance of the target diseases
– Mopping up in high risk areas
26/05/2020 56

DEWORMING STATUS ….
A child's body require Vitamin A for; Growth and development,
Protection against infections & reinforces the body’s immunity
Vit A deficiency may result from; Inadequate intake of vitamin A rich
foods, Poor absorption of the vitamin A & rapid utilization of vitamin
A stores due to illnesses
Vit A deficiency may lead to
 Increased incidence of illness
 Delays recovery from infections
 Leads to eye damage and may even lead to blindness
 Increases the risk of death in sick children

DEWORMING STATUS ….
Remember, Vit A supplementation can;
– Reduces measles mortality by 50%
– Reduces diarrhea mortality by 33%
– Reduces all causes of mortality by 23%
26/05/2020 58

CHECK CHILD’SIMMUNIZATION
Vaccines
Age BCG Oral Polio Diphtheria/
Pertussis/
Tetanus/HepB/
Haemophilus
influenzae type B
(pentavalent)
PCV 10 Rota
Virus****
Measles
Birth BCG* OPV 0
(Birth-
2wks
6 Weeks OPV 1 Pentavalent 1 PCV10 1 ROTA 1
10 Weeks OPV 2 Pentavalent 2 PCV10 2 ROTA 2
14 Weeks OPV 3 Pentavalent 3 PCV 10 3
6 Months Measles**
9 Months Measles Yellow
Fever***
26/05/2020 59

CHILD’SIMMUNIZATION – PLEASE NOTE
26/05/2020 60
 *If BCG not given at birth, it should not be given to children with symptomatic
HIV /AIDS
 **Measles vaccine at 6 months is for HIV exposed/ infected children
 ***Yellow fever vaccine should not be given to children with symptomatic HIV
/AIDS
 ***Yellow fever vaccine is only offered in ( Koibatek, Baringo, Keiyo, Marakwet )
in Rift valley province
 ****Rota Virus vaccine should not be given to children over 15 months
 Pentavalent not given if child had convulsion following previous dose or a child
with recurrent convulsions or another active neurological disease
 PCV10 & Pentavalent not given to Infants with a moderate or severe illness
(temperature ≥39°C) until their condition improves.
 PCV10 &Pentavalent contraindicated if severe allergic reactions or shock to a
prior dose or any component of the vaccine.
 Do not delay referrals of children with severe classifications to administer
immunizations

CHECK CHILD’S VITAMIN A & DEWORMING
Age Vitamin A Deworming
6 months Vitamin A Deworming
12 months Vitamin A Deworming
18months Vitamin A Deworming
26/05/2020 61

ASSESS OTHER PROBLEMS THE CHILD MIGHT HAVE
26/05/2020 62
It is important to remember that the already discussed IMCI case
management process ;
• Does not cover all symptoms
• Is not reviewing all pediatric medicine
• Remember to address some complaints the caregiver may have
raised, eg
• she may have said the child has an itchy skin
• You may have observed another problem the mother didn’t
say eg jiggers.
• Treat any other problems according to your training,
experience and clinic policy.
• Refer the child for any other problem you cannot manage in
clinic.

Management of the sick young
infant age up to 2 months

The process of assessing and
classifying the young infant
• Ask the mother what the young infant’s
problems are:
• Determine if this is an initial or follow up visit
for the problem,
• All sick young infant must be checked for signs
of very severe disease
Refer to chart booklet page27

Checking for very severe disease
• All sick young infant must be checked for signs
of very severe disease.
• The young infant must be calm when you
check for signs of very severe disease.

Ask Look, Listen and feel
•Has the young infant had
convulsions?
•Is the infant not able to feed or
breastfeed?
•Look for breathing: Is the baby gasping or not breathing at
all even when stimulated?
•Count the breaths in one minute- (Repeat if 60/min or
more)
•Look for severe chest indrawing
•Look and listen for grunting or wheezing
•Look for nasal flaring
•Look for central cyanosis
•Look and feel for bulging fontanelle

Look, Listen and feel
•Look for pus draining from the ear
•Look at the umbilicus. Is it red or draining pus?
•Measure temperature or feel for fever or low body temperature)
•Look for skin pustules
•See if the young infant is lethargic or unconscious
•Look at the young infant’s movement. Does the infant not move even when
stimulated?

CONVULSIONS
ASK: Has the young infant had convulsions?
• Use simple words the mother may know for
convulsions such as "fits" or "spasms“
• Ask this question in relation to the current illness
Convulsions may be:
 any abnormal movement noticed in any part
of the body
 that the young infant’s arms and legs stiffen
because the muscles are contracting
that the infant loses consciousness

NOT BEEN ABLE TO DRINK OR BREASTFEED
• ASK: Has the young infant not been able to drink or
breastfeed?
• If a mother says that the young infant is not able to
feed or breastfeed watch her try to breastfeed or feed
the young infant. with a cup to see what she means by
this.
• A young infant who is not able to feed or breastfeed
may have a serious infection

LOOK FOR BREATHING
Gasping:
• This is severe air hunger or struggle for air or
respiratory rate is less than 20 breaths per minute
Absence of respiration:
• This is when the young infant is not breathing at all, even
when stimulated.
Count the breaths in one minute.
• If the breaths are 60 or more per minute on second count,
then young infant has fast breathing.

LOOK for severe chest indrawing
• Mild chest indrawing is normal in a young infant
because the chest wall is soft
• Look for chest indrawing when the young infant
breathes IN.
• Look at the lower chest wall (lower ribs).
• The young infant has chest indrawing if the
lower chest wall goes IN when the infant
breathes IN

LOOK OR LISTEN FOR:
• Listen for:
• Grunting: Is soft, short sounds a young infant
makes when breathing out. It occurs when the
young infant is having trouble breathing
• Wheeze: is a soft, musical sound heard when the
child breathes out.
• Look for:
• Nasal flaring: is widening of the nostrils when the
young infant breathes in
• Central Cyanosis: is the blue coloration of tongue
and mouth
• The fontanele: is bulging rather than flat, this
may mean the young infant has meningitis.

Look for:
lethargic or unconscious:
• A lethargic young infant is not awake and alert
when he should be
• An unconscious young infant cannot be
wakened at all. He does not respond when he
is touched or spoken to
Young infant's movements:
• Does the infant move spontaneously or when
stimulated?

LOOK for
pus draining from the ear:
• A young infant with pus draining from the ear
has an ear infection.
Skin pustules:
• Skin pustules are red spots or blisters which
contain pus.
• Look at the Umbilicus:
 Is it red or draining pus?

Look for Stiff neck
• With one hand, hold the baby’s head and
then carefully bend the head forward towards
the chest
• If the neck bends easily, the child does not
have stiff neck and if there is resistance to
bending, the child has a stiff neck.
• Often a child with a stiff neck will cry when
you try to bend the neck.

Classify young infant for very severe disease
Signs Classify As
•Convulsions or convulsing now
•Not able to feed or breastfeed or
•Gasping or not breathing at all even when
stimulated or
•Respiratory rate less than 20 breaths per minute or
•Fast breathing (60 breaths per minute or more) or
•Severe chest indrawing or
•Grunting or wheezing or
•Nasal flaring or
•Central cyanosis or
•Bulging fontanelle or
•Pus draining from the ear or
•Fever (37.5oC or feels hot) or very low body
temperature (less than 35.5oC or feels cold) or
•Drowsy (Lethargic) or unconscious or
•No movement even when stimulated
•Very high pitched cry
•Stiff neck
VERY SEVERE
DISEASE

Classify young infant for very severe
disease cont’d
Signs Classify As
•Red umbilicus or draining pus or
•Skin pustules
LOCAL BACTERIAL INFECTION
None of the signs of Very Severe
Disease or local bacterial infection
VERY SEVERE DISEASE OR LOCAL
BACTERIAL INFECTION UNLIKELY
Temperature 35.5oC – 36.4oC LOW BODY TEMPERATURE

Management of very severe disease
• A young infant with very severe disease is at high
risk of dying and needs admission or urgent
referral to hospital.
• Before referral, give a first dose of intramuscular
antibiotics and treat to prevent low blood sugar
• Advise the mother to keep her sick young infant
warm
•

Jaundice:
• It’s the yellow coloration of the skin, mucous
membranes and or the eyes.
• It may be physiological (normal) or
pathological (abnormal).
• More than 50% of normal newborns and 80%
of preterm infants, have some jaundice.
• It is visible in a neonate when serum bilirubin
is more than 5mg/dl

Physiological jaundice
 Physiological jaundice usually appears between
48 – 72 hours of age; maximum intensity on days
4 & 5 in term babies and day 7 in pre-terms and
disappears by day 14.
 Physiological jaundice does not extend to palms
and soles and does not need any treatment. If
jaundice appears on the first day, persists for 14
days or more and extends to palms and soles it is
severe jaundice and requires urgent attention.

pathological jaundice
• Jaundice starting on the first day of life.
• Jaundice lasting longer than 14 days in term
and 21 days in preterm infants.
• Jaundice with fever.
• Deep jaundice: palms and soles of the baby
are deep yellow

ASSESS JAUNDICE
• ASK:
• Does the young infant have yellow
discoloration of palms and soles?
• If yes, for how long?
• LOOK:
• Look at the young infants palms and soles

Check for and Classify Jaundice
Signs Classify As
•Yellow palms and soles at any age or
•Any jaundice if age less than 24 hours
OR more than 14 days
SEVERE JAUNDICE
•No yellow palms and soles AND
•Jaundice appearing between 24 hours
and 14 days of age
JAUNDICE
•No signs to classify as severe jaundice
or jaundice
NO JAUNDICE

Check for eye Problem/infection
• Check all young infants for congenital eye
problems or infections .Eye assessments are done
at birth, 6 and at 9 Months
• Red and swollen eyes or eyes draining pus may be
caused by bacteria (e.g. gonococcus, Chlamydia,
staphylococcus) that are usually transmitted to
the baby at the time of birth
• Most causes of newborn eye problems will
respond to local treatment.
Refer to the chart booklet page 28 or MCH
booklet page 23

Assess eye problem/Infection
• ASK: Does the young infant have eye problems?
• If yes for how long?
• LOOK For: Crossed eyes
Excessive tearing
Fear of light
Clouding of the cornea
Squeezing of the eyes
Red eyes
Whiteness in the pupils
•

Eye Assessment Cont:
• ASK: Does the young infant have eye discharge?
• If yes for how long?
• LOOK for Eyes discharge?
• Eyes draining pus?
• Swollen eyes?
•
•

Classifying Eye Infection
Signs Classify As
Crossed eyes SQUINT
White spot on the pupil and
crossed eyes
CONGENITAL CANCER OF
THE EYE
Clouding of the cornea and
no signs of Measles, Fear of
light and excessive tearing
CONGENITAL GLAUCOMA
Eyes swollen or draining pus SEVERE EYE INFECTION
Eyes are red or have a
discharge
EYE INFECTION
No Signs to Classify for
Congenital or eye infection
CONGENITAL CONDITION
OR EYE INFECTION

Assess Diarrhoea:
• The normal frequent or loose stools of a
breastfed baby are not diarrhoea.
• The assessment is similar to that of the older
child except that we do not test for ability to
drink using water.
• Generally thirst is not assessed because it is
not possible to distinguish between thirst and
hunger in a young infant.

THEN ASK:
Does the young infant have Diarrhoea?
If yes, Ask: Look and feel
•For how long?
•Is there blood in the
stool?
Look at the young infant’s general
condition. Is the young infant:
•Lethargic of unconscious?
•Restless and Irritable?
•Look for sunken eyes
•Pinch the skin of the abdomen: Does it
go back:
-Very slowly (longer than 2 seconds)?
-Slowly?
-Immediately?

Classify Diarrhoea
Signs Classify As
Two of the following signs:
•Lethargic or unconscious
•Sunken eyes
•Skin pinch goes back very slowly
SEVERE DEHYDRATION
Any two of the following signs:
•Restless, irritable
•Sunken eyes
•Skin pinch goes back slowly
SOME DEHYDRATION
•Not enough signs to classify as some
or severe dehydration
NO DEHYDRATION
Diarrhoea lasting 7 or more SEVERE PROLONGED
DIARRHOEA
Blood in the stool POSSIBLE SERIOUS
ABDOMINALPROBLEM

• Child ≤ 18 months
-If mother’s HIV status is unknown,
conduct an antibody test (rapid test)
on the mother or child to determine
HIV exposure
• If mother’s or child’s antibody test is
POSITIVE, the child is HIV exposed.
Take DBS for DNA PCR testing at six
weeks or earliest contact thereafter.
See page 49 of IMCI chart booklet
ASK
• Ask for mother’s HIV
status to establish child’s
HIV exposure, Is it :
- Reactive
- Non reactive
- Unknown
• Ask if child has had any
TB contact
26/05/2020 91
LOOK AND FEEL AND DIAGNOSE
CHECK FOR HIV EXPOSURE OR INFECTION

LOOK FOR and FEEL:
• Pneumonia***
• Oral Candidiasis/Oral thrush
• Severe sepsis
• other AIDS defining conditions**
• Presumptive diagnosis HIV diagnosis MUST be
confirmed at the earliest opportunity
***Refer to IMCI chart booklet page 30
PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF
HIV INFECTION IN CHILDREN <18 MONTHS

CLASSIFY FOR HIV EXPOSURE OR INFECTION
Signs Classify As
• Child < 18 months and DNA PCR test POSITIVE CONFIRMED HIV INFECTION
Children < 18 months
If mother’s HIV status is POSITIVE and no test result
for child
Or
If child is antibody test POSITIVE
OR
IF DNA PCR test is NEGATIVE
HIV EXPOSED
•No test results for child or the mother
•2 or more of the following conditions:
•Severe pneumonia
•Oral Candidiasis/ thrush
•Severe sepsis
•OR
•An AIDS defining condition
SUSPECTED SYMPTOMATIC
HIV INFECTION
•If child is < months with UNKNOWN mothers’ HIV
status and tests antibody NEGATIVE
HIV INFECTION UNLIKELY

Check for Feeding Problem, Low Birth weight
OR Low Weight
• Ask about the current feeding practices
• Check for low birth weight or low weight
• Determine the infant’s weight for age
• Determine the mother’s HIV status and
infants feeding
• Assess breastfeeding position and
attachment

HOW TO ASSESS THE CHILD’S FEEDING
First, determine the current feeding practices by asking the following questions:
• Do you breastfeed your child? Yes----No----
if yes, how many times during the day?----
Do you breastfeed during the night? Yes ----No---- How many times?----
If you do not breastfeed, why?------------
 Does the child take any other food or fluids? Yes ----No----
if yes, what food or fluids?------------------------
How many times per day?----times. What do you use to feed the child------------
--------------------
• If very low weight for age, ask how large the servings are-----------------------------
---
• Is the child served on his/her own plate? Who feeds the child and how? --------
----------------------
 During the illness, has the child’s feeding changed? If yes, how?--------------------
----------
• How do you prepare the food/fluids?----------

DETERMINE LOW WEIGHT/MOTHER’S HIV STATUS
Determine child’ weight for age (using the weight for age chart)
and decide if:
 Very low weight
 Not very low weight
 Look for ulcers or oral thrush in the mouth
Determine the mother’s HIV status
 Reactive
 Non reactive
 Unknown
 Determine HIV exposed infant status
 Positive
 Negative
 Unknown
 IF baby less than one week, Check for Low birth weight

Classify and Manage Birth Weight
Birth weight Classification Treatment
Weight less than 2000g VERY LOW BIRTH WEIGHT Treat to prevent low blood
sugar
Keep the baby warm
Advice mother to keep the
young infant warm on the
way to hospital
Refer urgently to hospital
Weight between 2000g and
2500g
LOW BIRTH WEIGHT Manage as for feeding
problem or low weight
Advice mother to keep
young infant warm
Weight 2500g or more NORMAL BIRTH WEIGHT Advise mother to give
home care to the young
infant

Assessment of Breastfeeding
 Ask the mother to put the young infant to the breast
then observe the breastfeeding for 4 minutes if the
infant has not fed in the previous hour. Observe
 Is the infant correctly positioned? Positioning refers to
how the baby is placed during a breastfeed. To check
for correct positioning, look for:
1. Infant’s head and body straight
2. Infant facing the mother with the nose opposite the
nipple
3. Infant’s body close to the mother’s body
4. Mother supporting infant’s whole body and not just
neck and shoulders.
Decide on the positioning
ALL THE 4 SIGNS OF CORRECT POSITIONING MUST BE PRESENT TO DECIDE THERE IS
CORRECT POSITIONING

Assessment for Breast Attachment
Is the infant able to attach? To check for attachment
look for:
1. Mouth wide open
2.Chin touching the breast
3. lower lip turned outward
4. More areola seen above than below the mouth
Decide on the Attachment.
ALL THE 4 SIGNS OF GOOD ATTACHMENT MUST BE PRESENT
FOR ONE TO DECIDE THE INFANT HAS GOOD ATTACHMENT

Check for Low Birth Weight
Any baby whose birth weight is below 2500gm
is considered low birth weight. Such babies
could be preterm or small for gestational age.
Low birth weight babies may develop
complications and require special care to
prevent development of complications.
These babies require
- Provision of adequate warmth
- Adequate feeding support
-Prevention of infections

Classify Feeding, Low Weight or Low Birth Weight
Signs Classify As
Not well attached to the breast or
Not suckling effectively or
Less than 8 breastfeeds in 24 hours or
Receives other foods or drinks or
Low weight for age or
Thrush (white patches in mouth) or
Mouth ulcers
FEEDING PROBLEM OR
LOW WEIGHT
Not low weight for age and no other signs of
inadequate feeding
NO FEEDING PROBLEM

Check the young infant’s immunization status
• Check the young infant’s immunization status.
Follow the National immunization schedule.
• Remember that you should not give OPV 0
(zero) to a young infant who is more than 14
days old as this will disorganize the schedule.
• If a young infant has not received OPV 0 by the
time he is 15 days old, DO NOT GIVE OPV 0.
Give OPV1 when s/he is 6 weeks old together
with Penta 1,PCV 10 and 1 Rota v 1.

ASSESS CARE FOR DEVELOPMENT
• Ask how the Mother plays and communicates
with the child
– Ask questions about how the mother cares for her
child
– Compare the mother’s answers with the
recommendations for the child’s care for
development on page 21 of the IMCI chart booklet

Check for Special Treatment Needs& Treat
• Ask and check the mother’s PNC records for:
– Maternal Fever >38c within 2 weeks of delivery?
– Infection treated with antibiotics?
– Membranes ruptured > 18hrs before delivery?
– Foul smelling liquor
– Tested VDRL Positive
– HIV Positive
– On ARVs
– On TB treatment which began < 2 months ago?

EXERCISE
Nyaga is 12m old weighs 6kg and his height is 65cms, his
temperature is 37C and his mother says he has had a
dry cough for the last 3 weeks.he does not have any
danger sign the health worker assessed his cough. It
has been present for 21days. He counted 41b/m. the
health worker does not see chest indrawing, neither
stridor nor wheezing when the child is calm, nyaga
does not have diarrhea. He has not had a fever during
this illness. He does not have an ear problem. The
health worker checked for malnutrition and anemia. He
has visible wasting, his palms are very pale and appear
almost white. There is no edema on both feet. The
health worker determined his z score for weight for
age and height for age.

Cont’
• The health worker checked nyaga for HIV
exposure and infection. He has not had any
episode of persistent diarrhoea. His father is
under treatment of TB.The health worker finds
that Nyagas axillary lymph nodes and groin lymph
nodes are enlarged. He also has oral thrush. The
mother has her antenatal card which indicates
that she has been tested for hiv and found to be
reactive. No follow up has been made as the child
was born at home.
• Assess and classify Nyagas illness.

IDENTIFY TREATMENT AND TREAT THE
CHILD
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TREATMENT DECISIONS
• Does the child require urgent referral?
• If YES;
– Identify urgent pre referral treatment, administer it
then refer the child urgently
• If NO;
– give the treatments needed, give first dose at the
clinic, give return date for follow up.
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CLASSIFICATIONS NEEDING ADMISSION OR URGENT
REFERRAL (On the pink row of chart booklet)
• General Danger Signs
• Severe pneumonia or very severe disease
• Very severe febrile disease
• Severe complications of measles
• Mastoidis
26/05/2020 109

CLASSIFICATIONS NEEDING ADMISSION OR URGENT
REFERRAL (On the pink row of chart booklet)
• Severe acute malnutrition
• Severe anaemia
• Severe dehydration or severe persist diarrhoea if;
– occurring with another severe classification
– Rehydration is not possible at the facility
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IDENTIFY TREATMENT
• The identify treatment instructions for each classification are found on
the last column of the assess and classify chart in the chart booklet
pages 2 to 7.
• The identify treatment column also gives reference to the pages where
to find the appropriate medications and dosages.
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111

Example 1a: Identify treatment
• Severe pneumonia or very severe disease (pg 2)
– First dose of antibiotic: Chloramphenicol
– Treat to prevent low blood sugar
– Keep child warm
– Treat wheeze if present
– Admit or refer urgently to hospital
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Example 1b: Give pre referral treatment
Severe pneumonia or very severe disease (pg 12)
26/05/2020 113
Age or weight IM Chloramphenicol, Dose:40mg per
kg
Add 5.0 ml sterile water to vial
containing:
1000mg=5.6mls at 180mg per ml
2 months upt 4 months (4-<6 kg) 1.0ml=180mg
4months upto 9months (6- <8kg) 1.5ml=270 mg
9 months upto 12 monhs (8-<10kg) 2.0ml=380mg
12months – 3years (10-< 14kg) 2.5ml=450mg
3years upto 5 years (14-19kg) 3.5ml=630mg

Example 2: Identify treatment
• Severe dehydration
– Child has another severe classification - admit or refer urgently to
hospital. Give frequent sips of ORS on way to hospital, continue
breastfeeding
– Child with no other severe classification;
• Give fluid for severe dehydration – plan C
• give Vitamin A
• Give Zinc sulphate
• if child is over 2 years and there is cholera in the area, give antibiotic
(Erythromycin)
26/05/2020 114

Example 3: Identify treatment
• Severe Acute malnutrition
– Give oral antibiotic (amoxycillin) – Pg. 9
– Give Vitamin A
– Treat to prevent low blood sugar
– Keep child warm
– Manage as out patient if no danger sign
– Admit or refer urgently to hospital if with danger sign
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TREATING A CHILD NOT NEEDING REFERRAL
• Identify the needed treatment
• Give the mother information on the drugs
• Give the first dose of all prescribed drugs
• Dispense and explain how and when to give
treatment at home
• Check mother’s understanding on how to
administer the drug(s)
• Give a return date
26/05/2020 116

WHEN TO RETURN IMMEDIATELY
• For all children going home, advice the care giver when to
return.
• The mother should return immediately if the child ;
– Is not able to drink.
– Becomes sicker
– Develop fever.
• If the child has no pneumonia ,cough or cold should return if
– develops first breathing or difficulty in breathing.
• If the child has diarrhoea ,return if .
• There is blood in stool
• Drinking poorly
• Vomits everything
26/05/2020 117

Example 4 a: Identify treatment for child not needing referral
Child with pneumonia (pg 2)
• Give cotrimoxazole for 5 days
• Give Vitamin A
• Treat wheeze if present
• Soothe throat and relief cough with safe remedy
• If cough present 14 days or more, screen for TB or refer
• Check for HIV infection
• Advice mother when to return immediately
• Follow up in 2 days
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26/05/2020 119
Example 4 b: Give treatment for child not needing referral
Give an oral appropriate antibiotic FIRST-LINE ANTIBIOTIC: COTRIMOXAZOLE
FOR PNEUMONIA AND ACUTE EAR INFECTION
SECOND - LINE ANTIBIOTIC: AMOXYCILLIN
COTRIMOXAZOLE
(trimethprim + sulphamethoxazole)
Give two times daily for 5 days for pneumonia and acute ear
Infection
Give once every day continuously for symptomatic /HIV + child
AMOXYCILLIN
Give three times
daily for 5 days
AGE or Weight
Adult tablet
(80mg trimethoprim +
400mg
sulphamethoxazole)
Paediatric tablet
(20mg trimethoprim
+ 100mg
sulphamethoxazole)
Syrup (40mg
trimethoprim +
200mg
sulphamethoxaz
ole per 5 mls)
Tablet
250 mg
Syrup
125mg per
5 mls
2 months upto 12 months
(4 upto 10kg) 0.5 2 5 0.5 5
12 months up to 5 years
(10 upto 19 kg) 1 4 10 1 10

Example 5: Treatment for child not needing referral
Acute ear infection in a child aged 1 year weighing
10kg; Write the appropriate treatment
o Co-trimoxazole ½ adult tabs twice a day for 5 days.
o Paracetamol Tabs ¼ of the adult tabs 4 times daily.
o Wick the ear if there is ear discharge.
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MANAGEMENT OF DIARRHOEA
• Most children with diarrhoea are mismanaged and die from
dehydration
• The most important aspect of diarrhoea management is
REHYDRATION
• Antibiotics should ONLY be used for DYSENTERY or if there is
cholera in the area
• Always use ORS, ZINC and Vitamin A in management of
diarrhoea
• Emphasize diarrhoea prevention
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MANAGEMENT OF DIARRHOEA
• Plan A – used to manage diarrhoea at home when a child has
NO DEHYDRATION
• Plan B – used for management of diarrhoea at the clinic for a
child with SOME DEHYDRATION
• Plan C – Applied for managing diarrhoea when a child has
SEVERE DEHYDRATION
26/05/2020 122

PLAN A (1)
• Plan A has 4 rules;
Rule 1: Give extra fluids (as much as the child will take).
This prevents a child from developing dehydration
Rule 2 – Give Zinc sulphate
– Builds immunity
– Reduces the duration of diarrhoea
– Prevents diarrhoea 2-3 months after the episode
– Give for 10 days
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Plan A (2)
• Rule 3: Continue feeding
– Breastfeed more frequently and longer at each feed
– If exclusively breastfed, give ORS in addition to breast
milk
– If not exclusively breast fed, give ORS and other
appropriate fluids
– Give an extra meal
• Rule 4: Counsel mother on when to return for follow up
All children with diarrhoea should receive Vit. A if
they have not had a dose in the last one month.
NB: Refer to Chart booklet page 14 for details on plan A.
26/05/2020 124

PLAN B
• Give ORS over a period of 4 hours at the health facility
• Determine how much fluid to give during the first 4 hours
(see chart booklet pg 14)
• Re - assess after 4 hours and re - classify
NB: For effective management of Plan B, all facilities should
have an ORT corner (ORT corner notes below).
26/05/2020 125

PLAN C
• For management of children with severe dehydration
• Refer to the Plan C flow chart on page 15 of the chart booklet
Example 6
Gabriel is one year old and weighs 10 kg.
• His mother brings him to the clinic because he has diarrhoea.
• The health worker determines that he has none of the general
danger signs.
• He is classified as having SEVERE DEHYDRATION. He is able to
take small sips orally. The clinic can provide IV fluids.
How should the health worker treat Gabriel’s dehydration?
26/05/2020 126

REHYDRATION THERAPY FOR DIARRHOEA IN
CHILDREN WITH SEVERE MALNUTRITION (1)
• Only rehydrate until the weight deficit (5% of the measured or
estimated body weight) is corrected.
• Do not give extra fluids to prevent recurrence.
• For a child who is conscious - not in shock, give Rehydration
Solution for Malnutrition (ReSoMal);
-5mls/kg half hourly for the first 2 hours then
-5-10mls/kg hourly, for the next 10-12 hours
-If a child can not take orally, use an NG tube.
26/05/2020 127

REHYDRATION THERAPY FOR DIARRHOEA IN
CHILDREN WITH SEVERE MALNUTRITION (2)
Unconscious/IN SHOCK
• Do not give IV fluids unless the child is in SHOCK (cold
extremities, weak pulse, reduced level of consciousness).
• Treat hypoglycaemia and keep warm.
• Admit or refer URENTLY.
26/05/2020 128

WHERE REFERRAL IS NOT POSSIBLE
• In some cases, referral will not be possible
Discuss
For a guide, see the chart booklet page 12 for
some of the treatments.
26/05/2020 129

COUNSEL THE MOTHER ON:
•FEEDING
•CARE FOR DEVELOPMENT
•GIVING FLUIDS
• WHEN TO RETURN
•MOTHER’S OWN HEALTH

In practice make sure you:
Give relevant advice to each mother
• Use Chart booklet page 21 or MCH booklet
pages 33 &34
• Use any other National guidelines
REFERENCE MATERIALS FOR COUNSELLING

ASSESSING THE CHILD’S FEEDING
Feeding assessment should be done at all times
on all children who:
• Are less than 2 years old
• Have anemia
• Have malnutrition or at risk of Malnutrition
• Have growth faltering i.e. dropping or
flattening weight curve in 2 or more
consecutive recordings regardless of age OR
• Are HIV exposed or infected

HOW TO ASSESS THE CHILD’S FEEDING
First, determine the current feeding practices by asking the following questions:
• Do you breastfeed your child? Yes----No----
if yes, how many times during the day?----
Do you breastfeed during the night? Yes ----No---- How many times?----
If you do not breastfeed, why?------------
 Does the child take any other food or fluids? Yes ----No----
if yes, what food or fluids?------------------------
How many times per day?----times. What do you use to feed the child-----------------------
---------
• If very low weight for age, ask how large the servings are--------------------------------
• Is the child served on his/her own plate? Who feeds the child and how? --------------------
----------
 During the illness, has the child’s feeding changed? If yes, how?------------------------------
• How do you prepare the food/fluids?----------

FEEDING RECOMMENDATIONS:-UP TO 6 MONTHS
Counsel the mother to:
 Start exclusive breastfeeding soon after birth (within 1/2 hr) and
continue up to 6 months- Do not give other foods or fluids not
even water.
 Breastfeed as often as the baby wants, day and night, at least 8
times in 24 hours
 Express breast milk and leave for the baby when away for six hours
or more.
 If milk is ‘not enough’ assess and counsel accordingly
 If breastfeeding is not possible due to mother’s status : mother is
not alive or mother is not available, advise on replacement feeding.
 Exclusive breastfeeding is recommended for HIV positive mothers.
 If a HIV positive mother chooses to do replacement feeding, assess
for AFASS (affordable, feasible, acceptable, sustainable and safe)
and counsel accordingly.

FEEDING RECOMMENDATIONS: 6 MONTHS UPTO 12
MONTHS
Counsel mother to:
• Breastfeed as often as the baby wants
• Start introducing enriched complementary foods
• Food should be soft for ease of chewing and swallowing
• Give adequate servings of:
- Thick uji from available cereals and enriched with sugar, milk,
groundnuts, soya beans, margarine, fats or oils ( page 21 of the
chart booklet).
- Give complementary foods 3 times per day if breastfed, and 5
times per day if not breastfed.

FEEDING RECOMMENDATIONS: 12 MONTHS UPTO 2
YEARS
Counsel mother to:
• Breastfeed as often as the child wants
• Give adequate servings of enriched foods 5 times a day.
• Give thick enriched uji and family foods as described for
infants 6 months up to 12 months
• Add small bits of all types of meat, vegetables, oils or fats,
groundnuts, beans, green grams, peas, eggs.
• Give milk and any type of fruits.
• Add spoonful of extra oil/fat to child’s food

FEEDING RECOMMENDATIONS- 2 YEARS AND OLDER
• Give enriched family food 3 times a day.
• Give also at least 2 snacks in between e.g.
thick enriched uji, ripe bananas, arrow roots
or other nutritious snacks.
• Give at least 2 cups of milk per day.

FEEDING DURING ILLNESS
 If breastfeeding, give more frequent breastfeeds
day and night.
 If not able to breastfeed, express breast milk and
give by cup.
 If on replacement feeding, give feeds as per
recommendations.(Page 22 of the chart booklet)
 If feeding is poor, give small frequent enriched
feeds especially those that the child normally
likes.
 Give one extra meal per day up to 2 weeks after
illness
 Increase FLUIDS during illness

FEEDING RECOMMENDATIONS:-PERSISTENT DIARRHOEA
• If still breastfeeding, give more frequent, longer breastfeeds day
and night.
• If taking other milk :
– Reduce milk by half and replace with nutrient rich semi solid food
such as fermented porridge, thick enriched staple food OR
– Replace with fermented milk products (mala, yoghurt as these are
tolerated better
• For other foods follow feeding recommendations for the child’s
age
• Give an extra meal per day and continue until one month after
diarrhoea has stopped.
• Vitamin supplements should be given where appropriate

COUNSEL THE MOTHER ON FEEDING PROBLEMS
After the assessment of feeding, determine:
–What the mother is doing correctly to feed
her child
–Identify the feeding problem
–Determine what feeding advice is relevant for
the problem identified.
• For every feeding problem identified, it is
absolutely important to give RELEVANT
advice for that particular problem based on
the feeding recommendations.

CARE FOR DEVELOPMENT
Care for development assessment should be done at all times on all children
who:
• Are less than 2 years old
• Have anemia
• Have Malnutrition or at risk of Malnutrition
• Have growth faltering i.e. dropping or flattening weight curve in 2 or more
consecutive recordings regardless of age OR
• Are HIV exposed or infected
• Much of what children learn, they learn when they are very young. For their
brains to develop, they need to move, to hear sounds, to touch things and
explore and to play with others.
• Children need a safe environment as they learn.
• Children need consistent loving and attention from at least one person

CARE FOR DEVELOPMENT: RECOMMENDATIONS
Age group Play Communicate
Up to 4 months Provide ways for the child to see, hear and
move
Look into child’s eyes and smile .
Practice this during
Breastfeeding
4 up to 6 months Have large colourful things for your child
to reach for and new things to see
Talk to the child with sounds
and gestures
6 up to 12 months Have large colourful things for your child
to reach for, and new things to see
Talk to the child with sounds
and gestures
12 months upto 2 yrs Give the child things to stack up and to
put into containers and take out
Ask child simple questions.
Respond to child’s attempt to
talk. Play games like ‘bye’
2 years & older Help the child count, name and compare
things. Make simple toys for your child.
Encourage to talk and answer
child’s questions. Teach child
stories , songs & games
Ask questions about how the mother takes care of her child. Compare the mother’s answers to The
Recommendations For Care For Development for the child’s age below. Refer to the IMCI chart
booklet page 20 or MCH booklet
How do you play with your child?--------------------------------
How do you communicate with your child? --------------------------------

COUNSEL THE MOTHER of AN HIV EXPOSED AND
INFECTED CHILD
• On any new or continuing feeding problem.
• To bring the child back if any new illness develops
or she is worried
• On growth,development,nutrition,immunization,
vitamin A and deworming
• On ART and co-trimoxazole adherence
(Refer the participants to the IMCI chart booklet
page 22

COUNSEL THE MOTHER ON HER OWN
HEALTH
• If mother is sick provide care for her or refer for help
• Make sure she has access to family planning and
STI/HIV/Aids prevention
• Breast examination and cervical cancer screening.
• If HIV positive , counsel her on early testing for the
child and adherence to HIV treatment or refer to an
appropriate site.(IMCI chart booklet page 26)

Introduction
• Some sick children need to return to health
worker for follow up as previously instructed
on; when to return
• During follow up, the health worker (H/W) can
determine if the child is improving on
treatment
• The Health worker will decide on the next
course of action

Follow up 1
• Review follow up schedule on chart booklet page 17.
Follow up is also found as last column of the assess
and classify chart (page 2-7)
• Always ask the mother about the child’s problem
• Once you establish the child has come for follow up,
ask if child has developed any new problems
• A child with a new problem requires a full assessment

Follow up 2
• If a child has no new problem, locate and
follow instructions in the relevant follow up
box (chart booklet pages 17 to 19; 40 to 41)
• Children who;
– are not responding to treatment or
– get worse or
– repeatedly return to the clinic with new problems,
should be referred to hospital.

Follow up 3
• Follow up visit for feeding problem after five
days.
Reassess feeding by asking the feeding problem
found on the initial visits.
Counsel the mother about any new or continuing
problem and ask her to bring the child back
again.
If the child is very low weight for age, ask the
mother to return 14 days after the initial visit to
check weight.

• Follow up for Pneumonia
•After 2 days
•Check the child for general danger signs
•Assess the child for cough or difficult breathing
ASK
• Is the child breathing slower
•Is there less fever
•Is the child eating better
TREATMENT
• If child is worse (danger sign, chest in drawing) – give urgent pre referral treatment,
admit or refer to hospital
•If child’s condition is the same, give second line antibiotics, follow up in 2 days.
•If child has improved, continue with treatment to complete the 5 days.
N.B. If the child has improved, praise the mother and encourage her to complete
treatment. If not improved, discuss the problems if any, decide on appropriate
management and give another follow up date.
Follow up-example 1
26/05/2020 150

Exercise 1
• Kalisa is 11 months old. He weighs 7kg. His temperature is
37C and his height is 73 cms. His mother says he has had a
dry cough for the last 3 wks. He does not have any danger
sign. The health worker assessed his cough it has been
present for 21days. He counted 41b/mThe health worker
does not see any chest indrawing and no stridor when the
child is calm. He did not hear a wheeze. Kalisa does not have
diarrhea he does not have a fever during this illness. He
does not have an ear problem.the health worker checked
Kalisa fo malnutrition and anemia. The is no history of TB
contact.he does not have visible severe wasting. His palms
are very pale and almost paper white. There is no edema on
both feet. The health worker determined Kalisas weight for
age and height for age.
• Assess and classify kalisas signs and treat him.

Exercise 2
• Jonas is 11 months old. He weighs 5.5kg. His
temperature is 37C and his height is 60 cms. His mother
says he has had a cough for 2 days. The health worker
counted 37b/m.He does not have any danger sign. The
health worker does not see any chest indrawing and
does not hear a stridor nor a wheeze when the child is
calm. Jonas does not have diarrhea but had diarrhea for
2 days two months ago. he does not have a fever during
this illness. He does not have an ear problem.the health
worker checked Jonas for malnutrition and anemia. The
is no history of TB contact.he does not have visible
severe wasting. His palms are not pale . There is no
edema on both feet. The health worker determined
Jonas weight for age and height for age.
• Assess and classify Jonas signs and treat him.

Exercise 3
• Nerea is 6 weeks old .her weight is 4.2kgs. Her axillary temperature is
36.5c. Her mother brought her to the clinic because she has diarrhea
and seems very sick. When the health worker asks the mother if nera
has had convulsions she says no.Nerea is not able to breast feed the
health worker counts 50b/m. she has severe chest indrawing and
nasal flaring. She is not grunting nor gasping.she has no central
cyanosis and her fontanelle is not bulging. There is no pus draining
from the ears and her umbilicus and skin are normal. On underssing
Nerea, speaking to her , shaking her arms and legs and picking her up
do not wake She is unconscious.the health worker checks for
jaundice and eye infection. The mother says Nereas skin is not yellow
and the health worker does not see jaundice on the palms and the
soles. Her eyes are not swollen.in response to the mothers questions
the mother says that nerea has had diarrhea for 1 week and there is
no blood in stool. The health worker finds her eyes sunken. When
the skin on the abdomen is pinched it goes back very slowly.
• Assess , classify and treat Nerea.

Exercise 4
• Onyango is 6 weeks old .his weight is 3kgs. His axillary
temperature is 37c. His mother brought him to the clinic because
he has discharge from the eyes for the last 3 days.When the
health worker asks the mother if Onyango has had convulsions
she says no.he is feeding well.the health worker counts 58b/m.
she has mild chest indrawing and no nasal flaring. he is not
grunting nor gasping.he has no central cyanosis and his fontanelle
is not bulging. There is no pus draining from the ears and his
umbilicus is draining pus with no redness and there are no skin
pustules. Onyango is awake not lethargic and his movements are
normal .the health worker checks for jaundice and eye infection.
The mother says onyangos skin is not yellow and the health
worker does not see jaundice on the palms and the soles. His
eyes are draining pus but are not swollen.the mother says that
onyango does not have diarrhea but the eyes appear yellow in
colour. The health worker confirms the same.
• Assess , classify and treat Onyango

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