Share Intergrated Management of Chilfhood Illnesses- J NKOLE.ppt

INTERGRATED MANAGEMENT
OF CHILDHOOD ILLNESSES
PRESENTER
MR. J.NKOLE
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INTRODUCTION
IMCI is a way of delivering child care services in
which the contact with a child brings together
all possible ways and means for care of child and
mother
IMCI will be discussed in three parts which
cover:
1. General information on IMCI
2. IMCI process for children aged 2 months to 5
years
3. Infants aged 0 – 2 months

WHAT ACRONYMS
"I", "M", "C", "I"
I "Integrated" refers to bringing together curative,
preventive and development aspects of child care into one
strategy in addition to the proposed management
approach.
M. "Management" here should be seen as having both a
clinical, preventive and promotion part.
C. "Childhood“ refers to children under 5 yrs , the child age
group most vulnerable to illness and death.
I. "Illness" is used to address conditions that are first major
cause of death, severe illness or disability in U5 children

Introduction contd
• IMCI is a step by step process. Step by step
management helps to look at the entire sick child so
that major signs and symptoms of illness are not
overlooked.
• Integrated Management of Childhood Illness has 6
modules.
• Module 1 focuses on assessing and classifying a sick
child aged 2months up to 5 years.
• Module 2 will take you through identify treatment.
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Introduction contd
• Module 3 will cover Treat the child
• Module 4 will look at council the care taker
• Module 5 will look at management of the sick
infant
• Module 6 will take you through follow up.
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Learning objectives
• At the end of the presentation, students should be
able to:
 Describe the concept of Integrated management
of Childhood Illness(IMCI)
 Assess and classify the sick child aged two
months up to five years
 Identify treatment for the child
 Council the care taker on caring for the child’s
health growth and development
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Objectives contd
• Discuss the management of the sick young infants
up to two months.
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Objectives of IMCI
• To reduce significantly mortality and morbidity
associated with the major cause of diseases in
children
• To promote improved growth and development of
children.
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Definition
• IMCI IMCI is a holistic strategic approach
to child care that combines curative,
preventive and developmental care aspects
of children under the age of 5 years at
home, in the community or at the health
facility.
• The approach was developed by United
Nations Children's Fund and the World
Health Organization in 1995.
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AGE FOCUS FOR IMCI IN CHILDREN
• Treatment guidelines are for children under the age 5
years of age. These are divided into two categories:
1. Young infant aged up to 2 months.
All sick young infants under aged up to 2 months,
must be examined for signs of “possible serious
bacterial infection”
2. Children aged 2 months to five years
All sick children of 2 months up to 5 years must be
examined for “general danger signs”

Advantages of IMCI
1. Focuses on care of the child as a whole and not on the reason
for the visit.
2. Ensures the early identification of all seriously ill children
3. Ensures integrated management of all prevalent illnesses that
the child may present.
4. Includes the application of preventive measures along with
treatment for detected illnesses and health problems
5. Includes actions to improve parental practices in caring for
the child at home
6. Can be adapted to the local epidemiological situation

TRAININGS
• Basic Integrated Management of Childhood illness
(12 days)
• IMCI follow up Course (5 days) (Supervisors/PHNs)
• IMCI On the Job Training
• IMCI Supervisory Skills Trainings
(Follow after training is an essential activity to all
IMCI Trainings 1 month after and 3 months after)
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BASIC JOB AIDS and FORMS:
• IMCI Chart Booklet
• IMCI Patient’s Logbook
• Sick Child Recording Forms:
1. Age 2 months up to 5 years old
2. Sick young infant – age 1 week up to 2
months
• Mother’s Counselling Card
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COMMON CAUSES OF MORBIDITY AND
MORTALITY IN UNDER FIVE CHILDREN
Four (4) most common causes of ill health and death among
the under-fives. These illnesses are:
1. Pneumonia;
2. Diarrhoea;
3. Fever Malaria; measles
4. Ear infection.
Others include:
5. Acute malnutrition.
6. Tuberculosis
7. HIV
NB: Sick children come with a combination of illnesses

Essential IMCI Drugs at Health Facilities
Oral antibiotics
(1st line – Amoxicillin
Oral anti malarial
1st line-Artemether lumefantrine
2nd line – Quinine
Nalidixic Acid Tablets
Tetracycline tablets
Iron
Vitamin A
Paracetamol
Vaccine
Mebendazole
Albendazole
Tetracycline eye ointment
Gentian violet
Vitamin A
Chloramphenicol IM
(optional)
Gentamicin IM (optional)
Benzyl Penicillin IM
(Optional)
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Other Essential Equipment and
Supplies:
Equipments:
1-weighing scale
2-timing devices
3-refrigerator with voltage
regulator
4-sterilizers
5-BP apparatus
6-pediatric cuff
7-oral thermometer
Supplies:
1-cold chain supplies and
immunization supplies
2-ORT supplies
3-water jars
4-IV fluid (plain LR and
insertion sets
5-sterile water for dilutions
6-plaster, cotton swab, tongue
depressor.
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The IMCI Management Process
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IMCI Case Management process
IMCI case management requires to have
knowledge and skills in the following process:
1. Assess the under five sick children
2. Classify illness according to severity
3. Identify treatment for sick child
4. Treat child or young infant and or refer
5. Counsel of caretakers.
6. Give follow-up care

Assess and Classify the Sick Child
Age 2 months up to 5 years
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• Ensure you record the following first
• NAME OF THE CHILD
• AGE in months
• WEIGHT
• TEMPERATURE

STEPS THAT ARE INVOLVED IN IMCI
PROCESS
• ASSESS
• CLASSIFY
• IDENTIFY TREATMENT
• COUNCIL THE CARETAKER
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STEP 1. ASSESS THE CHILD FOR DANGER
SIGNS
• Ask the mother what the child’s problems are
then determine if this is an initial or follow up
visit for this problem.
• if initial visit, assess the child as follows:
a. Danger signs: Sick child may present signs and
symptoms in various degrees. Therefore determine
whether the child has danger signs: These are
i. Child not able to drink or breastfeed
ii. Child vomits everything,
iii. Child has or have had a convulsions
iv.Child LOOKS LETHARGIC OR UNCONSCIOUS

ASSESS
• CHECK FOR GENERAL DANGER SIGN
• If the child has had convulsions?
ASK:
• If the child is not able to drink or breastfeed?
• If the child is vomiting everything?
• Look:
- See if the child is lethargic or unconscious
- See if Child convulsing now
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CHECK FOR GENERAL DANGER SIGNS
MAKE SURE CHILD WITH ANY GENERAL
DANGER SIGN IS REFERRED
After first dose of an appropriate antibiotic and
other urgent treatments.
Exception: Rehydration of the child according to Plan
C may resolve danger signs so that referral is no
longer needed.
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GENERAL DANGER SIGNS IN
SUMMERY
• Convulsions
• not able to drink or breastfeed
• vomiting everything
• lethargic or unconscious
• Convulsing now
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Video on general danger sign
• video
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STEP 1 CONT’D
b. Whether or not there are danger signs, ask the
mother and check for 4 important main symptoms
(conditions):
i. Does the child have a cough and or
difficulties in breathing
ii. Does the child have diarrhoea
iii.Does the child have fever including malaria,
meningitis and measles
iv.Does the child have ear infection
For any: ‘yes’ answer, ask further questions, look and

ASSESSMENT CONT’D
C. Next, check for:
i. acute malnutrition and anaemia: Nutrition
status of a child – weight for age, anaemia
ii. immunization status
iii. Check for Vit A supplementation
iv. HIV status
v. Tuberculosis
• Then examine for any other condition eg, skin
condition and worms

STEP 2: CLASSIFY THE ILLNESS
a. To classify means to make a decision about the severity of
the illness.
b. The classification of severity are colour - coded triage
system.
c. Most children have more than one condition. Hence
each illness is classified according to whether it
requires, urgent treatment and referral, or specific
medical treatment and advice or simple advice on
home management
d. For each of the child’s main symptoms, you will select a
category, or “classification,” that corresponds to the
colour for severity of the child’s illnesses

CLASSIFICATION CONTINUED: COLOUR
CODES
The following are the colour cods for severity and
management.
a. Red indicates very severe and suggests referral
b. Yellow indicates moderate – initiating specific
treatment
c. Green indicates home treatment with advice to the
mother.
Classify each condition plus any other condition eg
nutrition status – eg pneumonia with underweight or
diarrhoea with under weight

CLASSIFICATION TABLE
RED This is for SEVERE CLASSIFICATION. Needs
Urgent Attention and Referral or Admission for in
Patient Care.
YELLO
W
This is a MODERATE OR MILD
CLASSIFICATION for
initiating specific treatment
GREEN indicates home treatment with advice to the mother.
MOTHER HOW TO CARE FOR HER CHILD AT
HOME.
As an example, advise mother on how to feed her sick
child or giving fluid for diarrhea
Classify each condition plus any other condition eg nutrition status
– eg pneumonia with underweight

3. IDENTIFY TREATMENT
After classifying all conditions, do the following:
a. Identify specific treatments for the child.
b. If a child requires urgent referral, give essential
treatment before the patient is transferred.
c. 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.
d. If a child should be immunized, give
immunizations.

4. TREAT THE CHILD
TREAT means:
a. Giving appropriate treatment in clinic – intramuscular
injections or IV fluids
b. If needs referral, give appropriate pre-referral treatment
and then refer
c. Prescribing drugs or other treatments to be given at
home,
d. Teaching the caretaker how to carry out the treatments
such as oral antibiotics, antimalarial, TB drugs, inhaled
salbutamol, paracetamol iron and folate
e. Teaching care taker to treat local infections at home
such as sore throat, eye or ear infections

5:COUNSELLING OF CARETAKERS.
Feeding counselling: Use infant feeding counselling skills
a. Assess child feeding practice in a child less than 2 years
of age if classified as having acute severe, or
moderate severe or not gaining weight or has
anaemia
b. Assess child’s appetite
c. Assess breastfeeding practice for child less than 2 years
– positioning and attachment and exclusive
breastfeeding in a child less than 6 months age
d. Assess complementary feeding practice with sustained
breastfeeding for a child aged

COUNSELLING CONT’D: FEEDING COUNSELLING
a. Counsel on feeding recommendations during illness
b. If HIV exposed, counsel feeding recommendations for
HIV exposed infants as per mother’s choice of feeding
practice
c. Counsel on how to stop breastfeeding when AFASS is
met
d. Feeding recommendations for a child with persistent
diarrhoea
e. Counsel on giving extra fluids during illness
f. Counsel on mother’s health – Breast conditions, HIV
status, STIs, TB, FP, tetanus toxoid status, maternal
nutrition

6.GIVE FOLLOW-UP CARE
a. Some sick children need to return to the health
worker for follow-up. Follow-up visit is determined
by severity and type of problem (such as in 2 days,
or 14 days).
b. Follow-up visit determines if the child is improving
on the drug or other treatment that was prescribed.
c. Some children may not respond to a particular
antibiotic or antimalarial and may need to try a
second drug.

COUNSEL MOTHER ON CARE FOR CHILD’S
HEALTH, GROWTH AND DEVELOPMENT
Importance of play and communication to age group:
a. 1 – 2 months
b. 3 – 4months
c. 5 – 6 months
d. 6 – 9 months
e. 9 – 12 months
f. 12 months – 2 years

GIVE FOLLOW-UP CARE CONT’D
i. Children with persistent diarrhoea also need
follow-up to be sure that the diarrhoea has
stopped.
ii. Children with fever or eye infection need to be
seen if they are not improving.
iii.Follow-up is especially important for children
with a feeding problem; to be sure they are
being fed adequately and are gaining weight.

IMCI PROCESS FOR CHILDREN
AGED
TWO (2) MONTHS – FIVE (5) YEARS
Follow IMCI process out lined

ASSESS AND CLASSIFY A CHILD
AGED 2 MONTHS – 5 YEARS
a. GREET THE MOTHER APPROPRIATELY AND
ASK ABOUT THE CHILD ▼ LOOK TO SEE IF
THE CHILD’S WEIGHT AND TEMPERATURE
HAVE BEEN RECORDED
b. ASK THE MOTHER WHAT THE CHILD’S
PROBLEMS ARE
c. DETERMINE IF THIS IS AN INITIAL OR
FOLLOW-UP VISIT FOR THIS PROBLEM
d. CHECK FOR GENERAL DANGER SIGNS –

CHECK FOR GENERAL DANGER SIGNS
Ask the mother/care giver Look
Is child able to drink or
breastfeed
See if child is lethargic or
unconscious
Does the child is vomit every
thing
Is the child convulsing now
Has the child had convulsions
this illness
A child with any danger sign requires urgent attention. Chose pink
code. Complete the assessment. Give pre-referral treatment
immediately and refer without delay

DANGER SIGNS CONT’D
Any
danger
general
sign
Very
severe
disease
a. Give diazepam if convulsing
now
b. Quickly complete assessment
c. Give pre- referral treatment
immediately
d. Treat to prevent low blood
sugar
e. Keep child warm
f. Refer urgently

1: PNEUMONIA - HOW TO ASSESS A CHILD WITH
A COUGH AND DIFFICULT IN BREATHING
Ask about the main symptom – Does the child
have cough or difficult breathing
• If yes, ask for how long
• Look, listen and feel
a. Count the breaths per minute
b. Look for chest in-drawing
c. Look and listen for stridor
d. Look and listen for wheezing
NB: Child must be calm in a-d

ASSESSMENT
• Ask about the main symptom – Does the child
have cough or difficult breathing
 ASK: Does the child have a cough or difficult
breathing?
 If caretaker answers YES, ask the next question.
• ASK: For how long? A child who has had cough
or difficulty breathing for more than 14 days has a
chronic cough.
• Count breathes per minute
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• Then look for;
• fast breathing,
• chest in drawing
• stridor
• wheezing in a calm child.
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FAST BREATHING
• The cut – off points for fast breathing
are as follows:
• If a child is 2 months up to 12
months, fast breathing is 50 breaths
per minute or more.
• while a child from 12 months up to 5
years, fast breathing is 40 breaths per
minute or more.
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Fast breathing
Video show
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Stridor and chest indrawing
Video show
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classify
• After you assess for the main symptoms and
related signs, classify the child's illness as follows:
• 1. SEVERE PNEUMONIA OR VERY
SEVERE DISEEASE (RED OR PINK ROLL)
• Any general danger sign or chest indrawing or
stridor in a calm child classifies this as severe
pneumonia.
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identify treatment for severe pneumonia or
severe febrile disease
• Give first dose of an appropriate antibiotic- refer
to the chartbooklet page 15.
• Treat wheezing if present. Refer to chart booklet
page 12
• Treat the child to prevent low blood sugar. Refer
to chartbooklet page 16
• Refer URGENTLY to hospital.
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2. CLASSIFY PNEUMONIA
• PNEUMONIA ( yellow roll)
• The sick child is classified to have pneumonia if
he/she has fast breathing.
• Identify treatment –
• give oral antibiotic
• If wheezing give trial of rapid acting
bronchodilator
• Sooth the throat and relief cough with the safe
remedy.
• Check HIV status.
• Give a follow up in next 2 days.
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3. COUGH OR COLD (green roll)
• The sick child is classified under cough or cold
when there is no sign of severe disease or
pneumonia.
Treatment
• A child with cough or cold does not need
antibiotics.
• Advise the caretaker on safe remedy for cough
and soothe the throat.eg warm tea with sugar.
• Advise to watch for fast breathing or difficulty in
breathing.
• You can then review the child after 5 days.
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Case 1
• Fatima is 18 months old. She weighs 11.5 kg. Her temperature is
37.5 C. The health worker asked, “What are the child’s
problems?” The mother said “Fatima has been coughing for 6
days, and she is having trouble breathing.” This is the initial visit
for this illness.
• The health worker checked Fatima for general danger signs. The
mother said that Fatima is able to drink. She has not been
vomiting. She has not had convulsions during this illness. The
health worker asked, “Does Fatima seem unusually sleepy?” The
mother said, “Yes.” The health worker clapped his hands. He
asked the mother to shake the child. Fatima opened her eyes, but
did not look around. The health worker talked to Fatima, but she
did not watch his face. She stared blankly and appeared not to
notice what was going on around her.

2. DIARRHOEA
• Diarrhoea is defined as three or more loose watery stool in a 24
hour period.
• Most diarrhoeas which cause dehydration are loose or watery.
Cholera is one example of loose or watery diarrhoea.
• If an episode of diarrhoea lasts less than 14 days, it is acute
diarrhoea. Acute watery diarrhoea causes dehydration and
contributes to malnutrition.
• If the diarrhoea lasts 14 days or more, it is persistent diarrhoea.
Up to 20% of episodes of diarrhoea become persistent. Persistent
diarrhoea often causes nutritional problems
• Diarrhoea 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.

DOES THE CHILD HAVE
DIARRHOEA
If yes ask Look and feel
Ask about
diarrhoea in
ALL children:
a. For how long
b. Is there
blood in
stool
a. Look at general condition
• Lethargic or unconscious
• Restless and irritable
b. Look for sunken eyes
c. Offer child fluid. Is child
• Not able to drink or drinking poorly
• Drinking eagerly, thirsty
d. Pinch skin of abdomen. Does it go back:
• Very slowly (longer than 2 seconds)
• Slowly?

PINCH SKIN OF ABDOMEN
• Classify diarrhoea for dehydration, if more than 14 days and if
blood is in stool

AREAS OF CLASSIFICATION IN DIARRHOEA
There are three (3) status of classification for
child with diarrhoea:
a. Dehydration status
b. If diarrhoea is 14 days or more
c. If there is blood in stool

Treatment for severe dehydration
• Any child this classification needs extra
fluids.
• Treat with IVF for plan C
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Treatment for some dehydration
• Treat with ORS for plan B
• Give addition fluids
• Give Zinc supplement
• Breastfed children should continue
breastfeeding.
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Treatment for no dehydration
• This child needs extra fluids to prevent
dehydration and home treatment
• Give fluids for plan A
• Give Zinc Supplement
• Continue feeding
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CLASSIFICATION FOR DIARRHOEA
WITH BLOOD IN STOOL
Sign Classify as Identify treatment
Blood in stool Yellow
DYSENTERY
Give ciprofloxacin
for 3 days
Treat dehydration
and give zinc
Follow-up in 2
days

DIARRHOEA CONT’D
a. You can assume that Shigella caused the dysentery because:
i. Shigella causes about 60% of dysentery cases seen
in clinics.
ii. Shigella causes nearly all cases of life-threatening
iii. dysentery.
b. Finding the actual cause of the dysentery requires a stool
culture for which it can take at least 2 days to obtain the
laboratory results.
c. As you assess and classify diarrhoea, circle the signs found
and write the classification(s) on

Case 1
• CASE 1: Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 C. The
health worker asked, “What are the child’s problems?” The mother said “Fatima has been
coughing for 6 days, and she is having trouble breathing.” This is the initial visit for this
illness.
• The health worker checked Fatima for general danger signs. The mother said that Fatima
is able to drink. She has not been vomiting. She has not had convulsions during this
illness. The health worker asked, “Does Fatima seem unusually sleepy?” The mother said,
“Yes.” The health worker clapped his hands. He asked the mother to shake the child.
Fatima opened her eyes, but did not look around. The health worker talked to Fatima, but
she did not watch his face. She stared blankly and appeared not to notice what was going
on around her.
• The health worker asked the mother to lift Fatima’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker
did not see any chest indrawing. He did not hear stridor.
• The health worker asked, “Does the child have diarrhoea?” The mother said, “Yes, for 3
days.” There was no blood in the stool. Fatima’s eyes looked sunken. The health worker
asked, “Do you notice anything different about Fatima’s eyes?” The mother said, “Yes.”
He gave the mother some clean water in a cup and asked her to offer it to Fatima. When
offered the cup, Fatima would not drink. When pinched, the skin of Fatima’s abdomen
went back slowly.

3. ASSESS AND CLASSTY FEVER
• In IMCI, a child with fever may have Malaria,
Meningitis, Measles, otitis media or another
severe disease. Fever in children may also be caused
by cough or cold or other viral infections.
• Child regarded as having fever by history, feels hot
or temperature of 37.5 c.
• Assessment
• Ask does the child have fever? If yes
• Then ask- for how long?
• If more than 7 days, has fever been present every
day?
• Look and feel for stiff neck
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• Ask the parent or caretaker for a history of
fever or if the child’s body feels hot. The child
has a history of fever if child has had any
fever with this illness. Measure the body
temperature of all sick children or child in this
case.
• Ask - has the child had measles in the last 3
months?
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• Look for signs of measles
 generalized rash and one of these:
• cough, runny nose or red eyes
• If the child had measles within the last three
months- look for complications of measles:
 Mouth ulcers- are they deep or extensive?
 Pus draining from the eyes
 Clouding of the cornea
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Classification for fever
• If the child has fever and no signs of measles
classify for fever only. If child has signs of
both fever and measles, classify fever and
measles.
• There are three possible classifications of
fever;
• Very severe febrile disease
• Malaria
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THEN ASK: Does the Child have Fever?
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* Any general
danger sign
or
* Stiff neck.
VERY SEVERE
FEBRILE DISEASE/
MALARIA
 Give first dose Artesunate
 Give first dose of an appropriate antibiotic.
 Treat the child to prevent low blood sugar.
 Give one dose of Paracetamol in health center
for high fever (38.5 0C or above).
 Refer URGENTLY to hospital.
* Do RDT or blood
slide
Blood smear (+)
If blood smear
not done:
* NO runny nose,
and
* NO measles, and
* NO other causes
of fever
MALARIA
 Treat the child with an oral antimalarial.
 Give one dose of paracetamol in health center
for high fever (38.5 0C or above).
 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.

Treatment for very severe
febrile disease
• Give a first dose of artesunate
• Treat the child to prevent low blood sugar-
p16
• Give a first dose of an appropriate antibiotic
p15
• Give the first dosage of paracetamol
• Refer urgently
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Treatment for malaria
 Treat the child with an oral antimalarial.
(Page 12)
 Give one dose of paracetamol in health
centre for high fever (38.5 0C or above).
 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
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Classification of measles
• There 3 possible classification of measle:
 Severe complicated measles
 Measles with eye or mouth complications
 measles
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THEN ASK: Does the Child have Fever?
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*Any GDS
- Clouding of
cornea or
* Deep or
extensive
Mouth ulcers
SEVERE
COMPLICATED
MEASLES
 Give vitamin A.
 Give first dose of an appropriate
antibiotic.
 If clouding of the cornea or pus draining
from the eye, apply tetracycline eye
ointment.
 Refer URGENTLY to hospital.
*Pus draining
from
the eye or
* Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
 Give Vitamin A for treatment
 If pus draining from the eye, apply
tetracycline eye ointment.
 If mouth ulcers, teach the mother to
treat with gentian violet.
 Follow-up in 2 days
*Measles now
or
within the last
3 months
MEASLES  Give Vitamin A for treatment
 Follow up in 14 days.

Treatment for Severe
complicated measles
 Give vitamin A.
 Give first dose of an appropriate
antibiotic.
 If clouding of the cornea or pus draining
from the eye, apply tetracycline eye
ointment.
 Refer URGENTLY to hospital
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Treatment- measles with eye
or mouth complication
 Give Vitamin A. page 14
 If pus draining from the eye, apply
tetracycline eye ointment.
 If mouth ulcers, teach the mother to treat
with gentian violet. Page 13
 Follow-up in 2 days
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EAR INFECTION
• A child with ear problem is assessed for:
Ear pain
Ear discharge
If discharge is present- how long has had
discharge.
Tender swelling behind the ear ( sign of
Mastoditis)
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ASSESS EAR INFECTION
• Ask if the child has an ear problem
• IF YES, ASK:
 If there is ear pain?
 If there is ear discharge?
• IF YES, for how long?
• LOOK AND FEEL:
 Look for pus draining from the ear.
 Feel for tender swelling or tender swelling behind
the ear
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Classify ear infection
• There are four classifications for ear
infection
• MASTODITIS
• ACUTE EAR INFECTION
• CHRONIC EAR INFECTION
• NO EAR INFECTION
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Classification for ear problem
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Treatment for mastoditis
• Give the first dose of appropriate antibiotic
• Give first dose of paracetamol for pain
• URGENTLY REFER
1/4/2024 86

ACUTE EAR INFECTION
• Give appropriate antibiotic for 5 days
• Give paracetamol for pain
• Dry ear by wicking
• If ear discharge- check for HIV infection
• Follow up in 5 days.
1/4/2024 87

Treatment for Chronic Ear
infection
• Dry ear by wicking
• Treat with topical quinolone ear drops for 2
weeks
• Check HIV infection
• Follow up in 5 days
1/4/2024 88

CHECK FOR MALNUTRITION
• Malnutrition is a condition that occurs
when food eaten is not enough or too much
than the body requires.
• Nutrition terms
• Under nutrition is the condition which
occurs when a persons diet does not contain
enough nutrients to meet the body
requirements.
1/4/2024
89

• Acute malnutrition (wasting) is the
condition in which a child suffers sudden
weight loss or oedema of both feet. There is
inadequate food intake and or illess within
the short period of time.
• Underweight is when a child weighs less
than he should for his age or low weight.
• Oedema is swelling from fluids in the
tissues is characteristic of kwashiorkor.
1/4/2024 90

• Severe wasting – child has reduced
subcutaneous fat, and appears like skin and
bone. These are signs of marasmus.
1/4/2024 91

ASSESS FOR ACUTE MALNUTRITION
There are five methods used to assess nutritional
status of children which include;
Oedema of both feet
MUAC
Weight for height/length (WFH/L)
Height for age (HFA)

ASK is there history of weight loss?
LOOK AND FEEL:
• Look for visible severe wasting
• Look for signs of acute malnutrition
• Oedema of both feet
• Determine WFH/L ------ Z – score
• Measure MUAC -----mm in a child 6 months
or older
• Look at the growth curve.
1/4/2024 93

CHECKING FOR ACUTE MALNUTRITION CONT’D
If WFH/L less than -3 z-score or MUAC less than 115 mm
then:
 Check for any medical complication present:
– Any general danger signs
– Any severe classification
– Pneumonia with chest in-drawing
 If no medical complications
 And child is 6 months or older, offer RUTF to eat. Is the
child
– Not able to finish RUTF portion
– Able to finish RUTF portion
 And child less than 6 months, assess breastfeeding:
– Does the child have a breastfeeding problem

CLASSIFY NUTRITION STATUS
• If visible severe
wasting or
• Oedema of both feet
or
• WFH/L less than -3 z-
score
• MUAC less than
115mm and any of the
following
• Medical complication
present
• Or not able to finish
RUTF(without
happetite)
COMPLICATE
D SEVERE
ACUTE
MALNUTRITI
ON
 Give first dose of
an appropriate
antibiotic
 Treat child to
prevent low blood
sugar
 Keep child warm
 Refer
URGENTLY to
hospital

• WFH/L
less than -
3 z-score
OR
• MUAC
less than
115mm
AND
• Able to
finish
RUTF
• (with
hapitite)
SEVERE ACUTE
MALNUTRITION
without
complications
 Give oral antibiotics for 5
days
 Give RUTF for a child
aged 6 months or more.
 If not available refer.
 Counsel mother on how to
feed the child.
 Asses for possible TB
infection
 Advise when to return
immediately
 Follow-up in 7 days.

• WFH/L
betwee
n -3
and -2
z-scores
OR
• MUAC
115 mm
MODERATE
ACUTE
MALNUTRITI
ON
 Assess child’s feeding &
counsel the mother on
feeding
recommendations
 If feeding problem,
follow-up in 7 days
 Asses for possible TB
infection
immediately

• WFH/
L -2 z-
scores
or
more
OR
• MUA
C 125
mm or
more
NO ACUTE
MALNUTRITI
ON
 If child less than 2
years old, assess
child’s feeding and
counsel mother on
feeding according to
the feeding
recommendations

ASSESS FOR ANAEMIA
Look for palmar pallor. Is it:
a. Severe palmar pallor
b. Some palmar pallor
c. If palmar pallor do malaria test
NB
If malaria test not available, give an oral antimalarial
If child has severe acute malnutrition and is receiving
RUTF, DO NOT GIVE iron because there is already
adequate amount of iron in RUTF

CLASSIFY ANAEMIA
Sign Classify
as
Identify treatment
• Severe
palmar
pallor
SEVERE
ANAEMI
A
 Urgently refer to hospital
• Some pallor ANAEMI
A
 Give iron
 Give oral antimalarial if malaria
test is positive
 Give mebendazole if child is one
year or older and has not had a
dose in previous 6 months.
immediately

CLASSIFY ANAEMIA
No
palmar
pallor
NO
ANAEMIA
 If child less than 2 years
old, assess child’s feeding
and counsel mother
according to the feeding
recommendations
 If feeding problems,
follow-up in 5 days

Check for HIV infection; assessment
for HIV infection
• If the child has no severe classification
proceed as follows;
• First ASK
• Has the mother and/or child had HIV test?
IF YES then note the HIV status;
• Mother HIV: +ve or –ve
• Child HIV: - PCR : +ve or –ve
• -serological test: +ve or –ve
• IF NO: status unknown, then test mother.
1/4/2024 102

CHECK FOR HIV INFECTION CONT’D
If mother is HIV + and child is negative or
unknown status, ASK
i. Was the child breastfeeding (b/f) at the time or
6 weeks before the test
ii. Is the child b/f now
iii. If b/f, ASK: is mother and child on ARV
prophylaxis

CLASSIFY HIV STATUS
Positive
virological
test in a
child
OR
Positive
serological
test in a
child 18
months or
older
YELLOW
CONFIRMED
HIV
INFECTION
 Give cotrimoxazole prophylaxis
 Give HIV care and initiate ART
treatment
 Assess child’s feeding and provide
appropriate counselling to the
mother
 Advise mother on home care
 Refer for further assessment and
initiation of antiretroviral therapy
 Follow –up in 14 days or as per
immunization schedule

CLASSIFY HIV STATUS CONT’D
Mother HIV +ve
AND negative
virological test in
child b/f or
if only stopped less
than 6 weeks ago
OR
Mother HIV +ve,
child not yet tested
OR
Positive serological
test in a child less
than 18 months old
Yellow
HIV
EXPOSED
 Give cotrimoxazole
prophylaxis
 Start or continue ARV
prophylaxis as recommended.
 Do PCR test to confirm HIV
status.
 Assess the child’s feeding and
provide appropriate
counselling to the mother.
 Advise the mother on home
care
 Follow –up in 14 days or as
per immunization schedule

CLASSIFY HIV STATUS
• Negative
HIV test in
mother or
child
HIV
INFECTI
ON
UNLIKEL
Y
 Treat, counsel
and follow-up
existing
infections

THEN CHECK FOR TB INFECTION
Ask about features of TB infection
a. Persistent, no-remitting cough or wheeze for more
than 2 weeks
b. Documented loss of weight or unsatisfactory
weight gain during the passed 3 months (
especially if not responding to de-worming
together with food and or micronutrients
supplementation)
c. Fatigue/reduced playfulness
d. Fever everyday for 14 days
Look for features of TB infection: Do chest x-ray

CLASSIFY for TB INFECTION
Sign Classify
as
Identify treatment
• A close TB
contact
• 2 or more
features of Tb
chest x-ray
• X-ray suggesting
TB
Yellow
TB
INFECTIO
N
 Treat for TB as per National
TB Guidelines
 Register in TB register
 Notify
 Trace contacts and manage
according to TB guidelines
 Counsel and test for HIV if
status unkown.
 Follow-up monthly for
review

CLASSIFY for TB INFECTION
• A close TB
contact
and
• No features of
TB
TB EXPOSED  Treat with INH for 6
months
 Trace contacts
 Follow-up monthly.
• All other
children
POSSIBLE TB
INFECTION
 Perform Tuberculine
Skin Test (TST)
 Follow – up in 2 days to
read the test
 Follow guidelines as per
test results

THEN CHECK CHILD IMMUNIZATION,
VITMIN AAND DE-WORMING STATUS
AGE VACCINE
Birth BCG OPV -
0
VITAMIN A
SUPPLEMENTATION
Give every child a dose of vitamin
A every 6 months from age of 6
moths
Record dose on child’s chart
6 wks DPT, HepB-
Hib 1
OPV1 Rotavrus
- 1
PCV- 1
10 wks DPT, HepB-
Hib 2
OPV2 Rotavrus
- 2
PCV- 2
14 wks DPT, HepB-
Hib 3
OPV23 PCV- 3 ROUTINE WORM
TREATMENT
Give every child Albendazole
every 6 months from age of one
year. Record dose on child’s card
9
months
Measles 1st
dose
18
months
Measles 2nd
dose
Do not give OPV 0 to an infant who is more than 14 days of age

Assess, Classify and Treat the Sick
Young Infant Age 1 week up to 2
months
1/4/2024 111

Assess
• Assess:
 Ask the mother what the problem for the
infants is.
 Determine if this is an initial visit or a follow
up visit.
 If the follow up visit use the follow up
instructions
1/4/2024 112

• Assess for;
• Very severe disease
• local bacterial infection
1/4/2024 113

 If initial visit assess the young infant as follows
• ASK
• Is the infant having difficulty in breathing?
• If the infant had convulsions.
• Look listen and feel
• Count the breaths for one minute and repeat if
60 br/ min
• Look for severe chest in drawing
• Measure axillary temperature
• Look and listen for granting
• Look and feel for bulging of the fontannelle.
1/4/2024 114

Assess contd
• Check for pus draining from the ear
• Look at the umbilicus , is it red or draining
pus) does the redness extending to the skin
• Measure the axillary temperature or feel for
fever or low body temperature
• Look for skin pustules, are there many or
severe pustules?
• See if the young infant is lethargic or
unconscious
• Look at the young infants movements, are
1/4/2024 115

Classify
• If the following signs are present
 Convulsions or
 Fast breathing(60 b/m or more) or
 Severe chest indrawing or
 Nasal flaring
 Grunting
 Bulging fontanelle or
 Pus draining from the ear
 Umbilicus redness extending to the skin
 Fever( 37.5oc or above or feels hot) or low body
temperature less than 35.5oc feels cold or
1/4/2024 116

Classify contd
 Many or severe skin pustules.
 Lethargic or unconscious
 Less than normal movements
1/4/2024 117

Identity treatment
• Very severe disease chart booklet page 37
• Local bacterial infection chart booklet page
38
1/4/2024 119

Check for jaundice
• LOOK, ASK:
• Look for jaundice (yellow eyes or skin)
• If jaundice is present, did it appear within
24hrs of birth.
• THEN look at the young infant’s palms and
soles. Are they yellow?
1/4/2024 120

Classify and identify treatment
• Classify jaundice refer to chart booklet page
31
• Identify treatment refer to chart booklet page
31
1/4/2024 121

DIARRHOEA
(does the young infant have diarrhoea)
1/4/2024 122

assess
• If yes ask:
 For how long the infant has had diarrhea?
 Find out if there is blood in stool?
• Look and feel
 Look at the infant’s general condition. Is the
infant lethargic or unconscious?
 Does the infant move only when stimulated?
 Does the infant not move even when
stimulated?
1/4/2024 123

 Is the infant restless and irritable.
 Look for sunken eyes
 Pinch the skin of the abdomen. Does it go
back very slowly( longer than 2 seconds) ?
Or slowly?
1/4/2024 124

Check for HIV
Same procedure as discussed for child age
2 months up to 5 years
1/4/2024 126

Check for feeding problem or low weight
for age
1/4/2024 127

• Check for feeding problem (for the child who is
not HIV exposed)
• Ask
• Is the infant breastfed?
• If yes, how many times in 24hrs?
• Does the infant usually receive any other foods or
drinks? If yes, how often?
• If yes ,what do you use to feed the infant?
1/4/2024 128

• ASSESS BREASTFEEDING:
• Has the infant breastfed in the previous hour?
• If not, ask the mother to put her infant to the
breast. Observe the breastfeed for 4 minutes.
• (If was fed, ask the mother if she can wait and
tell you when the infant is willing to feed
again.)
• Is the infant able to attach well?
1/4/2024 129

• TO CHECK ATTACHMENT, LOOK FOR: -
 Chin touching breast
 Mouth wide open
 Lower lip turned outward
 More areola visible above than below the
mouth
• (All of these signs should be present if the
attachment is good).
1/4/2024 130

• Is the infant suckling effectively (that is, slow
deep sucks, sometimes pausing)?
• Not suckling effectively or Suckling effectively
• Clear a blocked nose if it interferes with
breastfeeding.
• Look for ulcers or white patches in the
mouth (thrush).
1/4/2024 131

• Check feeding problem for the infant HIV
exposed
• Refer to chart booklet on page 62
1/4/2024 133

IMMUNIZATION
Refer to chart booklet page 63
1/4/2024 134

• ASSESS OTHER PROBLEMS
1/4/2024 135

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