INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD
Assess, Classify and Identify Treatment
Check for General Danger Signs ................................................... 2 Then Ask About Main Symptoms: Does the child have cough? .................................................... 2 Does the child have diarrhoea? ............................................... 3 Check for throat problem ......................................................... 4 Does the child have an ear problem? ...................................... 4 Does the child have fever? ...................................................... 5 Classify malaria ................................................................. 5 Classify measles ............................................................... 5 Then Check for Malnutrition and Anaemia ..................................... 6 Then Check the Childs Immunization and Vitamin A supplementation Status .......................................... 6 Assess Other Problems ................................................................. 6

TREAT THE CHILD, continued

Treat convulsing child with Diazepam ..................................... 12 Treat Wheezing ....................................................................... 12 Prevent Low Blood Sugar ........................................................ 13

MOPH&P

WHO/CHD UNICEF HCMC/CDP

Give Extra Fluid for Diarrhoea and Continue Feeding

Plan A: Treat Diarrhoea at Home ............................................. 14 Plan B: Treat Some Dehydration with ORS ............................. 14 Plan C: Treat Severe Dehydration Quickly .............................. 15

SICK YOUNG INFANT AGE UP TO 2 MONTHS

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT Assess, Classify and Identify Treatment
Check for Possible Serious Bacterial Infection ........................ 24 Check for Significant jaundice...................................................24 Then ask: Does the young infant have diarrhoea? .................. 25 Then Check for Feeding Problem or Low Weight .................... 26 Then Check the Young Infants Immunization Status .............. 27 Assess Other Problems ........................................................... 27

Immunize Every Sick Child, As Needed ......................... 15 Give Follow-up Care

Pneumonia .............................................................................. 16 No Pneumonia- Wheeze ......................................................... 16 Dysentery ................................................................................ 16 Persistent Diarrhoea ................................................................ 16 Malaria ..................................................................................... 17 Fever-Malaria Unlikely ............................................................. 17 Ear Infection ............................................................................ 17 Measles with Eye or Mouth Complications .............................. 17 Measles ................................................................................... 18 Feeding Problem ..................................................................... 18 Pallor ....................................................................................... 18 Low Weight .............................................................................. 18

TREAT THE CHILD Teach the Mother to Give Oral Drugs at Home
Oral Antibiotic .......................................................................... 7 Paracetamol ............................................................................ 8 Vitamin A .................................................................................. 8 Iron .......................................................................................... 8 Mebendazole ........................................................................... 8 Oral Antimalarial ...................................................................... 8 Oral Salbutamol ....................................................................... 8

Treat the Young Infant and Counsel the Mother

Oral Antibiotic .......................................................................... 28 Intramuscular Antibiotics .......................................................... 28 To Treat Convulsing young infant see TREAT THE CHILD Chart ..... 29 To Treat Diarrhoea, See TREAT THE CHILD Chart ................ 29 Immunize Every Sick Young Infant .......................................... 29 Treat Local Infections at Home ................................................ 29 Correct Positioning and Attachment for Breastfeeding ............ 30 Express Breast Milk If Indicated .............................................. 30 Home Care for Young Infant .................................................... 30

COUNSEL THE MOTHER Food

Assess the Childs Feeding ..................................................... 19 Feeding Recommendations ..................................................... 20 Counsel About Feeding Problems ........................................... 21

Teach the Mother to Treat Local Infections at Home

Treat Eye Infection with Tetracycline Eye Ointment ................ 9 Dry the Ear by Wicking ............................................................ 9 Treat Mouth Ulcers with Gentian Violet ................................... 9 Soothe the Throat, Relieve the Cough with a Safe Remedy ................................................................. 9

Give Follow-up Care for the Sick Young Infant

Local Bacterial Infection .......................................................... 31 Bacterial Infection Unlikely ...................................................... 31 Feeding Problem ..................................................................... 32 Low Weight .............................................................................. 32 Thrush ..................................................................................... 32

Fluid
Increase Fluid During Illness ................................................... 22

When to Return
Advise the Mother When to Return to Health Worker .......................................................... 22

Give These Treatments in Clinic Only

Intramuscular Antibiotic ........................................................... 10 Intramuscular Benzathine Penicillin ......................................... 10 Intramuscular Chloroquine for severe Malaria ......................... 11 Intramuscular Quinine for severe Malaria ................................ 11

Counsel the Mother About Her Own Health ................................................................ 23

RECORDING FORMS SICK YOUNG INFANT ...................................................... 33 SICK CHILD ....................................................................... 35 WEIGHT FOR AGE CHART ......................... on back cover

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ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASSESS
ASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE

CLASSIFY

Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows:

IDENTIFY TREATMENT
CLASSIFY AS
VERY SEVERE DISEASE

CHECK FOR GENERAL DANGER SIGNS

ASK:

SIGNS
Any general danger sign.

TREATMENT Treat convulsions if present now. Give first dose of an appropriate antibiotic. Complete assessment immediately. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*.

(Urgent pre-referral treatments are in bold print.)

Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions?

LOOK:

See if the child is lethargic or unconscious. See if the child is convulsing now.

THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing? IF YES,ASK: LOOK AND LISTEN: Classify COUGH or DIFFICULT BREATHING

For how long?

Count the breaths in one minute. Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze

Any general danger sign OR Stridor in calm child OR Chest indrawing (If chest indrawing and wheeze go directly to "Treat Wheezing" then reassess after treatment.

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.*

CHILD MUST BE CALM

Fast breathing (If wheeze, go directly to Treat Wheezing then reasess after treatment. PNEUMONIA

Give an appropriate antibiotic for 5 days. Treat wheezing if present.

If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow up in 2 days.

If the child is:

2 months up to 12 months 12 months up to 5 years

Fast breathing is:

50 breaths per minute or more 40 breaths per minute or more

Treat wheezing if present.

No signs of pneumonia or very severe disease (If wheeze, go directly to Treat Wheezing . NO PNEUMONIA: COUGH OR COLD If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow up in 2 days if wheezing. Follow-up in 5 days if not improving

Does the child have diarrhoea?

Two of the following signs:

IF YES, ASK:
For how long? Is there blood in the stool?

LOOK AND FEEL:

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and 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?

If child has no other severe classification: - Give fluid for severe dehydration (Plan C). OR
SEVERE DEHYDRATION If child also has another severe classification:** Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera.

for DEHYDRATION

Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly. Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly.

Classify DIARRHOEA

SOME DEHYDRATION

Give fluid and food for some dehydration (Plan B). If child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Advise mother when to return immediately. Follow-up in 5 days if not improving. Give fluid and food to treat diarrhoea at home (Plan A). Advise mother when to return immediately. Follow-up in 5 days if not improving.

Not enough signs to classify as some or severe dehydration.

NO DEHYDRATION

and if diarrhoea 14 days or more

Dehydration present.

SEVERE PERSISTENT DIARRHOEA

Treat dehydration before referral unless the child has another severe classification. Refer to hospital. Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. Give multivitamin, mineral supplement. Advise mother when to return immediately. Follow-up in 5 days. Treat for 5 days with an oral antibiotic recommended for Shigella. Advise mother when to return immediately. Follow-up in 2 days.

No dehydration.

PERSISTENT DIARRHOEA

and if blood in stool

Blood in the stool. DYSENTERY

*If referral is not possible, manage the child as described in Management of Childhood Illness, Treat the Child, ** If the other severe classification is based ONLY on lethargy , or unconsionus , not able to drink or drinking poorly go to plan C Annex: Where Referral Is Not Possible, and WHO guidelines for inpatient care.

DANGER SIGNS, COUGH, DIARRHOEA ASSESS AND CLASSIFY

Check for throat problem (In All children )

ASK:
Does the child have fever? (by history or feels hot or temperature 37.5c or above) Does the child have sore thoat? LOOK AND FEEL: Feel for enlarged tender lymph node(s) in the front of the neck. Look for red (congested) throat Look for white or yellow exudate on the throat and tonsils Classify THROAT PROBLEM Fever OR Sore throat AND TWO of the following: Red (congested) throat White or yellow exudate on the throat or tonsils. Enlarged tender lymph node(s) in the front of the neck. Insufficient criteria to classify as streptococcal sore throat

STREPTOCOCCAL* SORE THROAT

Give benzathine penicillin intramuscular**. (one dose) or Phenoxy methyl penicillin (penicillin V) orally for 10 days.
Soothe the throat with a safe remedy. Give paracetamol for pain or fever. Advise mother when to return immediately. Follow up in 5 days if not improving. Soothe the throat with a safe remedy. Give paracetamol for pain or fever. Advise mother when to return immediately. Follow up in 5 days if not improving. No treatment needed.

NON STREPTOCOCCAL SORE THROAT

No throat signs or symptoms (with or without fever)

NO THROAT PROBLEM

Does the child have an ear problem?

IF YES, ASK:
Are there ear pulling and irritability ? Is there severe ear pain (for older children)? Is there ear discharge? If yes, for how long?

LOOK AND FEEL:

Look for pus draining from the ear. Feel for tender swelling behind the ear.

Classify EAR PROBLEM

Tender swelling behind the ear.

MASTOIDITIS

Give first dose of an appropriate antibiotic. Give first dose of paracetamol for pain. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.
Give an antibiotic for 10 days. Give paracetamol for pain. Dry the ear by wicking. Advise mother when to return immediately. Follow-up in 5 days. Dry the ear by wicking. Refer to ENT specialist. Advise mother to go to ENT specialist for assessment.

Pus is seen draining from the ear and discharge is reported for less than 14 days, OR Ear pulling and irritabitity or severe ear pain. Pus is seen draining from the ear and discharge is reported for 14 days or more. No ear pain and No pus seen draining from the ear.

ACUTE EAR INFECTION

CHRONIC EAR INFECTION NO EAR INFECTION

*STREPTOCOCCAL SORE THROAT is the most important bactarial infection that affecting the throat which lead to rheumatic heart disease and must be treat vigorously. **Give benzathine penicillin intramuscular after sensitivity test . If sensitivity test is positive give erythromycin orally for 10 days (SEE TREAT THE CHILD).

Does the child have fever?

(by history or feels hot or temperature 37.5 C * or above) HIGH MALARIA RISK LOOK AND FEEL:
Look or feel for stiff neck. Look for runny nose .

HIGH MALARIA RISK

Any general danger sign OR . Stiff neck . Fever (by history or feels hot or temperature 37.5c** or above). VERY SEVERE FEBRILE DISEASE
Give first dos ofchloroquine or Quinine intramuscularly ** Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Give one dose of paracetamol in clinic for fever (38C or above). Refer URGENTLY to hospital***
Give oral antimalarial . Give one dose of paracetamol in clinic for high fever(38 C*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 5 days, refer for assessment.

IF YES :
Decide Malaria Risk high or low

THEN ASK
For how long? If more than 5 days, has fever been present every day? Has the child had measles within the last 3 months?

MALARIA

Look for signs of MEASLES Generalized rash and One of these: cough, runny nose, or red eyes.

Classify FEVER LOW MALARIA RISK

LOW MALARIA RISK

Any general danger sign OR Stiff neck
Fever (by history or feels hot or temperature 37.5c*or above ). No Runny nose. No Measles . No apparent bacterial causes of fever (e.g.pneumonia,dysentery, acute ear infection, streptococcal sore throat..****

VERY SEVERE FEBRILE DISEASE

Give first dose ofchloroquine or Quinine intramuscularly ** Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Give one dose of paracetamol in clinic for fever (38 C or above). Refer URGENTLY to hospital*** Treat with oral antimalarial. Give paracetamol for fever (38 C 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 5 days, refer for assessment. Give one dose of paracetamol for fever (38 C or above). Treat apparent bacterial causes of fever Advise mother when to return immediately. Follow-up in 2 days if fever persists. If fever is present every day for more than 5 days, refer for assessment. Give Vitamin A (three doses), see oral drug at home Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Give one dose of paracetamol in clinic for fever(38 C or above). If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment. Refer URGENTLY to hospital. Give Vitamin A(three doses), see oral drug at home. Give paracetamol for fever (38 C or above). If pus draining from the eye, treat eye infection with tetracycline eye ointment for 7 days. If mouth ulcers, treat with gentian violet maximally for 5 days. Follow-up in 2 days. Advice the mother to feed the child. Give paracetamol for fever (38 c or above) . Give Vitamin A. Advice the mother to feed the child. Advice mother when to return immediately . Follow - up in 2 days , if fever not improved.

MALARIA

If the child has measles now or within the last 3 months:

Look for mouth ulcers. Are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea.

Runny nose or . Measles or . Other bacterial causes of fever . Any general danger sign OR Clouding of cornea OR. Deep or extensive mouth ulcers OR Measles now and pueumonia .

FEVER MALARIA UNLIKELY

if MEASLES now or within last 3 months, Classify

SEVERE COMPLICATED MEASLES*****

Pus draining from the eye OR Mouth ulcers.

MEASLES WITH EYE OR MOUTH COMPLICATIONS*****

None of the above signs .

MEASLES

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5 C higher. ** First dose of intramuscular chloroquine or Quinine ,must be given by medical Doctor, or well trained paramedical staff. *** If the referral to hospital is not possible, the course of antimalarial and the antibiotic should be continued as prescribed in treatment given in clinic only (chart booklet)

5 5

**** Other apparent becterial causes of fever include cellulitis, abscess, or boil. *****Other important complications of measles - stridor, diarrhoea, ear infection and malnutrition- are classified in other tables.

SORE THROAT / EAR PROBLEM / FEVER , MESALES

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LOOK AND FEEL:
Look for visible severe wasting. Look for oedema of both feet. Determine weight for age. Visible severe wasting or Oedema of both feet. Low weight for age. LOW WEIGHT SEVERE MALNUTRITION Give Vitamin A. Treat the child to prevent low blood sugar.. Refer URGENTLY to hospital. Assess the childs feeding and counsel the mother on
feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days. Advise mother when to return immediately. Follow-up in 30 days.

THEN CHECK FOR MALNUTRITION AND ANAEMIA

Classify NUTRITIONAL STATUS

LOOK :
Look for palmar pallor and mucous membrane pallor Is it: Severe palmar pallor and /or mucous membrane pallor? Some palmar pallor and /or mucous membrane pallor?

Not low weight for age and no other signs of malnutrition.

NOT LOW WEIGHT

If child is less than 2 years old, assess the childs feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days.

Classify ANEMIA

Severe palmar and /or mucous membrane pallor

SEVERE ANEMIA

Treat the child to prevent low blood sugar Refer URGENTLY to hospital Assess the childs feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. Give Iron for 14 days. Give Mebendazole if child is 2 years or/older and has not had adose in the previous 6 months . Advise mother when to return immediately. Follow-up in 14 days.
If child is aged from 6 - 30 months, give one dose of Iron weekly.

Some palmar and /or mucous membrane pallor

ANEMIA

No palmar and /or mucous membrane pallor

NO ANEMIA

AGE IMMUNIZATION SCHEDULE:

At birth At 6 weeks At 10 weeks At 14 weeks At 9 months At 18 months

VACCINE
BCG opv-0 OPV-1 DPT-1 HB-1 OPV-2 DPT-2 HB-2 OPV-3 DPT-3 Measles Vit A HB-3 OPV-4 DPT (booster dose)

VITAMIN A SUPPLEMENTATION SCHEDULE:

9 months IU)

: one dose of vitamin A (100,000

ASSESS OTHER PROBLEMS

TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART Give an Appropriate Oral Antibiotic
FOR PNEUMONIA (give for 5 days), OR ACUTE EAR INFECTION (give for 10 days):
FIRST-LINE ANTIBIOTIC: AMOXYCILLIN SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

AGE or WEIGHT
Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table.
2 months up to 12 months (4 - <10 kg) 12 months up to 5 years (10 - 19 kg)

AMOXYCILLIN
Give three times daily for 5 or 10 days

COTRIMOXAZOLE
(trimethoprim + sulphamethoxazole) Give two times daily for 5 or 10 days

SYRUP
250 mg per 5 ml 2.5 ml 5 ml

SYRUP
125 mg per 5 ml 5 ml 10 ml

SYRUP
40 mg trimethoprim +200 mg sulphamethoxazole per 5 ml 5.0 ml 7.5 ml

Determine the appropriate drugs and dosage for the childs age or weight. Tell the mother the reason for giving the drug to the child. Demonstrate how to measure a dose. Watch the mother practise measuring a dose by herself. Ask the mother to give the first dose to her child. Explain carefully how to give the drug, then label and package the drug. Explain that all the oral drug syrups must be used to finish the course of treatment, even if the child gets better. Check the mothers understanding before she leaves the clinic.

FOR DYSENTERY:
GIVE ANTIBIONTIC RECOMMENDED FOR SHIGELLA FOR 5 DAYS. COTRIMOXAZOLE FIRST - LINE ANTIBIOTIC FOR SHIGELLA : SECOND-LINE ANTIBIOTIC FOR SHIGELLA: NALIDIXIC ACID

COTRIMOXAZOLE SYRUP
AGE or WEIGHT
(trimethoprim + sulphamethoxazole ) Give two times daily for 5 days

NALIDIXIC ACID
Give four times daily for 5 days

SYRUP
40 mg trimethoprim + 200 mg sulphamethoxazole per 5 ml 2 months up to 4 months (4 - <6 kg)

SYRUP
150 mg/5 ml 2.5 ml 5.0 ml 7.5 ml

5.0 ml 5.0 ml 7.5 ml

Give phenoxymethyl penicillin Orally For Streptococcal Sore Throat (Give for 10 days)
Age or wieght
2 months up to 12 months (4-<10 kg) 12 months up to 5 years (10-19 kg)

4 months up to 12 months (6 - <10 kg) 12 months up to 5 years (10 - 19 kg)

Phenoxymethyl Penicillin (penicillin V) syrup 400.000 Units per 5 ml = 250 mg/5 ml Give 4 times daily for 10 days
2.5 ml 5.0 ml

FOR CHOLERA:
GIVE ANTIBIONTIC RECOMMENDED FOR CHOLERA FOR 5 DAYS. FIRST - LINE ANTIBIOTIC FOR CHOLERA: COTRIMOXAZOLE SECOND-LINE ANTIBIOTIC FOR CHOLERA: ERYTHROMYCIN

COTRIMOXAZOLE SYRUP
AGE or WEIGHT
(trimethoprim + sulphamethoxazole ) Give two times daily for 5 days

ERYTHROMYCIN
Give four times daily for 5 days

SYRUP
40 mg trimethoprim + 200 mg sulphamethoxazole per 5 ml 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg)

SYRUP
200 mg/5 ml 1.25 ml 2.5 ml 5 ml

5.0 ml 5.0 ml 7.5 ml

ANTIBIOTICS
MALNUTRITION and ANAEMIA IMMUNIZATION STATUS

12 months up to 5 years (10 - 19 kg)

TREAT

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table.

Give an Oral Antimalarial:

FIRST LINE ANTIMALARIAL : chloroquine SECOND LINE ANTIMALARIAL: sulfadoxinet + pyrimethamine l IF CHLOROQUINE : l Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine. if the child vomits within 30 minutes, she should repeat the dose and return to the clinic for additional tablets or syrup. l Explain that itching is a possible side effect of the drug, but is not dangerous. l IF SULFADOXINET + PYRIMETHAMINE : Give single dose in clinic .

Give Paracetamol for Fever ( 38C) or Throat Pain or Ear Pain.

Give paracetamol every 6 hours until fever or throat pain or ear pain is gone.

CHLOROQUINE give for 3 days AGE OR weight

TABLET (150 mg base) TABLET (100 mg base) SYRUP (50 mg base) per 5ml

SULFADOXINE PYRIMETHAMINE Give single dose in Clinic

PARACETAMOL
AGE or WEIGHT 2 months up to 12 months (4-<10 kg)
12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg)

DAY 1 2 months up to 12 months (4-< 10 kg ) 12 months up to 3 years (10-< 14 kg) 3 years up to 5 years (14 - 19 kg ) 1/2 1 1 1/2

DAY 2 1/2 1 1 1/2

DAY 3 1/2 1/2 1/2

DAY 1 DAY 2 1 1 1/2 2 1 1 1/2 2

DAY 3 1/2 1/2 1

TABLET (500 mg suifadoxine+ DAY 1 DAY 2 DAY 3 25 mg pyrimethamine) 7.5ml 7.5ml 5.0ml 15.0ml 15.0ml 5.0ml 1/2 1 1

SYRUP (120 mg / 5 ml) 5 ml 7.5 ml 10 ml

Give Vitamin A (for treatment)

l

Give Iron
For treatment of anaemia: give one dose daily for 14 days, then reassess. For Iron supplementation: give one dose per week.

l l

Give 3 doses Give first dose of vitamin A in the clinic. Give mother two doses more of vitamin (A) to give her child at home. The second dose on the next day and the third 14 days (or in one month).

after

AGE
200 000 IU Up to 6 months 6 months up to 12 months 12 months up to 5 years 1/2 capsule 1 capsule

VITAMIN A CAPSULES
100 000 IU 1/2 capsule 1 capsule 2 capsules 50 000 IU 1 capsule 2 capsules 4 capsules

AGE or WEIGHT
2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg)

IRON SYRUP
Iron syrup 30 mg/ 5 ml (6 mg elemental iron per ml)

2.5 ml 5 ml 7.5 ml 10 ml

Give Oral Salbutamol

Give Salbutamol syrup three times daily for 5 days. AGE or WEIGHT
2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg) SALBUTAMOL SYRUP (Salbutamol syrup = 2 mg / 5 ml) 1.0 ml 2 ml 2.5 ml 5 ml

Give Mebendazole
Give 500 mg mebendazole tablets as a single dose in clinic if :
hookworm/whipworm are a problem in children in your area , and the child is 2 years of age or older , and the child has not had a dose in the previous 6 months .

Give multivitamin/ mineral supplement For persistent diarrhea, give one dose 5 ml daily of multivitamin / mineral mixture for two weeks

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given. Describe the treatment steps listed in the appropriate box. Watch the mother as she does the first treatment in the clinic (except remedy for cough or sore throat). Tell her how often to do the treatment at home. If needed for treatment at home, give mother the tube of tetracycline ointment or a Small bottle of gentian violet. Check the mothers understanding before she leaves the clinic.
Dry the ear at least 3 times daily.
l l l l

Dry the Ear by Wicking

Roll clean absorbent cloth or soft, strong tissue paper into a wick. Place the wick in the childs ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry.

Treat Mouth Ulcers with Gentian Violet

Treat the mouth ulcers twice daily. Wash hands. Wash the childs mouth with clean soft cloth wrapped around the finger and wet with salt water. l Paint the mouth with half-strength gentian violet. l Wash hands again.
l l

Treat Eye Infection with Tetracycline Eye Ointment For 7 Days.

Clean both eyes 3 times daily. Wash hands. Ask child to close the eye. Use clean cloth and water to gently wipe away pus. Then apply tetracycline eye ointment in both eyes 3 times daily. Ask the child to look up. Squirt a small amount of ointment on the inside of the lower lid. Wash hands again. Treat until redness is gone. Do not use other eye ointments or drops, or put anything else in the eye.
l

Soothe the Throat, Relieve the Cough with a Safe Remedy

l

Safe remedies to recommend: - Breastmilk for exclusively breastfed infant. - Home made remedies e.g. tea with lemon and honey, anise, tileo, guava leaves decoctions, chicken soup. Harmful remedies to discourage: - Cough syrups containing: codeine, antihistamines, alcohol, atropine and expectorants. - Oil, ghee.

9
ORAL DRUGS LOCAL INFECTIONS

10

GIVE THESE TREATMENTS IN CLINIC ONLY

Explain to the mother why the drug is given. Determine the dose appropriate for the childs weight (or age). Use a sterile needle and sterile syringe. Measure the dose accurately. Give the drug as an intramuscular injection. If child cannot be referred, follow the instructions provided.

Give Intramuscular Benzathine Penicillin (single dose) For Streptococcal Sore Throat

Benzathine Penicillin **
Add 5 ml sterile water for vial containing 1.200.000 Unit/ml =6ml at 200.000 Unit/ml

Give An Intramuscular Antibiotic

FOR CHILDREN BEING REFERRED URGENTLY:
Give first dose of intramuscular chloramphenicol and refer child urgently to hospital.

< 5 years= 3.0 ml = 600.000 units single dose intramusculary

Note:*must be given by medical doctor or well trained paramedical staff. Note: **Skin sensitivity test must be done before every intramuscular injection. If the skin test is positive give erythromycin orally (see treat the child module).

IF REFERRAL IS NOT POSSIBLE:

Repeat the chloramphenicol injection every 12 hours for 5 days. Then change to an appropriate oral antibiotic to complete 10 days of treatment.

CHLORAMPHENICOL AGE or WEIGHT

Dose: 40 mg per kg Add 5.0 ml sterile water to vial containing 1000 mg = 5.6 ml at 180 mg/ml

2 months up to 4 months (4 - < 6 kg) 4 months up to 9 months (6 - < 8 kg) 9 months up to 12 months (8 - < 10 kg) 12 months up to 3 years (10 - < 14 kg) 3 years up to 5 years (14 - 19 kg)

1.0 ml = 180 mg 1.5 ml = 270 mg 2.0 ml = 360 mg 2.5 ml = 450 mg 3.5 ml = 630 mg

Give intramuscular chloroquine for Severe Malaria.

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRIL DISEASE:
- Use undiluted chloroquine for injection. - Use only chloroquine ampoules containing 200mg base in 5ml at 40mg base/ml. - Dose: 3.5 mg base per kg intramuscular. - Give first dose of intramuscular chloroquine then refer the child to the hospital.

Give intramuscular Quinine* for Severe Malaria

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE :

Check which quinine formulation is available in your clinic. Quinine should be diluted in normal saline to a concentration of 60- 100 mg salt/ml. Give first dose of intramuscular quinine and refer child urgently to hospital.

IF REFERRAL IS NOT POSSIBLE :

Quinine should be diluted in normal saline to a concentration of 60- 100 mg salt/ml. Give first dose of intramuscularly quinine. The child should remain lying down for one hour. Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able to take an oral antimalarial. Do not continue quinine injections for more than 1 week. If low risk of malaria, do not give quinine to a child less than 4 months of age.

IF REFERRAL IS NOT POSSIBLE

- Use undiluted chloroquine for injection. - Use only chloroquine ampoules containing 200 mg base in 5 ml at 40 mg base/ml. - Dose: 3.5mg base per kg intramuscular. - Give first dose of intramuscular chloroquine. - The child should remain lying down for one hour. - Repeat the chloroquine injection every 6 hours until the child is able to take oral antimalarial then complete the remaining of the total dose with oral chloroquine 5 mg base/kg/day to complete a3-days course of treatment. - The total dose is 25 mg base/kg.

AGE OR WEIGHT

INTRAMUSCULAR QUININE (dose :10 mg/kg)

150 mg/ml* (in 2 ml ampoules) Add the ampoule of quinine(150mg/ml) to 1 ml of normal saline to make a concentration 100 mg/ml 300 mg/ml* (in 2 ml ampoules) Add the ampoule of quinine(300 mg/ml) to 4 ml of normal saline to make a concentration 100 mg/ml

AGE OR WEIGHT

INRAMUSCULAR CHLOROQUINE
Total dose: 25mg base/kg Dose: 3.5mg base/kg Ampoule: containing 200mgbase in 5ml ate 40mg base pre ml

1 kg< 2 kg 2 kg< 3 kg 3 kg< 4 kg 4 kg< 5 kg 5 kg< 6 kg 4 month up to 9 months (6 -<8kg) 9 month up to 12 months (8 -<10kg) 12 month up to 3 years (10 -<14kg) 3 years up to 5 years (14 -<19kg)

0.1 ml 0.2 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml 0.9 ml 1.2 ml 1.6 ml

0.1 ml 0.2 ml 0.3 ml 0.4 ml 0.5 ml 0.7 ml 0.9 ml 1.2 ml 1.6 ml

1 kg 2 kg 3 kg 4 kg-5 kg 4 month up to 9 months (6 kg-<8kg) 9 month up to 12 months (8 kg-<10kg) 12 month up to 3 years (10 kg-<14kg) 3 years up to 5 years (14 kg-<19kg)

0.1 ml 0.2 ml 0.3 ml 0.4 ml 0.5-0.6 ml 0.7-0.8 ml 1 ml 1.2-1.7 ml

* Quinine salt

INTRAMUSCULARE ANTIBIOTIC, INTRAMUSCULARE BENZATHINE PENICILLIN, INTRAMUSCULARE CHLOROQUINE, INTRAMUSCULARE QUININE.

11

12

Treat a Convulsing Child With Diazepam Rectally

Manage the Airway
Turn the child on his or her side to avoid aspiration Do not insert anything in the mouth. If the lips and tongue are blue, open the mouth and make sure the airway is clear. If necessary, remove secretions from the throat through a catheter inserted through the nose.

Treat Wheezing
Children with wheeze and GENERAL DANGER SIGN OR STRIDOR Children with wheezing and NO GENERAL DANGER SIGN AND NO STRIDOR IF: - CHEST INDRAWING PERSISTS - FAST BREATHING ALONE

Give one dose of rapid acting

bronchodilator and refer immediately

Give rapid acting bronchodilator and

reassess the child 30 minutes later

Give Diazepam Rectally : use diazepam ampoules for injection .

Do not dilute diazepam ampoules containing 5 mg / ml. Draw up the needed dose of diazepam into small syringe. Then remove the needle. Attach a piece of nasogastric tubing to the syringe if possible. Insert 4 to 5 cm of the tube or the tip of the syringe into the rectum and inject the diazepam, then inject 1ml of water to flush the tube. Hold buttocks together for a few minutes.

Treat for SEVERE PNEUMONIA (Refer) Treat for PNEUMONIA

Give further dose of rapid acting bronchodilator Give oral salbutamol for 5 days

If High Fever, Lower the Fever

Sponge the child with room temperature water

Treat the child to prevent low blood sugar DIAZEPAM ampoule for injection 1ml =5 mg Dose = 0.2-0.5 mg/kg Give rectally
0.5 ml (2.5 mg) 0.75 ml (3.75 mg) 1.0 ml (5 mg) 1.5 ml(7.5 mg)

- NO FAST BREATHING

Treat for NO PNEUMONIA:

COUGH OR COLD. (Give oral salbutamol for 5 days).

AGE or WEIGHT

GIVE RAPID ACTING BRONCHODILATOR

Nebulized Salbutamol 5 mg/ml Metered Dose Inhaler (MDI) with spacer device (100 mcg/dose) 0.5ml Salbutamol plus 2.0ml normal saline

GIVE ORAL SALBUTAMOL Three times daily for 5 days AGE or WEIGHT
2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10-<14 kg) 3 years up to 5 years (14 - 19 kg)

1 month up to 4 months (3-<6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10-<14 kg) 3 years up to 5 years (14-19 kg)

2 mg / 5 ml syrup
1.0 ml 2 ml 2.5 ml 5 ml

2-3 puffs

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:
Ask the mother to breastfeed the child.

If the child is not able to breastfeed but is able to swallow:

Give expressed breastmilk or a breastmilk substitute. If neither of these is available, give sugar water. Give 30-50 ml of milk or sugar water before departure.

To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water. If the child is not able to swallow:
Give 50 ml of milk or sugar water by nasogastric tube.

13
CONVULSING CHILD,WHEEZING, LOW BLOOD SUGAR,

14

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home

Counsel the mother on the 3 Rules of Home Treatment: Give Extra Fluid, Continue Feeding, When to Return 1. GIVE EXTRA FLUID (as much as the child will take)
TELL THE MOTHER: - Breastfeed frequently and for longer at each feed. - If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk. - If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids such as vegetables soup, ( Potato, Pamya, kousa, carrot ) rice water, yoghurt drink, carrot juice, banana, or clean boiled water after cooling it. It is especially important to give ORS at home when: - the child has been treated with Plan B or Plan C during this visit. - the child cannot return to a clinic if the diarrhoea gets worse. TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER A BOX OF 3 PACKETS OF ORS (special for Yemen) TO USE AT HOME and each packet mix with cleaned water in the bottle measured 750 ml . SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother to: - Give frequent small sips from a cup. - If the child vomits, wait 10 minutes. Then continue, but more slowly. - Continue giving extra fluid until the diarrhoea stops. 2. CONTINUE FEEDING 3. WHEN TO RETURN

Plan B: Treat Some Dehydration with ORS

Give in clinic recommended amount of ORS over 4-hour period DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.
AGE* WEIGHT In ml Up to 4 months < 6 kg 200 - 400 4 months up to 12 months 6 - < 10 kg 400 - 700 12 months up to 2 years 10 - < 12 kg 700 - 900 2 years up to 5 years 12 - 19 kg 900 - 1400

*Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) times 75.

If the child wants more ORS than shown, give more. For infants under 6 months who are not breastfed, also give 100-200 ml clean boiled water after cooling it. Give frequent small sips from a cup or cup and spoon (one spoon every 1-2 minutes) , or dropper If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding whenever the child wants. Reassess the child and classify the child for dehydration. Select the appropriate plan to continue treatment. Begin feeding the child in clinic.

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

AFTER 4 HOURS:

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

Show her how to prepare ORS solution at home. Show her how much ORS to give to finish 4-hour treatment at home. Give her enough ORS packets to complete rehydration. Also give her a box of 3 packets of ORS as recommended in Plan A. Explain the 3 Rules of Home Treatment:

See COUNSEL THE MOTHER chart

1. GIVE EXTRA FLUID 2. CONTINUE FEEDING 3. WHEN TO RETURN

See Plan A for recommended fluids and See COUNSEL THE MOTHER chart

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS YES, GO ACROSS. IF NO, GO DOWN.
Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringers Lactate Solution (or, if not available, normal saline), divided as follows: AGE First give 30 ml/kg in: 1 hour* 30 minutes* Then give 70 ml/kg in: 5 hours 2 1/2 hours

START HERE Can you give intravenous (IV) fluid immediately?

YES

Infants (under 12 months) Children (12 months up to 5 years)

* Repeat once if radial pulse is still very weak or not detectable. Reassess the child every 1- 2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip. Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours: - If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. - If hydration status is not improving after 3 hours, send the child for IV therapy. After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.

NO

Is IV treatment available nearby (within 30 minutes)?

YES

NO

Are you trained to use a naso-gastric (NG) tube for rehydration? NO Can the child drink? NO Refer URGENTLY to hospital for IV or NG treatment YES

NOTE: If possible, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.

IMMUNIZE EVERY SICK CHILD, AS NEEDED

15
PLAN A, PLAN B PLAN C

16

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart. PNEUMONIA After 2 days:
Check the child for general danger signs. Assess the child for cough or difficult breathing.

NO PNEUMONIA- WHEEZE After 2 days

Check the child for general danger signs. Assess the child for cough or difficult breathing.

Treatment: If any danger sign or stridor or chest indrawingTreat as SEVERE PNEUMONIA OR See ASSESS & VERY SEVERE DISEASE, give one dose of preCLASSIFY chart referral intramuscular antibiotic. Give one dose of rapid acting bronchodilator and refer URGENTLY to hospital.

Ask:
Is the child breathing slower? Is there less fever? Is the child eating better? Is the child still wheezing?

See ASSESS & CLASSIFY chart

If fast breathing-treat as PNEUMONIA, also give oral salbutamol. If child is wheezing but has no general danger signs, fast breathing or chest indrawing: - If this is the first episode of wheezing or if the child has previous episodes but has not been referred. continue salbutamol and refer for assessment. - If the child has already been referred for a pervious episode of wheezing advise the mother to continue with treatment prescribed by the referral hospital. Advise the mother to return if the childs breathing becomes more difficult. If this child returns because condition has worsened, refer URGENTLY to hospital for further treatment. If no wheezing- complete 5 days of oral salbutamol.

Treatment:
If child has a general danger sign or stridor or chest indrawing or has fast breathing and wheeze, give a dose of pre-referral intramuscular antibiotic. If wheezing also give dose of rapid acting bronchodilator. Then refer URGENTLY to hospital. If child is not wheezing but breathing rate, fever and eating are the same. Change to the second line antibiotic and advise the mother to return in 2 days or refer.(If this child had measles in the last three months,refer). If breathing slower, less fever, or eating better, complete the 5 days of antibiotic. If child is wheezing,also treat as below. If child is wheezing but has no general danger signs, fast breathing or chest indrawing: - If this is the first episode of wheezing or if the child has had previous episodes but has not been referred, continue salbutamol and refer for assessment. - If the child has had at least one episode of wheezing before this and has already been referred for assessment, advise mother to continue with treatment prescribed by the referralhospital.Advisethe mother to return if the childs breathing becomes more difficult.If this child returns because condition has worsened, refer for further treatment.

DYSENTERY After 2 days:

Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart.

Ask:
-Are there fewer stools? -Is there less fever? -Is the child eating better? -Is there less blood in the stool? -Is there less abdominal pain?

Treatment: PERSISTENT DIARRHOEA After 5 days: Ask:

-Has the diarrhoea stopped? -How many loose stools is the child having per day? If the child is dehydrated, treat dehydration. If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same or worse: Change to second-line oral antibiotic recommended for Shigella. Give it for 5 days. Advise the mother to return in 2 days. Exceptions - if the child: - is less than 12 months old, or Refer to - was dehydrated on the first visit, or hospital - had measles within the last 3 months

Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to hospital. If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the childs age. Tell the mother to continue giving the child the multivitamin mineral supplement.

If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving the same antibiotic until finished.

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

EAR INFECTION
After 5 days:
Reassess for ear problem. > See ASSESS & CLASSIFY chart. Measure the childs temperature.

Treatment:

MALARIA (Low or High Malaria Risk)

if fever persists after 2 days, or returns within 14 days: Do a full reassessment of the child. > see ASSESS & CLASSIFY chart. Assess for other causes of fever.

If there is tender swelling behind the ear or high fever (38.5C or above), refer URGENTLY to hospital. Acute ear infection: if ear pulling and irritability or severe ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up once again in 5 days. If ear pain or discharge persists refer. If no ear pain or discharge, praise the mother for her careful treatment. Ask the mother to continue the same antibiotic for other 5 days. If discharge, for 14 days or more, refer to ENT specialist for assessment .

Treatment:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If the child has any cause of fever other than malaria, provide treatment. If malaria is the only apparent cause of fever: -Treat with the second-line oral antimalarial. (If no second-line antimalarial available refer to hospital.) Advise the mother to return again in 2 days if the fever persists. -If fever has been present for 5 days, refer for assessment.

MEASLES WITH EYE OR MOUTH COMPLICATIONS

After 2 days:
Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth.

FEVER - MALARIA UNLIKELY (Low Malaria Risk)

If fever persists after 2 days: Do a full reassessment of the child.> See ASSESS & CLASSIFY chart. Assess for other causes of fever.

Treatment for Eye Infection:

If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct treatment. If the pus is gone but redness remains, continue the treatment. If no pus or redness, stop the treatment. Ask the mother, if the child has given vitamin (A) see treat the child. Treatment for Mouth Ulcers: If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days. Ask the mother, if the child has given vitamin (A) see treat the child.

Treatment:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If the child has any cause of fever other than malaria, provide treatment . If malaria is the only apparent cause of fever: -Treat with the first-line oral antimalarial.(If the first-line antimalarial is not available give second line ) Advise the mother to return again in 2 days if the fever persists. -If fever has been present for more than 5 days, refer for assessment.

PNEUMONIA, PERSISTENT DIARRHOEA , NO PNEUMONIA-WHEEZE, DYSENTERY, Malaria, FEVER, EAR INFECTION,,MEASLES

17

FOLLOW-UP

18

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

MEASLES
After 2 days:
Do a full reassessment of the child > see ASSESS & CLASSIFY chart.

LOW WEIGHT
After 30 days:
Weigh the child and determine if the child is still low weight for age. Reassess feeding. > See questions at the top of the COUNSEL chart.

Treatment:
If general danger sign or clouding of the cornea or deep extensive mouth ulcers or pneumonia, treat as SEVERE COMPLICATED MEASLES. If pus draining from the eye or mouth uclers,treat as MEASLES WITH EYE OR MOUTH COMPLICATIONS. If none of the above signs, advise the mother when to return immediately. Follow up in two days if not improving. * If the child received already the dose of vitamin A in the previous visit, do not repeat.

Treatment:
If the child is no longer low weight for age, praise the mother and encourage her to continue. If the child is still low weight for age, counsel the mother about any feeding problem found. Ask the mother to return again in one month. Continue to see the Child monthly until the child is feeding well and gaining weight regularly or is no longer low weight for age. Exception: If you do not think that feeding will improve, or if the child has lost weight, refer the child.

FEEDING PROBLEM
After 5 days:
Reassess feeding. > See questions at the top of the COUNSEL chart. Ask about any feeding problems found on the initial visit. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the child back again. If the child is low weight for age, ask the mother to return 30 days after the initial visit to measure the childs weight gain.

Anemia
After 14 days:
Give iron. Advise mother to return in 14 days for more iron. Continue giving iron daily for 2 months. If the child has palmar pallor and / or mucous membrane pallor after 2 months, refer for assessment.

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER OF THE NEXT FOLLOW-UP VISIT.

ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY. (SEE COUNSEL CHART.)

COUNSEL THE MOTHER

FOOD

Assess the Childs Feeding

Ask questions about the childs usual feeding and feeding during this illness. Compare the mothers answers to the Feeding Recommendations for the childs age in the box below.

ASK-

Do you breastfeed your child? - How many times during the day? - Do you also breastfeed during the night? Does the child take any other food or fluids? - What food or fluids? - How many times per day? - What do you use to feed the child? - If low weight for age: How large are servings? Does the child receive his own serving? Who feeds the child and how? During this illness, has the childs feeding changed? If yes, how?

19 19 FEEDING ASSESS
MEASLES, FEEDING PROBLEM PALLOR, LOW WEIGHT

COUNSEL

20

Feeding Recommendations During Sickness and Health

Since birth up to 6 Months of Age 6 Months up to 12 Months 12 Months up to 2 Years 2 Years and Older

Start breastfeeding through the first half hour after birth. Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Do not give other foods or fluids, or water. Breast milk can be expressed with high hygienic care (in the absence of mothers ) Only if the child is 4 months of age and is not gaining weight adequately : - Add complementary foods (listed under 6 months up to 12 months ) - Give these foods 1 or 2 times per day after breast feeding in small amounts gradually.

Breastfeed as often as the child wants. Give adequate semi solid servings of:- shebisa ( Boar , Dokhn , Dora+ Fasolia Adass, few drops of oil+ some milk) - Asidah (Boar+ Lahma) - Harisa Boar +Milk or hakin) - Khodar(Patata , Gozar , Tamatem , kusa , Duba ) and Rice . - Small amount of Dijaj or Laham or Samak or kibdah boiled egg and Jobnah. - Zabadi or hakin and khubz. - Natural fresh Seasonal Fruits Juice (Orange, Banana, Babay, Mango, lemon, Jawafa ). Give these foods: - 3 times per day if breastfed - 5 times per day if not breastfed

Breastfeed as often as the child wants. Give adequate solid servings of:- shebisa or Asidah . - Harisa (Boar + laham) - Khodar and Rice. - Small amount of Dijaj or Laham or Samak or kibdah and boiled egg. - Zabadi or jobnah or hakin and khubz - Natural fresh Seasonal Fruits or family foods 5 times per day, without spices. with continuing the breast feeding .

Give family foods at 3 meals each day. Also, twice daily, give nutritious food between meals, such as: -Fresh milk or Hakin, Khubz, Zabadi, Jobnah -Natural fresh seasonal fruites.

Avoid to give tea, sweets and shopping foods. Do not use bottle or teats. Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA
If still breastfeeding, give more frequent breastfeeds, day and night. If taking other milk: replace with increased breastfeeding OR replace with fermented milk products, such as yoghurt OR replace half the milk with nutrient-rich semisolid food as rice, beans and vegetable soup. give milk not more than 50 ml/kg. give frequent small meals at least 6 times a day. For other foods, follow feeding recommendations for the childs age.

Counsel the Mother About Feeding Problems

If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.) As needed, show the mother correct positioning and attachment for breastfeeding. If the child is less than 4 months old and is taking other milk or foods: or If the mother thinks she does not have enough milk - Assess breastfeeding: - Build mothers confidence that she can produce all the breastmilk that the child needs (proper weight gain). - Suggest giving more frequent, longer breastfeeds day and night, and gradually reducing other milk or foods. If other milk needs to be continued, counsel the mother to: - Breastfeed as much as possible, including at night. - Make sure that other milk is a locally appropriate breastmilk substitute. - Make sure other milk is correctly and hygienically prepared and given in adequate amounts. - Finish prepared milk within an hour. If the mother is using a bottle to feed the child: - Recommend substituting a cup for bottle. - Show the mother how to feed the child with a cup. If the child is not being fed actively, counsel the mother to: - Sit with the child and encourage eating. - Give the child an adequate serving in a separate plate or bowl.

If the child is not feeding well during illness, counsel the mother to:
Breastfeed more frequently and for longer if possible. Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feedings. Clear a blocked nose if it interferes with feeding. Expect that appetite will improve as child gets better. Express breast milk if necessary, under good hygienic conditions, and keep it in cold place.

Follow-up any feeding problem in 5 days. Advise the mother to expose her child to sunlight for prevention of rickets.

21
FEEDING RECOMMENDATIONS FEEDING PROBLEMS

22

FLUID
Advise the Mother to Increase Fluid During Illness
FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. Increase fluid. For example, give soup, rice water, yoghurt drinks,belila water, home fluids or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

WHEN TO RETURN
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT Advise the mother to come for follow-up at the earliest time listed for the childs problems. If the child has:
PNEUMONIA NO PNEUMONIA- WHEEZE DYSENTERY MALARIA, fever persists MALARIA UNLIKLEY, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS MEASLES, if not improving

Return for follow-up in:

2 days

WHEN TO RETURN IMMEDIATELY Advise mother to return immediately if the child has any of these signs:
5 days

PERSISTENT DIARRHOEA ACUTE EAR INFECTION FEEDING PROBLEM ANY OTHER ILLNESS, if not improving Pallor LOW WEIGHT FOR AGE

Any sick child

14 days 30 days

Not able to drink or breastfeed Becomes sicker Develops a fever Fast breathing Difficult breathing Blood in stool Drinking poorly

If child has NO PNEUMONIA: COUGH OR COLD, also return if: If child has Diarrhoea, also return if:

NEXT WELL-CHILD VISIT Advise mother when to return for next immunization according to immunization schedule. Advise the mother to give the child (from 6 to 30 months) the weekly dose of iron after recovery.

Counsel the Mother About Her Own Health

If the mother is sick, provide care for her, or refer her for help. If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help. Advise her to eat well to keep up her own strength and health, and to avoid too much spices, tea or coffee. Check the mothers immunization status and give her tetanus toxoid if needed. Check the mothers supplementation with iron and vitamin A according to the national policy. Make sure she has access to: - Family planning - Counselling on reproductive health problems. Advise mother to use iodized salt for the family foods instead of the ordinary salt. Advise mother to avoid bad habits such as kat and smoking. (shisha or madah)

23
FLUID WHEN TO RETURN MOTHERS HEALTH

24

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT AGE UP TO 2 MONTHS
ASSESS
ASK THE MOTHER WHAT THE YOUNG INFANTS PROBLEMS ARE
Determine if this is an initial or follow-up visit for this problem. - if follow-up visit, use the follow-up instructions on the bottom of this chart. - if initial visit, assess the young infant as follows:

CLASSIFY

IDENTIFY TREATMENT

SIGNS

CLASSIFY AS

TREATMENT
(Urgent pre-referral treatments are in bold print)

CHECK FOR POSSIBLE SRIOUS BACTERIAL INFECTION

ASK:
Has the infant had convulsions? Is the young infant not able to feed? Dose the young infant vomit every thing?

LOOK, LISTEN, FEEL:

See if the infant is convulsing now. Count the breaths in one minute. Repeat the count if elevated. YOUNG Look for severe chest indrawing. INFANT Look for nasal flaring. MUST BE Look and listen for grunting. CALM Look and listen for wheeze. Look and feel for bulging fontanelle. Look for pus draining from the ear. Look for pus draining from the eyes. Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin? Measure 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 they less than normal?

Classify ALL YOUNG INFANTS

Convulsions OR. Not able to feed OR Vomit every thing OR Fast breathing (60 breaths perminute or more) OR Severe chest indrawing OR Nasal flaring OR Grunting OR Wheeze OR Bulging fontanelle OR Pus draining from ear OR Umbilical redness extending to skin OR Fever(37.5C* or above or feels hot)or low body temperature(less than 35.5C* or feels cold)OR Many or severe skin pustules OR Lethargic or unconscious OR Less than normal movement .

Treat current convulsion with recta diazepam. Give first dose of intramuscular antibiotics.

POSSIBLE SERIOUS BACTERAIL INFECTION

Treat to prevent low blood sugar. if vomiting every thing, give nothing by mouth Advise mother how to keep the infant warm on the way to the hospital. Refer URGENTLY to hospital.**

Red umbilicus or draining pus OR Skin pustulesOR Pus draining from the eyes.

LOCAL BACTERIAL INFECTION

Give an appropriate oral antibiotic. Teach mother to treat local infections at home. Advise mother to give home care for the young infant. Follow-up in 2 days. Advise mother to give home care for the young infant. Follow-up in 2 days.

None of the above signs

BACTERAIL INFECTION UNLIKELY

CHECK FOR SIGNIFICANT JAUNDICE

ASK:
when did the jaundice start?

LOOK::
At the palms and soles. Are they JAUNDICED?

If JAUNDICE

Jaundice extending to palms or soles OR Jaundice starting on first day of life OR Jaundice still present after 14 days of age.

SIGNIFICANT JAUNDICE

Encourage breastfeeding If breastfeeding poorly, provide extra fluid by cup and spoon Refer URGENTLY to hospital

THEN ASK: Does the young infant have diarrhoea?

IF YES, ASK:
For how long? Is there blood in the stool?

Two of the following signs:

Lethargic or unconscious Sunken eyes Skin pinch goes back very slowly. SEVERE DEHYDRATION

LOOK AND FEEL:

Look at the young infants general condition. Is the infant: Lethargic or 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?

for DEHYDRATION

If infant does not have SEVERE CLASSIFICATION: -Give fluid for severe dehydration (Plan C). OR If infant also has SEVERE CLASSIFICATION: -Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise mother to continue breastfeeding.
Give fluid and food for some dehydration (Plan B). If infant also has SEVERE CLASSIFICATION: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. - Advise mother to continue breasfeeding. Give fluids to treat diarrhoea at home (Plan A).

Classify DIARRHOEA

Two of the following signs:

Restless, irritable Sunken eyes Skin pinch goes back slowly. Not enough signs to classify as some or severe dehydration. Diarrhoea lasting 14 days or more. SOME DEHYDRATION

NO DEHYDRATION

and if diarrhoea 14 days or more

SEVERE PERSISTENT DIARRHOEA

If the young infant is dehydrated, treat dehydration before referral unless the infant has also SEVERE CLASSIFICATION: Refer to hospital. Treat to prevent low blood sugar. Advise mother how to keep the infant warm on the way to the hospital. Refer URGENTLY to hospital.

Blood in the stool.

and if blood in stool

Blood in the stool.

These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher.

** If referral is not possible, see Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral Is Not Possible."

25 25
BACTERIAL INFECTION DIARRHOEA ASSESS AND CLASSIFY

26

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT:

ASK:
Is there any difficulty feeding? Is the infant breastfed? If yes, how many times in 24 hours? Is the infant breastfed during night? Does the infant usually receive any other foods or drinks? If yes, how often? What do you use to feed the infant?

LOOK, LISTEN,FEEL:
Determine weight for age. In newborn: determine birth weight

Classify FEEDING

Not able to feed or No attachment at all or Not suckling at all or Premature (Preterm) and not able to suck

NOT ABLE TO FEED - POSSIBLE SERIOUS BACTERIAL INFECTION

Give first dose of intramuscular antibiotics. Treat to prevent low blood sugar. Advise the mother how to keep the young infant warm on the way to the hospital. Refer URGENTLY to hospital. Teach the mother to correct positioning and attachment Follow up in 2 days
Advise the mother to breastfeed as often and for as long as the infant wants, day and night. Advise the mother to breastfeed at night . Follow up in 2 days

IF AN INFANT: Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, or low birth weight (2500 grams or less) Is in the first week of life AND Has no indications to refer urgently to hospital: ASSESS BREASTFEEDING: Has the infant If the infant has not fed in the previous hour, ask the mother to put her infant to breastfed in the the breast. Observe the breastfeed for 4 minutes. previous hour? (If the infant was fed during the last hour, ask the mother if she can wait and tell
you when the infant is willing to feed again.)

Poor positioning or Not well attached to breast or Not suckling effectively . Less than 8 breast feeds in 24 hours or No breast feeding at night . Not breast feeding at all. Receives other foods or drinks FEEDING PROBLEM OR LOW WEIGHT

Is the infant position correct? poor positioning

good positioning

TO CHECK POSITIONING , LOOK FOR:

- Infants neck is straight or bent slightly back, - Infants body is turned towards the mother, - Infantss body is close to mothers body, and - Infantss whole body supported. (If all of these signs are present, the infants positioning is good) IS the infant able to attach? no attachment at all not well attached

If receives other foods or drinks Refer for breastfeeding counselling and possible relactation. Follow up in 2 days . If not breastfeeding at all: Advise the mother about correctly preparing Breast milk substitutes and using a cup and a spoon . Advise the mother to breastfeed as often and for as long as the infant wants, day and night. Advise the mother to give home care for the young infant . Follow-up low weight for age in 14 days. Teach the mother to treat thrush at home. Follow up in 2 days .

Low weight for age .

good attachment Thrush (ulcers or white patches in mouth). Not low weight for age and no other signs of inadequate feeding. NO FEEDING PROBLEM

TO CHECK ATTACHMENT, LOOK FOR:

- Chin touching breast - Mouth wide open - Lower lip turned outward - More areola visible above than below the mouth (If all of these signs are present, the attachment is good.)
Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding. Look for ulcers or white patches in the mouth (thrush).

Advise mother to give home care for the young infant. Praise the mother for feeding the infant well.

THEN CHECK THE YOUNG INFANTS IMMUNIZATION

AGE VACCINE
BCG DPT-1 OPV-0 OPV-1

IMMUNIZATION SCHEDULE:

Birth 6 weeks

HBV-1

ASSESS OTHER PROBLEMS

27 27
FEEDING PROBLEM

28

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give an Appropriate Oral Antibiotic
For local bacterial infection:
First-line antibiotic : Second-line antibiotic: AMOXYCILLIN COTRIMOXAZOLE

AMOXYCILLIN
Give three times daily for 5 days

COTRIMOXAZOLE
(trimethoprim + sulphamethoxazole) Give two times daily for 5 days

AGE or WEIGHT

Syrup 125 mg in 5 ml

Syrup 250 mg in 5 ml

Syrup (40 mg trimethoprim +200 mg sulphamethoxazole) 1.25 ml

Birth up to 1 month (< 3 kg) 1 month up to 2 months (3-4 kg)

1.25 ml 2.5 ml 1.25 ml

2.5 ml

* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.

Give First Dose of Intramuscular Antibiotics

Give first dose of both ampicillin and gentamicin Intramuscularly . WEIGHT GENTAMICIN* Dose: 2.5 mg per kg /dose Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml 0.25 ml 0.50 ml 0.75 ml 1.00 ml 1.25 ml AMPICILLIN Dose: 50 mg / kg / dose To a vial of 250 mg (add 2 ml of sterile water 1 ml = 125 mg 0.4 ml 0.8 ml 1.2 ml 1.6 ml 2.0 ml

1 kg 2 kg 3 kg 4 kg 5 kg

Referral is the best option for a young infant classified with POSSIBLE SERIOUS BACTERAL INFECTION. If referral is not possible, give ampicillin and gentamicin intramuscularly every 8 hours for at least 5 days. *Avoid using undiluted 40 mg /ml gentamicin vials .

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

To Treat Convulsing Young Infant, See TREAT THE CHILD Chart.

To Treat Diarrhoea, See TREAT THE CHILD Chart.

Immunize Every Sick Young Infant, as Needed.

Teach the Mother to Treat Local Infections at Home

Explain how the treatment is given. Watch her as she does the first treatment in the clinic . The her to do the treatment twice daily . she should return to the clinic if the infection worsens.

To Treat Skin Pustules or Umbilical Infection

The mother should: Wash hands before applied treatment Gently wash off pus and crusts with soap and water Dry the area Paint with gentian violet Wash hands after applied treatment

To Treat Thrush (ulcers or white patches in mouth)

The mother should: Wash hands before applied treatment Wash mouth with clean soft cloth wrapped around the finger and wet with salt water Paint the mouth with half-strength gentian violet Wash hands after applied treatment

To Treat Eye Infection:

The mother should do the following 6-8 times daily: Wash her hands before applied treatment Wet clean cloth with water Use clean water and cloth to gently remove pus from the infants eyes Wash her hands after applied treatment Apply tetracycline eye ointment in both eyes 4times daily for 5days.

29 29
ANTIBIOTICS LOCAL INFECTIONS TREAT AND COUNSEL

30

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding
Show the mother how to hold her infant - make sure that the mother is in comfortable position, - with the infants neck straight or bent slightly back, - with infants body close to her body, - with infants body turned towards her, and - infants whole body is supported, not just neck and shoulders. Show her how to help the infant to attach. She should: - touch her infants lips with her nipple - wait until her infants mouth is opening wide - move her infant quickly in to her breast, aiming the infants lower lip well below the nipple. Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Advise Mother to Give Home Care for the Young Infant

FOOD

FLUIDS

- Breastfeeding (exclusive) frequently, as often and for as long as the infant wants, day or night, during sickness and health. - Do not use bottle at all.

WHEN TO RETURN
Follow-up Visit If the infant has:
LOCAL BACTERIAL INFECTION BACTERIAL INFECTION UNLIKELY ANY FEEDING PROBLEM THRUSH LOW WEIGHT FOR AGE

When to Return Immediately: Return for follow-up in:

2 days Advise the mother to return immediately if the young infant has any of these signs: Breastfeeding or drinking poorly Becomes sicker Develops a fever Fast breathing Difficult breathing Blood in stool

14 days

Teach The Mother To Express Breast Milk If Indicated

Infant - mother separation e.g. - admitted infant to NICU or sick infant - sick or working mother - mother travelling away from home Breast engorgement

MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.

In cool weather, cover the infants head and feet and dress the infant with extra clothing.

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

LOCAL BACTERIAL INFECTION
After 2 days: Look at the umbilicus. Is it red or draining pus? Does redness extend to the skin? Look at the skin pustules. Are there many or severe pustules? Look for pus draining from the eye(s). Treatment: If pus or redness remains or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home. If pus is still draining from the eye(s), treat with oral antibiotic for 14 days. If discharge has improved, reassure the mother. Tell her to continue to gently clean the infants eye until there is no pus at all.

BACTERIAL INFECTION UNLIKELY

After 2 days: Reassess the young infant for serious bacterial infection see Check for Possible serious bacterial infection above. Treatment: If signs of possible serious bacterial infection refer to hospital. If signs of local bacterial infection, treat accordingly. If still not improving, continue to give home care. If improving , praise the mother for caring the infant well.

31 31
BREASTFEEDING HOME CARE LOCAL INFECTIONS BACTERIAL INFECTION UNLIKELY FOLLOW-UP

32

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See Then Check for Feeding Problem or Low Weight above. Ask about any feeding problems found on the initial visit. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the young infant back again. If the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young infants weight gain. Exception: If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

LOW WEIGHT
After 14 days:
Weigh the young infant and determine if the infant is still low weight for age. Reassess feeding. > See Then Check for Feeding Problem or Low Weight above. If the infant is no longer low weight for age, praise the mother and encourage her to continue. If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within a month or when she returns for immunization. If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she returns for immunization, if this is within 2 weeks). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age. Exception: If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush). Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above. If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital. If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.

MANAGEMENT OF THE SICK CHILD AGE up to 2 MONTHS Name:___________________________Age:________Weight:_____kg Temperature:_____C Initial visit?______ Follow-up Visit?_____ ASK: What are the infants problems?_________________________________________________________________________________

ASSESS (Circle all signs present)

CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION
.has the infant had convulsions? .Is the young infant not able to feed? .Does the young infant vomit every thing? .Is the young infant convulsing now? .Count the breaths in one minute. _____ breaths per minute Repeat if elevated ________ Fast breathing? .Look for severe chest indrawing. .Look for nasal flaring . .Look and listen for grunting. .Look and listen for wheeze. .Look and feel for bulging fontanelle .Look for pus draining from the ear. .Look for pus draining from the eyes. .Look at umbilicus. Is it red or draining pus? Does the redness extend to the skin? look at young infant movment Are they less than normal .Fever (temperature 37.5C or feels hot) or low body temperature (below 35.5C or feels cool). .Look for skin pustules. Are there many or severe pustules? .See if young infant is lethargic or unconscious.

CLASSIFY

CHECK FOR SIGNIFICANT JAUNDICE

When did the jaundice start ? ____ day .Look at the palms and soles . Ary they JAUNDICED? Yes ___ No ___

Yes ____ No ___

DOES THE YOUNG INFANT HAVE DIARRHOEA?

.For how long? _______ Days .Is there blood in the stools? Look at the young infants general condition. Is the infant: Lethargic or 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?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

.Is there any difficulty feeding? Yes _____ No _______ .Is the infant breastfed? Yes _____ No ______ If Yes, how many times in 24 hours? _____ times if Yes, is the infant breastfed by night? .Does the infant usually receive any other foods or drinks? Yes _____ No _____ If Yes, how often?___________________________________ .What do you use to feed the child?_________________________ _____________________________________________________ Determine weight for age. Low ___ Not Low _______

If the infant has? any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age or low birth weight (2500 gram or less) , or is in the first week of life AND has NO indications to refer urgently to hospital: ASSESS BREAST FEEDING

ASSESS BREASTFEEDING:
If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. .Is the infant position correct? To check positioning,look for: -Infants neck straight or bent slightly back Yes ___ No ___ -Infants body turned towards mother Yes ___ No ___ -Infants body close to mothers body Yes ___ No ___ -Infants whole body supported Yes ___ No ___ poor positioning .Is the infant able to attach? To check attachment, look for: -Chin touching breast Yes ___ No ___ -Mouth wide open Yes ___ No ___ -Lower lip turned outward Yes ___ No ___ -More areola above than below the mouth Yes ___ No ___ no attachment at all not well attached good attachment good positioning

.Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling at all not suckling effectively suckling effectively look for ulcurs or white patches in the mouth (thrush).

CHECK THE YOUNG INFANTS IMMUNIZATION STATUS Circle immunizations needed today. BCG Opv -0 OPV-1 DPT-1 HB-1

Return for next immunization on: ______________ (Date)

ASSESS OTHER PROBLEMS

33 33

RECORDING FORM

TREAT

34

Return for follow-up in : Advice mother when to return immediately. Give any immunization needed today: Feeding advice:

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS up to 5 YEARS Name:___________________________Age:________Weight:_____kg Temperature:_____C Initial visit?______ Follow-up Visit?_____ ASK: What are the infants problems?_________________________________________________________________________________ ASSESS (Circle all signs present ) DOES THE CHILD HAVE ANY GENERAL DANGER SIGN?
NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING HISTORY OF CONVULSIONS LETHARGIC OR UNCONSIOUS CONVULSING NOW

CLASSIFY Yes __ No __

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

.For how long? ____ Days . Count the breaths in one minute. ____ breaths per minute. Fast breathing? .Look for chest indrawing . .Look and listen for stridor. .Look and listen for wheeze.

Yes __ No __

DOES THE CHILD HAVE DIARRHOEA?

For how long? ____ Days .Is there blood in the stools? .Look at the childs general condition Is the child: Lethargic or unconscious? Restless and 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 dose it go back: Very slowly (longer than 2 seconds)? Slowly?

Yes __ No __

CHECK FOR THROAT PROBLEM

Dose the child have fever? (by history or feels hot/temperature 37. 5c or above) Dose the child have sore throat? .Feel enlarged tender lymph node (s) on the front of the neck .Look for red (congested)throat .Look for white or yellow exudate on The throat and tonsils

DOES THE CHILD HAVE AN EAR PROBLEM?

. Are their ear pulling and irritability? (for young infants) . Is there sever ear pain? (for older children) . Is their ear discharge? If yes, for how long? ____ Days .Feel for tender swelling behind the ear. .Look for pus draining from the ear.

Yes __ No __

DOES THE CHILD HAVE FEVER?

. (by history or feels hot/temperature 37. 5 c or above) decide MALARIA RISK HIGH LOW . For how long? ____ Days If more than 5 days, has fever been present every day? . Has child had measles within the last three months? . Look or feel for stiff neck. . Look for runny nose. . Look for signs of MEASLES: Generalized rash and one of these: Cough, runny nose, or red eyes.

Yes __ No __

If the child has measles now or within the last 3 months:

. Look for mouth ulcers. If yes, are they deep and extensive? . Look for pus draining from the eye. . Look for clouding of the cornea.

CHECK FOR MALNUTRITION AND ANEMIA

. Look for visible severe wasting . Look for oedema of both feet. Determine weight for age. Low____ Not low____ . Look for palmar and mucous membrane pallor. Severe palmar and/or mucous membrane pallor? Some palmar and/or mucous membrane pallor?

CHECK THE CHILDS IMMUNIZATION AND VITAMIN A SUPPLEMTATION

STATUS.(circle immunizations and vitamin A needed today). At birth BCG OPV-0 At 6 weeks OPV-1 DPT-1 HB-1 At 10 weeks OPV-2 DPT-2 HB-2 At 14 weeks OPV-3 DPT-3 HB-3 At 9 months Measles +VIT A At 18 months OPV-4 DPT(booster dose )

Return for next immunization on: ______________ (Date)

ASSESS CHILDS FEEDING if child has ANEMIA OR LOW WEIGHT or is less than 2 years old.
. Do you breastfeed your child? Yes __ No __ If yes, how many times in 24 hours? ______ times. Do you breastfeed during the night? Yes __ No __ . Dose 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 low weight for age: How large are serving? __________________________________ .Dose the child receive his own serving? ______________________________________ Who feeds the child and how ? _____________________________________________ .During the illness, has the childs feeding changed? If yes, how? __________________________________________________________

FEEDING PROBLEMS

ASSESS OTHER PROBLEMS:

35 35

RECORDING FORM

TREAT

36

Return for follow-up in : Advice mother when to return immediately. Give any immunization needed today: Feeding advice:

NOTES

37

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