Integrated Management of Childhood Illnesses

Chart Booklet

2018
WHO Library Cataloguing-in-Publication Data:

Integrated Management of Childhood Illness: distance learning course.

15 booklets
Contents: - Introduction, self-study modules – Module 1: general danger signs for
the sick child – Module 2: The sick young infant – Module 3: Cough or difficult
breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and
anaemia – Module 7: Ear problems Module 8: Care of
the well child – Facilitator guide –
Implementation: introduction and roll out – Logbook – Chart book

1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health
Organization.

ISBN 978 92 4 150682 3 (NLM classification: WS 200)

© World Health Organization 2018

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health
Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]).
Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the
WHO website (www.who.int/about/licensing/copyright_form/en/index.html).
 Generic Integrated Management of Neonatal & Childhood Illness was prepared by the
World Health Organization's Division of Diarrhoeal and Acute Respiratory Disease Control
(CDR), now the Department of Child and Adolescent Health and Development (CAH), and
UNICEF through a contract with ACT International, Atlanta, Georgia, USA. This was
adapted for Pakistan by the IMNCI Adaptation Group, Ministry of Health, Pakistan with
the collaboration of WHO and UNICEF in 1998.

© Publication Rights:

This document is developed for the Ministry of Health, Pakistan by the World Health Organization.

All revision and publication rights are reserved with World Health Organization.
This document is neither for sale nor for any commercial purpose.

The views expressed in document by named authors and this document is joint responsibility of the World Health Organization and the
Ministry of Health, Pakistan.

Acknowledgements

World Health Organization acknowledges the support and involvement of all worthy colleagues and associates for their valuable
contribution to IMNCI documents & development of abridged course, edition and adaptation. Complete list of contributors is placed at
the end of this document.

Previous version of IMNCI document was edited by Liaquat University of Medical & Health Sciences (LUMHS), Jamshoro in 2014 with
technical guidance and support of World Health Organization.

Update of IMNCI guidelines and 6-day abridged course has been developed by Child Survival Program, Department of Health,
Government of Sindh with technical support from World Health Organization in collaboration with UNICEF and Aga Khan University in
2018.
 Integrated Management of Childhood Illness

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SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD
ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE
Determine if this is an initial or follow-up visit for USE ALL BOXES THAT MATCH THE
this problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up TO CLASSIFY THE ILLNESS
instructions on TREAT THE CHILD chart.
if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE
Quickly complete the assessment
breastfeed? or unconscious. DISEASE
Give any pre-referral treatment immediately
Does the child vomit Is the child convulsing URGENT attention Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions? If YES
Ask if more than 1
convulsion or if
prolonged more than
15 mins. If Yes to
either.

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.

1
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?

If yes, ask: Look, listen, feel*: Any general danger sign Pink: Give first dose of an appropriate antibiotic
For how long? Count the Classify Refer URGENTLY to hospital**
breaths in If stridor present nebulizer with Nor Saline
COUGH or
one minute. or SEVERE and refer immediately.
DIFFICULT
Look for Stridor in calm child.
BREATHING O2 saturation < 90% with
chest CHILD pulse oximeter (if
indrawing. MUST BE available) PNEUMONIA OR
Look and CALM VERY SEVERE
listen for
stridor. DISEASE
Look and Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
listen for Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
wheezing. acting bronchodilator) give an inhaled
bronchodilator for 5 days****
If wheezing with either
Soothe the throat and relieve the cough with a
fast breathing or chest
safe remedy
indrawing:
If coughing for more than 14 days or recurrent
Give a trial of rapid acting
wheeze, refer for possible TB or asthma
inhaled bronchodilator for up
assessment
to three times 15-20 minutes
Advise mother when to return immediately
apart. Count the breaths and
Follow-up in 3 days
look for chest indrawing again,
and then classify. No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting
Very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
If the child is: Fast breathing is:
5 days****
2 months up to 12 months 50 breaths per minute or more
Soothe the throat and relieve the cough with a
12 Months up to 5 years 40 breaths per minute or more safe remedy
If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
assessment
Advise mother when to return immediately
Follow-up in 5 days if not improving

*If pulse oximeter is available, determine oxygen saturation and refer if < 90%.
** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatment of severe acute wheeze.

2
Does the child have diarrhoea?

If yes, ask: Look and feel: Two of the following signs: Pink: If child has no other severe classification:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
For how long? Look at the child's general Sunken eyes DEHYDRATION OR
Is there blood in the stool? for DEHYDRATION
condition. Is the child:
Not able to drink or drinking If child also has another severe
Lethargic or
Classify DIARRHOEA poorly classification:
unconscious?
Skin pinch goes back very Refer URGENTLY to hospital with mother
Restless and irritable? slowly. giving frequent sips of ORS on the way
Look for sunken eyes. Advise the mother to continue
Offer the child fluid. Is breastfeeding
the child: If child is 2 years or older and there is
Not able to drink or cholera in your area, give antibiotic for
drinking poorly?
cholera
Drinking eagerly,
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some
thirsty?
Restless, irritable SOME dehydration (Plan B)
Pinch the skin of the
Sunken eyes DEHYDRATION If child also has a severe classification:
abdomen. Does it go back:
Drinks eagerly, thirsty Refer URGENTLY to hospital with mother
Very slowly (longer
Skin pinch goes back giving frequent sips of ORS on the way
than 2 seconds)? slowly. Advise the mother to continue
Slowly? breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat
as some or severe NO DEHYDRATION diarrhoea at home (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 5 days if not improving

Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhoea 14 SEVERE has another severe classification
PERSISTENT Refer to hospital
days or more
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
DIARRHOEA Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days

and if blood in stool Blood in the stool. Yellow: Give ciprofloxacin for 3 days
DYSENTERY Follow-up in 3 days

3
Does the child have an ear problem?

If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain
Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital
If yes, for how long? Feel for tender swelling Pus is seen draining from Yellow: Give an antibiotic for 5 days
behind the ear. the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR INFECTION
the ear.

5
THEN CHECK FOR ACUTE MALNUTRITION

CHECK FOR ACUTE MALNUTRITION Oedema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE Sugar
Look for oedema of both feet. STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
If WFH/L less than -3 z-scores or MUAC less than 115 complication present
mm, then: Or
Check for any medical complication present: Not able to finish RUTF
Any general danger signs Or
Any severe classification Breastfeeding
Pneumonia with chest indrawing problem.
If no medical complications present: WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
Child is 6 months or older, offer RUTF*** to Scores UNCOMPLICATED Give ready-to-use therapeutic food for a child
eat. Is the child: OR SEVERE ACUTE aged 6 months or more
MUAC less than 115 mm MALNUTRITION Counsel the mother on how to feed the child.
Not able to finish RUTF portion? Assess for possible TB infection
AND
Able to finish RUTF portion? Advise mother when to return immediately
Able to finish RUTF. Follow up in 7 days
Child is less than 6 months, assess
breastfeeding: WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
2 z-scores MODERATE ACUTE mother on the feeding recommendations
Does the child have a breastfeeding OR MALNUTRITION If feeding problem, follow up in 7 days
problem? Assess for possible TB infection.
MUAC 115 up to 125 mm. Advise mother when to return immediately

Follow-up in 30 days
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
More NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
Recommendations
MUAC 125 mm or more.
If feeding problem, follow-up in 7 days

*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malnutrition.

6
THEN CHECK FOR ANAEMIA

Check for anaemia

Look for palmar pallor. Is it: Severe palmar pallor Pink: Refer URGENTLY to hospital
Severe palmar pallor*? SEVERE ANAEMIA
Some palmar pallor? Classify
ANAEMIA Classification Some pallor Yellow: Give iron**
arrow

Give mebendazole if child is 1 year or older and has not

had a dose in the previous 6 months
ANAEMIA
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days

*Assess for sickle cell anaemia if common in your area.

**If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.

*** Check for Malaria before giving anti malarial

*** Include Malaria test for all those with pallor in high malaria risk

7
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE
Birth BCG* OPV-0 Hep B0 VITAMIN A

6 weeks PENTA-1 OPV-1 Hep B1 RTV1 PCV1*** SUPPLEMENTATION

Give every child a
10 weeks PENTA-2 OPV-2 Hep B2 RTV2 PCV2 dose of Vitamin A
every six months
from the age of 6
months. Record the
dose on the child's
chart.
14 weeks PENTA-3 OPV-3 Hep B3 PCV3 ROUTINE WORM
IPV TREATMENT
Give every child
mebendazole every 6
9 months Measles ** months from the age
of one year. Record
the dose on the
18 months DPT child's card.

*Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.
** Pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.

ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to
prevent low blood sugar.

8
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Give an Appropriate Oral Antibiotic
Follow the instructions below for every oral drug to be given at home.
FOR PNEUMONIA, ACUTE EAR INFECTION:
Also follow the instructions listed with each drug's dosage table.
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
Determine the appropriate drugs and dosage for the child's age or weight. AMOXICILLIN*
Tell the mother the reason for giving the drug to the child. Give two times daily for 5 days
AGE or WEIGHT
Demonstrate how to measure a dose. TABLET SYRUP
Watch the mother practise measuring a dose by herself. 250 mg 250mg/5 ml

Ask the mother to give the first dose to her child. 2 months up to 12 months (4 - <10 kg) 1 5 ml
Explain carefully how to give the drug, then label and package the drug. 12 months up to 3 years (10 - <14 kg) 2 10 ml
If more than one drug will be given, collect, count and package each drug 3 years up to 5 years (14-19 kg) 3 15 ml
separately. * Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy
and increasing high resistance to cotrimoxazole.
Explain that all the oral drug tablets or syrups must be used to finish the course of
:
treatment, even if the child gets better.
ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
Check the mother's understanding before she leaves the clinic.
COTRIMOXAZOLE
(trimethoprim + sulfamethoxazole)

AGE Give once a day starting at 4-6 weeks of age

Syrup Paediatric tablet Adult tablet
(40/200 mg/5ml) (Single strength 20/100 mg) (Single strength 80/400 mg)
Less than 6 months 2.5 ml 1 -
6 months up to 5 years 5 ml 2 1/2
FOR DYSENTERY give Ciprofloxacine
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
CIPROFLOXACINE
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet 500 mg tablet
Less than 6 months 1/2 1/4
6 months up to 5 years 1 1/2
FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
ERYTHROMYCIN TETRACYCLINE
Give four times daily for 3 days Give four times daily for 3 days
AGE or WEIGHT
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1

9
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Give Oral Antimalarial for MALARIA
Also follow the instructions listed with each drug's dosage table. ACT (Artemesinine based Combination Therapy),
CHLOROQUINE
IF Artemesinine based Combination Therapy (ACT), which is Artesunate + SULFADOXINE -
PYRIMETHAMINE:
Give the first dose as directly observed therapy in the clinic.
If the child vomits the drug within 30 minutes of intake, repeat the dose.

IF CHLOROQUINE:
Give Inhaled Salbutamol for Wheezing 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
USE OF A SPACER* to the clinic for additional tablets.
Explain that itching is a possible side effect of the drug, but is not dangerous
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years
should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used.
From Salbutamol metered dose 100 micrograms/puff, give 2 puffs.
Repeat up to 3 times every 15 minutes before classifying pneumonia.

Spacers can be made in the following way:

Use a 500ml drink bottle or similar.
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler.
This can be done using a sharp knife.
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of
the bottle.
Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as
a mask.
Flame the edge of the cut bottle with a candle or a lighter to soften it.
In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup.
Alternatively commercial spacers can be used if available.

To use an inhaler with a spacer:

Remove the inhaler cap. Shake the inhaler well.
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
The child should put the opening of the bottle into his mouth and breath in and out through the
mouth. A carer then presses down the inhaler and sprays into the bottle while the child continues to
breath normally.
Wait for three to four breaths and repeat.
For younger children place the cup over the child's mouth and use as a spacer in the same way.

* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
*Give Paracetamol for High fever (>38.5) or ear pain
Give paracetamol every 6 hours until high fever or ear pain is gone.

PARACETAMOL
AGE or WEIGHT
TABLET (100 mg) TABLET (500 mg)
2 months up to 3 years (4 - <14 kg) 1 1/4
3 years up to 5 years (14 - <19 kg) 1 1/2 1/2

10
*Recommended doses of chloroquine for vivax malaria : 10mg/kg/ single dose for 2 days; 5 mg/kg/single dose on day 3.
**For mixed infection, use artemether injection with lumefantarine for 3 days (4 mg artemether/kg body weight in combination with 6 fold of that dose for lumefantarine per day
as a single dose for 3 days)
*** For Falciparum Malaria use Artesunate with SP 3mg/kg./dose for 3 days
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 drug's dosage table.

Give Iron*
Give one dose daily for 14 days.
IRON/FOLATE
IRON SYRUP
TABLET
AGE or WEIGHT Ferrous sulfate
PJ—J Ferrous fumarate 100 mg per 5 ml (20 mg
Folate (60 mg elemental iron per ml)
elemental iron)
2 months up to 4 months (4 -
1.00 ml (< 1/4 tsp.)
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp.)
(6 - <10 kg)
12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp.)
(10 - <14 kg)
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
19 kg)
* Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
not be given Iron.

11
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
Treat for Mouth Ulcers with Gentian Violet (GV)
Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box. Treat for mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except for remedy for Wash hands.
cough or sore throat). Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
Tell her how often to do the treatment at home. Paint the mouth with half-strength gentian violet (0.25% dilution).
If needed for treatment at home, give mother the tube of tetracycline ointment or a Wash hands again.
small bottle of gentian violet. Continue using GV for 48 hours after the ulcers have been cured.
Check the mothers understanding before she leaves the clinic. Give paracetamol for pain relief.

Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin
Safe remedies to recommend: Treat thrush four times daily for 7 days

Breast milk for a breastfed infant. Wash hands

_____________________________________________________________________________ Wet a clean soft cloth with salt water and use it to wash the child’s mouth
Instill nystatin 1ml four times a day
_____________________________________________________________________________
Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
If breastfed, check mother’s breasts for thrush. If present treat with nystatin
_____________________________________________________________________________ Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
_____________________________________________________________________________ Give paracetamol if needed for pain
_____________________________________________________________________________

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 4 times daily.
Wash hands.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.

Clear the Ear by Dry Wicking and Give Eardrops*

Dry the ear at least 3 times daily.
Roll clean absorbent cloth or soft, strong tissue paper into a wick.
Place the wick in the child's ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps until the ear is dry.
Instill quinolone eardrops after dry wicking three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.

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GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC
Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately

Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHILDREN
Thereafter vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A
within the past month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
Always record the dose of Vitamin A given on the child's card.

AGE VITAMIN A DOSE

6 up to 12 months 100 000 IU
One year and older 200 000 IU

Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.

13
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Give Artesunate Suppositories or Intramuscular Artesunate or
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Quinine for Severe Malaria
Use a sterile needle and sterile syringe when giving an injection. FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Measure the dose accurately. Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
Give the drug as an intramuscular injection. artesunate injection or quinine).
If child cannot be referred, follow the instructions provided. Artesunate suppository: Insert first dose of the suppository and refer child urgently
Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE:
Give Intramuscular Antibiotics For artesunate injection:
Give first dose of artesunate intramuscular injection
GIVE TO CHILDREN BEING REFERRED URGENTLY Repeat dose after 12 hrs and daily until the child can take orally
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
AMPICILLIN Give first dose of suppository
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml). Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours. Give full dose of oral antimalarial as soon as the child is able to take orally
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4 For quinine:
times. Give first dose of intramuscular quinine.
The child should remain lying down for one hour.
GENTAMICIN Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able
7.5 mg/kg/day once daily 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.
AMPICILLIN GENTAMICIN
AGE or WEIGHT
500 mg vial 2ml/40 mg/ml vial
RECTAL ARTESUNATE INTRAMUSCULAR INTRAMUSCULAR
2 up to 4 months (4 - <6 kg) 1m 0.5-1.0 ml SUPPOSITORY ARTESUNATE QUININE
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml 50 mg 200 mg
AGE or WEIGHT 60 mg 150 mg/ml* 300 mg/ml*
12 months up to 3 years (10 - <14 kg) 3 ml 1.9-2.7 ml suppositories suppositories vial (20mg/ml) 2.4 (in 2 ml (in 2 ml
Dosage 10 Dosage 10
3 years up to 5 years (14 - 19 kg) 5m 2.8-3.5 ml mg/kg ampoules) ampoules)
mg/kg mg/kg
2 months up to 4
1 1/2 ml 0.4 ml 0.2 ml
months (4 - <6 kg)
Give Diazepam to Stop Convulsions 4 months up to 12
1 1 ml 0.6 ml 0.3 ml
months (6 - <10 kg)
Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. 12 months up to 2
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like 2 - 1.5 ml 0.8 ml 0.4 ml
years (10 - <12 kg)
a tuberculin syringe) or using a catheter.
Check for low blood sugar, then treat or prevent. 2 years up to 3
3 1 1.5 ml 1.0 ml 0.5 ml
Give oxygen and REFER years (12 - <14 kg)
If convulsions have not stopped after 10 minutes repeat diazepam dose 3 years up to 5
years (14 - 19 kg) 3 1 2 ml 1.2 ml 0.6 ml
AGE or WEIGHT DIAZEPAM
10mg/2mls * quinine salt
2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
12 months up to 3 years (10 - <14 kg) 1.5 ml
3 years up to 5 years (14-19 kg) 2.0 ml

14
GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:
Ask the mother to breastfeed the child.
If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
If neither of these is available, give sugar water*.
Give 30 - 50 ml of milk or sugar water* before departure.
If the child is not able to swallow:
Give 50 ml of milk or sugar water* by nasogastric tube.
If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
water.

15
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart)
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
PLAN A: TREAT DIARRHOEA AT HOME
WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5
Counsel the mother on the 4 Rules of Home Treatment:
months months years years
1. Give Extra Fluid In ml 200 - 450 450 - 800 800 - 960 960 - 1600
2. Give Zinc Supplements (age 2 months up to 5 years) * Use the child's age only when you do not know the weight. The approximate amount of ORS
3. Continue Feeding required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
If the child wants more ORS than shown, give more.
4. When to Return.
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
1. GIVE EXTRA FLUID (as much as the child will take) period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
TELL THE MOTHER: SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Breastfeed frequently and for longer at each feed. Give frequent small sips from a cup.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. If the child vomits, wait 10 minutes. Then continue, but more slowly.
If the child is not exclusively breastfed, give one or more of the following: Continue breastfeeding whenever the child wants.
ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean AFTER 4 HOURS:
water. Reassess the child and classify the child for dehydration.
It is especially important to give ORS at home when: Select the appropriate plan to continue treatment.
the child has been treated with Plan B or Plan C during this visit. Begin feeding the child in clinic.
the child cannot return to a clinic if the diarrhoea gets worse. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS Show her how to prepare ORS solution at home.
OF ORS TO USE AT HOME. Show her how much ORS to give to finish 4-hour treatment at home.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
FLUID INTAKE: in Plan A.
Up to 2 years 50 to 100 ml after each loose stool Explain the 4 Rules of Home Treatment:
2 years or more 100 to 200 ml after each loose stool 1. GIVE EXTRA FLUID
Tell the mother to: 2. GIVE ZINC (age 2 months up to 5 years)
Give frequent small sips from a cup. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
If the child vomits, wait 10 minutes. Then continue, but more slowly. 4. WHEN TO RETURN
Continue giving extra fluid until the diarrhoea stops.
2. GIVE ZINC (age 2 months up to 5 years)
TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
2 months up to 6 months 1/2 tablet daily for 14 days
6 months or more 1 tablet daily for 14 days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN

16
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
START HERE Start IV fluid immediately. If the child can drink, give ORS by
Can you give mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid Solution (or, if not available, normal saline), divided as follows
immediately? AGE First give Then give
30 ml/kg in: 70 ml/kg in:
Infants (under 12 1 hour* 5 hours
months)
Children (12 months up 30 minutes* 2 1/2 hours
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.

Is IV treatment
If the child can drink, provide the mother with ORS solution and
available nearby (within ĺ
show her how to give frequent sips during the trip or give ORS
30 minutes)?
by naso-gastric tube.
NO
Start rehydration by tube (or mouth) with ORS solution:
Are you trained to use give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
a naso- gastric (NG) Reassess the child every 1-2 hours while waiting for
tube for rehydration? transfer:
NO If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
Can the child drink? If hydration status is not improving after 3 hours, send the
child for IV therapy.
NO
After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.

NOTE:
Refer URGENTLY to If the child is not referred to hospital, observe the child at least
hospital for IV or NG 6 hours after rehydration to be sure the mother can maintain
treatment hydration giving the child ORS solution by mouth.

17
GIVE READY-TO-USE THERAPEUTIC FOOD

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Wash hands before giving the ready-to-use therapeutic food (RUTF).
Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
Encourage the child to eat the RUTF without forced feeding.
Give small, regular meals of RUTF and encourage the child to eat often 5-6 meals per day.
If still breastfeeding, continue by offering breast milk first before every RUTF feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE
MOTHER chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.

Recommended Amounts of Ready-to-Use Therapeutic Food

Packets per day
CHILD'S WEIGHT (kg) (92 g Packets Containing 500 kcal) Packets per Week Supply
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35

18
FOLLOW-UP

GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

DYSENTERY
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications. After 3 days:
If the child has any new problem, assess, classify and treat the new problem as on Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart.
the ASSESS AND CLASSIFY chart.
Ask:
Are there fewer stools?
PNEUMONIA Is there less blood in the stool?
Is there less fever?
Is there less abdominal pain?
After 3 days:
Is the child eating better?
Check the child for general danger signs.
Assess the child for cough or difficult breathing. Treatment:
Ask: If the child is dehydrated, treat dehydration.
Is the child breathing slower? See ASSESS & CLASSIFY chart. If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or
Is there a chest indrawing? the same:
Is there less fever? Change to second -line oral antibiotic recommended for dysentery in your area. Give it for 5 days.
Is the child eating better? Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to
hospital.
Treatment: Exceptions - if the child: is less than 12 months old, or
If any general danger sign or stridor, refer URGENTLY to hospital. was dehydrated on the first visit, or REFER to hospital.
If chest indrawing and/or breathing rate, fever and eating are the same or worse, refer if he had measles within the last 3 months
URGENTLY to hospital. If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better,
If breathing slower, no chest indrawing, less fever, and eating better, complete the 5 days of continue giving ciprofloxacin until finished.
antibiotic.
Ensure that mother understands the oral rehydration method fully and that she also understands
the need for an extra meal each day for a week.
PERSISTENT DIARRHOEA MALARIA
After 5 days:
If fever persists after 3 days:
Ask:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Has the diarrhoea stopped?
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
How many loose stools is the child having per day?

Treatment: Treatment:

If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
reassessment of the child. Treat for dehydration if present. Then refer to hospital. If the child has any othercause of fever other than malaria, provide appropriate treatment.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow If there is no other apparent cause of fever:
the usual feeding recommendations for the child's age. If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the
child to a hospital.
If there is no other apparent cause of fever and you do not have a microscopy to check for
parasites, refer the child to a hospital.

19
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is high grade fever with any general danger sign, refer URGENTLY to hospital.
Acute ear infection:
Treatment: If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. to dry the ear. Follow-up in 5 days.
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
finished the 5 days of antibiotic, tell her to use all of it before stopping.
days if the fever persists. Chronic ear infection:
If the child has any other cause of fever other than malaria, provide treatment.
Check that the mother is wicking the ear correctly and giving quinolone drops tree times a day.
If there is no other apparent cause of fever: Encourage her to continue.
If the fever has been present for 7 days, refer for assessment.

FEEDING PROBLEM
MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR After 7 days:
MOUTH ULCERS, OR THRUSH Reassess feeding. > See questions in the COUNSEL THE MOTHER chart.
Ask about any feeding problems found on the initial visit.
After 3 days:
Look for red eyes and pus draining from the eyes. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to
Look at mouth ulcers or white patches in the mouth (thrush). make significant changes in feeding, ask her to bring the child back again.
Smell the mouth. If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to return 30
days after the initial visit to measure the child's WFH/L, MUAC.
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. ANAEMIA
If the pus is gone but redness remains, continue the treatment.
If no pus or redness, stop the treatment. After 14 days:
Give iron. Advise mother to return in 14 days for more iron.
Treatment for mouth ulcers:
Continue giving iron every 14 days for 2 months.
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If the child has palmar pallor after 2 months, refer for assessment.
If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5
days.

Treatment for thrush:

If thrush is worse check that treatment is being given correctly.
If the child has problems with swallowing, refer to hospital.
If thrush is the same or better, and the child is feeding well, continue nystatine for a total of 7 days.

20
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

After 14 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for oedema of both feet.
Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older.

Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes
appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask
mother to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell her
to return again in 14 days. Continue to see the child every 14 days
scores or more, and/or MUAC is 125 mm or more.
If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).

MODERATE ACUTE MALNUTRITION

After 30 days:
Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit:
If WFH/L, weigh the child, measure height or length and determine if WFH/L.
If MUAC, measure using MUAC tape.
Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Treatment:
If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and
encourage her to continue.
If the child is still classified as MODERATE ACUTE MALNUTRITION, 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 his or her WFH/L is -2 z-scores or more or
MUAC is 125 mm. or more.
Exception:
If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has
diminished, refer the child.

21
COUNSEL THE MOTHER

FEEDING COUNSELLING

Assess Child's Appetite

All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (oedema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical
complication should be assessed for appetite.
Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed to
eating the RUTF. Usually the child eats the RUTF portion in 30 minutes.
Explain to the mother:
The purpose of assessing the child's appetite.
What is ready-to-use-therapeutic food (RUTF).
How to give RUTF:
Wash hands before giving the RUTF.
Sit with the child on the lap and gently offer the child RUTF to eat.
Encourage the child to eat the RUTF without feeding by force.
Offer plenty of clean water to drink from a cup when the child is eating the RUTF.
Offer appropriate amount of RUTF to the child to eat:
After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide:
Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.

22
FEEDING COUNSELLING

Assess Child's Feeding

Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA. Ask questions about the child's usual feeding and feeding during this illness. Compare the
mother's answers to the Feeding Recommendations for the child's age.
ASK - How are you feeding your child?
If the child is receiving any breast milk, ASK:
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 MODERATE ACUTE MALNUTRITION or if a child fails to gain weight or loses weight between monthly measurements, ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What foods are available in the home?
During this illness, has the child's feeding changed?
If yes, how?

23
FEEDING COUNSELLING

Feeding Recommendations
Feeding recommendations FOR ALL CHILDREN during sickness and health.

Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months

Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child EXWGRQRWIRUFH "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.

24
FEEDING COUNSELLING

Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup
Find a regular supply or formula or other milk (e.g. full cream cow milk)
Learn how to prepare a store milk safely at home

2. HELP MOTHER MAKE TRANSITION:

Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2 months)
Clean all utensils with soap and water
Start giving only formula or cow’s milk once baby takes all feed by cup
3. STOP BREASTFEEDING COMPLETELY:
Express and discard enough breast milk to keep comfortable until lactation stops

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer 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.
For other foods, follow feeding recommendations for the child's age.

25
EXTRA FLUIDS AND MOTHER'S HEALTH

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given.
Increase other fluids. For example, give soup, rice water, yoghurt drinks 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.

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.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counseling on STIs and AIDS prevention
.

26
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
child's problems.
If the child has: Return for
follow-up in:
PNEUMONIA 3 days
DYSENTERY
MALARIA, if fever persists
FEVER: NO MALARIA, if fever persists WHEN TO RETURN IMMEDIATELY
MEASLES WITH EYE OR MOUTH
Advise mother to return immediately if the child has any of these signs:
COMPLICATIONS
MOUTH OR GUM ULCERS OR THRUSH Any sick child Not able to drink or breastfeed
PERSISTENT DIARRHOEA 5 days Becomes sicker
ACUTE EAR INFECTION Develops a fever
CHRONIC EAR INFECTION If child has COUGH OR COLD, also return if: Fast breathing
COUGH OR COLD, if not improving Difficult breathing
UNCOMPLICATED SEVERE ACUTE 14 days If child has diarrhoea, also return if: Blood in stool
MALNUTRITION Drinking poorly
FEEDING PROBLEM
ANAEMIA 14 days

MODERATE ACUTE MALNUTRITION 30 days

NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.

27
Annex:

Skin Problems

IDENTIFY SKIN PROBLEM

28
IDENTIFY SKIN PROBLEM

IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT
AS:
Itching rash with small papules PAPULAR Treat itching:
and scratch marks. Dark spots ITCHING Calamine lotion
with pale centres RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV

for 12 months up to 5 years give 60 mg per day

or give griseofulvin 10mg/kg/day
if in hair shave hair treat itching as above

wrists. face spared days after washing and or 1% lindane cream or

lotion once wash off after 12 hours

29
IDENTIFY SKIN PROBLEM

IF SKIN HAS BLISTERS/SORES/PUSTULES

SIGNS CLASSIFY AS: TREATMENT

Vesicles over body. CHIKEN POX Treat itching as above
Vesicles appear Refer URGENTLY if pneumonia or
progressively over jaundice appear
days and
form scabs after they
rupture

Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days
body with intense pain Give pain relief
or scars Follow-up in 7 days
plus shooting pain.
Herpes zoster is
uncommon in
children except where
they are
immuno-compromised,
for example
if infected with HIV

Red, tender, warm IMPETIGO OR Clean sores with antiseptic

crusts or small lesions FOLLICULITIS Drain pus if fluctuant
Start cloxacillin if size >4cm or red streaks or tender nodes or multiple
abscesses for 5 days ( 25-50 mg/kg every 6 hours)
Refer URGENTLY if child has fever and /
or if infection extends to the muscle.

30
IDENTIFY SKIN PROBLEM

NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT

Skin coloured pearly white papules with MOLLUSCUM Can be treated by various
a central umblication. It is most CONTAGIOSUM modalities:
commonly seen on the face and trunk in Leave them alone unless
children. superinfected
Use of phenol: Pricking each lesion
with a needle or sharpened
orange stick and dabbing the lesion
with phenol
Electrodesiccation
Liquid nitrogen application (using
orange stick)
Curettage
The common wart appears as papules WARTS Treatment:
or nodules with a rough (verrucous) Topical salicylic acid preparations (
surface eg. Duofilm)
Liquid nitrogen cryotherapy.
Electrocautery

Greasy scales and redness on central SEBBHORREA Ketoconazole shampoo

face, body folds If severe, refer or provide tropical
steroids
For seborrheic dermatitis: 1%
hydrocortisone cream X 2 daily
If severe, refer

31
CLINICAL REACTION TO DRUGS

DRUG AND ALLERGIC REACTIONS

SIGNS CLASSIFY TREATMENT
AS:
Generalized red, wide spread with small bumps or blisters; or FIXED DRUG Stop medications give oral
one or more dark skin areas (fixed drug reactions) REACTIONS antihistamines, if pealing
rash refer

Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching

Severe reaction due to cotrimoxazole or NVP involving the

skin STEVEN Stop medication refer
as well as the eyes and the mouth. Might cause difficulty in JOHNSON Urgently
Breathing SYNDROME

32
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Height/Length (cm): 7HPSHUDWXUHƒ&
Ask: What are the child's problems? Initial Visit? Follow-up Visit?

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGN General danger sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
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 wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child:
Is there blood in the stool? 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 then 2 seconds)? Slowly?
Does the child have fever more than 37.5°C Yes __ No __
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
For how long? ___ Days Look for runny nose
If more than 7 days, has fever been present every day? Look for signs of MEASLES:
Has child had measles within the last 3 months? Generalized rash and
One of these: cough, runny nose, or red eyes
Do a malaria test, if NO general danger sign in all cases in
high malaria risk or NO obvious cause of fever in low Look for any other cause of fever.
malaria risk:
Test POSITIVE? P. falciparum P. vivax NEGATIVE?
If the child has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
Look for pus draining from the eye.
last 3 months: Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
Determine WFH/L z-score:
AND ANAEMIA Less than -3? Between -3 and -2? -2 or more ?
Child 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or Is there any medical complication: General danger sign?
WFH/L less than -3 Z scores: Any severe classification? Pneumonia with chest indrawing?
Child 6 months or older: Offer RUTF to eat. Is the child:
Not able to finish? Able to finish?
Child less than 6 months: Is there a breastfeeding problem?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
immunization on:
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A
________________
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole
(Date)
Hep B0 Hep B1 Hep B2 Hep B3
RTV-1 RTV-2 RTV-3
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, FEEDING
ANAEMIA, PROBLEMS
Do you breastfeed your child? Yes ___ No ___
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___
Does the child take any other foods or fluids? Yes ___ No ___
If Yes, what food or fluids?
How many times per day? ___ times. What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child's feeding changed? Yes ___ No ___
If Yes, how?
ASSESS OTHER PROBLEMS: Ask about mother's own health

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Contributors for adaptation of IMCI guidelines in Pakistan (1998 onwards)

Dr. Jose Martlines, Medical Officer, Department of CAH, WHO/HQ, Geneva

Dr. Tegest Ketsela, Short Term Consultant, WHO Geneva
Dr. Shamim Qazi, Medical Officer, Department of CAH, WHO/HQ, Geneva
Dr. Samira Aboubaker, Medical Officer/Department of CAH, WHO/HQ, Geneva
Dr. Professor Lulu Muhe, WHO/HQ, Geneva
Dr. Suyzanne Farhoud, Regional Advisor, WHO/EMRO, Cairo, Egypt
Dr. M. Linchnevski, Regional Advisor IMCI, WHO/EMRO, Alexandria, Egypt
Dr. Rafael Lopez, Short Term Professional, WHO/EMRO, Alexandria, Egypt
Prof. M. Naghib Masood, Prof of Paediatrics, Alexandria University, Egypt
Dr. Hashim A.G Osman, Paediatrics/ Consultant WHO, Cairo, Egypt
Prof. Magdi Omar Abdou, Professor of Paediatrics, Alexandria University, Egypt
Mr. Hassan Raza Pasha, Ex-Federal Secretary Health, Islamabad
Dr. Ghayyur H. Ayub, Ex-Director General Health, Islamabad
Lt. Gen. (Retd) Mohammad Saleem, Ex-Executive Director NIH, Islamabad
Dr. Mushtaq A.Khan, Chief, Health & Nutrition, Planning Division, Islamabad
Dr. Athar Saeed Dil, Executive Director NIH & Ex-Acting Director General Health, Islamabad
Dr. Gul Nayyar Rehman, National Focal Person for Adaptation of IMCI, PIMS, Islamabad
Dr. Amjad Ali, Scientific Oficer, Nutrition Division, NIH, Islamabad
Dr. Saleem Ansari, CDD Officer, EPI/CDD Cell, NIH, Islamabad
Dr. Mohammad Khalif Bile, WHO Medical Officer, PHC, Islamabad
Mr. Abdul Sattar. Chaudary Health Education Advisor, Ministry of Health, Islamabad
Mr. Khawaja Mussaddiq Ali, Secretary, WHO, Islamabad
Dr. Mahmood Jamal, Associate Professor of Paediatrics, PIMS, Islamabad
Dr. Salim Wali Khan, Programme Officer, NP & FP & PHC, Islamabad
Dr. Syed Zulfiqar Ali, Project Officer Child Health, UNICEF Pakistan, Islamabad
Dr. Anwar-ul-Haq, District Coordinator NP for FP & PHC, Abbottabad
Mr. Muhammad Ayub, Assistant Chief, Nutrition Section, P & D Division, Islamabad
Dr. Rehan Abdul Hafiz, National Programme Manager, EPI/CDD, NIH, Islamabad
Prof. Mumtaz Hassan, Professor of Paediatrics & National ARI Programme Manager, PIMS, Islamabad
Dr. Jaffar Hussain, National Operations Officer IMCI, WHO, Islamabad
Dr. Baqir Hussain Jaffery, Project & Monitoring Officer, NP for FP & PHC, Islamabad
Dr. Rauf Khalid, Deputy Drug Controller, Ministry of Health, Islamabad
Mr. Muhamamad Aslam Khan, Director, Directorate of Malaria Control, Islamabad
Dr. T.O Kyaw-Myint, Chief PHEC, UNICEF Pakistan, Islamabad
Dr. Husna J. Memon, Provisional Coordinator, NP for FP & PHC, Islamabad
Dr. Fazli-Haq Khattak, Deputy Chief Health & Nutrition, P & D Division, Islamabad
Dr. Zahid Larik, Deputy Director General Health(PHC) & National IMCI Coordinator, Islamabad
Dr. Jayantha B.L. Liyanage, Associate Professional Officer IMCI, WHO, Islamabad
Dr. M. Ahmed Kazi, Deputy National Coordinator (I) NP for FP & PHC, Islamabad
Dr. Mohammad Mansoor Kazi, UNICEF Consultant, Nutrition Cell, P&D, Islamabad
Dr. Fazal-ur-Hakeem Mian, Assistant Chief, H & N, Planning & Development Division, Islamabad
Dr. Imran Ravji, Consultant, UNICEF Pakistan, Islamabad
Dr. Ayub Salariya, Training Specialist, Federal PIU, Islamabad
Dr. Mohammad Saleem, Chief, Nutrition Cell, NIH Islamabad
Dr. S.M Mursalin, HMIS Officer NP for FP & PHC, Islamabad
Dr. Asifa Murtaza, Consultant Paediatrics & Head of Department, FGSH, Islamabad
Dr. Zafar Iqbal Naeem, Consultant Paediatrics, FGSH, Islamabad
Dr. Zareef ud din, NPO MNCH, WHO CO Islamabad, Dr. Durdana Poonam, TRF Islamabad
Dr. Riaz H. Sheikh, Deputy Drug Controller, Ministry of Health, Islamabad
Dr. Sardar Talat, ADG(PHC) Ministry of Health, Islamabad
Dr. S. Raza Mahmood Zaidi, Deputy National Coordinator (II) NP for FP & PHC, Islamabad
Dr. Tariq Zulqarnain, Epidemiologist, Directorate of Malaria Control, Islamabad
Dr. Parveen Tariq, Associate Professor of Paediatrics, Rawalpindi Medical College, Rawalpindi
Prof. Zafar ullah Kundi, Professor of Paediatrics, Rawalpindi Medical College, Rawalpindi
Dr. Mustatab Ahmed, Consultant on IMCI, Family Health Project, Lahore
Dr. Shaheena Ayaz, Director MCH, DGHS Office, Punjab, Lahore
Mr. M. Ismatullah Chaudary, WHO Operations Officer, Punjab, Lahore
Dr. Nadeem Jan, Programme Officer, NP for FP & PHC, Punjab, Lahore
Dr. Ejaz Rasool Qureshi, Director Health Services (D&E) DGHS Office Lahore
Dr. Mushtaq A. Salariya, Provincial Coordinator NP for FP & PHC, Punjab, Lahore
Dr. Ahsan Waheed Rathore, Associate Professor of Pediatrics, KEMC, Lahore
Dr. Zardar Mohammad, Registrar, Paediatrics, Nishtar Teaching Hospital, Multan
Dr. Ghulam Mustafa, Registrar, Paediatrics, Nishtar Teaching Hospital, Multan
Dr. Muhammad Siddique Saqib, District Coordinator, NP for FP & PHC, Multan
Dr. Muhammad Siddique Saqib, District Coordinator, NP for FP & PHC, Multan
Dr. Imran Iqbal, Associate Professor of Paediatrics, Nishtar Medical College, Multan
Dr. Ghulam Shabbir, Senior Registrar, Paediatrics, Nistar Medical College, Multan
Dr. Iftikhar Hussain Qureashi, District Health Officer, Multan
Dr. Tabish Nazir, Associate Professor of Paediatrics, Nishtar Medical College, Multan
Prof. Tariq Iqbal Bhutta, Principal & Prof. of Paediatrics, Nishtar Medical College, Multan
Prof. A.G. Billoo, Professor of Child Health, Aga Khan University Karachi
Dr. Saddiqa Ibrahim, Associate Professor of Paediatrics, NICH, Karachi
Prof. Zulfiqar Ahmed Bhutta, Professor of Child Health, Aga Khan University, Karachi
Prof. D.S. Akram, Professor of Paediatrics, Dow Medical College, Karachi
Prof. Zeenat Isani, Professor of Paediatrics, NICH, Karachi
Dr. Iqtidar Ahmed Khan, Associate Professor of Paediatrics, Agha Khan University, Karachi
Dr. Aisha Mehnaz, Associate Professor of Paediatrics, Dow Medical College, Karachi
Prof. Iqbal Memon, Professor of Paediatrics, Dow Medical College, Karachi
Dr. Salma Shaikh, Dean and Head of Paediatrics department, Liaquat University of Medical & Health Sciences (LUMHS), Jamshoro
Dr. Abdul Rehman Pirzadoo, NPO MNCH, WHO Sindh
Dr. Mohtaram Shah, Assistant Director, DGHS Office, Hyderabad
Dr. Capt. Mir M. Shiekh, Director MCH / CDD, DGHS Office, Hyderabad
Dr. Ghafran Saeed Babar, Registrar, Paediatrics, Ayub Teaching Hospital, Abbottabad.
Dr. Mumtaz Khan Burki, Associate Professor of Paediatrics, Ayub Medical College Abbottabad
Dr. Jamshed Khan Tanoli, ADHO / District Coordinator NP for FP & PHC, Abbottabad
Dr. Ubaid-ul-Haq, CDD Officer, DHO Office, Abbotabad
Dr. Shabir Ahmad Khawaja, NP for FP & PHC, AJK, Dr. Sher Baz Khan, Deputy Programme Coordinator, FANA, Gilgit
Prof. S. M. Naeem Agha Professor of Paediatrics, Bolan Medical College, Quetta
Dr. Saleem Akthar, Provincial Coordinator, NP for FP & PHC, Balochistan, Quetta
Dr Noor Khajjak, IMNCI Consultant for WHO country office, Islamabad
List of contributors for IMNCI Abridged course (2018)

Dr M.N.LAL, Director Child Survival Program, Sindh, Karachi (Lead Consultant)

Dr Farida Memon Deputy Director Child Survival Program, Sindh, Karachi
Dr Amina Khalid Medical Officer under 5 Years clinic, Paeds OPD civil Hospital Karachi
Dr Komal Moorpani, Technicl Editor Child Survival Program, Sindh
Dr. Shamim Qazi, Medical Officer HQ/FWC/MCA/MRD, WHO Headquarters, Geneva
Dr Samira Aboubaker, Medical Officer, HQ/FWC/MCA/PPP, WHO Headquarters, Geneva
Dr Jamela Al-Raiby, Medical Officer, EM/RGO/DHP/CAH, WHO Eastern Mediterranean Regional Office, Egypt
Dr Khalid Siddeeg, Medical Officer, EM/RGO/DHP/CAH, WHO Eastern Mediterranean Regional Office, Egypt
Dr Lulu Muhe, Consultant WHO Headquarters, Geneva
Dr Lamia Mahmoud, Medical Officer and Lead for Category 3, WHO country office Islamabad
Dr Sara Salman, Head of Sub Office, WHO Sub Office Sindh, Karachi
Dr Badar Munir, National Professional Officer RMNCH&N, WHO Sindh, Karachi
Dr Qudsia Uzma, National Professional Officer MNCAH, WHO country office, Islamabad.
Dr Maryam Ali, Intern, WHO country office, Islamabad
Dr Yahya Gulzar, National Professional Officer RMNCH&N, WHO Punjab, Lahore.
Dr Asfandyar Sherani, National Professional Officer RMNCH&N, WHO Balochistan, Quetta.
Dr Mazhar Khan, National Professional Officer RMNCH&N, WHO KP/FATA, Peshawar.
Dr Syed Kamal Asghar, Health Specialist, UNICEF Sindh, Karachi
Dr Sajid Soofi, Consultant Pediatrician, Aga Khan University Hospital, Karachi
Dr Shabina Arif, Consultant Pediatrician and Neonatologist, Aga Khan University Hospital, Karachi
Dr Ali Turab, Pediatrics Department, Aga Khan University Hospital, Karachi
Dr Malik Muhammd Safi, Director Programme Implementation, Ministry of National Health Services, Regulations and Coordination, Islamabad.
Dr Atiya Aabroo, Deputy Director, Ministry of National Health Services, Regulations and Coordination, Islamabad.
Dr Samia Rizwan, MNCH Specialist, UNICEF country office, Islamabad
Dr Inamullah Khan, MNCH Specialist, UNICEF country office, Islamabad