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Integrated Management of Childhood Illness
MaryGenericJune2011
Assess and classify the sick child aged 2 months up to 5 yearsASSESS AND CLASSIFY
CHECKFORGENERALDANGERSIGNS 4
THENASKABOUTMAINSYMPTOMS: 5
Doesthechildhavediarrhoea? 6
Doesthechildhavefever? 7
Doesthechildhaveanearproblem? 8
THE N CH EC K FO R MA LN UTRI TI ON A ND A NA EM IA 9
CHECKFORHIVINFECTION 10
WHO PAEDIATRIC CLINICAL STAGING FOR HIV 11THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A ANDDEWORMING STATUS 12
TREAT THE CHILDTEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME 14
GiveanAppropriateOralAntibiotic 14
G iv e an A pp ro pr ia te O ra l An ti bi ot ic f or D YS EN TE RY 1 4
Givecotrimoxazoleprophylaxis 14
GiveOralAntimalarial 15
GiveparacetamolforFeverorEarpain 15
GiveVitaminA 15
Giveironandorfolate 15
GiveMebendazoleoralbendazole 16
GiveInhaledSalbutamolforWheezing 16
Giveoralsalbutamol 16
TeachCaretakertoGiveARVs 18
GivepainreliefforChronicPain 18
TreatOpportunisticInfections 18TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME 19Tre at E ye I nf ec ti on w it h Te tr ac yc li ne E ye O in tm en t 1 9
C le ar t he E ar b y Dr y Wi ck in g an d Gi ve E ar d ro ps * 1 9
TreatMouthUlcerswithGentianVioletGV 19TREATTHRUSHWITHORALNYSTATIN 19
SoothetheThroat,RelievetheCoughwithaSafeRemedy 19
GIVE THESE TREATMENTS IN THE CLINIC ONLY 20
GiveanIntramuscularAntibiotic 20
Giveintramuscularquinine 20
GiveDiazepamtoStopConvulsions 20
TreattheChildtoPreventLowBloodSugar 21
Giveepinephrine 21
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING 21PlanA:TreatDiarrhoeaatHome 22
PlanB:TreatSomeDehydrationwithORS 22
PlanC:TreatSevereDehydrationQuickly 23
IMMUNIZEANDGIVEVITAMINATOEVERYSICKCHILD,ASNEEDED
23
FOLLOW-UPGIVE FOLLOW-UP CARE 24
PNEUMONIA 24
PERSISTENTDIARRHOEA 24
DYSENTERY 26
ORALTHRUSH 26
MALARIA 26M EA SL ES W ITH EY E OR M OU TH C OM PL IC ATIO NS 2 7
EARINFECTION 27
FEEDINGPROBLEM 27
VERYLOWWEIGHT 27ANAEMIA 27
HIVINFECTION 28
COUNSELFOOD 29
AssesstheFeedingofSickchildUnder2Yearsorifchildhasverylowweightforage 30FeedingRecommendationsDuringSicknessandHealth 31
FOOD 32
FeedingRecommendationsForaChildWhoHasPERSISTENTDIARRHOEA
32
CounseltheMotherAboutFeedingProblems 32
Counsel 33CounseltheMotheraboutherOwnHealth 33
FLUID 33AdvisetheMothertoIncreaseFluidDuringIllness 33WHEN TO RETURN 34
Recording Form 67
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Assess, classify and treat the sick young infant aged up to 2 monthsASSESS AND CLASSIFY
CHECKFORVERYSEVEREDISEASEANDLOCALBACTERIALINFECTION
36
THE N AS K: D oe s th e yo un g in fa nt h av e di ar rh oe a* ? 3 7
CHECKFORJAUNDICE 37
THENCHECKFORHIVINFECTION 38
THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFORAGE:FORBREASTFEEDINGINFANTS
39
THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFORAGEinNON-breastfedinfants
40
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMINA STATUS: 41ASSESSOTHERPROBLEMS 41
TREAT AND COUNSELTREAT THE YOUNG INFANT AND COUNSEL THE MOTHER 42
GiveFirstDoseofIntramuscularAntibiotics 42Tre at t he Y ou ng I nf an t to P re ve nt L ow B lo od S ug ar 4 3
TeachtheMotherHowtoKeeptheYoungInfantWarmontheWaytotheHospital
43
GiveanAppropriateOralAntibioticforLocalBacterialInfection 44
Tea ch t he M ot he r to Tre at L oc al I nf ec ti on s at H om e 4 5
To Tr ea t Di ar rh oe a, S ee TRE ATTHE C HI LD C ha rt . 4 5
Im mu ni ze Ev er y Si ck Yo un gI nfa nt, as Ne ed ed 4 5COUNSEL THE MOTHER 46TeachCorrectPositioningandAttachmentforBreastfeeding 46
T ea ch t he M oth er Ho w to Ex pre ss Br ea st Mil k 4 6
TeachtheMotherHowtoFeedbyaCup 46
TeachtheMotherHowtoKeeptheLowWeightInfantWarmatHome 46AdvisetheMothertoGiveHomeCarefortheYoungInfant 46
FOLLOW-UPGIVE FOLLOW-UP CARE FOR THE YOUNG INFANT 47
ASSESSEVERYYOUNGINFANTFOR"VERYSEVEREDISEASE"DURINGFOLLOW-UPVISIT
47
LOCALBACTERIALINFECTION 47
DIARRHOEA 48
JAUNDICE 48
FEEDINGPROBLEM 49
LOWWEIGHTFORAGE 50
THRUSH 50
Recording Form 69
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AnnexAnnex A: Skin and Mouth ConditionsIdentify Skin Problem 51
Ifskinisitching 52
Identify Skin Problem 53Ifskinhasblisters/sores/pustules 53
Identify Papular Lesions 54Non-Itchy 54
Mouth Problems 55Thrush 55
HerpesSimplex 56
ASSESS,CLASSIFYANDTREATSKINANDMOUTHCONDITIONS 57
Clinical reaction 58DrugandAllergicReactions 58
Annex B: ARV dosages andcombinationsARV dosage tables 59
EfivarenzEFV 59AbacavirABC 59Stavudined4T 59
Lamivudine3TC 59L amiv ud in e fo r PMT CT pr op hy la xi s in n ewb or ns 5 9
Combination ARV dosages 60DualFDCs 60
DualFDCs 60
TripleFDCs 60
TripleFDCs 60
Annex C: ARVs SIDE EFFECTSSideEffects* 61
Annex D: DRIED BLOOD SPOT DBSCOLLECTION FOR PCR - SUMMARY A good health care worker carrying out DBS procedure will: 62Annex E: TO MEASURE MID UPPERARM CIRCUMFERENCEMUACHOW TO MEASURE MID UPPER ARM CIRCUMFERENCEMUAC 65
STEPSFORMEASURINGMIDUPPERARMCIRCUMFERENCEMUAC 65
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Assess and classify the sick child aged 2 months up to 5 years
ASSESS AND CLASSIFY
ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE
Determine if this is an initial or follow-up visit for this
problem.if follow-up visit, use the follow-up instructionson TREAT THE CHILD chart.
if initial visit, assess the child as follows:
USE ALL BOXES THAT MATCH THE
CHILD'S SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS
CHECK FOR GENERAL DANGER SIGNS
Ask: L o o k :
Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions?
See if the child is lethargic or unconscious.
Is the child convulsing now?
A child with any general danger sign needs URGENTattention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
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THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
If yes, ask: Look , l i s ten , feel :
For how long? Count the
breaths in
one minute.
Look for
chest
indrawing.
Look and
listen forstridor.
Look and
listen for
wheezing.
CHILD
MUST BE
CALM
If wheezing and either
fast breathing or chest
indrawing:
Give a trial of rapid acting
inhaled bronchodilator for up
to three times 15-20 minutes
apart. Count the breaths and
look for chest indrawingagain, and then classify.
If the ch i ld is : Fas t b reath ing is :
2 months up to 12 months 50 breaths per minute or more
12 Monts up to 5 years 40 breaths per minute or more
Any general danger sign or
Chest indrawing or
Stridor in calm child.
P i n k :
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
Give first dose of an appropriate antibiotic
If wheezing give a rapid acting
bronchodilator or subcutanousadrenaline
Refer URGENTLY to hospital*
Fast breathing. Yel low:
PNEUMONIA
Give oral antibiotic for 5 days
If wheezing (even if it disappeared after rapidly
acting bronchodilator) give an inhaled
bronchodilator for 5 days**Soothe the throat and relieve the cough with a
safe remedy
If coughing for more than 3 weeks or if
having recurrent wheezing, refer for
assessment for TB or asthma
Advise mother when to return immediately
Follow-up in 2 days
No signs of pneumonia or very
severe disease.
Green:
COUGH OR COLD
If wheezing (even if it disappeared after rapidly
acting bronchodilator) give an inhaled
bronchodilator for 5 days**
Soothe the throat and relieve the cough with a
safe remedy
If coughing for more than 3 weeks or if havingrecurrent wheezing, refer for assessment for TB
or asthma
Advise mother when to return immediately
Follow-up in 5 days if not improving
Classi fy COUGH or
DIFFICULT BREATHING
* If referral is not possible, manage the child as described in In tegrated Management of Chi ldhood I l l ness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient
care.
** In settings where inhaled bronchodilator is not available, oral salbutamol may be the second choice.
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Does the child have diarrhoea?
If yes, ask: L oo k and feel :
For how long?
Is there blood in the stool?
Look at the child's 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 ordrinking poorly?
Drinking eagerly,
thirsty?
Pinch the skin of the
abdomen. Does it go back:
Very slowly (longer
than 2 seconds)?
Slowly?
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or
drinking poorly
Skin pinch goes back
very slowly.
P i n k :
SEVERE
DEHYDRATION
If child has no other severe
classification:
Give fluid for severe dehydration
(Plan C)
OR
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 continuebreastfeeding
If child is 2 years or older and there is
cholera in your area, give antibiotic for
cholera
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back
slowly.
Yel low:
SOME
DEHYDRATION
Give fluid, zinc supplements, 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
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify
as some or severe
dehydration.
Green:
NO
DEHYDRATION
Give fluid, zinc supplements, and food to treat
diarrhoea at home (Plan A)
Advise mother when to return immediately
Follow-up in 5 days if not improving
for DEHYDRATION
Classi fy DIARRHOEA
and if diarrhoea 14
days or more
Dehydration present. P i n k :
SEVERE
PERSISTENT
DIARRHOEA
Treat dehydration before referral unless the
child has another severe classification
Refer to hospital
No dehydration. Yel low:
PERSISTENT
DIARRHOEA
Give fluids Plan A
Advise the mother on feeding a child who has
PERSISTENT DIARRHOEAGive Vitamin A, multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days
and if blood in stoolBlood in the stool. Yel low:
DYSENTERY
Give ciprofloxacin for 3 days
Treat dehydration and gve zinc
Follow-up in 2 days
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Does the child have fever?
(by history or feels hot or temperature 37.5C* or above)
If yes:
Then ask : L ook and feel :
For how long?
If more than 7 days, has
fever been present every
day?
Has the child had measles
within the last 3 months?
Look or feel for stiff neck.
Do Rapid Diagnostic Test
(RDT) or Microscopy if NO
general danger sign or
stiff neck. If malaria test is
negative look for other
causes of fever***Look for signs of
MEASLES.
Generalized rash and
One of these: cough,
runny nose, or red
eyes.
Look for any other cause
of fever.
Any general danger sign
or
Stiff neck.
P i n k :
VERY SEVERE
FEBRILE DISEASE
Give first dose of quinine or artesunate for
severe malaria
Give first dose of an appropriate antibiotic
Treat the child to prevent low blood sugar
Give one dose of paracetamol in clinic for
high fever (38.5C or above)
Refer URGENTLY to hospital
Malaria test POSITIVE.** Yel low:
MALARIA
Give recommended first line oral
antimalarialGive one dose of paracetamol in clinic for
high fever (38.5C or above)
Advise mother when to return immediately
Follow-up in 3 days if fever persists
If fever is present every day for more than 7
days, refer for assessment
Malaria test NEGATIVE.
Runny nose PRESENT or
Measles PRESENT or
Other cause of fever
PRESENT
Green:
FEVER : NO
MALARIA
Assess for possible bacterial cause of fever***
and treat with appropriate drugs
Give one dose of paracetamol in clinic for high
fever (38.5C or above)
Advise mother when to return immediately
Follow-up in 2 days if fever persists
If fever is present every day for more than 7
days, refer for assessment
Class i fy
FEVER
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.
Any general danger sign
or
Clouding of cornea or
Deep or extensive mouth
ulcers.
P i n k :
SEVERE
COMPLICATED
MEASLES****
Give Vitamin A treatment
Give first dose of an appropriate
antibiotic
If clouding of the cornea or pus draining
from the eye, apply tetracycline eye
ointment
Refer URGENTLY to hospital
Pus draining from the eye
or
Mouth ulcers.
Ye l l ow:
MEASLES WITH EYE
OR MOUTH
COMPLICATIONS****
Give Vitamin A treatment
If pus draining from the eye, treat eye
infection with tetracycline eye ointment
If mouth ulcers, treat with gentian violet
Follow-up in 2 days
Measles now or within
the last 3 months.
Green:
MEASLES
Give Vitamin A treatment
I f MEASLES now or wi th in
last 3 months, Class i fy
* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5C higher.
** If no malaria test available and NO obvious cause of f ever - classify as MALARIA.
***Look for local tenderness, refusal to use a limb, hot tender swelling, red tender skin or boils, lower abdominal pain or pain on passing urine.
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables .
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Does the child have an ear problem?
If yes, ask: L oo k and feel :
Is there ear pain?
Is there ear discharge?
If yes, for how long?
Look for pus draining from
the ear.
Feel for tender swelling
behind the ear.
Tender swelling behind the
ear.
P i n k :
MASTOIDITIS
Give first dose of an appropriate antibiotic
Give first dose of paracetamol for pain
Refer URGENTLY to hospital
Pus is seen draining from
the ear and discharge is
reported for less than 14
days, or
Ear pain.
Yel low:
ACUTE EAR
INFECTION
Give an antibiotic for 5 days
Give paracetamol for pain
Dry the ear by wicking
Follow-up in 5 days
Pus is seen draining from
the ear and discharge isreported for 14 days or
more.
Yel low:
CHRONIC EARINFECTION
Dry the ear by wicking
Treat with topical quinolone eardrops for 2weeks
Follow-up in 5 days
No ear pain and
No pus seen draining from
the ear.
Green:
NO EAR
INFECTION
No treatment
Classi fy EAR PROBLEM
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THEN CHECK FOR MALNUTRITION AND ANAEMIA
CHECK FOR MAL NUTRITION
LOOK AND FEEL:
For all children
Determine weight for age
Look for oedema of both feet
Look for visible severe wasting
For children aged 6 months or more
Determine if MUAC* less than 110 mm
If age up to 6 months:
and visible severe
wasting
or oedema of both feet
If age 6 months and above
and:
MUAC less than 110
mm or
oedema of both feet or
visible severe wasting
P i n k :
SEVERE
MALNUTRITION
Treat the child to prevent low blood sugar
Refer URGENTLY to hospital
Very low weight for age Yel low:
VERY LOW
WEIGHT
Assess the child's feeding and counsel the
mother on feeding according to the feeding
recommendations.
If feeding problem, follow up in 5 days
Advise mother when to return immediately
Follow-up in 30 days
Not very low weight for
age and no other signs of
malnutrition
Green:
NOT VERY LOW
WEIGHT
If child is less than 2 years old, assess the
child's feeding and counsel the mother on
feeding according to the feeding
recommendations
If feeding problem, follow-up in 5 days
CLASSIFY NUTRITIONAL
STATUS
CHECK FOR ANAEMIA
LOOK AND FEEL:
Look for palmar pallor. Is it:
Severe palmar pallor?
Some palmar pallor?
Severe palmar pallor P i n k :
SEVERE
ANAEMIA
Refer URGENTLY to hosp i tal
Some palmar pallor Yel low:
ANAEMIA
Give iron
Give oral antimalarial if high malaria risk
Give mebendazole if child is 1 years or older
and has not had a dose in the previous 6
months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green:
NO ANAEMIA
If child is less than 2 years old, assess the
child's feeding and counsel the mother on
feeding according to the feeding
recommendations
If feeding problem, follow-up in 5 days
CLASSIFYANAEMIA
* MUAC is mid-upper arm circumference. If tapes are not available, look for oedema of both feet or visible severe wasting.
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CHECK FOR HIV INFECTION
If a child is already on ART or is HIV infected do not enter this box.
NOTE OR A SK IF CHILD HAS: LOOK AND
FEEL
Child HIV status
is:
Mothers HIV
status
seropositive
PCR positive
Seronegative
PCR negative
unknown*
Seropositive
Seronegative
Unknown*
Pnuemonia
Persistent diarrhoea now
Chronic ear infection now
Very low weight or growth faltering
Is there parotid enlargment for 14 days
or more
Any enlarged
lymph glands
now in two or
more of the
following
sites: Neck,
axilla or
groin?Is there oral;
thrush?
Check
for parotid
enlargement
Positive HIV antibody test
in a child 18 months old or
stopped breastfeeding 3
months ago OR
Positive HIV virological test
Ye l l ow :
CONFIRMED HIV
INFECTION
Treat counsel and follow up other
classifications
Give cotrimoxazole porphylaxis daily
Check immunisation status
Give vitamin A supplement every 6 months from
6 months of age
Assess the child's feeding and counsel on
feeding according to the FOOD BOX on the
Counsel the caretaker chart
Stage the disease and refer for further
assessment including HIV care/ARTAdvise the caretaker on home care
No test done or no test
results in a child with 2 or
more conditions OR
Positive antibody test in a
child less than 18 months
with 2 or more conditions
Ye l l ow :
SUSPECTED
SYMPTOMATIC
HIV INFECTION
Treat counsel and follow up other classifications
Give cotrimoxazole porphylaxis daily
Check immunisation status
Give vitamin A supplement every 6 months from 6
months of age
Assess the child's f eeding and counsel on
feeding according to the FOOD BOX on the Counsel
the caretaker chart
test to confirm HIV INfection
Stage disease and refer for further assessement
including HIV care/ART
If child less than 18 months collect dried blood
spot sample and refer sample for PCR (checkannex for DBS procedure)
Advise the caretaker on home care
Mother HIV positive and no
test result on child with
less than 2 conditions OR
Child less than 18 months
with positive antibody test
with less than 2 conditions
Ye l l ow :
POSSIBLE HIV
INFECTION or HIV
EXPOSED
Treat counsel and follow up other
classifications
Give cotrimoxazole porphylaxis daily
Check immunisation status
Give vitamin A supplement every 6 months from
6 months of age
Assess the child's feeding and counsel on
feeding according to the FOOD BOX on the
Counsel the caretaker chart
Confirm HIV infection status of child as soon as
possible with best available test
No test done or no test results
in child or mother OR less than
two conditions
Green:
SYMPTOMATIC
HIV INFECTION
UNLIKELY
Treat counsel and follow-up otherclassifications.
Advice the caretaker abou t feeding and about
her/his own health
Counsel and offer HIV testing
Negative HIV test in the
mother or child
Green:
HIV INFECTION
UNLIKELY
Treat, counsel and follow-up other
classifications
Counsel the caretaker about feeding and about
her/his own health
Class i fy
for HIV
in fec t i on
*If the HIV status is unknown and the child has no severe classification offer PITC.
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WHO PAEDIATRIC CLINICAL STAGING FOR HIV
Has the child beeen confirmed HIV infection?
If yes, perform clinical staging: any one condition in the highest staging determinanes stage, If no, you cannot stage the patient.
WHO PaediatricClinical
stage 1-Asymptomatic
WHOPaediatricClinical
stage 2- mildDisease
WHO Paediatric Clinical
stage 3 - ModerateDisease
WHO Paediatric Clinical
stage 4 - Severe Disease (AIDS)
Growth - - Moderate unexplainedmalnutrition not respondingto standard therapy
Severe unexplained wasting/stunting/severemalnutrition not responding to srtandardtherapy
Symptoms/
signs
No symptoms oronly:
PersistantGeneralised
Lymphadenopathy(PGL)
unexplainedpersistentenlargedliver and/orspleen
Unxeplainedpersistentenlargedparotidglands
Skinconditions(prurigo,seborrhoeicdermatitis,extensivemolleuscumcontegiosumor warts,fungal nailinfections,herpeszoster)
Mouthconditions(recurrentmouthulcerations,gingivalerythema)
Recurrent orchronic RTI(sinusitis,earinfections,tonsilitis,otorrhoea)
Oral thrush ( outsideneonatal period)
Oral hairy leucoplakia
Unexplained andunresponsive to standardtherapy;
Diarrhoea > 14 days
Fever more than 1month
thrombopcytopeania*(< 50,000/mm3 formore than 1 month)
Neutropenia* ( 1month (heamoglobin< 8gm)*
Recurrent severebacterial pneumonia
Pulmonary TB
Lymphonoid TB
Symptomatic LIP*
Acute necrotisingulcerativegivingivitis/periodontitis
Chronic HIV assosiatedlung disease includingbronchiectasis*
Oesophageal thrush
More than 1 month of herpes simplexulcerations
Severe multiple or recurrent bacterialinfections 2 episodes in a year (notincludinig pneumonia)
Pneumocystis pneumonia (PCP)*
Kaposis sarcoma
Extra pulmonary TB
Toxoplasma brain abcess*
Cryptococcal meningitis*
Chronic cryptosporidiosis
Chronic isosporiasis
Acquired HIV-associated rectal fistula
HIV encephalopathy*
Cerebral B cell non-Hodgkinslymphoma*
Symptomatic HIV associatedcardiomyopathy/nephropathy*
ARV
Therapy
Indicated only ifCD4 is available:
11 mo andCD4
25% ( or 1500cells)
12 - 35 mo andCD4
20% (or 750cells )
36 - 59 mo andCD4 15% (or
350 cells)
5 years andCD4 15%(
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THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND
DEWORMING STATUS
IMMUNIZATION
SCHEDULE:If the child did not receive
OPV- 0 at birth or within 13 days
after birth, give OPV- 4 at 9
months with measles
Follow national guidelines
AGE VACCINE
Birth BCG OPV-06 weeks DPT-Hib-HepB1 OPV-1 Rota vacine1 Pnuemo1
10 weeks DPT-Hib-HepB2 OPV-2 Rota vacine 2 Pnuemo2
14 weeks DPT-Hib-HepB3 OPV-3 Pnuemo3
9 months Measles 1
15 Months Measles 2
VITAMIN A SUPPLEMENTATION
VITAMIN A SUPPLEMENTATION SCHEDULE AGE FREQUENCY
BIRTH to 6 months NONE*6 months up to 5 years Every 6 months
*Exception: Give 50,000 IU for infants less than 6 months who are not breastfed.
Record the dose on the child's card.
ROUTINE WORM TREATMENT
Give every child mebendazole every 6 months from the age of one year. Record the dose on the 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.
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THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND
DEWORMING STATUS
ASSESS AND LOOK IF THE CHILD HAS OTHER PROBLEMS
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERREDafter first dose of an appropriate antibiotic and other urgent
treatments.
Exception:Rehydration of the child according to plan C may resolve danger
signs so that referral is no longer needed.
check the blood sugar in all children with a general dangar sign and treat or
prevent low blood sugar
ASSESS THE CARETAKER'S HEALTH
NEEDSASK
Do you have any health problemsyourself?.
Do you want help with family planning
Did you bring your health card? Ifyes, may I please look at the card?
If applicable check whether the
caretaker needs Tetanus toxoid orvitamin A supplementation
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TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLA SSIFYCHART
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.
Determine the appropriate drugs and dosage for the child's 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.
If more than one drug will be given, collect, count and package each drug
separately.
Explain that all the oral drug tablets or syrups must be used to finish the course of
treatment, even if the child gets better.
Check the mother's understanding before she leaves the clinic.
Give an Approp riate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION:
FIRST-LINE ANTIBIOTIC: AMOXICILLIN
SECOND-LINE ANTIBIOTIC: ERYTHROMYCIN
AGE or WEIGHTAMOXICILLIN
Give 3 times daily for 5 daysERYTHROMYCIN
Give four times daily for 5 days
Tablet 250mg Syrup 125mls/5mls Tablet 250mg Syrup 125mls/5mls
2 months up t o 4 months (4 -
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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 Oral Antimalarial
FIRST-LINE ANTIMALARIAL: ARTEMETHER-LUMEFANTRINE (AL)
Give Sulfadoxine + Pyrimethamine if cjild is less than 5kg or AL is not availableSECOND - LINE ANTIMALARIAL: ORAL QUININE
If Artemether-Lumefantrine (AL)
Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child vomits within an hour repeat thedose.
Give second dose at home after 8 hours.
Then twice daily for further two days as shown below.
Artemether-lumefantrine should be taken with food.
Explain to the caretaker to watch the child carefully for 30 minutes after giving a dose of artemether-lumefantrine. If the child vomiteswithin 30 minutes, inform the caretaker to repeat the dose and return to the clinic for additional tablets
If Sulfadoxine + Pyrimethamine:
Give single dose in the health center per table below using the fixed dose combination
AGE or WEIGHT
Artemether-Lumefantrine tablets(20 mg artemether and 120 mg
lumefantrine)
Give first dose in the clinic, 2nd dose
after 8 hoursThen twice daily for 2 days
Sulfadoxine + Pyrimethamine (give single dose inthe clinic)
TABLET (Give twice daily) SYRUP TABLET (500mg sulfadoxine + pyrimethamine)
2 months up to 12 months (5 -
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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.
Teach Caretaker to Give ARVs
ARV DOSAGES
WEIGHT (kg)
Efavirenz (EFZ)15 mg/kg/day (capsule or tablet) for age 3 years or more
Once daily
Capsule 200mg Capsule 100mg Capsule 50mg If no capsule give tablet Tablet 600mg
10-13.9 1
14-19.9 1 1
20-24.9 1 1
25-29.9 1 1 1
30-39.9 2
40 and over 3 OR 1
WEIGHT (kg)
STAVUDINE (d4T)1mg/kg/dose (to maximum 30mg dose)
Give dose twice daily
Solution Capsule 15mg Capsule 20mg Capsule 30mg
5-5.9 6mls
6-9.9 1/2
10-13.9 1
14-24.9 1
25 and above 1
WEIGHT (kg)
ABACAVIR (ABC)8mg/kg/dose (to maximum dose of 300mg/dose)
Give dose twice daily
Syrup 20mg/ml If no syrup give tablet Tablet 300mg
5-5.9 2mls
6-6.9 3mls
7-9.9 4mls
10-10.9 5mls
11-11.9 5mls OR 1/2
12-13.9 6mls OR 1/2
14-19.9 1/2
20-24.9 1 AM and 1/2 PM
25 and above 1
WEIGHT (kg)
LAMIVUDINE (3TC)
I4mg/kg/dose (to maximum 150mg dose)Give dose twice daily
Syrup 10mg/ml If no syrup give tablet Tablet 150mg
30 DAYS OR OLDER
5-6.9 3mls
7-9.9 4mls
10-11.9 5mls
12-13.9 6mls OR 1/2
14-19.9 1/2
20-24.9 1 AM and 1/2 PM
25kg and above 1
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WEIGHT
zidovudine (AZT or ZDV)TREATMENT DOSE:
180-240 mg/meter square/dose
Give dose twice daily
Syrup 10mg/mlIf no syrup give
capsule or tabletCapsule 100mg/ Tablet 300mg
5 - 5.9 6 ml
6 - 6.9 7 ml
7 - 7.9 8 ml
8 - 8.9 9 ml or 1
9 - 11.9 10 ml or 1
12 - 13.9 11 ml or 1
14 - 19.9 2 1/2
20 - 24.9 2 1/2
25 - 29.9 2 1AM & 1/2 PM
WEIGHT
Neverapine (NVP)TREATMENT: Maintenence dose: 160 - 200mg/msq/ dose
(To maximum 200mg twice daily dose)
Maintenwence dose - give dose twice daily
Lead - in dose during weeks 1 and 2 = only give AM dose
Syrup 10 mg/ml If no syrup give tablet Tablet 200mg
5 - 5.9 6 ml
6 - 6.9 7 mls
7 - 7.9 8 mls
8 - 8.9 9 mls
9 - 9.9 9 mls or 1/2
10 - 11.9 10 mls or 1/2
12 - 13.9 11 mls or 1/2
14 - 24.9 1 AM & 1/2 PM
25 and above
PMTCT prophylaxis in newborns
weight in kgsNiverapine 2 mg/kg/dose
Give within 72 hours of birth once daily Zidovidine 10mg /ml
Give 4 mg/kg/ dose twice daily
Dose Dose
Unknown weight 0.6 ml
1 -1.9 0.2 ml 0.4 ml
2 -2.9 0.4 ml 0.8 ml
3 - 3.9 0.6 ml 1.2 ml
4 - 4.9 0.8 ml 1.6 ml
COMBINATION ARV DOSAGES
Weight (Kg)
Stavudine + Lamivudine
(d4T - 3TC)30 mg d4T/ 150 mg 3TC tablet
Stavoidine + Lamividine + Niverapine
(d4T - 3TC - NVP)30 mg d4T/ 150 mg 3TC/ 200mg NVP tablets
AM PM AM PM
10 - 13.9 1/2 1/2 1/2 1/2
14 - 24.9 1 1/2 1 1/2
25 - 34.9 1 1 1 1
WEIGHT(Kg)
Zidovidine + Lamivudine (ZDV- 3TC = AZT-3TC)
300mg ZDV/ 150 mg 3TC tablet
Zidovudine + Lamivudine + Abacavir(ZDV-3TC-ABC = AZT-3TC -ABC)
300 mg ZDV/150mg 3TC/ 300mg ABC tablet
AM PM AM PM
14 - 19.9 1/2 1/2 1/2 1/2
20 - 29.9 1 1/2 1 1/2
30 or above 1 1 1 1
Give pain relief for Chronic Pain
Safe doses of paracetamol can be slightly higher for pain. use the table and teach mother to measure the right dose
Give paracetamol every 6 hours if pain persists
Stage 2 pain is chronic severe pain as might happen in illness such as HIV infection
Start treating Stage 2 pain with regular paracetamol
In older children, 1/2 tablet of paracetamol can replace 10mls syrup
If the pain is not controlled, add regular codeine 4 hourly
For severe pain morphine syrup can be given
AGE or WEIGHTPARACETAMOL
CODEINE30mg Tablet
ORAL MORPHINE5ng/5mls
Syrup(120mg/5mls)
TABLET100mg
TABLET500mg
2 months up to 4 months (4 - 2 years 400mg 8 hourly for 5 days
FOR SEVERE STAPHYLOCOCAL INFECTION OF MOUTH OF SKIN
WEIGHTCloxacillin / Flucloxacillin dosage every 6 hour for 5 days
Capsule 250 mg Suspension 125 mg / 5 mls
3 - < 6 kg - 5 mls
6 - < 10 kg 1 10 mls
10 - < 15 kg 1 10 mls
15 - < 20 kg 2 20 mls
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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 caretaker as she does the first treatment in the clinic (except for 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.
Treat Eye Infection w ith Tetracycl ine Eye Ointment
Clean both eyes 3 times daily.
Wash hands.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 3 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 or redness is gone.
Do not use other ointments or drops, or put anything else in the eye.
Clear the Ear by Dry Wick ing and Give Ear drops *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.
If chronic ear infection, instill quinolone eardrops after dry wicking three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.
Treat Mou th Ulcers with Gentian Violet (GV)
Treat mouth ulcers twice daily.
Wash hands.
Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.Paint the mouth with half-strength gentian violet (0.25% dilution).
Wash hands again.
Continue using GV for 48 hours after the ulcers have been cured.
Give paracetamol for pain relief.
TREAT THRUSH WITH ORAL NYSTATIN
Treat thrush four times daily for 7 days:
Wash hands.
Wet a clean soft cloth with salt water and use it to wash childs mouth.
Instill nystatin 1 ml four times a day
Avoid feeding for 20 minutes after medication.
If breastfed, check mothers breast for thrush. If present, treat with nystatin.
Advise mother to wash breast after feed. If bottle fed advise change to cup and spoon
If severe, recurrent or pharyngeal thrush consider symptomatic HIV and refer
Give paracetamol if needed for pain (Page 14)
Follow-up if not improving.
Soothe the Thro at, Rel ieve the Cough with a Safe Remedy
Safe remedies to recommend: Breast milk for a breastfed infant.
Tea with sugar or honey
Lemon drink
Harmful remedies to discourage: Cough syrup with codein, ephedrine, atropine or alcohol
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GIVE THESE TREATMENTS IN THE CLINIC ONLY
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age).
Use a sterile needle and sterile syringe when giving an injection.
Measure the dose accurately.
Give the drug as an intramuscular injection.
If child cannot be referred, follow the instructions provided.
Give an Intramus cular Antibiotic
FOR SEVERE PNEUMONIA OR SEVERE DISEASE OR VERY SEVERE FEBRILE ILLNESS OR MASTOIDITIS
For children being referred urgently:
Give first dose of intramuscular benzylpenicillin and gentamicin and refer child urgently to hospital.
If referral is not possible:
Repeat the benzylpenicillin every 6 hours and gentamicin injection every 8 hours for 5 days.
Then change to an appropriate oral antibiotic to complete 10 days of treatment.
Do not attempt to treat with benzylpenicillin alone.
AGE or WEIGHT
GENTAMICIN
2ml/40mg/mlvial
Give 2.5mgper kg
BENZYLPENICILLIN
To a vial of 600mg (1 000 000 IU): add 2.1mlof sterile water = 2.5mls at 400 000IU/ml
Give 50 000IU per kg exactly
CHLORAMPHENICOL40mg/kg
Add 5.0ml sterile water to vialcontaining 1 000mg = 5.6ml at
180mg/ml
2 up to 4 months (4 -
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GIVE THESE TREATMENTS IN THE CLINIC ONLY
Treat the Chi ld 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 isable 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. (See severemalnutrition guidelines for IV Dextrose)
To treat low sugar give 2ml/kg body weight of 10% dextrose
* To make sugar water: Dissolve 4 level teaspoons o f sugar (20 grams) in a 200-ml cup of clean water.
Give epinephrin e
For wheezing with respiratory distress
PREPARATION DOSE
Subcutaneous ephinephrine (adrenaline) 1:1 000= 0.1% 0.01ml per kg body weight
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See FOOD advice o n COUNSEL THE MOTHER chart)
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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See FOOD advice o n COUNSEL THE MOTHER chart)
Plan A: Treat Diarrhoea at Home
Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid
2. Give Zinc Supplements
3. Continue Feeding4. 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 breast milk.
If the child is not exclusively breastfed, give one or more of the following:ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water.
It is especially important to give ORS at home when:
the child has been treated with Plan B or Plan C during this visit.
the child cannot return to a clinic if the diarrhoea gets worse.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE:
Up to 2 years 50 to 100 ml after each loose stool
2 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 for 10 minutes. Then continue, but more slowly.
Continue giving extra fluid until the diarrhoea stops.
2. GIVE ZINC
TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
Up to 6 months 1/2 tablet daily for 10 days
6 months or more 1 tablet daily for 10 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
Plan B: Treat Some Dehydration with ORS
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
WEIGHT < 6 kg 6 -
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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
Plan C: Treat Severe Dehydr ation Quic kly
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 mouth while the dripis set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normalsaline), divided as follows
AGE First give 30 ml/kgin:
Then give 70 ml/kgin:
Infants (under 12 months) 1 hour* 5 hours
Children (12 months up to 5years)
30 minutes* 2 1/2 hours
* 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 theIV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4hours (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.
Can you give intravenous (IV)fluid immediately?
YES
NO
Is IV treatment availablenearby (within 30 minutes)?
YESRefer URGENTLY to hospital for IV treatment.
If the child can drink, provide the mother with ORS solution and show her how togive frequent sips during the trip or give ORS by naso-gastric tube.
NO
Are you trained to use a naso-gastric (NG) tube for
rehydration?
YES
Start rehydratin 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 while waiting for transfer:
If there is repeated vomiting or increasing abdominal distension, give the fluidmore 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 theappropriate plan (A, B or C) to continue treatment.
NO
Can the child drink? YES
NO
Refer URGENTLY to hospitalfor IV or NG treatment
NOTE:
If the child is not referred to hospital, observe the child at least 6 hours afterrehydration to be sure the mother can maintain hydration giving the child ORSsolution by mouth.
IMMUNIZE AND GIVE VITAMIN A TO EVERY SICK CHILD,
AS NEEDEDWhen immunizing, make sure you explain to the caretaker: Type of immunization and protection
side effects of the vaccines
When to return for the next immunization(s)
When give vitamin A, make sure you explain to the caretaker: How to give the vitamin A capsule at home
When to return for the next vitamin A supplementation
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FOLLOW-UP
GIVE FOLLOW-UP CARE
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications.
If the child has any new problem, assess, classify and treat the new problem as on
the ASSESS AND CLASSIFYchart.
PNEUMONIA
After 2 days:
Check the child for general danger signs.Assess the child for cough or difficult breathing.Ask:
SeeASSESS & CLASSIFYchart.
Is the child breathing slower?
Is there less fever?
Is the child eating better?
Treatment:
Ifchest indrawing or a general danger sign, give a dose of second line antibiotic or intramuscular chloramphenicol. Then referURGENTLY to hospital.
Ifbreathing rate, fever and eating are the s ame, change to the second-line antibiotic and advise the mother to return in 2 days orrefer. (If this child had measles within the last 3 months or is known to have HIV infection , refer.)
If the child has wheezing, give oral salbutamol
Ifbreathing slow er, less fever, or eating better, complete the 5 days of antibiotic.
PERSISTENT DIARRHOEA
After 5 days:Ask:
Has the diarrhoea stopped?
How many loose stools is the child having per day?
Check for HIV infection if it was not done before
Treatment:
Ifthe diarrhoea has not stopped(child is still having 3 or more loose stools per day), do a full reassessment of the child. Treat fordehydration if present. Then refer to hospital.
Ifthe diarrhoea has stopped(child having less than 3 loose stools per day), tell the mother to follow the usual feedingrecommendations for the child's age. SHE SHOULD CONTinue giving zinc and multivitamins
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GIVE FOLLOW-UP CARE
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DYSENTERY
After 2 days:
Check the child for generaldanger signs.Assess the child fordiarrhoea
See ASSESS &CLASSIFY chart
Ask:
Are there fewer stools?
Is there less blood in the stool?
Is there less fever?
Is there less abdominal pain?
Is the child eating better?
Treatment:If the child is dehydrated, treat dehydration.
Advise caretaker to continue giving zinc supplements until it is given for 14 days
Ifnumber of stoo ls, amount of blood in s tools, fever, abdominal pain, or eating are worse or the same:
Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days. Advise the mother to return in2 days. If you do not have the second line antibiotic, REFER to hospital.
Exceptions - if the child: is less than 12 months old, or
was dehydrated on the first visit, or
if he had measles within the last 3 months
REFER to hospital.
Iffewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving ciprofloxacin and zincsupplements until finished.
Ensure that mother understands the oral rehydration method fully and that she also understands the need for an extra mealeach day for at least a week.
ORAL THRUSH
AFTER 2 DAYS:
Look for mouth ulcers or thrush.
If thrush is worse, give 100,000IU of oral nystatin orally 4 times daily for 7 days
If thrush is the same or better, continue half-strength gentian violet for a total of 7 days
MALARIA
If fever persists after 2 days or returns after 14 days:
Do a full reassessment of thechild.
Measure the child's temperature
Assess for other problems
See ASSESS & CLASSIFY chart.
> DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
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 appropriate treatment.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do a microscopy to look for malaria parasites. If parasites are present and the child has finished a full course of the first lineantimalarial, give oral quinine, if available, or if quinine not available 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 ahospital.
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GIVE FOLLOW-UP CARE
MEASLES W ITH EYE OR MOUTH COMPLICATIONS
After 2 days:
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth.
Treatment for eye infection:
Ifpus is draining from the eye, ask the caretaker to describe how she has treated the eye infection. If treatment has been correct,
refer to hospital. If treatment has not been correct, teach caretaker correct treatment.Ifthe pus is gone but redness remains, continue the treatment.
Ifno pus or redness, stop the treatment.
Treatment for mouth ulcers:
Ifmouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Ifmouth ulc ers are the same or better, continue using half-strength gentian violet for a total of 5 days.
EAR INFECTION
After 5 days:
Reassess for ear problem.
Measure the child's temperature.
See ASSESS & CLASSIFYchart.
For chronic ear infection check for HIV infection if it was done
Treatment:
If there is tender swelling behind the ear or high fever (38.5C or above), refer URGENTLY to hospital.
Acute ear infection: if ear pain or dischargepersists, treat with 5 more days of the same antibiotic. Continue wicking to dry theear. Follow-up in 5 days.
Chronic ear infection:Check that the caretaker is wicking the ear correctly and instilling ciprofloxacin drops tree times a day.Encourage her to continue. Explain to the caretaker the importance of keeping the ear dry and instilling ear drops.
Ifno ear pain or discharge, praise the caretaker for his/her careful treatment. For acute ear infection if the caretaker has not yetfinished the 5 days of antibiotic, tell him/her to use all of it before stopping. For a child with chronic ear infection tell the caretaker tocontinue instilling ciprofloxacin ear drops for a total of 14 days.
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 caretaker about any new or continuing feeding problems. If you counsel the caretaker to make significant changes infeeding, ask him/her to bring the child back again in 5 days.
If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child's weight gain.
VERY LOW WEIGHT
After 30 days: Weigh the child and determine if the child is still very low weight for age or faltering.Reassess feeding. See questions at the top of the COUNSEL chart.
Treatment:
If the child is no longer very low weight for age or growth falter ing, praise the caretaker and encourage him/her to continuefeeding the child appropriately.
If the child is still very low weight for age or growth faltering, counsel the caretaker about any feeding problem found. Askthe caretaker to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weightregularly or is no longer very low weight for age.
Exception:If you do not think that feeding will improve, or if the child has lost weight, refer the child.
ANAEMIA
After 14 days:
Give iron and or folate. Advise mother to return in 14 days for more iron.
Continue giving iron and or folate every 14 days for 2 months.
If the child has palmar pallor after 2 months, refer for assessment.
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GIVE FOLLOW-UP CARE
HIV INFECTION
FIRST FOLLOW UP
Check if the child has had an HIV test and the result has been received. Make sure that the care taker receiveappropriate post-test counseling.
Assess the child's general condition.Do a full assessment > see Assess and Classify Pages 2 to 6
Treat the child for any classification found.
Check for oral thrush and mouth ulcers
Ask for any new feeding problems.Counsel the caretaker about any new or continuing feeding problems.
Check the child's weight and refer if there is growth faltering despite adequate diet
Check if the child is due for Vit A and de - worming or any immunizations. Give dose if due
Advise caretaker when to return immediately.
If HIV test positive
Continue cotrimoxazole prophylaxis for PCP. Counsel caretaker on importance of contnuing treatment
Counsel caretaker on any other problems and ensure community support is being given. Refer for furthercounselling if necessary
Follow up monthly after follow up
If HIV test is negative
Discountnue cotrimoxazole prophylaxis
If HIV test is not done
Continue cotrimoxazole prophylaxis for PCP
REPEAT FOLLOW UP EVERY MONTH
Asses the child's generalk condition. Do a full asssessment < see Assess and Clasify pages 2 - 6
Treat the Child for any classifications found
Check for oral thrush and mouth ulcers
Ask for any new feeding problems. Counsel ythe caretaker aboout any new or continuing feeding problemsCheck the child's weight and refer if there is growth faltering despite adequate diet
Check if child is due for Vitamin A and de-worming or any immunisation. Give dose if due
Advise caretaker when to return immediately
Give supply of cotrimoxazole for prophylaxis for PCP. Cousell caretaker on importance of continuing treatments
Counsel caretaker on any other problems and ensure community support is being given. Refer for further copunseling ifnecessary
Folllow - up monthly
IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE CARETAKEROF THE NEXT FOLLOW-UP VISIT
ALSO, ADVISE THE CARETAKER WHEN TORETURN IMMEDAITELY . (SEE CPUNSEL CHART)
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COUNSEL
FOOD
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FOOD
Assess the Feeding o f Sick ch ild Under 2 Years (or if ch ild
has very low weight for age)Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the FeedingRecommendationsfor the child's age.
ASK - How are you feeding your child?
If the child is receivinganybreast milk, ASK:
How many timesduring the day?
Do you alsobreastfeed duringthe night?
If the receiving replacement millk, Ask;
What replacement milk are yougiving?
How many times during day andnight?
How much is given at each feed?
How is the milk prepared and whoprepares it?
What do you use to feed the child?
How are you cleaning the utensils?
Does the child take
any other food orfluids?
What food or fluids?
How many times perday?
What do you use tofeed the child?
If very low weight forage, ASK:
How large areservings?
Does the child
receive his ownserving?
Who feeds the childand how?
During this illness,has the child's feedingchanged?
If yes, how?
Health worker to encourage care taker togive extra feeds and discourage mixiedfeeing
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FOOD
Feeding Recommendatio ns During Sickness and Health
Up to 6 Months of age
Breastfeed as often as the childwants, day and night, at least 10times in 24 hours.
Do not give other foods or fluids.(noteven water, traditional medice,glucose, gripe water, other milks or
porridge unless medically advised)
6 Months up to 12 months
Continue breast feedingday and nightr - at least 8times in 24 hours
Breastfeed as often as thechild wants.
Give adequate servings of
complementary foods atleast 3 times per dayif breastfed plus snacks.
5 times per day if notbreastfed plus snacks.
Give to 1 cup (150 -200ml) per feeding of:
Thick porridge enrichedwith suger, oil, poundedground nuts or Kapentamashed beans oravocado, soya flour,egg, pounded driedcatapillars or greenleafy vigitables or
Nshima mashed withrelish cooked in oil orpounded g/nuts
Between main meals giveother foods, such as fruits(banana, mango, avocado,etc) or chikanda, mashedpumpkins, beans, g/nuts orboiled sweet potatoes, milk,
munkoyo or fiseke.serve and feed the childseparately in own dish.
12 months up to 2 years
Breastfeed as often as the child wants.
Actively feed the child at least 5 times a day.
Give 1-1 cups (200-300ml) of the followingper feeding:
Nshima with mashed or pounded relish.Do not feed only the soup.
Thick porridge enriched with one or moreof the following: sugar, oil, poundedkapenta, g/nuts, or dried catapillars,mashed beans, egg, milk.
In between main meals give other foods suchas fruits, samp, boiled casava, mashed beans, g/nuts, pumpkins, sweet potatoes, rice withsugar or oil.
Serve the child separetly and encourage orsupervise the eating.
,
2 years and older
Give family foods at least 3 mealseach day.
Also, twice daily, give nutritiousfruits/foods between meals, (suchas: banana, avocado, oranges,mango, pawpaw, guava), samp,
fried sweet potatoes, bred, rice, withsugar or oil, egg or beans.
* A good daily diet should be adequate in qua ntity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, o r pulses; and fruits and
vegetables.
Feeding recommendation for a child who is not feeding well during or after an illness
If still breast feeding, give more frequent, longer breast feeds, day and night.
Offer frequent small feedings
Use soft, varied, appetizing, favourite foods.
Clear a blocked nose if it interfers with the feeding.
Encourage andd assist the chilkd to eat if necessary
For a week after the illness is over, offer increased amount of food and continue to give favourite food and
encourage the cjhild to feed as much as possible
Feeding recommendations for a child who has PERSISTANT DIA
If still breastfeeding, give more frequent, longer breastfeeds, .
If taking other milk:
Replace with increased breastfeeding OR
Replace witgh fermented milk products, such as sour milk
Replace half the milk with thick porridge and added vegetavegetables and finely ground chicken or fish OR
For other foods, follow feeding recomendation for the child's a .
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FOOD
Feeding Recommendations For a Chi ld 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.
Counsel the Mother Abou t 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 6 months old and is taking other milk or foods:
Build mother's confidence that she can produce all the breast milk that the child needs.
Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk orfoods.
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 breast milk 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 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, andoffer frequent small feedings.
Clear a blocked nose if it interferes with feeding.
Expect that appetite will improve as child gets better.
If the child has a poor appetite:
Plan small, frequent meals.
Give milk rather than other fluids except where there is diarrhoea with some dehydration.
Give snacks between meals.
Give high energy foods.
Check regularly.
If the child has sore mouth or ulcers:
Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
Avoid spicy, salty or acid foods.
Chop foods finely.
Give cold drinks or ice, if available.
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Counsel
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
Counselling on STD and AIDS prevention.
FLUID
Advise the Moth er to Increase Fluid During Il lness
FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milkgiven.
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.
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WHEN TO RETURN
Advise the Mother When to
Return to Health Wo rkerFOLLOW-UP VISIT:Advise the mother to come for follow-up atthe earliest time listed for the child's problems.
If the child has: Return for follow-up
in:
PNEUMONIA
DYSENTERY
FEVER: NO MALARIA, if fever persistsMEASLES WITH EYE OR MOUTHCOMPLICATIONS
2 days
MALARIA, if fever persists 3 days
PERSISTENT DIARRHOEA
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
COUGH OR COLD, if not improving
5 days
ANAEMIA 14 days
VERY LOW WEIGHT FOR AGE 30 days
NEXT WELL-CHILD VISIT:Advise the mother to return for nextimmunization according to immunization schedule.
WHEN TO RETURN IMMEDIATELY
Advise mother to return immediately if the child has anyof these signs:
Any sick child Not able to drink orbreastfeed
Becomes sicker
Develops a fever
If child has COUGH OR COLD,also return if:
Fast breathing
Difficult breathing
If child has Diarrhoea, also returnif:
Blood in stool
Drinking poorly
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Assess, classify and treat the sick young infant aged up to 2
monthsASSESS AND CLASSIFY
ASSESS CLASSIFY IDENTIFY TREATMENT
DO A RAPID APRAISAL OF ALL WAITING INFANTS
ASK THE MOTHER WHAT THE YOUNG INFANT'S
PROBLEMS ARE
Determine if this is an initial or follow-up visit for thisproblem.
if follow-up visit, use the follow-up instructions.
if initial visit, assess the child as follows:
USE ALL BOXES THAT MATCH THE
INFANT'S SYMPTOMS AND
PROBLEMS TO CLASSIFY THE
ILLNESS
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CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
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ASK : LOOK , L ISTEN, FEEL:
Is the infant having
difficulty in feeding?
Has the infant had
convulsions (fits)?
Count the
breaths in one
minute. Repeat
the count if
more than 60
breaths per
minute.
Look for
severe chest
indrawing.
YOUNG
INFANT
MUST
BE
CALM
Measure axillary
temperature.
Look at the umbilicus. Is it
red or draining pus?
Look for skin pustules.
Look at the young
infant's movements.
If infant is sleeping, ask
the mother to wake
him/her.
Does the infant moveon his/her own?
If the young infant is not
moving, gently stimulate
him/her.
Does the infant not
move at all?
Any one of the following
signs
Not feeding well or
Convulsions or
Fast breathing (60 breaths
per minute or more) or
Severe chest indrawing or
Fever (37.5C* or above)
or
Low body temperature
(less than 35.5C*) orMovement only when
stimulated or no movement
at all.
P i n k :
VERY SEVERE
DISEASE
Give first dose of intramuscular antibiotics
Treat to prevent low blood sugar
Refer URGENTLY to hospital **
Advise mother how to keep the infant
warm on the way to the hospital
Umbilicus red or draining
pus
Skin pustules
Ye l l ow:
LOCAL
BACTERIAL
INFECTION
Give an appropriate oral antibiotic
Teach the mother to treat local infections at home
Advise mother to give home care for the young
infant
Follow up in 2 days
None of the signs of very
severe disease or local
bacterial infection
Green:
SEVERE DISEASE
OR LOCAL
INFECTION
UNLIKELY
Advise mother to give home care.
Class i fy ALL YOUNG
INFANTS
* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher.
** If referral is not possible, see I n teg ra ted Managemen t o f Ch i l dhood I l l ness, Management of the sick young infant module, Annex 2 "Where referral is not possible".
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THEN ASK: Does the young infant have diarrhoea*?
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IF YES, LOOK AND FEEL:
Look at the young infant's general condition:
Infant's movements
Does the infant move on his/her own?
Does the infant not move even when stimulated but
then stops?
Does the infant not move at all?
Is the infant restless and irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?or slowly?
Two of the following signs:
Movement only when
stimulated or no
movement at all
Sunken eyes
Skin pinch goes back
very slowly.
P i n k :
SEVERE
DEHYDRATION
If infant has no other severe classification:
Give fluid for severe dehydration (Plan C)
OR
I f in fant a lso has another s evere
c lass i f i ca t ion:
Refer URGENTLY to hosp i tal with
mother g iv ing f requent s ips of ORS on
the way
Adv ise the mother to cont inue
breas t feeding
Two of the following signs:
Restless and irritable
Sunken eyes
Skin pinch goes back
slowly.
Yel low:
SOME
DEHYDRATION
Give fluid and breast milk for somedehydration (Plan B)
I f in fant has any severe c lass i f i ca tion:
Refer URGENTLY to hosp i tal with
mother g iv ing f requent s ips of ORS on
the way
Adv ise the mother to cont inue
breas t feeding
Advise mother when to return immediately
Follow-up in 2 days if not improving
Not enough signs to classify
as some or severe
dehydration.
Green:
NO
DEHYDRATION
Give fluids to treat diarrhoea at home and
continue breastfeeding (Plan A)
Advise mother when to return immediately
Follow-up in 2 days if not improving
Classi fy
DIARRHOEA for
DEHYDRATION
* What is diarrhoea in a young infant?
A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than fecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
CHECK FOR JAUNDICE
I f jaund ice p resen t, ASK : LOOK AND FEEL :
When did the jaundice
appear first?
Look for jaundice (yellow
eyes or skin)
Look at the young infant's
palms and soles. Are theyyellow?
Any jaundice if age less
than 24 hours or
Yellow palms and soles at
any age
P i n k :
SEVERE
JAUNDICE
Treat to prevent low blood sugar
Refer URGENTLY to hosp i tal
Adv ise mother how to keep the in fant
warm on the way to the hospi ta l
Jaundice appearing after
24 hours of age and
Palms and soles not
yellow
Yel low:
JAUNDICE
Advise the mother to give home care for the
young infant
Advise mother to return immediately if palms
and soles appear yellow.
If the young infant is older than 14 days, refer
to a hospital for assessment
Follow-up in 1 day
No jaundice Green:
NO JAUNDICE
Advise the mother to give home care for the
young infant
CLASSIFYJAUNDICE
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THEN CHECK FOR HIV INFECTION
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ASK
Has the mother and/or young infant had an HIV test?
IF YES: Then note mother's and/or you ng infant 's HIV
status
Mother's HIV status:
Serological test POSITIVE or NEGATIVE
Young infant's HIV status:
Virological test POSITIVE or NEGATIVE
Serological test POSITIVE or NEGATIVE
I f mother is HIV pos i t i ve and NO p os i t i ve v i ro log ica l
tes t in chi ld ASK:
Is the young infant breastfeeding now?
Was the young infant breastfeeding at the time of test
or before it?
Is the mother and young infant on ARV prophylaxis?*
IF NO tes t : Mother and young in fant s ta tus unknown
Perform HIV test for the mother; if positive, perform
virological test for the young infant
Positive virological test in
young infant
Yel low:
CONFIRMED HIV
INFECTION
Give cotrimoxazole prophylaxis from age 4-6
weeks
Give HIV care/ART
Advise the mother on home care
Consider presumptive severe HIV disease as
described before
If infant less than 3 days old give Nevirapine and
start AZT if not yet administered
Follow-up in one month.
Mother HIV positive ANDnegative virological test
in young
infant breastfeeding or if
only stopped less than 6
weeks ago.
OR
Mother HIV positive, young
infant not yet tested
OR
Positive serological test in
young infant
Yel low:POSSIBLE HIV
INFECTION or HIV
EXPOSED
Give cotrimoxazole prophylaxis from age 4-6weeks
Start or continue ARV prophylaxis as per
national recommendations*
Do virological test at age 4-6 weeks or repeat 6
weeks after the child stops breastfeeding
Advise the mother on home care
Follow-up regularly as per national guidelines
Negative HIV test in mother
or young infant
Green:
HIV INFECTIONUNLIKELY
Treat, counsel and follow-up existing infections
No HIV test in the child or
mother.
Green:
HIV INFECTION
STATUS
UNKNOWN
Treat, counsel and follow-up existing
classification.
Advise the mother about feeding and about her
health.
Refer/do counselling and testing for HIV.
Classi fy
HIV
status
* PMTCT for breastfed child:
OPTION A - If the mother is already on AZT prophylaxis and the baby is on NVP prophylaxis, continue until 1 week after breastfeeding has stopped.
OPTION B - If the mother is already on triple ARV regime, continue until 1 week after breastfeeding has stopped and give the baby AZT or NVP from birth until 4-6 weeks of age.
PMTCT for non-breastfed child: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.
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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE: FOR BREAST FEEDING INFANTS
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If an infant has no indications to refer urgently to hospital:
Ask : LOOK, L ISTEN, FEEL :
Is the infant breastfed? If
yes, how many times in 24
hours?
Does the infant usually
receive any other foods or
drinks? If yes, how often?
If yes, what do you use to
feed the infant?
Determine weight for age.
Look for ulcers or white
patches in the mouth
(thrush).
Not well attached to breast
or
Not suckling effectively or
Less than 8 breastfeeds in
24 hours or
Receives other foods or
drinks or
Low weight for age or
Thrush (ulcers or white
patches in mouth).
Ye l low:
FEEDING
PROBLEM
OR
LOW WEIGHT
If not well attached or not suckling effectively,
teach correct positioning and attachment
If not able to attach well immediately, teach
the mother to express breast milk and feed by
a cup
If breastfeeding less than 8 times in 24 hours,
advise to increase frequency of feeding. Advise
the mother to breastfeed as often and as long as
the infant wants, day and night
If receiving other foods or drinks, counsel the
mother about breastfeeding more, reducing other
foods or drinks, and using a cupIf not breastfeeding at all:
Refer for breastfeeding counselling and
possible relactation
Advise about correctly preparing breast-
milk substitutes and using a cup
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise mother to give home care for the young
infant
Follow-up any feeding problem or thrush in
2 days
Follow-up low weight for age in 14 days
Not low weight for age and
no other signs ofinadequate feeding.
Green :
NO FEEDINGPROBLEM
Advise mother to give home care for the young
infantPraise the mother for feeding the infant well
Classify FEEDING
ASSESS BREA STFEEDING:
Has the infant breastfed in the previous hour?
If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
(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.)
Is the infant well attached?
not wel l at tached good at tachment
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep
sucks, sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in NON-breastfed infants
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Use this chart for HIV EXPOSED infants when the national authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding AND the infant has no
indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL :
What milk are you giving?
How many times during
the day and night?
How much is given at
each feed?
How are you preparing
the milk?
Let mother demonstrate orexplain how a feed is
prepared, and how it is
given to the infant.
Are you giving any breast
milk at all?
What foods and fluids in
addition to replacement
feeds is given?
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
Determine weight for age.
Look for ulcers or white
patches in the mouth
(thrush).
Milk incorrectly or
unhygienically prepared o r
Giving inappropriate
replacement feeds or
Giving insufficient
replacement feeds or
An HIV positive mother
mixing breast and otherfeeds before 6 months or
Using a feeding bottle or
Low weight for age or
Thrush (ulcers or white
patches in mouth).
Yel low:
FEEDING
PROBLEM
OR
LOW WEIGHT
Counsel about feeding
Explain the guidelines for safe replacement
feeding
Identify concerns of mother and family about
feeding.
If mother is using a bottle, teach cup feeding
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise mother to give home care for the young
infant
Follow-up any feeding problem or thrush in
2 days
Follow-up low weight for age in 14 days
Not low weight for age and
no other signs of
inadequate feeding.
Green:
NO FEEDING
PROBLEM
Advise mother to give home care for the young
infant
Praise the mother for feeding the infant well
Classif y FEEDING
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THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN
A STATUS:
S
IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN ABirth BCG OPV-0 200 000 IU to the mother within 6
weeks of delivery6 weeks DPT+HIB-1 OPV-1 Hepatitis B110 weeks DPT+HIB-2 OPV-2 Hepatitis B2
Give all missed doses on this visit.
Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.
ASSESS OTHER PROBLEMS
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TREAT AND COUNSEL
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
Give First Dose of Intramuscu lar Antibiot ics
Give first dose of ampicillin intramuscularly and
Give first dose of gentamicin intramuscularly.
WEIGHT
AMPICILLINDose: 50 mg per kgTo a vial of 250 mg
GENTAMICIN
Add 1.3 ml sterile water = 250 mg/1.5ml
Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml
ORAdd 6 sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml
AGE = 7 daysDose: 7.5 mg per kg
1-
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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
Treat the Young Infant to Prevent Low Blood Sugar
If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10ml/kg) sugar water(To make sugar water: Dissolv e 4 level teaspoons of sugar (20 grams) in a 200-ml cu p of clean water).
If the young infant is not able to sw allow:
Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.
Teach the Mother How to Keep the Young Infant Warm on
the Way to the Hosp ital
Provide skin to skin contactOR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat,gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.
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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
Give an Appropriate Oral Antibiot ic for Local Bacterial
InfectionFirst-line antibiotic: ___________________________________________________________________________________________
Second-line antibiotic:_________________________________________________________________________________________
AGE or WEIGHT
COTRIMOXAZOLEtrimethoprim + sulphamethoxazole
Give 2 times daily for 5 days
AMOXICILLINGive 2 times
daily for 5 days
Adult Tabletsingle strength
(80 mg trimethoprim +400 mg sulphamethoxazole)
Pediatric Tablet(20 mg trimethoprim +
100 mg sulphamethoxazole)
Syrup(40 mg trimethoprim +
200 mg sulphamethoxazole)
Tablet
250 mg
Syrup125 mg
in 5 ml
Birth up to 1 month(
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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
Teach the Mother to Treat Local Infect ions at Home
Explain how the treatment is given.Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.
To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment twice daily for 5days:
Wash hands
Gently wash off pus and crusts with soap and water
Dry the areaPaint the skin or umbilicus/cord with fullstrength gentian violet (0.5%)
Wash hands
The mother should do the treatment four times daily for 7 days:
Wash hands
Paint the mouth with half-strength gentian violet (0.25%) using a soft clothwrapped around the finger
Wash hands
To Treat Diarrhoea, See TREAT THE CHILD Chart .
Immun ize Every Sick Young Infant, as Needed
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COUNSEL THE MOTHER
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COUNSEL THE MOTHER
Teach Correct Posit ioning and Attachment for
Breastfeeding
Show the mother how to hold her infant.
with the infant's head and body in line.
with the infant approaching breast with nose opposite to the nipple.
with the infant held close to the mother's body.
with the infant's whole body supported, not just neck and shoulders.
Show her how to help the infant to attach. She should:touch her infant's lips with her nipple
wait until her infant's mouth is opening wide
move her infant quickly onto her breast, aiming the infant's 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.
Teach the Moth er How to Express Breast Milk
Ask the mother to:
Wash her hands thoroughly.
Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other (at least 4
cm from the tip of the nipple).Compress and release the breast tissue between her finger and thumb a few times.
If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast asbefore.
Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not tosqueeze the nipple or to rub the skin or move her thumb or finger on the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.
Teach th e Mother How to Feed by a Cup
Put a cloth on the infant's front to protect his clothes as some milk can spill.
Hold the infant semi-upright on the lap.
Put a measured amount of milk in the cup.
Hold the cup so that it rests lightly on the infant's lower lip.Tip the cup so that the milk just reaches the infant's lips.
Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
Teach the Moth er How to K eep the Low Weight Infant Warm
at Home
Keep the young infant in the same bed with the mother.
Keep the room warm (at least 25C) with home heating device and make sure that there is no draught of cold air.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately andthoroughly after bathing and clothe the young infant immediately.
Change clothes (e.g. nappies) whenever they are wet.
Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's head turned to one side.
Cover the infant with mother's clothes (and an additional warm blanket in cold weather).
When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infantwith extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket.
Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
Breastfeed the infant frequently (or give expressed breast milk by cup).
Adv ise the Mother to Give Home Care for the Young Infant
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANTGive only breastfeeds to th