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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

SICK CHILD AGE 2 MONTHS UP TO 5 YEARS


ASSESS AND CLASSIFY THE SICK CHILD
Assess, Classify and Identify Treatment Check for General Danger Signs ..................................... 2 Then Ask About Main Symptoms: Does the child have cough or difficult breathing? ................ 2 Does the child have diarrhoea? ....................................... 3 Does the child have fever? ............................................. 4 Does the child have an ear problem? ............................... 5 Then Check for Malnutrition and Anaemia....................... 6 Then Check the Childs Immunization Status .................. 7 Assess Other Problems................................................... 7

World Health Organization


Division of Child Health and Development (CHD)

unicef

TREAT THE CHILD, continued


Give Extra Fluid for Diarrhoea and Continue Feeding Plan A: Treat Diarrhoea at Home ............................ 13 Plan B: Treat Some Dehydration with ORS ............. 13 Plan C: Treat Severe Dehydration Quickly .............. 14 Give Follow-up Care Pneumonia.............................................................. 15 Wheeze .................................................................. 15 Persistent Diarrhoea ............................................... 15 Dysentery ............................................................... 15 Malaria .................................................................... 16 Fever-Malaria Unlikely ............................................ 16 Measles with Eye or Mouth Complications .............. 16 Ear Infection............................................................ 17 Feeding Problem..................................................... 17 Anaemia ................................................................. 17 Very Low Weight ..................................................... 17

MINISTRY OF HEALTH MALAYSIA National Adaptation January 2011

SICK YOUNG INFANT AGE UP TO 2 MONTHS


ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
Assess, Classify and Identify Treatment Check for Very Severe Disease and Local Bacterial Infection ........ 23 Then check for Jaundice................................................................ 24 Then ask: Does the young infant have diarrhoea? ......................... 25 Then Check for Feeding Problem or Low Weight for Age .............. 26 Then Check the Young Infants Immunization ................................ 27 Assess Other Problems ................................................................. 27 Treat the Young Infant and Counsel the Mother Intramuscular Antibiotics ................................................................ 28 Prevent Low Blood Sugar .............................................................. 28 Keep the Young Infant Warm on the Way to the Hospital .............. 29 Oral Antibiotic ................................................................................ 29 Oral Nystatin.................................................................................. 29 Treat Local Infections at Home ...................................................... 30 Correct Positioning and Attachment for Breastfeeding ................... 31 Teach Mother How to Express Breast Milk .................................... 31 Teach Mother How to Feed with a Cup .......................................... 32 Keep the Low Weight Infant Warm at Home .................................. 32 Advise Mother to Give Home Care for Infant.................................. 33 Advise Mother When to Return Immediately .................................. 33 Give Follow-up Care for the Sick Young Infant Local Bacterial Infection ................................................................ 34 Jaundice ........................................................................................ 34 Diarrhoea ...................................................................................... 34 Feeding Problem ........................................................................... 35 Low Weight for Age ....................................................................... 35 Thrush ........................................................................................... 35 RECORDING FORMS SICK CHILD ..................................................................... 37 SICK YOUNG INFANT ..................................................... 39 WEIGHT FOR AGE CHART ................................................. on back cover

TREAT THE CHILD


Teach the Mother to Give Oral Drugs at Home Oral Antibiotic............................................................ 8 Oral Salbutamol ........................................................ 8 Oral Antimalarial ....................................................... 9 Oral Co-Artemether ................................................... 9 Paracetamol .............................................................. 9 Vitamin A .................................................................. 9 Iron ........................................................................... 9 Albendazole .............................................................. 9 Teach the Mother to Treat Local Infections at Home Treat eye infection with Chloramphenicol Eye Ointment ................................................................. 10 Dry the Ear by Wicking and Give Ear Drops ............ 10 Treat Mouth Ulcers with Sodium Bicarbonate .......... 10 Soothe the Throat, Relieve the Cough with a Safe Remedy .................................................................. 10 Give These Treatments in Clinic Only Intramuscular Antibiotic ........................................... 11 Treat Low Blood Sugar .......................................... .12 Treat Convulsion with Diazepam ............................. 12 Treat Wheeze with Nebulised/Inhaled Salbutamol... 12

COUNSEL THE MOTHER


Assess the Feeding of Sick Infants ......................... 18 Feeding Recommendations .................................... 19 Counsel the Mother About Feeding Problems ......... 20 Counsel the Mother About Her Own Health ............ 21 Advise the Mother to Increase Fluids During Illness 22 Advise the Mother When to Return to Clinic ............ 22 Advise the Mother When to Return Immediately ..... 22

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


ASSESS
ASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE Determine if this is an initial or follow-up visit for this problem.

CLASSIFY

IDENTIFY TREATMENT

- if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. - if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS


ASK:
Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions during this illness?

LOOK:
See if the child is drowsy or unconscious. See if the child is convulsing now.

USE ALL BOXES THAT MATCH THE CHILDS SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS.

If the child is convulsing now, manage the airway and treat the child with Diazepam. A child with any general danger sign needs URGENT attention; complete the assessment and
any pre-referral treatment immediately so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS:


Does the child have cough or difficult breathing?
IF YES, ASK:
For how long?

SIGNS
Any general danger sign or Chest indrawing or Stridor in calm child

CLASSIFY AS
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

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

LOOK, LISTEN, FEEL:


Count the breaths in one

minute. Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze.

CHILD MUST BE CALM

Classify COUGH or DIFFICULT BREATHING

Give first dose of an appropriate antibiotic. Refer URGENTLY to hospital.* Give oxygen if available. Treat wheeze if present with inhaled Salbutamol. Give oral antibiotic for 5 days. Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days. Soothe the throat and relieve cough with safe remedy. Advise mother when to return immediately. Follow up in 2 days. If cough more than 14 days / recurrent wheeze refer for assessment for TB / Asthma. Treat wheeze with inhaled Salbutamol and continue with oral Salbutamol for 5 days. Soothe throat and relieve cough with safe remedy. Advise mother when to return immediately. Follow up in 5 days. If cough more than 14 days / recurrent wheeze refer for assessment for TB / Asthma. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in 5 days if not improving. If cough more than 14 days / recurrent wheeze refer for assessment for TB /Asthma.

Fast breathing
PNEUMONIA

If wheezing and either fast breathing or chest indrawing: Give a trial of inhaled Salbutamol for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again and then classify.

Wheeze
WHEEZE

If the child is:


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

Fast breathing is:


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

No signs of pneumonia or very severe disease

COUGH OR COLD

* If referral is not possible, manage the child as described in Treat the Child Module Annex E: Where Referral Is Not Possible

Does the child have diarrhoea?


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

SIGNS
Two or more of the following signs:

CLASSIFY AS

(Urgent pre-referral treatments are in bold print) Refer URGENTLY to hospital. If child has no other severe classification or general danger sign:

TREATMENT

LOOK AND FEEL:


Look at the childs general condition
Is the child: Drowsy or unconscious? Restless or irritable?

For DEHYDRATION

Drowsy or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly.

SEVERE DEHYDRATION

Give fluid for severe dehydration (Plan C). OR If child also has another severe classification:

Look for sunken eyes. Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking eagerly, thirsty?

Give frequent sips of ORS on the way. Advise the mother to continue breastfeeding.

If child is 2 years or older and there is cholera in your area, give antibiotic for cholera after taking rectal swab. Give fluid, zinc supplements and food for some dehydration (Plan B). If child also has a severe classification:

Pinch the skin of the abdomen.


Does it go back: - Very slowly (longer than 2 seconds)? - Slowly?

Classify DIARRHOEA

Two or more of the following signs:


Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly.


SOME DEHYDRATION

Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding.


Not enough signs to classify as some or severe dehydration.

Advise mother when to return immediately. Follow-up in 5 days if not improving. 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.

NO DEHYDRATION

and if diarrhoea for 14 days or more

Dehydration present

SEVERE PERSISTENT DIARRHOEA PERSISTENT DIARRHOEA

Treat dehydration before referral unless the child has another severe classification. Refer to hospital. Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. Give multivitamins and minerals (including zinc) for 14 days. Follow-up in 5 days.

No dehydration

and if blood in stool

Blood in the stool

DYSENTERY

Treat with an oral antibiotic for 5 days. Follow-up in 2 days.

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DANGER SIGNS, COUGH DIARRHOEA

ASSESS AND CLASSIFY

Does the child have fever?


(by history or temperature 37.5C** or above)

SIGNS
Any general danger sign or Stiff neck.

CLASSIFY AS

MALARIA

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

IF YES:

ASK:
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 AND FEEL:


Look or feel for stiff neck. Look for runny nose.

Classify FEVER

VERY SEVERE FEBRILE DISEASE

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

Treat with oral antimalarial and refer to doctor. Give Paracetamol for fever and give first dose of Paracetamol in clinic for high fever (38.5 C or above). Advise mother when to return immediately. Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for assessment.

Do a blood slide for BFMP if no runny nose, no measles and no other cause of fever.

Runny nose PRESENT or Measles PRESENT or Other cause of fever PRESENT Or

FEVER MALARIA UNLIKELY

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

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

No other cause of fever and BFMP pending or negative.

Give Paracetamol for fever and give first 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. Trace BFMP if taken and call back patient for treatment if positive. If fever is present every day for more than 7 days, refer for assessment

IF MEASLES
now or within last 3 months,

Any general danger sign or Clouding of cornea or Deep or extensive mouth ulcers.

SEVERE COMPLICATED MEASLES***

Classify
Pus draining from the eye or Mouth ulcers.

Give Vitamin A. Give first dose of an appropriate antibiotic. If clouding of the cornea or pus draining from the eye, apply Chloramphenicol eye ointment. Refer URGENTLY to hospital. Give Vitamin A.

MEASLES WITH If pus draining from the eye, treat eye infection with ChloramEYE OR MOUTH phenicol eye ointment. COMPLICATIONS*** If mouth ulcers, treat with Sodium Bicarbonate solution.

Measles now or within the last 3 months.

Follow-up in 2 days. Give Vitamin A.

MEASLES

** These temperatures are based on axillary temperature readings. Rectal temperature readings are approximately 0.5C higher. *** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.

Does the child have ear problem?


IF YES, ASK:
Is there ear pain? Is there ear discharge?

SIGNS
Classify EAR PROBLEM
Tender swelling behind the ear.

CLASSIFY AS
MASTOIDITIS

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

LOOK AND FEEL:


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

Give first dose of an appropriate antibiotic. Give first dose of Paracetamol for pain. Refer URGENTLY to hospital. Give an antibiotic for 5 days. Give Paracetamol for pain. Dry the ear by wicking. Follow-up in 5 days.

If yes, for how long?

Pus is seen draining from the ear and discharge is reported for less than 14 days or Ear pain.

ACUTE EAR INFECTION

Pus is seen draining from the ear and discharge is reported for 14 days or more.

CHRONIC EAR INFECTION

Dry the ear by wicking. Treat with topical Chloramphenicol eardrops for 2 weeks. Follow-up in 5 days

No ear pain and No pus seen draining from the ear.

NO EAR INFECTION

No treatment.

FEVER MALARIA, MEASLES EAR PROBLEM

THEN CHECK FOR MALNUTRITION AND ANAEMIA CHECK FOR MALNUTRITION


LOOK AND FEEL:
Look for visible severe wasting. Look for oedema of both feet. Determine weight for age.

SIGNS
Visible severe wasting or Oedema of both feet. Very low weight for age.

CLASSIFY AS
SEVERE MALNUTRITION

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

Classify NUTRITIONAL STATUS

Treat the child to prevent low sugar. Refer URGENTLY to hospital. Assess the child`s feeding and counsel the mother on feeding

VERY LOW WEIGHT

according to the feeding recommendations in the COUNSEL THE MOTHER chart.

If feeding problem, follow-up in 5 days. Follow-up in 14 days.

Not very low weight for age and no other sign of malnutrition.

If child is less than 2 years old, assess the child`s feeding and
NOT VERY LOW WEIGHT counsel the mother on feeding according to the feeding recommendations in the COUNSEL THE MOTHER chart.

If feeding problem, follow-up in 5 days.

CHECK FOR ANAEMIA


LOOK AND FEEL:

Look for palmar pallor. Is it: - Severe palmar pallor? - Some palmar pallor?

Classify ANAEMIA

Severe palmar pallor. Some palmar pallor

SEVERE ANAEMIA

Refer URGENTLY to hospital. Assess the child`s feeding and counsel the mother on feeding
according to the feeding recommendations in the COUNSEL THE MOTHER chart.

ANAEMIA

If feeding problem, follow-up in 5 days. Give iron. Give Albendazole if child is 1 year or older and has not had a
dose in the previous 6 months.

Follow up in 14 days.
No palmar pallor 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 in the COUNSEL THE MOTHER chart.

If feeding problem, follow-up in 5 days. Give Albendazole if child is 1 year or older and has not had a
dose in the previous 6 months.

THEN CHECK THE CHILDS IMMUNIZATION STATUS AND DEWORMING STATUS


NATIONAL IMMUNIZATION SCHEDULE
AGE Birth 1 month 2 months 3 months 5 months 6 months 12 months 18 months In addition SABAH SARAWAK 6 months 9 months 10 months 18 months Measles JE 1 JE 2 JE 3 MMR (DTaP + Hib + IPV) ( booster )
...

VACCINE BCG (DTaP + Hib + IPV) 1 (DTaP + Hib + IPV) 2 (DTaP + Hib + IPV) 3 Hep B 3 Hep B 1 Hep B 2

ROUTINE WORM TREATMENT


Give every child Albendazole every 6 months from the age of one year. Record the dose on childs card.

... ...

ASSESS OTHER PROBLEMS

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent pre-referral treatments.

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MALNUTRITION, ANAEMIA IMMUNIZATION STATUS

TREAT THE CHILD


CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table.
Determine the appropriate drugs and dosage for the childs age or weight. Tell the mother the reason for giving the drug to the child. Demonstrate how to measure a dose. Watch the mother practise measuring a dose by herself. Ask the mother to give the first dose to her child. Explain carefully how to give the drug, then label and package the drug. 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 mothers understanding before she leaves the clinic.
AGE or WEIGHT AGE or WEIGHT

Give an Appropriate Oral Antibiotic


FOR PNEUMONIA, ACUTE EAR INFECTION, MASTOIDITIS OR VERY SEVERE DISEASE: FIRST-LINE ANTIBIOTIC: AMOXYCILLIN (25 mg/kg/dose) SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE (4 mg/kg/dose) AMOXYCILLIN Give TWO times daily for 5 days Syrup 125 mg/5 ml COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) Give TWO times daily for 5 days Syrup 40 mg Trimethoprim + 200 mg Sulphamethoxazole/5 ml

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

5 ml 7.5 ml 10 - 15 ml

2.5 ml 5 ml 7.5 -10 ml

FOR SEVERE PNEUMONIA OR VERY SEVERE DISEASE / MASTOIDITIS: If the child can take orally give double the dose of AMOXICILLIN before urgent referral. Do not use Cotrimoxazole. FOR DYSENTERY: FIRST-LINE ANTIBIOTIC FOR SHIGELLA: COTRIMOXAZOLE (4 mg/kg/dose) SECOND-LINE ANTIBIOTIC FOR SHIGELLA: AMPICILLIN (20 mg/kg/dose) COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) Give TWO times daily for 5 days Syrup 40 mg Trimethoprim + 200 mg Sulphamethoxazole/5 ml AMPICILLIN Give FOUR times daily for 5 days Syrup 125 mg/5 ml

GIVE ORAL SALBUTAMOL


ORAL SALBUTAMOL Give three times daily for 5 days AGE or WEIGHT 2 months up to 4 months (4 - < 6 kg) 4 months up to 12 months (6 - < 10 kg) 12 months up to 3 years (10 - < 14 kg) 3 years up to 5 years (14 - < 19 kg) 2mg/5 ml syrup 1 ml 2 ml 3.5 ml 5 ml

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

2.5 ml 5.0 ml 7.5 -10 ml

2.5 ml 5 ml 7.5 -10 ml

FOR CHOLERA: . FIRST-LINE ANTIBIOTIC FOR CHOLERA: COTRIMOXAZOLE (4 mg/kg/dose) SECOND-LINE ANTIBIOTIC FOR CHOLERA: ERYTHROMYCIN (20 mg/kg/dose) COTRIMOXAZOLE ERYTHROMYCIN (Trimethoprim + Sulphamethoxazole) Give TWO times daily for 3 days Give TWO times daily for 3 days Syrup 40 mg Trimethoprim + SYRUP AGE or WEIGHT 200 mg Sulphamethoxazole/5 ml 200 mg/5ML

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

2.5 ml 5 ml 7.5 - 10 ml

2.5 ml 5 ml 7.5 -10 ml

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Give an Oral Antimalarial


Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the clinic for additional tablets. Explain that itching is a possible side effect of the drug, but is not dangerous. 1 tab Chloroquine = 155 mg base 1 tab Primaquine = 7.5 mg base

Give Paracetamol for Fever or Ear Pain

Give paracetamol (15mg/kg/dose) every 6 hours until fever or ear pain is gone. PARACETAMOL AGE or WEIGHT Syrup (120 mg/5 ml) 2.5 ml 5 ml 7.5 ml 10 ml TABLET (500 mg) 1/4 1/2 1/2

2 months up to 4 months (4 - < 6 kg) 4 months up to 12 months ( 6 - <10 kg) 1 year up to 3 years (10 - < 14 kg)

a) P. Falciparum
Age < 1 year Antimalarial, Dose, Duration Chloroquine 1/2 tab daily for 3 days Primaquine 1/4 tab daily for 3 days Fansidar 1/4 tab stat Chloroquine 1 tab daily for 3 days Primaquine 1/2 tab daily for 3 days Fansidar 1/2 tab stat Chloroquine 1 tab daily for 3 days Primaquine 1/2 tab daily for 3 days Fansidar 1 tab stat

b) P. Vivax
Age < 1 year Antimalarial, Dose, Duration Chloroquine 1/2 tab daily for 3 days Primaquine 1/4 tab daily for 14 days Chloroquine 1 tab daily for 3 days Primaquine 1/2 tab daily for 14 days

3 years up to 5 years (14 - < 19 kg)

1 - < 4 years 4 - 5 years

Give Vitamin A

1 - 5 years

Give two doses. Give first dose in clinic. Give mother one dose to give at home the next day.
AGE VITAMIN A dosages

6 months up to 12 months

100,000 IU 200,000 IU

c) Mixed Infection :
Follow regime for P. Vivax, and add Tab. Fansidar 1/4 tablet on Day 1 for age less than 1 year, Tab. Fansidar 1/2 tablet on Day 1 for age 1 to 4 years, Tab. Fansidar 1 tab on Day 1 for age 4 to 5 years.

12 months up to 5 years

Alternative Treatment for P. Falciparum

Give Iron

Give Oral Co-Artemether


Give the first dose of co-Artemether in the clinic and observe for one hour. If child vomits within an hour repeat the dose. 2nd dose at home after 8 hours. Then twice daily for further 2 days as shown below. Co-Artemether should be taken with food.

Give one dose daily for 14 days. IRON SYRUP Ferrous Fumarate (FF) Mixture 2.5 ml 3.5 ml 5 ml 6 ml IRON SYRUP Ferrous Ammonium Citrate (FAC) Mixture 2 ml 3 ml 4 ml 5 ml

AGE or WEIGHT

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

Co-Artemether (20 mg Artemether and 120 mg Lumefantrine) Weight (age)


5 - <15 Kg (5 months up to 3 years) 15 - < 20 Kg (3 years up to 5 years)

0 hr 1 2

8h 1 2

24 h 1 2

36 h 1 2

48 h 1 2

60 h 1 2

3 years up to 5 years (14 - <19 kg)

Give Albendazole

Give 400 mg Albendazole as a single dose in clinic if:


the child is 1 years of age or older, and the child has not had a dose in the previous 6 months.

ORAL DRUGS ANTIBIOTICS SALBUTAMOL

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TREAT

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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.

Dry the Ear by Wicking and Give Eardrops

Describe the treatment steps listed in the appropriate box. Watch the mother as she does the first treatment in the clinic (except remedy for cough or sore throat). Tell her how often to do the treatment at home. If needed for treatment at home, give mother the tube of Chloramphenicol ointment or Sodium Bicarbonate powder. Check the mothers understanding before she leaves the clinic.

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 childs ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry. If the child has CHRONIC EAR INFECTION, put two drops of Chloramphenicol ear drops into ear after wicking. Treat for 14 days.

Treat Mouth Ulcers with 2% Sodium Bicarbonate


Solution

Treat Eye Infection with Chloramphenicol


Eye Ointment 1%

Treat the mouth ulcers three to four times daily .


Clean both eyes 3 times daily.


Wash hands. Ask child to close the eye. Use clean cloth and water to gently wipe away pus.

Wash hands. Use Sodium Bicarbonate 2% solution Wash the childs mouth with clean soft cloth wrapped around the finger and wet with Sodium Bicarbonate solution. Wash hands again. Continue for 2 days after ulcers has been cured.

Then apply Chloramphenicol eye ointment in both eyes 3 times daily.


Ask the child to look up. Squirt a small amount of ointment on the inside of the lower lid. Wash hands again.

Soothe the Throat, Relieve the Cough with a


Safe Remedy
Safe remedies to recommend: - Breastmilk for breastfed infant. - Warm water if not breastfed. Harmful remedies to discourage: - Cough syrup. - Nasal decongestants.

Treat until redness is gone. Do not use other eye ointments or drops, or put anything else in the eye.

GIVE THESE TREATMENTS IN CLINIC ONLY

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

Give An Intramuscular Antibiotic


FOR CHILDREN BEING REFERRED URGENTLY WHO CANNOT TAKE AN ORAL ANTIBIOTIC: Give first dose of intramuscular Ampicillin and Gentamicin. IF REFERRAL IS NOT POSSIBLE OR DELAYED: Give Ampicillin 6 hourly and Gentamicin daily for 5 days. GENTAMICIN Dose: 7.5 mg/kg/dose Vial contains 80 mg in 2 ml 1 ml contains 40 mg Gentamicin 0.8 ml 1.1 ml 1.5 ml 1.8 ml 2.5 ml AMPICILLIN Dose: 50 mg/kg/dose Vial contains 500 mg Add 1.8 ml of sterile water 1 ml contains 250 mg Ampicillin 0.8 ml 1.1 ml 1.5 ml 1.8 ml 2.5 ml

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

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LOCAL INFECTIONS INTRAMUSCULAR ANTIBIOTIC

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GIVE THESE TREATMENTS IN CLINIC ONLY


Treat the Convulsing Child with Diazepam

Treat the Child to Prevent Low Blood Sugar

Turn the child on his side and clear the airway. Extend the neck slightly to open the airway. Give oxygen. Do not insert anything in the mouth. Give Diazepam rectally according to dosage below. If convulsions have not stopped after 10 minutes, give a second dose of Diazepam rectally. Do not give oral medication until convulsions have stopped. 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 30-50 ml of expressed breastmilk or a breastmilk substitute. If neither of these is available, give 30-50 ml of 10% dextrose orally before departure

If the child is not able to swallow:


Give 30-50 ml of milk or 10% dextrose solution by nasogastric tube.

Methods of giving Rectal Diazepam:


1. Give Diazepam Rectally

Draw up the dose from an ampoule of diazepam into a tuberculin (1ml) syringe. Base the dose on the weight of the child, where possible. Then remove the needle. Insert the syringe 4-5 cm into the rectum and inject the diazepam solution. Hold buttocks together for a few minutes. OR

Treat Wheeze in the Child


1. Use of Nebuliser

2. Give Commercial Rectal Tube Diazepam If Available Insert the nozzle of the tube into the rectum and squeeze the amount according to the appropriate dose.

Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a nebulizer chamber. Place the mask to cover the childs nose and mouth. Give with oxygen flow of 6-8 liters/min. Nebulise until the liquid is used up or for at least 15 minutes.

Hold the buttocks together for a few minutes.


AGE or WEIGHT
Diazepam given rectally 10 mg/2 ml solution Dose 0.3 to 0.5 mg/kg Diazepam RECTAL TUBE 5 mg/ tube

2. Use of Spacer or Aerochamber


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

0.5 ml 0.75 ml 1 ml 1ml

1/2 tube 1/2 tube 1 tube 1 tube

Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler into spacer or Aerochamber. Depress the canister down to actuate the spray once. Gently place the mask of the spacer to cover the mouth and nose. Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child). Give 2 puffs (100mcg/puff ), allow at least 30 seconds between each puff. Replace inhaler cap.

If a spacer is being used for the first time or when the MDI has not been used for 2 weeks, it should be primed with 4 puffs from the inhaler.

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING


(See FOOD advice on COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home


Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid. 2. Give Zinc Supplements (Age 2 months up to 5 years). 3. Continue Feeding. 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.
4 months up to 12 months 12 months up to 2 years 2 years up to 5 years

AGE*
WEIGHT Amount of fluid (ml) over 4 hours

Up to 4 months

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 in addition to breastmilk. If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup), or cool boiled 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 8 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 or spoon. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue giving extra fluid until the diarrhoea stops.

< 6 kg 200 - 450

6 - < 10 kg 450 - 750

10 - < 12 kg 750 - 900

12 - < 20 kg 900 - 1500

* Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) times 75. If the child wants more ORS than shown, give more. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. Give frequent small sips from a cup or spoon. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding whenever the child wants. AFTER 4 HOURS: Reassess the child and classify the child for dehydration. Select the appropriate plan to continue treatment. Begin feeding the child in clinic. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT: Show her how to prepare ORS solution at home. Show her how much ORS to give to finish 4-hour treatment at home. Give her enough ORS packets to complete rehydration. Also give another 8 packets to use at home (Plan A). Explain the 4 Rules of Home Treatment:

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 clean water in a cup.

1. GIVE EXTRA FLUID 2. GIVE ZINC (age 2 months up to 5 years) 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN

3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN 13

DIAZEPAM, LOW BLOOD SUGAR, NEBULISED/ INHALED SALBUTAMOL, PLAN A, PLAN B

14

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING


(See FOOD advice on COUNSEL THE MOTHER chart)

Plan C: Treat Severe Dehydration Quickly


FOLLOW THE ARROWS. IF ANSWER IS YES, GO ACROSS. IF NO, GO DOWN. Start IV fluid immediately while arranging transport to hospital. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringers Lactate Solution or Normal Saline divided as

If Urgent Referral is NOT possible or while awaiting transport:


A. If you can give IV fluid:
Proceed to give remaining IV fluid 80 ml/kg (refer table). Review the child every 1 hour. 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. Observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS by mouth.

follows: Can you give intravenous (IV) fluid immediately? YES AGE
Infants (under 12 months) Children (12 months up to 5 years)

First give 20 ml/kg in: 1 hour* 30 minutes*

Then give 80 ml/kg in: 5 hours 2 1/2 hours

NO

1. 2. 3. 4. 5. 6.

Give 20 ml/kg IV fluid (refer table). Feel for radial pulse after completion of above bolus. If radial pulse not detectable, repeat 20 ml/kg IV fluid. Refer URGENTLY to hospital once transport is available. Continue IV fluids along the way. If urgent referral not possible or while awaiting transport, see the box on the right.

B. If you are trained to use naso-gastric tube or if the child can drink:
Give ORS 20ml/kg/hour for 6 hours (total 120ml/kg). Review the child every 1 hour. If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS by mouth.

Are you trained to use a nasogastric (NG) tube for rehydration?

NOTE: At all time, all efforts should be made to send the child to hospital as soon as possible.

NO YES Can the child drink?

Refer URGENTLY to Hospital Start Rehydration by tube (or mouth) with ORS solution : give 20

ml/kg/hour.
If urgent referral is not possible or while awaiting transport, see the

box on the right.

NO

IMMUNIZE EVERY SICK CHILD, AS NEEDED


Refer URGENTLY to hospital for treatment

GIVE FOLLOW-UP CARE


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

PNEUMONIA
After 2 days: Check the child for general danger signs. Assess the child for cough or difficult breathing. Ask: Is the child breathing slower? Is there less fever? Is the child eating better? Treatment:

PERSISTENT DIARRHOEA
After 5 days : ASSESS & CLASSIFY } See chart . Ask:

Has the diarrhoea stopped? How many loose stools is the child having per day?

Treatment:

If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Treat for dehydration if present. Then refer to hospital. If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the childs age.

If chest indrawing or a general danger sign, give a dose of intramuscular Ampicillin and Gentamicin. If child can take orally give double the dose of Amoxycillin.Then refer URGENTLY to hospital. If breathing rate, fever and eating are the same, change to the second-line antibiotic and advise the mother to return in 2 days or refer. (If this child had measles within the last 3 months, refer). If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.

DYSENTERY
After 2 days:
Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart. Ask: Treatment:
If the child is dehydrated, treat dehydration and refer to hospital. If number of stools, amount of blood in stools, fever, abdominal pain, or eating

Wheeze
After 5 days :

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?

If no wheeze, stop treatment. If wheeze is same or worse, refer for assessment. If history of recurrent wheezing, refer for assessment. If coughing more than 14 days, refer for assessment.

is the same or worse, refer to hospital.


If fewer stools, less blood in the stools, less fever, less abdominal pain, and

eating better, continue giving the same antibiotic until finished.

PLAN C, PNEUMONIA, WHEEZE, PERSISTENT DIARRHOEA, DYSENTRY

15

FOLLOW-UP

16

GIVE FOLLOW-UP CARE


Care for the child who returns for follow -up using all the boxes that

match the childs previous classifications.


If the child has any new problem, assess, classify and treat the new

FEVER-MALARIA UNLIKELY
If fever persists after 2 days: Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Assess for other causes of fever. Do a blood film for malaria parasite if no other cause of fever. Treatment:

problem as on the ASSESS AND CLASSIFY chart.

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

If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE and refer Urgently to hospital. If the child has any cause of fever other than malaria, provide treatment. If BFMP from initial visit is positive : Treat with oral antimalarial and refer to doctor. Advise the mother to return again in 2 days if the fever persists. If fever has been present for 7 days, refer for assessment.

If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE and refer Urgently to hospital. If the child has any cause of fever other than malaria, provide treatment. If malaria is the only cause of fever and BFMP positive: - Refer to hospital If fever has been present for 7 days, refer for assessment.

MEASLES WITH EYE OR MOUTH COMPLICATIONS


After 2 days: Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth. 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 the correct treatment. If the pus is gone but redness remains, continue the treatment. If no pus or redness, stop the treatment.

Treatment for Mouth Ulcers: If mouth ulcers are worse, or there is a very foul smell from the mouth , refer to hospital. If mouth ulcers are the same or better, continue sodium bicarbonate oral toilet for a total of 5 days.

GIVE FOLLOW-UP CARE


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

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

ANAEMIA
After 14 days:

Give iron. Advise mother to return in 14 days for more iron. Continue giving iron every 14 days for 2 months. If the child has palmar pallor after 2 months, refer for assessment.

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 discharge persists, treat with 5 more days of the same antibiotic. Continue wicking 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 finished the 5 days of antibiotic, tell her to finish the antibiotics. Chronic ear infection: check the mother is wicking and putting the ear drops into the ear correctly. Follow up in 10 days and refer patient if discharge still persists.

VERY LOW WEIGHT


After 14 days: Weigh the child and determine if the child is still very low weight for age Reassess feeding > See questions at the top of the COUNSEL chart Treatment:

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.

If the child is no longer very low weight for age, praise the mother and encourage her to continue. If the child is still very low weight for age, counsel the mother about any feeding problem found. Ask the mother to return again in 14 days. Continue to see the child 2 weekly until the child is feeding well and gaining weight regularly or is no longer very low weight for age. Important: If you do not think that feeding will improve, or if the child has lost weight, refer the child.

Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the child back again. If the child is very low weight for age, ask the mother to return 14 days after the initial visit to measure the childs weight gain.

17
MALARIA, FEVER-MALARIA UNLIKELY, MEASLES, EAR INFECTION, FEEDING PROBLEM, ANAEMIA, VERY LOW WEIGHT

18

COUNSEL THE MOTHER

Assess the Feeding of Sick Child under 2 years

(or if child has very low weight for age or anaemia)


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

ASK - How are you feeding your child ?


If the infant is receiving any breast milk, ASK :
- How many times during the day? - Do you also breastfeed during the night?

Does the infant take any other food or fluids?


- What food or fluids? - How many times per day? - What do you use to feed the child?

If very low weight for age, ASK :


- How large are servings? - Does the child receive his own serving? - Who feeds the child and how?

During this illness, has the childs feeding changed?


- If yes, how?

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH


Up to 6 Months of Age 6 Months up to 12 Months 12 Months up to 2 Years 2 Years and Older

Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Do not give other foods or fluids. Only if the child is older than 4 months: shows interest in semisolid foods, or appears hungry after breastfeeding, or is not gaining weight adequately. Then add complementary foods (listed under 6 months up to 12 months). Give 1-2 tablespoon of these foods, 1 or 2 times per day after the breastfeeding.

Breastfeed as often as the child wants. Give adequate servings of complementary foods such as: Thick cereal/ thick porridge/ bread / Biscuit. Fish/ Chicken/ meat/ eggs / tauhu. Mashed fruit / bite size fruits. Mashed vegetables/ beans / tapioca / sweet potato / potato / carrots. 3 times per day if breastfed. 5 times per day if not breastfed.

Breastfeed as often as the child wants. Give adequate servings of complementary food such as: Thick porridge/ rice/ mee / biscuit / bread. Fish/ Chicken/ meat/ eggs / Ikan bilis. Tapioca / sweet potato / potato / carrots. Green vegetables / beans. Fruit / bite size fruits.

Give family foods at 3 meals each day. Also, twice daily, give nutritious snacks between meals, such as: Mee / Mee Hoon / Bread/ Kuih Muih Fruits/ soya bean / sweet corn / tauhu / tapioca / sweet potato / potato / carrots. Sandwich / bun / cake / biscuits.. Red beans / green beans / dhall. Oat / sardine / egg. Milk / yogurt / cheese.

or family foods 5 times per day Give small chewable soft items to eat with fingers. Let the child try to feed himself, but provide help.

* 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 beans; and fruits and vegetables.

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 half the milk with nutrient-rich semisolid food e.g. thick porridge, cereals or yogurt drinks. For other foods follow feeding recommendation for the childs age.

ASSESS FEEDING, FEEDING RECOMMENDATIONS

19
COUNSEL

20

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS


If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:
If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.)

As needed, show the mother correct positioning and attachment for breastfeeding. If the child is less than 6 months old and is taking other milk or foods: - Build mothers confidence that she can produce all the breastmilk that the child needs. - Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods. If other milk needs to be continued, counsel the mother to: - Breastfeed as much as possible, including at night. - Make sure that other milk is a locally appropriate breastmilk substitute. - Make sure other milk is correctly and hygienically prepared and given in adequate amounts. - Finish prepared milk within an hour. If the mother is using a bottle to feed the child: - Recommend substituting a cup for bottle. - Show the mother how to feed the child with a cup. If the child is not being fed actively, counsel the mother to: - Sit with the child and encourage eating. - Give the child an adequate serving in a separate plate or bowl. If the child is not feeding well during illness, counsel the mother to: - Breastfeed more frequently and for longer if possible. - Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feedings. - Clear a blocked nose if it interferes with feeding. - Expect that appetite will improve as child gets better. 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 banana, papaya, pumpkin or potato. - Avoid spicy, salty or sour foods. - Chop foods finely. - Give cold drinks if available.

COUNSEL THE MOTHER

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 mothers immunization status and give her tetanus toxoid if needed. Make sure she has access to: Family planning PAP Smear Breast Self Examination Counselling on STD and AIDS prevention

21
COUNSEL THE MOTHER ABOUT FEEDING PROBLEM COUNSEL THE MOTHER ABOUT OWN HEALTH

22

FLUID
Advise the Mother to Increase Fluid During Illness
FOR ANY SICK CHILD: If child is breastfed, 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, coconut water, cool boiled water. FOR CHILD WITH DIARRHOEA: Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

WHEN TO RETURN
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT
Advise mother to come for follow-up at the earliest time listed for the childs problems.

If the child has:


PNEUMONIA DYSENTERY MALARIA, if fever persists FEVER-MALARIA UNLIKELY, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS WHEEZE PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEM ANY OTHER ILLNESS, if not improving

Return for first follow-up in:

2 days

WHEN TO RETURN IMMEDIATELY


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

Any sick child

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

ANAEMIA VERY LOW WEIGHT FOR AGE

14 days

If child has COUGH OR COLD, also return if: If child has Diarrhoea, also return if:

NEXT WELL-CHILD VISIT


Advise mother when to return for next immunization according to immunization schedule.

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

USE ALL BOXES THAT MATCH INFANTS SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS. SIGNS
Not able to feed or Feeding poorly 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* ) or Movement only when stimulated or no movement at all. Umbilicus red or draining pus or Skin pustules.

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION


ASK:
Is the infant not able

CLASSIFY AS

TREATMENT
(Urgent pre referral treatments are in bold print)

LOOK, LISTEN, FEEL:


Count the breaths in one minute Repeat the count if 60 or more breaths per minute Look for severe chest indrawing Measure axillary temperature*

to feed?
Is the infant feeding

poorly?
Has the infant had

YOUNG INFANT MUST BE CALM

Classify ALL YOUNG INFANTS

Give first dose of intramuscular Antibiotics

VERY SEVERE DISEASE

Give oxygen if available Treat to prevent low blood sugar Refer URGENTLY to hospital** Advise mother how to keep the infant warm on the way to the hospital Give an appropriate oral antibiotic

convulsions (fits)?

Look at the umbilicus. Is it red or draining pus? Look for skin pustules. Look at the young infants movements. If infant is sleeping, ask the mother to wake him/her: - Does the infant move on his/her own ?

LOCAL infections at home BACTERIAL Advise mother to give home care for the INFECTION young infant.
Follow-up in 2 days

Teach the mother to treat local

If the infant is not moving, gently stimulate him/her:


- Does the infant move only when stimulated but then stops? - Does the infant not move at all? No sign of very severe disease and local bacterial infection.

Advise mother to give home care for the SEVERE young infant. DISEASE AND LOCAL INFECTION UNLIKELY

* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher. ** If referral is not possible, see IMCI Young Infant Modules, Annex 2 When referral is not possible

23

BACTERIAL INFECTION

ASSESS AND CLASSIFY YOUNG INFANT

24

THEN CHECK FOR JAUNDICE


If Jaundice present, ASK:
Does the infant have jaundice If Yes, when did the jaundice first appear ? before 24 hours of age or after 24 hours of age

SIGNS
Jaundice appearing before 24

CLASSIFY AS

TREATMENT
(Urgent pre referral treatments are in bold print)

Treat to prevent low blood sugar.

LOOK and FEEL:


Look for level of jaundice: jaundice above the umbilicus? jaundice below the umbilicus

Classify JAUNDICE

hours of age or
Jaundiced palms and soles at

any age.

SEVERE JAUNDICE

Refer URGENTLY to hospital. Advise mother how to keep the infant warm on the way to the hospital.

Is the infant aged more than 14 jaundice palms and soles days?

Jaundice appearing after 24

Refer to doctor immediately.

hours of age and


Jaundice below umbilicus.

MODERATE Advise mother how to keep the infant warm on the way. JAUNDICE
Advise the mother to continue breastfeeding.

Jaundice appearing after 24 hours of age and Jaundice above umbilicus.

Advise the mother to give home care for the young infant.

MILD JAUNDICE

Advise mother to return immediately if jaundiced below umbilicus or jaundiced palms and soles. If young infant is older than 14 days, refer for assessment. Follow-up in 1 day.

No jaundice.

NO JAUNDICE

Advise mother to give home care for the young infant.

THEN ASK: Does the young infant have diarrhoea*?


IF YES, LOOK AND FEEL:
Look at the young infants general condition : Infants movements - Does the infant move on his/her own ? - Does the infant move only when stimulated but then stops ? - Does the infant not move at all ? Is the infant restless or irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: - Very slowly (longer than 2 seconds)? or - Slowly?

SIGNS

CLASSIFY AS

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

Classify DIARRHOEA For DEHYDRATION

Two of the following signs: Movement only when stimulated or no movement at all. Sunken eyes. Skin pinch goes back very slowly.

Refer URGENTLY to hospital. If infant has no other severe classification: - Give fluid for severe dehydration (Plan C). OR If infant also has another severe classification: - Give frequent sips of ORS on the way. - Advise the mother to continue breastfeeding. Advise mother to keep infant warm on the way to Hospital.

SEVERE DEHYDRATION

Two of the following signs: Restless or irritable. Sunken eyes. Skin pinch goes back slowly.

Refer URGENTLY to hospital. Give fluid for some dehydration and continue breastfeeding (Plan B). OR If infant has any sign of VERY SEVERE DISEASE : - Give frequent sips of ORS on the way. - Advise the mother to continue breastfeeding. Advise mother to keep infant warm on the way to hospital. Give fluid to treat for diarrhoea at home and continue breastfeeding (Plan A). Advise mother when to return immediately. Follow up in 2 days if not improving.

SOME DEHYDRATION

Not enough signs to classify as

some or severe dehydration.

NO DEHYDRATION

* What is diarrhoea in young infant? A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter). The normally frequent or semi-solid stool of a breastfed baby are not diarrhoea.

25
JAUNDICE DIARRHOEA

26

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE


If an infant has no indications to refer urgently to hospital: SIGNS
Not well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24 hours or

CLASSIFY AS

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

ASK:
Is the infant breastfed? If yes, how many

LOOK, LISTEN and FEEL:


Determine weight for age. Look for ulcers or white patches in the

If not well attached or not suckling effective-

times in 24 hours?
Does the infant usually receive any other

Classify FEEDING

foods or drinks? If yes, how often?


If yes, what do you use to feed the infant?

mouth (thrush).

ly, teach correct positioning and attachment. If not able to attach well immediately, teach the mother to express breast milk and feed with a cup.
If breastfeeding less than 8 times in 24

ASSESS BREASTFEEDING: 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 well attached good attachment
Thrush (ulcers or white Low weight for age or Receives other foods or

hours, advise to increase frequency of feeding. Advise the mother to breastfeed as often and for as long as the infant wants, day and night.
If receiving other foods or drinks, counsel

drinks or

FEEDING PROBLEM OR LOW WEIGHT FOR AGE

the mother about breastfeeding more, reducing other foods or drinks, and using a cup. If not breastfeeding at all: - Refer for breastfeeding counseling and possible relactation. - Advise about correctly preparing breastmilk 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

TO CHECK ATTACHMENT, LOOK FOR: - More areola seen above infants top lip than below bottom lip - Mouth wide open - Lower lip turned outwards - Chin touching breast (All of these signs should be present if the attachment is good)

patches in mouth).

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 7 days.

Is the infant suckling effectively (that is, slow deep sucks,


sometimes pausing)? not suckling effectively suckling effectively

Not low weight for age and no other signs of inadequate feeding.

NO FEEDING PROBLEM

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

Clear a blocked nose if it interferes with breastfeeding.

THEN CHECK THE YOUNG INFANTS IMMUNIZATION:


AGE VACCINE

IMMUNIZATION SCHEDULE:

Birth 1 month

BCG

Hep B 1 Hep B 2

Give all missed doses on this visit. Immunize sick infants unless being referred. Advise the mother when to return for the next dose.

ASSESS OTHER PROBLEMS

27
FEEDING PROBLEM INFANTS IMMUNIZATION STATUS

28

TREAT THE YOUNG INFANT


Give First Dose of Intramuscular Antibiotics
Give first dose of

both Ampicillin and Gentamicin intramuscular.


AMPICILLIN Dose: 50 kg / kg/ dose 50 mg /kg 1 vial (500 mg) Add 1.8 ml sterile water = 250 mg/ 1 ml GENTAMICIN Dose: 7.5 mg/ kg/ dose Add 3 ml sterile water to 1 ml containing 40 mg = 4 ml at 10 mg/ml Age < 7 days Dose: 5mg/kg Age > 7 days Dose: 7.5 mg/kg

WEIGHT

1 - < 1.5 kg 1.5 - < 2 kg 2 - < 2.5 kg 2.5 - < 3 kg 3 - < 3.5 kg 3.5 - < 4 kg 4 - < 4.5 kg > 4.5 kg

0.2 ml 0.3 ml 0.4 ml 0.5 ml 0.6 ml 0.7 ml 0.8 ml 0.9 ml

0.6 ml 0.9 ml 1.1 ml 1.4 ml 1.6 ml 1.9 ml 2.1 ml 2.4 ml

0.9 ml 1.3 ml 1.7 ml 2.0 ml 2.4 ml 2.8 ml 3.2 ml 3.5 ml

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, give Ampicillin and Gentamicin for at least 5 days. Give Ampicillin two times daily to infants less than one week of age and 3 times daily to infants one week or older.

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 (10 ml/kg) Dextrose 10 % before departure. If the young infant is not able to swallow: Give 20 - 50 ml (10 ml/kg) of expressed breast milk or Dextrose 10 % by naso-gastric tube.

TREAT THE YOUNG INFANT


Teach the Mother How to Keep the Young Infant Warm on the way To the Hospital
Provide skin to skin contact. OR 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 .

Give an Appropriate Oral Antibiotic


For local bacterial infection: First-line antibiotic : Second-line antibiotic:
CLOXACILLIN (25 mg/ kg/ dose) ERYTHROMYCIN (20 mg/ kg/ dose) CLOXACILLIN Give FOUR times daily for 5 days AGE or WEIGHT Birth up to 1 month (< 4 kg) 1 month up to 2 months ( 4-6 kg) Syrup 125 mg/ 5 ml 2.5 ml 5.0 ml ERYTHROMYCIN Give TWO times daily for 5 days Syrup 200 mg/ 5 ml 1.5 ml 2.5 ml

Give Syrup Nystatin for Oral Thrush


Syrup Nystatin
(100,000 IU/ ml) 1.0 ml Give four times daily for 7 days

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KEEP THE YOUNG INFANT WARM ORAL and IM ANTIBIOTIC, NYSTATIN

TREAT AND COUNSEL

30

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER


Teach the Mother to Treat Local Infections at Home
Explain how the treatment is given. Watch her as she does the first treatment in the clinic. Tell her to return to the clinic if the infection worsens.

To Treat Skin Pustules


Do the treatment twice daily for 5 days: Wash hands. Gently wash off pus and crusts with Normal Saline 0.9% solution or Chlorhexidine 0.05% lotion. Expose to dry. Wash hands.

To Treat Umbilical Infection


Do the treatment twice daily for 5 days: Wash hands. Gently wash off pus and crusts with Chlorhexidine 0.05% spirit. Expose to dry. Wash hands.

To Treat Thrush (Ulcers or white patches in mouth)


Do the treatment four times daily for 7 days: Wash hands. Wash mouth with clean soft cloth wrapped around the finger and wet with cooled boiled water. Drop 1 ml of syrup Nystatin into the mouth. Wash hands.

To Treat Diarrhoea, See TREAT THE CHILD Chart

Immunize Every Sick Young Infant, as Needed

COUNSEL THE MOTHER


Teach Correct Positioning and Attachment for Breastfeeding
Show the mother how to hold her infant - with the infants head and body in line. - with the infant approaching with nose opposite to nipple. - with the infant held close to the mothers body. - with the infants whole body supported, not just neck or shoulders. Show her how to help the infant to attach. She should: - touch her infants lips with her nipple. - wait until her infants mouth is opening wide. - move her infant quickly onto her breast, aiming the infants lower lip well below the nipple. Look for signs of good attachment and effective suckling. Good Attachment (All of these signs should be present): - more areola seen above infants top lip than below bottom lip. - mouth wide open. - lower lip turned outwards. - chin touching breast. Effective suckling : - slow deep sucks, sometimes pausing. If the attachment or suckling is not good, try again.

Teach the Mother 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 index 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 as before.


Compress and release all the way around the breast, keeping her fingers the same distance from the nipple.

Be careful not to squeeze 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 from the other breast until the milk just drips. Alternate between breasts 5 or 6 times, for least 20-30 minutes. Stop expressing when the milk no longer flows but drips from the start.

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LOCAL INFECTION BREASTFEEDING

32

COUNSEL THE MOTHER


Teach the Mother How to Feed with a Cup

Put a cloth on the infants 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 infants lower lip. Tip the cup so that the milk just reaches the infants lips. Allow the infant to take the milk himself. DO NOT pour the milk into the infants mouth .

Teach the Mother How to Keep the Low Weight Infant Warm at Home

Keep the room warm (at least 25 C). Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly 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. 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 mothers chest between the mothers breasts. Keep the infants head turned to one side. - Cover the infant with mothers 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 infant with extra clothing including cap, mittens and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket or bubble sheet. Check frequently if the hands and feet are warm. If cold, re -warm the baby using skin to skin contact. Breastfeed (or expressed breast milk by cup) the infant frequently.

COUNSEL THE MOTHER


Advise Mother to Give Home Care for the Young Infant
1. EXCLUSIVE BREASTFEED THE YOUNG INFANT Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the infant wants. MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES In cool weather, cover the infants head and feet and dress the infant with extra clothing WHEN TO RETURN IMMEDIATELY: Follow up visit If the infant has:
JAUNDICE

2.

3. WHEN TO RETURN

Return for first follow-up in: 1 day

Advise the mother to return immediately if the young infant has any of these signs:

LOCAL BACTERIAL INFECTION FEEDING PROBLEM THRUSH DIARRHOEA

2 days

LOW WEIGHT FOR AGE

7 days

Feeding poorly Not able to feed Reduced activity Becomes sicker Develops a fever Feels unusually cold Fast breathing Difficult breathing Jaundice below umbilicus Palms and soles appear yellow

33

KEEP THE INFANT WARM COUNSEL THE MOTHER HOME CARE

34

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT


ASSESS EVERY YOUNG INFANT FOR VERY SEVERE DISEASE DURING FOLLOW-UP VISIT

LOCAL BACTERIAL INFECTION


After 2 days: Look at the umbilicus. Is it red or draining pus? Look for skin pustules. Treatment: If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness have improved, tell the mother to continue giving the 5 days antibiotic and continue treating the local infection at home. If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

JAUNDICE
After 1 day : Look for jaundice. Are palms and soles jaundiced? Is jaundice below the umbilicus?

If palms and soles are jaundiced, refer URGENTLY to hospital. If jaundice below umbilicus, refer to doctor. If jaundice is not below umbilicus but has not decreased, advise the mother home care and ask her to return for follow up in 1 day. If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 14 days of age. If jaundice is still present, refer the young infant to doctor for further assessment of prolonged jaundice.

DIARRHOEA
After 2 days : Ask:- Has the diarrhoea stopped? Treatment: If the diarrhoea has not stopped > SEE Does the Young Infant have Diarrhoea?
Do a reassessment of the infant. Treat for dehydration if present. Then refer to hospital.

If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT


FEEDING PROBLEM
After 2 days: Reassess feeding. > See Then Check for Feeding Problem or Low Weight for Age chart. Ask about any feeding problems found on the initial visit. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the young infant back again after 2 days. If the young infant is low weight for age, ask the mother to return in 7 days to measure the young infants weight gain. Continue follow-up until the child is gaining weight well. IMPORTANT: If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

LOW WEIGHT FOR AGE


After 7 days: Weigh the young infant and determine if the infant is still low weight for age. Reassess feeding. > See Then Check for Feeding Problem or Low Weight for Age chart. If the infant is no longer low weight for age, praise the mother and encourage her to continue. If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within 7 days or when she returns for immunization, whichever is the earlier. Continue to see the young infant every 2 weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age. IMPORTANT: If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

If the infant is still low weight for age and still has a feeding problem, refer to hospital.

THRUSH
After 2 days: Look for ulcers or white patches in the mouth (thrush). Reassess feeding. > See Then Check for Feeding Problem or Low Weight for Age chart. If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital. If thrush is the same or better, and if the infant is feeding well, continue syrup Nystatin for a total of 7 days.

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FOLLOW-UP

NOTES

36

Date of Visit:____________________

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS


Name: _______________________________________________ ASK: What are the childs problems? ___________________________________________________ Initial visit? ____ Follow-up Visit? ____ ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS DURING THIS ILLNESS DROWSY OR UNCONSCIOUS CONVULSING NOW General danger signs present? Yes___ No___ 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 wheeze.

Age: _____________ Weight: __________ kg

Temperature: ________C

DOES THE CHILD HAVE DIARRHOEA? Yes ___No___ For how long? _____ Days Is there blood in the stools? Look at the childs general condition. Is the child: Drowsy or unconscious? Restless or irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

DOES THE CHILD HAVE FEVER? (by history/temperature 37.5C or above) Yes___No___ BFMP: Positive ( Falciparum/ Vivax) / Negative / not done / pending For how long? _____ Days If more than 7 days, has fever been present every day? Has child had measles within the last three months? If the child has measles now or within the last 3 months: Look for mouth ulcers. If Yes, are they deep or extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for signs of MEASLES now: Generalized measles rash and One of these: cough, runny nose, or red eyes. Look or feel for stiff neck. Look for runny nose.

DOES THE CHILD HAVE EAR PROBLEM? Yes___ No___ Is there ear pain? Is there ear discharge? If Yes, for how long? ___ days THEN CHECK FOR MALNUTRITION Look for visible severe wasting. Look for oedema of both feet. Determine weight for age. Very Low ___ Not Very Low ___ CHECK FOR ANAEMIA Look for palmar pallor. Severe palmar pallor? Some palmar pallor? CHECK THE CHILDS IMMUNIZATION STATUS
_____ BCG _____ Hep B 1 _____ Hep B 2 _____________ (DTaP+Hib+IPV)1 _____________ (DTaP+Hib+IPV)2

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

Circle immunizations needed today.


_____________ (DTaP+Hib+IPV)3 _____ Hep B 3 _____ Measles ____ MMR ____ JE 1 ____ JE 2 ______________ DTaP+Hib+IPV) booster ____ JE 3

Return for next immunization on: ______________________ (Date) Feeding Problem:

ASSESS CHILDS FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old. Do you breastfeed your child? Yes____ No ____ If Yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes___ No___ Does the child take any other food or fluids? Yes___ No ___ If Yes, what food or fluids? __________________________________________________________________________ ________________________________________________________________________________________________ How many times per day? ___ times. What do you use to feed the child? ______________________________________ If very low weight for age: How large are servings? ___________________________________________________________ Does the child receive his own serving? ___ Who feeds the child and how? ___________________________________ During the illness, has the childs feeding changed? Yes ____ No ____ If Yes, how? ______________________________________________________________________________________ ASSESS OTHER PROBLEMS Ask about mothers own health

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RECORDING FORM

TREAT
Remember to refer any child who has a danger sign and no other severe classification

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
Return for follow-up in:________________________ Advise mother when to return immediately. Give any immunizations needed today. Feeding advice:_______________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

38

Signature Name

: ___________________________________________________________________ : ___________________________________________________________________ Clinic / Hospital : ___________________________________________________________________

Date of Visit:____________________

MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS


Name: _______________________________________________ ASK: What are the infants problems? ___________________________________________________ Initial visit? ____ Follow-up Visit? ____ ASSESS (Circle all signs present) CLASSIFY
Classify all young infants CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant not able to feed? Is the infant feeding poorly? Has the infant had convulsions? Count the breaths in one minute. _______ breaths per minute Repeat if 60 breaths or more ________ Fast breathing? Look for severe chest indrawing. Fever (temperature 37.5C or above) Low body temperature (less than 35.5C ). Look at umbilicus. Is it red or draining pus? Look for skin pustules. Look at young infants movements. Does the infant move only when stimulated? Does the infant not move at all?

Age: ____________ Weight: __________ kg

Temperature: _______C

THEN CHECK FOR JAUNDICE

Does the infant have jaundice? If Yes, when did jaundice first appear? before 24 hours of age or after 24 hours of age
Look for level of jaundice: Jaundice above umbilicus Jaundice below umbilicus Jaundice palms and soles Yes _____ No ______ Look at the young infants general condition. Does the infant move only when simulated Does the infant not move at all? Is the infant restless or irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? If the infant has no indications to refer urgently to hospital THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT Is the infant breastfed? Yes _____ No _____ If Yes, how many times in 24 hours? _____ times Does the infant usually receive any other foods or drinks? Yes _____ No _____ If Yes, how often?___________________________________ If Yes, what do you use to feed the infant?________________ ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: - More areola seen above infants top lip than below bottom lip Yes ___ No ___ - Mouth wide open Yes ___ No ___ - Lower lip turned outwards Yes ___ No ___ - Chin touching breast Yes ___ No ___ not well attached good attachment 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 CHECK THE YOUNG INFANTS IMMUNIZATION STATUS Circle immunizations needed today. _____ BCG _______ ______ Hep B 1 Hep B 2 ASSESS OTHER PROBLEMS Ask about mothers own health Determine weight for age. Low ___ Not Low _____ Look for ulcers or white patches in the mouth (thrush)

Is the infant aged more than 14 days?


DOES THE YOUNG INFANT HAVE DIARRHOEA?

Return for next immunization on: ______________ (Date)

39

RECORDING FORM

TREAT _________________________________________________________ ________________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Return for follow up in :_________________________________ Give any immunizations needed today:______________________

40

Signature Name

: _________________________________________________________________ : _________________________________________________________________ Clinic / Hospital : _________________________________________________________________