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

CHECK FOR GENERAL DANGER SIGNS

ASK
• Is the child able to drink or breast-feed?
• Does the child vomit every thing?
• Has he had had convulsions? (during present illness)
LOOK
• See if the child is abnormally sleepy or difficult to awaken.
THEN ASK ABOUT THE MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
IF YES, ASK: LOOK, LISTEN:
• For how long? > Count the breaths in 1 minute.
> Look for chest indrawing, CHILD MUST
> Look and listen for stridor and for wheeze. BE CALM
IF WHEEZING AND EITHER FAST BREATHING/CHEST INDRAWING: Give a trial of rapid acting inhaled
bronchodilator for up to 3x 15-20min apart. Count the breaths & look for chest indrawing again & then classify.
IF THE CHILD IS: FAST BREATHING IS:
2mos up to 12mos old > 50 bpm/more
12mos up to 5 yrs. Old > 40 bpm/more

SIGNS CLASSIFY AS TREATMENT

Give 1st dose of an appropriate antibiotic.
Any danger sign, OR SEVERE Give vit.A
Stridor in calm child, OR PNEUMONIA OR If chest indrawing & wheeze, go directly to treat wheezing.
Chest indrawing VERY SEVERE DISEASE Treat the child to prevent low blood sugar.
Refer urgently to hospital.
Give an appropriate antibiotic for 3 days.
If wheezing(even if it disappeared after rapid-acting
bronchodilator), give an inhaled bronchodilator for 5 days.
Soothe the throat and relieve the cough w/ a safe remedy.
Fast breathing PNEUMONIA If coughing for more than 3 wks or if having recurrent
wheezing, refer for assessment for TB or asthma.
Advise the mother when to return immediately.
Follow up in 2 days.
Give an appropriate antibiotic for 3 days.
If wheezing(even if it disappeared after rapid-acting
bronchodilator), give an inhaled bronchodilator for 5 days.
No signs of pneumonia or very NO PNEUMONIA: COUGH Soothe the throat and relieve the cough w/ a safe remedy.
severe disease OR COLD If coughing for more than 30 days, refer for assessment
Advise the mother when to return immediately.
Follow up in 5 days if not improving; if treated for wheeze,
follow up in 2 days.

ASK: DOES THE CHILD HAVE DIARRHEA?

IF YES ASK:
For how long?
Is there blood in the stools?
TWO of the following signs:
Abnormally sleepy or difficult to
awaken
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly
TWO of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
Not enough signs to classify as
some or severe dehydration
LOOK :
Look at the child’s general condition, Is the child:
> Abnormally sleepy or difficult to awaken?
> Restless and irritable?
> Look for sunken eyes
> Offer the child fluid. Is the child:
> Not able to drink or drinking poorly?
> Drinking eagerly, thirsty?
FEEL: Pinch the skin on the abdomen.
Does it go back :
> Very slowly (longer than 2 seconds)?
If the child has no other severe classification: Give fluid for
severe dehydration (Plan C) OR
If the child has another severe classification:
SEVERE DEHYDRATION Refer urgently to hospital, w/ mother giving frequent sips of
ORS on the way.
Advise the mother to continue breastfeeding.
If child is 2 yrs. or older & there is cholera in your area, give
antibiotic for cholera.
Give ORS, zinc supplements and food for some dehydration
(Plan B).
SOME DEHYDRATION If the child has another severe classification:
Refer urgently to hospital, w/ mother giving frequent sips of
ORS on the way.
Advise the mother to continue breastfeeding.
Advise the mother when to return immediately.
Follow up in 5 days if not improving.
Give ORS, zinc supplements & food to treat diarrhea at home
NO DEHYDRATION (Plan A).
Advise the mother when to return immediately.
Follow up in 5 days if not improving.
 AND IF DIARRHEA FOR 14 DAYS OR MORE
Treat dehydration before referral unless the child has another severe
Dehydration present SEVERE PERSISTENT classification.
DIARRHEA Give vit. A.
Refer to hospital.
Advise the mother on feeding a child who has persistent diarrhea.
Give vit. A.
No dehydration PERSISTENT DIARRHEA Give multivitamins & minerals(including zinc)for 14 days.
Follow up in 5 days.
Advise the mother when to return immediately.

Give ciprofloxacin for 3 days.

Blood in the stools DYSENTERY Follow up in 2 days.
Advise the mother when to return immediately.

THEN ASK: DOES THE CHILD HAVE FEVER? (temp. 37.5 or above)
Decide Malaria Risk
ASK

• Does the child live in a malaria area?

• Has the child visited /travelled or stayed overnight in a malaria area in the past 4 weeks?
If Yes to either, obtain a blood smear: LOOK AND FEEL:
THEN ASK: • Look and feel for stiff neck.
> For how long has the child had fever? • Look for runny nose.
> If more than 7 days , has the fever been present every day? Look for signs of Measles:
> Has the child had measles within the last 3 months? General rash, and
ONE of theses: cough, runny nose or red eyes
MALARIA RISK (including travel or overnight stay in malaria area)
Give 1st dose of quinine (under medical supervision/if a hospital is not
Any general danger sign or VERY SEVERE accessible within 4 hours).
Stiff neck FEBRILE Give 1st dose of an appropriate antibiotic.
DISEASE / Treat the child to prevent low blood sugar.
MALARIA Give 1 dose of paracetamol in health center for high fever (38.5/above).
Send a blood smear w/ the patient.
Refer urgently to hospital.
Blood smear (+) Treat the child with an oral antimalarial.
If blood smear not done: Give 1 dose of paracetamol in health center for high fever (38.5/above).
NO runny nose, and MALARIA Advise the mother when to return immediately.
NO measles, and Follow up in 2 days if fever persists.
NO other causes of fever If fever is present every day for more than 7 days, refer for assessment
Blood smear (-) Treat the child with an oral antimalarial.
Runny nose or Give 1 dose of paracetamol in health center for high fever (38.5/above).
Measles or FEVER: Advise the mother when to return immediately.
Other causes of fever MALARIA Follow up in 2 days if fever persists.
UNLIKELY If fever is present every day for more than 7 days, refer for assessment
Treat other causes of fever.

NO MALARIA RISK
Give 1 dose of an appropriate antibiotic.
Any general danger sign. Or VERY SEVERE Treat the child to prevent low blood sugar.
Stiff neck FEBRILE DISEASE Give 1 dose of paracetamol in health center for high fever (38.5/above).
Refer urgently to hospital.
No signs of a very severe FEVER: Give 1 dose of paracetamol in health center for high fever (38.5/above).
febrile disease No Malaria Advise the 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
Treat other causes of fever

If the child has measles nor or within the last three months:
• Look for mouth ulcers. Are they deep and extensive?
• Look for pus draining from the eyes
• Look for clouding of the cornea.
Give vit. A.
Any danger sign, or SEVERE Give 1st dose of an appropriate antibiotic.
Clouding of the cornea or COMPLICATED If there is clouding of the cornea/pus draining from the eye,
Deep or extensive mouth ulcers MEASLES apply tetracycline eye ointment.
Refer urgently to hospital.
Give vit. A.
Pus draining from the eye or MEASLES WITH EYE Give 1st dose of an appropriate antibiotic.
Mouth ulcers OR MOUTH If pus draining from the eye, apply tetracycline eye ointment.
COMPLICATIONS If mouth ulcers are present, teach the mother to treat them w/
gentian violet.
Follow up in 2 days.
Advise the mother when to return immediately.
Give vit. A
Measles nor or within the last 3 months MEASLES Advise the mother when to return immediately.
 ASSESS DENGUE HEMORRHAGIC FEVER
Ask: LOOK and FEEL:
Has the child had any bleeding from the nose or gums, or in the vomitus or stools? • Look for bleeding from the nose or
Has the child had black vomitus? gums
Has the child had black stools? • Look for skin petechiae
Has the child had persistent abdominal pain? • Feel for cold and clammy extremities
Has the child had persistent vomiting? • Check for slow capillary refill.
If NONE of the ASK, LOOK, FEEL signs are present and the child is 6 months or
older & present for more than 3 days.
• Perform the tourniquet test
If persistent vomiting or persistent abdominal pain or skin petechiae or Bleeding from nose or gums or
positive tourniquet test are the only positive signs, give ORS (Plan B). Bleeding in stools or vomitus or
If any other signs of bleeding are present, give fluids rapidly (Plan C). SEVERE Black stools or vomitus or
Treat the child to prevent low blood sugar. DENGUE Skin petechiae or
Refer all children urgently to hospital. HEMORRHAGIC Cold & clammy extremities or
Do not give aspirin. FEVER Capillary refill more than 3 seconds
Persistent abdominal pain or
Persistent vomiting or
Tourniquet test positive
Advise the mother when to return immediately. FEVER: Dengue No signs of a severe dengue
Follow up in 2 days if fever persists/child shows signs of bleeding. Hemorrhagic hemorrhagic fever
Do not give aspirin. Fever unlikely

THEN ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

LOOK and FEEL:
ain? • Look for the pus draining from the ear.
scharge? • Feel for tender swelling behind the ear.

propriate antibiotic.
etamol for pain. MASTOIDITIS Tender swelling behind the ear
tal.
days.
ain. ACUTE Pus is seen draining from the ear, and
EAR discharge is reported less than 14 days
INFECTION Ear pain
n to return immediately.

ops for 2 wks. CHRONIC EAR Pus is seen draining from the ear, and
INFECTION discharge is reported for 14 days/more.
n to return immediately.
t. No ear pain, and
n to return immediately. NO EAR INFECTION No pus is seen draining from the ear

CHECK FOR MALNUTRITION

LOOK & FEEL:
For all children:
 Determine weight for age.
 Look for edema of both feet.
 Look for visible severe wasting.
 For children aged 6 mos. or more, determine if MUAC is less than 115 mm.

If age up to 6 mos and
> Visible severe wasting or
> Edema of both feet
If age 6 mos & above and:
> MUAC is less than 115mm, or
> has edema of both feet, or
> has visible severe wasting
Very low weight for age
Not very low weight for age, and no
other signs of malnutrition
Treat the child to prevent low blood sugar.
Give vit. A.
Refer urgently to hospital.
SEVERE
MALNUTRITION
Assess the child’s feeding & counsel the mother on feeding
according to the feeding recommendations and care for
VERY LOW WEIGHT development.
Give vit. A.
Advise the mother when to return immediately.
Follow up in 30 days.
If the child less than 2 y.o. assess the child’s feeding & counsel
NOT VERY LOW the mother on feeding according to the feeding recommendations
WEIGHT and care for development.
If feeding is a problem, follow up in 5 days.
Advise the mother when to return immediately.

CHECK FOR ANEMIA

LOOK:
For all children:
Look for palmar pallor. Is it:
 Severe palmar pallor?
 Some palmar pallor?
Severe palmar pallor SEVERE ANEMIA Refer urgently to hospital.

Assess the child’s feeding & counsel the mother on feeding according to the
feeding recommendations and care for development.
Some palmar pallor ANEMIA Give iron.
Give ALBENDAZOLE/MEBENDAZOLE if child is 1 yr/older & has not had a
dose in the previous 6 mos.
Advise the mother when to return immediately.
Follow up in 14 days.
If the child less than 2 y.o. assess the child’s feeding & counsel the mother on
No palmar pallor NO ANEMIA feeding according to the feeding recommendations and care for development.
If feeding is a problem, follow up in 5 days.
Advise the mother when to return immediately.

ASSESS, CLASSIFY, AND TREAT THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
CHECK FOR VERY SEVERE DISEASE AND LOCAL INFECTION
ASK:
Is the infant having difficulty in feeding?
Has the infant had convulsions (fits)?
LOOK, LISTEN
Count the breaths in 1 min. Repeat the count if 60/more bpm. Young infant must be calm.
Look for severre chest indrawwing.
Measure axillary temp.
Look at the umbilicus. Is it red/draining pus?
Look for skin pustules.
Look at the young infant’s movement. If the infant is sleeping, ask the mother to wake him/her.
Does the infant move on his/her own?
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?

Any of the ff. signs:

Not feeding well or
Convulsions
Fast breathing (60 bpm) or
Severe chest indrawing of
Fever (37.5 C /above) or
Low body temp. (less than 37.5 C) or
Movement only when stimulated or no
movement at all
Umbilicus red/draining pus or
Skin pustules
None of the signs of very severe disease
or local bacterial infection
Give 1st dose of intramuscular antibiotics.
Treat to prevent low blood sugar level.
VERY SEVERE Refer urgently to hospital.
DISEASE Advise mother on how to keep the infant warm on the way
to the hospital.
Give an appropriate oral antibiotic.
LOCAL BACTERIAL Teach the mother to treat local infection at home.
INFECTION Advise the mother to give home care for the young infant.
Assess & counsel the mother on care for development.
Follow up in 2 days.
SEVERE DISEASE OR Advise the mother to give home care for the young infant.
LOCAL INFECTION Assess & counsel the mother on care for development.
UNLIKELY

THEN CHECK FOR JAUNDICE

LOOK:
 LOOK for jaundice (yellow eyes/skin)
 LOOK at the young infant’s palm & soles. Are they yellow?
Any jaundice if age is less than 24hrs. or
Yellow palms & soles at any age
Jaundice appearing after 24hrs. of age
and
Palms & soles not yellow
No jaundice
Treat to prevent low blood sugar.
Severe jaundice Refer urgently to hospital.
Advise the mother how to keep the infant warm on the way
to the hospital.
Advise the mother to give home care for the young infant.
Advise the mother to return immediately if palms & soles
Jaundice appear yellow.
Assess & counsel the mother on care for development
Follow up in 1 day.
No jaundice Assess & counsel the mother on care for development
Advise the mother to give home care for the young infant.

THEN ASK: DOES THE YOUNG INFANT HAVE DIARRHEA?

If YES, ask:
For how long?
Is there blood in the stool?
LOOK and FEEL:
Look at the young infant’s general condition. Is the young infant:
- 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)
 - Slowly?
TWO of the following signs:
Move only when stimulated/no
movement at all
Sunken eyes
Skin pinch goes back very slowly
TWO of the following signs:
Restless, irritable
Sunken eyes
Skin pinch goes back slowly
Not enough signs to classify as some
or severe dehydration
If the infant does not have very severe disease, severe jaundice
nor dysentery: Give fluid for severe dehydration (Plan C). or
If infant also has a very severe disease, severe jaundice, or
SEVERE dysentery: Refer urgently to hospital, w/ mother giving frequent
DEHYDRATION sips of ORS on the way.
Advise the mother to continue breastfeeding.
Advise mother on how to keep the infant warm on the way to the
hospital.
Give fluid for some dehydration (Plan B).
If infant also has a very severe disease, severe jaundice, or
SOME dysentery: Refer urgently to hospital, w/ mother giving frequent
DEHYDRATION sips of ORS on the way.
Advise the mother to continue breastfeeding.
Assess & counsel the mother on care for development
NO DEHYDRATION Give fluid to treat diarrhea at home (Plan A).
Assess & counsel the mother on care for development

If the young infant has dehydration, treat dehydration before

Diarrhea lasting for 14 dyas Severe persistent diarrhea referral unless the infant also has very severe disease.
Refer to hospital

Blood in the stool Dysentery Refer urgently to hospital, w/ mother giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding.

THEN CHECK FOR FEEDING PROBLEMS OR IF LOW-WEIGHT-FOR-AGE (FOR BREASTFED INFANTS)

If an infant has no indications to be referred urgently to the hospital:
ASK:
Is the infant breasfeed? If yes, how many times in 24 hrs?
Does the infant usually receive any other food or drink? If yes, how often?
If yes, what do you use to feed the infant?
LOOK :
Determine weight for age.
Look for ulcers/white patches in the mouth(thrush)
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 her breast. Observe the breastfeed for 4 minutes.
(If the infant has 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.
TO CHECK FOR ATTACHMENT, LOOK FOR:
> Chin touching the breast
> Mouth wide open
> Lower lip turned outward
> More areola above than below the mouth.
(all these signs should be present if the attachment is good.)
Is the infant suckling effectively (i.e., slow, deep, sucks, sometimes pausing)?
> Not sucking effectively.
> Suckling effectively.
Clear blocked nose if it interferes with breastfeeding.

If not able to attach well/not sucking effectively, teach correct

Not well attached to breast or
Not sucking effectively or
Less than 8 breastfeeds in 24hrs or
Receives other foods or drinks or
Low weight for age or
Thrush (ulcers/white patches in the mouth).
Not low-weight-for-age, and no other signs
of inadequate feeding
positioning and attachment.
If unable to attach well immediately, teach the mother to
express breast milk & feed using a cup.
If breastfeeding is done less frequently than 8 times every
24hrs, advise to increase frequency of breastfeeding. Advise the
mother to breastfeed as often & as long as the infant’s want,
day/night.
Feeding problem If the mother gives her infant other foods/drinks, counsel her
or low weight for about breastfeeding further & instruct her to reduce other foods
age & drinks, & to use a cup.
If not breastfeeding at all:
> refer to breastfeeding counseling & possible relactation.
> advise about the correct preparation of breastmilk substitutes
& the use of a cup.
Advise the mother how to feed & keep the low weight infant
warm at home.
If thrush, teach the mother to treat thrush at home.
Advise the mother to give home care for the young infant.
Follow up any feeding problem/thrush in 2 days.
Follow up weight for age in 14 days.
Assess & counsel the mother on care for development
No feeding Assess & counsel the mother on care for development.
problem Advise the mother to give home care for the young infant.
Praise the mother for feeding the infant well.
IMMUNIZATION SCHEDULE
@ BIRTH: BCG, HEP B1
6 wks: DPT1, OPV1, HEP B2
10 wks: DPT2, OPV2
14 wks: DPT3, OPV3, HEP B3
9 mos: MEASLES

FOR PNEUMONIA, MASTOIDITIS/ACUTE EAR INFECTION, OR VERY SEVERE DISEASE:

1ST Line antibiotic: Amoxicillin – give 2 times daily for 3 days (pneumonia)
- give 3 times daily for 5 days (acute ear infection/mastoiditis)
2nd Line antibiotic: Cotrimoxazole – give 2 times daily for 3 days (pneumonia).
- give 3 times daily for 5 days (acute ear infection/mastoiditis)
FOR DYSENTERY:
GIVE ANTIBIOTIC RECOMMENDED FOR SHIGELLA IN YOUR AREA FOR 3 DAYS
1st line antibiotic: Ciprofloxacin- give 2 times daily for 3 days.

FOR CHOLERA:
GIVE ANTIBIOTIC RECOMMENDED FOR CHOLERA IN YOUR AREA FOR 3 DAYS
1st line antibiotic: Tetracycline - give 2 times daily for 3 days.

GIVE AN ORAL ANTIMALARIAL

1st Line anti-malarial: Artemether-Lumefantrine
2nd Line anti-malarial: Chloroquine, Primaquine, Sulfadoxine, and Pyramethamine
IF SULFADDOXINE + PYRAMETHAMINE: Give a single dose in the health center 2hrs before intake of chloroquine.
IF PRIMAQUINE: Give single dose on day 4 for P. falciparum.
IF ARMETHER-LUMEFANTRINE combination: Given for 3 days

GIVE VITAMIN A
Give 1 dose in the health center if: > child is 6mos of age/older, and
> child has not receive a dose of vit. A in the past 6 mos.

GIVE MEBENDAZOLE OR ALBENDAZOLE

Give 500mg Mebendazole or 400mg Albendazole as a single dose in the health center if the child is 12 mos. up to 59 mos. & has
not had a dose in the previous 6 mos.

GIVE AN INTRAMUSCULAR ANTIBIOTIC

Give to children being referred urgently. Give Gentamicin (7.5mg/kg) & Benzyl Penicillin (50,000 units/kg).