ASSESS AND CLASSIFY THE SICK CHILD

AGE 2 MONTHS UP TO 5 YEARS

ASSESS CLASSIFY IDENTIFY
ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE USE ALL BOXES THAT MATCH THE CHILD’S
SYMPTOMS AND PROBLEMS TO CLASSIFY TREATMENT
 Determine if this is an initial or follow-up visit for this problem. THE ILLNESS
- If follow-up visit, use the follow –up instructions on the TREAT THE CHILD chart.
- If initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

ASK:
 Is the child not able to drink or
breastfeed?
 Does the child vomit everything?
 Has the child had convulsions
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first
dose of an appropriate antibiotic and other urgent treatments.
LOOK:
 See if the child is
abnormally sleepy or
IF YES Exception: Re-hydration of the child according to Plan C may resolve danger signs so
that referral is no longer needed.
difficult to awaken

A child with any general danger sign needs URGENT attention. Complete the
assessment and any pre–referral treatment so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS:

SIGNS CLASSIFY AS TREATMENT
Does the child have cough or difficult breathing? (Urgent pre-referral treatments are in bold print)

 Give first dose of an appropriate

Classify  Any general danger antibiotic.
IF YES, ASK LOOK, LISTEN: COUGH or sign or
SEVERE PNEUMONIA
 Give Vitamin A.
 For how long?  Count the breaths in one minute OR VERY SEVERE
CHILD  Chest indrawing or  Treat the child to prevent low
DIFFICULT DISEASE
 Look for chest indrawing  Stridor in calm child blood sugar.
MUST BE BREATHING  Refer URGENTLY to hospital.
 Look and listen for stridor
CALM.  Give an appropriate antibiotic for 5
days.
PNEUMONIA  Soothe the throat and relieve the
 Fast breathing cough with a safe remedy.
 Advise mother when to return
immediately.
IF the child Is: Fast Breathing Is:   Follow up in 2 days.

 2 months up  50 breaths per  If coughing more than 30 days, refer

to 12 months minute or more for assessment.
 12 months up  40 breaths per  No signs of  Soothe the throat and relieve the
NO PNEUMONIA;
minute or more pneumonia or very cough with a safe remedy.
COUGH OR COLD
severe disease  Advise mother when to return
immediately.
 Follow up in 5 days if not improving.
THEN ASK: Does the child have diarrhea?
Two of the following signs  If child has no other severe classification:
IF YES, ASK; LOOK AND FEEL: -Give fluid for severe dehydration (Plan C). OR
 Abnormally sleepy or difficult
 For how long?  Look at the child’s general For
to awaken. If child also has another severe classification:
DEHYDRATION
 Is there blood in the condition. - Refer URGENTLY to hospital with mother
stool?  Sunken eyes SEVERE giving frequent sips of ORS on the way.
Is the child:
 Not able to drink or drinking DEHYDRATION - Advise mother to continue breastfeeding.
- Abnormally sleepy or difficult to
poorly  If child is 2 years or older and there is
awaken?
 Skin pinch goes back very cholera in your area , give antibiotic for
- Restless and irritable? cholera
 Look for sunken eyes.
slowly.
Classify
 Offer the child fluid. Is the child: Two of the following signs:  Give fluid and food for some dehydration (Plan
DIARRHEA
B).
- Not able to drink or drinking  Restless, irritable SOME  If child also has a severe classification:
poorly?  Sunken eyes DEHYDRATION - Refer URGENTLY to hospital with mother
- Drinking eagerly, thirsty? giving frequent sips of ORS on the way.
 Drinks eagerly, thirsty - Advise mother to continue breastfeeding
 Pinch the skin of the abdomen.  Advise mother when to return immediately
 Skin pinch goes back slowly
Does it go back:  Follow –up in 5 days if not improving.
-Very slowly (longer than 2  Give fluid and food to treat diarrhea at home
NO (Plan A).
seconds)?  Not enough signs to classify  Give Zinc supplements.
DEHYDRATION
-Slowly as some or severe dehydration  Advise mother when to return immediately
 Follow-up in 5 days if not improving

 Treat
Treatdehydration
dehydration
before
before
referral
referral
unless
unless
thethe
SEVERE child
child
hashas
another
anothersevere
severe
classification.
classification.
 Dehydration present
if diarrhea 14 PERSISTENT  Give
Givevitamin
vitaminA.A.
days or more DIARRHEA  Refer
Refertotohospital.
hospital.

 Advise the mother on feeding a child who has

PERSISTENT PERSISTENT DIARRHEA.
 No dehydration
DIARRHEA  Give vitamin A.
 Follow up in 5 days.
 Advise mother when to return immediately.

 Treat for 5 days with an oral antibiotic

DYSENTERY recommended for Shigella in your area.
 Blood in the stool
and if blood  Follow up in 2 days.
in stool  Advise mother when to return immediately.

THEN ASK: Does the child have fever?
(by history, or feels hot or temperature 37.5°C or above)
Decide Malaria Risk
Ask:
 Does the child live in a malaria area?
 Has the child visited/traveled or stayed overnight in a
malaria area in past 4 weeks?
If Yes to either, obtain a blood smear.
THEN ASK:
 For how long has the child had
fever?
 If more than 7 days, has fever
been present every day?
 Has the child had measles within
the last 3 months?
………………………………………………………………………………
If the child has measles
now or within the last
three months:
………………………………………………………………………………
Decide Dengue Risk: Yes or No
If Dengue risk:
THEN ASK:
 Has the child had any bleeding
from the nose or gums or in the
vomitus or stools?
 Has the child had tarry black
stools?
 Has the child had abdominal pain?
 Has the child been vomiting?
LOOK AND FEEL:
 Look or feel for stiff neck.
 Look for runny nose
Look for signs of MEASLES:
 Generalized rash, and
 One of these: Cough, runny
nose or red eyes
 Look for mouth ulcers
Are they deep and extensive?
 Look for pus draining from the
eye.
 Look for clouding of the cornea
LOOK AND FEEL:
 Look for bleeding from nose
or gums.
 Look for skin petechiae
 Feel for cold and clammy
extremities.
 Check for slow capillary refill.
If none of the above ASK or
LOOK and FEEL signs are
present and the child is 6
months or older and fever
present for more than three
days:
- Perform the tourniquet test.
MALARIA RISK
 Give first dose of Quanine (under medical supervision or if a
hospital is not accessible within 4 hours).
 Any general danger sign or
VERY SEVERE  Give first dose of an appropriate antibiotic.
 Stiff neck FEBRILE  Treat the child to prevent low blood sugar
Malaria Risk
DISEASE/  Give one dose of paracetamol in health center for high fever
(including travel MALARIA (38.5°C or above)
to malaria area)  Send a blood smear with the patient
 Refer URGENTLY to hospital.
 Blood smear(+)  Treat the child with an oral antimalarial.
 Give one dose of paracetamol in health center
If Blood smear not done: MALARIA For high fever (38.5°C or above).
 NO runny nose, and  Advise 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.
 Give one dose of paracetamol in health center for high fever
Classify
FEVER  Blood smear(+) FEVER (38.5°C or above)
 Runny nose ,or MALARIA  Advise mother when to return immediately
 UNLIKELY  Follow up in 2 days if fever persist
Measles,or
 Other causes of fever  If fever is present every day for more than 7days, refer for
assessment.
 Treat other causes of fever
NO MALARIA RISK
 Any general danger sign or  Give first dose of an appropriate antibiotic.
No Malaria  Treat the child to prevent low blood sugar
VERY SEVERE
Risk  Stiff neck  Give dose of paracetamol in health center for high fever
FEBRILE
DISEASE (38.5°C or above)
 Refer URGENTLY to hospital
 Give first dose of paracetamol in health center for high fever
(38.5C) or above ).
 No signs of very severe
 Advise mother when to return immediately
FEVER: NO
febrile disease MALARIA  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
 Any general danger sign  Give Vitamin A.

 Clouding of cornea or SEVERE Give first dose of an appropriate antibiotic.
If MEASLES now  If clouding of the cornea or pus draining from the eye, apply
or within last 3
 Deep or extensive mouth COMPLICATED
ulcers MEASLES tetracycline eye ointment
months Classify  Refer URGENTLY to hospital
 Pus draining from the eye or MEASLES WITH  Give Vitamin A.
 Mouth ulcers EYE OR MOUTH  If pus draining from the eye, apply tetracycline eye ointment.
………………………… COMPLICATION  If mouth ulcers, teach the mother to treat with gentian violet.
 Follow-up in 2 days.
…………………………  Advise mother when to return immediately.
 …….
Measles now or within the  Give vitamin A.
last 3 months MEASLES  Advise mother when to return immediately.
if DENGUE Risk,  Bleeding from nose or gums or  If persistent vomiting or persistent abdominal pain or skin
Classify  Bleeding in stools or vomitus or petachiae or positive tourniquet test are the only positive
 Black stools or vomitus or signs, give ORS (Plan B)
SEVERE
 Skin petechiae or  If any other signs of bleeding are positive, give fluids rapidly
 Cold and clammy extremities or
DENGUE
HEMORRHAGIC as in Plan C.
 Capillary refill more than 3  Treat the child to prevent low blood sugar.
seconds or FEVER
 Refer all child URGENTLY to hospital.
 Persistent abdominal pain or
 DO NOT GIVE ASPIRIN.
 Persistent vomiting or
 Tourniquet test positive
 No signs of severe dengue FEVER:DENGUE  Advise mother when to return immediately.
hemorrhagic fever. HEMORRHAGIC  Follow up in 2 days if fever persist or child shows sign of
FEVER UNLIKELY bleeding.
 DO NOT GIVE ASPIRIN.
Other Causes of fever:
 Severe dengue hemorrhagic fever
 Pneumonia  Mastoiditis
 Dysentery  Acute ear infection
 Severe complicated measles  Abscess, cellulitis, steomyelitis
 Measles with eye or mouth complications  Severe pneumonia or very severe disease
 measles

THEN ASK: Does the child have an ear problem?

IF YES: LOOK AND FEEL:
 Is there ear pain?  Look for pus draining from
 Is there ear discharge? the ear.
If yes, for how long?  Feel for tender swelling
behind the ear.
 Tender swelling behind the ear.
Classify
EAR PROBLEM
 Pus is seen draining from the ear and
discharge is reported for less than 14
days, or
 Give first dose of an appropriate
MASTOIDITIS antibiotic
ACUTE EAR  Give an antibiotic for 5 days.
INFECTION  Give paracetamol for pain
 Dry the ear by wicking
 Follow up in 5 days

 Ear pain.
…………………………………………… ………………... …………………………………………………
 Pus is seen draining from the ear and CHRONIC  Dry the ear by wicking
discharge is reported for 14 days or EAR  Follow –up in 5 days
more INFECTION

 No ear pain, and NO EAR  No additional treatment.

 No pus is seen draining from the ear. INFECTION
 THEN CHECK OR MALNUTRITION AND ANEMIA
LOOK AND FEEL: Classify
NUTRITIONAL  Visible severe wasting or SEVERE  Give Vitamin A.
 Edema of both feet or MALNUTRITION OR  Refer URGENTLY to hospital.
 Look for visible severe wasting. STATUS  Severe palmar pallor. SEVERE ANEMIA
 Look for edema of both feet.
 Look for palmar pallor. Is it:
 Some palmar pallor or  Assess the child’s feeding and counsel the
- Severe palmar pallor?
 Very low weight for age. mother on feeding according to the FOOD box
- Some palmar pallor? ANEMIA on the COUNSEL THE MOTHER chart.
OR VERY LOW - If feeding problem, follow-up in 5 days
 Determine weight for age. WEIGHT
 If some pallor:
- Give iron.
- Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months
- Follow-up in 30 days
 Advise mother when to return immediately.
 If the child is less than 2 years old, assess the
 Not very low weight for age NO ANEMIA child ‘s feeding and counsel the mother on
and no other signs of AND NOT VERY LOW feeding according to the FOOD box on the
malnutrition. WEIGHT COUNSEL THE MOTHER chart.
- If feeding problem, follow up 5 days.
Advise mother when to return immediately

THEN CHECK THE CHILD”S IMMUNIZATION STATUS THEN CHECK THE VITAMIN A STATUS
VITAMIN A SUPPLEMENTATION SCHEDULE:
AGE VACCINE
IMMUNIZATION SCHEDULE Birth BCG HEP B-1 SUPPLEMENTATION: The first dose at 6 months or above.
6 weeks DPT-1 OPV-1 HEP B-2 Subsequent doses every 6 months.
10 weeks DPT-2 OPV-2 TREATMENT: 1 CAPSULE TODAY
14 weeks DPT-3 OPV-3 HEP B-3 1 CAPSULE TOMORROW
9 months Measles 1 CAPSULE AFTER 2 WEEKS

ASSESS OTHER PROBLEMS

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

 Give an Appropriate Oral Antibiotic

 FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS
FIRST – LINE ANTIBIOTIC: COTRIMOXAZOLE
SECOND – LINE ANTIBIOTIC: AMOXYCILLIN
TEACH THE MOTHER TO GIVE COTRIMOXAZOLE AMOXYCILIN
ORAL DRUGS AT HOME (Trimethoprim+Sulphamethoxazole)  Give two times daily
Follow the instructions below for every oral drug to be given at home.  Give two times daily for 3 days for 5 days
Also follow the instructions listed with each drug’s dosage table.
AGE OR WEIGHT ADULT TABLET SYRUP TABLET SYRUP
 Determine the appropriate drugs and dosage for 80 mg trimethoprim 40 mg trimethoprim +
the child’s age or weight. + 400 mg 200 mg 250 mg 125 MG
sulphamethoxazole Sulphamethozole per 5 PER 5 ML
 Tell the mother the reason for giving the drug to the child. ml
2 months up to 12 1/2 5.0 1/2 5 ML
Months (4-<10 kg)
 Demonstrate how to measure a dose.
12 months up to 1 10.0 ml 1 10 ML
 Watch the mother practice measuring a dose by herself. 5 years (10-19kg)

 Ask the mother to give the first dose to her child.  FOR DYSENTRY:
Give antibiotic recommended for Shigella in your area for 5 days
 Explain carefully how to give the drug, then label and FIRST-LINE ANTIBIOTIC FOR SHIGELLA: COTRIMOXAZOLE
SECOND –LINE ANTIBIOTIC FOR SHIGELLA: NALIDIXIC ACID
package the drug.
COTRIMOXAMOLE NALIDIXIC ACID
 If more than one drug will be given, collect, count and (trimethoprim+Sulphamethoxazol)  Give four times daily for 5 days
package each drug separately. AGE OR WEIGHT e)
SYRUP 250 mg/5 ml
 Explain that all the oral drug tablets or syrups must be 2 months up to 4 months (4-<6 kg)
See doses above. 1.25 ml(1/4 tsp.)
used to finish the course of treatment even if the child
gets better. 4 months up to 12 months (6-<10kg)
2.5 ml(1/2 tsp.)
12 months up to 5 months (10-<19 kg)
 Check the mother’s understanding before she leaves 5 ml(1 tsp.)
the health center.
 FOR CHOLERA:
Give antibiotic recommended Cholera in your area for 5 days
FIRST-LINE ANTIBIOTIC FOR CHOLERA: TETRACYCLINE
SECOND –LINE ANTIBIOTIC FORCHOLERA: COTRIMOXAZOLE
TETRACYCLINE COTRIMOXAZOLE
 Give four times daily for 3 days (Trimethoprim+sulphamethoxazole)
 Give two times daily for 5 days
2 months up to 4 months (4-<6 kg) CAPSULE250 mg
2 months up to 4 months (4-<6 kg) TETRACYCLINE NOT
RECOMMENDED See doses above
4 months up to 12 months (6-<10kg) 1/2
12 months up to 5 years (10-19 kg.) 1
 TEACH THE MOTHER TO GIVE
ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug’s dosage.

 Give an Oral Antimalarial  Give Vitamin A

FIRST-LINE ANTIMALARIAL: CHLOROQUINE AND PRIMAQUINE
SECOND –LINE ANTIMALARIAL: SULFADOXINE AND PYRIMETHAMINE TREATMENT TREATMENT
SUPPLEMENTATION
 IF CHLOROQUINE:  Give one dose in the health center  Give one dose in health center if:
 Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of - child is six months of age or older.
choloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the health - child has not received a dose of
center for additional tablets. Vitamin A in the past six months.
 Explain that itching is a possible side effect of the drug, but it is not dangerous.
Age VITAMIN A CAPSULES
 IF SULFADOXINE + PYRIMETHAMINE: Give single dose in health center.
100,000 IU 200,000 IU

CHLOROQUINE PRIMAQUINE PRIMAQUINE SULFADOXINE+ 6 months up tot 12 months 1 1/2 capsule

 Give for 3 days  Give a single dose in  Give daily for 14 PYRIMETHAMINE
health center for days for P.vivax  Give a single dose in 12 months up to 5 years - 1 capsule
P.Falciparum health center

TABLETS
150 mg base
AGE TABLET TABLET TABLET
DAY 1 DAY 2 DAY 3
15 mg base 15 mg base (500 mg sulfadoxine)  Give Iron
25 mg pyrimethamine
 Give one dose daily for 14 days.
2 months up 1/2 1/2 1/2 1/4
to 5 months IRON/FOLATE TABLET IRON SYRUP IRON DROPS
Ferrous sulfate 200 mg + Ferrous sulfate 150 mg Ferrous sulfate 25 mg
AGE OR WEIGHT Per 5 ml
250 mcg Folate Per 5 ml
5 months up 1/2 1/2 1/2 1/2 (25 mg elemental iron per ml)
(60 mg elemental iron) (6 mg elemental iron per ml)
to 12 months
3 months up to 4 months (4-< 6 kg) 2.5 ml (1/2 tsp) 0.6 ml
12 months up 1 1 1/2 1/2 1/4 3/4
to 3 years
4 months up to 12 months (6-< 10 kg) 4 ml (3/4 tsp) 1.0 ml
3 years up to 1 1/2 1 1/2 1 3/4 1/2 1
5 years 12 months up to 3 years (10-<14 kg) 1/2 tablet 5 ml (1 tsp) 1.5 ml

3 years up to 5 years (14 - 19 kg) 1 tablet 10 ml (1 1/2 tsp) 2.0 ml

 Give Paracetamol for High Fever(38.5°C or more)

or Ear Pain  Give Mebendazole/Albendazole
 Give paracetamol every 6 hours until high fever or ear pain is gone.
 Give 500 mg Mebendazole/400 mg Albendazole as a single dose in health if the child is 12 months up to 59 months
PARACETAMOL and has not had a dose in the previous 6 months, with the following dose;

AGE OR WEIGHT TABLET (500mg) SYRUP (120mg/5 ml) AGE OR WEIGHT Albendazole 400 mg tablet Mebendazole 500 mg tablet

2 months up to 3 years (4-<14kg) 1/4 5 ml (1 tsp) 12 months up to 23 months ½ 1

24 months up to 59 months 1 1
3 years up to 5 years (14-19 kg) 1/2 10 ml (2 tsp)
 TEACH THE MOTHER HOW TO TREAT LOCAL INFECTIONS AT HOME
 Explain to the mother what the treatment is and why it should be given.
 Describe the treatment steps listed in the appropriate box.
 Watch the mother as she does the first treatment in the health center.  Dry the Ear by Wicking
(except remedy for cough or sore throat)
 Dry the ear at least 3 times daily.
 Tell her how often to do the treatment at home.
 Roll clean absorbent cloth or soft, strong tissue paper into a wick.
 If needed for treatment at home, give mother the tube of tetracycline ointment
 Place the wick in the child’s ear.
or a small bottle of gentian violet.
 Remove the wick when wet.
 Check the mother’s understanding before she leaves the health center.
 Replace the wick with a clean one and repeat these steps until the ear is dry.

 Treat Eye Infection with Tetracycline

Eye Ointment  Treat Mouth Ulcers with Gentian Violet
 Treat the mouth ulcers twice daily.
 Clean both eyes 3 times daily.
 Wash hands.  Wash hands.
 Ask child to close the eye.
 Wash child’s mouth with clean soft cloth wrapped around the finger and wet with
 Use clean cloth and water to gently wipe away pus.
salt water.
 Then apply tetracycline eye ointment in both eyes 3 times daily
 Ask the child to look up.  Paint the mouth ulcer with half-strength gentian violet
 Squirt a small amount of ointment on the inside of the lower lid.  Wash hands again.
 Wash hands again.

 Treat until redness is gone.

 Do not use other eye ointments or drops, or put anything else in the eye.
 Soothe the Troath ,Relieve the Cough with a Safe
Remedy
 Safe remedies to recommend:
 Breast milk for exclusively breastfed infant.
 Tamarind, Calamansi and Ginger.
 Harmful remedies to discourage:
 Codeine cough syrup.
 Other cough syrup.
 Oral or nasal decongestants.
GIVE THESE TREATMENTS IN HEALTH CENTER ONLY
 Explain to the mother why the drug is given.
 Determine the dose appropriate for the child’s weight (or age).
 Use a sterile needle and sterile syringe. Measure the dose accurately.
 Give the drug as an intramuscular injection.
 If the child cannot be referred, follow the instructions provided.

 Give An Intramuscular Antibiotic  Give Quinine for Severe Malaria

FOR CHILDREN BEING REFERRED WHO CANNOT TAKE AN ORAL ANTIBIOTIC: FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE /MALARIA
 Give fist dose of intramuscular chloramphenicol and refer child urgently to hospital.  Give fist dose of intramuscular quinine and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE: IF REFERRAL IS NOT POSSIBLE:
 Repeat the chloramphenicol injection every 12 hours for 5 days.
 Give first dose of intramuscular Quinine
 Then change to an appropriate oral antibiotic to complete 10 days of treatment.  The child should remain lying down for one hour.
 Repeat the QUININE Injection at 4 and 8 hours later, and then every 12 hours until the child
CHLORAMPENICOL is able to take an oral antimalarial .Do not continue Quinine injections for more than 1 week.
Dose: 40 mg per kg
AGE OR WEIGHT Add 5.0ml sterile water to vial  DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE
containing
1,000 mg= 5.6 ml at 180 mg/ml
AGE OR WEIGHT INTRAMUSCULAR QUININE
2 months up to 4 months (4-< 6 Kg) 1.0 ml =180 mg
) 300 mg /ml*( in ml ampoules)
4 months up to 9 months (6-< 8 Kg) 1.5 ml=270 mg
4 months up to 12 months (6-< 10 Kg) 0.3 ml
9 months up to 12 months (8-<10 Kg) 2 ml= 360 mg
12 months up to 2 years (10-< 12Kg) 0.4 ml
12 months up to 3 years (10-< 14 Kg) 2.5 ml=450 mg
2 years up to 3 years (12-< 14 Kg) 0.5 ml
3 years up to 5 years (14-< 19 Kg) 3.5 ml=630 mg
3 years up to 5 years (14-< 19 Kg) 0.6 ml

*quinine salt
 Treat the Child to Prevent
Low Blood Sugar
 If the child is able to breastfeed:

Ask the mother to breastfeed the child

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

Give expressed breastmilk or a breastmilk substitute.

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

To make sugar water: Dissolve 4 level teaspoon of sugar

(20 grams) in a 200-ml cup of clean water.

 If the child is not able to swallow:

Give 50 ml of milk or sugar water by nasogastric tube.

 If the child is difficult to awaken or unconscious, start IV infusion ;

 Give 5 ml/kg of 10% dextrose solution (D10) over a few minutes

 Or give 1 ml/kg of 50% dextrose solution (D50) by slow push
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
(See FOOD advice on COUNSEL THE MOTHER chart)

PLAN A: Treat Diarrhea at Home PLAN B: Treat Some Dehydration with ORS
Counsel the Mother on the 3 Rules of Home Treatment: Give in health center recommended amount of ORS over a 4-hour period
Give Extra Fluid, Continue Feeding, When to Return
1. DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.

1. Give EXTRA FLUID (as much as the child will take)

AGE Up to 4 months 4 months Up to 12 months Up to 2 years Up to
 TELL THE MOTHER: 12 months 2 years 5 years

- Breastfeed more frequently and longer at each feed.

- If the child is exclusively breastfed, give ORS or clean water in addition to WEIGHT < 6 kg 6 -< 10 kg 10 -< 12 kg 12 – 19 kg
breastmilk.
- If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fluids (such as soup, rice water, or “buko juice”)., or In ml 200-400 400-700 700-900 900-1400
clean water.
* Use the child’s age only when you do not know the weight. The approximate amount of ORS required in (ml) can also
It is especially important to give ORS at home when: be calculated by multiplying the child’s weight (in kg) times 75.
- the child has been treated with Plan B or Plan C during the visit.
- the child cannot return to a health center if the diarrhea gets worse.  If the child wants more ORS than shown above, give more.
 For infants under 6 months who are not breastfed ,also give 100-200 ml clean
 TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 water during this period
PACKETS OF ORS TO USE AT HOME.
 SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
 SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL  Give frequent small sips from a cup.
FLUID INTAKE:
 If the child vomits, wait for 10 minutes then continue, but more slowly.
Up to 2 years 50 to 100 ml. after each loose stool  Continue breastfeeding whenever the child wants.
2 years or more 100 to 200 ml after each loose stool
 AFTER 4 HOURS
Tell the mother to:  Reassess the child and classify the child for dehydration.
- Give frequent small sips from a cup.  Select the appropriate plan to continue treatment.
- If the child vomits, wait for 10 minutes then continue, but more slowly.  Begin feeding the child in Health center.
- Continue giving extra fluid until the diarrhea stops.
 IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
2. GIVE ZINC SUPPLEMENTS
 Show her how to prepare ORS solution at home.
 10 mg per day in infants < 6 mos. for 10-14 days  Show her how much ORS to give to finish a 4-hour treatment at home
 20 mg per day in children 6 mos. -5 years old for 10-14 days See COUNSEL  Give her enough ORS packets to complete re-hydration. Also give her 2
THE MOTHER packets as recommended in Plan A.
3. CONTINUE FEEDING chart  Explain the 4 rules of home Treatment

4. WHEN TO RETURN 1. GIVE EXTRA FLUID

2. GIVE ZINC SUPPLEMENTS See Plan A for recommended fluids
3. CONTINUE FEEDING and
4. WHEN TO RETURN See COUNSEL THE MOTHER chart
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
(See FOOD advice on COUNSEL THE MOTHER chart)

 Plan C: Treat Severe Dehydration Quickly

 FOLLOW THE ARROWS. IF THE ANSWER IS “YES”, GO ACROSS. IF “NO”, GO DOWN

 Start IV fluid immediately. If the child can drink, give ORS by mouth while
the drip is set up. Give 100 ml/kg Ringer’s Lactate Solution (or, if not
available, normal saline), divided as follows:
START HERE
AGE First give Then give
Can you give 30 ml/kg 70 ml/kg in:
intravenous (IV) fluid YES in:
Infants (under 12 months) 1 hour 5 hours
immediately?
Children
(12 months up to 5 years 30 minutes 2 ½ hours

*Repeat once if radial pulse is still very weak or not detectable.

NO
Is IV treatment
available nearby
YES
within 30 minutes?
NO
Are you trained to use
naso-gastric (NG)
tube for re-hydration?
NO
YES
Can the child drink?
NO
Refer URGENTLY to
hospital for IV or NG
treatment.
 Reassess the child every 1-2 hours. If hydration status is not improving,
give the IV drip more rapidly.
 Also give ORS (about 5 ml/kg/hour) as soon as the child can drink:
usually after 3-4 hours (infants) or 1-2 hours (children).
 Reassess an infant after 6 hours and a child after 3 hours. Classify
dehydration. Then choose the appropriate plan (A, B or C) to continue
GIVE VITAMIN A
treatment. SUPPLEMENTATION AS NEEDED
 Refer URGENTLY to hospital for IV treatment.
 If the child can drink, provide the mother with ORS solution
and show her how to give frequent sips during the trip. IMMUNIZE EVERY SICK CHILD AS
NEEDED
 Start re-hydration by tube (or mouth) with ORS solution: give
20 ml/kg/hour for 6 hours (total of 120 ml/kg).
 Re-assess the child every 1-2 hours:
- If there is repeated vomiting or increasing abdominal
distention, give fluid more slowly.
- If hydration status is not improving after 3 hours, send the
child for IV therapy.
- After 6 hours, reassess the child. Classify dehydration.
Then choose the appropriate plan (A, B or C) to continue
treatment.
-

NOTE:
If possible, observe the child at least 6 hours after re-hydration
to be sure the mother can maintain hydration by giving the child
ORS Solution by mouth
GIVE FOLLOW-UP CARE
 Care for the child who returns for follow-up using all the boxes that match the child’s previous classifications.
 If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

PNUEMONIA
After 2 days

Check the child for general danger signs

Assess the child for cough or difficult breathing.
See ASSESS &
CLASSIFY chart
 DYSENTERY
Ask After 2 days:
- Is the child breathing slower?
- Is there less fever? Assess the child for diarrhea (See ASSESS & CLASSIFY chart)
- Is the child eating better?
Ask:
Treatment
- Are there fewer stools?
 If chest indrawing or a general danger sign, give a dose of - Is there less blood in the stool?
second –line antibiotic or intramuscular chloramphenicol. Then - Is there less fever?
refer URGENTLY to hospital - Is there less abdominal pain?
 If breathing rate ,fever and eating are the same, change to the - Is the child eating better?
second-line antibiotic and advise the mother to return in 2 days
or refer .(if the child had measles within 3 months ,refer) Treatment:
 If breathing slower ,less fever ,or eating better, complete the
5 days of antibiotic  If the child is dehydrated ~ treat dehydration.
 If cough is more than 30 days, refer for assessment.
If number of stool, amount of blood in stools, fever, abdominal pain or eating is the same
or worse:
 PERSISTENT DIARRHEA - Change to second –line oral antibiotic recommended for Shigella in your area.
After 5 days: - Give it for 5 days. Advise the mother to return in 2 days.

Ask: Exceptions- if the child:

- Has the diarrhea stopped?
- How many loose stools is the child having per day?
TREATMENT:
 If the diarrhea has not stopped (child is still having 3 or more
loose stools per day), do a full reassessment of the child. Give
any treatment needed. Then refer to hospital.
- is less than 12 months old or
- was dehydrated on the first visit, or Refer to the Hospital
- had measles within the last 3 months
 If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better:
continue giving the same antibiotic until finished

 If the diarrhea has stopped (child having less than 3 loose

stools per day), tell the mother to follow the usual
recommendations for the child’s age.
GIVE FOLLOW-UP CARE
 Care for the child who returns for follow-up using all the boxes that
match the child’s previous classifications.
 If the child has any new problem, assess, classify and treat the new
problem as on the ASSESS AND CLASSIFY chart.
MALARIA
If fever persists after 2 days, or returns within 14 days:
Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
Assess for other cause of fever.
Treatment:
 If the child has any general danger sign or stiff neck, treat as VERY
SEVERE FEBRILE DISEASE/MALARIA.
 If the child has any cause of fever other than malaria, provide treatment.
 If malaria is the only apparent cause of fever
- Take a blood smear.
- Give second-line oral antimalarial without waiting for result of blood smear.
- Advise mother to return in 2 days if fever persists.
- If fever persists after 2 days of treatment with second-line oral antimalarial,
refer with blood smear for reassessment.
- If fever has been present for 7 days, refer for assessment.
FEVER-MALARIA UNLIKELY
If fever persists after 2 days:
Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
Assess for other cause of fever.
Treatment:
 If the child has any general danger sign or stiff neck, treat as VERY
SEVERE FEBRILE DISEASE/MALARIA.
 If malaria is the only apparent cause of fever
- Take a blood smear.
- Treat with the first-line oral antimalarial. Advise the mother to return again in 2
days if the fever persists.
- If fever has been present for 7 days, refer for assessment.
FEVER (NO MALARIA)
If fever persists after 2 days:
Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
Make sure that there has been no travel and/or overnight stay in a malaria area.
If there has been travel and/or overnight stay, take blood smear if possible.
Treatment:
 If there has been travel and/or overnight stay to a malaria area and the blood
smear is positive or there is no blood smear – classify according to fever with
Malaria Risk and treat accordingly.
 If there has been no travel to a malaria area or blood smear is negative:
- If the child has any general danger signs or stiff neck treat as VERY SEVERE
FEBRILE DISEASE
- If the child has any apparent cause of fever, provide treatment.
- If no apparent cause of fever, advise the mother to return again in 2 days if fever
persists.
- If fever has been present for 7 days, refer for assessment.
GIVE FOLLOW-UP CARE
 Care for the child who returns for follow-up using all the boxes that
match the child’s previous classification.
FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
 If the child has any new problem, assess, classify and treat the new If fever persists after 2 days:
problem as on the ASSESS AND CLASSIFY chart.
Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
Do a tourniquet test.
Assess for other causes of fever.
MEASLES WITH EYE OR MOUTH
Treatment:
COMPLICATIONS
 If the child has any signs of bleeding, including skin petechiae or a positive
After 2 days:
tourniquet test, or signs of shock, or persistent abdominal pain or persistent
Look for red eyes and pus draining from the eyes. vomiting treat as SEVERE DENGUE HEMORRHAGIC FEVER.
Look at mouth ulcers.
Smell the mouth.  If the child has any other apparent cause of fever, provide treatment.

Treatment for eye Infection:  If fever has been present for 7 days, refer for assessment.

 If pus is draining from the eye, ask the mother to describe how she has treated the
eye infection. If treatment has been correct, refer to hospital. If treatment has not
been correct, teach mother correct treatment.
 If the pus is gone but redness remains, stop the treatment.
 If no apparent cause of fever, advise the mother to return daily until the child has had no
fever for at least 48 hours.
 Advise mother to make sure child is given more fluids and is eating.

 If no pus or redness, stop the treatment.

Treatment for Mouth Ulcers. EAR INFECTION

 If mouth ulcers are worse, or is a very foul smell from the mouth, refer to After 5 days:
hospital.
Reassess for ear problem. (See ASSESS & CLASSIFY chart)
 If mouth ulcers are the same or better, continue using half-strength gentian violet Measure the child’s temperature.
for a total of 5 days
Treatment:

 If there is tender swelling behind the ear or high fever (38.5°C or above), treat as
MASTOIDITIS).

 Acute ear infection: If ear pain or discharge persists, treat for 5 or more days with the
same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.

 Chronic ear infection: Check that the mother is wicking the ear correctly.
Encourage her to continue.

 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 use all of it before stopping.
 GIVE FOLLOW-UP CARE
 Care for the child who returns for follow-up using all the
boxes that match the child’s previous classification.

 If the child has any new problem, assess, classify and treat
the new problem as on the ASSESS AND CLASSIFY chart.

FEEDING PROBLEM VERY LOW WEIGHT

After 5 days:
Reassess feeding. (See questions at the top of the COUNSEL chart)
Ask about any feeding problems found on the initial visit.
 Counsel the mother about any new or continuing feeding problems. If you
counsel the mother to make significant changes in feeding, ask her to
bring the child back again.
 If the child is very low weight for age, ask the mother to return 30 days
after the initial visit to measure the child’s weight gain.
After 30 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:
 If the child is no longer very low weight for age, praise the mother and
encourage her to continue.
 If the child is very low weight for age, counsel the mother about any feeding
problem found. Continue to see the child monthly until the child is feeding
well and gaining weight regularly or is no longer very low weight for age.

Exception:
If you do not think that feeding will improve, or if the child has lost weight,
ANEMIA refer the child.
After 14 days:

 Give iron. Advise mother to return in 14 days for more iron.

 Continue giving iron every day for 2 months with follow-up every 14
IF ANY MORE FOLLOW-UP VISITS ARE NEEDED
days. BASED ON THE INITIAL VISIT OR THIS VISIT,
ADVISE THE MOTHER OF THE
 If the child has any palmar pallor after 2 months, refer to assessment. NEXT FOLLOW-UP VISIT

ALSO, ADVISE THE MOTHER

WHEN TO RETURN IMMEDIATELY.
(See COUNSEL chart)
 COUNSEL THE MOTHER

FOOD

Assess the Child’s Feeding

Ask questions about the child’s usual feeding and feeding during this illness. Compare the mother’s answers to the Feeding Recommendations
for the child’s age in the box.

ASK - Do you breastfeed your child?

- How many times during the day?
- Do you breastfeed during the night?

Does the child take any other food or fluids?

- What food or fluids?
- How many times per day?
- What do you use to feed the child?
- If very low weight for age: How large are the servings? Does the child receive his own serving? Who feeds the child and how?

During this illness has the child’s feeding changed? If yes, how?

Assess the Child’s Care for Development Sample Feeding Problem

Ask questions about how mother cares for her child. Compare the 1. difficulty in breastfeeding
mother’s answers to the Recommendation for Care for Development. 2. child less than 4 months taking other milk/food
3. use of breastfeed substitute / cow’s milk / evap milk
ASK - - How do you play with your child? 4. use of feeding bottles
- How do you communicate with your child? 5. lack of active feeding
6. not feeding well during illness
7. complementary food not enough in quantity / quality / variety
8. child 6 months above not yet given complementary foods
9. infant not exclusively breastfed
10. improper handling and use of breastmilk suubstitute
 Recommendation for Feeding and Care for Development
Birth up to 6 months 6 months to 12 months 12 months to 2 years 2 years and older

 Breastfeed as often as the child wants.  Breastfeed as often as the child wants.  Give adequate amount of family food at
 Exclusively breastfeed as often as 3 meals a day
 Add any of the following  Give adequate amount of family foods
the child wants, day and night at
such as: rice, camote, potato, fish
least 8 times in 24 hours. o Lugaw with added oil, mashed chicken, meat, mongo, steamed  Give twice daily
vegetables or beans, steamed tokwa, tokwa, pulverized roasted dilis, milk nutritious food
 Don not give other foods or fluids. flaked fish, pulverized roasted dilis, between
and eggs, dark green leafy and yellow
finely ground meat, eggyolk, bite-size vegetables (malunggay, squash), fruits meals such as,
Birth up to 6 months fruits. (papaya, banana) Boiled yellow
camote, boiled
o 3 times per day if
Play:  Add oil or yellow corn,
breastfed peanuts, boiled saba, banana,
margarine
 o 5 times per day if taho, fruits and fruit juices.
Provide an area where the child could  5 times per day
move, play and develop his senses of not breastfed
sight, touch and hearing.  Feed the baby 2 years and olfder
 Have large colorful things for your child 6 months to 12 months nutritious snacks like fruits
to reach for and new things to see. Play:
Play: 12 months to 2 years  Help your child count, name and
Communicate: compare things.
 Give your child clean, safe household
 Look into your child’s eyes and smile things to handle, bang and drop. Play:  Make simple toys
at him or her.  Give your child things to stack up and to for your child
 When you are breastfeeding it is a put into container and take out
good time to talk to your child Communicate:
and get a
conversation  Encourage your
Communicate:
child to talk and
going with  Ask your child answer your
sounds or Communicate: simple questions. child’s questions.
gestures  Respond to your child’s sounds and Respond to your Teach your child
interest. Tell your child the names of child’s attempts to talk. Play games stories, song and
things and people.
like “bye” games

Feeding recommendation for a child who has PERSISTENT DIARRHEA

 If still breastfeeding, give more frequent, longer breastfeeding, day and night.
 If taking other milk such as milk supplements.
 Replace with increased brestfeeding or
 Replace half the milk with nutrient-rich semi-solid food.
 Do not use condensed or evaporated filled milk.
 For other foods, follow feeding recommendations for the child’s age.
Counsel 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 mother’s confidence that she can produce all the breastmilk that the child needs.
- Suggest giving more frequent, longer breastfeeds, day and night, and gradually reducing other milk or
foods
- Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
- Prepare only an amount of milk which the child can consume within an hour. If there is some
left-over milk, discard.

 If the mother is using a bottle to feed the child:

- Recommend substituting the bottle with a cup.

- Show the mother how to feed the child using 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.
- Observe what the child likes and consider these in the preparation of his/her food.

 If the child is not feeding well during illness, counsel the mother to:

- Breastfeed more frequently and longer if possible.

- Use soft, varied, appetizing, favorite foods to encourage the child to eat as much as possible-
offer in frequent, small feedings.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.

 Follow-up any feeding problem in 5 days.

FLUID

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
 Breastfeed more frequently and for longer at each feed.
 Increase fluid. For example, give soup, rice water, buko juice or clean water.

FOR CHILD WITH DIARRHEA:

 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

FOR ANY SICK CHILD:
Advise the mother to come for follow-up at the earliest time listed
for the child’s problems.
Return for WHEN TO RETURN IMMEDIATELY
If the child has: Follow-up
in: Advise mother to return immediately if the child has any of
PNEUMONIA these signs:
DYSENTERY 2 days
MALARIA, if fever persist Any sick child  Not able to drink or breastfeed
FEVER-MALARIA UNLIKELY, if fever persists  Becomes sicker
FEVER (NO MALARIA), if fever persists  Develops a fever
MEASLES WITH EYE OR MOUTH COMPLICATIONS
DENGUE HEMORRHAGIC FEVER UNLIKELY, if fever
If child has NO  Fast breathing
persists
PNEUMONIA:  Difficult breathing
COUGH OR COLD, return
PERSISTENT DIARRHEA also if:
ACUTE EAR INFECTION 5 days
CHRONIC EAR INFECTION
If child has Diarrhea, return  Blood in stool
FEEDING PROBLEM
also if:  Drinking poorly
ANY OTHER ILLNESS, if not improving

If child has FEVER:  Any sign of bleeding

ANEMIA 14 days DENGUE HEMORRHAGIC  Persistent abdominal pain
FEVER UNLIKELY return  Persistent vomiting
VERY LOW WEIGHT FOR AGE 30 days
also if:  Skin petechiae
 Skin rash
Counsel the Mother About Her Own Health
 If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother’s immunization status and give her Tetanus Toxoid if needed.
Make sure she has access to:
- Family Planning
- Counseling on STI’s and AIDS prevention
 ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
AGE 1 WEEK UP TO 2 MONTHS

ASSESS CLASSIFY IDENTIFY

TREATMENT
ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE USE ALL BOXES THAT MATCH THE INFANT’S
 Determine if this is an initial or follow-up visit for this problem. SYMPTOMS AND PROBLEMS TO
- If follow-up visit, use the follow-up instructions in the follow-up section. CLASSIFY THE ILLNESS
- If initial visit, assess the young infant as follows:

CHECK FOR POSSIBLE BACTERIAL INFECTION SIGNS CLASSIFY AS REATMENT

Classify  Convulsions or
ASK LOOK, LISTEN, FEEL: ALL  Fast breathing (60 breaths per  Give first dose of intramuscular
minute or more) or antibiotics
 Count the breaths in one minute. YOUNG
 Severe chest indrawing or
Has the infant Repeat the count if elevated. YOUNG INFANT INFANTS  Nasal flaring or  Treat the child to prevent low
had  Look for severe chest indrawing MUST BE CALM  Grunting or blood sugar
Convulsions?  Look for nasal flaring.  Bulging fontanelle or
 Look and listen for grunting.  Pus draining from ear or  Advise mother how to keep the
 Look and feel for bulging fontanelle.  Umbilical redness extending to POSSIBLE infant warm on the way to the
 Look for pus draining from the ear. the skin or SERIOUS hospital.
 Look at the umbilicus. Is it red or draining pus?  Fever (37.5о C* or above or feels BACTERIAL
Does the redness extend to the skin? hot) or low body temperature INFECTION  Refer URGENTLY to the
 Measure temperature (or feel for fever or low body (less than 35.5о C* or feels cold) hospital.**
temperature) or
 Look for skin pustules. Are there many or severe  Many or severe skin pustules or
pustules?  Abnormally sleepy or difficult to
 See if the young infant is abnormally sleepy or awaken or
difficult to awaken.  Less than normal movement.
 Look at the young infants movements.
Are they less than normal//?  Give an appropriate oral
 Red umbilicus or draining LOCAL antibiotic
pus or BACTERIAL  Treat local infection in the health
INFECTION center and teach the mother to
 Skin pustules. treat local infections at home
 Advise mother to give home care
for young infant.
 Follow-up in 2days.
THEN ASK: Two of the following  If infant does not have POSSIBLE SERIOUS
Does the young infant have diarrhea? For
signs BACTERIAL INFECTION nor DYSENTERY
- Give fluid for severe dehydration (Plan C)
DEHYDRATION  Abnormally sleepy or OR
If infant also has POSSIBLE SERIOUS
difficult to awaken SEVERE BACTERIAL INFECTION or DYSENTERY.
IF YES, ASK: LOOK AND FEEL: DEHYDRATION
 Sunken eyes - Refer URGENTLY to hospital with
 For how long?  Look at the young infant’s mother giving frequent sips of ORS on
 Skin pinch goes back the way.
 Is there blood in general condition. Is the child: very slowly - Advise mother to continue breastfeeding.
the stood? - abnormally sleepy or difficult - Advise mother how to keep the young
infant warm on the way to the hospital
to awaken?
- Restless and irritable?
Classify Two of the following
 Look for sunken eyes. DIARRHEA signs:  Give fluid for some dehydration (Plan B)
SOME
 If infant also has POSSIBLE SERIOUS
 Pinch the skin of the abdomen.  Restless, irritable DEHYDRATION
BACTERIAL INFECTION or DYSENTERY.
Does it go back: - Refer URGENTLY to hospital with mother
 Sunken eyes giving frequent sips of ORS on the way.
- Very slowly (longer than 2
- Advise mother to continue breastfeeding.
seconds)?  Skin pinch goes back
- Slowly? slowly

 Not enough signs to  Give fluid to treat diarrhea at home (Plan A)

NO
classify as Some or DEHYDRATION
Severe Dehydration

 Diarrhea lasting 14  If the young infant has dehydration, treat

days or more dehydration before referral unless infant
SEVERE also has POSSIBLE SERIOUS
if diarrhea 14 PERSISTENT BACTERIAL INFECTION.
days or more DIARRHEA
 Refer to hospital.

 Refer URGENTLY to hospital with mother

 Blood in the stool. DYSENTERY giving frequent sips or ORS on the way.
and if blood
in stool Advise mother to continue breastfeeding.
THEN CHECK FOR FEEDING PROBLEM
OR LOW WEIGHT:
IF YES, ASK: LOOK AND FEEL:
 Not able to feed or
Classify  Give the first dose of
 Is there any difficult feeding? Determine weight for age. intramuscular antibiotic
FEEDING  No attachment at all NOT ABLE TO
 Treat to prevent low blood
 Is the infant breastfed? If yes, or FEED
sugar.
how many times in 24 hours? POSSIBLE
 Advise the mother how to keep
 Not suckling at all SERIOUS
the young infant warm on the
 Does the infant usually receive BACTERIAL
way to the hospital
any other foods or drinks? If yes, INFECTION
 Refer URGENTLY to hospital.
how often?
 What do you use to feed the infant?
 Advise the mother to breastfeed as
 Not well attached to
often and for as long as the infant
IF AN INFANT: Has any difficulty in feeding. breast or wants, day and night.
Is breastfeeding less than 8 times in 24 hours,  Not suckling  If not well attached or not
Is taking any other foods or drinks, or effectively or suckling effectively, teach
FEEDING correct positioning and
Is low weight for age,
PROBLEM attachment.
 Less than 8 OR  If breastfeeding less than 8
AND
breastfeeds in 24 LOW WEIGHT times in 24 hours, advise to
Has no indications to refer urgently to hospital: hours or increase frequency of feeding.

ASSESS BREASTFEEDING:  Receives other foods  If receiving other foods or drinks,

or drinks or counsel mother about
 Has the infant If the infant has not fed in the previous breastfeeding more, reducing other
breastfed hours, ask the mother to put her infant to  Low weight for age or foods and drinks and using a cup.
in previous hour? the breast. Observe her breastfeed for 4 mins. - If not breastfeeding at all:
Refer for breastfeeding
 Thrush (ulcers or
(If the infant was fed during the last hour, ask counseling and possible
white patches in
relactation.
the mother if she can wait and tell you when the mouth)
- Advise about correctly
infant is willing to feed again) preparing breastmilk
substitutes and using a cup.
 Is the infant able to attach?
 If thrush, teach the mother to
No attachment at all not well attached good attachment
treat thrush at home.
TO CHECK ATTACHEMENT LOOK FOR:  Advise mother to give home
care for the young infant.
- Chin touching breast
 Follow-up any feeding problem
- Mouth wide open or thrush in 2 days.
- Lower lip turned outward  Follow-up low weight for age in
- More areola visible above than below the mouth 14 days.
(All of the signs should be present if the attachment is good)

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

sometimes pausing?)  Not low weight for  Advise mother to give home
NO FEEDING
Not suckling at all not suckling effectively suckling effectively age and no signs of care for the young infant.
PROBLEM
inadequate feeding.  Praise the mother for feeding
Clear a blocked nose if it interferes with breastfeeding. the infant well.
 Look for ulcers or white patches in the mouth (thrush).
THEN CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS:

AGE VACCINE
IMMUNIZATION SCHEDULE Birth BCG Hep B – 1
6 weeks DPT – 1 OPV - 1 Hep B - 2

ASSESS OTHER PROBLEMS

 TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give the Appropriate Oral Antibiotic

For local bacterial infection:
First-line antibiotic: COTRIMOXAZOLE
Second-line antibiotic: AMOXICILLIN
COTIMOXAZOLE AMOXYCILIN
(trimethoprim + sulphamethoxazole)
 Give two times daily for 5 days  Give three times daily for 5 days
ADULT TABLET SYRUP
Single strength TABLET SYRUP
(40 mg trimethoprim
AGE OR WEIGHT (80 mg trimethoprin + 400) 250 mg 125 mg in 5 ml
+ 200 mg
mg sulphamethoxazole Sulphamethoxazole)

Birth up to 1 month (<3 kg) 1.25 ml* 1.25 ml

1 month up to 2 months (3-4 kg) 1/4 2.5 ml 1/4 2.5 ml

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

Give First Dose of Intramuscular Antibiotics

 Give first dose of both Benzylpenicillin and Gentamicin intramuscular
GENTAMICIN BENZYLPENICILLIN
Dose: 5 mg per kg Dose: 50,000 units per kg

WEIGHT Undiluted 2 ml OR Add 6 ml sterile water To a vial of 600 (1,00,00 units)

Vial containing to 2ml vial containing Add 2.1 ml sterile water = OR Add 3.6 ml sterile water =
20 mg=2ml at 10 mg/ml 80 mg* =8ml at 10 mg/ml 2.5 ml at 400,000 units/ml 4.0 ml at 2,500 units/ml

1 kg 0.5 ml* 0.1 ml 0.2 ml

2 kg 1.0 ml* 0.2 ml 0.4 ml

3 kg 1.5 ml* 0.4 ml 0.6 ml

4 kg 2.0 ml* 0.5 ml 0.8 ml

5 kg 2.5 ml* 0.6 ml 1.0 ml

* Avoid using undiluted 40 mg/ml Gentamicin
 Refferal is the best option for a young infant classified with POSSIBLE SERIOUS BACTERIAL INFECTION. If referral is not
possible, give benzypenicillin and gentamicin for at least 5 days. Give benzylpenicillin every 6 hours plus gentamicin one
dose daily.
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

To treat Diarrhea, See TREAT THE CHILD chart.

Immunize Every Sick Young Infant, as Needed.

Teach the Mother to Treat Local Infections at Home.

 Explain how the treatment is given.

 Watch her as she does the first treatment in the health center.

 Tell her to do the treatment twice daily. She should return to the health center if the infection worsens.

To Treat Skin Pustules To Treat Umbilical Infection Treat Oral Thrush (ulcers or white patches in mouth)

The Mother should: The mother should: The mother should:

 Wash hands.  Wash hands.  Wash hands.

 Gently wash off pus and
crusts with soap and water.
 Dry the area.
 Paint with gentian violet.
 Wash hands.
 Clean with 70% ethyl alcohol.
 Paint with gentian violet.
 Wash hands.
 Wash mouth with clean soft cloth wrapped
around the finger and wet with salt water
 Paint the mouth ulcer with half-strength
gentian violet.
 Wash hands.
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
Teach Correct Positioning and Attachment for Breastfeeding.
 Show the mother how to hold her infant.
- with infant’s head and body straight
- facing her breast, with infant’s nose opposite her nipples
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and shoulders
 Show her how to help the infant to attach. She should:
- touch her infant’s lips with her nipple
- wait until her infant’s mouth is opening wide
- move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.
 Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Advise Mother to Give Home Care for the Young Infant.

 FOOD
Breastfeed frequently, as often and for as long as the infant
wants, day or night, during sickness and health.
FLUID

 WHEN TO RETURN

Follow-up visit When to Return Immediately:

If the infant has: Return for follow-up in: Advise the mother to return immediately if the
young infant has any of these signs:
LOCAL BACTERIAL
INFECTION ANY 2 days Breastfeeding or drinking poorly
FEEDING PROBLEM Becomes sicker
THRUSH Develops a fever
LOW WEIGHT FOR AGE 14 days Fast breathing
Difficult breathing
Blood in stool
 MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.
- In cool weather, cover the infant’s head and feet and
dress the infant with extra clothing.
GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

LOCAL BACTERIAL INFECTION

After 2 days

Look at the umbilicus. Is it red or draining pus? Does redness extend to the skin?
Look at the skin pustules. Are there many or severe pustules?

Treatment:

 If the pus or redness remains or is worse, refer to hospital.

 If pus and redness are improved tell the mother to continue giving antibiotic for 5 days and continue
treating the local infection at home.
GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

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

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

ORAL 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” chart above)

 If thrush is worse, or if the infant has problems with attachment or suckling, refer to hospital.
 If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.