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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

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

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)

Classify  Give first dose of an


IF YES, ASK LOOK, LISTEN: • Any general SEVERE PNEUMONIA appropriate antibiotic.
COUGH or danger sign or  Give Vitamin A.
• For how long? • Count the breaths in one OR VERY SEVERE
CHILD DIFFICULT • Chest indrawing DISEASE  Treat the child to prevent low
minute or blood sugar.
MUST BE BREATHING
• Look for chest indrawing • Stridor in calm  Refer URGENTLY to hospital.
CALM.  Give an appropriate antibiotic
• Look and listen for stridor 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 minute
to 12 months or more  If coughing more than 30 days,
12 months up 40 breaths per minute refer for assessment.
• No signs of NO PNEUMONIA;
or more  Soothe the throat and relieve the
pneumonia or very COUGH OR COLD cough with a safe remedy.
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
For
• For how long? • Look at the child’s general
DEHYDRATION difficult to awaken. If child also has another severe classification:
• Is there blood in condition.
- Refer URGENTLY to hospital with mother
the stool? • Sunken eyes SEVERE giving frequent sips of ORS on the way.
Is the child:
• Not able to drink or DEHYDRATION - Advise mother to continue breastfeeding.
- Abnormally sleepy or difficult to
awaken? drinking poorly  If child is 2 years or older and there is
- Restless and irritable? • Skin pinch goes back cholera in your area , give antibiotic for
cholera
• Look for sunken eyes. very slowly.
Classify
• Offer the child fluid. Is the child: DIARRHEA Two of the following signs:  Give fluid and food for some dehydration
(Plan 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
• Skin pinch goes back  Advise mother when to return immediately
abdomen.  Follow –up in 5 days if not improving.
slowly
Does it go back:  Give fluid and food to treat diarrhea at home
-Very slowly (longer than 2 NO (Plan A).
• Not enough signs to DEHYDRATION  Give Zinc supplements.
seconds)?
classify as some or severe  Advise mother when to return immediately
dehydration  Follow-up in 5 days if not improving

Treatdehydration
Treat dehydration
before referral
before unless
referralthe
unless
childthe
SEVERE has another
child hassevere
another
classification.
severe classification.
if diarrhea 14 • Dehydration present PERSISTENT
days or more  Give
Givevitamin
vitaminA.A.
DIARRHEA  Refer
Refertotohospital.
hospital.

 Advise the mother on feeding a child who


PERSISTENT has 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.
and if blood • Blood in the stool
 Follow up in 2 days.
in stool
 Advise mother when to return immediately.
MALARIA RISK
THEN ASK: Does the child have fever?  Give first dose of Quanine (under medical supervision or
(by history, or feels hot or temperature 37.5°C or above) • Any general danger
if a hospital is not accessible within 4 hours).
VERY SEVERE  Give first dose of an appropriate antibiotic.
Malaria Risk sign or FEBRILE  Treat the child to prevent low blood sugar
(including travel to DISEASE/  Give one dose of paracetamol in health center for high
• Stiff neck
malaria area) MALARIA fever (38.5°C or above)
Decide Malaria Risk  Send a blood smear with the patient
Ask:  Refer URGENTLY to hospital.
• Blood smear(+)  Treat the child with an oral antimalarial.
• Does the child live in a malaria area?
 Give one dose of paracetamol in health center
• Has the child visited/traveled or stayed overnight in a If Blood smear not done: MALARIA For high fever (38.5°C or above).
malaria area in past 4 weeks? • NO runny nose, and  Advise mother when to return immediately.
NO measles, and  Follow –up in 2 days if fever persists.
If Yes to either, obtain a blood smear. NO other causes of fever
 If fever is present every day for more than 7 days, refer
LOOK AND FEEL: for assessment.
THEN ASK: Classify  Give one dose of paracetamol in health center for high
• Look or feel for stiff neck.
• For how long has the child had FEVER Blood smear(+) FEVER fever (38.5°C or above)
fever? • Look for runny nose MALARIA
Runny nose ,or  Advise mother when to return immediately
• If more than 7 days, has fever Measles,or UNLIKELY
 Follow up in 2 days if fever persist
Look for signs of MEASLES:
been present every day? Other causes of fever
 If fever is present every day for more than 7days, refer
• Generalized rash, and
• Has the child had measles for assessment.
within the last 3 months? • One of these: Cough, runny
 Treat other causes of fever
nose or red eyes
NO MALARIA RISK
No Malaria • Any general danger sign or  Give first dose of an appropriate antibiotic.
Risk VERY SEVERE
……………………………………………………………………………… Stiff neck
 Treat the child to prevent low blood sugar
FEBRILE
DISEASE  Give dose of paracetamol in health center for high fever
• Look for mouth ulcers (38.5°C or above)
If the child has measles now
Are they deep and extensive?  Refer URGENTLY to hospital
or within the last three  Give first dose of paracetamol in health center for high
months: • Look for pus draining from the
eye. fever (38.5C) or above ).
• No signs of very severe
FEVER: NO  Advise mother when to return immediately
• Look for clouding of the febrile disease MALARIA  Follow –up in 2 days if fever persists.
cornea
 If fever is present every day for more than 7 days refer
for assessment.
………………………………………………………………………………
 Treat other causes of fever

Decide Dengue Risk: Yes or No • Any general danger sign  Give Vitamin A.
If Dengue risk: If MEASLES now or • Clouding of cornea or SEVERE  Give first dose of an appropriate antibiotic.
within last 3 months • Deep or extensive mouth COMPLICATED  If clouding of the cornea or pus draining from the eye,
THEN ASK: LOOK AND FEEL: Classify ulcers MEASLES apply tetracycline eye ointment
• Has the child had any bleeding from • Look for bleeding from  Refer URGENTLY to hospital
the nose or gums or in the vomitus or nose or gums. • Pus draining from the eye or M E A S L E S W IT H  Give Vitamin A.
stools? • Look for skin petechiae • Mouth ulcers EYE OR M OUTH  If pus draining from the eye, apply tetracycline eye
• Has the child had tarry black stools? • Feel for cold and clammy ………………………… C O M P L IC A T IO N ointment.
• Has the child had abdominal pain? extremities.  If mouth ulcers, teach the mother to treat with gentian
………………………… violet.
• Has the child been vomiting? • Check for slow capillary
refill. ……. now or within the
• Measles  Give vitamin A.
last 3 months MEASLES  Advise mother when to return immediately.
If none of the above ASK or
LOOK and FEEL signs are
present and the child is 6 months if DENGUE Risk, • Bleeding from nose or gums or  If persistent vomiting or persistent abdominal pain or
or older and fever present for Classify • Bleeding in stools or vomitus or skin petachiae or positive tourniquet test are the only
more than three days: • Black stools or vomitus or positive signs, give ORS (Plan B)
SEVERE
- Perform the tourniquet test. • Skin petechiae or DENGUE  If any other signs of bleeding are positive, give fluids
• Cold and clammy extremities or HEMORRHAGIC rapidly as in Plan C.
• Capillary refill more than 3 FEVER  Treat the child to prevent low blood sugar.
seconds or  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 F E V E R :D E N G U E  Advise mother when to return immediately.
hemorrhagic fever. H E M O R R H A G IC  Follow up in 2 days if fever persist or child shows sign of
F E V E RU N L IK E L Y 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:  Give first dose of an appropriate


• Is there ear pain? • Look for pus draining from Tender swelling behind the ear. MASTOIDITIS antibiotic
• Is there ear discharge? the ear.
If yes, for how long? • Feel for tender swelling Classify
behind the ear. EAR PROBLEM ACUTE EAR  Give an antibiotic for 5 days.
• Pus is seen draining from the ear and INFECTION  Give paracetamol for pain
discharge is reported for less than 14  Dry the ear by wicking
days, or  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 Visible severe wasting or
NUTRITIONAL Edema of both feet or SEVERE Give Vitamin A.
• Look for visible severe wasting. Severe palmar pallor. MALNUTRITION OR Refer URGENTLY to hospital.
STATUS SEVERE ANEMIA
• Look for edema of both feet.
• Look for palmar pallor. Is it:
Assess the child’s feeding and counsel the
- Severe palmar pallor? mother on feeding according to the FOOD box
- Some palmar pallor? on the COUNSEL THE MOTHER chart.
- If feeding problem, follow-up in 5 days
• Determine weight Some palmar pallor or
Very low weight for age.
for age. If some pallor:
Anemia
Give iron.
or very low
Give mebendazole if child is 2 years or older and
weight
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
child ‘s feeding and counsel the mother on
feeding according to the FOOD box on the
Not very low weight for age and
COUNSEL THE MOTHER chart.
no other signs of malnutrition. NO Anemia
If feeding problem, follow up 5 days.
AND NOT very low
Advise mother when to return immediately
weight

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
Follow the instructions below for every oral drug to be given at home.  Give two times daily for 3 days daily 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)
 FOR DYSENTRY:
 Ask the mother to give the first dose to her child. Give antibiotic recommended for Shigella in your area for 5 days
FIRST-LINE ANTIBIOTIC FOR SHIGELLA: COTRIMOXAZOLE
 Explain carefully how to give the drug, then label and SECOND –LINE ANTIBIOTIC FOR SHIGELLA: NALIDIXIC ACID

package the drug. COTRIMOXAMOLE NALIDIXIC ACID


(trimethoprim+Sulphamethoxazol)  Give four times daily for 5 days
 If more than one drug will be given, collect, count and AGE OR WEIGHT e)
package each drug separately. SYRUP 250 mg/5 ml
2 months up to 4 months (4-<6 kg)
 Explain that all the oral drug tablets or syrups must be See doses above. 1.25 ml(1/4 tsp.)
used to finish the course of treatment even if the child 4 months up to 12 months (6-<10kg)
2.5 ml(1/2 tsp.)
gets better.
12 months up to 5 months (10-<19 kg)
5 ml(1 tsp.)
 Check the mother’s understanding before she leaves
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 (Trimethoprim+sulphamethoxazole)
days  Give two times daily for 5 days
2 months up to 4 months (4-<6 kg) CAPSULE250 mg
TEACH THE MOTHER TO GIVE ORAL 2 months up to 4 months (4-<6 kg) TETRACYCLINE NOT RECOMMENDED
See doses above
DRUGS AT HOME 4 months up to 12 months (6-<10kg) 1/2
12 months up to 5 years (10-19 kg.) 1
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug’s dosage.
TEACH
Give an THE MOTHER HOW TO TREAT LOCAL 
Oral Antimalarial INFECTIONS AT HOME
Give Vitamin A
FIRST-LINE ANTIMALARIAL: CHLOROQUINE AND PRIMAQUINE
SECOND –LINE ANTIMALARIAL: SULFADOXINE AND PYRIMETHAMINE TREATMENT SUPPLEMENTATION
TREATMENT
 IF CHLOROQUINE:   Give one dose in health center if:
Give one dose in the health center
• 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  Give daily for PYRIMETHAMINE
dose in health center 14 days for  Give a single dose 12 months up to 5 years - 1 capsule
for P.Falciparum P.vivax in health center

TABLETS
AGE 150 mg base
TABLET TABLET TABLET
DAY 1 DAY 2 DAY 3
15 mg base 15 mg base (500 mg sulfadoxine)
25 mg pyrimethamine
 Give Iron
 Give one dose daily for 14 days.
2 months up to 1/2 1/2 1/2 1/4
5 months IRON/FOLATE IRON SYRUP IRON DROPS
TABLET Ferrous sulfate 150 Ferrous sulfate 25
AGE OR WEIGHT mg
5 months up to 1/2 1/2 1/2 Ferrous sulfate 200 mg
1/2 Per 5 m l Per 5 m l
12 months mg +
250 m cg Folate (6 mg elemental ( 2 5 m g e le m e n t a l ir o n
3 months up to 4 months 2.5 ml (1/2 0.6 ml
12 months up 1 1 1/2 1/2 1/4 3/4 (4-< 6 kg) tsp)
to 3 years
4 months up to 12 months 4 ml (3/4 tsp) 1.0 ml
(6-< 10 kg)
3 years up to 5 1 1/2 1 1/2 1 3/4 1/2 1
years 12 months up to 3 years 1/2 tablet 5 ml (1 tsp) 1.5 ml
(10-<14 kg)
3 years up to 5 years (14 - 1 tablet 10 ml (1 1/2 2.0 ml
19 kg) tsp)

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
PARACETAMOL the child is 12 months up to 59 months 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)
 Explain to the mother what the treatment is and why it should be given.
GIVE THESE
 Describe TREATMENTS
the treatment IN HEALTH
steps listed in the appropriate box. CENTER ONLY
 Watch the mother as she does the first treatment in the health center.  Dry the Ear by Wicking
• (except
Explain remedy
to the for why
mother cough
theordrug
soreisthroat)
given.
 Dry the ear at least 3 times daily.
•  Tell
Determine theher how
dose often to dofor
appropriate the treatment
the at home.
child’s weight (or age).
• Roll clean absorbent cloth or soft, strong tissue paper into a wick.
• If needed
Usea sterile needlefor
andtreatment at home,
sterile syringe. give mother
Measure the tube
the dose of tetracycline
accurately.
• Place the wick in the child’s ear.
• ointment
Give the drugoras
a an
small bottle of gentian
intramuscular violet.
injection.
• Remove the wick when wet.
•  childCheck
If the thebemother’s
cannot referred,understanding before she
follow the instructions leaves the health center.
provided.
• 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
• Use clean cloth and water to gently wipe away pus.
with 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 • Wash hands again.
lid.
• Wash hands again.

 Treat until redness is gone.


 Do not use other eye ointments or drops, or put
 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 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.
CHLORAMPENICOL  Repeat the QUININE Injection at 4 and 8 hours later, and then every 12 hours until the
Dose: 40 mg per kg child is able to take an oral antimalarial .Do not continue Quinine injections for more than 1
AGE OR WEIGHT Add 5.0ml sterile water to vial week.
containing
1,000 mg= 5.6 ml at 180 mg/ml  DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE
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
GIVEEXTRA
GIVE EXTRAFLUID
FLUIDFOR
FORDIARRHEA
DIARRHEAAND
ANDCONTINUE
CONTINUEFEEDING
FEEDING
(See
(See FOOD
FOOD advice
advice onon COUNSEL
COUNSEL THE
THE MOTHER
MOTHER chart)
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:
In ml 200-400 400-700 700-900 900-1400
ORS solution, food-based fluids (such as soup, rice water, or “buko juice”)., or
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
 TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 clean 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 • Give frequent small sips from a cup.
USUAL FLUID INTAKE: • If the child vomits, wait for 10 minutes then continue, but more slowly.
• Continue breastfeeding whenever the child wants.
Up to 2 years 50 to 100 ml. after each loose stool
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.

2. GIVE ZINC SUPPLEMENTS


IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
• 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
• 20 mg per day in children 6 mos. -5 years old for 10-14 days See COUNSEL treatment at home
THE MOTHER • Give her enough ORS packets to complete re-hydration.
3. CONTINUE FEEDING chart Also give her 2 packets as recommended in Plan A.
• 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
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
30 ml/kg 70 ml/kg in:
GIVE Can
FOLLOW-UP
you give
intravenous (IV) fluid
CARE
YES in:
Infants (under 12 months) 1 hour 5 hours
 Careimmediately?
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
Children and treat the new problem as on the ASSESS AND CLASSIFY chart.
(12 months up to 5 years 30 minutes 2 ½ hours

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


NO
• 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 GIVE VITAMIN A
dehydration. Then choose the appropriate plan (A, B or C) to continue
treatment. SUPPLEMENTATION AS NEEDED
Is IV treatment
available nearby
YES Refer URGENTLY to hospital for IV treatment.
within 30 minutes?
• If the child can drink, provide the mother with ORS
NO solution and show her how to give frequent sips during the IMMUNIZE EVERY SICK CHILD AS
trip.
NEEDED
• Start re-hydration by tube (or mouth) with ORS solution:
Are you trained to use give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
naso-gastric (NG) • Re-assess the child every 1-2 hours:
tube for re-hydration? - If there is repeated vomiting or increasing
abdominal distention, give fluid more slowly.
NO - If hydration status is not improving after 3 hours,
YES send the child for IV therapy.
- After 6 hours, reassess the child. Classify
dehydration. Then choose the appropriate plan (A, B or
Can the child drink? C) to continue treatment.
-

NO
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
Refer URGENTLY to ORS Solution by mouth
hospital for IV or NG
treatment.
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?
Is there less blood in the stool?
 If chest indrawing or a general danger sign, give a dose of
Is there less fever?
second –line antibiotic or intramuscular chloramphenicol. Then
Is there less abdominal pain?
refer URGENTLY to hospital
Is the child eating better?
 If breathing rate ,fever and eating are the same, change to
the second-line antibiotic and advise the mother to return in 2
Treatment:
days or refer .(if the child had measles within 3 months ,refer)
 If breathing slower ,less fever ,or eating better, complete the
If the child is dehydrated ~ treat dehydration.
5 days of antibiotic
 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? - is less than 12 months old or
- was dehydrated on the first visit, or Refer to the Hospital
TREATMENT: - had measles within the last 3 months
 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  If fewer stools, less blood in the stools, less fever, less abdominal pain, and
any treatment needed. Then refer to hospital. 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 FEVER-MALARIA UNLIKELY
problem as on the ASSESS AND CLASSIFY chart.
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
MALARIA SEVERE FEBRILE DISEASE/MALARIA.
If fever persists after 2 days, or returns within 14 days:
 If malaria is the only apparent cause of fever
Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
Assess for other cause of fever. - Take a blood smear.
- Treat with the first-line oral antimalarial. Advise the mother to return again in 2
Treatment: 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/MALARIA.

 If the child has any cause of fever other than malaria, provide treatment. FEVER (NO MALARIA)
If malaria is the only apparent cause of fever If fever persists after 2 days:

- Take a blood smear. Do a full re-assessment of the child. (See ASSESSS & CLASSIFY chart)
- Give second-line oral antimalarial without waiting for result of blood smear. Make sure that there has been no travel and/or overnight stay in a malaria area.
- Advise mother to return in 2 days if fever persists. If there has been travel and/or overnight stay, take blood smear if possible.
- If fever persists after 2 days of treatment with second-line oral antimalarial,
refer with blood smear for reassessment. 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.

If the child has any new problem, assess, classify and treat the new
problem as on the ASSESS AND CLASSIFY chart.
FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
If fever persists after 2 days:

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
After 2 days:  If the child has any signs of bleeding, including skin petechiae or a positive
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  If no apparent cause of fever, advise the mother to return daily until the child has had
the eye infection. If treatment has been correct, refer to hospital. If treatment has not no fever for at least 48 hours.
been correct, teach mother correct treatment.
 Advise mother to make sure child is given more fluids and is eating.
 If the pus is gone but redness remains, stop the treatment.

 If no pus or redness, stop the treatment.

Treatment for Mouth Ulcers. EAR INFECTION


After 5 days:
 If mouth ulcers are worse, or is a very foul smell from the mouth, refer to
hospital. Reassess for ear problem. (See ASSESS & CLASSIFY chart)
 If mouth ulcers are the same or better, continue using half-strength gentian Measure the child’s temperature.
violet 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: After 30 days:
Reassess feeding. (See questions at the top of the COUNSEL chart) Weigh the child and determine if the child is still very low weight for age.
Ask about any feeding problems found on the initial visit. Reassess feeding. (See questions at the top of the COUNSEL chart)

 Counsel the mother about any new or continuing feeding problems. If Treatment:
you counsel the mother to make significant changes in feeding, ask her
to bring the child back again.  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, ask the mother to return 30 days
after the initial visit to measure the child’s weight gain.  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:
ANEMIA If you do not think that feeding will improve, or if the child has lost weight,
After 14 days: refer the child.

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


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

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
the child wants, day and night at
foods such as: rice, camote, potato,
least 8 times in 24 hours. o Lugaw with added oil, mashed fish 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 meals such as,
Birth up to 6 months fruits.
vegetables (malunggay, squash), fruits
Boiled yellow
(papaya, banana)
camote, boiled
o 3 times per day if • Add oil or yellow corn,
Play: breastfed margarine peanuts, boiled saba, banana,
• Provide an area where the child o 5 times per day if taho, fruits and fruit juices.
5 times per day
could move, play and develop his not breastfed
senses of sight, touch and hearing. • Feed the baby 2 years and olfder
• Have large colorful things for your 6 months to 12 months nutritious snacks like fruits
child to reach for and new things to Play:
see. Play: 12 months to 2 years • Help your child count, name and
compare things.
Communicate: • Give your child clean, safe household
Play: • Make simple toys
things to handle, bang and drop.
• Look into your child’s eyes and smile • Give your child things to stack up and for your child
at him or her. to put into container and take out
• When you are breastfeeding it is a Communicate:
good time to talk to your child
• Encourage your
and get a Communicate: child to talk and
conversation • Ask your child answer your
going with Communicate: simple questions. child’s questions.
sounds or • Respond to your child’s sounds and Respond to your Teach your child
gestures 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


• Replace half the milk with nutrient-rich semi-solid food.
• If still breastfeeding, give more frequent, longer breastfeeding, day and night.
• If taking other milk such as milk supplements. • Do not use condensed or evaporated filled milk.
• Replace with increased brestfeeding or • 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

WHEN TO RETURN
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.

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
also if: Skin petechiae
VERY LOW WEIGHT FOR AGE 30 days
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
Count the breaths in one minute. YOUNG minute or more) or intramuscular antibiotics
Has the infant Repeat the count if elevated. YOUNG INFANT INFANTS • Severe chest indrawing or
had Look for severe chest indrawing MUST BE CALM • Nasal flaring or  Treat the child to prevent
• Grunting or low blood sugar
Convulsions? Look for nasal flaring.
Look and listen for grunting. • Bulging fontanelle or
• Pus draining from ear or  Advise mother how to keep
Look and feel for bulging fontanelle. POSSIBLE
• Umbilical redness extending to the infant warm on the way to
Look for pus draining from the ear. SERIOUS
the skin or the hospital.
Look at the umbilicus. Is it red or draining pus? BACTERIAL
• Fever (37.5о C* or above or feels INFECTION
Does the redness extend to the skin?
hot) or low body temperature  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
INFECTION health center and teach the
Skin pustules. mother to treat local infections at
home
 Advise mother to give home
care for young infant.

Classify
and if blood
DIARRHEA
in stool
THEN ASK:
Two of the following  If infant does not have POSSIBLE SERIOUS
Does the young infant have diarrhea? For DEHYDRATION signs BACTERIAL INFECTION nor DYSENTERY
- Give fluid for severe dehydration (Plan C)
• 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
general condition. Is the child: • Skin pinch goes back the way.
Is there blood in very slowly - Advise mother to continue breastfeeding.
the stood? - abnormally sleepy or difficult to - Advise mother how to keep the young
awaken? infant warm on the way to the hospital
- Restless and irritable?
Two of the following
 Look for sunken eyes. signs: Give fluid for some dehydration (Plan B)
SOME
 Pinch the skin of the abdomen. Restless, irritable DEHYDRATION  If infant also has POSSIBLE SERIOUS
BACTERIAL INFECTION or DYSENTERY.
Does it go back: - Refer URGENTLY to hospital with mother
Sunken eyes
- Very slowly (longer than 2 giving frequent sips of ORS on the way.
- Advise mother to continue breastfeeding.
seconds)? • Skin pinch goes back
- Slowly? slowly

• Not enough signs to NO


Give fluid to treat diarrhea at home (Plan A)
classify as Some or DEHYDRATION
Severe Dehydration

• Diarrhea lasting 14  If the young infant has dehydration,


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

Blood in the stool. DYSENTERY  Refer URGENTLY to hospital with


mother giving frequent sips or ORS on the
way.
Advise mother to continue breastfeeding.
THEN CHECK FOR FEEDING PROBLEM
OR LOW WEIGHT:
IF YES, ASK: LOOK AND FEEL:
Classify Not able to feed or
 Give the first dose of
Is there any difficult feeding? Determine weight for age. FEEDING NOT ABLE TO intramuscular antibiotic
• No attachment at all
Is the infant breastfed? If yes, or FEED  Treat to prevent low blood
how many times in 24 hours? POSSIBLE sugar.
Not suckling at all SERIOUS  Advise the mother how to
Does the infant usually receive BACTERIAL keep the young infant warm on
any other foods or drinks? If yes, INFECTION the way to the hospital
 Refer URGENTLY to
how often? hospital.
What do you use to feed the infant?
 Advise the mother to
• Not well attached to
breastfeed as often and for as long
IF AN INFANT: Has any difficulty in feeding. breast or as the infant wants, day and night.
Is breastfeeding less than 8 times in 24 hours, • If not well attached or
• Not suckling
Is taking any other foods or drinks, or effectively or not suckling effectively, teach
FEEDING
Is low weight for age, correct positioning and
PROBLEM attachment.
AND • Less than 8 OR • If breastfeeding less
breastfeeds in 24 LOW WEIGHT than 8 times in 24 hours, advise
Has no indications to refer urgently to hospital: hours or to increase frequency of
feeding.
ASSESS BREASTFEEDING: • Receives other foods
or drinks or  If receiving other
• Has the infant If the infant has not fed in the previous foods or drinks, counsel mother
breastfed hours, ask the mother to put her infant to • Low weight for age or about breastfeeding more, reducing
in previous hour? the breast. Observe her breastfeed for 4 mins. other foods and drinks and using a
cup.
• Thrush (ulcers or - If not breastfeeding at all:
(If the infant was fed during the last hour, ask white patches in
the mother if she can wait and tell you when the Refer for breastfeeding
mouth) counseling and possible
infant is willing to feed again)
relactation.
- Advise about correctly
• Is the infant able to attach? preparing breastmilk
substitutes and using a cup.
No attachment at all not well attached good attachment

TO CHECK ATTACHEMENT LOOK FOR:  If thrush, teach the mother to


- Chin touching breast treat thrush at home.
- Mouth wide open  Advise mother to give home
care for the young infant.
- Lower lip turned outward
 Follow-up any feeding
- More areola visible above than below the mouth
problem or thrush in 2 days.
(All of the signs should be present if the attachment is good)
 Follow-up low weight for age
• Is the infant suckling effectively (that is, slow, deep sucks, in 14 days.
sometimes pausing?)  Advise mother to give home
• Not low weight NO FEEDING
Not suckling at all not suckling effectively suckling effectively for age and no signs PROBLEM care for the young infant.
of inadequate  Praise the mother for feeding
Clear a blocked nose if it interferes with breastfeeding. the infant well.
feeding.
• 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) + 200 mg
250 mg 125 mg in 5 ml
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. Clean with 70% ethyl alcohol.  Wash mouth with clean soft cloth
 Gently wash off pus and Paint with gentian violet. wrapped around the finger and wet with salt
crusts with soap and water. Wash hands. water
 Dry the area.  Paint the mouth ulcer with half-strength
 Paint with gentian violet. gentian violet.
 Wash hands.  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
 MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.
Blood in stool

- 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.