INTEGRATED

MANAGEMENT OF
CHILDHOOD ILLNESS
INTRODUCTION
Introduction
 1999 World Health Report shows that children in low-to
middle-income countries are ten times more likely to die
before reaching the age of five than children living in the
industrial world
 70% of these deaths are due to acute respiratory
infections, diarrhea, measles, malaria, malnutrition or
often a combination of these
 Sick children are not properly assessed and treated
 Diagnostic facilities, drugs, and equipment are minimal
or non-existent
Introduction
 Improvement of child health is dependent on
effective strategies that are based on holistic
approach, availability, capacity of the health
system, and acceptability
 During mid-1990s, WHO, together with UNICEF
and other agencies developed IMCI
 Intended to give curative care, and address
disease prevention and health promotion
 The objectives are to reduce death and the
frequency of illness and disability, and
contribute to improved growth and development
The Integrated Case
Management Process
 Can be used by any health care
professionals who see sick infants and
children aged 1 week to 5 years
 For first level facility
 Routine assessment of child for general
danger signs, common illnesses,
malnutrition, anemia, et. al.
Three Components of the
IMCI
 Upgrading the case management skills of the
health care providers
 Strengthening the health system for effective

management of childhood illness

 Improving family and community practices

related to child health and nutrition

The IMCI involves the following elements:
 Assess a child by checking first for danger signs
(or possible bacterial infection in a young infant)
and common conditions
Three Components of the
IMCI
 Classify using color-coded triage system
 Urgent pre-referral treatment and referral (pink)
 Specific medical treatment and advice (yellow)
 Simple advice on home management (green)

 Identify treatments for the child

 Provide practical treatment instructions

 Assess feeding, including breastfeeding

practices. Counsel to solve any problems found
in the child and the mother
 Give follow-up care
Principles of Integrated
Care
 Must be examined for “general danger signs”
 Must be assessed for major symptoms
 2 months to 5 years: cough or difficulty of
breathing, diarrhea, fever, ear problem
 1 week to 2 months: bacterial infection and
diarrhea
 Must also be assessed for nutrition and
immunization status, feeding problems and
other potential problems
 Only a limited number of carefully-selected
clinical signs are used
Principles of Integrated
Care
 Combination of individual signs leads to a
classification rather than a diagnosis
 Addresses most, but not all, major reasons
a sick child is brought for consult
 Uses a limited number of drugs and
encourage active participation of
caretakers in the treatment
 Includes counselling about home
management, feeding, fluids and when to
return to a health facility
ASSESS AND CLASSIFY THE
SICK CHILD
Aged 2 Months Up to 5 Years
Objectives
 Asking the mother about the child’s problem
 Checking for general danger signs
 Asking the mother about the four main
symptoms:
 Cough or difficulty breathing
 Diarrhea
 Fever
 Ear problem
 Checking when a main symptom is present
 Assessing for related signs
 Classifying the illness according to presence or
absence of signs
Objectives
 Checking for signs of malnutrition and
anemia and classifying the child’s
nutritional status
 Checking the child’s immunization status
 Checking the child’s Vitamin A
supplementation status
 Assessing any other problems
Ask the Mother what the
Child’s Problems are
 Greet the mother appropriately
 Use good communication and reassure
the mother
 Listen carefully
 Use words that are easily understandable

 Give time to answer the questions

 Ask additional questions when the mother

is not sure about her answer
Check for General Danger
Signs
Check ALL sick children for general danger signs. A
child with ANY of the danger signs has a serious
problem and needs URGENT referral to the hospital
 The child is not able to drink or breastfeed

 The child vomits everything

 The child has convulsions\

 The child is abnormally sleepy or difficult to

awaken
Check for General Danger
Signs
ASK: Is the child able to drink or breastfeed?
 If you are not sure about the mother’s answer,

ask her to offer the child a drink and observe

the child’s response
 Breastfeeding children may have difficulty

sucking when their nose is blocked

ASK: Does the child vomit everything?
ASK: Has the child had convulsions?
 Use also other terms like “fits”, “spasms”, or

“jerky movements”
Check for General Danger
Signs
LOOK: See if the child is abnormally sleepy or
difficult to awaken
 An abnormally sleepy child is drowsy

 Does not show interest in what is happening

around
 Does not look at his/her mother or watch your

face when you talk

 May stare blankly

 Does not respond when touched, shaken, or

spoken to
Check for the Four Main
Symptoms
1. Cough or Difficult Breathing
 Assess cough or difficult breathing

 The child may have pneumonia or another severe

respiratory infection
 Pneumonia is easily identified by checking for these
two clinical signs: FAST BREATHING and CHEST
INDRAWING
 A child with cough or difficult breathing is assessed
for
 How long has the child had these symptoms
 Fast breathing
 Chest indrawing
 Stridor in a calm child
Check for the Four Main
Symptoms
 The cut-off for fast breathing in a calm child
depends on the child’s age
2 months to 12 months: ≥ 50 bpm
 12 months to 5 years: ≥ 40 bpm

 LOOK for chest indrawing

 Ifyou are not sure, change the child’s position
so that he/she is lying flat
 Chest indrawing must be present all the time
and not only during feeding or crying
 Intercostal indrawing is NOT chest indrawing
Check for the Four Main
Symptoms
 LOOK and LISTEN for stridor
 Stridor is a harsh noise when the child breathes IN.
 May be caused by swollen larynx, trachea or epiglottis
 Listen only when the child is calm
 If the sound is heard when the child breathes out, this is
wheezing and NOT stridor
 Classify cough or difficult breathing
 CLASSIFY means to make a decision about the severity
of illness. They are not exact disease diagnoses.
Instead, they are categories that are used to determine
the appropriate action or treatment
Check for the Four Main
Symptoms
 The classification table is color-coded to tell quickly if
the child has a serious illness
 PINK row needs urgent attention and referral or admission for
in-patient care. This is a SEVERE classification
 YELLOW row means the child needs an appropriate antibiotic,
an oral antimalarial, or another treatment
 GREEN row means the child does not need specific medical
treatment. The health worker teaches the mother how to care
for her child at home
 The child is classified only ONCE. If the child has signs
from more than one row, always select the more serious
classification
Check for the Four Main
Symptoms
SIGNS CLASSIFY AS TREATMENT

- Any general danger SEVERE PNEUMONIA

sign OR VERY SEVERE
- Chest indrawing DISEASE
- Stridor in a calm child

- Fast breathing PNEUMONIA

- No signs of NO PNEUMONIA;
pneumonia or very COUGH, OR COLD
severe disease
Check for the Four Main
Symptoms
2. Diarrhea
 Assess diarrhea

 Diarrhea is assessed for

 How long
 Blood in the stool
 Signs of dehydration

 ASK about diarrhea in all children

 ASK: For how long?
 Diarrhea
lasting for 14 days or more is PERSISTENT
DIARRHEA
Check for the Four Main
Symptoms
 ASK: Is there blood in the stool? If yes, consider this
a case of DYSENTERY
 LOOK and FEEL for the following signs of dehydration
 Abnormally sleepy or difficult to awaken
 Restless and irritable
 Sunken eyes
 Offer the child water. Is the child not able to drink or
drinks poorly?
 Pinch the skin of the abdomen. Does it go back: very
slowly (longer than two seconds)? Slowly? Immediately?
Check for the Four Main
Symptoms
 Classify dehydration
 There are three classifications
 SEVEREDEHYDRATION
 SOME DEHYDRATION
 NO DEHYDRATION

 If there is one sign present in the PINK row

and one in the YELLOW, classify him/her on
the YELLOW row
Check for the Four Main
Symptoms
Two of the following signs: SEVERE DEHYDRATION
- Abnormally sleepy or difficult
to awaken
- Sunken eyes
- Not able to drink or drinks
poorly
- Skin pinch goes back very
slowly
Two of the following signs: SOME DEHYDRATION
-Restless and irritable
- Sunken eyes
- Drinks eagerly, thirstily
- Skin pinch goes back slowly
Not enough signs to classify as NO DEHYDRATION
having some or severe dehydration
Check for the Four Main
Symptoms
 Classify persistent diarrhea
 PERSISTENT DIARRHEA is diarrhea for14
days or more, which has no signs of
dehydration
 SEVERE PERSISTENT DIARRHEA is diarrhea
for 14 days or more with severe dehydration
 Classify dysentery
 Diarrhea and blood in the stool
Check for the Four Main
Symptoms
3. Fever
 Assess and classify fever

 Malaria
 Deciding malaria risk: Per AO No. 129-S, dated June
12, 2002, all the provinces in the Philippines are
categorized according to the malaria situation
 Category of provinces:
 Category A: Provinces with no significant improvement in
malaria situation in the last ten years or the situation
worsened in the last five years, the average number cases
of is more than 1,000 in the last ten years
Check for the Four Main
Symptoms
Agusan del Sur Misamis Oriental

Agusan del Norte Mindoro Occidental

Apayao Palawan
Basilan Quezon
Bukidnon Quirino
Cagayan Saranggani
Compostela Valley (Pilot) Sulu
Davao del Sur Surigao del Sur
Davao del Norte Tawi-tawi
Ifugao Zambales
Isabela Zamboanga del Sur
Kalinga (pilot area)
Check for the Four Main
Symptoms
 Category B: Provinces where the situation has
improved in the last five years or the average
number of cases is 100 – 1,000 per year
Abra North Cotabato
Aurora Nueva Ecija
Bataan Nueva Viscaya
Bulacan Pangasinan
Camarines Norte Rizal
Camarines Sur Romblon
Ilocos Norte Sultan Kudarat
Lanao del Sur Tarlac
Maguindanao Zamboanga del
Norte
Mindoro Oriental
Check for the Four Main
Symptoms
 Category C: Provinces with a significant reduction
in cases in the last five years
Albay Masbate
Antique Negros Oriental
Batanes Negros Occidental
Batangas Misamis Occidental
Benguet Pampanga
Cavite Samar (Eastern)
Ilocos Sur Samar (Western)
La Union Sorsogon
Marinduque Surigao del Norte
Check for the Four Main
Symptoms
 Category D: Provinces that are malaria-free,
although some are still potentially malarious due to
vectors
Aklan Cebu
Biliran Guimaras
Camiguin Leyte, Norte and Sur
Capiz Northern Samar
Catanduanes Siquijor
A child who lives in these areas or who has
visited and stayed overnight in any of these
areas in the past FOUR weeks or who has had
blood transfusion during the past six months
should be considered to be at RISK for malaria.
Check for the Four Main
Symptoms
 Measles
 Feverand generalized rash are the main symptoms of
measles. The measles virus can also damage the immune
system for many weeks after the onset of measles
 Complications include:
 Diarrhea (including dysentery and persistent diarrhea)
 Pneumonia
 Mouth ulcers
 Ear infection
 Severe eye infection (which may lead to corneal ulceration and
blindness)
 Encephalitis
Check for the Four Main
Symptoms
 Dengue Hemorrhagic Fever
 You must know the Dengue risk in your area
 All regions in the country are endemic for
dengue. The NCR is highly endemic all year
round usually peaking two months after rainfall

A child has the main symptom fever

if
-The child has history of fever, or
-The child feels hot, or
-The child has an axillary
temperature of 37.5˚C or above
Check for the Four Main
Symptoms
 If the child had fever, determine
 How long?
 History of measles
 Stiff neck
 Runny nose
 Signs suggesting measles
 If the child has measles now or within the last
three months, assess for signs of complications
such as mouth ulcers, pus draining from the
eyes and clouding of the cornea
Check for the Four Main
Symptoms
 Then, for all children with fever
 Decide the Dengue fever risk
 If with risk, assess for signs suggesting dengue
 Bleeding from the nose or gums or in vomitus or stools
 Black vomitus or black stools
 Petechiae in the skin
 Signs of shock
 Persistent abdominal pain
 Persistent vomiting
 Ifall signs are negative and the child is six months
or older, with fever in a dengue risk area, perform a
torniquet test
Check for the Four Main
Symptoms
 Classify Fever
 Thereare three possible classifications of
fever when there is malaria risk:
 VERY SEVERE FEBRILE DISEASE/MALARIA
 MALARIA
 FEVER: MALARIA UNLIKELY

 VERY SEVERE FEBRILE DISEASE/ MALARIA

 Ifthe child has any general danger sign or
 Stiff neck
Check for the Four Main
Symptoms
 MALARIA
 Ifthere is a risk of malaria
 Has fever but no runny nose
 No measles and no other causes of fever, or
 Positive blood smear

 FEVER: MALARIA UNLIKELY

 Does not have signs of very severe febrile
disease
 Has runny nose
 Has measles or other causes of fever, or
 Negative blood smear
Check for the Four Main
Symptoms
 Other causes of fever:
 Severe pneumonia  UTI
 Very severe disease  Osteomyelitis
 Cough or cold
 Erysepelas
 Dysentery
 Abcess
 Measles
 Impetigo/ Pyoderma
 Measles with eye/mouth
complication  Tonsilopharyngitis
 Dengue hemorrhagic  Infected wounds
fever  Nephritis
 Ear infection
 Typhoid fever
 Mastoiditis
 Diarrhea
Check for the Four Main
Symptoms
 Classify Measles
 There are three possible classifications
 SEVERECOMPLICATED MEASLES
 MEASLES WITH EYE OR MOUTH COMPLICATIONS
 MEASLES
 SEVERE COMPLICATED MEASLES
 With
clouding of the cornea or deep or extensive
mouth ulcers
 MEASLES WITH EYE OR MOUTH COMPLICATIONS
 Withpus draining from the eyes or mouth ulcers,
which are not deep or extensive
Check for the Four Main
Symptoms
 MEASLES
 Measlesnow or within the last three months and
with none of the complications listed in the PINK
or YELLOW row
 Classify dengue hemorrhagic fever (DHF)
 There are two possible classifications
 SEVERE DENGUE HEMORRHAGIC FEVER
 FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
Check for the Four Main
Symptoms
 SEVERE DENGUE HEMORRHAGIC FEVER
 Bleeding from the nose or gums or in the
vomitus or stool
 Skin petechiae
 Shock
 Persistent abdominal pain and vomiting
 Positive torniquet test

 FEVER: DENGUE HEMORRHAGIC FEVER

UNLIKELY
 Noneof the signs needed for classification of
severe DHF
Check for the Four Main
Symptoms
4. Ear problems
 A child with an ear problem is assessed

for
 Ear pain
 Ear discharge

 If ear discharge is present, the duration

 Tender swelling behind the ear

Check for the Four Main
Symptoms
 There are four classifications
 MASTOIDITIS
 Tender swelling behind the ear
 ACUTE EAR INFECTION
 Pus draining from the ear for less than two weeks or
 Ear pain
 Chronic ear infection
 Pus draining from the ear for two weeks or more
 NO EAR INFECTION
 No ear pain
 No ear discharge
Check for Malnutrition and
Anemia
 Check ALL sick children for signs suggesting
malnutrition and anemia by
 Looking for VISIBLE SEVERE WASTING
 Very thin, has no fat, and looks like skin and bones
 Looking for PALMAR PALLOR
 SOME palmar pallor if skin of the palm is pale
 SEVERE palmar pallor is the skin of the palm is very
pale so that it appears white
 Lookingand feeling for EDEMA OF BOTH FEET
 Determining weight for age
 Use the weight for age chart
Check for Malnutrition and
Anemia
 Classify nutritional status
 There are three classifications
 SEVERE MALNUTRITION OR SEVERE ANEMIA
 Visible severe wasting
 Severe palmar pallor, or
 Edema on both feet
 ANEMIA OR VERY LOW WEIGHT
 Some palmar pallor, or
 Very low weight for age
 NO ANEMIA OR NOT VERY LOW WEIGHT
 Not very low weight for age
 No other signs of malnutrition
Check the Child’s
Immunization Status
 Check the immunization status of all sick
children. Determine if they are up to
date and if they need any immunization
today
 Use the recommended schedule
AGE VACCINE
Birth BCG
6 weeks DPT1, OPV1, HEP B1
10 weeks DPT2, OPV2, HEP B2
14 weeks DPT3, OPV3, HEP B3
9 months MEASLES
Check for Malnutrition and
Anemia
 Observe contraindications to
immunization
 If the child is going to be referred, do not
immunize the child before referral
 Children with diarrhea who are due for
OPV should receive the dose but it is
NOT counted. The child should return
when the next dose of OPV is due for an
extra dose of OPV
Check the Child’s Vitamin A
Status
 Check the Vitamin A status of all sick
children
 Use the recommended Vitamin A
schedule
 The first dose is six months or above
(100,000 IU)
 Subsequent doses every six months
(200,000 IU) up to the age of 59 months (4
years and 11 months)
Assess Other Problems
 Since the ASSESS and CLASSFIY chart
does not address all of a sick child’s
problems, the health worker must now
assess the other problems the mother
says. Refer if the child cannot be
managed in the health center
IDENTIFY TREATMENT
Aged 2 Months Up to 5 Years
Introduction
 If condition is under more than one classification, look in
more than one place in the ASSESS and CLASSIFY chart for
the treatments listed. Some treatments may be the same
 “Refer urgently to a hospital” means health facility with
expertise and resources to treat a very sick child
 If the child must be referred urgently, decide which
treatment to do before the referral. Refer only if you
expect that the child will actually receive better care. In
some instances, giving your best care is better than
sending a child on a long trip to a hospital
Introduction
 If referral is not possible or if the parents
refuse to take the child, the health
worker should help the family take care
of the child.
Objectives
 Determine if urgent referral is needed
 Determine treatments needed
 For patients who need urgent referral
 Identifythe urgent pre-referral treatment
 Explaining the need for referral to the
mother, and
 Writing the referral note
Referral for Severe
Classification
 SEVERE PNEUMONIA OR VERY SEVERE DISEASE
 SEVERE DEHYDRATION
 SEVERE PERSISTENT DIARRHEA
 VERY SEVERE FEBRILE DISEASE/ MALARIA
 VERY SEVERE FEBRILE DISEASE
 SEVERE COMPLICATED MEASLES
 SEVERE DENGUE HEMORRHAGIC FEVER
 MASTOIDITIS
 SEVERE MALNUTRITION OR SEVERE ANEMIA
Referral for Severe
Classification
 Do not give treatments that would
unnecessarily delay the referral except in
 SEVERE PERSISTENT DIARRHEA
 Referral is needed, but not as urgent
 If the child’s only severe classification is SEVERE
DEHYDRATION
 Keep and treat the child if the health center has the
ability to do so (Plan C)
 If the child has another severe classification in
addition to SEVERE DEHYDRATION, referral is needed
Referral for General Danger
Signs

MAKE SURE SHILD WITH ANY GENERAL

DANGER SIGN IS REFERRED after the
first dose of an appropriate antibiotic
and other urgent treatments.

Exception: Rehydration of the child

according to Plan C may resolve danger
signs so that referral is no longer
needed.
Referral for Other Severe
Problems
 Since the ASSESS and CLASSIFY chart
does not include all problems that the
child may have, ask the mother for any
other problem that the child may have.
You will need to refer them if you cannot
treat a severe problem
Identify Treatments for
Patients Who Do Not Need
Urgent Referral
 Write treatments at the back of the SICK CHILD
RECORDING FORM
 Include items that begin with the words “Follow
up.” if several times are specified for follow-up,
look for the earliest definite time
 Some treatments, like Vitamin A, are listed for
more than one problem. List it only once.
However, each specific antibiotic must be listed
When to Return
Immediately
 Return immediately if the child
 Is not able to drink or breastfeed
 Becomes sicker
 Develops fever
 Watch for the following signs in a child with
a simple cough or cold
 Fast breathing
 Difficult breathing
 Watch for the following in a child with
diarrhea
 Blood in the stool
 Drinking poorly
When to Return
Immediately
 Watch for the following in a child with
FEVER: DENGUE HEMORRHAGIC FEVER
UNLIKELY
 Anysigns of bleeding
 Abdominal pain

 Vomiting
Identify Urgent Pre-referral
Treatment Needed
 When needing urgent referral, quickly identify
and begin the most urgent treatment. Give just
the first dose of the drugs before referral
 Give an appropriate antibiotic
 Give quinine for severe malaria

 Give Vitamin A

 Treat the child to prevent low blood sugar

 Start IV fluids according to Plan C for a child with

SEVERE DENGUE HEMORRHAGIC FEVER with
bleeding, cold clammy skin, capillary refill of more
than three seconds
Identify Urgent Pre-referral
Treatment Needed
 Give ORS according to Plan B for a child with
SEVERE DENGUE HEMORRHAGIC FEVER with only
petechiae, positive torniquet test, or abdominal
pain or vomiting but without cold clammy skin
and with a normal capillary refill time
 Give an oral antimalarial
 Give paracetamol for high fever (38.5˚C or
above) or pain from mastoiditis
 Apply tetracycline eye ointment if pus is draining
from the eye
 Provide ORS so that the mother can give frequent
sips on the way
Identify Urgent Pre-referral
Treatment Needed
 The first five treatments are urgent because
they can prevent serious consequences
 Bacterial meningitis or cerebral malaria
 Corneal rupture

 Brain damage

 Death

 Do not delay referral to give non-urgent

treatments
 If immunizations are needed, do not give
them before the referral
Give Urgent Pre-referral
Treatment
 If the child with danger signs will not be able to
take anything orally, he/she will need to be given
an intramuscular injection of chloramphenicol
 If the child needs treatment to prevent low blood
sugar, and NGT can be inserted, give sugar water
or breastmilk substitute by NG before referral
 Four steps to refer a child
 Explain to the mother the need for a referral and get
her agreement to take the child. If you suspect that
she does not want to take the child, find out why
Give Urgent Pre-referral
Treatment
 Calm the mother’s fears and help her
resolve any problems
 Write a referral note for the mother to take
with her to the hospital. Tell her to give it to
the health worker there
 Give the mother supplies and instructions
needed to care for the child on the way to
the hospital
TREAT THE CHILD
Aged 2 Months Up to 5 Years
Objectives
 Determining appropriate oral drugs and dosages
 Giving oral drugs and teaching how and when to
give oral drugs at home
 Treating local infections and teaching how and
when to give treatments at home
 Checking the mother’s understanding
 Giving injectable pre-referral drugs
 Preventing low blood sugar
 Treating different classifications of dehydration
and teaching about extra fluids to give at home
 Immunizing children
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give an appropriate antibiotic
 The following needs antibiotic
 General danger signs
 Severe pneumonia or very severe disease
 Pneumonia
 Severe dehydration with cholera in the area
 Dysentery
 Very severe febrile disease/malaria
 Severe complicated measles
 Mastoiditis
 Acute ear infection
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give first-line oral antibiotic if it is available.
Second-line antibiotic is given only if the
first-line is unavailable, or the illness does
not respond to the first-line antibiotic
 Sometimes, one antibiotic can be given for
several illnesses. Do not double the dose or
prolong the duration of giving the drug
 To determine the correct dose, choose the
row for the weight or age. Weight is better
used in choosing the right dose
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 For PNEUMONIA, ACUTE EAR INFECTION,
VERY SEVERE DISEASE, MASTOIDITIS
 First-line
antibiotic: Cotrimoxazole
 Second-line antibiotic: Amoxycillin

AGE OR WEIGHT COTRIMOXAZOLE AMOXYCILLIN

- Give two times daily for 5 - Give three times daily for
days 5 days
ADULT TABLET SYRUP TABLET SYRUP
80 mg/ 400/mg 40 mg/ 200 250 mg 125 mg/ 5 mL
mg/ 5 mL

2 months up to 12 1/2 5 mL 1/2 5 mL

months (4-10 kg)
12 months up to 5 1 10 mL 1 10 mL
years (10-19 kg)
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 For DYSENTERY: Give antibiotic
recommended for Shigella in your area
for 5 days
 First-line
antibiotic: Cotrimoxazole
 Second-line antibiotic: Nalidixic
COTRIMOXAZOLE Acid
NALIDIXIC ACID
- Give two times daily for 5 - Give four times daily for
days 5 days
AGE OR WEIGHT See above dosage SYRUP 250 mg/ 5 mL

2 months up to 4 1.25 mL (1/4 tsp)

months (4-6 kg)

4 months up to 2.5 mL (1/2 tsp)

12 months (6-10
kg)
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 For CHOLERA: Give an antibiotic
recommended for Cholera in your area
for 3 days
 First-line
antibiotic: Tetracycline
 Second-lineTETRACYCLINE
antibiotic: Cotrimoxazole
COTRIMOXAZOLE
- Give four times daily - Give two times daily
for 3 days for 5 days
AGE OR WEIGHT CAPSULE (250 mg) See above dosage
2 months up to 4 months
(4-6 kg)
4 months up to 12 months 1/2
(6-10 kg)
12 months up to 5 years 1
(10-19 kg)
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give an Oral Antimalarial
 Treatment with Chloroquine assumes that the child has
not yet been treated with that drug before. Confirm this
with the mother. Use instructions in the GIVE FOLLOW-UP
CARE MALARIA on the TREAT THE CHILD chart if it is a
follow-up visit
 Reduce the dose for the three-day treatment of
Chloroquine
 Explain the possible itching as a side effect of the drug
 If (+) for P. Falciparum, a single dose of
Sulfadoxine/Primaquine is given. Then the first dose of
Chloroquine is given after two hours to minimize gastric
irritation. A single dose of Primaquine will be given on Day
4 at the health center
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 If (+) P. Vivax, a first dose of Primaquine
and Chloroquine is given in the center, the,
one dose each day for another 13 days
 For mixed infections, treat as P. Falciparum
and start Primaquine as in P. Vivax
 If no blood smear test done, treat as P.
Falciparum
 DO NOT give Primaquine to children under
12 months of age
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give an oral antimalarial
 First-line:
Chloroquine, Primaquine,
Sulfadoxine and Pyrimethamine
 Second-line: Artemeter-Lumefrantine

 If Chloroquine
 Explain to watch child carefully for 30
minutes after giving a dose of Chloroquine.
Repeat ifthe child vomits after 30 minutes
 Itching is a possible side-effect of the drug
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 If Sulfadoxine + Pyrimethamine
 Givesingle dose in the health center 2
hours before intake of Chloroquine
 If Primaquine
 Give single dose on Day 4 for P. Falciparum
 If Artemeter-Lumefrantine
 Give for three days
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
CHLOROQUINE PRIMAQUINE PRIMAQUIN SULFADOXINE +
- Give for 3 days - Give single E PYRIMETHAMINE
dose in health - Give daily - Give single dose
center for P. for 14 days in health center
falciparum for p. vivax

AGE TABLET TABLET TABLET TABLET

(150 mg) (15 mg) (15 mg) (500 mg/ 25 mg)
DAY 1 DAY 2 DAY 3
2 months up 1/2 1/2 1/2 1/4
to 5 months
(4-7 kg)

5 months up 1/2 1/2 1/2 1/2

to 12
months (7-
10 kg)
12 months 1 1 1/2 1/2 1/4 3/4
up to 3
years (10-14
kg)
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give Paracetamol for High Fever (38.5˚
or higher) or Ear Pain
 Giveone dose Paracetamol in the center
then give enough for one day

PARACETAMOL

AGE OR WEIGHT TABLET (500 mg) SYRUP (120 mg/ 5 mL)

2 months up to 3 years 1/4 5 mL (1 tsp)

(4-14 kg)
3 to 5 years (14-19 kg) 1/2 10 mL (2 tsp)
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give Vitamin A
 Vitamin A is given in SEVERE PNEUMONIA or VERY
SEVERE DISEASE, SEVERE PERSISTENT DIARRHEA
or PERSISTENT DIARRHEA, or MEASLES, or SEVERE
MALNUTRITION or VERY LOW WEIGHT
 For both treatment and supplementation, a single
dose is given in the health center
 Should be given only
 Age six months and older
 Children who have not had a dose in the past six
months
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule

AGE VITAMIN A CAPSULES

100,000 IU 200,000 IU

6 months up to 12 1 1/2
months

12 months up to years - 1
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give Iron
 Some palmar pallor
 Give syrup to a child under 12 months old. Iron/folate
tablet for children above 12 months
 Give mother enough iron for 14 days and tell to give
one dose daily. Teach how to give and what to observe
 If receiving antimalarial sulfadozine pyrimethamine
(Fansidar), do not give Iron/Folate tablet yet until a
follow-up visit in two weeks. If the Iron available does
not contain Folate, it may be given
 Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
AGE OR IRON/FOLATE IRON SYRUP IRON DROPS
WEIGHT TABLET Ferrous sulfate Ferrous sulfate
Ferrous sulfate 150 mg/ 5mL 25 mg
200 mg + 250 (6 mg (25 mg
mcg folate elemental iron elemental iron/
(60 mg per mL) mL)
elemental iron)

3 months up to 4 2.5 mL (1/2 tsp) 0.6 mL

months (4-6 kg)

4 months up to 4 mL (3/4 tsp) 1 mL

12 months (6-10
kg)
12 months up to 1/2 5 mL 1.5 mL
3 years (10-14
Select an Appropriate Oral
Drug and Determine the Dose
and the Schedule
 Give Mebendazole
A one-year old child who is anemic and with

hookworms or whipworms needs to be
given this drug
 Mebendazole 500 mg or Albendazole 400
mg as single dose is given at the center if
the child has not been given one in the
AGE OR WEIGHT ALBENDAZOLE 400 MEBENDAZOLE 500
previous six mg
months
Tablet mg Tablet
12 months up to 23 1/2 1
months
24 months up to 59 1 1
months
Use Good Communication
Skills
 Success of home treatment depends on how well
the health care worker communicated. The
mother needs to know how to give the treatment
and understand the importance of the treament
 Skills in communication include the following
 ASK questions and LISTEN to find out what the mother
is already doing for the child
 PRAISE for what she has done well
 ADVISE how to treat at home
 CHECK the understanding
Use Good Communication
Skills
 ADVISE THE MOTHER HOW TO TREAT HER
CHILD AT HOME
 Three basic steps in teaching
 Give information – explain how to do the task
 Show an example – show how to do the task
 Let her practice – ask to do the task while you watch

 When teaching
 Use words easily understood
 Use teaching aids that are familiar, such as common
containers
 Give feedback
 Encourage to ask questions
 Use Good Communication
Skills
 CHECK THE MOTHER’S UNDERSTANDING
 Use
good checking questions to help make
sure that the mother learns and remembers
how to treat her child
 Good checking questions require that she
describeQUESTIONS
GOOD CHECKING WHY, HOW, or WHEN
POOR CHECKING QUESTIONS

How will you prepare the ORS? Do you remember how to mix
How often should you breastfeed your the ORS?
child? Should you breastfeed your
On what part of the eye do you apply child?
the ointment? Have you used ointment on your
How much extra fluid should you give child before?
after each loose stool? Do you know how to give extra
Why is it important for you to wash your fluids?
Teach the Mother to Give Oral
Drugs at Home
 Follow these instructions
 Determine the appropriate drugs and dosage
for age and weight
 Tell the reason for giving the drug including
why and what problem it is treating
 Demonstrate how to measure a dose
 If the drug is in syrup form, show how to
measure using common household teaspoon
 1.25 mL – ¼ tsp
 2.5 mL – ½ tsp
 5 mL – 1 tsp
Teach the Mother to Give Oral
Drugs at Home
 Show how to give Vitamin A capsule
 Watch the mother practice measuring a dose
 Ask the mother to give the first dose. If the child
vomits within 30 minutes, give another dose. If the
child is dehydrated and vomiting, wait until the child
is rehydrated before giving the dose again
 Explain carefully, then label and package the drug
 To write information on a drug label
 Full
name of the drug and the total amount to complete the
treatment
Teach the Mother to Give Oral
Drugs at Home
 Write the correct dose and when to give
 Write the daily dose and schedule
 Write clearly
 Put the drug in its own labelled container, keeping it
clean and dry
 Ask questions to make sure the mother understands
 If more than one drug will be given, package each
drug separately
 Explain that all oral drugs must be used to finish the
course of treatment even if the child gets better
 Advise to store drugs properly
 Check mother’s understanding before she leaves
Teach the Mother to Treat
Local Infections at Home
 Treat eye infection with Tetracycline eye
ointment
 If the child will be referred, clean eye gently and
squirt a small amount
 If the child will not be referred, teach how to
apply drug at home
 Treat both eyes until redness is gone from the
infected eye
 Do not use any other eye ointments, drops, or
alternative treatments
 Bring the child to health center after two days
Teach the Mother to Give Oral
Drugs at Home
 Dry the ear by wicking
 Use clean, absorbent cotton cloth or soft
strong tissue paper for making a wick
 Done three times daily until wick no longer
gets wet
 Do not place anything in the ear between
wicking treatments. Do not allow water to
get in the ear
Teach the Mother to Give Oral
Drugs at Home
 Treat mouth ulcers with gentian violet
 Use half-strength gentian violet
 Use clean soft cloth dipped in salt water

 Use cotton-tipped stick to paint the gentian

violet on the mouth ulcers. Do not allow
child to drink the gentian violet
 Treat mouth ulcers two times per day for
five days
Teach the Mother to Give Oral
Drugs at Home
 Soothe the throat and relieve cough with
safe remedy
 Should not contain atropine (oral and nasal
decongestants), codeine derivatives or
alcohol
 Safe remedies to recommend
 Breastmilkfor exclusively breastfed infants
 Tamarind, calamansi, or ginger
Determine Priority of Advice
 When the child has several problems, the
instructions to the mother can be quite complex.
In this case, instructions will have to be limited to
what is most important
 How much likely can this mother understand and
remember?
 Is she likely to come back for follow-up treatment? If
so, some advice can wait until then
 What advice is most important
Determine Priority of Advice
 Essential treatments include giving
antibiotics or antimalarial drugs, and
giving fluids to a child with diarrhea
 If necessary, OMIT or DELAY
 Feeding assessment and couselling
 Soothing remedy for cough and cold

 Paracetamol

 Iron treatment

 Wicking the ear

Give These Treatments in
Health Center Only
 May need to be given in the health center
 Intramuscular antibiotic if the child cannot take
oral antibiotic
 Quinine for severe malaria
 Breastmilk or sugar water to prevent low blood
sugar
 Intramuscular Chloramphenicol may need to
be given before leaving for the hospital if
 Not able to drink or breastfeed
 Vomits everything
 Has convulsions
 Abnormally sleepy or difficult to awaken
 Cannot take oral antibiotic
 Give These Treatments in
Health Center Only
 Give an intramuscular antibiotic
 First dose is given then refer urgently to
hospital
 If referral is not possible

AGE OR  Repeat injection

WEIGHT every 12 hours for 5 days
CHLORAMPHENICOL
40 mg/ kg
 Change to appropriate antibiotic to complete
Add 5 mL sterile water to vial
10 days of treatment
containing 1,000 mg = 5.6 mL at 180
mg/ mL
2 months up to 4 months (4- 1 mL = 180 mg
6 kg)
4 months up to 9 months (6- 1.5 mL = 270 mg
8 kg)
9 months up to 12 months 2 mL = 360 mg
(8-10 kg)
Give These Treatments in
Health Center Only
 Quinine injection is given to a child with
VERY SEVERE FEBRILE DISEASE/ MALARIA
if there is going to be any delay in the
child reaching the referral hospital. It is
given intramuscularly ONLY because of
these possible side effects
 Sudden drop in blood pressure
 Dizziness
 Ringing of the ears
 Sterile abscess

 Should remain lying down for one hour

Give These Treatments in
Health Center Only
 Give first dose of intramuscular Quinine
then refer urgently to hospital
 If referral is not possible
 Repeat Quinine injection at 4 to 8 hours
later, then 12 hours until child is able to
take oral antimalarial. Do not continue
injections for more than 1 week
 DO NOT GIVE QUININE TO A CHILD LESS
THAN 4 MONTHS OF AGE
 Give These Treatments in
Health Center Only

AGE OR WEIGHT INTRAMUSCULAR QUININE

300 mg/ mL (in ampules)

4 months up to 12 months (6-10 0.3 mL

kg)
12 months up to 2 years (10-12 kg)0.4 mL

2 years up to 3 years (12-14 kg) 0.5 mL

3 years up to 5 years 914-19 kg) 0.6 mL

Give These Treatments in
Health Center Only
 Treat the child to prevent low blood sugar
 Low blood sugar occurs in serious infections such as severe
malaria or meningitis, or when the child is not able to eat
for many hours
 Giving some breastmilk, breastmilk substitute, or sugar
water is done before the child is referred
 Give 30-50 mL of milk or sugar water before departure
 Tomake sugar water: Dissolve 4 level teaspoons of sugar (20
grams) in 200-mL cup of clean water
Give These Treatments in
Health Center Only
 If the child is not able to swallow
 Give 50 mL of milk or sugar water by
nasogastric tube
 Ifthe child is difficult to awaken or
unconscious, start IV infusion
 Give 5 mL/ kg of 10% of dextrose solution
(D10) over a few minutes
 Or give 1 ml/ kg of 50% (D50) by slow push
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 Plan A: Treat diarrhea at home
 Treatment plan for child with diarrhea with
NO DEHYDRATION
 Three rules of home treatment
 Give extra fluids (as much as the child will
take)
 Continue feeding
 When to return
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 GIVE EXTRA FLUIDS
 Tell the mother
 For exclusively breastfed babies, breastfeed frequently and
longer, and give ORS or clean water. For children over six
months, no food-based fluids
 For children not exclusively breastfed, give one or more of the
following: ORS, food-based fluids, and/or clean water
 Teach how to mix and give ORS. Give two packets of ORS
to use at home
 Show how much fluid to give in addition to the usual fluid
intake
 Up to 2 years – 50 to 100 mL after each loose stool
 2 years or older – 100 to 200 mL after each loose stool
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 CONTINUE FEEDING
 WHEN TO RETURN
 The following signs indicate that the child
should be returned immediately
 Not able to drink of breastfeed
 Becomes weaker
 Develops fever
 Ifthe child has diarrhea, also tell the mother to
return if the child
 Has blood in the stool
 Drinking poorly
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 Plan B: Treat some dehydration with ORS
 Initial treatment for four hours in the health
center
 If the child is for referral, do not try to
rehydrate before leaving. The child will be
given frequent sips of ORS on the way
 After four hours, reassess and classify
 DETERMINE THE AMOUNT OF ORS TO GIVE
DURING THE FIRST FOUR HOURS
 Theage or weight, degree of dehydration, and
number of stools passed during rehydration will
affect the amount of ORS needed
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 To determine the amount needed
 Multiply child’s weight (in kilograms) by 75
 GivingORS should not interfere with
breastfeeding. For infants under six months
who are not breastfed, 100-200 mL clean water
should be given during the first four hours in
addition to the ORS
 SHOW MOTHER HOW TO GIVE ORS
 Foodshould not be given within the first four
hours of treatment
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 AFTER FOUR HOURS
 Reassess using the ASSESS and CLASSIFY chart
 Reassess child BEFORE four hours if child is not
taking ORS or seems to be getting worse
 If child’s eyes are puffy, it is a sign of overhydration.
Stop ORS and give clean water or breastmilk. ORS is
resumed when puffiness is gone
 IF THE MOTHER MUST LEAVE BEFORE
COMPLETING TREATMENT
 Show how to prepare ORS
 Show how much to give to complete the 4-hour
treatment
 Give enough packets to complete rehydration plus
two more packets as recommended in Plan A
 Explain the three Rules of Home Treatment
Give Extra Fluid for Diarrhea
and DHF and Continue Feeding
 Plan C: Treat severe dehydration quickly
 Treatment depends on
 Type of equipment available
 Training of the health worker
 Whether the child can drink

 Treat persistent diarrhea

 Requires special feeding
 Treat dysentery
 Oral antibiotic recommended for Shigella is given
and mother is told to return in two days for
follow-up
Immunize Every Sick Child as
Needed
 If the child is well enough to go home, give the
necessary immunization before he/she leaves
the center
 Immunization is given even if only one child
needs the immunization
 Reconstituted vaccines must be discarded after
six hours
 Opened vials of OPV may be kept if
 Not yet expired
 Stored between 0 to 8 degrees Celsius
 Not taken out of the health center
 OPV vials with vaccine vial monitors that
changed in color indicate expiration
Immunize Every Sick Child as
Needed
 Record all immunizations on the child’s
immunization card
 If the child has diarrhea and needs OPV, give it
but do not record the dose. Tell the mother to
return in four weeks for an extra dose
 Tell the possible side effects of each vaccine
 BCG: ulceration
 OPV: none
 DPT: fever, irritability and soreness
 Measles: fever and mild rash a week after lasting for
oneto three days
 Hepatitis B: none
COUNSEL THE MOTHER
Objectives
 Assess the child’s feeding
 Identifying feeding problems
 Counselling about feeding problems
 Assessing the child’s care for development
 Identifying problems in care for development
 Counselling about care for development problems
 Advising to increase fluid intake during illness
 Advising
 When to return for follow-up visits
 When to return immediately
 When to return for immunizations
Feeding Recommendations
 Ages from birth up to six months
 Breastfeed exclusively
 Breastmilk contains protein, fat, lactose,
Vitamins A and C, iron, fatty acids needed for
the infant’s growing brain, eyes, and blood
vessels and all the water an infant needs
 Breastmilk protect an infant against infection
and help to develop a loving relationship
 Ages six months to 12 months
 Breastfeeding should still be continued
Feeding Recommendations
 Complementary foods are increased gradually asthe
child nears 12 months. By then, complementary foods
are the main source of energy
 If a child is breastfed, give complementary foods three
times daily; if a child is not breastfed, give
complementary foods five times daily
 It is important to ACTIVELY feed the child. Child should
be encouraged to eat, not having to compete with
siblings from a common plate
 Child should get adequate serving
Feeding Recommendations
 Good complementary foods
 Energy and nutrient-rich and locally affordable foods
 Examples are thick cereal with added oil or milk, fruits,
vegetables, legumes, beans, meat, eggs, fish, and milk
products
 When giving complementary food to a child between four
and six months old, introduce them one at a time at least
three days apart to rule out any allergic reaction
 If the child receives cow’s milk or any other breastmilk
substitute, these and any other drinks should be given by
cup, NOT by feeding bottle
Feeding Recommendations
 Ages 12 months up to two years
 Continue breastfeeding as often as the child wants
and also give nutritious complementary foods
 Family food should become an important part of the
child’s diet
 By 12 months, the child should share the family rice

 Ages two years and older

 Childshould be taking variety of family foods in
three meals per day plus two extra meals or snacks
per day
Special Recommendations for
Children with Persistent
Diarrhea
 May have difficulty digesting milk other
than breastmilk
 Temporarily reduce the amount of other
milks in their diet and take more breastmilk
or replace half the milk with nutrient-rich,
semi-solid foods
 DO NOT USE CONDENSED OR EVAPORATED
MILK
 For other foods, follow the feeding
recommendation for the child’s age
Assess the Child’s Feeding
 Assess the feeding of children who
 Classified as having ANEMIA or VERY LOW WEIGHT, or
 Less than 2 years old

 Ask questions about usual feeding and during this

illness. Compare mother’s answers to the FEEDING
RECOMMENDATIONS chart
 Ask:
 Do you breastfeed your child?
 How many times during the day?
 Do you also breastfeed during the night?
Assess the Child’s Feeding
 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
servings? Does the child receive his/ her own
serving? Who feeds the child and how?
 During this illness, has the child’s feeding
changed? If yes, how?
Identify Feeding Problems
 Identify differences between actual feeding
and the recommendations
 Examples of feeding problems
 Difficulty in breastfeeding – check the mother’s
reason. Show correct positioning and attachment
 Use of feeding bottle – often dirty. Demonstrate
the use of spoon or cups
 Lack of active feeding – child not encouraged to
eat, is not given own serving, has to compete
with other siblings
 Not feeding well during illness – offer favorite
food to encourage eating. Breastfeed more
frequently, offer nutritious, varied, and appetizing
foods. Clear blocked nose
Identify Feeding Problems
 Not giving protein source of food in lugaw
or rice – add or mix protein-rich sources of
food such as flaked fish, chicken, pulverized
roasted dilis, chopped meat, egg yolk,
steamed tokwa, and munggo
 Improper handling and use of breastmilk
substitute - counsel on proper preparation
and handling of breastmilk substitute
Counsel the Mother About
Feeding Problems
 If mother reports difficulty with breastfeeding,
assess breastfeeding. As needed, show correct
positioning and attachment for breastfeeding
 If 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 breastfeeding,
day and night, and gradually reducing other milk or
foods
Counsel the Mother About
Feeding Problems
 If other milk needs to be continued, counsel to
breastfeed as much as possible, including night.
 Make sure that other milk is locally appropriate
breastmilk substitute and give only when necessary
 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. Discard left-overs
 If mother is using a bottle to feed the child
 Recommend substituting a cup for bottle
 Show how to feed with a cup. Do NOT pour the milk
into the baby’s mouth
Counsel the Mother About
Feeding Problems
 If the child is not being fed actively, counsel to
 Sit with child and encourage eating
 Give child an adequate serving in a separate bowl
 Observe what the child likes and consider this in the
preparation of his/her food
 If the child is not feeding well during illness, counsel to
 Breastfeed more frequently and longer
 Use soft, varied, appetizing, favorite foods and offer frequent
small feedings
 Clear blocked nose
 Expect that appetite will improve as child gets better
 Follow up any feeding problem in 5 days
Use Good Communication
Skills (ALPAC)
 Ask and Listen
 Find out what the mother is already doing for her
child then you will know what practice needs to
be changed
 Praise
 Give praise that is genuine and only for actions
that are helpful to the child
 Advise
 Limit to what is relevant
 Use language that the mother will understand.
Use pictures or real objects if possible
Use Good Communication
Skills (ALPAC)
 Advise against any harmful practice. Be clear
but be careful not to make the mother feel
guilty or incompetent. Explain why the
practice is harmful
 Check understanding
 Ask questions to find out what the mother
understands and what needs further
explanation
 Avoid asking leading questions (which suggest
the right answer) and questions answerable
with yes or no
Use of Mother’s Card
A mother’s card can be given to help remember
appropriate foods and fluids, and when to return
to health worker. It has words and pictures that
illustrate the main points of advice
 There are many reasons why a Mother’s Card is

helpful
 It will remind you or other health care workers of
important points to cover when counselling
 It will remind the mother what to do
 The mother may show the card to other family
members
Use of Mother’s Card
 The mother will appreciate being given something
during the visit
 Multivisit cards can be used as a record of
treatments and immunizations given
 When reviewing a Mother’s Card with a mother
 Hold the card so the mother can easily see the
pictures or allow her to hold it herself
 Explain and point to each picture
 Circle or record relevant information
 Watch to see if the mother seems worried or
puzzled
 Ask the mother to tell what she should do at home
using the card
Advise the Mother to Increase
Fluids During the Illness
 For any sick child
 Breastfeed more frequently and longer at
each feed
 Increase fluid. For example giving soup,
rice water, buko juice or clean water
 For child with diarrhea
 Give according to Plan A or Plan B on the
TREAT THE CHILD CHART
 Advise the Mother When to
Return to a Health Center
 Follow-up visit
If the child has Return for follow-up
in
PNEUMONIA 2 days
DYSENTERY
MALARIA, if the fever persists
FEVER-MALARIA UNLIKELY, if fever persists
FEVER (NO MALARIA), if fever persists
MEASLES WITH EYE OR MOUTH COMPLICATIONS
DENDUE HEMORRHAGIC FEVER UNLIKELY, if fever
persists
PERSISTENT DIARRHEA 5 days
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEMS
MANY OTHER ILLNESSES, if not improving
ANEMIA 14 days
VERY LOW WEIGHT FOR AGE 30 days
 Advise the Mother When to
Return to a Health Center
 When to return immediately
Any sick child -Not able to drink or
breastfeed
-Becomes sicker
-Develops fever
If the child has NO PNEUMONIA: -Fast breathing
COUGH OR COLD -Difficult breathing
If the child has diarrhea -Blood in stool
If the child has FEVER: DENGUE -Any sign of bleeding
HEMORRHAGIC FEVER UNLIKELY -Persistent abdominal pain
-Persistent vomiting
-Skin petechiae
-Skin rash
Counsel the Mother About Her
Own Health
 If mother is sick, provide care for her, or refer for
help
 If she has breast problem (engorgement, sore
nipples, breast infection) provide care for her or
refer for help
 Advise her to eat well
 Check mother’s immunization status and give her
Tetanus toxoid if needed
 Make sure she has access to
 Family planning
 Counselling on STD and AIDS prevention
Care for Development
Children who are poorly nourished often
have difficulty learning. They may be
timid and easily upset, harder to feed, and
less likely to play and communicate. They
have special needs for care. Their mothers
may also need help to understand how
their children communicate their needs
Children are different at birth and this affect
how they learn. Early care also affects
their learning.
Care for Development
 Much of what children learn, they learn when they are
very young
 Children need a safe environment as they learn
 Children need consistent loving attention from at
least one person
 Mothers can help their children learn by responding
to their words, actions, and interests
 Children learn by playing and trying things out, and
by observing and copying what others do
Recommendation By Age
Group
 Birth to 4 months
 Play: Learning is through seeing, hearing,
feeling, and moving.
 Communicate: Crying.
 4 months up to 6 months
 Play:Reaching for objects and putting
things in mouth. Have clean, large, colorful
things to see and reach
 Communicate: New sounds like squeals and
laughter. Smile at the child and
communicate with sounds and gestures
Recommendation By Age
Group
 6 months up to 12 months
 Play: Making noise like banging objects together or
dropping them. Give them clean things to handle
 Communicate: Imitation of sounds and actions.
Children understand words before they learn to say
them. Begin telling the names of things and people
 12 months up to 2 years
 Play: More active and wants to move around and
explore. They like to stack things up and put things
into containers
Recommendation By Age
Group
 Communicate: Learning to speak. Can
answer simple questions.
 2 years and older
 Play: Help your child count, name and
compare things
 Communicate: Encourage to talk, and
answer child’s questions. Teach stories,
games, and songs. Should be corrected
gently so that they will not be discouraged
or feel ashamed
Assess the Child’s Care for
Development
Observe the mother and the child from the
beginning of the consultation
 How does the mother respond when the child
reaches for her?
 How does she get the child’s attention?

 How does she comfort the child?

 Does the mother look at the child and smile?

 How does the child respond to the mother?

 Does the child follow the mother’s sounds and

movements?
 Does the child look to the mother for comfort?
Identify Problems in Care for
Development
 Identify the difference between the actual care
provided and the recommendations for care and
give some recommendations. Examples of
common problems are:
 Mother cannot breastfeed
 Mother does not know what her child does to play and
communicate
 Mother feels she does not have enough time to provide
care for development. She feels she needs extra time
because of the many household chores
Identify Problems in Care for
Development
 Mother has no toys for her child to play with. She may think
that all toys must be bought
 Child is not responding or seems “slow”. Some children may
have learning disabilities but they can learn more with
special care
 Child is being raised by someone other than the mother
 Counsel the mother about care for development
 Give relevant advice
 Use good communication skills (ALPAC)
 Counsel the mother about her own health
FOLLOW-UP
Aged 2 Months Up to 5 Years
Objectives
 Deciding if the child’s visit is for follow-up
 Assessing signs specified in the follow-up box for
the child’s previous classification
 Selecting treatments based on the child’s signs
 If the child has any new problems, assessing and
classifying them as in an initial visit
 Ask the mother about the child’s problem. Determine if
this is a follow-up or an initial visit for this illness
 If for follow-up, ask if the child has developed any new
problem. This requires a full assessment
Objectives
 If no new problem, follow the instructions in the FOLLOW-
UP box that matches the child’s previous classification
 If the child has any kind of diarrhea, classify and treat the
dehydration as in an initial assessment
 Children with repeatedly chronic problems should be
referred to a hospital when they do not improve
 If with several problems, showing signs of shock, or is
getting worse, refer the child to a hospital
 Refer if a second-line drug is unavailable
 If a child has not improved with the treatment, he/she may
have an illness different from that suggested by the chart.
He/she may need other treatments provided in a hospital
Pneumonia
 After 2 days
 Check for general danger signs
 Assess for cough or difficult breathing

 Ask
 Is the child breathing slower?
 Is there less fever?
 Is the child eating better?

 Treatment
 If chest indrawing or a general danger sign, give a
dose of second-line antibiotic or intramuscular
chloramphenicol, then refer urgently to hospital
Pneumonia
 If breathing rate, fever, and eating are the
same, change to the second-line antibiotic
and advise mother to return in 2 days or
refer. If the child had measles within the
last 3 months, refer
 If breathing rate slower, less fever, or
eating better, complete the 5 days of
antibiotic
 If cough is more than 30 days, refer
Persistent Diarrhea
 After 5 days, ask
 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
less than 3 or more loose stools per day), do a full
reassessment. Give any treatment needed, then
refer to a hospital
 If diarrhea has stopped (child having less than 3
loose stools per day), tell to follow the usual
recommendations for the child’s age
Dysentery
 After 2 days
 Assess the child for diarrhea
 Ask
 Are there fewer stools?
 Is there less blood in the stool?
 Is there less fever?
 Is there less abdominal pain?
 Is the child eating better?
 Treatment
 If the child is dehydrated, treat dehydration
Dysentery
 Ifnumber of stools, amount of blood of stools, fever,
abdominal pain, or eating is the same or worse,
change to second-line oral antibiotic recommended
for Shigella. Give for 5 days. Advise to return in 2
days
 Except if the child
 Less than 12 months old, or
 Was dehydrated on the first visit, or
 Had measles within the last 3 months, REFER to hospital
 Iffewer stools, less blood in the stools, less fever,
less abdominal pain, and eating better, continue
giving antibiotic until finished
Malaria
 If fever persists after 2 days, or returns within
14 days, do a full assessment
 Treatment
 If with any general danger sign or stiff neck, treat
as VERY SEVER FEBRILE DISEASE/ MALARIA
 If with any cause of fever other than malaria,
provide treatment
 If malaria is the only apparent cause of fever
 Take blood smear
 Give second-line oral antimalarial without waiting for
result of blood smear
Malaria
 Advise to return if fever persists
 If fever persists after 2 days 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 full assessment
 Assess for other causes of fever
 Treatment
 If with any general danger sign or stiff neck, treat as
VERY SEVERE FEBRILE DISEASE/ MALARIA
 If malaria is the only apparent cause of fever
 Take blood smear
 Treat with first-line oral antimalarial. Advise to return in 2
days if 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
assessment
 Make sure there has been no travel to
malarious area and overnight stay in malaria
area.
 If there has been travel and overnight stay, do
blood smear if possible
 Treatment
 If there has been travel and overnight stay to a
malarious area and the blood smear is positive or
there is no blood smear, classify and treat as
FEVER with MALARIA RISK
Fever (No Malaria)
 If there has been no travel to malarious
area and blood smear is negative
 If with any general danger sign or stiff neck,
treat as VERY SEVERE FEBRILE DISEASE
 If with any apparent cause of fever, provide
treatment
 If no apparent cause of fever, advise to return
in 2 days if fever persists
 If fever has been present for 7 days, refer for
assessment
Fever: Dengue Hemorrhagic
Fever Unlikely
 If fever persists after 2 days
 Do full assessment
 Do torniquet test

 Assess for other causes of fever

 Treatment
 If with any signs of bleeding, including skin
petechiae or a positive torniquet test, or
signs of shock, or persistent abdominal pain
or persistent vomiting, treat as DENGUE
HEMORRHAGIC FEVER
Fever: Dengue Hemorrhagic
Fever Unlikely
 If with any other apparent cause of fever,
provide treatment
 If fever has been present for 7 days, refer
for assessment
 If no apparent cause of fever, advise to
return daily until the child has had no fever
for at least 48 hours
 Advise to make sure child is given more
fluids and is eating
Measles With Eye or Mouth
Complications
 After 2 days
 Look for red eyes and pus draining from the eyes
 Look at mouth ulcers
 Smell the mouth

 Treatment for eye infection

 If pus draining from the eye, ask how mother treated
the infection. If correct, refer to hospital. If incorrect,
teach the correct treatment
 If pus is gone but redness remains, continue
treatment
 If no pus or redness, stop treatment
Measles With Eye or Mouth
Complications
 Treatment for mouth ulcers
 If mouth ulcers are worse, or there is a very
foul smell from the mouth, refer to hospital
 If mouth ulcers are the same or better,
continue using half-strength gentian violet
for a total of 5 days
Ear Infection
 After 5 days
 Reassess for ear problem
 Measure the child’s temperature

 Treatment
 Ifthere 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 with 5 more days of the same
antibiotic. Continue wicking ear. Follow-up in 5
days
Ear Infection
 Chronic ear infection: Check if the mother is
wicking the ear correctly and encourage to
continue
 If no ear pain or discharge, praise the
mother for her careful treatment. Tell to
use up all the antibiotic for 5 days before
stopping
Feeding Problem
 After 5 days
 Reassess feeding
 Ask about any feeding problems found on the
initial visit
 Counsel about any new or continuing
feeding problems. If you advise significant
changes in feeding, ask to return
 If child has very low weight for age, ask to
return in 30 days after initial visit to
measure weight gain
Anemia
 After 14 days
 Give iron. Advise to return in 14 days for
more iron
 Continue giving iron every day for 2 months
with follow-up every 14 days
 If with palmar pallor after 2 months, refer
for assessment
Very Low Weight
 After 30 days
 Weigh and determine if still with very low weight
for age
 Reassess feeding
 Treatment
 If no longer very low weight for age, praise and
encourage to continue
 If still very low weight for age, counsel about any
feeding problem found. Continue to see child
monthly until child is feeding well and gaining
weight regularly or is no longer very low weight for
age
 Except if you do not think feeding will improve
or if the child has lost weight, refer
MANAGEMENT OF THE SICK
YOUNG INFANT
Aged 1 Week to 2 Months
Introduction
 Young infants have special
characteristics that must be considered
when classifying their illness
 They can become sick and die very
quickly from serious bacterial infections.
 They frequently have only general signs
such as few movements, fever, or low
body temperature
Objectives
 Assessing and classifying for possible bacterial
infection
 Assessing and classifying for diarrhea
 Checking for feeding problem or low weight,
assessing breastfeeding, and classifying feeding
 Treating with oral or intramuscular antibiotics
 Giving fluids for treatment of diarrhea
 Teaching mother to treat local infections
 Teaching correct positioning and attachment for
breastfeeding
 Advising how to give home care
Assess and Classify the Sick,
Young Infant
 Check the young infant for possible
bacterial infection
 The infant must be calm while assessing the
first four signs
 Ask: Has the infant had any convulsions?

 Look and listen

 Fastbreathing(>60 bpm), repeat count if elevated
 Severe chest indrawing
 Nasal flaring
 Grunting
Assess and Classify the Sick,
Young Infant
 Bulging fontanels
 Pus draining from the ear
 Umbilicus: Red or draining pus? Does the
redness extend to the skin?
 Feel or measure body temperature. Fever =
Axillary temperature of >37.5˚C or rectal
temperature of >38˚C
 Skin pustules: Are there many or severe
pustules?
 Abnormally sleepy or difficult to awaken
 Movements: Are they less than normal?
Assess and Classify the Sick,
Young Infant
 Classify all sick, young infants for bacterial
infection
 Any sign classifies the infant as having POSSIBLE
SERIOUS BACTERIAL INFECTION and needs urgent
referral to the hospital
 Classified as LOCAL BACTERIAL INFECTION if only
red umbilicus or draining pus or skin pustules
 Assess diarrhea
 Normally frequent or loose stool of a breastfed
baby is not diarrhea
 Thirst is not assessed because it is not possible to
distinguish thirst from hunger
Assess and Classify the Sick,
Young Infant
 Classify diarrhea
 Classified in the same way as older child
 Classify status of dehydration

 Classify if with diarrhea for more than 14 days

 There is only one classification for persistent diarrhea
 Refer immediately

 Classify if with blood in the stool

 Referimmediately
 Do not start antibiotic but give frequent sips of ORS on
the way
Assess and Classify the Sick,
Young Infant
 Check for feeding problem or low birth weight
 Growth is assessed by determining weight for age
 Best way to feed infant is through exclusive
breastfeeding
 ASK: Is there any difficulty feeding?

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

in 24 hours?
 ASK: Does the young infant usually receive any other
food or drink? If yes, how often?
Assess and Classify the Sick,
Young Infant
 ASK: What do you use to feed your infant?
 LOOK: Determine the weight for age

 Assess breastfeeding
 Do not assess if
 Exclusivelybreastfed without difficulty and is
not low weight for age
 Not breastfed at all
 With serious problem requiring urgent referral
Assess and Classify the Sick,
Young Infant
 Assess breastfeeding if an infant
 Has any difficulty feeding
 Is breastfeeding less than eight times in 24 hours
 Is taking any other foods or drinks
 Is low weight for age
 Has no indications for urgent referral

 ASK: Has the infant breastfed in the previous hour? If

not, ask to put infant to the breast and observe for 4
minutes
 If infant was fed during the last hour, ask if mother can
wait and tell you when the infant is willing to feed
again
Assess and Classify the Sick,
Young Infant
 Is the infant able to attach?
 No attachment at all
 Not well attached
 Good attachment

 To check attachment, LOOK for all of these

signs
 Chintouching breast
 Mouth wide open
 Lower lip turned outward
 More areola visible above than below the mouth
Assess and Classify the Sick,
Young Infant
 Isthe infant sucking effectively? not
sucking at all? Not sucking effectively?
A satisfied infant releases the breast
spontaneously
 Clear blocked nose
 Look for ulcers or white patches in the
mouth (thrush)
Assess and Classify the Sick,
Young Infant
 Classify feeding
 NOT ABLE TO FEED: POSSIBLE SERIOUS
BACTERIAL INFECTION
 Give first dose of intramuscular antibiotics
 Treat to prevent low blood sugar level
 Advise how to keep warm
 Refer URGENTLY

 FEEDING PROBLEM OR LOW WEIGHT

 Advise to breastfeed as often and for as long as
the infant wants, day and night
Assess and Classify the Sick,
Young Infant
 If receiving other foods or drinks, counsel about
breastfeeding more, reducing other foods and
drinks and using a cup
 If thrush, teach how to treat
 Advise to give home care
 Follow-up any feeding problem or thrush in 2
days
 Follow up low weight for age in 14 days

 NO FEEDING PROBLEM
 Advise to give home care
 Praise for feeding well
Assess and Classify the Sick,
Young Infant
 Check the infant’s immunization status
 Assess other problems
Identify Appropriate
Treatment
 Determine if the young infant needs urgent referral
 If infant has POSSIBLE SERIOUS BACTERIAL INFECTION
 If infant has SEVERE DEHYDRATION, and needs
rehydration with IV fluids according to Plan C. If you can
give IV therapy, you can treat the infant in health
center. Otherwise, refer urgently
 If both with SEVERE DEHYDRATION and POSSIBLE
SEVERE BACTERIAL INFECTION, refer urgently. Mother
should give frequent sips and continue breastfeeding
Identify Appropriate
Treatment
 Identify treatments for a young infant
who does not need urgent referral
 Record treatments, advice, and when to
return for follow-up
 Refer the young infant
 Same procedures as in referring a young
child
 Referralnote
 Explain why to refer
 Teach what she needs to do along the way
Identify Appropriate
Treatment
 Explain that young infants are particularly
vulnerable
 If mother will not take the infant to the hospital,
follow guidelines WHEN REFERRAL IS NOT
POSSIBLE
 Treat the Sick Young Infant
and Counsel the Mother
 Give an appropriate antibiotic
 First-line:
Cotrimoxazole
 Second-line: Amoxicillin

COTRIMOXAZOLE AMOXICILLIN
Give two times daily for Give three times daily
5 days for 5 days
AGE OR ADULT SYRUP TABLET SYRUP
WEIGHT TABLET (40 mg/ 200 (250 mg) (125 mg/ 5
(80 mg/ 400 mg/ 5 mL) mL)
mg)
Birth up to 1 1.25 mL 1.25 mL
month (<3
kg)
1 to 2 months 1/4 2.5 mL 1/4 2.5 mL
(3-4 kg)
Treat the Sick Young Infant
and Counsel the Mother
 Avoid giving Cotrimoxazole to young infant less than one month
of age who is premature or jaundiced. Give Amoxicillin or
Benzylpenicillin instead
 Give first dose of intramuscular antibiotics
 Gentamicin and Benzylpenicillin. Combination is effective against
broader range of bacteria
 Referral is best option for infant with POSSIBLE BACTERIAL
INFECTION. If not possible, give Benzylpenicillin every 6 hours
and Gentamicin one dose daily for at least five days.
 Treat the Sick Young Infant
and Counsel the Mother

WEIGH GENTAMICIN BENZYLPENICILLIN

T 5 mg per kg 50,000 units per kg
Undiluted 2 Add 6 ml To a vial of 600 mg (1,000,000
ml vial sterile water units)
containing to 2 ml vial Add 2.1 ml Add 3.6 ml
20 mg = 2 containing 80 sterile water = sterile water =
ml at 10 mg = 8 ml at 2.5 ml at 4.0 ml at
mg/ml 10 mg/ml 400,000 units/ 250,000 units/
ml 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
Treat the Sick Young Infant
and Counsel the Mother
 Treat diarrhea according to TREAT THE CHILD chart
 Immunize every sick, young infant, as needed
 Treat the mother to treat local infections at home
 Local infections treated the same way that mouth ulcers are treated
in an older child
 Clean the infected area twice a day with gentian violet. Half strength
used in the mouth
 Explain and demonstrate the treatment. Watch and guide her.
 Return for follow-up in two days or sooner if infection worsens
Treat the Sick Young Infant
and Counsel the Mother
 Stop gentian violet after five days
 To treat skin pustules
 Wash hands
 Wash off pus and crusts with soap and water
 Dry the area
 Paint with gentian violet
 Wash hands
 To treat umbilical infection
 Wash hands
 Clean with 70% ethyl alcohol
 Pain with gentian violet
 Wash hands
Treat the Sick Young Infant
and Counsel the Mother
 To treat oral thrush
 Wash hands
 Wash mouth with clean soft cloth wrapped around
finger and wet with salt water
 Paint the mouth with half-strength gentian violet
 Wash hands

 Teach correct positioning and attachment

for breastfeeding
 Show how to hold infant
 With the infant’s head and body straight
Treat the Sick Young Infant
and Counsel the Mother
 Facing mother’s 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.
 Touch infant’s lips with mother’s nipple
 Wait until infant’s mouth is opening wide
 Move infant quickly onto breast, aiming infant’s
lower lip well below the nipple
Treat the Sick Young Infant
and Counsel the Mother
 Counselling the mother about feeding
problems
 Advise the mother to give home care for
the young infant
 Foods and fluids
 Frequent breastfeeding will give nourishment and
help prevent dehydration
 When to return
 Follow-up
 LOCAL BACTERIAL INFECTION, ANY FEEDING
PROBLEM, THRUSH: 2 days
Treat the Sick Young Infant
and Counsel the Mother
 LOW WEIGHT FOR AGE: 14 days
 When to return immediately
 Breastfeeding or drinking poorly
 Becomes sicker
 Develops fever
 Fast breathing
 Difficult breathing
 Blood in stool
 Make sure the young infant stays warm at all
times
 Keeping
a sick young infant warm is very important.
Low temperature alone can kill
FOLLOW-UP
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
 If improved, continue giving the 5 days of
antibiotic and continue treating the local
infection at home
Feeding Problem
 After 2 days
 Reassess feeding
 Ask about any feeding problems found on the
initial visit
 Counsel about any new or continuing problems. If
you counsel to make significant changes in feeding,
ask to bring the infant back again
 If infant is low weight for age, ask to return in 14
days after initial visit to measure weight gain
 Exception: if you think that feeding will not
improve, or young infant has lost weight, refer
Low Weight
 After 14 days
 Weigh and determine if still low weight for age
 Reassess feeding
 If no longer low weight for age, praise the mother
and encourage to continue
 If still low weight for age, but feeding well, praise
mother. Ask to return within a month or when she
returns for immunization
 If still low weight for age, and still with feeding
problem, counsel about feeding problem. Ask to
return within 14 days or when she returns for
immunization, if this is within 2 weeks
Low Weight
 Exception: if you think that feeding will not
improve, or young infant has lost weight,
refer
Oral Thrush
 After 2 days
 Lookfor ulcers or white patches in the
mouth
 Reassess feeding
 If thrush is worse, or if with problems with
attachment or sucking, refer
 If thrush is the same or better, and is feeding
well, continue half-strength gentian violet for a
total of 5 days