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MANGEMENT OF
CHILDHOOD
ILLNESSES
(IMCI)
ARACELI F. SURAT
BACKGROUND
Each year more than 10 million children in low-
and middle-income countries die before they
reach their fifth birthday.
Seven in ten of these deaths are due to just five
preventable and treatable conditions: pneumonia,
diarrhoea, malaria, measles, and malnutrition, and
often to a combination of these conditions
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Factors
Every day, millions of parents seek health
care for their sick children, taking them to
hospitals, health centers, pharmacists,
doctors and traditional healers.
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Factors
At first-level health facilities in low-income
countries, diagnostic supports such as radiology
and laboratory services are minimal or non-
existent, and drugs and equipment are often
scarce.
Limited supplies and equipment, combined
with an irregular flow of patients
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Factors
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These factors make providing quality
care to sick children a serious challenge.
WHO and UNICEF have addressed this
challenge by developing a strategy
called Integrated Management of
Childhood Illness (IMCI).
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What is IMCI?
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Objectives of IMCI
Major objectives:
To reduce under five mortality
and morbidity.
To improve growth and
development of children.
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In health facilities:
the IMCI strategy promotes the accurate
identification of childhood illnesses in outpatient
settings
ensures appropriate combined treatment of all
major illnesses
strengthens the counselling of caretakers
speeds up the referral of severely ill children.
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In the home setting:
it promotes appropriate care
seeking behaviors
improved nutrition and
preventative care, and the correct
implementation of prescribed care
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How does IMCI accomplish
these goals?
Introducing and
implementing the IMCI
strategy in a country is a
phased process that requires
a great deal of coordination
among existing health
programs and services.
ARACELI F. SURAT
The main steps involve
ARACELI F. SURAT
The main steps involve
Making upgraded care possible by ensuring that
enough of the right low-cost medicines and
simple equipment are available.
Strengthening care in hospitals for those children
too sick to be treated in an outpatient clinic.
Developing support mechanisms within
communities for preventing disease, for helping
families to care for sick children, and for getting
children to clinics or hospitals when needed
ARACELI F. SURAT
3 Main Components of
Strategy
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1. Improving case management skills of the
health-care staff
Provision of case management guidelines
and standards.
Training of public and private health care
providers ( pre- and in-service)
Follow-up and support supervision of trained
health workers.
Train health workers in problem solving in
the community
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2. Improving the overall health system
Sound district planning and management
based on burden of disease.
Facilitating essential drug supply and
management.
Improving support supervision at health
facilities.
.
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2. Improving the overall health
system
. Strengthen the service quality and
organization at health facilities.
Reinforce referral services
Ensure equity of access to health care
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3. Improving family and community
health care practices
Appropriate and timely care seeking
behavior
Appropriate feeding practices
Appropriate home case management
and adherence to recommended
treatment prescriptions.
ARACELI F. SURAT
3. Improving family and community health care
practices
Community involvement I health service planning and
monitoring
Develop interventions to strengthen community
participation.
Promote appropriate family response to childhood illness
Promote child nutrition
Create safe environment for children
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How is IMCI implemented?
IMCI is implemented by
working with local governments
and ministries of health to plan
and adapt the principles of this
approach to local circumstances.
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Case Management Process
- presented on a series of charts which
show the sequence of steps and
provide information for performing
them.
Relies on case detection using simple
clinical signs and empirical treatment.
The treatments are developed accdg to
action-oriented classification rather
than exact diagnosis.
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STEPS
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Step #1: ASSESS the
child or young infant
means taking a history
and doing a physical
examination
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Step #2: CLASSIFY the Illness
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Step #2: CLASSIFY the Illness
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Step #2: CLASSIFY the Illness
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Step #2: CLASSIFY the Illness
Continiation B.
The health worker advises
her about caring for the
child at home and when she
return .
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Step #2: CLASSIFY the Illness
C. A classification in green
row means that the child
does not need specific
medical treatment such as
antibiotics. The health
worker teaches the mother
how to care for her child at
home .
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Step # 3: IDENTIFY treatment
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Step # 4 : TREAT the child
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Step # 5: COUNSEL the
mother
Includes assessing how the
child is fed
about the foods and fluids
to give the child
when to bring the child back
to the health center.
Health of the mother
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Step# 6: Give FOLLOW-UP care :
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HOW TO SELECT THE
APPROPRIATE CASE
MANAGEMENT CHARTS?
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Decide which age group is in:
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2. Age 2 months up to 5 years
Use ASSESS AND CLASSIFY THE SICK
CHILD AGE 2 MONTHS UP TO 5 YEARS
means the child has not yet had his 5th birthday.
This age group includes a child who is 4 years
and 11 moths but not a child who is 5 year old.
If the child who is 2 months old would be in the
group 2 months up to 5 years, not in the group 1
week up to 2 months
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ASSESS AND CLASSIFY THE SICK
YOUNG CHILD AGED 2 MONTHS
TO 5
YEARS
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WHAT TO DO:
ARACELI F. SURAT
If the child is 1 week up to 2 months,
assess and classify the young infant
according to the steps on the YOUNG
IFANT chart
Look also if the child’s weight and
temperature have been measured and
recorded. If not weigh the child and
measure his temperature later when
you assess and classify the child’s
main symptoms.
Do not undress or disturb the child
now.
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2. Ask the mother what are child’s problem are and
record in the recording form using good
communication skills.
Listen carefully to what the mother tells you. This will
show her that you are taking her concerns seriously.
Use words the mother will understand. If she does not
understand the questions you ask, she cannot give
information you need to assess the child and to
classify his or her illness correctly.
Give the mother time to answer the questions. She
may need time to decide whether the sign you’ve
asked about is present.
ARACELI F. SURAT
Ask additional questions when the
mother is not sure about her answer.
When you ask about a main
symptom or related sign, the mother
may not be sure if t is present. Ask
he additional questions to help her
give clearer answer.
ARACELI F. SURAT
Communicating well with the mother helps
reassure her that her child will receive good
care.
Determine if this is an initial visit or follow –
up visit for this problem.
If follow-up visit: If the child was seen a
few days ago for the same illness, use the
follow-up visit for this problem
If initial visit: If this is the child’s first visit
for this episode of an illness, assess the
child from the 1st step.
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A. Check for General Danger
Signs
A child with a general danger sign has a
serious problem.
Needs URGENT referral to the hospital
Complete the rest of the assessment
immediately.
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General Danger Signs:
1. Unable to drink or breastfeed
2. Convulsion
3. Vomits everything
4. Lethargic/abnormally sleepy/unconscious
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1. Is the child able to drink or breastfeed?
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NOTE:
If you are not sure about the mother’s answer,
ask her to offer the child drink of clean water
or breast milk. Look to see if the child is
swallowing the water or breast milk.
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2. Does the child vomit everything
he or she takes in?
• A child who is not able to hold anything down at all has the sign
“vomits everything”. A child who vomits everything he or she
takes in will not be able to hold down food, fluids, or oral drugs.
• What goes down goes up. A child who vomits several times but
can hold down some fluids does not have this general danger sign.
• Ask the mother how often the child vomits. Also ask, if the child
vomits each time he or she swallow foods or fluids.
• If you are no sure of the answer, ask the mother to offer the child
drink and see if the child will vomit.
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3. Has the child had convulsions?
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3. Has the child had convulsions?
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4. Look : See if the child is
abnormally sleepy or difficult to
awaken
An abnormal sleepy child is not awake
and alert when he or she should be.
He or she is drowsy
does not show interest in what is
happening around him or her.
.
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4. Look : See if the child is abnormally
sleepy or difficult to awaken
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4. Look : See if the child is abnormally
sleepy or difficult to awaken
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B. ASK ABOUT THE MAIN
SYMPTOMS
1. Cough or difficult breathing
2. Diarrhea
3. Fever
4. Ear Problem
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B1. Assess Cough or Difficult
Breathing
ARACELI F. SURAT
B1. Assess Cough or Difficult Breathing
ARACELI F. SURAT
B1. Assess Cough or Difficult
Breathing
If the mother says YES, ask the next
question
Ask: for how long?
A child who has cough or difficult
breathing for more than 30 days has
chronic cough. This may be a sign of
tuberculosis, asthma, whooping cough or
another problem
ARACELI F. SURAT
B1. Assess Cough or Difficult
Breathing
Look and listen:
Count the child’s breaths in one minute to decide if
the child has fast breathing. The child must be
quiet an calm when you look and listen to his
breathing
Tell the mother you are going to count her child’s
breathing. Remind her to keep her child calm.
If the child is sleeping, do not wake the child.
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B1. Assess Cough or Difficult Breathing
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B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
The child has chest indrawing if the
lower chest wall goes IN when the
child breath IN.
In normal breathing: The whole chest
wall ( upper and lower) and the
abdomen move OUT when the child
breaths IN.
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B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
If can’t hardly visualize the chest indrawing
ask the mother to change the position of
the child lying flat in her lap. If still you
do not see the lower chest wall go IN
when the child breaths IN, the child does
not have chest indrawing
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B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
Chest indrawing should be present , must
be clearly visible at all time. If you any
see chest indrawing when the child is
crying or feeding, the child does not
have chest indrawing.
ARACELI F. SURAT
B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
If the child has abdominal distention and
malnutrition, what appears to be chest
indrawing may not be the “real chest
indrawing”.
ARACELI F. SURAT
B1. Assess Cough or Difficult
Breathing
Look and listen for stridor
ARACELI F. SURAT
B1. Assess Cough or Difficult
Breathing
Look and listen for stridor
To look and listen for stridor,, look to see
when the child breaths IN.
Listen for the stridor. Put your ear near the
child’s mouth because stridor can be
difficult to hear.
The child should be calm.
You may hear a wheezing noise when the
child breaths OUT. This is not stridor it is
ARACELI F. SURAT
WHEEZES.
B2. Classify cough or difficulty in
breathing
ARACELI F. SURAT
B2. Classify cough or difficulty in
breathing
Classification of cough 0r
difficult breathing:
• Severe Pneumonia or Very Severe Disease
• Pneumonia
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2. Assess Diarrhea
ARACELI F. SURAT
2. Assess Diarrhea
ASK: Does the child have diarrhea?
If he mother says NO, ask about the next
main symptom, fever. You do not need to
assess the child further signs related to
diarrhea.
If the mother says YES, if the mother said
earlier that diarrhea was the reason for
coming to the health center, record her
answer. Then assess the child for signs of
dehydration, persistent diarrhea and
dysentery.
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
d. LOOK for the condition of the child
• abnormally sleepy or difficult to
awaken?
• Restless and irritable?
A child has the sign restless and irritable
if the child is restless and irritable
• Has sunken eyes?
ARACELI F. SURAT
2. Assess Diarrhea
d. LOOK for the condition of the child
Ask the mother if she thinks her child’s eyes look
unusual. Her opinion helps you confirm that the child’s
eyes are sunken.
In a severely malnourished child who is visibly wasted
( that is, who has marasmus), the eyes may always look
sunken, even if the child is not dehydrated. Even though
sunken eyes is less reliable in a visibly wasted child, still
use the sign to classify the child’s dehydration.
ARACELI F. SURAT
2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
Ask the mother to offer the child some water in a
cup or a spoon. Watch the child drink. If the child is
exclusively breastfeed, offer expressed breast milk.
A child is not able to drink if he is not able to take
fluid in his mouth and swallow it. or not able to
suck and swallow.
ARACELI F. SURAT
2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
A child is drinking poorly if the
child is weak and cannot drink
without help.
He may be able to swallow only if
fluid is put in his mouth.
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2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
A child is drinking eagerly, thirsty if it is clear
that the child wants to drink.
The child reaches out for the cup or spoon when
you offer him water.
When the water is taken away, see if the child is
unhappy because he wants to drink more
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
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2. Assess Diarrhea
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B2. Classify Diarrhea
There are three classification tables for classifying
diarrhea:
All children with diarrhea are classified for
dehydration
If the child had diarrhea for 14 days or more,
classify the child for persistent diarrhea
If the child has blood in the stool, classify the
child with dysentery.
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B3. Classify Dehydration
To classify the child’s dehydration , begin
with the pink row.
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B3. Classify Dehydration
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B3. Classify Dehydration
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B4. Classify Persistent Diarrhea
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Classify Dysentery
Dysentery – blood in the
stool
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SELECTING THE APPROPRIATE TREATMENT
PLAN ACCORDING THE DEGREE OF
DEHYDRATION
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TREATMENT PLAN A:
TREAT DIARRHEA AT HOME
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A. Counsel the mother regarding the 3 Rules of Home
Treatment:
ARACELI F. SURAT
A. Counsel the mother regarding the 3 Rules of
Home Treatment:
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A. Counsel the mother regarding the 3 Rules of Home
Treatment:
1. . Give Extra Fluid ( as much as the child will take)
a. Tell the mother:
If the child is not exclusively breastfed, give
one or more of the following:
Continue giving the extra fluid until the diarrhea
stops
It is especially important to give ORS at home when:
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
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A. Counsel the mother regarding the 3 Rules of
Home Treatment:
1. . Give Extra Fluid ( as much as the child will
take)
B. Teach the mother how to mix and give ORS
Give the mother 2 packets of ORS to use at home
Show the mother how much fluid to give the child
in addition to he
child’s usual fluid intake:
Up to 2 years 50 to 100 ml after each loose
stool evacuation
2 years or more 100 to 200 ml after each loose
evacuation
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B. Continue Feeding
Assess the child’s feeding pattern
Ask questions about the child’s usual
feeding and his or her feeding during
illness. Compare the mother’s answers
with the Feeding Recommendations for
the child’s age n the Box below.
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B. Continue Feeding
Assess the child’s feeding pattern
ASK:
Do you breastfeed your child?
How many times do you do so during the day?
Do you also breastfeed during the night?
Does the child take in any other food or fluid?
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B. Continue Feeding
What food or fluid does the child take
in?
How many times per day does the child
take in this food or fluid?
What do you use to feed the child?
If he child has very low weight for age:
How large are his or her servings? Is the
child given hi or her own serving? Who feeds the chills and how?
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B. Continue Feeding
During this illness, has the child’s feeding changed? If
yes,, in what way has it changed?
Advise the mother to increase the child’s Fluid Intake
during Illness
For any sick child:
Breastfeed the child more frequently an for
a longer time each feed
Increase the child’s fluid intake. For
example, give the child soup, rice water,
buko juice or clean water
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B. Continue Feeding
During this illness, has the child’s feeding changed? If
yes,, in what way has it changed?
Advise the mother to increase the child’s Fluid Intake
during Illness
For a Child with diarrhea:
Giving the child extra fluid can save his or life.
Give the child fluid according to Plan A or Plan B
on the TREAT the CHILD chart.
Instruct the mother what are the recommended
food to be given to the child depending on the
child’s age
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C. Counsel the mother about the child’s
feeding problems
If the child is not being fed as described in
the above recommendations, counsel the
mother accordingly.
If the mother reports difficulty with
breastfeeding, assess the child’s breast
feeding. If needed show the mother the
correct positioning and attachment for
breastfeeding.
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C. Counsel the mother about the child’s
feeding problems
If the child is less than 4 months old and is taking
other kinds of milk of foods:
Build the mother’s confidence by telling her that
she can produce all the breast milk that her child
needs.
Suggests giving the child more frequent, longer
breastfeed, day and night, and gradually reducing
the child’s intake of other kinds of milk or foods.
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C. Counsel the mother about the child’s feeding
problems
If the child’s intake of other kinds of milk needs to be
continue, counsel the mother to:
Breastfeed the child often as possible, including at
night.
Make sure that the other kind of milk to be given to
h child is a locally appropriate breast milk
substitute, and give it to the child only when
necessary,
Make sure that the other kind of milk to be given Is
correctly and hygienically prepared, and that it is given
in adequate amounts
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C. Counsel the mother about the child’s
feeding problems
Prepare only an amount of milk that the child
can consume within an hour. Discard leftover
milk, If any.
If the mother is using a bottle to feed the child:
Recommend substituting a cup for a bottle
Show the mother how to feed the child using a
cup
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C. Counsel the mother about the child’s
feeding problems
IF the child is not being fed actively,
counsel the mother to:
Sit with the child while the latter is
eating, and encourage him or her to eat
Give he child an adequate serving in a
separate late or bowl.
Observe what the child likes and consider
these in the preparation of hjs or her food.
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C. Counsel the mother about the child’s
feeding problems
If the child I not feeding well during illness,
counsel the mother to:
Breastfeed the child more frequently and for a
longer time at each feed, if possible.
Give the child soft, varied and appetizing foods, as
well as the child’s favorite foods, to encourage
him or her to eat as much as possible and offer the
child frequent small feedings.
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C. Counsel the mother about the child’s
feeding problems
Clear the child’s blocked nostril if they
interfere with his o her feeding.
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Feeding Recommendations for a
child who has Persistent
Diarrhea:
.
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If the child is still breastfeeding, give him
or her more frequent, longer breastfeeds,
day and night
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If the child is taking other kinds of milk,
such as milk supplements:
Replace these with increased beast
feeding or
Replace half the child’s milk intake with
nutrient rich, semi-solid foods
Do not give the child condensed milk or
evaporated milk.
For other foods, follow the feeding
recommendations for the child’s age.
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Know when to Return
Advise the mother regarding when to return to
the Health Center if the child has any of these
signs:
Persistent diarrhea
Return after 5 days
Ask: Has the diarrhea stopped?
How many times does the child evacuate
loose stool per day?
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Treatment:
If the diarrhea has not stopped ( the child still
evacuates loose stool 3 or more times per day),
conduct a full assessment of the child. Give him or her
any treatment he or she needs. Then, refer the child to
a hospital.
If the diarrhea has stopped ( the child evacuates loose
stool less than 3 times per day), tell the mother to
follow he usual recommendations for the child’s age.
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Feeding problem
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TREATMENT PLAN B : TREAT
SOME DEHYDRATION WITH ORS
ARACELI F. SURAT
Determine the amount of ORS to give to the
child during the first 4 hours.
Use the child’s age only when you do
not know the weight. The approximate
amount of ORS required ( in ml ) can
also be calculated by multiplying the
child’s weight ( in kg ) by 75.
If the child wants more ORS than
shown, give him or her more.
ARACELI F. SURAT
For infants under 6 months of age who
are not being breastfeed, give 100 -200
ml clean water as well during this period.
Show the mother how to give ORS
solution to her child:
Give the child frequent sips from a cup.
If the child vomits, wait for 10 minutes.
Then continue, but more slowly.
Continue breastfeeding whenever the
child wants o be breastfeed.
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After 4 hours:
Reassess the child and
classify him or her for
dehydration
Select the appropriate plan to
use in continuing the
treatment
Begin feeding the child in
the health center
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If the mother must leave before completing the
treatment:
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TREATMENT PLAN C : TREAT
SEVERE DEHYDRATION QUICKLY
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Assess the following:
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Also give ORS (about 5 ml/kg/hr) as
soon as the child can drink: usually
after 3 – 4 hours ( infants) or 1- 2
hour ( children)
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IF THERE IS IV TREATMET
AVAILABLE EARBY WITHIN 30
MINUTES:
ARACELI F. SURAT
IF YOU ARE TRAINED TO PLACE
NGT FOR REHYDRATION AND IF
THE CHILD ABLE TO DRINK:
ARACELI F. SURAT
If the child’s hydration status has not
improved after 3 hours, send the child for
IV therapy.