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 If
for chest indrawing
you 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
- Any general danger SEVERE PNEUMONIA sign OR VERY SEVERE - Chest indrawing DISEASE - Stridor in a calm child - Fast breathing
PNEUMONIA
- No signs of pneumonia or very severe disease
NO PNEUMONIA; COUGH, OR COLD
TREATMENT
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 SEVERE
DEHYDRATION 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: -Restless and irritable - Sunken eyes - Drinks eagerly, thirstily - Skin pinch goes back slowly
SOME DEHYDRATION
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 Agusan del Norte Apayao Basilan Bukidnon Cagayan Compostela Valley (Pilot) Davao del Sur Davao del Norte Ifugao Isabela Kalinga (pilot area)
Misamis Oriental Mindoro Occidental Palawan Quezon Quirino Saranggani Sulu Surigao del Sur Tawi-tawi Zambales Zamboanga del Sur
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 Fever
and 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
If
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
all 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 There
are three possible classifications of fever when there is malaria risk: VERY
SEVERE FEBRILE DISEASE/MALARIA MALARIA FEVER: MALARIA UNLIKELY VERY If
SEVERE FEBRILE DISEASE/ MALARIA
the child has any general danger sign or Stiff neck
Check for the Four Main Symptoms
MALARIA If
there is a risk of malaria Has fever but no runny nose No measles and no other causes of fever, or Positive blood smear FEVER: Does
MALARIA UNLIKELY
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 Very severe disease Cough or cold Dysentery Measles Measles with eye/mouth complication Dengue hemorrhagic fever Ear infection Mastoiditis
UTI Osteomyelitis Erysepelas Abcess Impetigo/ Pyoderma Tonsilopharyngitis Infected wounds Nephritis Typhoid fever Diarrhea
Check for the Four Main Symptoms
Classify Measles
There are three possible classifications SEVERE
COMPLICATED MEASLES MEASLES WITH EYE OR MOUTH COMPLICATIONS MEASLES SEVERE
COMPLICATED MEASLES
With
clouding of the cornea or deep or extensive mouth ulcers
MEASLES With
WITH EYE OR MOUTH COMPLICATIONS
pus draining from the eyes or mouth ulcers, which are not deep or extensive
Check for the Four Main Symptoms
MEASLES Measles
now 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 None
of 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
ACUTE
swelling behind the ear
EAR INFECTION
Pus
draining from the ear for less than two weeks or Ear pain Chronic Pus
NO
ear infection
draining from the ear for two weeks or more
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 Looking
and 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
Visible severe wasting Severe palmar pallor, or Edema on both feet
ANEMIA
NO
MALNUTRITION OR SEVERE ANEMIA
OR VERY LOW WEIGHT
Some palmar pallor, or Very low weight for age
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 Identify
the 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 Any
signs 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 80 mg/ 400/mg 40 mg/ 200 mg/ 5 mL
TABLET 250 mg
SYRUP 125 mg/ 5 mL
2 months up to 12 months (4-10 kg)
1/2
5 mL
1/2
5 mL
12 months up to 5 years (10-19 kg)
1
10 mL
1
10 mL
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 COTRIMOXAZOLE NALIDIXIC ACID antibiotic: Nalidixic Acid - Give two times daily for 5 days
- Give four times daily for 5 days
AGE OR WEIGHT See above dosage
SYRUP 250 mg/ 5 mL
2 months up to 4 months (4-6 kg)
1.25 mL (1/4 tsp)
4 months up to 12 months (6-10 kg)
2.5 mL (1/2 tsp)
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 COTRIMOXAZOLE Second-lineTETRACYCLINE antibiotic: Cotrimoxazole - Give four times daily - Give two times daily AGE OR WEIGHT
for 3 days
for 5 days
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 (10-19 kg)
1
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 Give
single 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 - Give for 3 days
PRIMAQUINE PRIMAQUIN - Give single E dose in health - Give daily center for P. for 14 days falciparum for p. vivax
SULFADOXINE + PYRIMETHAMINE - Give single dose in health center
AGE
TABLET (15 mg)
TABLET (500 mg/ 25 mg)
TABLET (150 mg) DAY 1
TABLET (15 mg)
DAY 2
DAY 3
2 months up 1/2 to 5 months (4-7 kg)
1/2
1/2
1/4
5 months up 1/2 to 12 months (710 kg)
1/2
1/2
1/2
12 months 1 up to 3 years (10-14 kg)
1
1/2
1/2
1/4
3/4
Select an Appropriate Oral Drug and Determine the Dose and the Schedule
Give Paracetamol for High Fever (38.5˚ or higher) or Ear Pain Give
one 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 (4-14 kg)
5 mL (1 tsp)
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
6 months up to 12 months
VITAMIN A CAPSULES
100,000 IU
200,000 IU
1
1/2
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 WEIGHT
IRON/FOLATE IRON SYRUP TABLET Ferrous sulfate Ferrous sulfate 150 mg/ 5mL 200 mg + 250 (6 mg mcg folate elemental iron (60 mg per mL) elemental iron)
3 months up to 4 months (4-6 kg) 4 months up to 12 months (6-10 kg) 12 months up to 1/2 3 years (10-14
IRON DROPS Ferrous sulfate 25 mg (25 mg elemental iron/ mL)
2.5 mL (1/2 tsp) 0.6 mL
4 mL (3/4 tsp)
5 mL
1 mL
1.5 mL
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 months
1/2
1
24 months up to 59 months
1
1
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 GOOD CHECKING POOR CHECKING QUESTIONS describeQUESTIONS WHY, HOW, or WHEN 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 Breastmilk
for 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 Repeat injection every 12 hours for 5 days AGE OR WEIGHT 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 (8-10 kg)
2 mL = 360 mg
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 kg)
0.3 mL
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
To
make 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
If
the 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
If
the 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
The
age 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
Giving
ORS 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 Food
MOTHER HOW TO GIVE ORS
should 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 Child
should 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 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
2 days
PERSISTENT DIARRHEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEMS MANY OTHER ILLNESSES, if not improving
5 days
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: COUGH OR COLD
-Fast breathing -Difficult breathing
If the child has diarrhea
-Blood in stool
If the child has FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
-Any sign of bleeding -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 FOLLOWUP 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 Is Is Is Is
there fewer stools? there less blood in the stool? there less fever? there less abdominal pain? the child eating better?
Treatment If
the child is dehydrated, treat dehydration
Dysentery If
number 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
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
fewer 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 If
there is tender swelling behind the ear or high fever (38.5˚C or above), treat as MASTOIDITIS Acute ear infection: if ear pain or discharge persists, treat 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
Fast
breathing(>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 Refer
if with blood in the stool
immediately 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
Exclusively
breastfed 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 Chin
touching breast Mouth wide open Lower lip turned outward More areola visible above than below the mouth
Assess and Classify the Sick, Young Infant Is
the 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 Advise
PROBLEM OR LOW WEIGHT
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 Referral
note 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 WEIGHT
ADULT SYRUP TABLET (40 mg/ 200 (80 mg/ 400 mg/ 5 mL) mg)
Birth up to 1 month (<3 kg)
1.25 mL
1 to 2 months 1/4 (3-4 kg)
2.5 mL
TABLET (250 mg)
SYRUP (125 mg/ 5 mL) 1.25 mL
1/4
2.5 mL
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 T 5 mg per kg Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml
Add 6 ml sterile water to 2 ml vial containing 80 mg = 8 ml at 10 mg/ml
BENZYLPENICILLIN 50,000 units per kg To a vial of 600 mg (1,000,000 units) Add 2.1 ml sterile water = 2.5 ml at 400,000 units/ ml
Add 3.6 ml sterile water = 4.0 ml at 250,000 units/ ml
1 kg
0.5 ml
0.1 ml
0.2 ml
2 kg
1.0 ml
0.2 ml
0.4 ml
3 kg
1.5 ml
0.4 ml
0.6 ml
4 kg
2.0 ml
0.5 ml
0.8 ml
5 kg
2.5 ml
0.6 ml
1.0 ml
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 With
how to hold infant 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 Look
for 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