November 2011

INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESS

SICK YOUNG INFANT
FROM BIRTH UPTO 2 MONTHS SICK CHILD 2 MONTHS UP TO 5 YEARS
TREAT THE CHILD, continued
Assess the Young Infant and Counsel the Mother 1 Assess and Classify and Identify Treatment 19 - 28 Give Extra Fluid for Diarrhoea and Continue Feeding
Essential Newborn Care Actions 1 Check for general danger signs 19 Plan A: Treat diarrhoea at home 36
Check the newborn for Birth Asphyxia 2 Ask about main symptoms: 19 Plan B: Treat some dehydration with ORS 36
Assess the newborn for birth weight and gestational age 3 Does the child have cough or difficult breathing? 19 Plan C: Treat severe dehydration quickly 37
Assess, the sick young infant from birth up to 2 months 4 Does the child have diarrhoea? 20 COUNSEL THE MOTHER 38 - 47
Check for Very Severe Disease & Local Bacterial Infection 4 Does the child have fever? 21 Food: Assess the child’s feeding 38
Check for Jaundice 5 Classify malaria & measles 21 Feeding recommendations during sickness and health 39
Does the young infant have diarrhoea? 6 Does the child have an ear problem? 22 Feeding for uncomplicated SAM 39
Check for HIV exposure and infection 7 Check for Anaemia 23 Feeding for child with persistent diarrhoea 39
Check for feeding problem or underweight 8 Check for acute malnutrition ( < 6 months) 24 Feeding recommendations if mother is HIV positive 40
Check for feeding problem: HIV positive mother not breastfeeding 9 Check for acute malnutrition (6 - 59 months) 25 Counsel the mother about feeding problems 41 - 42
Check the young infant’s immunization status 10 Assess for HIV infection ( 2 - 18 months) 26 Safe preparation of formula milk 43
Treat the Young Infant and Counsel the Mother 11 Assess for HIV infection ( 18 - 59 months) 27 Counsel the HIV positive mother not breastfeeding 43
Essential Newborn Care: Newborn Resuscitation 11 Check the child’s immunization and Vitamin A status 28 Appropriate amount of formula needed per day 44
Care of the low birth weight newborn 12 TREAT THE CHILD 29- 37 How to feed a baby with a cup 44
Teach the Mother to Give Oral Drugs at Home 29 - 32 Fluid: Advise the mother to increase fluid during illness 45
Keep the young infant warm 13 Appropriate oral antibiotic 29 When to Return: Advise the mother when to return 45
Oral antibiotics 14 Oral antimalarial 30 Counsel the mother about her own health 46
Intramuscular antibiotic 14 Cotrimoxazole prophylaxis 31 Family Health Card 47
Teach the mother to treat local infection at home 14 Paracetamol for high fever 31 Give Follow-up Care 48 - 50
Teach correct positioning and attachment for breastfeeding 15 Vitamin A, Zinc supplementation & Iron 32 Pneumonia, Persistent diarrhea, Dysentery 48
Advise mother to give home care for the young infant 15 Mebendazole or Albendazole 32 Malaria (low or high malaria risk) 49
Give Follow-up Care for the Sick Young Infant 16 Teach the Mother to Treat Local Infections at Home 33 Fever-malaria unlikely (low malaria risk) 49
Low birth weight/preterm, low body temperature 16 Treat eye infection with Tetracycline eye ointment 33 Fever (no malaria) (no malaria risk) 49
Local bacterial infection 16 Clean the ear by dry wicking 33 Measles with eye or mouth complications 49
Jaundice 16 Treat mouth ulcer with Gentian Violet 33 Ear Infection, Feeding Problem & Anemia 50
Diarrhoea (Some Dehydration) 16 Treat thrush with Nystatin or Gentian Violet 33 Uncomplicated SAM 50
Feeding problem 17 Soothe the throat, relieve cough with a safe remedy 33 Moderate Acute Malnutrition, Underweight 50
Thrush 17 Give These Treatments in Clinic Only 34 - 35 Where referral is not possible 51 - 63
Under weight 17 Give an intramuscular antibiotic 34 Treat wheezing 54
Routine Postnatal follow-up visits 18 Treat a convulsing child with Diazepam rectally 34 Appetite test & OTP of uncomplicated SAM 64 - 67
Newborn danger signs 18 Treat the child to prevent low blood sugar 34 Recording forms 68 - 71
Give Artesunate/Arthemeter for severe malaria 35 Weight for age chart ( Z Score) 72 - 73
Give Quinine for severe malaria 35 Weight for length/Height Table (% of NCHS median) 74 -75
Weight for Length/Height chart ( Z Score) 76 - 77
Table for target weight for discharge from OTP follow-up 78
 Summary of major changes in the 2011 version of the IMNCI Materials
This revised version (2011 edition) of the Integrated Management of Newborn and Childhood Illness training material has incorporated the following changes over the 2008 version.

1. Young Infants section:-

 The signs for the assessment of Very Severe Disease or Local Bacterial Infection have been reduced to the eight key signs as per the 2010 WHO Generic IMCI Guideline.

 The HIV assessment box has now four classifications with the new addition being “HIV Status Unknown”.

 The classification “Feeding Problem or Low Weight” has been changed to “Feeding Problem or Under-weight”.

 The postnatal follow-up actions at 6-24 hours, 3 and 7 days and 6 weeks have been revised.

2. Sick Child section:-

A. Cough for > 14 days is taken as indication for referral for TB assessment as per the national TB guideline (previously it was 21 days, 2008 version).

B. Malaria

 Travel history to malarious areas during the last 30 days is taken for malaria risk assessment (previously 14 days, 2008).

 “Fever-Malaria Unlikely” classification included under High Malaria Risk box when the blood film or RDT test is negative.

 New pre-referral anti-malarial treatment options (Artesunate & Arthimeter) included as per the 3rd edition of the national malaria treatment guideline (2009).

C. Malnutrition – Fully revised as per the 2007 national SAM treatment guideline.

 Weight/Length (height) included for the assessment of degree of wasting using either the WHO Z-score or the NCHS percent of the Median standards. Thus, the classification

“Very Low Weight” which was based on Wt/age criteria has been replaced by “Moderate Acute Malnutrition” using the Wt/Ht assessment.

 There are separate malnutrition assessment and classification boxes for infants < 6 months and those aged 6-59 months.

 Several medical conditions are considered in the assessment for complicated severe acute malnutrition as per the 2007 national SAM treatment guideline.

 Administration of first dose of Vitamin A is not recommended for patients with SAM who are initiated on the standard therapeutic feeds.

D. HIV:-

 The HIV assessment has been changed to a test results-based algorithm and the previous symptom-based classification no longer exists.

 Besides, the infant feeding recommendations for the HIV exposed infant have been revised as per the national Pediatric HIV/AIDS treatment and care guideline.

 Once HIV exposed or infected children are identified, they should be referred/linked to the PMTCT/ART clinic for follow up. Thus, no follow up boxes for HIV in the current guideline.

E. Pre-referral antibiotics – the current guideline recommends the use of parenteral antibiotics for pre-referral dose whenever these preparations are available.
ESSENTIAL NEWBORN CARE ACTIONS
Immediate Newborn Care After Birth

Step 1 Step 5
Deliver baby on to mothers Place the baby in skin-
abdomen. to-skin contact and on
the breast to initiate
breastfeeding.
Step 2
Dry baby’s body with dry and warm
towel. Wipe eyes, as you dry stim-
Eye care at the time of birth
ulate breathing. Drying the baby
Immediate skin contact
immediately after birth

Step 6
Step 3 Apply Tetracycline eye
Assess breathing & color -See BIRTH ASPHYXIA Chart and ointment once on both
manage accordingly. eyes.

Step 4
Clamp/tie the cord two fingers from
abdomen and another clamp/tie two Step 7 ENCC 3 10

fingers from the 1st one. Give Vitamin K,1mg IM on anterior mid thigh.

Cut the cord between the 1st and 2nd

clamp/tie.
Step 8
Weigh baby & classify -
See BIRTH WEIGHT & GESTATIONAL AGE Chart.
NOTES
• Delay bathing of the baby for 24 hours after birth.
• Provide three postnatal visits at 6 - 24 hours, 3 days,7days and immunization visit at 6 weeks.
• Give BCG and OPV 0 before discharge.
• If baby needs resuscitation cut the cord immediately. Otherwise, wait for 1- 3 minutes.

1
CHECK THE NEWBORN FOR BIRTH ASPHYXIA
ASSESS CLASSIFY IDENTIFY TREATMENT

IF YOU ARE ATTENDING DELIVERY or

BABY BROUGHT TO YOU IMMEDIATELY AFTER BIRTH SIGNS CLASSIFY AS TREATMENT
Assess and check for Birth Asphyxia while drying and (Urgent pre-referral treatments are in bold print)
wrapping with dry cloth
If any of the following sign: Start resuscitation
 Not breathing, OR  Clamp/tie and cut the cord immediately
 Gasping, OR BIRTH  Position the newborn supine with neck slightly
Assess, Look Classify
 Breathing poorly extended
ALL ASPHYXIA
(<30 breaths/minute),  Clear mouth and nose with bulb syringe
Newborns  Ventilate with appropriate size bag & mask
 Look the breathing OR
- Is baby not breathing?  Cyanosis (blue tongue,  If the resuscitation is successful, continue
- Is baby gasping? lips) giving essential newborn care
 If the baby remains weak or is having irregular
- Is baby breathing poorly
breathing after 20 minutes of resuscitation;
(<30 breaths/minute)?
refer urgently to hospital while continuing to
- Is baby breathing normally resuscitate on the way
(Crying or ≥30 breaths/minute)?  Stop resuscitation after 20 minutes if no response
(no spontaneous breathing)
 Look the color of tongue & lips  Monitor continuously for 6 hours
- Blue  Follow after 12 hrs, 24 hrs, 3 days ,7 days and 6
- Pink weeks
 Give cord care
• Breathing normally  Initiate skin-to-skin contact
(crying or ≥30 breaths/ NO  Give eye care
minute) BIRTH  Give Vitamin K
AND ASPHYXIA  Initiate breastfeeding
• Pink tongue & lips  Give BCG and OPV 0
 Advise mother when to return immediately
 Follow after, 6 hrs, 3 days and 7days and 6
weeks

2
ASSESS THE NEWBORN FOR BIRTH WEIGHT AND GESTATIONAL AGE

ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold print)
• Weight < 1,500gm  Continue breastfeeding (if not sucking
Assess, Look Classify OR VERY LOW feed expressed breast milk by cup)
ALL • Gestational age < 32 weeks BIRTH WEIGHT  Start Kangaroo Mother Care
- Ask the gestational age Newborn Babies AND/OR  Give Vitamin K 1mg IM on anterior mid
- Ask for birth weight or VERY PRETERM thigh, if not already given
- Weigh the baby (with in 7 days of  Refer URGENTLY with mother to hospital
life) with KMC position
• Weight 1,500 - 2,500 gm  KMC if <2,000gm (see page 13)
OR LOW  Counsel on optimal breastfeeding
• Gestational age 32-37 weeks BIRTH WEIGHT  Counsel mother on prevention of infection
AND/OR  Give Vitamin K 1mg IM on anterior mid thigh
PRETERM  Provide follow-up for KMC
 If baby ≥ 2,000 gms follow-up visits
at age 6 –24 hrs, 3 days,7 days & 6 weeks
 Give 1st dose of vaccine
 Advise mother when to return immediately
• Weight ≥ 2,500 gm  Counsel on optimal breastfeeding
OR NORMAL  Counsel mother/family on prevention of
• Gestational age ≥ 37 BIRTH WEIGHT infection
weeks  Provide follow-up visits at age 6-24 hrs,
AND/OR
TERM 3 days, 7 days & 6 weeks
 Give 1st dose of vaccine
 Give Vitamin K 1mg IM on anterior mid thigh
 Advise mother when to return immediately

3
 ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT FROM BIRTH UP TO 2 MONTHS
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)
 Not feeding well, OR  Give first dose of intramuscular Ampicillin and
 History of Convulsions/convulsing now, OR Gentamycin
 Fast breathing (≥60 breaths per minute), OR
VERY  Treat to prevent low blood sugar
Ask Look, Listen, Feel: Classify
all young  Severe chest indrawing, OR SEVERE  Warm the young infant by skin-to-skin contact if
infants
 Fever (≥37.5°C* or feels hot), OR DISEASE temperature is less than 36.5°C (or feels cold to
 Low body temperature (< 35.5°C* or feels touch) while arranging referral
 Is the infant  Count the breaths in one minute. YOUNGINFANT  Advise mother how to keep the young infant
- Repeat the count if ≥ 60/min MUST BE cold), OR
having CALM
 Movement only when stimulated or no warm on the way to the hospital
difficulty in  Look for severe chest indrawing.  Refer URGENTLY to hospital
movement even when stimulated.
feeding?  See if the young infant is not feeding.
 See if the infant is convulsing now.
 Red umbilicus or draining pus, OR  Give Amoxycillin for 5 days
 Look at the umbilicus. Is it red or draining LOCAL
 Has the infant  Teach the mother to treat local infections at
pus?  Skin pustules BACTERIAL
had home
 Measure temperature (or feel for fever or
convulsions? INFECTION  Advise mother when to return immediately
low body temperature)
 Follow-up in 2 days
 Look for skin pustules.
 Look at the young infant’s movements.  None of the signs of Very Severe SEVERE  Advise mother to give home care for the young
- Infant move on his/her own Disease, or Local bacterial infection DISEASE, infant
- Infant move only when stimulated OR
- Infant doesn’t move even when LOCAL
stimulated INFECTION
UNLIKELY
AND if
temp. is  Temperature from 35.5°C – 36.4°C  Treat to prevent low blood sugar
from (both values inclusive) LOW  Warm the young infant using skin-to-skin contact
35.5 - 36.4°C BODY for one hour and reassess. If temperature
TEMPERATURE remains same or worse, refer. (Advise mother to
continue feeding and keep the infant warm on
* These thresholds are based on axillary temperature. The thresholds the way to the hospital).
for rectal temperature readings are approximately 0.5°C higher.  Advise mother when to return immediately
 Follow-up in 2 days
** If referral is not possible, see Pages 51- 63“Where Referral is Not Possible”

4
CHECK FOR JAUNDICE

ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold print)

• Palms and/or soles yellow, OR • Treat to prevent low blood sugar

Classify
all infants • Skin and eyes yellow and baby is • Warm the young infant by skin-to-skin contact if
 Look for jaundice: < 24 hrs old, OR temperature is less than 36.5°C (or feels cold to
• Is skin on the face or eyes yellow? SEVERE
• Skin and eyes yellow and baby is touch) while arranging referral
• Are the palms and soles yellow? ≥14 days old JAUNDICE • Advise mother how to keep the young infant
warm on the way to the hospital
• Refer URGENTLY to hospital

• Only skin on the face or eyes • Advise mother to give home care for the young infant
yellow, AND JAUNDICE • Advise mother when to return immediately
• Infant aged 2-13 days old • Follow-up in 2 days

• No yellowish discoloration of the NO • Advise mother to give home care for the infant
eye or skin JAUNDICE

5
 ASSESS THE YOUNG INFANT FOR DIARRHOEA
SIGNS CLASSIFY TREATMENT
AS (Urgent pre-referral treatments are in bold print)
Two of the following ►If infant has another severe classification:
THEN ASK: Does the Young Infant Have signs: SEVERE - Refer URGENTLY to hospital with mother giving frequent
Diarrhoea?  Movement only sips of ORS on the way
for DEHYDRATION - Advise mother to continue breastfeeding more frequently
dehydration when stimulated, or
- Advise mother how to keep the young infant warm on the
no movement even
Ask Look and Feel: when stimulated
way to hospital
►If infant does not have any other severe classification; give fluid
 Sunken eyes for severe dehydration (Plan C).
 For how  Look at the young infant’s general
condition.  Skin pinch goes
long? back very slowly
- Infant moves only when Classify
Is there stimulated DIARRHOEA
 Two of the following  If infant has another severe classification:
- Infant does not move even when
blood in the signs: SOME - Refer URGENTLY to hospital with mother giving frequent
stimulated sips of ORS on the way
stool?  Restless, irritable DEHYDRATION
- Infant restless and irritable. - Advise mother to continue breastfeeding more frequently
 Sunken eyes
 Skin pinch goes
- Advise mother how to keep the young infant warm on the
 Look for sunken eyes way to hospital
back slowly
 If infant does not have any other severe classification;
 Pinch the skin of the abdomen. - Give fluid for some dehydration (Plan B)
Does it go back: - Advise mother when to return immediately
- Very slowly (> 2 sec.)? - Follow-up in 2 days
- Slowly?  Not enough signs to NO  Advise mother when to return immediately
classify as some or DEHYDRATION  Follow-up in 5 days if not improving
severe dehydration  Give fluids to treat diarrhoea at home (Plan A)

 Diarrhoea lasting 14 SEVERE  Give first dose of IM Ampicillin and Gentamycin

and if diarrhoea days or more PERSISTENT  Treat to prevent low blood sugar
14 days or more DIARRHOEA  Advise how to keep infant warm on the way to the hospital
 Refer to hospital

* What is diarrhoea in young infant?

If the stools have changed from usual pattern: many and watery  Blood in stool DYSENTERY  Give first dose of IM Ampicillin and Gentamycin
(more water than fecal matter). The frequent and loose stools of and if blood  Treat to prevent low blood sugar
a breastfed baby may be normal and are not always diarrhoea in stool  Advise how to keep infant warm on the way to the hospital
 Refer to hospital

6
CHECK THE YOUNG INFANT FOR HIV EXPOSURE AND INFECTION

SIGN CLASSIFY AS TREATMENT

 Young infant DNA PCR positive  Give Cotrimoxazole Prophylaxis from 6

HIV weeks of age
ASK: Classify
 Assess feeding and counsel
by INFECTED
• What is the HIV status of the mother?  Advise on home care
• Positive Test Result  Refer to ART clinic for immediate ART
• Negative initiation and care
• Unknown  Ensure mother is tested and enrolled for
HIV care and treatment

• What is the HIV status of the young infant?  Mother HIV positive, AND  Give Cotrimoxazole Prophylaxis from 6
Antibody: young infant DNA PCR HIV weeks of age
• Positive negative/unknown EXPOSED  Assess feeding and counsel
 If DNA PCR test is unknown, test as
• Negative
OR soon as possible starting from 6 weeks
• Unknown of age
 Young infant HIV antibody  Refer to ART clinic for follow-up
DNA PCR: positive  Ensure mother is tested & enrolled in HIV
• Positive care and treatment
• Negative  Mother and young infant not HIV  Counsel the mother for HIV testing for
• Unknown tested STATUS herself and the infant
UNKNOWN  Advise on home care of infant
 Assess feeding and counsel
 Mother or young infant HIV HIV  Advise on home care of infant
antibody negative INFECTION  Assess feeding and counsel
UNLIKELY  Advise the mother on HIV prevention

7
CHECK THE YOUNG INFANT FOR FEEDING PROBLEM OR UNDERWEIGHT
SIGN CLASSIFY AS TREATMENT
If any of the following signs:  Advise the mother to breastfeed as often and
Ask Look and Feel: for as long as the infant wants, day and night
 Is there any difficulty of feeding?  Determine weight for age  Not well positioned or
Classify  If not well positioned, attached or not
 Is the infant breastfed? If yes?  Look for ulcers or white patches in the
 Not well attached to suckling effectively, teach correct
How many times in 24 hours? mouth (thrush) FEEDING & positioning and attachment
 Do you empty one breast before switching to UNDER- breast or
the other?  If breastfeeding less than 8 times in 24
 Do you increase frequency of breastfeeding
WEIGHT hours, advise to increase frequency of
 Not suckling effectively FEEDING feeding
during illness? or PROBLEM  Empty one breast completely before
 Does the infant receive any other foods or
drinks? If yes, how often? OR switching to the other
 Less than 8 breastfeeds UNDERWEIGHT  Increase frequency of feeding during and
- Has no indication to refer urgently to hospital, and in 24 hours or after illness
IF AN INFANT - Infant is on breastfeeding
Assess Breastfeeding  Switching the breast  If receiving other foods or drinks, counsel
frequently or mother on exclusive breast feeding.
ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour?  If not breastfeeding at all:
 Not increasing frequency  Counsel on breastfeeding and relactation
of breastfeeding during  If no possibility of breastfeeding:* Advise
- If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. illness or about correct preparation of breast milk
Observe the breastfeeding for 4 minutes. substitutes and using a cup
- If the infant was fed during the last hour, ask the mother if she can wait and tell you when the  Receives other foods or
infant is willing to feed again  If thrush, teach the mother to treat thrush at
drinks or home
• Is the infant well positioned?  Advise mother to give home care for the
 The mother not young infant
To check the positioning, look for:
breastfeeding at all or  Ensure HIV testing in the infant
- Infant’s head and body straight
- Facing her breast  Follow-up any feeding problem or thrush in 2
 Underweight days
- Infant’s body close to her body
 Follow-up for underweight in 14 days
- Supporting the infant’s whole body (all of these signs should be present if the
positioning is good)  Thrush (ulcers or white
patches in mouth)
• Is the infant able to attach?
To check the attachment, look for:  Not UNDERWEIGHT and NO FEEDING  Advise mother to give home care for the
- Chin touching the breast no other signs of PROBLEM AND young infant
FEEDING PROBLEM NOT  Praise the mother for feeding the infant well
- Mouth wide open UNDERWEIGHT
- Lower lip turned outward
- More areola visible above than below the mouth (all of these signs should be *If no possibility of breastfeeding use the chart on page 43, “Check for feeding problem or underweight
present if the attachment is good)
when an HIV positive mother has decided not to breast feed OR no chance of breast feeding by any
reason.”
• Is the infant suckling effectively (that is slow deep sucks, sometimes pausing)?
Not suckling at all Not suckling effectively Suckling effectively
NB. If the young infant has visible severe wasting or edema, use the sick child acute malnutrition
Clear blocked nose if it interferes with breastfeeding
assessment box to classify for Severe Acute Malnutrition.

8
CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT
WHEN AN HIV POSITIVE MOTHER HAS MADE INFORMED DECISION NOT TO BREASTFEED,
OR NO CHANCE OF BREASTFEEDING BY ANY OTHER REASON

SIGNS CLASSIFY AS TREATMENT

If any of the following signs:

 Counsel on optimal replacement
 Milk incorrectly or feeding
Ask Look, Feel: Classify unhygienically prepared
FEEDING & or  Identify concerns of the mother
 Is there any difficulty in feeding?  Determine weight for age UNDER- and the family about feeding. Help
 What milk are you giving?  Look for mouth ulcers or white WEIGHT  Giving inappropriate the mother gradually withdraw
 How many times during the day and patches in the mouth (oral replacement milk or other foods or fluids
night? thrush). other foods/fluids or
 How much is given at each feed?
FEEDING
PROBLEM  If mother is using a bottle, teach
 How are you preparing the milk?  Giving insufficient cup feeding
- Let the mother demonstrate or explain OR
replacement feeds or
how a feed is prepared, and how it is UNDERWEIGHT
 If thrush, teach the mother to treat
given to the infant  Mother mixing breastmilk thrush at home
 Are you giving any breastmilk? and other feeds or
 What foods or fluids in addition to the  Advise mother to give home care
replacement feeding is given?  Using a feeding bottle or for the young infant
 How is the milk being given? Cup or
bottle?  Underweight  Follow-up any feeding problem or
 How are you cleaning the utensils? thrush in 2 days
 Thrush (ulcers or white
patches in mouth)  Follow-up underweight in 14 days

 Not UNDERWEIGHT and NO  Advise mother to give home care

no other signs of FEEDING FEEDING for the young infant
PROBLEM
PROBLEM
 Praise the mother for feeding the
&
infant well
NOT
UNDERWEIGHT

9
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS
IMMUNIZATION SCHEDULE:
AGE VACCINE

Birth BCG OPV- 0*

6 weeks DPT1-HepB1-Hib1 OPV– 1 PCV-1

*Do not Give OPV-0 to an infant who is more than 14 days old.
Keep an interval of at least 4 weeks between OPV-0 and OPV-1.

ASSESS OTHER PROBLEMS

COUNSEL THE MOTHER ABOUT HER OWN HEALTH

CHECK FOR MATERNAL DANGER SIGNS (Only for women presenting within 6 weeks of delivery).
Maternal danger signs:- Refer mother and baby urgently for proper care if any of the following is present:
• Excessive Vaginal bleeding
• Foul smelling Vaginal discharge
• Severe abdominal pain
• Fever
• Excessive tiredness or breathlessness
• Swelling of the hands and face
• Severe headache or blurred vision
• Convulsion or impaired consciousness

10
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

NEWBORN RESUSCITATION
Incorrect Position Incorrect Position Correct Position

Position  Place the baby on his back with the neck

slightly extended.
 Put a towel or cloth behind the shoulder to
facilitate positioning
Clear  Clear the airway by wiping out the mouth with
airway gauze or syringe bulb
 Suction the baby's mouth and nose gently
 Reassess the baby's breathing
Ventilate  Use baby bag and mask to ventilate at 40 Incorrect: Bigger Mask Incorrect: Smaller Mask Correct: Proper Mask
breaths per minute
 Continue to ventilate until the baby breathes
independently
 If the baby remains weak or is having irregular
breathing after 20 minutes of resuscitation;
refer urgently to hospital while continuing to
resuscitate on the way
 Stop after 20 minutes if the baby has not
responded How to ventilate
Monitor  Keep the baby warm (skin-to-skin) How to Ventilate
• Squeeze bag with 2 fingers or whole

 Defer bathing for 24 hours after the baby is Bag & Mask Resuscitation  Squeeze bag withhand,
2 fingers or whole hand, 2-3 times
2-3 times

stable  Observe for rise

• of chest.for rise of chest.
Observe
• IF CHEST IS NOT RISING:
 Breastfeed as soon as possible  IF CHEST IS NOT–RISING:
reposition the head

 Watch for signs of a breathing problem; rapid, • Reposition the –head

check mask seal

• Check mask seal

labored, or noisy breathing, blue color of the • Squeeze bag harder with whole hand
 Squeeze bag harder with whole hand
tongue, trunk • Once good seal and chest rising,
 Once good seal and chestatrising,
ventilate ventilate
40 squeezes at 40
per minute
 If breathing problem occurs, stimulate, give
squeezes per minute
oxygen [if available], and refer • Observe the chest while ventilating:
 Observe the chest–while ventilating:
is it moving with the ventilation?
– is baby breathing spontaneously?
• Is it moving with the ventilation?
ENCC - 8 11
• Is baby breathing spontaneously?

11
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
CARE OF THE LOW BIRTH WEIGHT NEWBORN
Tips to help a mother breastfeed her low birth weight baby
 Express a few drops of milk on the bay’s lip to help the baby start nursing.
 Give the baby short rests during a breastfeed; feeding is hard work for LBW baby.
 If the baby coughs, gags, or spits up when starting to breastfeed, the milk may be letting down too fast for the little
baby. Teach the mother to take the baby off the breast if this happens.
 Hold the baby against her chest until the baby can breathe well again then put it back to the breast after the let-
down of milk has passed.
 If the LBW baby does not have enough energy to suck for long or a strong enough sucking reflex: Teach the
mother to express breastmilk and feed it by a cup.

Expressing breastmilk (can take 20-30 minutes or longer in the beginning)

 Wash hands with soap and water.
 Prepare a cleaned and boiled cup or container with a wide opening.
 Sit comfortably and lean slightly toward the container. Hold the breast in a “C-hold”.
 Gently massage and pat the breast from all directions.
 Press thumb and fingers toward the chest wall, role thumb forward as if taking a thumb print so that milk
is expressed from all areas of the breast.
 Express the milk from one breast for at least 3-4 minutes until the flow slows and shift to the other breast.

TIPS for storing and using stored breastmilk

Fresh breastmilk has the highest quality. If the breastmilk must be saved, advise the mother and family to:
 Use either a glass or hard plastic container with a large opening and a tight lid to store breastmilk.
 Use a container and lid which have been boiled for 10 minutes.
 If the mother is literate, teach her to write the time and date the milk was expressed (or morning, afternoon, Technique for expressing breastmilk and cup
evening) on the container before storing. feeding of young infants
 store the milk in a refrigerator for 24 hours or in a cool place for 8 hours.

Show families how to cup feed

 Hold the baby closely sitting a little upright as shown in the picture.
 Hold a small cup half-filled to the babies lower lip.
 When the baby becomes awake and opens mouth, keep the cup at the baby’s lips letting the baby take the milk.
 Give the baby time to swallow and rest between sips.
 When the baby takes enough and refuses put to the shoulder & burp her/him by rubbing the back.
 Measure baby’s intake over 24 hours rather than at each feeding.

12
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

KEEP THE YOUNG INFANT WARM

Kangaroo Mother Care — KMC
Warm the young infant using skin-to-skin contact for babies below 2,000gm
Provide privacy to the mother. If mother is not available, skin-to-skin contact may be provided by the father or any other adult.
 Council the mother on the importance and how to do KMC
 Check if the mother can correctly provide KMC
 Request the mother to sit or recline comfortably
 Undress the baby gently, except for cap, nappy and socks
 Place the baby prone on mother’s chest in an upright and extended posture, between her breasts, in skin-to-skin contact;
turn baby’s head to one side to keep airways clear. Keep the baby in this position for 24 hrs every day
 Cover the baby with mother’s blouse, ‘or gown; wrap the baby-mother together with an added blanket or “Gabi” .
 Breastfeed the baby every two hours
 Keep the room warm

REASSESS after 1 hour:

 Check for signs of Very Severe Disease and
 Measure axillary temperature by placing the thermometer in the axilla for 5 minutes (or feel for low body temperature).
 If any signs of Very Severe Disease OR temperature still below 36.5°C (or feels cold to touch),
 Refer URGENTLY to hospital after giving pre-referral treatments for Very Severe Disease.
 If no sign of Very Severe Disease AND temperature 36.5°C or more (or is not cold to touch):
- Advise how to keep the infant warm at home
- Advise mother to give home care
- Advise mother when to return immediately
 If skin-to-skin contact is not possible:
- Clothe the baby in 3-4 layers, cover head with a cap and body with a blanket ; hold baby close to caregiver’s body, OR
- Place the baby under overhead radiant warmer, if available.

Keep the young infant warm on the way to the hospital

 By skin-to-skin contact, OR
 Clothe the baby in 3-4 layers, cover head with a cap and body with a blanket or Gabi;
hold baby close to caregiver’s body.

13
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER  To Treat Diarrhoea,
 Give an Appropriate Oral Antibiotic - AMOXYCILLIN See TREAT THE CHILD Chart
• For local bacterial infection:

AMOXYCILLIN
 Immunize Every Sick Young Infant,
AGE or WEIGHT
Give three times daily for 5 days
TABLET SYRUP
as Needed
250 mg 125 mg in 5 ml
Birth up to 1 month (< 3 kg) 1.25 ml
1 month up to 2 months (3-4 kg) ¼ 2.5 ml  Teach the Mother to Treat Local
Infections at Home
 Give First Dose of Intramuscular Antibiotics- Ampicillin & Gentamycin  Explain how the treatment is given.
• For Very Severe Disease  Watch her as she does the first treatment in the clinic.
• Give first dose of Ampicillin and Gentamycin intramuscular  Tell her to do the treatment twice daily. She should return to
the clinic if the infection worsens.
To Treat Skin Pustules or Umbilical Infection
The mother should
• Wash hands
• Gently wash off pus and crusts with soap and water
• Dry the area
• Paint with Gentian Violet (0.5%) twice daily
• Wash hands

To Treat Thrush (ulcers or white patches in mouth)

The mother should:
• Wash hands
• Wash mouth with clean soft cloth wrapped around
the finger and wet with salt water
• Instill Nystatin 1ml 4 times a day or
• Paint the mouth with half-strength (0.25%) GV
* Avoid using undiluted 40mg/ml Gentamycin. The dose is ¼ of that listed twice daily for 7 days.
• Referral is the best option for a young infant classified with VERY SEVERE DISEASE. • Avoid feeding for 20 minutes after medication
• If referral is not possible, give Benzyl Penicillin/Ampicillin and Gentamycin for at least 7 days. Give Benzyl Penicillin/ • Wash hands
Ampicillin every 12 hours

14
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
 Teach correct positioning and attachment for breastfeeding
 Show the mother how to hold/position her infant
- with the infant’s head and body straight
- facing her breast, with infant’s nose opposite her nipple
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and shoulders.
 Show her how to help the infant to attach. She should:
- touch her infant’s lips with her nipple
- wait until her infant’s mouth is opening wide
- move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.
 Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.
 Advise the mother to empty one breast before switching to the other so that the infant gets the nutrient-rich hind milk

 Advise mother to give home care for the young infant

1. Food & Fluids - Breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and health. More frequently during sickness
2. Keep the young infant warm at all times - In cool weather, cover the infant’s head and feet and dress the infant with extra clothing
3. When to Return - advise mother to bring the young infant for follow up visit or immediately according to the tables below

When to Return Immediately:

Follow up visits
If the infant has: Return in: Return immediately if the young infant has any of these signs:
• LBW/PRETERM • Breastfeeding or drinking poorly
• LOCAL BACTERIAL INFECTION 2 days • Vomiting after each feeding
• LOW BODY TEMPERATURE • Convulsion
• JAUNDICE • Reduced activity
• SOME DEHYDRATION • Fast or difficult breathing
• FEEDING PROBLEM • Develops a fever or feels cold to touch
• THRUSH • Blood in stool
• UNDERWEIGHT 14 days • Becomes sicker

NB: All newborns should be seen on day 1, 3, 7 and 6 weeks.

15
FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

 LOW BIRTH WEIGHT/PRETERM,  LOCAL BACTERIAL INFECTION

LOW BODY TEMPERATURE
After 2 days:
After 2 days • Ask for new problems, if there is any do a full assessment.
Weekly follow-up for low birth weight • Look at the umbilicus. Is it red or draining pus? Does redness extend to the
skin?
• Check for danger signs in the newborn • Look at the skin pustules. Are there many or severe pustules?
• Counsel and support optimal breastfeeding
• Follow-up of kangaroo mother care Treatment:
• Follow-up of counseling given during previous visits  If pus or redness remains or is worse, refer to hospital.
• Counsel mother/ family to protect baby from infection  If pus and redness are improved, tell the mother to continue giving the 5
• Give one capsule of 200,000IU Vitamin A to the mother if not given days of antibiotic and continue treating the local infection at home.
before
• Immunize baby with OPV & BCG if not given before

 JAUNDICE  DIARRHOEA (Some Dehydration)

After 2 days:
• Ask for new problems, if there is any do a full assessment.
After 2 days:
• Look for jaundice - Are the palms and soles yellow?
Ask for new problem, if there is any do a full assessment.
Ask if the diarrhoea has stopped?
Treatment:
 If the palms and soles are yellow or age ≥14 days. refer to hospital Treatment:
 If palms and soles are not yellow and age ≤14 days, and jaundice has not  If diarrhoea persists, Assess the young infant for diarrhoea and manage
decreased; advise on home care, when to return immediately and ask her as per initial visit (see Assess the Young Infant for Diarrhoea chart) .
to return for f/up in 2 days.  If diarrhoea stopped-reinforce exclusive breastfeeding.
 If jaundice has started decreasing, reassure mother and ask her to
continue home care. Ask her to return for f/up at 2 weeks of age. If
jaundice continues beyond 2 weeks of age, refer to hospital.

16
FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

 FEEDING PROBLEM  THRUSH

After 2 days: After 2 days
• Ask for new problems, if there is any do a full assessment. • Ask for new problems, if there is any do a full assessment.
• Reassess feeding. See “ Check for Feeding Problem or Underweight” chart. • Look for ulcers or white patches in the mouth (thrush).
• Ask about any feeding problems found on the initial visit. • Reassess feeding. See “Check for feeding problem or
underweight” above.
Treatment:
 Counsel the mother about any new or continuing feeding problem. If you counsel the mother Treatment:
to make significant changes in feeding, ask her to bring the young infant back again.  If thrush is worse, or the infant has problems with attachment or
 If the young infant is underweight for age, ask the mother to return in 14 days after the initial suckling, refer to hospital.
visit to measure the young infant’s weight gain.  If thrush is the same or better, and if the infant is feeding
well, continue Nystatin or half-strength gentian violet (0.25%)
Exception: for a total of 7 days.
• If you think that feeding will not improve, or if the young infant has lost weight, refer the
child.

 UNDERWEIGHT IN YOUNG INFANT

After 14 days:
• Ask for new problems, if there is any do a full assessment.
• Weigh the young infant and determine if the infant is still underweight.
• Reassess feeding. See “Check for Feeding Problem or underweight.” above.

Treatment:
 If the infant is no longer underweight, praise the mother and encourage her to continue.
 If the infant is still underweight, but is feeding well; praise the mother. Ask her to have her infant weighed again within a month or when she returns for immunization.
 If the infant is still underweight and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she
returns for immunization, if this is within 2 weeks). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly or is no longer
underweight.

Exception:
If you think that feeding will not improve, or if the young infant has lost weight, refer to hospital.

17
FOLLOW-UP CARE FOR THE SICK YOUNG INFANT
Routine Postnatal Follow Up Care
6 –24 hours evaluation/visit 3 & 7 days’ visit 6 weeks visit
• Measure and record weight & temperature • Measure temperature; & weight (if no birth weight record)
• Check for any newborn danger signs listed below • Check for any newborn danger signs listed below • Check for danger signs in the newborn and
• Check for any danger signs in the mother (see page 10) • Check for any danger signs in the mother (see page 10) mother
• Check for Feeding Problem or Underweight
• Refer newborn & mother to hospital if any danger sign in the • Refer newborn & mother to hospital if any danger sign in the
(see ASSESS & CLASSIFY Chart)
newborn or mother newborn or mother
• Classify by birth weight/GA (see Assess & Classify Chart) & • Classify by birth weight/GA (see Assess & Classify Chart) & • Refer newborn & mother to hospital if any dan-
counsel on extra care for the Low Birth Weight baby (pg.12& 13) counsel on extra care for the Low Birth Weight baby (pg.12& ger sign in the newborn or mother
13) • Give appropriate counseling based on the as-
• Give Vitamin K, OPV-0 & BCG if not given • Give OPV-0 & BCG if not given before sessment for Feeding Problem or Underweight
• Counsel mother on optimal breastfeeding, & teach ALL mothers • Counsel mother on optimal breastfeeding, & teach ALL • Give DPT1- HepB1-Hib1, OPV-1, PCV-1; &
on proper positioning & attachment for breast feeding mothers on proper positioning & attachment for breast BCG (if not given before)
• Counsel mother to keep the baby warm (delay bath after first 24 feeding • Follow-up advices given during previous visits
hrs, skin-to-skin care, proper wrapping & put a hat) • Counsel mother to keep the baby warm (delay bath after first • Counsel mother to protect baby from infection &
• Counsel on hygiene and good skin, eye and cord care 24 hrs, skin-to-skin care, proper wrapping & put a hat) to continue immunization schedule
• Teach mother to identify neonatal danger signs & to seek care • Counsel on hygiene and good skin, eye and cord care • Counsel mother on the need of family planning
immediately • Teach mother to identify neonatal danger signs & to seek & eating 2 more extra meals
care immediately • Give 200,000IU Vitamin A to the mother if not
• Counsel the lactating mother to take at least 2 more variety given before
meals than usual • Counsel the lactating mother to take at least 2 more variety
meals than usual • Advise mother & baby to sleep under ITN (in
• Give one capsule of 200,000 Vitamin A to the mother malarious areas)
• Advise on importance of postnatal visits on days 3 & 7 • Give one capsule of 200,000 Vitamin A to the mother if not
given before
• Advise mother to return for next PNC follow up visit

Newborn danger signs

• Unable to feed or sucking poorly • Fever (hot to touch or axillary temperature ≥ 37.5°C)
• Repeated Vomiting • Hypothermia (cold to touch or axillary temperature <35.5°C)
• Convulsions • Severe jaundice (observed at <24 hrs or ≥ 14 days of age, or involving soles & palms)
• Movement only when stimulated or no movement, even when stimulated • Pallor or bleeding from any site
• Gasping or breathing < 30 per minute • Red swollen eyelids and pus discharge from the eyes
• Cyanosis (Blue tongue & lips) • Very small baby (<1500 grams or <32 weeks gestational age)
• Fast breathing (>60/minute, counted 2 times), grunting or severe chest indrawing • Any other serious newborn problem

18
 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UPTO 5 YEARS
ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE
- Determine if this is an initial or follow-up visit for this problem.
- If follow-up visit, use the instructions on ‘GIVE FOLLOW UP CARE” chart. - If initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

ASK LOOK
• Is the child able to drink or breastfeed? • See if the child is lethargic or unconscious
• Does the child vomit everything? • See if the child is convulsing now
• Has the child had convulsions?
If the child is convulsing now, manage the airways and treat the child with Diazepam.
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so that referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing? SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)
IF YES, LOOK, LISTEN, FEEL:  Any general danger SEVERE  Give first dose of IV/IM Ampicillin or
Classify sign or PNEUMONIA Chloramphenicol *
ASK: COUGH or  Chest indrawing or OR VERY
CHILD DIFFICULT
• For how • Count the breaths in one minute  Stridor in calm child SEVERE DISEASE  Refer URGENTLY to hospital**
MUST BREATHING
long? • Look for chest indrawing BE
• Look and listen for stridor CALM
 Give Cotrimoxazole*** for 5 days
 Fast breathing PNEUMONIA  Soothe the throat and relieve the cough
with a safe remedy
If the child is: Fast breathing is:  Advise mother when to return
2 months up to 12 ≥50 breaths per minute immediately
 Follow-up in 2 days
12 months up to 5 years No signs of: NO  If coughing for ≥ 14 days, refer for
PNEUMONIA assessment
* Give oral Amoxycillin , if IV/IM Ampicillin/Chloramphenicol is not available.
** If referral is not possible manage the child as described on page 51– 63 “Where Referral  Very Severe Disease COUGH  Soothe the throat and relieve the cough
is Not Possible”, or Pediatric Hospital Care in Ethiopia. OR COLD with a safe remedy
.***Use Amoxicillin as first line drug for pneumonia if the child has been on Cotrimoxazole AND  Advise mother when to return
Prophylaxis for PCP. immediately.
NB: If the child has wheezes, treat the child as per the ‘Treat Wheezes” guide on page 54.  Pneumonia  Follow-up in 5 days if not improving

19
Does the child have Diarrhoea? SIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatments are in bold print)
Two of the following signs: If child has no other severe classification:
 Lethargic or SEVERE - Give fluid for severe dehydration (Plan C).
For unconscious OR
IF YES, ASK LOOK AND FEEL: Dehydration  Sunken eyes
DEHYDRATION
If child also has another severe classification:
 Not able to drink or  Refer URGENTLY to hospital with mother giving
• For how long? • Look at the child’s general drinking poorly frequent sips of ORS on the way. Advise the
condition  Skin pinch goes back mother to continue breastfeeding.
very slowly  If child is 2 years or older, and there is cholera in
• Is there blood in Is the child:
your area, give antibiotic for cholera
the stool? - Lethargic or unconscious?
Classify Two of the following signs:  Give fluid, Zinc supplements and food for some
- Restless and irritable?  Restless, irritable dehydration (Plan B)
DIARRHOEA SOME If child also has a severe classification:
 Sunken eyes
• Look for sunken eyes.  Drinks eagerly, thirsty DEHYDRATION - Refer URGENTLY to hospital with mother giving
 Skin pinch goes back frequent sips of ORS on the way.
• Offer the child fluid. Is the child: slowly Advise the mother to continue breastfeeding.
- Not able to drink or drinking  Advise mother when to return immediately.
poorly?  Follow-up in 5 days if not improving
- Drinking eagerly, thirsty?  Not enough signs to  Give fluid, Zinc supplements and food to treat
classify as some or NO diarrhoea at home (Plan A)
• Pinch the skin of the abdomen. severe dehydration DEHYDRATION  Advise mother when to return immediately.
 Follow-up in 5 days if not improving.
Does it go back:
- Very slowly (≥ 2 seconds)?
- Slowly? and if
 Dehydration present SEVERE  Treat dehydration before referral unless the child
diarrhoea has another severe classification.
PERSISTENT
14 days or  Give Vitamin A
DIARRHOEA
more  Refer to hospital
 No dehydration  Advise the mother on feeding recommendation for a
PERSISTENT child who has PERSISTENT DIARRHOEA
DIARRHOEA  Give Vitamin A, therapeutic dose
 Advise mother when to return immediately
 Follow-up in 5 days.

and if
 Blood in the stool  Treat for 5 days with Cotrimoxazole
blood
DYSENTERY  Advise mother when to return immediately
in stool  Follow-up in 2 days.

20
Does the Child Have Fever? (by history, or feels hot or temp. of ≥37.5°C )*
SIGNS CLASSIFY TREATMENT
IF YES: Do blood film or RDT, If (Urgent pre-referral treatments are in bold print)
• Decide Malaria Risk: High, Low or No. malaria risk is High, or Low  Any general danger sign, VERY  Give first dose Artesunate or Quinine for severe malaria
If “low or no” malaria risk, then ask: or history of travel to a OR SEVERE  Give first dose of IV/IM Chloramphenicol/Ampicillin
• Has the child traveled outside this area malarious area, AND there High FEBRILE  Treat the child to prevent low blood sugar
 Stiff neck, OR
during the previous 30 days? is no sign of Very Severe Malaria DISEASE  Give Paracetamol in health facility for high fever (≥38.5°C)
 Bulging fontanels (< 1yr)
• If yes has he been to a malarious area? Febrile Disease. Risk  Refer URGENTLY to hospital
 Positive blood film/RDT,  Treat with Coartem for P. falcip. or mixed or no confirmatory test done.
THEN ASK: LOOK AND FEEL: OR MALARIA  Treat with Chloroquine for confirmed P. vivax
 For how long has the child  Look or feel for stiff neck.  If blood film/RDT not  Give Paracetamol in health facility for high fever (38.5°C or above)
had fever?  Look or feel for bulging fontanels available, any fever  Advise mother when to return immediately.
 If more than 7 days, has fever (< 1 year of age) (by history, or feels hot, or  Follow-up in 2 days if fever persists.
been present every day?  Look for runny nose. Classify temp ≥ 37.5ºC )  If fever is present every day for more than 7 days, refer for assessment
 Has the child had measles  Look for signs of MEASLES FEVER  RDT negative, OR  Give one dose of Paracetamol in health facility for high fever (≥38.5°C)
within the last 3 months? - Generalized rash, AND one of these:  Blood film negative FEVER:  Treat other obvious causes of fever
cough, runny nose or red eyes. MALARIA  Advise mother when to return immediately
UNLIKELY  Follow-up in 2 days if fever persists.
 Look for mouth ulcers:
If the child has measles now OR - Are they deep or extensive?  If fever is present every day for more than 7 days, refer for assessment.
within the last 3 months - Are they not deep or extensive?
 Look for pus draining from the eye.  Any general danger sign, OR VERY Give first dose Artesunate or Quinine for severe malaria
 Look for clouding of the cornea.  Stiff neck, OR SEVERE Give first dose of IV/IM Chloramphenicol/Ampicillin
 Bulging fontanels FEBRILE Treat the child to prevent low blood sugar
(< 1 year of age) DISEASE Give Paracetamol in health facility for high fever (≥38.5°C)
IF MEASLES now or
Refer URGENTLY to hospital
within the last 3 months, Classify
 Positive blood film/RDT, OR  Treat with Coartem for P. fa. or mixed or no confirmatory test done.
Low MALARIA  Treat with Chloroquine for confirmed P. vivax
 If blood film/RDT not
 Give Vitamin A, first dose
Malaria available,  Give Paracetamol in health facility for high fever (38.5°C or above)
 Any general danger
sign, OR SEVERE  Give first dose of IV/IM Chloramphenicol or Risk - No runny nose AND  Advise mother when to return immediately
 Clouding of cornea, or COMPLICATED Ampicillin - No measles AND  Follow-up in 2 days if fever persists
 Deep or extensive MEASLES ***  If clouding of the cornea or pus draining - No other cause of fever **  If fever is present every day for more than 7 days, refer for assessment
mouth ulcers from the eye, apply Tetracycline eye  Negative blood film/RDT, OR  Give one dose of Paracetamol in health facility for high fever (≥38.5°C)
ointment  If blood film/RDT not available FEVER:  Treat other obvious causes of fever
 Refer URGENTLY to hospital - Runny nose PRESENT or MALARIA  Advise mother when to return immediately
 Pus draining from the MEASLES  Give Vitamin A, therapeutic dose - Measles PRESENT or UNLIKELY  Follow-up in 2 days if fever persists
eye or WITH  If pus draining from the eye, treat eye - Other cause of fever **  If fever is present every day for more than 7 days, refer for assessment
 Mouth ulcers (not EYE OR MOUTH infection with Tetracycline eye ointment PRESENT
deep or extensive) COMPLICATIONS  If mouth ulcers, treat with gentian violet
***  Advise mother when to return immediately
 Any general danger sign, OR VERY  Give first dose of IV/IM Chloramphenicol/Ampicillin.
 Follow–up in 2 days SEVERE  Treat the child to prevent low blood sugar.
MEASLES
 Stiff neck, OR
 Measles now or within  Give Vitamin A, therapeutic dose FEBRILE  Give Paracetamol in health facility for high fever (≥38.5°C)
the last 3 months  Advise mother when to return immediately No  Bulging fontanels (< 1yr)
DISEASE  Refer URGENTLY to hospital
Malaria
* These temperatures are based on axillary temperature . Rectal temperature readings are approximately  Any fever  Give one dose of Paracetamol in health facility for high fever (≥38.5°C)
0.5oC higher. Risk
FEVER:  Treat other obvious causes of fever
** Includes cellulitis or abscess (red hot tender skin or swelling), bone or joint infections (local tenderness, NO  Advise mother when to return immediately
refusal to use a limb) and UTI (lower abdominal pain or pain on passing urine). MALARIA  Follow-up in 2 days if fever persists
*** Other important complications of measles – pneumonia, stridor, diarrhoea, ear infection, and  If fever is present every day for more than 7 days refer for assessment
malnutrition – are classified in other tables.
21
Does the Child Have an Ear Problem?

SIGNS CLASSIFY AS TREATMENT

IF YES, ASK: LOOK, AND FEEL: (Urgent pre-referral treatments are in bold print)
Classify
EAR • Tender swelling behind the ear MASTOIDITIS  Give first dose of Chloramphenicol/Ampicillin
• Is there ear pain? • Look for pus IV/IM
PROBLEM
draining from  Give first dose of Paracetamol for pain
• Is there ear discharge? the ear  Refer URGENTLY to hospital
If yes, for how long?
• Feel for tender  Ear pain,  Give Cotrimoxazole for 5 days
swelling behind the OR ACUTE EAR  Give Paracetamol for pain
ear  Pus is seen draining from the INFECTION  Dry the ear by wicking
ear and discharge is  Follow-up in 5 days
reported for less than 14
days
 Pus is seen draining from the  Dry the ear by wicking
ear and discharge is CHRONIC  Treat with topical Quinolone eardrops for 2
reported for 14 days or more EAR weeks
INFECTION  Follow-up in 5 days

 No ear pain and  No additional treatment

 No pus seen draining from NO EAR
the ear INFECTION

22
CHECK FOR ANAEMIA

SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold print)
LOOK • Severe palmar pallor SEVERE  Refer URGENTLY to hospital
Classify ANAEMIA
ANAEMIA
• Look for palmar pallor, is it; • Some palmar pallor  Assess the child’s feeding and counsel the mother on
ANAEMIA feeding according to the FOOD box on the COUNSEL THE
• Severe palmar pallor? MOTHER chart.
 Give Iron
• Some palmar pallor?  Do blood film or RDT for malaria, if malaria risk is High or
• No palmar pallor? has travel history to malarious area in last 30 days.
 Give Mebendazole or Albendazole, if the child is ≥ 2 years
old and has not had a dose in the previous six months
 Advise mother when to return immediately
 Follow-up in 14 days

• No palmar pallor NO  No additional treatment

ANAEMIA

23
CHECK FOR ACUTE MALNUTRTION, IN INFANTS < 6 MONTHS

SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold print)
If child is less than six months Classify
for • Pitting edema of both feet, OR  Give 1st dose of Ampicillin and Gentamycin IM
Acute • Visible severe wasting, OR COMPLICATED  Treat the child to prevent low blood sugar
LOOK AND FEEL:
Malnutrition • WFL < -3Z, or SEVERE  Advise mother on the need of referral
• Look for pitting edema of both feet ACUTE
WFL <70% of median  Refer Urgently to Hospital
MALNUTRITION
• Look for visible severe wasting
• Measure length and determine • No pitting edema of both feet, AND  Assess feeding and advise the mother on feeding
• No visible severe wasting, AND MODERATE  Follow up in 5days if feeding problem
Weight For Length (WFL) ACUTE
• WFL ≥ -3Z to < -2Z, or  Follow up in 30 days
WFL ≥ 70% to <80% of median MALNUTRITION

• No pitting edema of both feet, AND  Assess feeding and advise the mother on feeding
• No visible severe wasting, AND NO  If feeding problem—follow up in 5days
• WFL ≥ -2Z, or ACUTE  If no feeding problem—praise the mother
WFL ≥ 80% of median MALNUTRITION

24
CHECK FOR ACUTE MALNUTRTION, IN CHILDREN 6 - 59 MONTHS

SIGNS CLASSIFY AS TREATMENT

(Urgent pre-referral treatments are in bold print)
• Pitting edema of both feet, or  Give 1st dose of Ampicillin and Gentamycin IM
For children aged 6 months up to 5 years:
LOOK AND FEEL: WFH <-3 Z or WFH <70%, or COMPLICATED  Treat the child to prevent low blood sugar
Classify MUAC <11cm; AND Any of the SEVERE  Advise the mother to feed and keep the child warm
• Look for pitting edema of both feet
• Measure length or height and determine for following: ACUTE  Advise mother on the need of referral
- WFH Z-score (< -3, -3 to -2, ≥ -2), or Acute • Any general danger sign, MALNUTRITION  Refer Urgently to Hospital or admit to inpatient care
- WFH percent of median (<70%, 70% to 80%, ≥ 80%) Malnutrition • Any medical complication
• Measure MUAC (<11cm, 11 to 12cm, ≥ 12cm) • +++ Dermatosis
• Failed appetite test
If child has edema, or WFH <-3 Z-score [<70%] or MUAC <11cm; OR
- NOTE for medical complications, and • +++ Edema,OR
- LOOK & CHECK for degree of edema and dermatosis: • Marasmic kwashiorkor
- DO APPETITE TEST as per the criteria below (Edema of both feet with WFH< -3 Z, or with
Note: WFH<70% or with MUAC<11cm)
• Any General Danger Sign • Pitting edema of both feet (+, ++),  If Outpatient Treatment Program (OTP) is available,
• Any severe classification or WFH <-3 Z or WFH <70%, UNCOMPLICATED manage as follows:
• Pneumonia or MUAC <11cm; SEVERE • Give RUTF for 7 days,
• Dehydration* ACUTE • Give oral amoxicillin for 7 days
• Persistent diarrhea AND MALNUTRITION • Give single dose of 5mg folic acid for those with anemia
• Dysentery • No general danger sign, and • Counsel on how to feed RUTF to the child
• Fever ≥ 38.5ºC • No medical complication, and • Advise the mother when to return immediately
• Measles [now or with eye/mouth complications] • Passed appetite test. • Follow-up in 7 days
• Low body temperature (<35ºC axillary)
If OTP is not available, refer to a facility with OTP service
Look and Check:
• Edema ** (+, ++, +++) • No pitting edema of both feet,  Refer to Supplementary Feeding Program if available
• Dermatosis*** (+, ++, +++) AND MODERATE  Asses for feeding and counsel the mother accordingly
• WFH ≥ –3 Z to < -2 Z, or ACUTE  If feeding problem, follow up in 5 days
Do Appetite test (Passed, Failed) WFH 70% to < 80%, or MALNUTRITION  Follow up in 30 days
• Appetite test should be done ONLY when there is: MUAC 11 to < 12cm
• NO medical complication, and
• NO +++ edema, and • No pitting edema of both feet,  Assess feeding and advise the mother on feeding
• NO +++ dermatosis, and AND NO  If feeding problem—follow up in 5days
• NO marasmic kwashiorkor **** • WFH ≥ -2 Z,or ACUTE  If no feeding problem—praise the mother
WFH ≥ 80%, or MALNUTRITION
MUAC ≥ 12cm

* Dehydration in SAM is watery diarrhea with recent sunken eye balls.

** Edema grading: bilateral edema below ankles (+); below the knees & the elbows (++); generalized edema involving the upper arms & face (+++).
*** Dermatosis grading: few discolored or rough patches of skin (+); multiple patches on arms and/or legs (++); flaking skin, raw skin or fissures (openings in the skin) is grade +++ dermatosis.
**** Child with WFH <-3 Z (WFH <70%) plus edema, or with MUAC<11cm plus edema.

25
CHECK FOR HIV EXPOSURE AND INFECTION, IN CHILDREN 2 - < 18 MONTHS

SIGN CLASSIFY TREATMENT

ASK: Classify
for
• What is the HIV status of the mother?
HIV • Child DNA PCR positive  Give Cotrimoxazole prophylaxis
• Positive Infection
• Negative HIV  Assess feeding and counsel
• Unknown INFECTED  Advise on home care
• What is the HIV antibody test result  Refer to ART clinic for ART initiation/care &
of the sick child? treatment
• Positive  Ensure mother is tested & enrolled in HIV care &
• Negative treatment
• Unknown • Mother positive, and  Give Cotrimoxazole prophylaxis
• What is the DNA/PCR test result of child Antibody or DNA/PCR negative, Assess feeding and counsel
the sick child? *
HIV 
and breast feeding, EXPOSED  If child DNA/PCR is unknown, test as soon as
• Positive
• Negative
OR possible.
• Unknown • Mother positive, and  Refer to ART clinic for follow up
• Is child on breast feeding? child Antibody & DNA/PCR unknown,  Ensure mother is tested & enrolled in HIV care &
• Yes OR treatment
• No • Child Antibody positive
• If no, was child breastfed in the last
6 weeks? • Mother and child not tested HIV  Counsel the mother for HIV testing for herself & the
• Yes STATUS child
• No UNKNOWN  Advise the mother to give home care
 Assess feeding and counsel
• Mother negative, HIV  Advise on home care
OR INFECTION  Assess feeding and counsel
Note:
• Mother positive, and UNLIKELY  Advise on HIV prevention
- If DNA PCR isn’t available, AND child antibody is positive, child DNA PCR negative, and  Encourage mother to be tested
AND two of the following are present (Oral thrush, Severe not breastfeeding,  If mother HIV status is unknown, advise her on HIV
pneumonia or Very Severe Disease); Consider this child to OR testing
have “PRESUMPTIVE SEVERE HIV DISEASE”. • Mother HIV status unknown, and
And this child should be referred and treated as “HIV IN- Child antibody negative
FECTED” child.

26
CHECK FOR HIV EXPOSURE AND INFECTION, IN CHILDREN 18 - 59 MONTHS

SIGN CLASSIFY TREATMENT

ASK: Classify • Child antibody positive  Give Cotrimoxazole prophylaxis

• What is the HIV status of the for HIV  Assess feeding and counsel
HIV  Advise on home care
mother? Infection INFECTED
• Positive  Refer to ART clinic for HIV care & treatment
• Negative  Ensure mother is tested & enrolled in HIV care &
• Unknown treatment
• Mother positive,  Give Cotrimoxazole prophylaxis
• What is the HIV antibody test AND Assess feeding and counsel
HIV 
result of the sick child? • Child antibody negative or  If child antibody test is unknown, test as soon as
• Positive EXPOSED
unknown, and possible.
• Negative breast feeding  If child antibody test is negative, repeat 6 wks after
• Unknown complete cessation of breast feeding
 Refer to ART clinic for follow up
• Is child on breast feeding?  Ensure mother is enrolled in HIV care & treatment
• Yes
• No • Mother and child not tested HIV  Counsel the mother for HIV testing for herself and
STATUS the child
• If no, was child breastfed in UNKNOWN  Advise the mother to give home care
the last 6 weeks?  Assess feeding and counsel
• Yes • Mother negative HIV  Advise on home care
• No INFECTION  Assess feeding and counsel
UNLIKELY  Advise on HIV prevention
 If possible, do HIV antibody test for the child
• Child antibody negative at least HIV  Advise on home care
6 weeks after complete UNINFECTED  Assess feeding and counsel
cessation of breastfeeding  Advise on HIV prevention

27
CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A STATUS

AGE VACCINE VITAMIN A SUPPLEMENTATION

If 6 months or older
Birth BCG OPV - 0  Check if child has received a dose of Vitamin A during the previous 6
months. If not, give Vitamin A supplementation every 6 months up to the
IMMUNIZATION 6 weeks DPT1-HepB1-Hib1, OPV - 1 age of 5 years.
SCHEDULE: PCV-1  Record the dose on the child’s card.
10 weeks DPT2-HepB2-Hib2, OPV - 2
PCV-2 ROUTINE WORM TREATMENT
If 2 years or older
14 weeks DPT3-HepB3-Hib3, OPV - 3  Check if child has received Mebendazole or Albendazole during the
PCV-3 previous 6 months. If not, give child Mebendazole or Albendazole every 6
months.
9 months Measles Vitamin A  Record the dose on the child’s card.
(if not given with in last 6 months)

ASSESS OTHER PROBLEMS COUNSEL THE MOTHER ABOUT HER OWN HEALTH

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after 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.

28
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
INSTRUCTIONS TO TEACH THE MOTHER
Give an Appropriate Oral Antibiotic
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug’s dosage table.  FOR DYSENTERY:
Give antibiotic recommended for Shigella in your area for 3 - 5 days.
 Determine the appropriate drugs and dosage for the child’s age or weight. First-Line Antibiotic: COTRIMOXAZOLE Second-Line Antibiotic: CIPROFLOXACIN
 Tell the mother the reason for giving the drug to the child. COTRIMOXAZOLE CIPROFOXACIN
 Demonstrate how to measure a dose. AGE Give two times daily for 5 days Give two times daily for 3 days
or
 Watch the mother practice measuring a dose by herself. WEIGHT
TABLET
250 mg
 Ask the mother to give the first dose to her child. See doses above
 Explain carefully how to give the drug, then label and package the drug.
2 months up to 4 months (4-6 kg)
(on pneumonia, acute ear infection
¼
 If more than one drug will be given, collect, count and package each drug
4 months up to 12 months (6-10kg) table) ½
12 months up to 5 years (10-19kg) 1
separately.
 Explain that all the oral drug tablets or syrups must be used to finish the
course of treatment, even if the child gets better.  FOR CHOLERA:
Give antibiotic recommended for Cholera in your area for 3 days.
 Check the mother’s understanding before she leaves the health facility. First-Line Antibiotic: TETRACYCLINE Second-Line Antibiotic: COTRIMOXAZOLE

TETRACYCLINE COTRIMOXAZOLE
Give four times daily for 3 days Give two times daily for 3 days
AGE or WEIGHT
TABLET 250 mg
Give an Appropriate Oral Antibiotic 2 months up to 4 months (4-6 kg) See doses above

 FOR PNEUMONIA, ACUTE EAR INFECTION OR VERY SEVERE DISEASE * : 4 months up to 12 months (6-10kg) ½
First-Line Antibiotic: COTRIMOXAZOLE ** Second-Line Antibiotic: AMOXYCILLIN 12 months up to 5 years (10-19kg) 1
COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) AMOXYCILLIN
Give two times daily for 5 days Give 3 times daily for 5 days
FOR SEVERE ACUTE MALNUTRITION :
ADULT TABLET PEDIATRIC TABLET SYRUP TABLET SYRUP Give Amoxycillin for 7days
80 mg Trimethoprim 20 mg Trimethoprim 40 mg Trimethoprim 250 mg 125mg
+ + + 200 mg Per First-Line Antibiotic: AMOXYCILLIN
AGE or WEIGHT 400 mg 100 mg Sulphamethoxazole 5 ml AMOXYCILLIN
Sulphamethoxazole Sulphamethoxazole per 5 ml WEIGHT Give 2 times daily for 7 days
SYRUP TABLET TABLET or CAPSULE
2 up to 12 months ½ 2 5.0 ml ½ 5 ml 125mg per 5 ml 250mg 500mg
(4-10 kg)
12 months up to 5 1 3 7.5 ml 1 10 ml
< 5 kg 5 ml ½
years (10-19 kg) 5-10 Kg 10 ml 1
10-20 kg 20 ml 2 1
* For Severe Pneumonia or Very Severe Disease, use oral Amoxycillin for pre referral treatment, if IV/IM Ampicillin/
Chloramphenicol is not available.
20-35 kg 2½ 1½
** Use Amoxicillin as first line drug for pneumonia if the child has been on Cotrimoxazole Prophylaxis for PCP. >35 kg 2

29
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Give an Oral Antimalarial
• First line for P. falciparum and Mixed infections (falciparum + vivax malaria) - COARTEM
• First line for P. falciparum and Mixed infections in infants <5kg body weight - QUININE
• First line for P. vivax - CHLOROQUINE
• Second line antimalarial: QUININE

Artemether-Lumefantrine (COARTEM) Chloroquine

Tablet containing 20 mg Artemether and 120 mg Lumefantrine. • Tablet 150mg base (250mg Salt)
• Syrup 50mg base in 5ml (80mg Salt per 5ml)
Weight Age Number of tablets per dose • A total dose of 25mg base per kg over 3 days (10mg base per kg on day 1 and 2 and,
(kg) twice daily for 3 days 5mg base per kg on day 3).
5-15 3 months—2 years 1
Weight Age Day 1 Day 2 Day 3
15-25 3-7 years 2 (kg) (month or year)
5–7 <4 month
25-35 7 - 10 years 3 Tablet 1/4 1/4 1/4
Syrup 5 ml 5 ml 2.5 ml
35+ 10 + years 4 7 – 11 4-11 month
Tablet 1/2 1/2 1/2
Syrup 7.5 ml 7.5 ml 5 ml
11 – 15 1-<3 year
Quinine: Tablet 1 1 1/2
8 mg base/kg, 3 times daily for 7 days Syrup 12.5 ml 12.5 ml 7.5 ml
15 – 19 3-<5 year
Weight Oral tablets, dosage Tablet 1 1 1
Age Syrup 15 ml 15 ml 15 ml
(kg)
200 mg salt 300 mg salt 19 – 25 5-<8 year
Tablet 1 1/2 1 1/2 1
4-6 2 - 4 months ¼ Syrup 20 ml 20 ml 15 ml
25 – 36 8-<11 year
6-10 4 -12 months 1 /3 ¼ Tablet 2½ 2½ 1
36 – 50 11-<14 year
10-12 1 - 2 years ½ 1 /3 Tablet 3 3 2
50+ 14+ year
Tablet 4 4 2
12-19 2 - 5 years ¾ ½

30
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Give Cotrimoxazole Prophylaxis for HIV Exposed & Infected Infant/Child

 For HIV exposed , give Cotrimoxazole once daily from the age of 6 weeks until HIV infection has been definitely ruled out and the
mother is no longer breastfeeding.
 For HIV INFECTED give Cotrimoxazole once daily
 DO NOT GIVE COTRIMOXAZOLE TO INFANTS UNDER 6 WEEKS OF AGE

Recommended Cotrimoxazole dosage for infants and children

Age Syrup Paediatric tablet Adult tablet

(40mg Trimethoprim + 200mg (20 mg Trimethoprim + (Single strength tablet)
Sulphamethoxazole in 5 mls) 100mg Sulphamethoxazole) (80mg Trimethoprim +
400mgSulphamethoxazole)
< 6 months 2.5 ml 1 tablet ¼ tablet

6 months – < 6 years 5 ml 2 tablets ½ tablet

6 – 14 years 10 ml 3 tablets 1 tablet

 Give Paracetamol for high fever

• (≥38.5°C) or ear pain
• Give Paracetamol every 6 hours until high fever or ear pain is gone, usually for 3 days.
PARACETAMOL

AGE TABLET TABLET Syrup Syrup Suppository Suppository

or WEIGHT (100mg) (500mg) (120mg/5ml) (250mg/5ml) (125mg) (250mg)
2 months up to 3 years (4-14 kg) 1 ¼ 5ml 2.5ml 1
3 years up to 5 years (14-19 kg) 1½ ½ 7.5ml 5ml 2 1

31
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

 Give Vitamin A
 For MEASLES, MEASLES with EYE/MOUTH complications or PERSISTENT DIARRHOEA,
give three doses
 Give first dose in health facility
 Give two doses in the health facility on days 2 and 15  Give Zinc for all children > 2 months with
 For SEVERE COMPLICATED MEASLES or SEVERE PERSISTENT DIARRHOEA, give one diarrhoea
dose in health facility and then refer.
 For SEVERE MALNUTRITION: give vitamin A on the day of discharge (for those children who
have completed Phase 2 as an in-patient) or at the 4th week of the treatment for those in out- AGE DOSE (20 mg tablet)
patient care. 2-6 months 1/2 tablet
 For Routine Vitamin A supplementation for children 6 months up to 5 years, give one dose
in health facility if the child has not received a dose within the last 6 months. 6 months and above 1 tablet
VITAMIN A CAPSULES
AGE
200 000 IU 100 000 IU 50 000 IU
For infants, dissolve the Zinc tablet in a small amount (5 ml) of expressed
Up to 6 months ½ capsule 1 capsule breastmilk, ORS, or clean water in a small spoon. Older children can swallow,
chew or take it dissolved in a small amount of clean water.
6 months up to 12 months ½ capsule 1 capsule 2 capsules

12 months up to 5 years 1 capsule 2 capsules 4 capsules

 Give Iron  Give Mebendazole or Albendazole

 Give one dose daily for 14 days
Give a single dose if child is ≥ 2 years
and didn’t get within the previous 6 months
AGE IRON TABLET IRON SYRUP
or Ferrous sulfate 300 mg Ferrous Fumarate 100 mg per 5 ml Mebendazole Mebendazole Albendazole Albendazole
WEIGHT (60 mg elemental iron) (20 gm elemental iron per ml) Age
500 mg tablet, or Syrup, 400mg tablet Syrup,
2 months up to 4 months (4-6 kg) 1.00 ml (15 drops) 5 tablets of 100 mg 100mg/5ml 100mg/5ml

4 months up to 12 months (6-10 kg) 1.25 ml (20 drops)

2 - 5 years 1 tablet 5 tsp 1 tablet 4 tsp
12 months up to 3 years (10-14 kg) ½ tablet 2.00 ml (30 drops)
( 500mg) (25ml) (20ml)
3 years up to 5 years (14-19 kg) ½ tablet 2.5 ml (35 drops)

32
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
INSTRUCTIONS TO TEACH THE MOTHER  Dry the Ear by Wicking and Give Quinolone Eardrops
Follow the instructions below for every local treatment to be given at home. (Ciprofloxacin, Norfloxacin, or Ofloxacin ear drops)
 Explain to the mother what the treatment is and why it should be given.
 Describe the treatment steps listed in the appropriate box. Dry the ear at least 3 times daily, till discharge stops
 Roll clean absorbent cloth or soft, strong tissue paper into a wick
 Watch the mother as she does the first treatment in the clinic (except remedy for cough
 Place the wick in the child’s ear
or sore throat).  Remove the wick when wet
 Tell her how often to do the treatment at home.  Replace the wick with a clean one and repeat these steps until the ear is dry
 Instil Ciprofloxacin eardrops (2-3 drops) after dry wicking three times daily for two
 If needed for treatment at home, give mother the tube of Tetracycline ointment or a weeks
small bottle of gentian violet.
 Check the mother’s understanding before she leaves the clinic.

 Treat Eye Infection with Tetracycline Eye Ointment  Treat Thrush with Nystatin or Gentian Violet (0.25%)
 Clean both eyes 3 times daily.
• Wash hands. Treat for thrush four times daily for 7 days
• Ask child to close the eye.  Wash hands
• Use clean cloth and water to gently wipe away pus  Wet a clean soft cloth with salt water and use it to wash the child’s mouth
 Instill Nystatin 1 ml four times a day or paint with GV as above for 7 days
 Then apply Tetracycline eye ointment in both eyes 3 times daily.
 Avoid feeding for 20 minutes after medication
• Ask the child to look up
 If breastfed, check mother’s breasts for thrush. If present treat with Nystatin or GV
• Squirt a small amount of ointment on the inside of the lower lid.
 Advise mother to wash breasts after feeds. If bottle fed advise change to cup
• Wash hands again.
 If severe, recurrent or pharyngeal thrush consider symptomatic HIV
 Treat until redness is gone.  Give Paracetamol if needed for pain
 Do not use other eye ointments or drops, or put anything else in the eye.

 Treat Mouth Ulcers with Gentian Violet (0.25%)  Soothe the Throat, Relieve the Cough with a Safe
Treat for mouth ulcers two times daily
 Wash hands
Remedy
 Wash the child’s mouth with a clean soft cloth wrapped around the finger and wet with
 Safe remedies to recommend:
salt water
• Breastmilk for exclusively breastfed infant.
 Paint the mouth with 0.25% Gentian Violet (dilute the 1% solution to 1:3 with water)
• Home fluids such as tea with honey, fruit juices
 Wash hands again
 Continue using GV for 48 hours after the ulcers have been cured  Harmful remedies to discourage: Cough syrups containing Diphenyl Hydramine and/or
 Give Paracetamol if needed for pain Codeine. Examples: benylin with and without codein, Berantin .

33
GIVE THESE TREATMENTS IN CLINIC ONLY

INSTRUCTIONS ON HOW TO GIVE TREATMENTS

 Explain to the mother why the drug is given.
 Treat a Convulsing Child with Diazepam Rectally
 Determine the dose appropriate for the child’s weight (or age).
MANAGE THE AIRWAYS
• Turn the child on his/her side to avoid aspiration
 Use a sterile needle and sterile syringe. Measure the dose accurately. • Do not insert anything into the mouth
 Give the drug as an intramuscular injection. • If the child is blue, open the mouth and make sure the airway is clear
 If child cannot be referred, follow the instructions provided. • If necessary, remove secretions from the mouth by inserting a catheter via the nose.
GIVE DIAZEPAM RECTALLY
• Draw up the dose from an intravenous preparation of Diazepam into a small syringe,
then REMOVE THE NEEDLE.
 Give An Intramuscular Antibiotic • Insert approximately 5 cm of a nasogastric tube into the rectum.
• Inject the Diazepam solution into the nasogastric tube and flush it with 2 – 3 ml of water
FOR CHILDREN BEING REFERRED URGENTLY WHO CANNOT TAKE AN ORAL at room temperature.
ANTIBIOTIC: • If High Fever (temperature 40°C or more), lower the fever. Sponge the child with room
 Sick child: Give first dose of IV/IM Ampicillin/Chloramphenicol and refer child urgently to temperature water.
hospital,
 Young infant: Give first dose of Ampicillin (50mg/kg) and Gentamycin (7.5mg/kg) and DIAZEPAM RECTALLY
refer child urgently to hospital AGE or WEIGHT 10 mg/2 ml Solution, Dose 0.3 mg/kg
2 months up to 4 months (4 - 6 kg) 0.30 ml
IF REFERRAL IS NOT POSSIBLE OR DELAYED
4 months up to 9 months (6 - 8 kg) 0.50 ml
 Repeat the Chloramphenicol injection every 12 hours for 5 days, or
 Repeat the Ampicillin injection every 6 hours (200mg/kg/day) 9 months up to 24 months (8 - 12 kg) 0.60 ml

 Repeat the Gentamycin every 24 hours (7.5mg/kg/day) 2 years up to 3 years (12 - 14 kg) 0.75 ml
 Where there is a strong suspicion of meningitis, the dose of Ampicillin can be increased to 3 years up to 5 years (14 - 19 kg) 1.00 ml
300mg/kg/day in 4 divided doses.

 Treat the Child to Prevent Low Blood Sugar

CHLORAMPHENICOL   IfIfthe
thechild
childisisable
abletotobreastfeed:
breastfeed:
AGE or WEIGHT Dose: 40 mg per kg • •AskAskthethe mother
mother to to breastfeed
breastfeed thethe child.
child.
(Add 5.0 ml sterile water to vial containing   IfIfthe
thechild
childisisnot
notable
abletotobreastfeed
breastfeedbut butisisable
abletotoswallow
swallow
1000 mg = 5.6 ml at 180 mg/ml)
Give
• •Give expressed
expressed breastmilk
breastmilk or or a breastmilk
a breastmilk substitute.
substitute.
2 months up to 4 months (4 – 6 kg) 1.0 ml = 180 mg If neither
• •If neither of of these
these is available,
is available, give
give sugar
sugar water.
water.
4 months up to 9 months (6 – 8 kg) 1.5 ml = 270 mg Give
• •Give 30-50
30-50 mlmlof of milk
milk or or sugar
sugar water
water before
before departure.
departure.
9 months up to 12 months (8 – 10kg) 2.0 ml = 360 mg • •ToTo make
make sugar
sugar water:
water: Dissolve
Dissolve 4 level
4 level teaspoons
teaspoons of of sugar
sugar (20(20 grams)
grams) in
in a 200-ml
a 200-ml cup
cup of of clean
clean water.
water.
12 months up to 3 years (10 – 14kg) 2.5 ml = 450 mg
  IfIfthe
thechild
childisisnot
notable
abletotoswallow:
swallow:
3 years up to 5 years (14 – 19kg) 3.5 ml = 630 mg Give
• •Give 5050mlmlof of milk
milk or or sugar
sugar water
water byby nasogastric
nasogastric tube.
tube.

34
GIVE THESE TREATMENTS IN CLINIC ONLY
Artesunate rectal suppository: pre-referral for VERY SEVERE FEBRILE DISEASE (only
for high or Low malaria risk areas). Pre referral single dose for children weighing ≥ 5 kg. Artemether IM: Artemether is an Alternative Pre-referral drug, where Artesunate
Weight (kg) Age Artesunate (mg) Regimen (single dose) suppository is not available.
5–9 2–13 months 50 One 50-mg suppository - Dose - 3.2 mg/kg body weight Artemether IM
9–20 13–43 months 100 One 100-mg suppository
20–30 43–60 months 200 Two 100-mg suppository
30–40 6–14 years 300 Three 100-mg suppositories
40+ 14+ years 400 One 400-mg suppository Quinine: for VERY SEVERE FEBRILE DISEASE, if Artesunate is not available
NB:-Hold the buttocks together for 10 min to ensure retention of the rectal Artesunate. If the Artesunate is expelled FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
from the rectum within 30 min of insertion, a second suppository should be inserted.  Check which Quinine formulation is available in your clinic.
 Give first dose of intramuscular Quinine and refer child urgently to hospital. Advise
PARENTERAL ARTESUNATE: First line treatment for VERY SEVERE FEBRILE DISEASE (only for mother to keep child lying down on his way to the hospital
high or Low malaria risk areas)
IF REFERRAL IS NOT POSSIBLE:
 Give Artesunate 2.4 mg/kg preferably IV, or IM (alternative) on admission (time = 0), then at 12 h and 24 h, then
once a day for 5-7 days. After a minimum of 24 hours of parenteral Artesunate treatment, and as soon as patient is  Give first dose of intramuscular Quinine –
able to take tablets, complete the treatment with full dose of oral Coartem. - Loading dose of 20mg/kg IM (divided into 2 sites, anterior thigh)
 Artesunate 2.4 mg/kg IV or IM can be given as pre-referral dose when Artesunate suppository is not available.  The child should remain lying down for one hour.
DOSES of PARENTERAL ARTESUNATE  Repeat the Quinine injection at dose of 10mg/kg, every 8 hours until the child is
AGE or WEIGHT To prepare IV infusion of 10 mg/ml, To prepare IM of 20 mg/ml, reconstitute able to take an oral antimalarial. After 48 hours of parenteral therapy, reduce the
reconstitute 60mg artesunate powder with 60mg artesunate powder with 1 ml of maintenance dose by 1/3 to 1/2, 5-7mg/kg every 8 hours. It is unusual to continue
1 ml of 5% sodium bicarbonate solution, 5% sodium bicarbonate solution, then Quinine injections for more than 4-5 days.
then shake 2-3 minutes, then add 5 ml of shake 2-3 minutes, then add 2 ml of 5%
5% glucose or normal saline* glucose or normal saline INTRAMUSCULAR QUININE
AGE or WEIGHT
2 - 4 mths (5 – 6 kg) 1 ml 0.5 ml 150mg/ml* 300 mg/ml*
4 - 12 mths (6 – 10 kg) 2 ml 1 ml (in 2 ml ampoules) (in 2 ml ampoules)
12 - 24 mths (10 – 12kg) 2.5 ml 1.25 ml 2 months up to 4 months (4 – 6 kg) 0.4 ml 0.2 ml
2 - 3 years (12 – 14 kg) 3.0 ml 1.5 ml
3 - 5 years (14 – 19kg) 3.5 ml 2.0 ml
4 months up to 12 months (6 – 10 kg) 0.6 ml 0.3 ml
19-22 kg 5 ml 2.5 ml
22-29 kg 6 ml 3.0 ml 12 months up to 2 years (10 – 12kg) 0.8 ml 0.4 ml
29-33 kg 7 ml 3.5 ml
32-36 kg 8 ml 4 ml 2 years up to 3 years (12 – 14 kg) 1.0 ml 0.5 ml
36-40 kg 9 ml 4.5 ml
3 years up to 5 years (14 – 19kg) 1.2 ml 0.6 ml
40-45 kg 10 ml 5 ml
45-49 kg 11 ml 5.5 ml
50 kg + 12 ml 6 ml * Quinine salt
NB: If possible, for intramuscular use, Quinine should be diluted in sterile Normal
*Infuse slowly for intravenous administration (3-4 ml per minute) Saline to a concentration of 60mg/ml.

35
GIVE EXTRA FLUIDS FOR DIARRHOEA AND CONTINUE FEEDING (See FOOD advice on COUNSEL THE MOTHER chart)

 Plan A: Treat Diarrhoea at Home  Plan B: Treat Some Dehydration with ORS
Counsel the mother on the 4 Rules of Home Treatment: Give in clinic recommended amount of ORS over 4-hour period
Give Extra Fluids, Give Zinc Supplements, Continue Feeding, When to Return
 DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
1. GIVE EXTRA FLUIDS (as much as the child will take)
 TELL THE MOTHER:
- Breastfeed frequently and for longer at each feed.
AGE Up to 4 months 4 - 12 months 12 mo - 2 years 2 - 5 years
- If the child is exclusively breastfed, give ORS in addition to breastmilk. Weight in kg <6 kg 6-10kg 10-12 kg 12-19 kg
- If the child is not exclusively breastfed, give one or more of the following: ORS
solution, food-based fluids (such as soup, rice water and yoghurt drinks), or clean water. ORS in ml 200-400 400-700 700-900 900-1400

It is especially important to give ORS at home when: ORS in coffee 3-6 6-10 10-13 13-20
- The child has been treated with Plan B or Plan C during this visit. cups (70ml)
- The child cannot return to a clinic if the diarrhoea gets worse.
* Use the child’s age only when you do not know the weight. The approximate amount of ORS
 TEACH THE MOTHER HOW TO MIX AND GIVE ORS. required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75
GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME.  If the child wants more ORS than shown, give more.
 SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID  For infants under 6 months who are not breastfed, also give 100-200 ml
INTAKE: clean water during this period.
Up to 2 years 50 to 100 ml after each loose stool
2 years or more 100 to 200 ml after each loose stool  SHOW THE MOTHER HOW TO GIVE ORS SOLUTION:
 Give frequent small sips from a cup.
Tell the mother to:  If the child vomits, wait 10 minutes. Then continue, but more slowly.
 Continue breastfeeding whenever the child wants.
- Give frequent small sips from a cup.
- If the child vomits, wait 10 minutes. Then continue, but more slowly.
 AFTER 4 HOURS:
- Continue giving extra fluid until the diarrhoea stops.  Reassess the child and classify the child for dehydration.
 Select the appropriate plan to continue treatment.
2. GIVE ZINC SUPPLEMENTS (age 2 month upto 5 years)  Begin feeding the child in clinic.
 TELL THE MOTHER HOW MUCH ZINC TO GIVE:
2 mo to 6 months - 1/2 tablet for 10 days  IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
6 months or more - 1 tablet for 10 days  Show her how to prepare ORS solution at home.
 Show her how much ORS to give to finish 4-hour treatment at home
 SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS  Give her enough ORS packets to complete rehydration. Also give
Infants- dissolve tablet in a small amount of expressed breastmilk, ORS or clean water in a cup her 2 packets as recommended in plan A
Older children- tablets can be chewed or dissolved in a small amount of clean water in a cup  Explain the 4 Rules of Home Treatment:
1. GIVE EXTRA FLUID
3. CONTINUE FEEDING See COUNSEL THE MOTHER chart 2. GIVE ZINC
See Plan A for recommended fluid
4. WHEN TO RETURN 3. CONTINUE FEEDING and
4. WHEN TO RETURN See COUNSEL THE MOTHER chart

36
GIVE EXTRA FLUID FOR DIARHOEA AND CONTINUE FEEDING (See FOOD advice on COUNSEL THE MOTHER chart)

 Plan C: Treat Severe Dehydration Quickly

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

START HERE  Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up.
Give 100ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows:

Can you give AGE First give Then give

Intravenous (IV) Fluid 30 ml/kg in: 70 ml/kg in:
immediately? YES
Infants 1 hour* 5 hours
(under 12 months)

Children 30 minutes* 2 ½ hours

NO
(12 months up to 5 years)

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

 Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly.
 Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children).
 Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C)
to continue treatment.
Is IV treatment
available nearby
(within 30 minutes)?  Refer URGENTLY to hospital for IV treatment.
YES  If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip
NO

Are you trained to

use a naso-gastric (NG)  Start rehydration by tube (or mouth) with ORS solution give 20 ml/kg/hour for 6 hours (total of 120 ml/kg)
tube for rehydration?  Reassess the child every 1-2 hours:
- If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly.
- If hydration status is not improving after 3 hours, send the child for IV therapy.
NO YES  After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.

Can the child drink?

NO
NOTE:
Refer URGENTLY  If possible, observe the child at least 6 hours after rehydration to be sure.
to hospital for IV or NG
treatment

37
COUNSEL THE MOTHER

FOOD

 Assess the Child’s Feeding

Ask questions about the child’s usual feeding and feeding during this illness. Note whether the mother is HIV infected, uninfected, or
does not know her status. Compare the mother’s answers to the feeding recommendations for the child’s age in the box below.

ASK:
• Do you breastfeed your child? Yes______ No_____
If Yes, how many times in 24 hours? ________ times.
Do you breastfeed during the night? Yes______ No_____
• Does the child take any other food or fluids? Yes______ No_____
If Yes, what food or fluids? ________________________________________________
How much is given at each feed?___________________________________________
How many times in 24 hours? ________ times.
What do you use to feed the child? Cup____ Bottle____ Other_________________
• If on replacement milk: What replacement milk are you giving?___________________________
How many times in 24 hours? ________ times
How much is given at each feed? ______________________________________
How is the milk prepared? _________________________________________
How are you cleaning the utensils? ______________________________________
• If underweight or moderately malnourished:
How large are servings? _________________________________________________
Does the child receive his own serving? Yes______ No_____
Who feeds the child and how? ________________________________________
• During the illness, has the child’s feeding changed? Yes______ No_____
If Yes, how? _______________________________________________________________

38
COUNSEL THE MOTHER Feeding Recommendations During Sickness and Health
Up to 6 Months of Age 6 Months Up to 12 Months 12 Months Up to 2 Years 2 Years and Older

 Breastfeed as often as the child wants.

 Continue breast feeding.  Give adequate servings of enriched
family foods: porridge made of cereal and
legume mixes, shiro, kik, merek fitfit,
 Give adequate servings of freshly prepared mashed potatoes and carrot, gommen,
and enriched; porridge made of cereal and legume mixes, shiro undiluted milk and egg and fruits.
 Breastfeed as often as the fitfiit, merek fitfit, mashed potatoes and carrot, mashed gommen,  Give adequate servings of freshly prepared
child wants, day and night, eggs and fruits.  Add some extra butter or oil to child’s food. Give also animal enriched family foods, 3 meals a day
at least 8 times in 24 hours. foods (meat, liver, fish, eggs), legumes, vegetables (green
leafy, carrots) and yellow fruits (orange, papaya, mangos)  Also, twice daily, give nutritious food between
 Feed your child only breast  Enrich the food by adding some oil or butter every time; give meals, such as: Egg, milk, fruits, kitta, Dabo,
 Give these foods at least 3-4 meals plus 2 snacks / mekses
milk for the first 6 months, also animal foods (meat, liver, fish, eggs), legumes, vegetables ripe yellow fruits
if breast feeding or taking other milk.
not even giving water (green leafy, carrots) and yellow fruits (orange, papaya, mangos)
 Give these foods; 5 times/day plus 2 snacks / mekses, if not  Give your baby his/her own servings and
 Empty one breast before  Give these foods; 3times/day plus 2 snacks/mekses, if breast feeding or taking other milk feeds. actively feed the child
switching to the other for breastfeeding or taking other milk.  Babies who stopped breastfeeding at early age should also
your baby to get the most get adequate other milk feeds besides complementary  Give freshly prepared food and use clean
 Give these foods; 5 times/day plus 2 snacks/mekses, if not
nutritious hind milk feeding. utensils
breastfeeding or taking other milk feeds, .
 During illness and for at  Give your baby his/her own servings and actively feed the  Increase intake of food and fluids during
least up to 2 weeks after the  Increase intake of food and fluids during illness, and give one child illness, and give one additional meal of solid
i l l n e ss in crea se the additional meal of solid food for about 2 weeks after illness for  Give freshly prepared food and use clean utensils food for about 2 weeks after illness for fast
frequency of breastfeeding fast recovery.  Increase intake of food and fluids during illness, and give recovery
to recover faster  Give Vitamin A supplements from the age of 6 months, 2 times one additional meal of solid food for about 2 weeks after  Give Vitamin A supplements and
illness for fast recovery Mebendazole / Albenfazole every 6 months
 Do not give other foods or
per year.
 Give Vitamin A supplements and Mebendazole /
fluids including water  Expose child to sunshine for 15 to 20 minutes daily
albendazole every 6 months
 Expose child to sunshine for
15 to 20 minutes daily
starting within 2weeks of
age

Feeding recommendations for a child with Feeding Recommendations for a child with PERSISTENT DIARRHOEA
UNCOMPLICATED SEVERE ACUTE MALNUTRITION
 If still breastfeeding, give more frequent, longer breastfeeds, day and night  If still breastfeeding, give more frequent, longer breastfeeds, day and night.
 Always give breast milk before RUTF  If taking other milk:
- Replace with increased breastfeeding OR
 Feed the child RUTF (Ready to Use Therapeutic Food) until cured
- Replace with fermented milk products, such as yoghurt OR
 Do not give other food than RUTF except breast milk - Replace half the milk with nutrient-rich semisolid food.
 Offer plenty of clean water to drink with RUTF  For other foods, follow feeding recommendations for the child’s age.
 Give the RUTF only to the severely malnourished child

39
COUNSEL THE MOTHER
Feeding Recommendations for HIV Exposed Infant & Child
Up to 6 Months of Age 6 Months Up to 12 Months 12 Months Up to 2 Years 2 Years and Older

 Continue breast feeding.  Consider replacement feeding and

discontinuation of breast feeding as early
as possible if mother can provide adequate
 Start complementary foods at 6 months of age.
and safe replacement. (Give at least 3 cups (3X300ml) of
boiled full cream milk per day)
 Give adequate servings of freshly prepared and enriched;
porridge made of cereal and legume mixes, shiro fitfiit, merek  .Give adequate servings of enriched family foods: porridge
fitfit, mashed potatoes and carrot, mashed gommen, eggs and made of cereal and legume mixes, shiro, kik, merek fitfit,
mashed potatoes and carrot, gommen, undiluted milk and  Give adequate servings of freshly prepared
fruits.
 Breastfeed as often as the egg and fruits. enriched family foods, 3 meals a day
child wants, day and night,
at least 8 times in 24 hours.  Enrich the food by adding some oil or butter every time; give  Add some extra butter or oil to child’s food. Give also animal  Also, twice daily, give nutritious food between
also animal foods (meat, liver, fish, eggs), legumes, vegetables foods (meat, liver, fish, eggs), legumes, vegetables (green meals, such as: Egg, milk, fruits, kitta, Dabo,
 Feed your child only breast (green leafy, carrots) and yellow fruits (orange, papaya, mangos) leafy, carrots) and yellow fruits (orange, papaya, mangos) ripe yellow fruits
milk for the first 6 months,
not even giving water  Give these foods; 3times/day plus 2 snacks/mekses, if breast  Give these foods at least 3-4 meals plus 2 snacks / mekses  Give your baby his/her own servings and
if breast feeding or taking other milk. actively feed the child
feeding or taking other milk.
 Empty one breast before  Give these foods; 5 times/day plus 2 snacks / mekses, if not  Give freshly prepared food and use clean
switching to the other for breast feeding or taking other milk feeds. utensils
your baby to get the most  Give these foods; 5 times/day plus 2 snacks / mekses, if not
nutritious hind milk breast feeding or taking other milk feeds, .  Babies who stopped breastfeeding at early age should also  Increase intake of food and fluids during
get adequate other milk feeds besides complementary illness, and give one additional meal of solid
 During illness and for at  Increase intake of food and fluids during illness, and give one feeding. food for about 2 weeks after illness for fast
least up to 2 weeks after the additional meal of solid food for about 2 weeks after illness for  Give your baby his/her own servings and actively feed the recovery
i l l n e ss in crea se the child  Give Vitamin A supplements and
frequency of breastfeeding
fast recovery. Mebendazole / Albenfazole every 6 months
to recover faster  Give freshly prepared food and use clean utensils
 Give Vitamin A supplements from the age of 6 months, 2 times  Increase intake of food and fluids during illness, and give
 Do not give other foods or per year. one additional meal of solid food for about 2 weeks after
fluids including water illness for fast recovery
 Expose child to sunshine for 15 to 20 minutes daily  Give Vitamin A supplements and Mebendazole /
 Expose child to sunshine for albendazole every 6 months
15 to 20 minutes daily
starting within 2weeks of
age

Note: With adequate counseling, if mother prefers not to breastfed refer about actions on replacement feeding on page 43 & 44.

40
Counsel the Mother About Feeding Problems
If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

 If the mother reports difficulty with breastfeeding, assess breastfeeding (See YOUNG INFANT chart.)
As needed, show the mother correct positioning and attachment for breastfeeding.

 If the child is less than 6 months old and is taking other milk or foods:
- Build mother’s confidence that she can produce all the breastmilk that the child needs.
- Suggest giving more frequent, longer breastfeeds, day or night, and gradually reducing other milk or foods

 If other milk needs to be continued, counsel the mother to:

- Breastfeed as much as possible, including at night. (for infants who are not HIV exposed)
- Make sure that other milk is a locally appropriate breast milk substitute. (for infants who are not HIV exposed)
- Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
- Finish prepared milk within an hour.

 If the child is being given diluted milk or gruel (muk):

- Do not dilute the milk
- Remind mother that thick foods which are dense in energy and nutrients are needed by infants and young children.

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

- Recommend substituting a cup for bottle.
- Show the mother how to feed the child with a cup (senee or finjal)

 If the child is not being fed actively, counsel the mother to:
- Sit with the child and encourage eating.
- Give the child an adequate serving in a separate plate or bowl.

 If the child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and for longer if possible.
- Use soft, varied, appetizing, favorite foods to encourage the child to eat as much as possible, and offer frequent small feedings.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.

41
Counsel the Mother About Feeding Problems (contd.)
If the child is not being fed as described in the above recommendations, counsel the mother accordingly.
In addition:

 If the mother is not giving Vitamin A-rich foods:

- Encourage her to provide Vitamin A-rich foods frequently - Cabbage (gommen), liver, carrot, egg

 If the mother is not giving the young child a share of meat, chicken or fish when these are eaten by the family:
- Explain young child needs them and encourage her to provide whenever they are available in the household.

 If the child has poor appetite

- Plan small frequent meals

- Give milk rather than other fluids except where there is diarrhoea with some dehydration
- Give snacks between meals
- Give high energy foods by adding oil or butter to the food.
- Check regularly for oral thrush or ulcers

 If the child has sore mouth or ulcers

- Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado
- Avoid spicy, salty or acid foods
- Chop foods finely
- Give cold drinks or ice (if available) before feeding

 Follow-up any feeding problem in 5 days

42
COUNSEL THE MOTHER about Safe Preparation of Formula Feeding
Safe Preparation of Formula Milk Counsel the HIV Positive Mother
Always use a marked cup or glass and
Who Has Chosen Not to Breastfeed
spoon to measure water and the scoop to
measure the formula powder. The mother or caretaker should have received full
counseling before making this decision
Wash your hands before preparing a feed.
 Asses and ensure that the mother or caretaker has an
adequate supply of commercial infant formula (at least
Bring the water to the boil and then let
it cool. Keep it covered while it cools. for 12 months)

 Asses and ensure that the mother or caretaker knows

Measure the formula powder into a marked
cup or glass according to the preparation how to prepare milk correctly & safely and has the
advise on the package of the formula milk.
facility and resources to do it

 Demonstrate how to feed with a cup and spoon rather

Add a small amount of the cooled boiled water
and stir. Fill the cup or glass to the mark with than a bottle
the water. Stir well.

 Make sure that the mother or caretaker understands

that mixing breastfeeding with replacement feeding may
Feed the baby using a cup.
increase the risk of HIV infection and should not be
done.
Wash the utensils.

43
COUNSEL THE MOTHER about Safe Preparation of Formula Feeding (contd...)

Appropriate amount of formula needed per day

Previously Number of
Approx. amount formula in 24 Approx.
Age Weight boiled water scoops
hours No. of feeds
in months in Kg per feed per feed
Birth 3 400ml 50 2 8 x 50ml

2 weeks 3 400ml 50 2 8 x 50ml

6 weeks 4 600ml 75 3 7 x 75ml

10 weeks 5 750ml 125 5 6 x 125ml

14 weeks 6.5 900ml 150 6 6 x 150ml

4 months 7 1050ml 175 7 6 x 175ml

5 months 8 1200ml 200 8 6 x 200ml

6-12 months Starting from 6 months of age the amount of formula may range from 700 to 800 ml in 24 hours.

 How to feed a baby with a cup

 Hold the baby sitting upright or semi-upright on your lap
 Hold a small cup of milk to the baby’s lips
 tip the cup so the milk just touches the baby’s lips
 the cup rests gently on the baby’s lower lip and the edges of the cup and touch the outer part of the baby’s upper lip
 the baby becomes alert and opens his mouth and eyes
 Do not pour the milk into the baby’s mouth. A young infant starts to take the milk with the tongue. An older/ bigger baby sucks
the milk, spilling some of it
 When the baby has had enough he closes his mouth and will not take any more. If the baby has not taken the required
amount, wait and then offer the cup again or feed more frequently

44
COUNSEL THE MOTHER about Fluids and When to Return

FLUID - Advise the mother to increase fluids during illness

FOR ANY SICK CHILD:
 Breastfeed more frequently and for longer at each feed.
 For children on complementary or replacement feeding increase fluid. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

 Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

WHEN TO RETURN - Advise the mother when to return to the health worker

A. FOLLOW – UP VISIT - Advise the mother to come for follow-up B. Return Immediately - Advise the mother to come immediately if the
at the earliest time listed for the child’s problems. child has any of these signs.

If the child has: Return for

Follow-up in: Any sick child  Not able to drink or breastfeed
• PNEUMONIA  Becomes sicker
• SOME DEHYDRATION  Develops a fever
• DYSENTERY
• MALARIA, if fever persists 2 days If child has NO PNEUMONIA, COUGH OR  Fast breathing
• FEVER-MALARIA UNLIKELY, if fever persists COLD, also return if:  Difficult breathing
• FEVER NO MALARIA (NO MALARIA RISK), if fever persists
If child has diarrhoea, also return if:  Blood in stool
• MEASLES WITH EYE OR MOUTH COMPLICATIONS  Drinking poorly
• PERSISTENT DIARRHOEA
• ACUTE EAR INFECTION
• CHRONIC EAR INFECTION 5 days
• FEEDING PROBLEM
• ANY OTHER ILLNESS, if not improving C. NEXT WELL-CHILD VISIT: - Advise mother when to return for:
• Next immunization
• UNCOMPLICATED SEVERE ACUTE MALNUTRITION 7 days • Next dose of Vitamin A and Mebendazole
• ANAEMIA 14 days • Do growth monitoring at each well-child visit using growth charts.
• MODERATE ACUTE MALNUTRITION
• UNDERWEIGHT 30 days

45
Counsel the Mother About Her Own Health

 If the mother is sick, provide care for her, or refer her for help
 If she has a breast problem (such as engorgement, sore nipples, breast infection), advise her not to feed her baby from the affected breast,
until it heals express and discard the milk from the affected breast. Provide clinical care for the mother or refer her for help.
 Advise her to eat well to keep up her own strength and health.
 If she is breastfeeding, advise her to eat 2 more varied extra meals a day to maintain her health and health of the baby.
 Advise her to take Vitamin A supplementation within 45 days of delivery for the baby’s health and strength
 Advise a mother from malarious area for herself and all under five children to sleep under ITN to prevent malaria
 Advise the mother to ensure that all family food is cooked using iodized salt so that family members remain healthy
 Check the mother’s immunization status and give her tetanus toxoid if needed.
 Make sure she has access to:
 Family planning
 Counseling on STD and AIDS prevention
 Antenatal care if she is pregnant
 Encourage her to seek voluntary HIV counseling and testing
 Reassure her that with regular follow-up, much can be done to prevent serious illness, and maintain her and the child’s health.
 Emphasize good hygiene, and early treatment of illnesses

46
COUNSEL THE MOTHER using the Family Health Card (FHC)

Counsel the mother on foods, fluids and when to return immediately

using the Family Health Card (FHC: September 2011 version): See
the messages below:

1. About Food
► Messages 27 - 40 & 44
► And specifically about feeding during illness
Messages: 45 & 46

2. About Fluids
► Messages 45 - 48

3. When to return immediately

► Young infant - See messages 25
► Any sick child - Messages 49
► Child with Diarrhoea - Messages 32

4. About Immunization:
► Message 31

47
GIVE FOLLOW–UP CARE
 Care for the child who returns for follow-up using all the boxes that match the child’s previous classifications.
 If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

 PNEUMONIA IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT
OR THIS VISIT, ADVISE THE MOTHER THE NEXT FOLLOW-UP VISIT
After 2 days:
ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY
Check the child for general danger signs.
See ASSESS & CLASSIFY chart (SEE COUNSEL CHART)
Assess the child for cough or difficult breathing.

Ask:
- Is the child breathing slower?
- Is there less fever?  DYSENTERY
- Is the child eating better?
After 2 days:
Treatment:
 If chest indrawing or a general danger sign, give a dose of IV/IM Ampicillin or Assess the child for diarrhoea. See ASSESS & CLASSIFY chart
Chloramphenicol, if not give second-line oral antibiotic. Then refer URGENTLY to hospital
 If breathing rate, fever, and eating are the same, change to the second-line Ask:
antibiotic and advise the mother to return in 2 days or refer. (If this child had - Are there fewer stools?
measles within the last 3 months or is known or suspected to have symptomatic - Is there less blood in the stool?
HIV infection, refer.) - Is there less fever?
 If breathing slower, less fever, and eating better, complete the 5 days of - Is there less abdominal pain?
- Is the child eating better?
antibiotic.
Treatment:
 PERSISTENT DIARRHOEA  If the child is dehydrated, treat dehydration

After 5 days:  If number of stools, amount of blood in stools, fever, abdominal pain, or
eating is the same or worse:
Ask:
- Has the diarrhoea stopped? Change to second-line oral antibiotic recommended for Shigella in your area.
- How many loose stools is the child having per day? Give it for 3 days. Advise the mother to return in 2 days.
Refer
to
Treatment: Exceptions - if the child: - is less than 12 months old, or hospital
 If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), - was dehydrated on the first visit, or
do a full reassessment of the child. Give any treatment needed. Then refer to hospital. - had measles within the last 3 months

 If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the  If fewer stools, less blood In the stools, less fever, less abdominal pain, and
mother to follow the usual feeding recommendations for the child’s age. eating better, continue giving the same antibiotic until finished.

48
GIVE FOLLOW–UP CARE
 MALARIA (Low or High Malaria Risk)  FEVER-MALARIA UNLIKELY (Low/high Malaria Risk)
If fever persists after 2 days: If fever persists after 2 days:
• Do a full reassessment of the child. See ASSESS & CLASSIFY Chart
• Assess for other causes of fever. • Do a full reassessment of the child. See ASSESS & CLASSIFY Chart
• Ask if the child has actually been taking his antimalarial. • Assess for other causes of fever.

Treatment: Treatment:
 If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.  If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DIS-
 If fever has been present every day for more than 7 days, refer for assessment. EASE.
 Suspect relapsing fever if other cases are occurring and the child has high fever, headache with chills and  If fever has been present every day for more than 7 days, refer for assessment.
rigor, refer. If referral is not possible treat with Amoxicillin. Advise the mother to return again in 2 days  Suspect relapsing fever if other cases are occurring and the child has high fever, headache with
 If the child has any cause of fever other than malaria, provide treatment. chills and rigor, refer, if not possible treat with Amoxycillin. Advise the mother to return again in 2
If malaria is the only apparent cause of fever days.
• Repeat blood film:  If the child has any cause of fever other than malaria, provide treatment.
• If positive and no improvement,
- If he hasn’t taken the antimalarial properly, make sure that he takes it. If malaria is the only apparent cause of fever:
- If he took the antimalarial properly, give second line antimalarial drug. If no second line antimalarial • Repeat BF/RDT:
refer. • If positive treat with the first -line oral antimalarial. Advise the mother to return again in 2
• If negative , advise mother to complete the antimalarial treatment properly and to return if no improve- days if the fever persists.
ment. And manage for other causes of fever. • If negative manage for other causes of fever

 FEVER (NO MALARIA) (No Malaria Risk)  MEASLES WITH EYE OR MOUTH COMPLICATIONS
If fever persists after 2 days: After 2 days:
Do a full reassessment of the child. See ASSESS & CLASSIFY Chart
Do a full reassessment of the child,. See ASSESS & CLASSIFY Chart Look for red eyes and pus draining from the eyes.
Enquire thoroughly about travel to malarious areas Look for mouth ulcers.
Assess for other causes of fever.
. Treatment
Treatment:  If the child has any general danger sign or clouding of cornea or deep or extensive
 If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. mouth ulcer, treat as SEVERE COMPLICATED MEASLES
 If there is travel history do BF/RDT.  If pus is draining from the eye, ask the mother to describe how she has treated the eye
• If positive treat with first-line oral anti malarial and advise the mother to return again in 2 days if infection. If treatment has been correct, refer to hospital. If treatment has not been correct,
the fever persists. teach mother correct treatment.
• If BF/RDT is negative manage for other cause of fever  If the pus is gone but redness remains, continue the treatment.
 If fever has been present every day for more than 7 days, refer for assessment.  If no pus or redness, stop the treatment.
 Suspect relapsing fever if other cases are occurring and the child has high fever with chills and head-  If mouth ulcers are the same or better, continue using half-strength gentian violet for a total
ache, refer, if not possible treat with Amoxycillin. Advise the mother to return again in 2 days if fever of 5 days.
persists

49
GIVE FOLLOW–UP CARE
 UNCOMPLICATED SEVERE MALNUTRITION
 EAR INFECTION After 7 days: - (Repeat every week for at least 2 months)
After 5 days: Ask about
Reassess for ear problem. See ASSESS & CLASSIFY chart - Feeding, if the child is finishing the weekly ration
- Diarrhoea, vomiting, fever or any other new complaint
Treatment: Check for - General danger signs, Medical complication, Temperature and Respiratory Rate
 If there is tender swelling behind the ear refer URGENTLY to hospital. - Weight, MUAC, oedema and anaemia
 Acute ear infection: if ear pain or discharge persists, treat with second line - Do appetite test
antibiotics for 5 more days. Continue wicking to dry the ear. Follow-up in 5 days. - Assess and classify if there is any new complaint (Use Assess & Classify Chart)
 Chronic ear infection: Check that the mother is wicking the ear correctly. Treatment:
 Encourage her to continue wicking and the topical Quinolone ear drops. If there is any one of the following, refer for inpatient care :
• Any danger sign or medical complication present or failed appetite test
 If no ear pain or discharge, praise the mother for her careful treatment. If she
• Poor response - Increase/develop oedema, weight loss of more than 5% of body weight at any visit
has not yet finished the 5 days of antibiotic, tell her to use all of it before or for 2 consecutive visits, static weight for 3 consecutive visits or failure to reach the discharge crite-
stopping. ria after 2 months of OTP treatment.
If there is no indication for referral, :
• Continue OTP treatment :give a weekly ration of RUTF
• Give routine drugs at appropriate times: Mebendazole on 2nd visit; Measles Vaccine on the 4th
 FEEDING PROBLEM week; Vitamin A on the 4th week or at discharge if edema persist.
After 5 days: • Record the information on the OTP card
Reassess feeding. See question at the top of the COUNSEL chart. • Give appointment for next follow up
Ask about any feeding problems found on the initial visit. If the following criteria are fulfilled, discharge from OTP follow up :
Treatment: • For a child admitted with edema - absence of oedema for 2 consecutive visits
• Counsel about any new or continuing feeding problems. If you counsel the mother to • For a child admitted without edema (WFH<-3 Z-score or MUAC<11cm) - attainment of discharge
make significant changes in feeding, ask her to bring the child back again. target weight (see on Page 78) for 2 consecutive visits
• If the child is <2 months and Underweight or has Moderate Acute Malnutrition, ask • For admissions with WFH <70% of median; discharge at >85% WFH for 2 consecutive weeks/visits
the mother to return 14 days after the initial visit to measure the child’s weight gain.
• If the child is 2 months to 5 years and has Moderate Acute Malnutrition or
Underweight, ask the mother to return 30 days after the initial visit to measure the  Moderate Acute Malnutrition (MAM) or Underweight (UW)
child’s weight gain. After 30 days:
• Weigh the child and determine if the child still has MAM or UW for age.
• Reassess feeding. See questions at the top of the COUNSEL chart.
 ANAEMIA Treatment:
After 14 days: • If feeding did not improve and/or child has lost weight, refer the child. And also if you think that
Reassess feeding. See question at the top of the COUNSEL chart. feeding will not improve, refer the child.
Ask about any feeding problems found on the initial visit. • If the child no longer has MAM or UW for age, praise the mother and encourage her to con-
Treatment: tinue age appropriate feeding.
 Give iron. Advise mother to return in 14 days for more iron. • If the child still has MAM or UW for age, counsel the mother about any feeding problem
 Continue giving iron every 14 days for 2 months. found. Ask the mother to return again in one month. Continue to see the child monthly until
 If the child has palmar pallor after 2 months, refer for assessment the child is feeding well and gaining weight regularly or no longer has MAM or UW for age.

50
WHERE REFERRAL IS NOT POSSIBLE

INTRODUCTION

The best possible treatment for a child with a very severe illness is usually at a hospital. Sometimes referral is not possible. Distances to a hospital might be too far;
the hospital might not have adequate equipment or staff to care for the child; transportation might not be available. Sometimes parents refuse to take a child to a
hospital, in spite of the health worker's effort to explain the need for referral.

If referral is not possible, you should do whatever you can to help the family care for the child. To help reduce deaths in severely ill children who cannot be referred,
you may need to arrange to have the child stay in or near the clinic where he may be seen several times a day. If not possible, arrange for visits at home.

This Part of the module describes treatment to be given for specific severe disease classifications when the very sick child cannot be referred. It is divided into 2
sections: "Essential Care" and "Treatment Instructions on How to Give Specific Treatment for Severely Ill Children Who Cannot Be Referred".

To use this part of the chart booklet, first find the child's classifications and note the essential care required. Then refer to the respective treatment boxes on the chart
booklet and the instructions in this section of the booklet. Because it may be difficult to treat a child at specific times during the day in clinic or at home, the Treatment
Instructions include 6-hour, 8-hour and 12-hour dosing schedules for giving various drugs.

Remember that you must also give treatment for the non-severe classifications that you identified. These treatments should be marked on the Sick Child
Recording Form. For example, if the child has SEVERE PNEUMONIA and MALARIA, you must treat the MALARIA and follow the guidelines below to treat the
SEVERE PNEUMONIA.

Although only a well-equipped hospital with trained staff can provide optimal care for a child with a very severe illness, following these guidelines may reduce mortality
in high risk children where referral is not possible.

51
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Essential Care for
SEVERE PNEUMONIA OR VERY SEVERE DISEASE
1. Give antibiotic treatment - It is essential that children with SEVERE PNEUMONIA OR VERY SEVERE DISEASE receive antibiotic treatment.

 If the child has a general danger sign or chest in-drawing but does not have the classification VERY SEVERE FEBRILE DISEASE, give IM Ampicillin/Chloramphenicol.
Treat with IM Ampicillin/Chloramphenicol until the child has improved. Then continue with oral Amoxicillin/Chloramphenicol. Treat the child for 10 days total.
If IM Ampicillin/Chloramphenicol is not available, give IM Benzyl Penicillin. If neither IM Ampicillin/Chloramphenicol nor Benzyl Penicillin is available, give oral Amoxicillin
(preferred) or Cotrimoxazole, as specified on the TREAT chart. If the child vomits, repeat the dose. If available, combination of IM/IV Ampicillin plus Gentamycin is preferable
than Ampicillin/Chloramphenicol alone for critically sick children. See the child daily.

 In children less than 1 year of age with severe pneumonia and suspected symptomatic or confirmed HIV infection, consider PCP and treat accordingly. Give Cotrimoxazole at
a dose of 20mg/kg/day of Trimethoprim divided into 4 doses (every 6 hrs) to be continued for 21 days. Add Prednisolone if in severe distress, at 2mg/kg/day in 2 divided doses
for 7 days. Refer the infant to hospital as early as possible for appropriate management.

 If the child also has the classification VERY SEVERE FEBRILE DISEASE, give benzyl penicillin and Chloramphenicol and antimalrials (for High or Low malaria risk areas) IV/
IM Artesunate or IV/IM Quinine as per the guide on page 35.

2. Give a bronchodilator - If the child is wheezing give a bronchodilator if you have it (See Treat Wheezing, Page 54).*

3. Treat fever - If the child has an axillary temperature of 38.5°C or above, give Paracetamol every 6 hours. This is especially important for children with pneumonia because fever
increases consumption of oxygen.

4. Manage fluids carefully - Children with SEVERE PNEUMONIA or VERY SEVERE DISEASE can become overloaded with fluids. If they can drink, give fluids by mouth. However,
children with SEVERE PNEUMONIA or VERY SEVERE DISEASE often lose water during a respiratory infection, especially if there is fever. Therefore, give fluids, but give them
cautiously. Encourage the mother to continue breastfeeding if the child is not in respiratory distress. If the child is too ill to breastfeed but can swallow, have the mother express milk
into a cup and slowly feed the child the breastmilk with a spoon.

Encourage the child to drink. If the child is not able to drink, either use a dropper to give the child fluid very slowly or drip fluid from a cup or a syringe without a needle. Avoid using
a NG tube if the child is in respiratory distress. Wait until the next day if there is no other option.
______________
* Instructions are provided in Acute Respiratory Infection in Children: Case Management in Small Hospitals in Developing Countries, A manual for doctors and other senior health workers (1990) WHO/ARI/90.5.

52
Essential Care for
SEVERE PNEUMONIA OR VERY SEVERE DISEASE ….

AGE Approximate amount of milk or formula to give Total amount in 24 hours

FLUIDS IN SEVERE PNEUMONIA
OR VERY SEVERE DISEASE Less than 12 months 5 ml/kg/hour 120 ml/kg
12 months up to 5 years 3 - 4 ml/kg/hour 72 - 96 ml/kg

Avoid giving fluids intravenously unless the child is in shock. A child in shock has cold extremities, a weak and rapid pulse, and is lethargic.

5. Manage the airway – Check if there is a blocked nose and clear it. A blocked nose can interfere with feeding. Use a plastic syringe (without needle) to gently suck any
secretions from the nose. Dry or thick, sticky mucous can be loosened by wiping with a soft cloth moistened with salt water. Help the child to cough up secretions.

6. Keep the infant warm - Small infants lose heat rapidly, especially when wet. Feel the infant's hands and feet. They should be warm. To maintain the body temperature,
keep the sick infant dry and well wrapped. If possible, have the mother keep her infant next to her body, ideally between her breasts. A hat or bonnet will prevent heat loss
from the head. If possible, keep the room warm.

7. Give Oxygen (if available) for children having any of the following signs of very severe respiratory distress
• Blue lips and tongue (central cyanosis)
• Grunting with every breath
• Unable to feed due to respiratory distress
• Convulsions, lethargy or unconscious
Give the oxygen through nasal prongs or a nasal catheter at a flow rate of 1-2 liters/minute until the child's condition improves.

53
TREAT WHEEZING
This annex descries how to treat a child 2 months up to 5 years with a first episode of wheezing, and how to assess a RAPID ACTING BRONCHODILATOR*
child who has recurrent wheezing. Use a bronchodilator to treat a child with a first episode of wheezing.
Nebulized Salbutamol, 0.5 ml Salbutamol plus 2.0
Before giving the bronchodilator, look to see if the child who is in “respiratory distress” (fast breathing + use of accessory 5 mg/ml ml sterile water
muscles of breathing). A child in respiratory distress is uncomfortable, and is obviously not getting enough air into the
lungs. The child may have trouble feeding or talking because he cannot get enough air. The condition can usually be
recognized by simple observation. They are alert and are getting enough air into their lungs. Subcutaneous Epinephrine 0.01 ml/kg body weight
(Adrenaline), 1:1000 (maximum 0.3 ml)
solution
The steps to follow when treating a child with wheezing
* Salbutamol 0.5 ml (2.5mg) diluted in 2.0 ml of sterile
Treat Wheezing water per dose nebulization (vaporization) should be
used. If Salbutamol is not available, use Epinephrine
Children with first episode of wheezing (Adrenaline), 0.01 ml/kg (up to a maximum of 0.3ml) of
1:1000 solution given subcutaneously with a 1 ml syringe.
If in respiratory distress Give a rapid – acting bronchodilator and refer. In the absence of a response to the first dose, the 2nd
dose is given after 30 minutes and the 3rd dose after an
If not in respiratory distress Give oral Salbutamol. hour.

Children with Recurrent Wheezing (Asthma)

ŸGives a rapid acting bronchodilator
Ÿ Assess the child’s condition 30 minutes later.

IF: THEN:
ORAL SALBUTAMOL, three times daily for five days
RESIRATORY DISTRESS OR Treat for SEVERE PNEUMONIA or
ANY DANGER SIGN VERY SEVERE DISEASE (Refer).
Age or Weight 2 mg/5ml, 2 mg, 4 mg
syrup tablet tablet
NO RESIRATORY DISTRESS AND:
2 months up to 12 2.5 ml 1/2 1/4
FAST BREATHING Treat for PNEUMONIA.
months (4-10 kg)
Give oral Salbutamol.

NO FAST BREATHING Treat for NO PNEUMONIA: 12 months up to 5 years) 5.0 ml 1 1/2

COUGH OR COLD (10- 19 kg)
Give oral Salbutamol

54
Essential Care for
VERY SEVERE FEBRILE DISEASE
1. Give antibiotic and antimalarial treatment - A child with VERY SEVERE FEBRILE DISEASE needs treatment for both meningitis and severe malaria (in high or low malaria
risk areas). It is clinically difficult to differentiate between the two. Treat for both possibilities.

 For meningitis, give both IV/IM Chloramphenicol and Benzyl Penicillin or Ampicillin. It is preferable to give an injection every 6 hours. If this is not possible, use the
8-hour or the 12-hour dosing schedule (see Treatment Instructions). Give both antibiotics by injection for at least 3-5 days. If the child has improved by this time,
switch to oral Chloramphenicol. The total treatment duration should be 10 days.
 For SEVERE MALARIA, give IV/IM Artesunate (preferable) or IV/IM Quinine. If you start Quinine, repeat the Quinine injection at a dose of 10mg/kg, every 8 hours until the
child is able to take an oral antimalarial. See Treatment Instructions on Page 35.

2. Manage fluids carefully - The fluid plan depends on the child's signs.
 If the child also has diarrhoea with SEVERE DEHYDRATION, but has no stiff neck and no SEVERE MALNUTRITION OR SEVERE ANAEMIA, give fluids
according to Plan C.

The general danger sign which resulted in the classification VERY SEVERE FEBRILE DISEASE may have been due only to dehydration. Rehydrate, and then
completely reassess and reclassify the child. The reassessment and reclassification of the child after rehydration may lead to a change in treatment plan if the child
no longer is classified as VERY SEVERE FEBRILE DISEASE. If the child rapidly loses his danger signs with rehydration, do not continue treatment with Quinine,
Benzyl Penicillin and Chloramphenicol.

If the child has VERY SEVERE FEBRILE DISEASE with a stiff neck or bulging fontanelle, restrict fluids. The child may have meningitis. Be careful to restrict the
amount of fluid as follows:

AGE Approximate amount of formula to give Total amount in 24 hours

FLUIDS IF MENINGITIS SUSPECTED
(stiff neck or bulging fontanelle) Less than 12 months: 3.3 ml/kg/hour 80 ml/kg/day
12 months up to 5 years: 2.5 ml/kg/hour 60 ml/kg/day

 Avoid giving intravenous fluids.

 If the child is vomiting everything or not able to drink or breastfeed, give fluid by NG tube.
 If you do not know how to use a NG tube and the child is able to swallow, use a dropper to give the child fluid very slowly, or drip fluid from a cup or a
syringe (without needle).
 If the child has SEVERE MALNUTRITION, give fluids as described under Essential Care for SEVERE PNEUMONIA or VERY SEVERE DISEASE (Page 52-53).

3. Treat the child to prevent low blood sugar - See Treatment Instructions on Page 63.

55
Essential Care for SEVERE PERSISTENT DIARRHOEA
1. Treat dehydration using the appropriate fluid plan

2. Advise mother how to feed child with persistent diarrhoea - See the box on the COUNSEL THE MOTHER chart. For infants less than 6 months, exclusive breastfeeding is very
important. If the mother has stopped breastfeeding, help her relactate (or get help from someone who knows how to counsel on relactation).

3. Give vitamins and minerals - Give supplementary vitamins and minerals every day for 2 weeks. Use a mixture containing a broad range of vitamins and minerals, including at least twice
the recommended daily allowance of folate, Vitamin A, zinc, magnesium and copper.

4. Identify and treat infection - Some children with PERSISTENT DIARRHOEA have dysentery and other infections such as pneumonia, sepsis, and urinary tract infection. These require
specific antibiotic treatment. If no specific infection is identified, do not give antibiotic treatment because routine treatment with antibiotics is not effective.

5. Monitor the child - See the mother and the child each day. Monitor the child's feeding and treatments and the child's response. Ask what food the child eats and how much. Ask about
the number of diarrhoeal stools. Check for signs of dehydration and fever.
Once the child is feeding well and has no signs of dehydration, see the child again in 2 to 3 days. If there are any signs of dehydration or problems with the changes in feeding, continue to
see the child every day. Help the mother as much as possible.

Essential Care for SEVERE COMPLICATED MEASLES

1. Manage measles complications - Management depends on which complications are present.

 If the child has mouth ulcers, apply half-strength (0.25%) gentian violet. Help the mother feed her child. If the child cannot swallow, feed the child by NG tube. Treat with IM
Chloramphenicol.

 If the child has corneal clouding, be very gentle in examining the child's eye. Treat the eye with Tetracycline eye ointment carefully. Only pull down on the lower lid and do not
apply pressure to the globe of the eye. Keep the eye patched gently with clean gauze.

 Also treat other complications of measles, such as pneumonia, diarrhoea, ear infection.

2. Give Vitamin A - Give 3 doses of Vitamin A. Give the first dose on the first day and the second dose on day 2. Give the third dose on day 15 (14 days from the 2nd dose).

3. Feed the child to prevent malnutrition

Essential Care for MASTOIDITIS - Give IV/IM Benzyl Penicillin/Ampicillin and IV/IM Chloramphenicol. Treat for 10 days total. Switch to oral Chloramphenicol after 3-5 days.

Essential Care for SEVERE MALNUTRITION - see pages 65 - 67.

56
Essential Care for SEVERE ANAEMIA - A child with severe anaemia is in danger of heart failure.

1. Give iron by mouth

2. Give antimalarial, if needed
3. Give Mebendazole/albendazole for hookworm or whipworm.
4. Feed the child - Give good complementary foods.
5. Give Paracetamol if fever is present - Give Paracetamol every 6 hours.
6. Give fluids carefully - Let the child drink according to his thirst. Do not give IV or NG fluids.

Essential Care for Cough of 14 Days or more - Follow the current national TB guideline.

1. Give first-line antibiotic for PNEUMONIA - If the child has not been treated recently with an effective antibiotic for PNEUMONIA, give an antibiotic for 5 days.
2. Give Salbutamol—if the child is wheezing or coughing at night and there is a family history of asthma, give salbutamol for 5-7 days.
3. Weigh the child and inquire about Tuberculosis (TB) in the family
4. Follow-up in 2 weeks - If there is no response to the antibiotic (with or without Salbutamol) or if the child is losing weight, refer to hospital for appropriate
investigation and treatment.

Essential Care for Convulsions (current convulsions, not by history but during this illness)

1. Manage the airway -Turn the child on his side to reduce the risk of aspiration. Do not try to insert an oral airway or keep the mouth open with a spoon or
spatula. Make sure that the child is able to breathe. If secretions are interfering with breathing, insert a catheter through the nose into the pharynx and clear
the secretions with suction.
2. Give Diazepam followed by paraldehyde- See Treatment Instructions on Page 63.
3. If high fever present, lower the fever - Give Paracetamol and sponge the child with tepid water.
4. Treat the child to prevent low blood sugar - See Treatment Instructions on Page 63.

57
SICK YOUNG INFANT BIRTH UP TO 2 MONTHS

Essential Care for VERY SEVERE DISEASE

This young infant may have pneumonia, sepsis or meningitis.

1. Give IV/M Ampicillin or Benzyl Penicillin and IM Gentamycin - If meningitis is suspected treat for 21 days total. Give the Gentamycin only for a maximum
of 14 days. If meningitis is not suspected, treat for at least 7 days.

When the infant's condition has improved substantially, substitute an appropriate oral antibiotic such as Amoxycillin for IM Benzyl Penicillin or IM Ampicillin.
However, continue to give IM Gentamycin for upto 14 days.

If there is no response to the treatment after 48 hours, or if the infant's condition deteriorates, URGENTLY refer to hospital.

2. Keep the young infant warm.

3. Manage fluids carefully - The mother should breastfeed the infant frequently. If the infant has difficulty breathing or is too sick to suckle, help the mother
express breast milk. Feed the expressed breast milk to the infant by dropper (if able to swallow) or by NG tube 6 times per day. Give 20 ml of breast milk per
kilogram of body weight at each feed. Give a total of 120 ml/kg/day.

If the mother is not able to express breastmilk, prepare a breastmilk substitute , as described in page 43 & 44 of the chart booklet.

4. Treat the child to prevent low blood sugar - See Treatment instructions for treating low blood sugar, Page 63.

58
TREATMENT INSTRUCTIONS

Recommendations on how to give specific treatments for severely ill children who cannot be referred

Three dosing schedules for drugs are provided in this annex. The schedules are for every 6 hours (or four times per day), every 8 hours (or three times per day),
and every 12 hours (or twice per day). Choose the most frequent schedule that you are able to provide.

For IM Gentamycin daily dosing schedule at a dose of 7.5mg/kg once daily, except for newborns < 7 days old who require 5 mg/kg of Gentamycin once daily.

Ideally, the treatment doses should be evenly spaced. Often this is not possible due to difficulty giving a dose during the night. Compromise as needed, spreading
the doses as widely as possible.

Some treatments described below are impractical for a mother to give her child at home without frequent assistance from a health worker, for example, giving
injections or giving frequent feedings as needed by a severely malnourished child. In some cases, a health worker may be willing to care for the child at or near his
home or in the clinic to permit the frequent care necessary. In other cases, it is simply not practical to give the child the treatments that he needs.

Benzyl Penicillin - The first choice is to give IM Benzyl Penicillin. IM Ampicillin can be substituted for Benzyl Penicillin. If you are not able to give IM Benzyl
Penicillin or IM Ampicillin, give oral Amoxycillin.

Ampicillin – Ampicillin can be given IV/IM at a dose of 50mg/kg/dose every 6 hours. It should be diluted to a concentration of 200mg/ml (vial of 500 mg mixed with
2.1 ml of sterile water for injection to give 500mg/2.5 ml solution).

59
TREATMENT INSTRUCTIONS...

Gentamycin - Give IM Gentamycin every 24 hours, 7.5mg/kg/dose for those ≥ 7 days old. Newborns < 7 days old are given 5 mg/kg of Gentamycin once daily.
If Gentamycin is not available, give young infants with VERY SEVERE DISEASE both Benzyl Penicillin/Ampicillin and Chloramphenicol.

Avoid using undiluted 40mg/ml Gentamycin. Add 6 ml sterile water to 2 ml vial containing 80 mg which gives you an 8 ml solution with a 10mg/ml Gentamycin
concentration.

Chloramphenicol - Give IM Chloramphenicol for 5 days. Then switch to an oral antibiotic to complete 10 days of antibiotic treatment. If you are not able to give
IM antibiotic treatment, but oral Chloramphenicol is available, give oral Chloramphenicol by mouth or NG tube. Give every 6 hours, if possible.

Quinine – See instruction on Page 62

Give first dose of IM Quinine at a loading dose of 20mg/kg (divided into 2 sites, anterior thigh). Repeat the IM Quinine injection at a dose of 10mg/kg every 8
hours until the child is able to take an oral anti-malarial. After 48 hours of parenteral therapy, reduce the maintenance dose by 1/3 to ½, that is, 5-7mg/kg every
8 hours. Stop the IM Quinine as soon as the child is able to take an oral antimalarial.

The injections of Quinine usually should not continue for more than 4-5 days. Too high of a dosage can cause deafness and blindness, as well as irregular
heartbeat or cardiac arrest.

The child should remain lying down for one hour after each injection as the child's blood pressure may drop. The effect stops after 15 - 20 minutes.

When the child can take an oral antimalarial, give a full dose according to national guidelines for completing the treatment of severe malaria. Currently, the oral
antimalarial recommended is Coartem.

60
TREATMENT INSTRUCTIONS ...

61
TREATMENT INSTRUCTIONS...

62
Treat the Child to Prevent Low Blood Sugar
If the child is conscious, follow the instructions on the TREAT chart. Feed the child frequently, every 2 hours, if possible.
If the child is unconscious and you have dextrose solution and facilities for an intravenous (IV) infusion, start the IV infusion. Once you are sure that the IV is
running well, give 5 ml/kg of 10 % dextrose solution (D10) push, or give 1 ml/kg of 40% dextrose solution (D50) by very slow push. Then insert a NG tube and
begin feeding every 2 hours.

Potassium Chloride Solution (100 grams KCl per litre) - Give 0.5 ml (or 10 drops from a dropper) per kilogram of body weight with each feed. Mix well into the feed.

Diazepam and paraldehyde

Per rectum - Use a plastic syringe (the smallest available) without a needle. Put the Diazepam or Paraldehyde in the syringe. Gently insert the syringe into the
rectum. Squirt the Diazepam or Paraldehyde. Keep the buttocks squeezed tight to prevent loss of the drug.
If both Diazepam and Paraldehyde are available, use the following schedule:
1. Give Diazepam.
2. In 10 minutes, if convulsions continue, give Diazepam again.
3. In 10 more minutes (that is, 20 minutes after the first dose), if convulsions continue, give Paraldehyde.
4. In 10 more minutes (that is, 30 minutes after the first dose), if convulsions continue, give Paraldehyde again.
This is the preferred treatment. It is safer than giving 3 doses of Diazepam in a row due to the danger of respiratory depression.
If only Diazepam is available, use the following schedule:
1. Give Diazepam.
2. In 10 minutes, if convulsions continue, give Diazepam again.
3. In 10 more minutes (that is, 20 minutes after the first dose), if convulsions continue and the child is breathing well, give Diazepam again. Watch closely for
respiratory depression.
If only Paraldehyde is available, use the following schedule:
1. Give Paraldehyde.
2. In 10 minutes, if convulsions continue, give Paraldehyde again.
3. In 10 more minutes (that is, 20 minutes after the first dose), if convulsions continue, give Paraldehyde again.

DOSAGE TABLE - DIAZEPAM and PARALDEHYDE

DIAZEPAM (10 mg/2 ml solution) PARALDEHYDE, (1 g/ml solution)

AGE or WEIGHT Dose: 0.2 - 0.4 mg/kg, Give rectally. Dose: 0.15 - 0.3 ml/kg, Give rectally.
1 month up to 4 months (3 - <6 kg) 0.5 ml (2.5 mg) 1.0 ml
4 months up to 12 months (6 - 10 kg) 1.0 ml (5 mg) 1.5 ml
12 months up to 3 years (10 - <14 kg) 1.25 ml (6.25 mg) 2.0 ml
3 years up to 5 years (14 - 19 kg) 1.5 ml (7.5 mg) 3.0 ml

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 APPETITE TEST FOR CHILDREN WITH SEVERE MALNUTRITION

In a child who is 6 months or older, if MUAC is less than 11 cms or if edema of both feet and has no medical complications (pneumonia, persistent diarrhoea, watery
diarrhea with dehydration, dysentery, malaria, measles, hypothermia (axillary temperature <350C) or high fever (> 38.50C), open skin lesions, signs of vitamin A deficiency,
and excessive edema involving the feet, legs, hands and face), assess appetite.

How to do the appetite test?

1. The appetite test should be conducted in a separate quiet area.
2. Explain to the care taker the purpose of the appetite test and how it will be carried out.
3. The care taker, where possible, should wash his hands.
4. The care taker should sit comfortably with the child on his lap and either offers the Ready to Use Therapeutic Food (RUTF) from the packet or put a small amount on
his finger and give it to the child.
5. The care taker should offer the child the RUTF gently, encouraging the child all the time. If the child refuses then the care taker should continue to quietly encourage
the child and take time over the test. The test usually takes 15-30 minutes but may take up to one hour. The child must not be forced to take the RUTF.
6. The child needs to be offered plenty of water to drink from a cup as he/she is taking the RUTF.

The result of the appetite test -See the appetite test table on the next page to determine pass or fail depending on the amount of RUTF consumed.
Pass
1. A child who takes at least the amount shown in the appetite test table (see next page 65) passes the appetite test.
2. Explain to the care taker the choices of treatment option and decide with the care taker whether the child should be treated as an out-patient or in-patient (nearly all
care takers will opt for out-patient treatment).
3. Guide the patient to the Outpatient Therapeutic Program (OTP) for registration and initiation of treatment.

Fail
1. A child that does not take at least the amount of RUTF shown in the table below should be referred for in-patient care.
2. Explain to the care taker the choices of treatment options and the reasons for recommending in-patient care; decide with the care taker whether the patient will be
treated as an in-patient or out-patient.
3. Refer the patient to the nearest Therapeutic Feeding Unit (TFU) or hospital for Phase 1 management.

The appetite test should always be performed carefully. Patients who fail their appetite tests should always be offered treatment as in-patients. If there is any doubt then the
patient should be referred for in-patient treatment until the appetite returns.

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 APPETITE TEST TABLE
APPETITE TEST
This is the minimum amount that malnourished patients should take to pass the appetite test

RUTF (Plumpy Nut) BP 100

Body Weight (Kg) Sachet Body weight (Kg) Bars
<4 ⅛. <5 ¼
4 up to 10 ¼ 5 up to 10 ½
10 up to 15 ½ 10 up to 15 ¾
> 15 ¾ > 15 1

OUTPATIENT MANAGEMENT OF UNCOMPLICATED SEVERE MALNUTRITION

Children (> 6 months) with severe acute malnutrition (SAM) WITHOUT medical complications and who PASS the appetite test – can be treated as
outpatients with:

1. Ready to Use Therapeutic Food (RUTF) according to the following table

RUTF (Plumpy Nut) BP 100 biscuits

(500 Kcal/92 gm sachet) (1 BP100 Bar = 56.7gm= 300Kcal)
Weight of child (kgs) Sachet per day Sachet per week Bars per day Bars per week
3.0 up to 3.5 1¼ 9 2 14
3.5 up to 5.0 1½ 11 2½ 17 ½
5.0 up to 7.0 2 14 4 28
7.0 up to 10 3 21 5 35
10 up to 15 4 28 7 49
15 up to 20 5 35 9 63

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Key education messages for care takers of children on OTP

1. RUTF is a food and medicine for malnourished children only. It should not be shared
2. Sick children often do not like to eat. Give small regular meals of RUTF and encourage the child to eat often, every 3-4 hours (up to 8 meals per day)
3. RUTF is the only food these children need to recover during their time in OTP
4. For breast-fed children, always give breast milk before the RUTF and on demand
5. Always offer plenty of clean water to drink while eating RUTF
6. Use soap for child’s hand and face before feeding, if possible
7. Keep food clean and covered
8. Sick children get cold quickly, always keep the child covered and warm
9. With diarrhea, never stop feeding. Give extra food and clean water (or breast milk)
NB – Check the mothers understanding using appropriate checking questions.

2. Oral antibiotics – Give Amoxicillin three times per day for 7 days (for dosage see drug table).

3. Vitamin A - Give vitamin A on the day of discharge (for those children who have completed Phase 2 as an in-patient) or at the 4th week of the treatment for those in out-patient care. Do not
give Vitamin A at admission for children to be started on therapeutic diet. A high dose of vitamin A should be given ONLY at the end of the rehabilitation phase for children with SAM (with or
without edema) receiving fortified feeds (or after 4 weeks of treatment when the child is treated as outpatient), or whenever the child is switched from F100 or RUTF to the family diet.

However, vitamin A should be given immediately at admission if:

• the child has visible clinical signs of vitamin A deficiency (Bitot’s spots, corneal clouding, or corneal ulceration)
• the child has signs of eye infection (pus, inflammation); or
• the child has measles now or has had measles in the past 3 months.

4. Give Mebendazole/Albendazole at the 2nd outpatient visit (after 7 days).

5. Give Measles vaccine on the 4th week of treatment for all children aged 9 months/more and without a vaccination card (unvaccinated).

6. Children should be brought back to the health facility on a weekly basis until they recover. At each follow up visit, health staff should check the following:-
A) Record weight, MUAC and check for oedema
B) Conduct the appetite test (every visit)
C) Do a complete reassessment according to the assess chart (if the child has developed medical complications they should be referred to the nearest in-patient unit)

7. Children may be discharged from the OTP when they reach the following criteria
A) For admissions with oedema - absence of oedema for 2 consecutive visits (2 weeks after edema disappears)
B) For admissions without edema – achievement of target weight for discharge (see page 78) or a 20% weight gain from admission weight (e.g.- child was 4.7 kgs on admission: 4.7
+ 20% = 5.6 kg) for 2 consecutive weeks.
C) If a child fails to reach the discharge criteria after 2 months of treatment, they should be referred to the nearest in-patient unit for further investigation and discharged as ‘non
recovered’ from OTP

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 8. Criteria for transfer of OTP patients to in-patient care - Out-patients, who develop any sign of a serious medical complication or develops any of the
following s/he should be referred to the in-patient facility.

Criteria for failure to respond and to move back from out-patient to in-patient care Time after admission

Primary failure to respond

Failure to gain any weight (non-oedematous children) 21 days

Failure to start to lose oedema 14 days
Oedema still present 21 days
Secondary failure to respond
(signs of deterioration after initial response in appetite, weight gain in marasmic children and loss
of all edema in kwash patients)
Failure of Appetite test At any visit
Weight loss of 5% of body weight At any visit
Weight loss for two successive visits During OTP care
Failure to gain more than 2.5g / kg / d for 21days (after loss of oedema (kwashiorkor) or after day During OTP care
14 (marasmus)

If a child requires in-patient care, all anthropometric measurements, medical history and physical findings are recorded in the OTP card and the child is classified
as transfer.

Children with severe acute malnutrition WITH complications or who FAIL the appetite test – need to be referred to an in-patient unit for treatment with therapeutic
milks (F-75 and F-100), until their condition stabilizes and they can continue their treatment at home with RUTF.

In-patient treatment should be given in accordance with the Ethiopian National Guideline “Protocol for the management of Severe Acute Malnutrition”
FMoH, revised March 2007.

If a carer refuses to take their child to the in-patient unit, the child should be given treatment in OTP and ‘refused transfer’ recorded on the chart.

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MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS
Name: _____________________________________ Age: _____ weeks Sex:____ Weight: _______ gm Length: _______ cm Temperature: ____°C
ASK: What are the infant’s problems? ___________________________________________________________ Initial visit? ___ Follow-up Visit? ___
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR BIRTH ASPHYXIA (immediately after birth) Not breathing Gasping
Is breathing poorly (< 30 per minute)
Blue tounge & lips
ASSESS FOR BIRTH WEIGHT AND GESTATIONAL AGE
(the first7 days of life) Weigh the baby:
Ask gestational age; <32 wks, 32-37wks, ≥ 37wks <1,500gms, 1,500-2,500gms, ≥2,500gms
CHECK FOR VERY SEVERE DISEASE and LOCAL BACTERIAL INFECTION
· Count the breaths in one minute. ____breaths per minute
- Is the infant having feeding difficulty? Repeat if (≥ 60) elevated ________ Fast breathing?
· Look for severe chest indrawing.
· Look if the Infant is convulsing now.
- Has the infant had convulsions?
· Look at umbilicus. Is it red or draining pus?
· Fever (temperature > 37.5°C or feels hot) or body temperature < 35.5°C (or feels
cool) or body temperature between 35.5 - 36.4°C.
· Look for skin pustules.
· Look at young infant’s movements.
Does the infant move only when stimulated?
Does the infant not move even when stimulated?
CHECK FOR JAUNDICE Are skin on the face or eyes yellow?
Are the palms and soles yellow?
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes ____ No ____ ·Look at the young infant’s general condition.
Does the infant move only when stimulated?
· For how long? _______ Days Does the infant not move even when stimulated?
Is the infant restless or irritable?
Look for sunken eyes.
· Is there blood in the stools? Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?
CHECK FOR HIV INFECTION
ASK: HIV status of the mother? Positive_____ , Negative____ , Unknown _____
Antibody HIV status of the infant? Positive_____, Negative____ , Unknown _____
DNA/PCR HIV status of the infant? Positive_____ , Negative____ , Unknown _____

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THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT
· Is there any difficulty of feeding? Yes _____ No _____ · Determine weight for age.
· Is the infant breastfed? Yes _____ No _____ If Yes, how many times in 24 hrs? _____ times Underweight ___
· Do you empty one breast before switching to the other? Yes___No__ NOT Underweight ___
· Do you increase frequency of breastfeeding during illness? Yes___No___ · Look for ulcers or white patches in the mouth (oral thrush).
· Does the infant receive any other foods or drinks? Yes ___ No ___ If Yes, how often?_____ times
· What do you use to feed the child?
If the infant has no indications to refer urgently AND infant is on breastfeeding, ASSESS BREASTFEEDING:
- Has the infant breastfed in the previous hour? - Is the infant able to attach? To check attachment, look for:
- If infant has not fed in the previous hour, ask the mother to put her infant - Chin touching breast Yes ___ No ___
to the breast. Observe the breastfeed for 4 minutes. - Mouth wide open Yes ___ No ___
- If the infant was fed during the last hour, ask the mother if she can wait - Lower lip turned outward Yes ___ No ___
and tell you when the infant is willing to feed again - More areola above than below the mouth Yes ___ No ___
Good attachment_____ Poor attachment______ No attachment at all ____
- Is the infant positioned well? To check positioning, look for:
- Infant’s head and body straight Yes ___ No ___ - Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
- Facing the breast Yes ___ No ___ Suckling effectively_____ not suckling effectively______ not suckling at all____
- Infant’s body close to her body Yes ___ No ___
- Supporting the whole body Yes ___ No ___
Good Positioning_____ Poor positioning________
ASSESS FEEDING, WHEN HIV POSITIVE MOTHER NOT BREAST FEEDING
ŸIs there any difficulty feeding?
ŸWhat milk are you giving?__________________ · Determine weight for age.
ŸHow many times during the day and night? Underweight ___
ŸHow much is given at each feed? NOT Underweight ___
ŸHow are you preparing the milk? · Look for ulcers or white patches in the mouth (oral thrush).
Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant
ŸAre you giving any breastmilk at all?
ŸWhat foods or fluids in addition to the replacement feeding is given?
ŸHow is the milk being given? Cup or bottle?
ŸHow are you cleaning the feeding utensils
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS Circle immunizations needed today. Return for next
__________ ____________ ___________ _______________ ____________ immunization on:
OPV 0 BCG OPV 1 DPT1-HepB1-Hib1 PCV1 ______________
ASSESS OTHER PROBLEMS:
COUNSEL THE MOTHER ABOUT HER OWN HEALTH
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Return for follow-up in:_____________________
Give any immunizations needed today:________
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 Remember to refer any child who has a danger sign
and no other severe classification
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Return for follow-up in:_____________________
Advise mother when to return immediately
Give any immunizations needed today:________
Feeding advise:
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TARGET WEIGHT FOR DISCHARGE FROM OTP FOLLOW-UP

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 Contact Address
Federal Ministry of Health
Health Promotion and Disease Prevention General Directorate
E-mail: moh@ethionet.et
Tel: +251-11-515 99 78; +251-11-515 0407
Fax: 552 45 49
P.O.Box: 1234