INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

 Nursing Responsibility: ACT (Assess, Classify, Treat)

 CHILD – 2 MOS. UP TO 5 YEARS OF AGE

I. ASSESS

 GENERAL DANGER SIGNS

 Inability to drink or breastfeed
 Vomiting all intake
 Convulsion
 Abnormally sleepy; difficult to arouse

TAKE NOTE: Make sure the child with any general danger sign is referred after
first dose of an appropriate antibiotics & other urgent treatments
Exception: Rehydration of the child according to Plan C may resolve the danger
signs so that referral is no longer needed.

 MAIN SYMPTOMS

 COUGH OR DIFFICULT BREATHING

 Ask for how long?
 Count the breaths in one minute check for fast breathing
 2mos to 1yo: 50bpm
 1yo to 5yo: 40bpm
 Look for chest indrawing
 Look & listen for stridor
 Look & listen for wheezes
 If with wheezing & either fast breathing or chest indrawing:
 Give a trial of rapid-acting inhaled bronchodilator for up to three times
15-20 minutes apart. Count the breaths & look for chest indrawing
again, & then classify.

 DIARRHEA
 Ask for how long?
 Look at the child’s general condition
 Abnormally sleepy or difficult to awaken?
 Restless or irritable?
 Sunken eyes?
 Offer child fluid (not able to drink or drinking poorly? or eagerly or
thirstily)
 Pinch the skin of the abdomen (color goes back very slowly – longer than 2
seconds; or slowly?
 Is there blood in the stool?

 FEVER (temperature of 37.5°C or more) CBQ

 Malaria/Measles
 ASK
 Does the child live in a malaria area?
 Has the child visited/traveled or stayed overnight in a malaria area in
the past 4 weeks?
(If yes to either, obtain a blood smear)
 THEN ASK
 For how long has the child had fever?
 If more than 7 days, has fever been present every day?
 Has the child had measles within the last 3 months?
 LOOK & FEEL
 Stiff neck, runny nose
  Signs of measles:
 Generalized rash
 One of these: cough, runny nose, or red eyes
 If the child has measles now or within the last three months:
 LOOK FOR:
 Mouth ulcers; are they deep & extensive?
 Pus draining from the eye
 Clouding of the cornea

 Dengue
 ASK:
 Has the child had any bleeding from the nose or gums or in the
vomitus or stools?
 Has the child had black vomitus?
 Has the child had black stools?
 Has the child had abdominal pain?
 Has the child been vomiting?
 LOOK & FEEL
 Look for bleeding from nose or gums
 Look for skin petechiae
 Feel for cold & clammy extremities
 Check for slow capillary refill
 If none of the above ASK or LOOK & FEEL signs are present & the
child is 6 months or older & fever is present for more than three days:
 Perform the tourniquet test

 Ear Problem (CBQ)

 ASK
 Is there ear pain?
 Is there ear discharge?
 If yes, for how long?
 LOOK & FEEL
 Look for pus draining from the ear
 Feel for tender swelling behind the ear

 CHECK FOR MALNUTRITION:

 LOOK & FEEL
 For all children:
 Determine weight for age
 Look for edema of both feet
 Look for visible severe wasting
 For children aged 6 months or more; determine if MUAC (mid-upper arm
circumference) is less than 110mm; (if tapes are not available, look for visible
severe wasting

 CHECK FOR ANEMIA

 LOOK & FEEL
 Look for palmar pallor (Is it severe or some palmar pallor?)

 CHECK CHILD’S IMMUNIZATION STATUS

 Birth – BCG, HEPA B (1st dose)
 6wks – DPT, OPV, HEPA B (2nd dose)
 10wks - DPT, OPV (2nd dose)
 14wks - DPT, OPV, HEPA B (3rd dose)
 9mos – Measles

 CHECK VITAMIN A STATUS

 First Dose at 6 months or above
 Subsequent doses every 6 months
 CHECK DEWORMING STATUS:
 Give every child Mebendazole every 6 months from the age 1. Record the case on
the child’s card.

 ASSESS OTHER PROBLEMS

II. CLASSIFY & TREAT:

 Cough & Difficult Breathing

CLASSIFICATION SIGNS TREATMENT

SEVERE PNEUMONIA Any of the ff: *Give 1st dose of appropriate antibiotic
OR VERY SEVERE *any danger sign *Give Vit.A regardless of last dose
DISEASE *chest indrawing *If with chest indrawing & wheezes,
*stridor in calm child go to treat wheezing
*Treat child to prevent ↓ bld sugar
*Refer urgently to hospital
PNEUMONIA Fast Breathing (if with *Give appropriate antibiotic for 3 days
wheezing, go directly to * If wheezing (even if it disappeared
treat wheezing) after rapid-acting bronchodilator for
five days)
*Soothe the throat & relieve cough w/
a safe remedy
* If coughing for more than 3 weeks
or if having recurrent wheezing,
refer for assessment for TB &
asthma
*Advise mother when to return ASAP
*Follow up in 2 days
NO PNEUMONIA; No signs of pneumonia or * If wheezing (even if it disappeared
COUGH OR COLD very severe disease (if after rapid-acting bronchodilator)
wheezing go directly to for five days
treat wheezing) * If coughing is more than 30days,
refer for assessment
*Soothe the throat to relieve cough w/
safe remedy
*Advise mother when to return ASAP
*Follow up in 5 days if not improving

 Diarrhea

CLASSIFICATION SIGNS TREATMENT

SEVERE 2 of the ff signs: *If child has no other severe
DEHYDRATION *Abnormally sleepy or difficult classification – give fluid for
to arouse severe dehydration (PLAN C)
*Sunken eyes OR
*Not able to drink or drinking *If child also has another severe
poorly classification – refer urgently to
*Skin pinch goes back very hospital with mother giving
slowly frequent sips of ORS on the way;
advise mother to continue breast-
feeding
*If child is 2yo or older & there is
cholera in your area, give
antibiotic for cholera
SOME 2 of the ff signs: *Give fluid & food for some
DEHYDRATION *Restless, irritable dehydration (PLAN B)
*Sunken eyes *If child also has a severe
*Drinks eagerly, thirstily classification – refer urgently to
*Skin pinch goes back slowly hospital with mother giving
frequent sips of ORS on the way;
advise mother to continue breast-
feeding
*Advise mother when to return
immediately
*Follow up in 5 days if not
improving
NO DEHYDRATION Not enough signs to classify as *Give ORS, zinc supplements &
some or severe dehydration food to treat diarrhea at home
(PLAN A)
*Advise mother when to return
 immediately
*Follow up in 5 days if not
improving
SEVERE Diarrhea is 14 days or more *Treat dehydration before referral
PERSISTENT Dehydration is present unless child has another severe
DIARRHEA classification
*Give Vit.A
*Refer to hospital
PERSISTENT Diarrhea is 14 days or more *Advise the mother on feeding a
DIARRHEA No dehydration child who has persistent diarrhea
*Give multivitamins & minerals
(including zinc) for 14 days
*Follow up in 5 days
*Advise when to return
immediately
DYSENTERY Blood in the stool *Give Ciprofloxacin for 3 days
*Follow up in 2 days
*Advise when to return
immediately

 Fever

Malaria Risk
CLASSIFY SIGNS TREATMENT
VERY SEVERE Any general danger sign or *Give 1st dose of quinine (under
FEBRILE DISEASE/ Stiff neck medical supervision or if a
MALARIA hospital is not accessible within 4
hours)
*Give first dose of an appropriate
antibiotic
*Treat the child to prevent low
blood sugar
*Give one dose of paracetamol in
health center for high fever
(38.5°C or above)
*Send blood smear with the
patient
*Refer urgently to the hospital
MALARIA Blood smear (+) *Treat the child with an oral
If blood smear not done: antimalarial
NO runny nose & *Give one dose of paracetamol in
NO measles & health center for high fever
NO other cause of fever (38.5°C or above)
*Advise mother when to return
immediately
*Follow up in 2 days if fever
persists
*If fever is present every day for
more than 7 days, refer for
assessment
FEVER; MALARIA Blood smear (-) or *Give one dose of paracetamol in
UNLIKELY Runny nose or health center for high fever
Measles or (38.5°C of above)
Other causes of fever *Advise mother when to return
immediately
*Follow up in 2 days if fever
persists
*If fever is present every day for
more than 7 days, refer for
assessment
*Treat other causes of fever

No Malaria Risk
CLASSIFY SIGNS TREATMENT
VERY SEVERE Any general danger signs or *Give one dose of an appropriate
FEBRILE DISEASE Stiff neck antibiotic
*Treat the child to prevent low
blood sugar
*Give one dose of paracetamol in
health center for high fever
(38.5°C of above)
*Refer urgently to hospital
FEVER; NO No signs of very severe febrile * Give one dose of paracetamol
 MALARIA disease in health center for high fever
(38.5°C of above)
*Advise mother when to return
immediately
*Follow up in 2 days if fever
persists
* If fever is present every day for
more than 7 days, refer for
assessment

If measles now or within last 3 months

CLASSIFY SIGNS TREATMENT
SEVERE Any danger sign *Give Vit.A
COMPLICATED Clouding of cornea or *Give 1st dose of an appropriate
MEASLES Deep or extensive mouth ulcers antibiotic
*If clouding of the cornea or pus
draining from the eye, apply
tetracycline eye ointment
*Refer urgently to the hospital.
MEASLES WITH Pus draining from eye or *Give Vit.A
EYE OR MOUTH Mouth ulcers *If pus draining from the eye,
COMPLICATIONS apply tetracycline eye ointment
*If with mouth ulcers, teach the
mother to treat with gentian
violet
*Follow up in 2 days
*Advise mother when to return
immediately
MEASLES Measles now or within the last 3 *Give Vit.A
months *Advise mother when to return
immediately

Dengue Risk
CLASSIFY SIGNS TREATMENT
SEVERE DENGUE Bleeding from nose or gums or *If persistent vomiting or
HEMORRHAGIC Bleeding in stools or vomitus or persistent abdominal pain or skin
FEVER Black stools or vomitus or petechiae or (+) tourniquet test
Skin petechiae or are the only positive signs; give
Cold & clammy extremities or ORS as in Plan B
Capillary refill >3sec or *If any other signs are positive,
Persistent abdominal pain or give fluids rapidly as in Plan C
Persistent vomiting or *Treat the child to prevent low
Tourniquet test (+) blood sugar
*Refer urgently to hospital
*Do not give ASPIRIN
FEVER: DENGUE No signs of severe dengue *Advise mother when to return
HEMORRHAGIC hemorrhagic fever immediately
FEVER UNLIKELY *Follow up in 2 days if fever
persists or child shows signs of
bleeding
*Do not give aspirin

 Ear Problem

CLASSIFICATION SIGNS TREATMENT

MASTOIDITIS Tender swelling behind the ear *Give 1st dose of an appropriate
antibiotic
*Give 1st dose of paracetamol for
pain
*Refer urgently to hospital
ACUTE EAR Pus is seen draining from the ear *Give antibiotic for 5 days
INFECTION & discharge is reported for less *Give paracetamol for pain
than 14 days or *Dry the ear by wicking
Ear pain *Follow up in 5 days
*Give advise when to report
immediately
CHRONIC EAR Pus is seen draining from the ear *Dry the ear by wicking
INFECTION & discharge is reported for 14 *Instill otic drops for 2 weeks
days or more *Follow up in 14 days
*Advise when to return
immediately
NO EAR INFECTION No ear pain & no pus seen *No additional treatment
 draining from the ear *Advise mother when to report
immediately

 Malnutrition

CLASSIFICATION SIGNS TREATMENT

SEVERE *If age up to 6mos *Treat the child to prevent low
MALNUTRITION - & visible severe wasting or sugar
- edema of both feet *Refer urgently to hospital
*If age 6mos & above &
-MUAC less than 110mm or
edema of both feet or visible
severe wasting
VERY LOW WEIGHT Very low weight for age *Assess the child’s feeding &
counsel the mother on feeding
according to the feeding
recommendations
*Advise mother when to return
immediately
*Follow up in 30 days
NOT VERY LOW Not very low weight for age & no *If the child is less than 2yo,
WEIGHT other signs of malnutrition assess the child’s feeding &
counsel the mother on feeding
according to the feeding
recommendations
- If feeding is a problem, follow
up in 5 days
*Advise mother when to return
immediately

 Anemia

SEVERE ANEMIA *Severe palmar pallor *Refer urgently to a hospital

ANEMIA *Some palmar pallor *Give iron
*Give oral antimalarial if malaria risk
*Give mebendazole if child is 1yo or
older & has not had a dose in the
previous six months
*Advise mother when to return
immediately
*Follow up in 14 days
NO ANEMIA *No palmar pallor *If child is less than 2yo, assess the
child’s feeding & counsel the mother
on feeding according to the feeding
recommendations
-If with feeding problem, follow up in
5days

TREAT THE CHILD

Carry out the Treatment Steps
Identified in the Classification Chart

 TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

 Determine the appropriate drugs & dosage for the child’s age or weight
 Tell the mother the reason for giving the drug to the child
 Demonstrate how to measure a dose
 Watch the mother practice measuring a dose by herself
 Ask the mother to give the first dose to her child
 Explain carefully how to give the drug, then label & package the drug
 If more than one drug will be given, collect, count & package each drug 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
 Check the mother’s understanding before she leaves the health center
 GIVE AN APPROPRIATE ORAL ANTIBIOTIC
VAMP
For Pneumonia, Acute Ear Infection or Very Severe Disease, Mastoiditis
1st Line Antibiotic: AMOXICILLIN
nd
2 Line Antibiotic: COTRIMOXAZOLE
AMOXICILLIN COTRIMOXAZOLE
Pneumonia: Give 2x daily for Pneumonia: Give 2x daily for
3days 3days
Acute Ear Infection: Give 3x Acute Ear Infection: Give 3x a
daily for 5days day for 5 days

AGE or WEIGHT Adult Tablet Syrup Tablet: 80mg Syrup: 40mg tri-
(250mg) (125mg/5ml) trimethoprim methoprim +
+ 400mg 200mg sulfame
sulfame- thoxazole
thoxazole

2mos – 6 mos ½ 5.0ml ½ 5ml

(3-5kg)
6mos – 12 mos 1 10ml ½ 5ml
(6-9kg)
12mos – 3years 1½ 15ml 1 10ml
(10kg-14kg)
3yrs – 5yrs 2 1 10ml
(15-19kg)

For Dysentery
Give antibiotic recommended for Shigella in the area for 3 days
1st Line Antibiotic: CIPROFLOXACIN (Give 2x for 3days)
AGE or WEIGHT 100mg TABLET (dose/tab) 250mg TABLET (dose/tab)
2mos – 6mos (3-5kg) ½ tablet ¼ tablet
6mos – 12 mos (6-9kg) 1 tablet ½ tablet
12 mos – 3yo (10-14kg) 1 ½ tablet ½ tablet
12mos – 5yo (10-19kg) 2 tablets 1 tablet

For Cholera
1st Line Antibiotic: Tetracycline
2nd Line Antibiotic: Erythromycin
TETRACYCLINE ERYTHROMYCIN
Give 4x daily for 3 days Give 4x daily for 3days
AGE or WEIGHT Tablet 250mg Tablet 250mg
2yo – 5yo (10-19kg) 1 1

 GIVE AN ORAL ANTIMALARIAL

1ST LINE ANTIMALARIAL: ARTEMETER - LUMEFANTRINE
 2nd Line – CHLOROQUINE & PRIMAQUINE; SULFADOXINE &
PYRIMETHAMINE
 If Chloroquine/Primaquine
 Explain to the mother that she should watch her child carefully for
30minutes after giving a dose of Chloroquine; if the child vomits within
30minutes, she should repeat the dose & return to the health center for
additional tablets
 Explain that itching is a possible side effect of the drug but it is not
dangerous
 If Sulfadoxine/Pyrimethamine: Give single dose in health center 2 hours before
intake of Chloroquine
 If Primaquine: Give single dose on day 4 for P. Falciparum
 If Artemether-Lumenfantrine combination: Give for 3 days

 DOSE OF ARTEMETER-LUMEFANTRINE (20 & 120mg respectively)

5-<15kg 15-< 25kg 25-<35kg

 (6mos. to 3yo) (4 to 8yo) (9 to 13 yo)
Day 0 1 tab 2 tabs 3 tabs
8 hrs after 1 tab 2 tabs 3 tabs
Day 1 1 tab BID 2 tabs BID 3 tabs BID
Day 2 1 tab BID 2 tabs BID 3 tabs BID
Day 3 Give primaquine only Primaquine ½ to ¾ Primaquine 1 tablet
to >1yo ½ tablet tab single dose single dose
Single dose

 Preferably taken with high fat diet

 Not recommended during pregnancy, lactation & in infant < 1yo & in severe
malaria
 See other table for Primaquine dosage

 TREATMENT SCHEDULE FOR PROBABLE MALARIA & CONFIRMED

P. FALCIPARUM

Age Number of Chloroquine Sulfadoxine/Pyrimethamine Primaquine

(years) tablet (150mg (500mg/25mg/tablet) (15mg/tablet)
base/tablet) No. of tablet
Day 1- 10mg base/kbw Single dose only
Day 2- 10mg base/kbw Single dose only
Day 3- 10mg base/kbw
Day 1 Day 2 Day 3 Day 1 Day 4
0-4mos ½ ½ ½ ¼ Not included
5-11mos ½ ½ ½ ½ Not included
1-3yo 1 1 ½ 1 ½
4-6yo 1½ 1½ 1 1 1
7-11yo 2 2 1 1½ 2
12-15yo 3 3 1½ 2 3
16yo & > 4 4 2 3 3

 Treatment should be given after meals

 First day of treatment should be under the supervision of the health worker
 SP are generally well tolerated when used at the recommended doses for
malaria & serious events are associated with hypersensitivity to sulfa
component involving the skin & mucous membranes including Steven-
Johnson syndrome & normally occurring after repeated administration

 TREATMENT SCHEDULE FOR CONFIRMED P. VIVAX CASES

Age No. of Chloroquine tablet Primaquine
(years) (150mg base/tablet) (15mg/tablet)
Dosage same as in P. falciparum 1-14 days treatment
Day 1 Day 2 Day 3 Day 4
0-4mos. ½ ½ ½ not included
5-11mos. ½ ½ ½ not included
1-3yo 1 1 ½ ½ daily
4-6yo 1½ 1½ 1 1 daily
7-11yo 2 2 1 ¾ daily
12-15yo 3 3 1½ 1 daily
15yo & > 4 4 2 1 daily

 TREATMENT SCHEDULE FOR MIXED P. FALCIPARUM & P. VIVAX

INFECTION
Age No. of Chloroquine tablet Sulfadoxine/Pyrimethamine Primaquine
(years) (150mg base/tablet) (500mg/25mg/tablet) (15mg/tablet)
No. of Tablet No. of tablets
Single dose only For 14 days
Day 1 Day2 Day 3 Day 1
0-4mos. ½ ½ ½ ¼ not included
5-11mos. ½ ½ ½ ½ not included
1-3yo 1 1 ½ 1 ½ daily
4-6yo 1½ 1½ 1 1 ½
7-11yo 2 2 1 1½ ¾
12-15yo 3 3 1½ 2 1
16yo & > 4 4 2 3 1

 Treatment should be given after meals

  First day of treatment should be under the supervision of the health worker

 GIVE VITAMIN A
 Treatment: Give one dose in the health center
 Supplementation: Give one dose in health center if -
 Child is six months of age or older &
 Child has not received a dose of Vit.A in the past nine months

AGE VITAMIN A CAPSULE

100,000 IU 200,000 IU
6 mos up to 12 mos. 1 ½ capsule
12 mos up to 5yo 1 capsule

 GIVE PARACETAMOL FOR HIGH FEVER (38.5°C OR MORE) & EAR PAIN
 Give paracetamol every 6hours until high fever or ear pain is gone

AGE or WEIGHT TABLET (500mg) SYRUP (120mg/5ml)

2mos – 3yo (4-<14kg) ¼ 5ml (1tsp)
3yo – 5yo (14-19kg) ½ 10ml (2tsps)

 GIVE IRON
 Give one dose daily for 14 days

AGE or WEIGHT IRON/FOLATE IRON SYRUP IRON DROPS

TABLET Ferrous SO4 150mg Ferrous SO4 25mg
Ferrous SO4 200mg per 5ml (25mg elemental iron
+ 250mcg Folate (6mg elemental iron per ml)
(60mg elemental per ml)
iron)
3mos up to 4 mos. 2.5ml (1/2 tsp) 0.6ml
(4-<6kg)
4mos up to 12 mos. 4ml (3/4 tsp) 1.0ml
(6-<10kg)
12 mos up to 3yo ½ tablet 5ml (1tsp) 1.5ml
(10-<14kg)
3yo up to 5yo 1 tablet 10ml (1 ½ tsp) 2.0ml
(14-<10kg)

 GIVE MEBENDAZOLE/ALBENDAZOLE
 Give 500mg Mebendazole/400mg Albendazole as a single dose in health center
if:
 The child is 12 mos up to 59 mos.
 The child has not had a dose in the previous 6 months

AGE OR WEIGHT ALBENDAZOLE 400mg MEBENDAZOLE 500mg

12 mos up to 23 mos. 1/2 1
24 mos up to 59 mos. 1 1

 GIVE MULTIVITAMINS & MINERALS FOR PERSISTENT DIARRHEA

 All children with persistent diarrhea should receive supplementary
multivitamins & minerals each day for two weeks.
 Locally available preparations are often suitable; these should provide a
broad range of vitamins & minerals as possible including at least two
Recommended Energy & Nutrient Intake (RENI) of folate, vitamin A, zinc,
magnesium & copper.

 TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

 Explain to the mother what the treatment is & why it should be given
 Describe the treatment steps
 Watch the mother as she does the first treatment in the health center (except remedy
for cough or sore throat)
 Tell her how often to do the treatment at home
  If needed for treatment at home; give mother the tube of tetracycline ointment or a
small bottle of gentian violet
 Check the mother’s understanding before she leaves the health center

 TREAT EYE INFECTION WITH TETRACYCLINE OINTMENT

 Clean both eyes 4 times daily
 Wash hands
 Ask child to close eyes
 Use clean cloth & water to gently wipe away pus
 Then apply tetracycline eye ointment in both eyes 4 times daily
 Ask the child to look up
 Squirt a small amount of ointment on the inside of the lower lid
 Wash hands again
 Treat until there is no pus discharge
 Do not put anything else in the eye

 DRY THE EAR BY WICKING & INSTILL QUINOLONE EARDROPS

 Dry the ear at least 3 times daily
 Roll clean absorbent cloth or soft, strong tissue paper into a wick
 Place the wick in the child’s ear
 Remove the wick when wet
 Replace the wick with a clean one & repeat these steps until the ear is dry
 Instill quinolone eardrops after dry wicking three times daily for two weeks

 TREAT MOUTH ULCERS WITH GENTIAN VIOLET

 Treat the mouth ulcers twice daily
 Wash hands
 Wash the child’s mouth with clean soft cloth wrapped around the finger &
wet with salt water
 Paint the mouth with half-strength gentian violet (0.25% dilution)
 Wash hands again
 Continue using GV for 48 hours after the ulcers have been cured
 Give paracetamol for pain relief

 SOOTHE THE THROAT, RELIEVE COUGH WITH A SAFE REMEDY

 Safe remedies to recommend:
 Breastmilk for exclusively breastfed infant
 Tamarind, Calamansi & Ginger decoction
 Harmful remedies to discourage:
 Codeine Cough Syrup
 Other Cough Syrups
 Oral & Nasal Decongestants

 GIVE THESE TREATMENTS IN HEALTH CENTER ONLY

 Explain to the mother why the drug is given
 Determine the dose appropriate for the child’s weight (or age)
 Use a sterile needle & sterile syringe
 Measure the dose accurately
 Give the drug as an IM injection
 If the child cannot be referred, follow the instructions provided

 GIVE AN INTRAMUSCULAR ANTIBIOTIC

 Give to children being referred urgently
 Give Gentamicin (7.5mg/kg) & Benzyl Penicillin (50,000 units per kg)

AGE OR WEIGHT GENTAMICIN BENZYL PENICILLIN

Dose: 7.5mg/kg Dose: 50,000 units per kg
80mg vial (40mg/ml) To a vial of 600mg
undiluted (1,000,000 units) add 1.6ml sterile
water to give 500,000 units/1ml
3-<6kg 0.5ml – 0.9ml 0.4ml
6-<10kg 1.1ml – 1.7ml 0.75ml
10-<15kg 1.9ml – 2.6ml 1.2ml
 15-<20kg 2.8ml – 3.5ml 1.7ml

NOTE: Calculate exact dose of Gentamicin base on body weight.

 GIVE QUININE FOR SEVERE MALARIA

 For children being referred with very severe febrile disease:
 Check which quinine formulation is available in your clinic
 Give first dose of intramuscular quinine & refer urgently to hospital
 If referral is not possible:
 Give first dose of IM Quinine (4-8-12 hours)
 The child should remain lying down for one hour (1)
 Repeat the Quinine injection at 4 & 8 hours later, & then every 12 hours
until the child is able to take an oral antimalarial; do not continue Quinine
injection for more than 1 week
 If no malaria risk, do not give Quinine to a child less than 4 mos of age

AGE OR WEIGHT INTRAMUSCULAR QUININE

150mg/ml * (in 2ml) 300mg/ml* (in 2ml)
2mos up to 4mos (4-<6kg) 0.4ml 0.2ml
4mos up to 12 mos (6-<10kg) 0.6ml 0.3ml
12mos up to 2y0 (10-<12kg) 0.8ml 0.4ml
2yo up to 3yo (12-<14kg) 1.0ml 0.5ml
3yo up to 5yo (14-10kg) 1.2ml 0.6ml
* Quinine Salt

 GIVE INHALED SALBUTAMOL FOR WHEEZING

 Use of a Spacer*
 A spacer is a way of delivering the bronchodilator drugs effectively into the
lungs. No child under 5 years should be given an inhaler without a spacer. A
spacer works as well as a nebulizer if correctly used
 From salbutamol metered dose inhaler (100ug/puff) give 2 puffs
 Repeat up to 3 times every 15 minutes before classifying pneumonia
 Spacers are made on the ff way:
 Use a 500ml drink bottle or similar
 Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler.
This can be done using a sharp knife.
 Cut the bottle between the upper quarter & the lower ¾ & discard the upper
quarter of the bottle
 Cut a small V border of the large open part of the bottle to fit the child’s nose &
be used as a mask.
 To use an inhaler with a spacer:
 Remove the inhaler cap. Shake the inhaler well.
 Insert the mouthpiece of the inhaler through the hole in the bottle or plastic cup.
 The child should put the opening of the bottle into his mouth & breathe in & out
through the mouth.
 A carer then presses down the inhaler & spray into the bottle while the child
continues to breathe normally.
 Wait for three to four breaths & repeat for total of five sprays
 For younger children, place the cup over the child’s mouth & use as a spacer in
the same way.
*If a spacer is being used for the first time, it should be primed by 4-5 extra puffs
from the inhaler.

 TREAT THE CHILD TO PREVENT LOW BLOOD SUGAR

 If the child is able to breastfeed
 Ask the mother to breastfeed the child
 If the child is not able to breastfeed but is able to swallow
 Give expressed breastmilk or a breastmilk substitute
 If neither of these is available, give sugar water
 Give 30-50ml of milk or sugar water before departure
  To make sugar water: Dissolve 4 level tsps of sugar (20grams) in a 200ml cup
of clean water
 4 tsp sugar :200 ml water
 If the child is not able to swallow
 Give 50ml of milk or sugar water by nasogastric tube

 GIVE EXTRA FLUID FOR DIARRHEA & CONTINUE FEEDING

 PLAN A: TREAT DIARRHEA AT HOME

 Counsel the mother on the 4 Rules on Home Treatment:
 Give extra fluid
 Give zinc supplements (age 2mos up to 5yo)
 Continue feeding
 When to return

 Give extra fluid (as much as the child will take)

 Tell the mother
- Breastfeed frequently & for longer at each feed
- If the child is exclusively breastfed, give ORS or clean water in addition
to breastmilk
- If the child is not exclusively breastfed, give one or more of the ff food-
based fluid (such as soup, rice water, or yogurt drinks) or ORS
- It is especially important to give ORS at home when:
* The child has been treated with Plan B or Plan C during this visit
* The child cannot return to a health center if the diarrhea gets worst
 Teach the mother how to mix & give ORS; give the mother 2 packets of
ORS to usual fluid intake
 Composition of Oresol - Potassium : 1.5 g. ; Sodium Bicarbonate
2.5g; Sodium Chloride 3.5g; Glucose 20 g (“Pa – BCG”)
 Homemade ORS:
 1 glass of water, 1 pinch of salt and 2 tsp of sugar 1:1:2
 1 liter of water, 2 tsp of salt; 8 tsp sugar 1:2:8
 Show the mother how much fluid to give in addition to the usual fluid
intake:
- Up to 2yo: 50-100ml after each loose stool
- 2yo or more: 100-200ml after each loose stool
- Tell the mother to:
* Give frequent small sips from a cup
* If the child vomits, wait 10minutes, then continue but more slowly
* Continue to give extra fluid until the diarrhea stops

 Give Zinc supplements (age 2mos up to 5yo)

 Tell the mother how much zinc to give (20mg tab):
- 2 to 6 mos: ½ tab daily for 14 days
- 6 mos or more: 1 tablet daily for 14 days
 Show the mother how to give zinc supplements:
- Infants: dissolve tablet in a small amount of expressed breast milk, ORS
or clean water in a cup
- Older children: tablets can be chewed or dissolved in a small amount of
clean water in a cup
 Continue feeding (exclusive breastfeeding if age is less than 6mos.)
 When to return

 PLAN B: TREAT SOME DEHYDRATION WITH ORS

 In the clinic, give recommended amount of reformulated ORS over a 4-hour
period

AGE Up to 4mos 4-12mos 1-2yo 2-5yo

WEIGHT <6kg 6-<10kg 10-<12kg 12-<20kg
In ml 200-450 450-800 800-960 960-1600

 Determine amount of ORS to give during first 4 hours

 *Use the child’s age only when you do not know the weight; this approximate
amount of ORS required (in ml) can also be calculated by multiplying the child
weight (in kg) x 75
*If the child wants more ORS than shown, give more
*For infants under 6mos who are not breastfed, also give 100-200ml clean water
during this period
 Show the mother how to give ORS solution
 Give frequent small sips from a cup
 If the child vomits, wait 10minutes; then continue, but more slowly
 Continue breastfeeding whenever the child wants
 After 4 hours:
 Reassess the child & classify the child for dehydration
 Select the appropriate plan to continue treatment
 Begin feeding the child in health center
 If the mother must leave before completing treatment:
 Show her how to prepare ORS solution at home
 Show her how much ORS to give to finish 4hour treatment at home
 Give her instructions how to prepare salt & sugar solution for use at home
 Explain 4 Rules of Home Treatment

 PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

 Ask the following questions:

 Can you give IV fluid immediately?

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

AGE FIRST GIVE 30ML/KG IN: THEN GIVE 70ML/KG IN:

Infants (under 12mos) 1 hour* 5 hours
1-5yo 30 minutes* 2 ½ hours
*Repeat once if radial pulse is still very weak or not detectable
- Reassess the child every 1-2hours; if hydration status is not improving,
give the IV drip more rapidly
- Also give ORS (about 5ml/kg/hour) as soon as the child can drink;
usually after 3-4hours (infants) or 1-2hours (children)
- Reassess an infant after 6 hours & a child after 3 hours; classify
dehydration then choose the appropriate plan (A,B,C) to continue the
treatment

 IF NO, ASK THE NEXT QUESTION

 Is IV treatment available nearby (within 30 minutes)?

 IF YES
- Refer urgently to hospital for IV treatment
- If the child can drink, provide the mother with ORS solution & show her
how to give frequent sips during the trip

 IF NO, ASK THE NEXT QUESTION

 Are you trained to use a nasogastric (NG) tube for rehydration?

 IF YES
- Start rehydration by tube with ORS solution: give 20ml/kg/hour for 6
hours (total of 120ml/kg)
- Reassess the child every 1-2 hours:
* If there is repeated vomiting or increasing abdominal distention, give
the fluid more slowly
 * If hydration status is not improving after 3 hours, send the child for IV
therapy
- After 6 hours, reassess the child; classify dehydration then choose the
appropriate plan (A,B,C) to continue treatment

 IF NO, ASK THE NEXT QUESTION

 Can the child drink?

 IF YES
- Start rehydration by mouth with ORS solution: give 20ml/kg/hour for 6
hours (total of 120ml/kg)
- Reassess the child every 1-2 hours:
* If there is repeated vomiting or increasing abdominal distention, give
the fluid more slowly
* If hydration status is not improving after 3 hours, send the child for IV
therapy
- After 6 hours, reassess the child; classify dehydration then choose the
appropriate plan (A,B,C) to continue treatment

 IF NO
- Refer urgently to the hospital for IV or NG tube treatment

NOTE: If the child is not referred to hospital, observe the child at least 6 hours
after rehydration to be sure the mother can maintain hydration giving the
child ORS solution by mouth.

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up

 PNEUMONIA
 After 2 days:
 Check the child for general danger signs
 Assess the child for cough or difficult breathing
 Ask:
 Is the child breathing slower?
 Is there less fever?
 Is the child eating better?
 Treatment:
 If with chest indrawing or a general danger sign: give a dose of second-line
antibiotic or IM Benzyl Penicillin & Gentamicin; then refer urgently to the
hospital
 If breathing rate, fever & eating are the same: change to the second-line
antibiotic & advise mother to return in 2 days or refer if the child had measles
within the last 3 mos
 If breathing is slower, fever is less & eating is better: complete the 3 days of
antibiotic

 PERSISTENT DIARRHEA
 After 5 days:
 Ask:
 Has the diarrhea stopped?
 How many loose stools is the child having per day?
 Treatment:
 If the diarrhea has not stopped (child is still having 3 or more loose stools per
day): do a full reassessment of the child; give any treatment needed; then refer
to hospital
 If the diarrhea has stopped (child is having less than 3 loose stools per day): tell
the mother to follow the usual feeding recommendation for the child’s age

 DYSENTERY
  After 2 days:
 Assess the child for diarrhea
 Ask:
 Are there fewer stools?
 Is there less blood in the stool?
 Is there less fever?
 Is there less abdominal pain?
 Is the child eating better?
 Treatment:
 If the child is dehydrated, treat dehydration
 If number of stools, amount of blood in stools, fever, abdominal pain or eating
is the same or worse:
 Change to second-line oral antibiotic recommended for dysentery in the area;
give it for 5 days; advise mother to return in 2 days. If you do not have the
second line antibiotic, refer to the hospital.
 Exceptions if the child:
- Is less than 12 months old, or
- Was dehydrated on the first visit, or
- Had measles within the last 3 months
* Refer to hospital
 If fewer stools, less blood in the stools, less fever, less abdominal pain & eating
better: continue giving the same antibiotic until finished
 Ensure that the mother understands the oral rehydration method fully & that she
also understands the need for an extra meal each day for a week.

 MALARIA
 If fever persists after 2 days, or returns within 14 days:
 Do a full assessment of the child
 Assess for other causes of fever
 Treatment:
 If the child has any general danger signs or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE/MALARIA (artemeter po, )
 If the child has any cause of fever other than malaria, provide treatment
 If malaria is the only apparent cause of fever:
 Take a blood smear. (+)
 Give second-line oral antimalarial without waiting for result of blood smear
 Advise mother to return if fever persists
 If fever persists after 2 days treatment with second-line oral antimalarial, refer
with blood smear for reassessment
 If fever has been present for 7 days, refer for assessment

 FEVER-MALARIA UNLIKELY
 If fever persists after 2 days:
 Do a full reassessment of the child
 Assess for other causes of fever
 Treatment:
 If the child has any general danger sign or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE/MALARIA
 If the child has any cause of fever other than malaria, provide treatment
 If malaria is the only apparent cause of fever:
 Take a blood smear
 Treat with first-line oral antimalarial
 Advise mother to return again in 2 days if fever persists
 If fever has been present for 7 days, refer for assessment

 FEVER (NO MALARIA)

 If fever persists after 2 days:
 Do a full reassessment of the child
 Make sure that there has been no travel to malarious area
 If there has been travel, take blood smear if possible
 Treatment:
  If there has been travel to a malarious area & the blood smear is positive or
there is no blood smear – classify according to fever with malaria risk & treat
accordingly
 If there has been no travel to malarious area or blood smear is negative:
 If child has any general danger signs or stiff neck: treat as VERY SEVERE
FEBRILE DISEASE/MALARIA
 If the child has any apparent cause of fever: provide treatment
 If there is no apparent cause of fever: advise mother to return again in 2 days
if fever persists
 If fever has been present for 7 days, refer for assessment

 MEASLES WITH EYE OR MOUTH COMPLICATIONS

 After 2 days:
 Look for red eyes & pus draining from the eyes
 Look at mouth ulcers
 Smell the mouth
 Treatment for Eye Infection:
 If pus is draining from the eye
 Ask the mother to describe how she has treated the eye infection
 If treatment has been correct, refer to the hospital
 If treatment has not been correct, teach the mother the correct treatment
 If the pus is gone & redness remains, continue the treatment
 If pus & redness is gone, stop the treatment
 Treatment for Mouth Ulcers:
 If mouth ulcers are worse, or there is a very foul smell of the mouth, refer to the
hospital
 If mouth ulcers are the same or better, continue using half-strength gentian
violet for a total of 5 days

 FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

 If fever persists after 2 days:
 Do a full reassessment of the child
 Do a tourniquet test
 Assess for other causes of fever
 Treatment:
 If the child has any signs of bleeding, including skin petechiae or a positive
tourniquet test, or signs of shock or persistent abdominal pain or persistent
vomiting: treat as SEVERE DENGUE HEMORRHAGIC FEVER
 If the child has any other apparent cause of fever, provide treatment
 If fever has been present for 7 days, refer for assessment
 If there is no apparent cause of fever, advise the mother to return daily until
child has had no fever for at least 48 hours
 Advise mother to make sure child is given more fluids & is eating

 EAR INFECTION
 After 5 days:
 Reassess for ear problem
 Obtain child’s temperature
 Treatment:
 If there is tender swelling behind the ear or high fever (38.5˚C or above), refer
urgently to hospital.
 Acute ear infection: if ear pain or discharge persists, treat with 5 more days of
the same antibiotic; continue wicking to dry the ear; follow up in 5 days
 Chronic ear infection: check that the mother is wicking the ear correctly; &
instilling the quinolone drops. Encourage her to continue. See the child again in
5 days.
 If no ear pain or discharge: praise the mother for her careful treatment; if she
has not yet finished the 5-day antibiotics, tell her to use all of it before stopping

 FEEDING PROBLEM
 After 5 days:
  Reassess feeding
 Ask about any feeding problems on the initial visit
 Counsel the mother about any new or continuing feeding problems. If you
counsel the mother to make significant changes in feeding, ask her to bring the
child back again
 If the child is very low weigh for age, ask the mother to return in 30 days after
the initial visit to measure the child’s weight gain

 ANEMIA
 After 14 days:
 Give iron; advise mother to return in 14 days for more iron
 Continue giving iron every day for 2 months with follow up every 14 days
 If the child has any palmar pallor after 2 months, refer for reassessment

 VERY LOW WEIGHT

 After 30 days:
 Weigh the child & determine if the child is still very low weight for age
 Reassess feeding
 Treatment:
 If the child is no longer very low weight for age, praise the mother & encourage
her to continue
 If the child is still very low weight for age, counsel the mother about any
feeding problems found; continue to see the child monthly until the child is
feeding well & gaining weight regularly or is no longer very low weight for age
 Exception: if you do not think that feeding will improve or if the child has lost
weight, refer the child

COUNSEL THE MOTHER

 FOOD

 ASSESS THE CHILD’S FEEDING

 Ask questions about the child’s usual feeding & feeding during this illness
 Compare the mother’s answers to the “Feeding Recommendations” for the
child’s age
 Ask:
 Do you breastfeed your child?
 How many times during the day?
 Do you also breastfeed during the night?
 Does the child take any other food?
 What food or fluids?
 How many times per day?
 What do you use to feed the child?
 If very low weight for age: How large are the servings? Does the child
receive his own serving? Who feeds the child & how?
 During this illness, has the child’s feeding changed? If yes, how?

 ASSESS THE CHILD’S CARE FOR DEVELOPMENT

 Observe & ask questions about how mother cares for her child
 Compare the mother’s answers to the Recommendations for Care &
Development
 Observe: How the mother plays & communicates with the child.
 As:
 How do you play with your child?
 How do you communicate with your child?
 SAMPLE FEEDING PROBLEMS
 Difficulty in breastfeeding
 Child less than 4mos. taking other milk/food
  Use of breastmilk substitute/cow’s milk/evaporated milk
 Use of feeding bottles
 Lack of active feeding
 Not feeding well during illness
 Complementary food not enough in quantity/quality/variety
 Child 6mos. above not yet given complementary foods
 Infants not exclusively breastfed
 Improper handling & use of breastmilk substitute

 RECOMMENDATION FOR FEEDING & CARE FOR DEVELOPMENT

 Up to 4 months of age
 Play: provide ways for your child to see, hear, feel & move
 Communicate:
 Look into your child’s eyes & smile at him or her
 When you are breastfeeding, it is a good time to talk to your child & get
a conversation going with sounds & gestures.
 Breastfeed as often as the child wants, day & night, at least 8x in 24 hours
 Do not give other foods or fluids

 4 to 6 months
 Play: Have large colorful things for your child to reach for & new things to
see
 Communicate: Talk to your child & get a conversation going with sounds &
gestures.
 Breastfeed as often as the child wants, day or night, at least 8x in 24 hours
 Do not give other foods & fluids.

 6 to 12 months
 Play: Give your child clean, safe household things to handle, bang & drop
 Communicate: Respond to your child’s sounds & interest. Tell your child
the names of things & people.
 Breastfeed as often as the child wants
 Add any of the ff:
 Lugaw with added oil, mashed vegetables or beans, steamed tokwa, flaked
fish, pulverized roasted dilis, finely-ground meat, eggyolk, bite-sized fruits
 Give these foods 3x per day if breastfed & 5x per day if not breastfed

 1 to 2 yo
 Play: Give your child things to stack up & to put into container & take out.
 Communicate: Ask your child simple questions. Respond to your child’s
attempts to talk. Play games like “byebye.”
 Breastfeed as often as the child wants
 Give adequate amount of family foods or give rice, camote, potato, fish,
chicken, meat, mongo, steamed tokwa, pulverized roasted dilis, milk &
eggs, dark green leafy & yellow vegetables (malunggay, squash); fruits
(papaya & banana); add oil & margarine
 Give these foods 5x per day
 Feed the baby nutritious snacks like fruits

 2yo & older

 Play: Help your child count, name & compare things. Make simple toys for
your child.
 Communicate: Encourage your child to talk & answer your child’s
questions. Teach your child stories, songs & games.
 Give adequate amount of family foods at 3 meals each day
 Twice daily, give nutritious foods between meals such as boiled yellow
camote, boiled yellow corn, peanuts, boiled saba banana, taho, fruits, fruit
juices
  FEEDING RECOMMENDATIONS FOR A CHILD WITH PERSISTENT
DIARRHEA
 If still breastfeeding, give more frequent, longer breastfeeds, day & night
 If taking other milk such as milk supplements:
 Replace with increased breastfeeding
 Replace half the milk with nutrient-rich semi-solid food
 Do not use condensed or evaporated milk
 For other foods, follow feeding recommendation for the child’s age

 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; as

needed, show the mother correct positioning & attachment for breastfeeding

 If the child is less than 6mos old & 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 & night & gradually
reducing other milk or foods
 If other milk needs are to be continued, counsel the mother to:
 Breastfeed as much as possible, including at night
 Make sure that other milk is a locally appropriate breastmilk substitute,
give only when necessary
 Make sure that other milk is correctly & hygienically prepared & given in
adequate amounts
 Prepare only an amount of milk which the child can consume within an
hour; if there is some left-over milk, discard

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

 Recommend substituting the bottle for a cup
 Show the mother how to feed the child with a cup

 If the child is not being fed actively, counsel the mother to:
 Sit with the child & encourage eating
 Give the child an adequate serving in a separate plate or bowl
 Observe what the child likes & consider these in the preparation of his/her
food

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

 Follow up any feeding problems in 5 days

 FLUID

 FOR ANY SICK CHILD:

 Breastfeed more frequently & for longer periods at each feeding
 Increase fluids (ex: give soup, rice water, buko juice, clean water)

 FOR CHILD WITH DIARRHEA:

 Giving extra fluid can be life-saving; give fluid according to Plan A or B

 WHEN TO RETURN

 FOLLOW UP VISITS
 If the child has Return for follow up in:
Pneumonia
Dysentery
Malaria, if fever persists
Fever-Malaria Unlikely, if fever persists 2 days
Fever-No Malaria, if fever persists
Measles with Eye or Mouth Complications
Dengue Hemorrhagic Fever Unlikely, if fever persists
Persistent Diarrhea
Acute Ear Infection
Chronic Ear Infection 5 days
Feeding Problem
Any other illness, if not improving
Anemia 14 days
Very Low Weight for Age 30 days

 RETURN IMMEDIATELY

Any sick child *Not being able to drink or breastfeed

*Becomes sicker
*Develops a fever
If child has NO PNEUMONIA, COUGH, OR *Fast breathing
COLD, also return if: *Difficult breathing
If child has DIARRHEA, also return if: *Blood in the stool
*Drinking poorly
If child has FEVER, DENGUE *Any sign of bleeding
HEMORRHAGIC FEVER UNLIKELY, also *Abdominal pain
return if: *Vomiting

 ABOUT OWN HEALTH

 If the mother is sick, provide care for her or refer her for help
 If she has a breast problem (such as engorgement, sore nipples, breast infection)
provide care for her or refer her for help
 Advise her to eat well to keep up her own strength & health
 Check the mother’s immunization status & give her Tetanus Toxoid if needed
 Make sure she has access to family planning & counseling on STD & AIDS
prevention