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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

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SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD
Assess Classify and Identify Treatment
Check for the general danger Signs Then Ask About Main Symptoms: Does the child have cough or difficult breathing? Does the child have diarrhoea? Does the child have fever? Classify Malaria Classify Measles Classify Dengue Fever Does the child has ear problem? Check for Malnutrition and Anaemia Check the Childs Immunization Status Check the Vitamin A status? Check Anti helmintic status? 2 2 3 4 4 5 5 6 7 7 7 7

World Health Organization Ministrio de Sade (Minister of Health) TREATMENT, continued


Give Extra Fluid for Diarrhoea
Plan A: Treat Diarrhoea at Home Plan B: Treat Some Dehydration with ORS Plan C: Treat Severe Dehydration 17 17 18

Pre Referral Fluid for Dengue Hemorrhagic Fever 18

Give Follow-up Care


Pneumonia Persistent Diarrhoea Dysentery Malaria Measles with Eye or Mouth Complication Possible DHF and fever: Possible not DHF Ear Infection Feeding Problem Anaemia Very low Weight 19 19 19 20 20 20 21 21 21 22

COUNSEL THE MOTHER Food


Assess the childs feeding 23 Feeding Recommendations during 24 illness and Health The way to feed babies and young 25 - 27 children, so they grow and develop well and stay healthy Counsel about Feeding Problem 28 Teach correct positioning and attachment 29 for breastfeeding

TREATMENT
Teach the to give Oral Drugs at Home
Oral Antibiotic Oral Anti malaria Paracetamol Iron for treatment Give Vitamin A for treatment Give anti-Helmintic for treatment 8 10 11 11 11 11

Fluid Teach the Mother to Treat Local Infection at Home


Treat Eye Infection with Tetracycline / Chloramphenicol Eye Ointment Dry the Ear by Wicking Treat Mouth Ulcer with Gentian Violet Treat for Thrush with Nystatin Soothe the throat, Relieve the cough with a safe remedy 12 12 12 12 12 Increase Fluid During Illness 30

When to return
Advise the Mother When to return to health Worker Counsel the mother About Her Own Health 30 31

Give these Treatments in Clinic Only


Intramuscular Antibiotic Intramuscular antimalarial drugs Quinine for Severe malaria Artesunate suppository for severe malaria Treat a convulsing child with diazepam Give inhaled salbutamol for wheezing Give oral salbutamol Prevent Low Blood Sugar 13 13 14 14 15 15 16 16

RECORDING FORMS SICK YOUNG INFANT AGE 2 MONTHS UP TO 5 YEARS 32 - 33 WEIGHT FOR AGE CHART 34

ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS


ASSESS
ASK THE MOTHER WHAT IS THE CHILDS PROBLEM

Determine if this is an initial or follow-up visit for this problem If follow-up visit, use the follow-up instructions. If initial visit, assess the child as following:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS


ASK: LOOK: Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsion? See if the child is lethargic or unconscious

USE ALL BOXES THAT MATCH THE CHILDSYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately, so referral will not be delayed.

THEN ASK ABOUT MAIN SYMPTOMS:


Does the child have cough or difficult breathing?
IF YES ASK:
- For how long?

SIGNS
Any general danger

CLASSIFY AS
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

TREATMENT
Give first dose of an appropriate antibiotic If child is fitting, manage airway and treat with the first dosage of appropriate anticonvulsion drug. Refer URGENTLY

(Urgent pre-referral treatments are in bold print) sign common danger sign or Chest in drawing or Stridor in calm child

LOOK, LISTEN, FEEL:


- Count the breaths in one minute - Look for chest in drawing - Look and listen for stridor - Look and listen for wheezing
CHILD BE MUST CALM

Classify COUGH or DIFFICULT BREATHING

If wheezing and either fast breathing or chest indrawing: Give a trial of rapid acting bronchodilator for up to three times, then count the breaths and look for chest indrawing again, and then classify.

Fast breathing

PNEUMONIA

Give oral antibiotic for 5 days. If wheezing give an inhaled bronchodilator for 5 days * Soothe the throat and relieve the cough with a safe remedy. If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advice mother when to return immediately Follow-up in 2 days. If wheezing give an inhaled bronchodilator for 5 days * Soothe the throat and relieve the cough If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advice mother when to return immediately Follow-up in 5 days if not improving

If the child is: 2 months up to 12 months

Fast breathing is: 50 times breaths per minute or more 40 times breaths per minute or more

No sign of pneumonia
or severe disease

COUGH OR COLD

12 months up to 5 years

* When bronchodilator (salbutamol inhalation) is not available, give oral salbutamol as the second-line treatment. Try Salbutamol only if child > 9 month of age

Does the child have diarrhoea?


For
DEHYDRATION

IF YES, ASK :
For how long? Is there blood in the stool?

LOOK, LISTEN, FEEL:


- Look at the childs general condition Is the child: Lethargic or unconscious? Restless and irritable? - Look for sunken eyes - Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? - Pinch the skin of the abdomen Does it go back: Very slowly (longer than 2 second) Slowly?

Two or more of the following Signs: Lethargic or unconscious Sunken eye Not able to drink or drinking poorly Skin pinch goes back very slowly

SEVERE DEHYDRATION

If child doesnt have other severe classification: - Give fluid for severe dehydration (Plan C) If child also has another severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way - Advise the mother to continue breastfeeding the baby If it there cholera in your area, give antibiotic for cholera Give fluid, zinc supplements and food for some dehydration (Plan B) If the child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. - Advise the mother to continue breastfeeding the baby Advise mother when to return immediately Follow-up in 5 days if not improving

Classify DIARRHOEA

Two or more of the following Signs: Restless, irritable Sunken eyes Drinking eagerly, thirsty Skin pinch goes back slowly

SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration

NO DEHYDRATION

Give fluid, zinc supplements and food to treat the diarrhoea at home (Plan A) Advise the mother when to return immediately Follow-up in 5 days if not improving

And if diarrhoea 14 days or more

Dehydration present

SEVERE PERSISTENT DIARRHOEA

Treat dehydration before referral unless the child has another sever classification Refer to hospital

No dehydration PERSISTENT DIARRHOEA

Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamin and minerals (including zinc) for 14 days Follow-up in 5 days

And if blood *If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the child, in stool
Annex: Where Referral Is Not Possible, and WHO guidelines for inpatient care.

Blood in the stool

DYSENTRY

Treat for 5 days with ciprofloxacin. Treat dehydration Give zinc supplementation Follow-up in 2 days

Does the child have fever?


(by history or feels hot or temperature 37.5 C** or above)

Malaria
Any general danger sign or Stiff neck Give first dose of antimalarial drug. Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar Give one dose of paracetamol in clinic for high fever (38.5C or higher) Refer URGENTLY If child is fitting, manage airway and treat with the first dosage of appropriate anticonvulsions drug. Treat the child with an appropriate antimalarial drug according to rapid test or microscopy finding. Give one dose of paracetamol in clinic for high fever (38.5C or higher) Take a blood sample Advice mother when to return immediately. Follow-up in 3 days if fever persists. If fever is present every day for more than 7 days, refer for further assessment. Give one dose of paracetamol in clinic for high fever (38.5C or higher) Treat any other causes of fever found If rapid test negative and no microscopy available and there is no other cause of fever treat for P. vivax. Advice mother when to return immediately. Follow-up in 3 days if fever persists. If fever is present every day for more than 7 days, refer for assessment.

IF YES, THEN ASK:


For how long? If more than 7 days, has fever been present every day? Has the child had measles within the last 3 months?

LOOK, AND FEEL:


Look or feel for stiff neck. Look for runny nose Look for signs of MEASLES Generalised rash and One of these: cough, runny nose, or red eyes? Look for mouth ulcers. Are they deep and extensive? Look for pus draining from the eye Look for clouding of the cornea. Do Rapid Diagnostic Test (RDT) or thin thick blood smear microscopy if available.

VERY SEVERE FEBRILE DISEASE

Malaria
Fever (by history or feels hot or temperature 37.5C** or higher) with positive rapid test or microscopy

If the child has measles now or within the last 3 months:

Classify FEVER

MALARIA

Fever (by history or feels


hot or temperature 37.5C* or higher) but negative rapid test or microscopy

FEVER: MALARIA UNLIKELY

Continued to next page

* These temperature are based on axillary temperature **Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables

MEASLES
Any common danger sign or Clouding of cornea or Deep or extensive mouth ulcers

Classify Fever for Dengue


(only if fever 2 days Up to less than 7 days):
ASK: Has the child recently had any severe bleeding from the nose or gums? Has the child vomited? If yes: Frequently? Has child had blood or coffee ground vomits? Has the child had any tarry black stools? Does the child have epigastria pain or is the child restless? LOOK AND FEEL: Look for: Severe bleeding from nose or gums. Skin petechiae. If yes and no other signs of dengue, do tourniquet test if possible Check for signs of shock: Cold and clammy extremities and Radial pulse is very weak or not detectable

SEVERE COMPLICATED MEASLES**

Classify MEASLES
Pus draining from the eye or Mouth ulcers If fever is 2 days up to 7 days

Give vitamin A Give first dose of an appropriate antibiotic. If clouding of cornea or pus draining from the eye, apply tetracycline eye ointment. Give Give first dose of paracetamol in clinic for high fever (38.5C or higher) Refer URGENTLY to hospital. Give vitamin A If pus draining from the eye, treat eye infection with tetracycline or chloramphenicol eye ointment. If mouth ulcers, treat with gentian violet and Follow-up in two days Give vitamin A

MEASLES WITH EYE OR MOUTH COMPLICATIONS **

No Sign Above

MEASLES

DENGUE HAEMORRAGIC FEVER


Signs of shock: cold clammy extremities and weak radial pulse or Blood or coffee ground vomit or Tarry black stools or Severe bleeding from nose or gums or Skin petechiae and positive tourniquet test or Frequent vomiting and no diarrhoea.

DENGUE HAEMORRAGIC FEVER

DENGUE HAEMORRA GIC FEVER (DHF)

If signs of shock present, give fluids as in fluid plan for dengue fever. If no signs of shock, give extra fluids or ORS as much as possible on the way to hospital. Prevent low blood sugar. Give first dose of paracetamol in clinic for high fever (38.5 C or above). Refer URGENTLY Give first dose of paracetamol in clinic for high fever (38.5 C or above). Advise mother to give child extra fluids or ORS. Advise mother when to return immediately. Follow up daily until fever resolved for 2 days or until cause for fever is identified. Treat other obvious causes of fever Give first dose of paracetamol in clinic for high fever (38.5 C or above). Advise mother when to return immediately Follow up in 2 days if fever persist.

Epigastria pain or restless or Skin petechiae and negative tourniquet test (***)

POSSIBLE DHF

None of the above signs

FEVER: DHF UNLIKELY

**Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables *** If there are petechiae and no others signs of dengue fever and no tourniquet test can be done classify as Dengue Fever

Does the child have an ear problem?


IF YES, ASK:
Is there ear pain? Is there ear discharge ? if yes, for how long?

LOOK AND FEEL:


Look for pus draining form the ear Feel for tender swelling behind the ear

Classify EAR PROBLEM

Tender swelling behind the ear

MASTOIDITIS

Give first dose of an appropriate antibiotic Give first dose of paracetamol for pain Refer URGENTLY to hospital Give an antibiotic for 5 days. Give paracetamol for pain. Dry the ear by wicking Follow-up in 5 days. Give ear drops antibiotic for 2 weeks Give Dry the ear by wicking. Follow up in 5 days No additional treatment

Pus is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain Pus is seen draining from the ear and discharge is reported for 14 days or more No ear pain and No pus seen draining from the ear.

ACUTE EAR IN FECTION

CHRONIC EAR INFECTION

NO EAR INFECTION

THEN CHECK FOR MALNUTRITION AND ANAEMIA


LOOK AND FEEL:
Look for visible severe wasting. Look for palmar pallor. Is it: - Severe palmar pallor? - Some palmar pallor? Look for oedema of both feet. Determine weight for age

Classify NUTRITIONAL STATUS

Visible severe wasting or Severe Palmar pallor or Oedema of both feet

SEVERE MALNUTRITION AND/OR SEVERE ANAEMIA

Give vitamin A for < 6 months, if visible severe wasting or oedema on both feet. Refer URGENTLY to Hospital

Some palmar pallor or Very low weight for age

ANAEMIA AND/OR VERY LOW WEIGHT

Assess the childs feeding and counsel the mother - On feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days If Anemia - Give iron - Give vit A for > 6 months old and if none was given in the last one month. - Give Albendazole (only if child is 2 - 5 years and has not had a dose in the previous 6 months). - Follow-up after 4 weeks Advice mother when to return immediately. If very low weight for age, refer to a supplementary feeding program and follow-up in 4 weeks

Not very low weight for age and no other signs of malnutrition

NO ANAEMIA AND VERY LOW WEIGHT

If child is less than 2 years old, assess the childs feeding according to the FOOD box on the COUNSEL THE MOTHER CHART If feeding problem, follow up in 5 days Advise mother when to return immediately

THEN CHECK THE CHILDS IMMUNIZATION STATUS

CHECK VITAMIN A STATUS


VITAMIN A SCHEDULE
First dose 100 000IU for 6 months up to 1 year. Next dose 200.000 IU every 6 months (age 1 year to 5 years), February and August. If a child has not received a dose in last 6 months, give a dose.

CHECK ANTIHELMINTHIC STATUS

AGE

VACCINE
BCG OPV-0 Hep B-1 OPV-1 Hep B-2 OPV-2 Hep B-3 OPV-3 Measles DPT-1 DPT-2 DPT-3

*ANTIHEMINTHIC COVERED
All children 1 to 5 years should receive worm medicine albendazole single dose every 6 months

At birth IMMUNIZATION 6 weeks SCHEDULE: 10 weeks 14 weeks 9 months

ASSESS OTHER PROBLEMS


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 severely daily dehydration child according to plan C may resolve danger signs so that referral is no longer needed.

TREATMENT
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME


Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table. Determine the appropriate drugs and dosage for the childs age or weight Tell the mother the reason for giving the drug to the child Demonstrate how to measure the 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 and package the drug If more than one drug will be given, collect, count and package the each drug separately Explain that all the oral drug tablets or syrups must be used to finish the course treatment, even if the child gets better Check the mothers understanding before she leaves the clinic

Give appropriate oral dosage antibiotics


For all classification that require administration of appropriate oral antibiotic except Pneumonia First-line antibiotic: COTRIMOXAZOLE Second-line antibiotic: AMOXYCILIN Age or Weight * COTRIMOXAZOLE (Trimethoprim -TMP + sulfamethoxazole-SMX) twice a day for 5 days Syrup/5 ml Child Adult Tablets Tablets 40 mg TMP 20 mg TMP + 80 mg TMP + 200 mg + SMX 400 mg SMX 100 mg SMX 1 1 2 3 2.5 ml 5 ml 7.5 ml AMOXYCILLIN (25mg/kg) Give three times a day for 5 days Syrup Tablet 125 250 mg/5 ml mg

For Pneumonia
First-line antibiotic: AMOXYCILIN Second-line antibiotic: COTRIMOXAZOLE
Age or Weight AMOXYCILLIN (25mg/kg) Give twice a day for 5 days Syrup Tablet 250 mg 125 mg/5 ml

2-4 mths ( 4-<6 kg) 4-12 mths (6-<10 kg) 12 mths-5yrs (10-<19 kg)

5 ml 10 ml 15 ml

1 1

* Avoid the use of cotrimoxazole in baby less than one month of age, premature baby or with jaundice.

* COTRIMOXAZOLE (Trimethoprim -TMP + sulfamethoxazoleSMX) twice a day for 5 days Adult Tablets 80 mg TMP + 400 mg SMX 1 Child Tablets 20 mg TMP + 100 mg SMX 1 2 3 Syrup/ 5 ml 40 mg TMP + 200 mg SMX 2.5 ml 5 ml 7.5 ml

Dosage and administration of Amoxycilin for severe pneumonia where referral is not possible.
Amoxycilin (50mg/kg) Give twice in a day for 3 days Tablet 250 mg (2-4 mths) 3 - < 6 kg (4-12 mths) 6 - < 10 kg (12 mths 5 yrs) 10 - <15 kg 4 5 yrs 15 - < 20 kg 1 1 2 Syrup (125mg/5ml) 10 ml 15 ml 25 ml -

Age or Weight

2-4 mths ( 4-<6 kg) 4-12 mths (6-<10 kg) 12 mths-5yrs (10-<19 kg)

5 ml 10 ml 15 ml

1 1

* Avoid the use of cotrimoxazole in baby less than one month of age, premature baby or with jaundice.

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME:


Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table
Dysentry: Give antibiotic recommended for shigella for 5 days FIRST LINE ANTIBIOTIC: CIPROFLOXACIN Give 2 times a day for 3 days 100 mg 3 - < 6 kg 6 - < 10 kg 10 - 15 kg 15 - <20 kg 20 - 29 kg 1 1 2 3 250 mg 1 1 AGE or WEIGHT 2 to 4 months (4 - <6 kg) 4 to 12 months (6 - <10 kg) 1 to 5 years (10 - 19 kg CIPROFLOXACIN NALIDIXID ACID Tablet 500 mg Give 4 times a day for 5 days SECOND LINE ANTIBIOTIC: NALIDIXID ACID

WEIGHT

CHOLERA: FIRST LINE ANTIBIOTIC: SECOND LINE ANTIBIOTIC: * AGE or WEIGHT

2- 4 months (4 - <6kg) 4 - 12 months (6 - <10 kg) 1 - 5 years (10 19 kg)

Give antibiotic recommended for 3 days COTRIMOXAZOLE (TRIMETHOPRIM + SULPHAMETHOXAZOLE DOXYCYCLINE DOXYCYCLINE COTRIMOXAZOLE TABLET 100 mg (Trimethoprin + Sulphamethoxazole) Give once daily Give 2 times daily for 5 days for 5 days ADULT TABLET CHILD TABLET SYRUP/5 ml 80mg trimethoprim + 20 mg trimethoprim 40mg trimethoprim TABLET 100 mg 400 mg + 100mg + 200mg sulphamethoxazole sulphamethoxazole sulphamethoxazole DO NOT GIVE 1 2.5 ml 1 2 3 5 ml 7.5 mg

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME:


Give an Oral Antimalarial
FIRST LINE ANTIMALARIAL: Artemether-Lumefantrine (Coartem) or Chloroquine SECOND - LINE ANTIMALARIAL: Quinine + Clindamycin FOR COARTEM (malaria falciparum & mix infections) Explain to the mother that she should watch her child carefully for 1 hour after giving a dose of coartem. If the child vomits within 1 hour, she should repeat the dose and return to the clinic for additional tablets. Tell the mother that, the child must eat coartem tablet as soon as it is taken out from the blisters. If the tablet is exposed to air the medicine becomes ineffective. Explain to the mother that for small children, paracetamol and coartem can be crushed, diluted in water and then put either directly into the mouth using a syringe or given with a spoon. FOR CHLOROQUINE (malaria vivax): Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the clinic for additional tablets. Explain than itching is a possible side effect of the drug, but is not dangerous.
CHLOROQUINE Give daily for 3 days TABLET (150 mg base) Day 1 2 4 months (<4kg) 4 - 12 months (4 - <10kg) 12 months to 5 years (10 19kg) 1 Day 2 1/8 1 Day 3 1/8 PRIMAQUIINE TABLET (300 mg) 3 times daily for 7 days -

AGE or WEIGHT

ARTEMETHER LUMEFANTRINE (Coartem)


Age group 4 months to 5y Weight group 5 to 14 kg Blister color Yellow (Day 1) 1 tb , 1 tb (Day 2) 1 tb , 1 tb (Day 3) 1 tb , 1 tb

Second-line treatment (Follow-up care)


QUININE Age group Weight group (kg) (300 mg) give 10mg salt/kg bw 3 times a day for 7 days 2 - 12 months 13 months - 5 years 4 - < 10 10 - <19 CLINDAMYCIN (300mg), give 10mg/kg bw Twice a day for 7 days

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TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME:


Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drugs dosage table

Give Paracetamol for High Fever ( 38.5 C) or Ear Pain


AGE or WEIGHT 2months to 6 months (4 <7 kg) 6 months to 3 years (7 - < 14 kg) 3 years to 5 years (14 - < 19 kg) TABLET 500 mg PARACETAMOL TABLET Syrup 100mg (120mg/5ml)

Treatment
If the child has had a dose of vitamin A within the past month, DO NOT GIVE VITAMIN A AGE * Less than 6 months 6 months to 12 months 12 months up to 5 years VITAMIN A CAPSULE 50,000 IU 1 capsule 2 capsule 4 capsules

1/8

1 2

2.5 ml 5 ml 10 ml

( tsp) (1 tsp) (2 tsp)

* Give a dose of vitamin A as a treatment ONLY for child < 6 month where the child has SEVERE MALNUTRITION or PERSISTENT DIARRHOEA.

Give anti helmintic for treatment

Give Iron for treatment


Give daily for 4 weeks for child age 6 months to 5 years IRON TABLET/FOLATE Ferrous sulphate 200 mg + 400 mcg pholate (60mg elementary Iron) Give once a day 1 1 IRON SYRUP Ferrous sulphate 40mg/ml (8 mg elementary Iron per ml) Give once a day 5 ml ( tsp) 7.5 ml ( 1 tsp)

If child is aged 1 year to 5 years and has not received a dose in previous 6 months. Give albendazole single dose in clinic. If child is 4 12 months and worms are seen give pyrantel single dose

AGE or WEIGHT

AGE or WEIGHT 4 9 mths; 6 < 8 kg 9 mths-1 yr; 8-< 10 kg 1 2 years 2 - 5 years

PYRANTEL PAMOATE
syrup 250/5ml

ALBENDAZOLE
(400 mg tablet)

1.5ml (75mg) 1.8ml (90mg) -

(200 mg) 1 (400 mg)

6 to 12 months (7 - <10 kg) 12 months to 5 years (10 - < 19 kg)

Child less than 1 year old can only received Pyrantel Pamoat based on the evidence from laboratory and it is not recommended for routine treatment

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TEACH THE MOTHER TO TREAT LOCAL INFECTION AT HOME


Explain to the mother what the treatment is and why it should be given. Describe the treatment steps listed in the appropriate box. Watch the mother as she does the first treatment in the clinic (Except remedy for cough or core throat). Tell her how often to do the treatment at home If needed for treatment at home, give mother the tube of Tetracycline/ chlorampenicol ointment or a small bottle of gentian violet Check the mothers understanding before she leaves the clinic

Treat Eye Infection with Tetracycline or Chloramphenicol Eye Ointment


Clean both eyes 3 times daily Wash hands Ask child to close the eyes Use clean cloth and water to gently wipe away pus Then apply Tetracycline/ Chloramphenicol ointment in both eyes 3 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 redness is gone Do not use other eye ointments or drops, or put anything else in the eye

Treat mouth Ulcers with Gentian Violet


Treat the mouth ulcers twice daily Wash hands Wash the childs mouth with clean soft wrapped around the finger and wet with salt water Paint the mouth with gentian violet. 0.5% in child mouth Wash hands again

Soothe the Throat, Relieve the Cough with a Safe Remedy


Safe remedies to recommend: -Exclusively Breast milk to breastfed infant up to 6 months. - Sweet soy sauce or honey mixed with lime water Harmful remedies to discourage - All commercial cough syrups that contain codeine - Decongestant food for oral or spray/ nose drops

Clear the ear by dry wicking and give 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 childs ear Remove the wick when wet Replace the wick with a clean one and repeat these steps until the ear is dry Lie the child down turn the head on the side and drop the ear drop Give ciprofloxacin ear drop once a day for 2 weeks.

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GIVE THESE TREATMENTS IN CLINIC ONLY


Explain to the mother why the drug is given Determine the dose appropriate for the childs weight (or age) Use a sterile needle and sterile syringe. Measure the dose accurately Give the drug as a intramuscular injection If child cannot be referred, follow the instructions provided

Give An Intramuscular Antibiotic


FOR CHILDREN BEING REFERRED URGENTLY WHO CANNOT TAKE AN ORAL ANTIBIOTIC:
Give first dose of intramuscular chlorampenicol and refer child urgently to hospital

Give intramuscular antimalarial drugs


FOR UNCOMPLICATED MALARIA FALCIPARUM IN YOUNG INFANT
Give IM Arteminisin derivatives first dose (preferably when available) and continue with the oral artesunate until day 7. Administration of Artemisinin derivatives or Quinine for malaria falciparum for 2-4 months infant.

IF REFERRAL IS NOT POSSIBLE:


Repeat the chlorampenicol injection every 12 hours for 5 days Then change to an appropriate antibiotic to complete 10 days treatment. Age group Weight group Artemisinin **First dose IM Artesunate (60mg) or Artemether (40mg) # Oral Artesunate (50mg) 2mg/kg/ day on day 2 to day 7 1/8 1/6 *Quinine Oral Quinine (300mg) 10mg/ kg TID for 4 days 1/8 1/6 15-20 mg/kg TID for the next 4 days 1/6 1/4

CHLORAMPHENICOL AGE or WEIGHT


Dose: 40 mg per kg Add 5.0 ml sterile water to vial containing 1000 mg = 5.6 ml at 180 mg/ml 1.0 ml = 180 mg 1.5 ml = 270 mg 2.0 ml = 360 mg 2.5 ml = 450 mg 3.5 ml = 630 mg

Artesunate 1.2 mg/kg 2 - <3 months 3-4 months 4.2 mg (0.07ml) 5.4 mg (0.09ml)

Artemether 1.6 mg/kg 5.6 mg (0.14ml) 7.2 mg (0.18ml)

2 months up to 4 months (4 - < 6 kg) 4 months up to 9 months (6 - < 8 kg) 9 months up to 12 months (8 - < 10 kg) 12 months up to 3 years (10 - < 14 kg) 3 years up to 5 years (14 19 kg)

3 - 4 kg 4 - 5 kg

* Treat the infant with Quinine when Artemisinin is not available. ** Preferably parenteral Arteminisin if available, # Oral artesunate is given on day 1 to day 7 when IM Artemisinin is not available.

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Give Artesunate Suppository for Severe Malaria


FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE/ MALARIA:
Give single dose Artesunate suppository and refer immediately to hospital. Weight group (kg) 5 8.9 9 19 20 29 Artesunate dose (mg) 50 100 200

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 and refer immediately

IF REFERRAL IS NOT POSSIBLE AND THERE IS NO DOCTOR


Give first dose of intramuscular quinine The child should remain lying down for one hour Repeat the quinine injection every 8 hours until the child is able to take an oral antimalarial. Do not continue quinine injections for more than 1 week Age or Weight 2 months up to 4 months (4 < 6 kg) 4 months up to 12 months (6 < 10kg) 12 months up to 2 years (10 < 12 kg) 2 years up to 3 years (12 < 14 kg) 3 years up to 5 years (14 < 19 kg)
* Quinine salt solution

Age 0 12 months 13 42 months 43 60 months

Regimen (single dose) One 50 mg suppository One 100 mg suppository Two 100 mg suppositories

Intramuscular Quinine 150 mg/ml* (in 2 ml ampoules) 0.4 ml 0.6 ml 0.8 ml 1.0 ml 1.2 ml 300 mg/ml* (in 2 ml ampoules) 0.2 ml 0.3 ml 0.4 ml 0.5 ml 0.6ml

In case Artesunate is not available, give Quinine for children with severe malaria.

14

Treat a Convulsing Child With Diazepam Rectally


Manage the Airway Turn the child on his or her side to avoid aspiration Do not insert anything in the mouth If the lips and tongue are blue, open the mouth and make sure the airways is clear. If necessary, remove secretions from the throat through a catheter inserted through the nose. Give Diazepam Rectally: Draw up the dose from an ampoule of diazepam into a tuberculin (1ml) syringe. Base the dose on the weight of the child, where possible. Then remove the needle. Insert the syringe into the rectum 4 to 5 cm and inject the diazepam solution. Hold buttock together for a few minutes. Diazepam given rectally 10mg/2ml solution (Dose 0.1ml/kg) Dose (mg) 2 - <4 months 4 - <12 months 1 - 3 years 3 - 5 years 4 - <6kg 6 - <10kg 10 - <14kg 14 - 19 kg 2.5 5 6.25 7.5 * Dose (ml) 0.5 1 1.25 1.5

Give Inhaled Salbutamol for Wheezing


USE OF 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 nebuliser if correctly used. From salbutamol metered dose inhaler (100g/puff) give 2 puffs. Repeat up to 3 times every 15 minutes before classifying pneumonia. If a spacer is being used for the first time, it should be primed by 45 extra puffs from the inhaler. Spacers can be made in the following 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 fourth and the lower and disregard the upper fourth of the bottle. Cut a small V in the border of the large open part of the bottle to fit to the childs nose and be used as a mask. Flame with a candle or a lighter the edge of the cut bottle to soften it. In a small babay a mask can be made by making a similar hole in a plastic (not polystyrene) cup. Alternatively commercial spacers can be used if available. To use an inhaler with a spacer: Remove the inhaler cap. Shake the inhaler well. Insert 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 and breath in and out through the mouth. A carer then presses down the inhaler and sprays into the bottle while the child continues to breathe normally. Wait for three to four breaths and repeat for total of five sprays. For younger children place the cup over the childs mouth and use as a spacer in the same way.

Age

Weight

* Use 2 ml syringe If convulsion continues after 10 minutes, give a second dose of diazepam rectally [or give diazepam intravenously (0.05ml/kg = 0.25 mg/kg) if IV infusion is running]. If convulsion continues after another 10 minutes, give a third dose of diazepam rectally or give paraldehyde rectally (or Phenobarbital IV or IM 15mg/kg) If high fever: Sponge the child with room-temperature water to reduce the fever. Do not give oral medication until the convulsion has been controlled (danger of aspiration).

15

GIVE TREATMENT IN CLINIC ONLY


Explain to the mother why the drug is given Determine the dose appropriate for the childs weight (or age)

Oral Salbutamol
Give oral salbutamol three times daily for 5 days when inhaled salbutamol is not available.

Treat the child to prevent low blood sugar


If the child is able to breastfeed: Ask the mother to breastfeed the child

Dosage and administration of oral Salbutamol Age or Weight 2 4 months (4 - < 6kg) 4 12 months (6 - < 10kg) 12 months 3 years (10 - < 14kg) 3 - 5 years (14 19kg) Syrup 2mg/ml

If the child is not able to breastfeed but able to swallow: Give expressed breast milk or breast milk substitute. If neither of these is available, give sugar water. Give 30 50 ml of milk or sugar water before departure. To make sugar water: dissolve 4 level tea spoons of sugar (20 grams) in a 200-ml cup of clean water If the child is not able to swallow:

1 ml

2 ml

2.5 ml

Give 50 ml of milk or sugar water using a nasogastric tube (exception for dengue fever)* If nasogastric not available, refer urgently

5 ml

* Insertion of a nasogastric tube in a dengue fever patient can cause bleeding of the gastro intestinal system.

16

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING


(See FOOD ADVICE ON COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home


Counsel the mother on the 4 Rules of Home Treatment: Give Extra Fluid, Give Zinc Supplements, Continue Feeding, When to Return

Plan B: Treat Some Dehydration with ORS


Give in clinic recommended amount of ORS over 4-hours period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

AGE*

1. GIVE EXTRA FLUID (as much as the child will take)


TELL THE MOTHER Breastfeed frequently and for longer at each feed. If the child is exclusively breastfed, give ORS or clean water in
WEIGHT In ml

Up to 4 months
< 6 kg 200 - 400

4 months up to 12 months
6 10 kg 400 - 700

12 months up to 2 years
10 - < 12 kg 700 - 900

2 years up to 5 years
12 19 kg 900 - 1400

addition to breastmilk. 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 yogurt drinks), or clean water

* Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) by 75. If the child wants more ORS than shown above, give more For infants under 6 months who are not breastfed, also give 100 200 ml clean water during this period Give frequent small sips from a cup If the child vomits, wait 10 minutes. Then continue, but more slowly Continue breastfeeding whenever the child wants Reassess the child and classify the child for dehydration Select the appropriate therapy to continue treatment Begin feeding the child in clinic Show her how to prepare ORS solution at home Show her how much ORS to give to finish the 4 hours treatment at home Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A Explain the 4 Rules of Home Treatment 1. 2. 3. 4. GIVE EXTRA FLUID GIVE ZINC SUPPLEMENTS CONTINUE FEEDING WHEN TO RETURN See Plan A for recommended fluids and See COUNSEL THE MOTHER chart

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 clinic if the diarrhoea gets worse. TEACH THE MOTHER HOW MUCH TO MIX AND GIVE ORS. GIVE THE MOTHER 6 PACKETS OF ORS TO USE AT HOME SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE DAILY: Up to 2 year 50 to 100 ml after each loose stool 2 year to 5 years 100 to 200 ml after each loose stool

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION


AFTER 4 HOURS

Tell the mother to:


Give frequent small sips from a cup If the child vomits, wait for 10 minutes. Then continue, but more slowly. Continue giving extra fluid until the diarrhoea stops

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT

2. GIVE ZINC SUPPLEMENTS


Tell the mother how much zinc to give: Up to 6 months tablet (10mg) per day for 10-14 days 6 months and more 1 tablet (20mg) per day for 10-14 days Show the mother how to give zinc supplements Infants, dissolve the tablet in a small amount of clean water, expressed milk or ORS in a small cup or spoon. Older children, tablet can be chewed or dissolve in a small amount of clean water o small water in a cup or spoon. Remind the mother to give the zinc supplements for full 10-14 days

3. CONTINUE FEEDING
See COUNSEL THE MOTHER chart

4. WHEN TO RETURN

17

GIVE EXTRA FLUID FOR DIARRHOEA 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 IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringers Lactate Solution (or, if not available, normal saline), divided as follows:
AGE Infants (under 12 months) Children (12 months up to 5 years) First Give 30 ml/kg 1 hour* Then give 70 ml/kg in: 5 hours

Give pre-referral fluids for Dengue Hemorrhagic Fever


If any shock signs treat immediately. Give intravena fluids urgently (*). Give ringers lactate (**) if not available give NaCL fluids: 12-20 ml/kg weight in 30 minutes. Reassess the child after 30 minutes: - If childs pulse palpable, give IV fluid with drops of 10 ml/kg weight in 1 hour and refer urgently to hospital. - If Childs pulse not palpated, give IV drops of 15-20 ml/kg weight in 1 hour and refer urgently to hospital. If no shock signs: Give extra fluids or ORS as much as possible on the way to hospital. NOTE: (*) If not able to give IV fluids, give the child ORS or other fluid often and frequent sips during the way to hospital. (**) If possible, give 5% glucose solution in ringers lactate

START HERE

30 minutes*

2 hours

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


Can you give intravenous (IV) Fluid Immediately?

YES

NO

Reassess the child every 15 to 30 minutes. 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 or a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip. Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours:

Is IV treatment available nearby (within 30 minutes)? NO

IMMUNIZE EVERY SICK CHILDS AS NEEDED

YES

Are you trained to use a naso-gastric (NG) tube for rehydration? NO YES

Can the child drink?

After 6 hours, reassess the child, Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment.

- 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.

GIVE SUPPLEMENT VITAMIN A AS NEEDED

NO

GIVE DEWORMING DRUGS AS NEEDED

Refer URGENTLY to hospital for IV or NG treatment.

NOTE : If possible, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.

Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).

* Note: 1 ml = 20 drops/minute

- macro infusion 60 drops/minute - micro infusion

18

GIVE FOLLOW-UP CARE


Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

PNEUMONIA
After 2 days: Check the child for general danger signs. See ASSESS & Assess the child for cough or difficult breathing. CLASSIFY chart. Ask: Is the child breathing slower? Is the child eating better? Treatment: If chest indrawing or general dangers sign, give first dose of second-line antibiotic or intra muscular chloramphenicol. Then refer URGENTLY to hospital. If there is no improving on breathing rate and eating is the same, change with the of second-line antibiotic and advise the mother to return within 2 days or refer. (if there is no second-line antibiotic or if the child had measles within the last 3 months.) If breathing slower, eating better, complete the 5 days of antibiotic.

DYSENTERY
After 2 days: Assess if the child for has diarrhoea. => See ASSESS & CLASSIFY chart. Ask: Are there fewer stools? Is there less blood in the stool? Is the child eating better? Treatment: If the child is dehydrated, treat dehydration. If number of stools, amount of blood in stools, eating is the same or worse, change with second-line oral antibiotic recommended for Shigella in your area. Give it for 5 days. Advise the mother to return in 2 days. 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.

PERSISTENT DIARRHOEA
After 5 days: Ask: - Has the diarrhea stopped? Treatment: If the diarrhea has not stopped do a full reassessment on the child. Give any treatment, and then refer to hospital. If the diarrhea has stopped, tell the mother to follow the usual feeding recommendations for the childs age as mentioned on the Mother Advice Card.

If fewer stools, less blood in the stools, eating better, continue giving the same antibiotic until finish.

19

GIVE FOLLOW-UP CARE


Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

MEASLES WITH EYE OR MOUTH COMPLICATIONS


After 2 days: Look for red eyes and pus from the eyes. Look at mouth ulcers. Smell the mouth. Treatment for eye infection: If pus is still draining from the eye, ask the mother to describe how she has treated the eye infection. If treatment has been correct, refer to hospital. If treatment has not been correct, teach the mother correct treatment. If the pus is gone but redness remains, continue the treatment. If no pus or redness, stop the treatment, and praise the mother Treatment for Mouth Ulcers: If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If mouth ulcers are the same or better, continue gentian violet for total 5 days.

Malaria
If fever persist after 2 days, or relapses within 14 days: Do a full reassessment for the chief symptoms => See ASSESS & CLASSIFY chart. Assess for other causes of fever. Treatment: If the child has any general danger sign or stiff neck, treat as SEVERE FEBRILE DISEASE. If the child has any cause of fever other than malaria, provide treatment. If malaria is the only apparent cause of fever: Treatment failure within 14 days of receiving coartem is extremely rare and is more likely to be an inadequate absorption of the drug(s) than resistance of the parasites. It is important to determine from the patients history whether the child vomited during the previous treatment or did not complete the full course. If patient is in health facility where microscope is available failure of treatment should be confirmed parasitologically or refer to the facility where microscope is available. o If it is positive falciparum, vivax or mixed infection, treat with the second-line oral antimalarial. In all situation the patients conditions should be monitored and in case no improvement within two days they should be referred and admitted to the referral. If the blood smear testing is negative, refer for follow-up care.

POSSIBLE DENGUE HAEMORRAGIC FEVER AND FEVER: DENGUE HAEMORRAGIC FEVER UNLIKELY For possibly DHF follow-up daily until the fever has resolved for 2 days or until another causes of fever is identified: for DHF unlikely follow-up in 2 days if fever persists. Do a full reassessment of the child. => see ASSESS & CLASSIFY chart. Assess for other causes of fever. Treatment: If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If the child has any cause of fever other than malaria, provide treatment. If the child has symptoms of Dengue Hemorrhagic Fever (DHF), treat as DHF.

Fever has been present for 7 days, refer for assessment.

20

GIVE FOLLOW-UP CARE


Care for the child who returns for follow-up using all the boxes that match the childs previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

EAR INFECTION
After 5 days: Reassess for ear problem. > See ASSESS & CLASSIFY chart. Measure the childs 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 discharges persist, 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 wick the ear correctly. Encourage her to continue giving ciprofloxacin for 2 weeks. If no ear pain or discharge, praise the mother for her careful treatment, if she has not yet finished the 5 days of antibiotic, tell her to use all of it before stopping

FEEDING PROBLEM
After 5 days: Reassess feeding. = > see questions at the top of the COUNSEL chart. Ask about any feeding problems found 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 weight for age, ask the mother to return 30 days after the initial visit to measure the childs weight gain.

ANAEMIA
After 14 days: Give iron for next 4 weeks. Advise mother to return in 4 weeks for more iron. If the child still has some pallor after 8 weeks, refer for assessment If the child has no palmar pallor after 8 weeks, no additional treatment.

21

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

VERY LOW WEIGHT


After 4 weeks: Weigh the child and determine if the child is still very low weight for age. Reassess feeding. => See questions at the top of the COUNSELING THE MOTHER chart. Treatment: If the child is no longer very low weight for age, praise the mother and encourage her to continue. If the child is still very low weight for age, counsel the mother about any feeding problem found. Continue to see the child monthly until the child is feeding well and 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.

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER OF THE NEXT FOLLOW-UP VISIT

ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMDIATELY. (SEE COUNSELING THE MOTHER CHART)

COUNSEL THE MOTHER

22

FOOD
Assess the Childs Feeding Ask questions about the childs usual feeding and feeding during this illness. Compare the mothers answers to the Feeding Recommendations for the childs age in the box below.
ASK
Do you breastfeed your child? o How many times during the day? o Do you also breastfeed during the night? Does the child take any other food or fluids? o What food or fluids? o How many times per day? o What do you use to feed the child? o If very low weight for age: How large are servings? Does the child receive his own serving? o Who feeds the child and how? During this illness, has the childs feeding changed? If yes, how?

23

Feeding recommendation During Sickness and Health


6 months up to 12 months

6 months up to 12 months

after baby tolerating quantities in column to the left then gradually increase as below
Breastfeed as Often as the child wants. Give rice porridge and egg yolk / chicken / fish / soy bean / tofu / beef / carrot / spinach / green beans / oil. Give daily foods in 3 times a day, give adequate serving of: -6 months = 6 table spoons -7 months = 7 table spoons -8 months = 8 table spoons -9 months = 8 table spoons -10 months = 10 table spoons -11 months = 11 table spoons Give additional foods in 2 times a day: -Green bean porridge, banana, biscuit, steamed cassava.

begin with
Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Do not give other foods or fluids.

Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Give other foods 2 times per day after breastfeeding, each time 2 tablespoons. Breastfeed before give other food (add food). Add Foods as: - Mashed rice-porridge added with egg yolk / chicken / fish / soy bean / tofu / beef / carrot / spinach / green beans / oil.

Breastfeed as often as the child wants. Give steamed rice with egg yolk / chicken / fish / soy bean / tofu / beef / carrot / spinach / green bean /oil Give add foods 2 times a day: -green beans porridge, banana, biscuit, steamed cassava.

Give family foods at 3 meals each day as: consisting of rice, meat, side dishes, vegetables and fruits. Give add foods 2 times a day: -Green bean porridge -Biscuit -Steamed cassava.

24

The way to feed babies and young children So they grow and develop well and stay healthy
1. Put the baby to the mothers breast when the baby is born. WHY? Because skin contact between the mother and baby helps prevent the baby from getting cold; skin contact and the baby sucking on the breast stimulates a good flow of the mothers milk; skin contact helps the bonding between mother and baby; and, helps the uterus to contract and so reduces blood loss.

2. Do not throw away the first milk, colostrum, which is yellow, but let the baby drink it. WHY? Because colostrum is very rich in vitamins and other protective substances which protect the baby from sicknesses and help the baby to grow well.

3. Give only breastmilk to your baby until he/she is 6 months old. WHY? This is the only food and liquid that the young baby needs. If other foods, or drinks, like sugar water, are given, these will harm the babys stomach. 4. Breastfeed as often as the baby wants, day and night. WHY? When the baby breastfeeds often, the breast will produce more and more milk to meet the babys needs. You must place the baby on the area around nipple correctly so that the breastmilk will flow well. 5. Do not give babies and young children bottles containing milk bought from the shop, or other drinks, and do not give them dummies (pacifiers). WHY? Other milks are not as good for the baby as breastmilk; they are expensive and bottle feeding and dummies carry germs and germs will give the baby diarrhea. 6. Start to give a variety of other foods to a baby when the baby is about 6 months old and keep breastfeeding your child until he/she is 2 years old or more. WHY? When a baby is about 6 months old breastmilk does not provide all that the baby needs to grow well. 7. Patiently teach the young baby how to eat at times when he is happy and not tired. WHY? A baby does not know how to eat and needs help to learn how to feed himself.

25

8. Always wash your hands with soap and water before preparing food and after going to the toilet, and wash childrens hands before they begin eating. WHY? This will help prevent children from getting diarrhea and many other illnesses. 9. When starting to give foods to the young baby, make the food soft and thick and not runny or watery. You can add a little oil, to increase the energy in the food. WHY? If the food is watery, the baby will not put on weight and grow well. 10. Give babies from six months and young children a variety of food to eat, like ripe banana, papaya, pumpkin, mango, rice porridge, mashed potato, chicken, fish, meat, eggs, corn, beans, and dark green leafy vegetables, WHY? Young children need to eat a variety of foods so they will grow well. 11. Dont forget to add a little iodised salt to the young childs food. Why? Iodine is important for the mental and physical development of children and also important for pregnant women. 12. Feed the young child many times during the day. WHY? A young child is growing rapidly and has a small stomach. So that he can grow and develop he needs to eat often many meals and snacks throughout the day. 13. Continue to breast-feed when a child is sick, and, if the child is over six months encourage him/her to eat and drink and give him/her extra food when he is well again. WHY? If the child does not eat he will lose weight, become weak and is more likely to get sick again.

26

The table below provides some guidelines on types of foods, frequency and quantity for different age groups of children.

Age group

How to prepare the food

How many times in the day

How many spoons or cups each time 6 9 small spoons

6 months

7-8 months

Rice porridge mixed with soft pumpkin, potato, ripe banana or pawpaw, tofu, and later, egg yolk. Rice porridge mixed with soft pumpkin, potato, ripe banana or pawpaw, egg yolk, meat, fish, with bones removed, tempura, tofu, green leafy vegetables. Fruits All kinds of food, soft, cut into small pieces and which baby can hold and feed himself. Fruits

2 times and breastfeed often

3 times, and breastfeed often

Increase slowly the quantity of food up to about two thirds of a cup

9-11 months

3 times, and aslo snacks between meals, and breastmilk as much as the child wants

About a cup of food

12-24 months

All kinds of foods eaten by the rest of the family, cut small and made soft as necessary Fruits

3 times, and aslo snacks between meals, and breastmilk as much the child wants

A full cup or more after each meal

Important; Dont forget to take your baby or young child to the health clinic every month for growth monitoring, vaccinations, vitamin A, and de-worming tablets, and other health assistance!

27

*
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 mothers confidence that she can produce all the breast milk that the child needs. - Suggest giving more frequent, longer breastfeeds, day and 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 night. - Make sure that other milk is locally appropriate breast milk substitute. - Make sure other milk is correctly and hygienically prepared and given in adequate amounts. - Prepare only an amount of milk which the child can consume within one hour. If there is some left-over milk, discard.

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 cup. 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. - observe what the child likes, and consider these in the preparation the child foods. 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. Follow-up any feeding problem in 5 days.

28

Teach Correct Positioning and Attachment for Breastfeeding


Show the mother how to hold her baby correctly - With the babys head and body straight - Facing her breast, with babys nose opposite her nipple - With baby body close to her body - Supporting babys whole body, not only neck and shoulders. Show her how to help the baby to attach properly. Ensure the mother holds the baby correctly with the babys nose opposite her nipple. Do the following steps: - touch her babys lips with her nipple - then wait until her babys mouth open wide - after mouth opens wide, attach the baby mouth onto her breast immediately such that her nipple inside babys mouth, aiming the babys lower lip well below the nipple. Observe good signs of attachment and sucking effectively. If not, try once again.

29

FLUID
Advise the mother to Increase Fluid During Illness
FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed.

Increase fluid. For example, give soup, rice water, yogurt 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 FOLLOW-UP VISIT:

Advise the mother to come for follow-up at the earliest time listed for the childs problems.
If the child has:
MAYBE DENGUE FEVER, until fever has resolved 2 days or another caused of the fever has been found. FEVER-MAYBE NOT DENGUE FEVER, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS PNEUMONIA DYSENTRY MALARIA if fever persists

Follow-up in: daily 2 days

RETURN IMMEDIATELY:
Advise mother to return immediately if the child has any of these signs: Not able to drink Any sick child Becomes sicker Develops a fever Child with cough: not Difficult breathing pneumonia Fast breathing If child has diarrhoea Any bleeding Cold and clammy extremities Pit of the stomach pain and restless Vomit repeatedly Any bleeding signs Cold and clammy extremities Pit of the stomach pain and restless Vomiting weak or drowsy Refusing to eat Restless and altered behaviour Cold and clummy skin No urine for 4 6 hours

3 days 5 days

PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEM ANY OTHER ILLNESS, if not improving ANAEMIA
VERY LOW WEIGHT FOR AGE

If child has DHF or fever maybe not Dengue Fever

4 weeks/1 month
4 weeks/1 month

NEXT WELL CHILD VISIT: Advise the mother when to return for the next immunization and vitamin A supplementation according to the respective schedules.

30

Counsel

the Mother about Her Own Health


If the mother is sick, provide any care for her, refer her for help If she has a breast problem (such as engorgement, sore nipples, and breast infection), provide care for her or refer for help Advise her to eat well to keep up her own strength and health. Check the mothers immunization status and give her tetanus toxoid (TT) if needed. Make sure she access to: - Family planning - Counseling on STD and AIDS prevention

31

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS


NAME:____________________ Age:______ weight: ______kg Temperature __________ C

ASK: What are the childs problems?_____________ Initial visit?________ Follow-up visit_______ ASSESS (Circle all signs present) CHECK FOR GENERAL DANGER SIGNS Not able to drink or breastfeed Lethargic or unconscious Vomiting everything Convulsion CLASSIFY
Common danger signs Yes___ No___ Remember to use danger sign when selecting classifications

TREATMENT
Remember to refer every child who has general danger signs

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes__ No__ For how long?___ Days Count the breaths in one minute._______Breaths per minute. Fast breathing? Look for the chest indrawing. Look and listen for stridor or wheezing DOES THE CHILD HAVE DIARRHOEA? Yes______ No______ Blood smear taken?

For how long?___ Days Is there blood in the stool?

Look at the child general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

Yes___ No___

DOES THE CHILD HAVE FEVER?


(by history/feels hot/temperature 37.5C or above)

Yes_____ No______

IF YES:

For how long has the child had fever? ____Days If more than 7 days, has fever been present every day? Has child had measles within the last 3 months? Look or feel for stiff neck. Look for signs of MEASLES: - Generalized rash and - One of these: cough, runny nose, or red eyes.

If the child has measles now or within the last 3 months:


Look for mouth ulcers or thrush. If yes, are they deep and extensive? Look for pus draining from the eye. Look for the clouding of the cornea

Classify DENGUE FEVER if FEVER present from 2 to less than 7 days


Any severe bleeding from nose or gums Is the child vomit? If yes: Is often? Any bleeding in the vomit? or coffee ground vomit? Has the child had any tarry black stool? Does the child have epigastric pain or is restless? Look for any severe bleeding from nose or gums. Look for any bleeding spots in the skin (petechiae) If other signs of DNF there or not there, do tourniquet test Check for any shock signs Cold and clammy extremities and radial pulse is very weak or not detectable.

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ASSESS (Circle all sign present)


DOES THE CHILD HAVE AN EAR PROBLEM?

CLASSIFY TREATMENT Yes___ No___

Is there ear pain? Is there ear discharges? If yes, for how long?___ days

Look for pus draining from the eye. Feel for tender swelling behind the ear

THENCHECK FOR MALNUTRITION AND ANAEMIA? Look for visible severe wasting. Look for palmar pallor - Severe palmar pallor? - Some palmar pallor Look for oedema of both feet. Determine weight for age. Very Low_____ Not Very Low_____ CHECK THE CHILDS IMMUNIZATION STATUS (Circle immunization needed today) _____ BCG _____ DPT1 _____ Polio0 _______ Hep B1 _____ DPT2 _____ Polio1 ______ Hep B2 _____ DPT3 _____ Polio2 ______ Hep B3 ______ Campak _____ Polio3 Immunization to be given to day:

CHECK THE CHILDS VITAMIN A SUPPLEMENT STATUS Vitamin A Needed? Yes___ No___
CHECK THE CHILDREN AGED 1 - 5 YEAR ALBENDAZOLE SUPPLEMENT STATUS? ALBENDAZOLE Needed

Vitamin A to be given today: Yes__ No__ Whether give Albendazole or to day: Yes__ No__

Yes___ No___
ASSESS THE PROBLEM OR SIGNS ASSESS CHILDS FEEDING if the child has ANAEMIA or VERY LOW WEIGHT or CHILDS AGE< 2 YEARS

Feeding problems:

Feeding problems:

Do you breastfeed your child? If yes, how many times in 24 hours? _______ Times. Is the child breastfeed at night? Does the child receive other food or drink: If yes, what food and drink?

Yes___ No___ Yes___ No___ Yes___ No___

________________________________________________________________ How many times per day? ______ times. What do you use to feed the child?
_________________________________________________________________ If the child Very Low Weight: how large are the servings? Yes___ No___ _______________________________________________________________________ Does the child receive own servings? Who feeds the child and how? _______________________________________________________________________ During illness, has the childs feeding changed? Yes___ No___ If yes, how?
Advise the mother when to return immediately Return for follow up in .days

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Childs Growth and Development Chart


A healthy child will gain weight as they grow older

3 6 months

9 12 months
Walk with holding

12 18 months
Drinks alone and not spill out

18 14 months
or ballpoints

Raise the head straightly at face downward position

Scribble with pencil

2 3 years
Stand with one leg without holding

2 3 years
Undress on their own

3 4 years

Recognize and mention at least one color

4 5 years

Wash and dry hands without any help

CORRECT TIME FOR IMMUNIZATIONS

PERIOD FOR EXCLUSIVE BREASTFEEDING

Write childs age into this column Write the subsequent months into the subsequent column

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