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8/9/2019 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS(as of 2009 update)
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INTEGRATED
MANAGEMENT OFCHILDHOOD ILLNESS
Chart Booklet
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ASSESS AND CLASSIFY THE SICK CHILD
AGE 2 MONTHS UP TO 5 YEARS
Determine if this is an initial or
follow-up visit for this problem
If follow-up visit, use the follow-up
instruction on TREAT THE CHILDchart
If initial visit, assess the child as
follows:
USE ALL BOXES THAT
MATCH THE CHILDS
SYMTOMS AND
PROBLEMS TO
CLASSIFY THE
ILLNESS
ASK THE MOTHER WHAT THE
CHILDS PROBLEM ARE
IDENTIFY
TREATMENT
CLASSIFYASSESS
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CHECK FOR GENERAL DANGER SIGNS
A child with any general danger signs need URGENT attention; complete the
assessment and any pre-referral treatment immediately so referral is not delayed.
LOOK: See if the child is abnormally sleepy or
difficult to awaken
ASK: Is the child not able to drink or
breastfeed?
Does the child vomit everything?
Has the child had convulsions?
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED
after first dose of an appropriate antibiotic and other urgent treatments.
Exception: Rehydration of the child according to Plan C may resolve danger
signs so that referral is no longer needed.
IF YES:
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Classify COUGH or DIFFICULT BREATHINGTREATMENT
(Urgent pre-referral treatments are in bold print)
CLASSIFY ASSIGNS
Give an appropriate antibiotic for 3 days.
If wheezing (even if it disappeared after rapid acting
bronchodilator) give an inhaled bronchodilator for 5
days.
Soothe the throat and relieve the cough with a safe
remedy.
Advise mother when to return immediately.
Follow-up in 2 days.
PNEUMONIA Fast breathing
If wheezing (even if it disappeared after rapid acting
bronchodilator) give an inhaled bronchodilator for 5
days.
If coughing more than 30 days, refer for assessment.
Soothe the throat and relieve the cough with a safe remedy.
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
NO PNEUMONIA:
COUGH OR COLD
No signs of
pneumonia or very
severe disease
Give first dose of an appropriate antibiotic
Give Vitamin A.
Treat the child to prevent low blood sugar
Refer URGENTLY to hospital *.
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
Any general danger
sign or
Chest indrawing or
Stridor in calm child
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*If referral is not possible, manage the child asdescribed in management of Childhood Illness, Treat
the Child, Annex: Where Referral is not Possible, and
WHO guidelines for in-patient care.
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THEN ASK: Does the child have diarrhea?
LOOK AND FEEL: Look at the childs general condition.
Is the child:
o Abnormally sleepy or difficult to awaken?
o Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the Child:
o Not able to drink or drinking poorly?
o Drinking eagerly, thirsty?
Pinch the skin of the abdomen
Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
IF YES, ASK:
For how long?
Is there blood in the
stool?
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Signs Classify Treatment
Give ORS, zinc supplements and food for some
dehydration (Plan B)
If child also has a severe classification:
ReferURGENTLYto hospital with mother givingfrequent sips of ORS on the way.
Advise mother to continue breastfeeding.
Advise mother when to return immediately
Follow-up in 5 days if not improving
SOME
DEHYDRATION
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back
slowly
Give ORS, zinc supplements and food for some
dehydration (Plan B)
Give fluid and food to treat diarrhea at home (Plan A)
Advise mother when to return immediately
Follow-up in 5 days if not improving
NO
DEHYDRATION
Not enough signs to
classify as some or
severe dehydration
If child has no other severe classification:
Give fluid for severe dehydration (Plan C) OR
If child also has another severe classification:
ReferURGENTLYto hospital with mother
giving frequent slips of ORS on the way.
Advise the mother to continue breastfeeding.
If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera
SEVERE
DEHYDRATION
Two of the following signs:
Abnormally sleepy or
difficult to awaken
Sunken eyes
Not able to drink or
drinking poorly
Skin pinch goes back very
slowly
Classify DIARRHEA for dehydration
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Classify DIARRHEA and if diarrhea 14 days or more
Advise the mother on feeding a child who
has PERSISTENT DIARRHEA
Give Vitamin A
Follow-up in 5 days
Advise mother when to return immediately.
PERSISTENT
DIARRHEA
No dehydration
Treat dehydration before referral unless
the child has another severe classification
Give Vitamin A
Refer to hospital
SEVERE
PERSISTENT
DIARRHEA
Dehydration
present
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Classify DIARRHEA and if blood in stool
Give ciprofloxacin for 3 days.
Follow-up in 2 days
Advise mother when to returnimmediately.
DYSENTERYBlood in the stool
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THEN ASK: Does the child have fever?
(by history, or feels hot, or if temp. Is 37.5 *C or above)
LOOK AND FEEL:
Look or feel for stiff neck
Look for runny nose
Look for signs of MEASLES: Generalized rash and
One of these: cough, runny nose,
or red eyes
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?
Decide Malaria Risk
Ask:
Does the child live in a malaria area?
Has the child visited /stayed overnight in a malaria area in the past 4 weeks?
If Yes to either, obtain a blood smear - Pv Pf + Not Done
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
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Treat the child with an oral antimalarial
Give one dose of paracetamol in health center
for high fever (38.5C 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
MALARIA
Blood smear(+)
If blood smear not
done:
NO runny nose, and
NO measles, and
NO other causes of
fever
Give one dose of paracetamol in health center for
high fever (38.5C 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
UNLIKELY
Blood smear( - ) or
Runny nose, or
Measles, or
Other causes of fever
Give first dose of quinine (under medical supervision
or if a 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 (38.5C or above).
Send a blood smear with the patient.
ReferURGENTLYto hospital.
VERY
SEVERE
FEBRILE
DISEASE/
MALARIA
Any general
danger sign or
Stiff neck
Classify FEVERMalaria Risk(including travel/overnight stay to malaria area)
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Give one dose of paracetamol in health center
for high fever (38.5C 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:
NO
MALARIA
No sign of very
severe febrile
disease
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 (38.5C or above)
ReferURGENTLYto hospital
VERY
SEVERE
FEBRILE
DISEASE
Any general
danger sign or
Stiff neck
Classify FEVERNo Malaria Risk
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Look for mouth ulcers.
Are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
If the child has
measles now or
within the lastthree months:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Give Vitamin A
If pus draining from the eye, apply
tetracycline eye ointment
If mouth ulcers, teach the mother to treat with
gentian violet.
Follow-up in 2 days
Advise mother when to return immediately
MEASLES
WITH EYE OR
MOUTHCOMPLICATIONS ***
Pus draining
from the eye or
Mouth ulcers
Give Vitamin A
Advise mother when to return immediatelyMEASLES
Measles now or
within the last 3
months
Give Vitamin A.
Give first dose of an appropriate antibiotic
If clouding of the cornea or pus draining
from the eye, apply tetracycline eye
ointment.
ReferURGENTLYto hospital.
SEVERE
COMPLICATED
MEASLES***
Any general dangersign or
Clouding of cornea
or
Deep or extensive
mouth ulcers
If MEASLES now or within the last 3 months,classify
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LOOK AND FEEL:
Look for bleeding from nose or
gums.
Look for skin petechiae.
Feel for cold and clammyextremities.
Check for slow capillary refill
Ifnone of above ASK or LOOK and
FEEL signs are presentandthe
child is 6 months or olderandfeverpresent for more than three days
do
Perform the tourniquet test
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 persistent
abdominal pain?
Has the child had persistent
vomiting?
Assess Dengue Hemorrhagic Fever:
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Advise mother when to returnimmediately
Follow-up in 2 days if fever persists or
child shows signs of bleeding
DO NOTGIVE ASPIRIN
FEVER:DENGUE
HEMORRHAGIC
FEVER
UNLIKELY
No signs of severe dengue
hemorrhagic fever
If persistent vomiting or persistent
abdominal pain or positive
tourniquet test are the only positive
signs give ORS (Plan B).
If any other signs of bleeding are
present, give fluids rapidly as in
Plan C. Treat the child to prevent low blood
sugar.
ReferURGENTLYto hospital.
DO NOTGIVE ASPIRIN.
SEVERE
DENGUEHEMORRHAGIC
FEVER
Bleeding from nose or gums or
Bleeding in stools or vomitus or
Black stools or vomitus or
Skin petechiae or
Cold and clammy extremities or
Capillary refill more than 3seconds or
Persistent Abdominal pain or
Persistent Vomiting or
Tourniquet test positive
Classify DENGUE HEMORRHAGIC FEVER
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THEN ASK: Does the child have an ear problem?
LOOK AND FEEL:
Look for pus draining from the
ear
Feel for tender swelling behind
the ear
IF YES, ASK:
Is there ear pain?
Is there ear
discharge?
If yes, for how long?
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Dry the ear by wicking.
Instill Quinolone otic drops for2 weeks Follow-up in 5 days.
Advise mother when to return
immediately.
CHRONIC
EARINFECTION
Pus is seen draining from
the ear and discharge isreported for 14 days or
more
Give an antibiotic for 5 days.
Give paracetamol for pain. Dry ear by wicking.
Follow-up in 5 days.
Advise mother when to return
immediately..
ACUTE EARINFECTION
Pus is seen draining from
the ear and discharge isreported for less than 14
days, or
Ear pain
No treatment..
Advise mother when to return
immediately
NO EAR
INFECTION
No ear pain and
No pus seen draining from
the ear
Give first dose of an appropriate
antibiotic.
Give first dose of paracetamol for
pain.
ReferURGENTLYto hospital.
MASTOIDITIS Tender swelling behind the
ear
Classify EAR PROBLEM
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THEN CHECK FOR MALNUTRITION & ANEMIA
LOOK AND FEEL:
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* is less than 110 mm.
CHECK FOR MALNUTRITION
*MUAC is Mid-Upper Arm Circumference. If tapes are notavailable, look for visible severe wasting.
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Classify NUTRITIONAL STATUS
Assess the childs feeding and counsel the
mother on feeding recommendations
Give Vitamin A.
Advise mother when to return immediately.
Follow-up in 30 days.
VERY LOW
WEIGHT Very low weight for age
If the child is less than 2 years old, assessthe childs feeding and counsel the mother
on feeding recommendations
If feeding is a problem, follow-up in 5
days
Advise mother when to return immediately
NOT VERYLOW WEIGHT Not very low weight for age
and no other signs of
malnutrition
Give Vitamin A
Treat the child to prevent low blood
sugar.
ReferURGENTLYto hospital
SEVERE
MALNUTRITION
If age up to 6 months and
- visible severe wasting or
- edema of both feet
If age 6 months and above
and:
-MUAC less than 110 mm or
-edema of both feet
- visible severe wasting
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CHECK FOR ANEMIA
LOOK AND FEEL:
Look for palmar pallor. Is
it:
Severe palmar pallor? Some palmar pallor?
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Classify ANEMIA
Assess the childs feeding and counsel
the mother on feeding according to the
feeding recommendations
Give iron
Give oral anti-malarial if malaria risk
Give Mebendazole/Albendazole if child is
1 year or older and has not had a dose in
the previous 6 months
Advise mother when to return
immediately
Follow-up in 14 days
ANEMIASome palmar
pallor
If the child is less than 2 years old,
assess the childs feeding and counsel
the mother on feeding according to
feeding recommendations If feeding is a problem, follow-up in 5 days
Advise mother when to return immediately
NO ANEMIANo palmar pallor
ReferURGENTLYto hospitalSEVEREANEMIA
Severe palmar
pallor
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THEN CHECK THE CHILDS IMMUNIZATION, VITAMIN AND DEWORMING STATUS:
IMMUNIZATION SCHEDULE:
AGE VACCINE
Birth BCG Hep B-1
6 weeks DPT-1 OPV-1 Hep B-2
10 weeks DPT-2 OPV-2
14 weeks DPT-3 OPV-3 Hep B-3
9 months Measles
VITAMIN A PROPHYLAXIS
VITAMIN A SUPPLEMENTATION SCHEDULE:
The first dose at 6 months or above. Subsequent doses every 6 months.
ROUTINE WORM TREATMENTGive every child mebendazole/albendazole every 6 months from the age of
one year. Record dose on the childs card.24
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ASSESS OTHER PROBLEMS
MAKE SURE CHILD WITH ANYGENERALDANGER SIGN IS REFERRED after firstdose of an appropriate and other urgent
treatments
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TREAT THE CHILD
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TREAT THE CHILDCARRY OUT THE TREATMENT STEPS IDENTIFIED ON
THE ASSESS AND CLASSIFYCHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
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 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 and package the drug.
If more than one drug will be given, collect, count and 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 mothers understanding before she leaves the health center.
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AGE OR
WEIGHT
AMOXYCILLIN
Give 2x daily for 3 days
(pneumonia)
Give 3x daily for 5 days (acute earinfection)
COTRIMOXAZOLE
Give 2x daily for 3 days (pneumonia)
Give 3x daily for 5 days (acute ear
infection)
ADULT TABLET
(250 MG)
SYRUP
(125 MG/5 ML)
TABLET
80 mg
trimethoprim+
400 mg sulfame-
thoxazole)
TABLET
40 mg trimethoprim
+ 200 mg sulfame-
thoxazole)
2 mos up
to 6 mos
(3-5 kg) 5 ml 5 ml
Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS
FIRST-LINE ANTIBIOTIC: AMOXYCILLIN
SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE
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AGE ORWEIGHT
AMOXYCILLIN
Give 2x daily for 3 days (pneumonia)
Give 3x daily for 5 days (acute ear
infection)
COTRIMOXAZOLE
Give 2x daily for 3 days (pneumonia)
Give 3x daily for 5 days (acute ear
infection)
ADULT
TABLET (250
MG)
SYRUP
(125 MG/5 ML)
TABLET
80 mg
trimethoprim+
400 mg sulfame-
thoxazole)
TABLET
40 mg trimethoprim
+ 200 mg sulfame-
thoxazole)
6 mos. Upto 12 mos.
(6-9kg) 1 10 ml 5 ml
12 mos. 3
yrs.
(10-14 kg) 1 15 ml
1 10 ml3 yrs up to5 yrs.
(15-19 kg.) 2 --
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FOR CHOLERA:
FIRST-LINE ANTIBIOTIC: TETRACYCLINE
SECOND-LINE ANTIBIOTIC: ERYTHROMYCIN
AGE OR
WEIGHT
TETRACYCLINE ERYTHROMYCIN
Give 4x daily for 3 days Give 4 x daily for 3 days
250 MG TABLET 250 MG TABLET
2 years up to 5 years
(10-19 kg) 1 1
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FOR DYSENTERY:
Give antibiotic recommended for Shigella in your area for 3 days.
FIRST-LINE ANTIBIOTIC FOR SHIGELLA: CIPROFLOXACIN
CIPROFLOXACIN
Give 2 times daily for 3 days
AGE OR WEIGHT 100 mg Tablet
(dose/tabs)
250 mg Tablet
(dose/tabs)
2 mos up to 6 mos.
(3-5 kg) 1/4
6 mos. Up to 12 mos.
(6-9kg)1
12 mos. 3 yrs.
(10-14 kg)1
3 yrs up to 5 yrs.
(15-19 kg.)2 1
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Give an Oral Antimalarial
FIRST-LINE ANTIMALARIAL: ARTEMETHER-LUMEFRANTINE
SECOND-LINE ANTIMALARIAL: CHLOROQUINE , PRIMAQUINE,
SULFADOXINE and PYRIMETHAMINE
If ARTEMETHER-LUMEFRANTINE combination: Give 3 days.
If CHLOROQUINE:
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 health
center for additional tablets.
Explain that itching is a possible side effect of the drug, but is notdangerous.
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
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DAY 0 8 HRS
AFTER
DAY 1 DAY 2 DAY 3
6 mos. Up
to 3 years
(5 - < 15 kg.)
1 tab 1 tab 1 tab BID 1 tab BIDGive Primaquine
only to > 1 yr ,
tab SINGLE
DOSE
4 years up
to 8 years
(15 - < 25
kg)
2 tabs 2 tabs 2 tabs BID 2 tabs BID Primaquine
to tab,SINGLE DOSE
Dose ofArtemether-Lumefrantine (20 and 120 mg
respectively)
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Preferably taken with high fat diet
Not recommended during pregnancy/lactation and in infant < 1 yr, and is severemalariaSee
Preferably taken with high fat diet
Not recommended during pregnancy/ lactationand in infant < 1 yr, and is Severe Malaria See other table for Primaquine dosage
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Treatment Schedule for Probable Malaria and
Confirmed P. falciparum Cases
AGE
Chloroquine(150 mg base/tab)
Day 1 10 mg base/kg body wt.
Day 2 10 mg-base/kg body wt.
Day 3- 5 mg base/kg body wt.
Sulfadoxine +
Pyrimethamine(500 mg/25mg/tab)
SINGLE DOSE
ONLY
Primaquine
(15 mg/tab)
SINGLE DOSE
ONLY
DAY1 DAY2 DAY3 DAY1 DAY4
0-4 mos. Not indicated
5-11 mos. Not indicated
1-3 yrs. 1 1 1
4-6 yrs. 1 1 1 1 135
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Treatment Schedule for Mixed P. falciparumandP. Vivax Infection Cases
AGE
Chloroquine
(150 mg base/tablet)
DAY 1 DAY 2 DAY3
Sulfadoxine +
Pyrimethamine
(500 mg/25 mg
Tablet)
Single doseonly
DAY 1
Primaquine
(15 mg/tablet)
for 14 days
0-4 months Not indicated
5-11 months Not indicated
1-3 years 1 1 1 daily
4-6 years 1 1 1 1 daily37
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AGE or WEIGHT
IRON/FOLATE
TABLET
Ferrous sulfate
200 mg +250 mcg
Folate
(60 mg elemental
iron)
IRON SYRUP
Ferrous sulfate
150 mg per 5 ml (6
mg elemental iron
per ml)
IRON DROP
Ferrous sulfate25mg
(25 mg elementaliron per ml)
2 months up to 4 months
(4-
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AGE OR WEIGHT Albendazole 400 mg tablet Mebendazole 500 mg tablet
12 months up to 24
months
1/2 1
24 months up to 59months
1 1
Give Mebendazole / Albendazole
Give 500 mg Mebendazole/ 400 mg Albendazole as a single dose in health center if:
hookworm/whipworm are a problem in children in your area, and
the child is 12 months of age or order, and
the child has not had a dose in the previous 6 months
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TEACH THE MOTHER TO TREAT LOCAL INFECTIONS 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 healthcenter (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 small bottle of gentian violet.
Check the mothers understanding before she leaves the healthcenter.
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Treat Eye Infection with Tetracycline Eye Ointment
Clean both eyes 3 times daily.
Wash hands.
Ask child to close the eye.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye 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.
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Dry the Ear by Wicking and 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 childs ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps until the ear is dry.
Instill Quinolone (may include Ciprofloxacine, Norfloxacin eardrops) eardrops
after dry wicking 3X daily for2 weeks
Treat Mouth Ulcers with Gentian Violet
Treat the mouth ulcers twice daily.
Wash hands.
Wash the childs mouth with clean soft cloth wrapped around the finger andwet with salt water.
Paint the mouth with half-strength gentian violet (0.25% dilutiion)
Wash hands again.
Continue using GV for 48 hours after the ulcers have been cured
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Soothe the Throat, Relieve the Cough with a Safe
Remedy
Safe remedies to recommend:
Breastmilk for exclusively breastfed infant.
Tamarind, Calamansi and Ginger.
Harmful remedies to discourage:
Codeine cough syrup
Other cough syrups
Oral and nasal decongestants
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GIVE THESE TREATMENTS IN HEALTH CENTER 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 an intramuscular injection.
If children cannot be referred, follow the instructions provided on the next
slides.
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Give An Intramuscular Antibiotic
GIVE TO CHILDREN BEING REFERRED URGENTLY
Give GENTAMICIN (7.5mg/kg) and BENZYL PENICILLIN (50,000 units per kg)
Age or Weight GENTAMICINDose (7.5 mg/kg)
80 mg vial (40mg/ml)
Undiluted
BENZYL PENICILLINDose (50,000 units/kg)
To a vial of 600mg
(1,000,000 units)= add 1.6 ml
Sterile water to give
500,000 units/ml
3 - < 6 kg 0.5 ml 0.9 ml 0.4 ml
6 - < 10 kg 1.1 ml 1.7 ml 0.75 ml
10 - < 15 kg 1.9 ml 2.6 ml 1.2 ml
15 - < 20 kg 2.8 ml 3.5 ml 1.7 ml
NOTE: Calculate EXACT DOSE ofGENTAMICIN BASED ONBODY WEIGHT
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Give Quinine for Severe Malaria
FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE/MALARIA:
Check which Quinine formulation is available in your clinic
Give first dose of intramuscular QUININE and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE:
Give first dose of intramuscular QUININE.
The child should remain lying down for one hour.
Repeat the QUINNE injection at 4 and 8 hours later, and then every 12 hours until the child isable to take an oral antimalarial. Do not continue QUININE injections for more than 1 week.
DO NOT GIVE QUININE TO A CHILD LESS THAN 4 MONTHS OF AGE.
* quinine salt
AGE OR WEIGHT INTRAMUSCULAR QUININE
150mg/ml* (in 2ml) 300mg/ml*(in 2ml)
2 months up to 4 months (4 - < 6 kg) 0.4 ml 0.2 ml
4 months up to 12months (6 - < 10 kg) 0.6 ml 0.3 ml
12 months up to 2 years (10 - < 12 kg) 0.8 ml 0.4 ml
2 years up to 3 years (12 - < 14 kg) 1.0 ml 0.5 ml
3 years up to 5 years (14 19 kg) 1.2 ml 0.6 ml
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Give Inhaled Salbutamol for Wheezing
Use of a Spacer
A spacer is a way of delivering the bronchodilator drugseffectively into the lungs. No child under 5 years shouldbe given an inhaler without a spacer. A spacer works aswell 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.
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Spacers are made on the following way:
Use a 500ml drink bottle or similar.
Cut a hole in the bottle base in the same shape as themouthpiece of the inhaler. This can be done using asharp knife.
Cut the bottle between the upper quarter and thelower and discard the upper quarter of the bottle.
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Cut a small V in the border of the large open partof the bottle to fit the childs nose and be used as
mask.
Flame the edge of the cut bottle with a smallcandle or lighter to soften it. In a small baby, a
mask can be made by making a similar hole in aplastic (not polystyrene) cup.
Alternatively commercial spacers can be used if
available.
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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 bottleinto his mouth and breath in and out through the
mouth.
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A cared then presses down the inhaler and sprayinto the bottle while the child continue to breathnormally.
Wait for3 to 4 breaths and repeat for total of fivesprays.
For younger children place the cup over thechilds mouth and use as a spacer in the sameway.
If a spacer is being used for the first time, itshould be primed by 4-5 extra puffs from theinhaler.
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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 30-50 ml of milk or sugar water before departure.
To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams)
in a 200-ml cup of clean water.
If the child is not able to swallow:
Give 50 ml of milk or sugar water by nasogastric tube.
If child is difficult to awaken or unconscious, start IV infusion:
Give 5mg/kg of 10% dextrose soln (D10) over a few minutes OR
Give 1ml/kg of 50% dextrose soln (D50) by slow push.
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Plan A: Treat No Dehydration at Home
Counsel the mother on the 3 Rules of Home Treatment:
Give Extra Fluid, Give Zinc Supplements (age 2 months up to 5 years), Continue Feeding & When to
Return
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 breastfeed, give ORS or clean water in addition to breastmilk.
If the child is not exclusively breastfeed, give one or more of the following: ORS solution,
food-based fluids (such as soup, rice water, or buko juice), or clean water.
It is especially important to give ORS at home when:
The child has been treated with Plan B or Plan C during the visit.
The child cannot return to a health center if the diarrhea gets worse.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS.
GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME.
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Plan A: Treat Some Dehydration with ORS
2. GIVE ZINC SUPPLEMENTS (age 2 months up to 5 years)
Tell the mother how much ZINC to give (20mg/tab)
2 months up to 6 months ------------------- tablet daily for 14 days
6months 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
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6months)
4. WHEN TO RETURN
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Plan B: Treat Some Dehydration with ORS
Give in health center recommended amount of ORS over 4-hour period
960 1600800 960450 800200 450In ml
12 -20 kg
2 years up to
5 years
* Use the childs age only when you do not know the weight. The approximate amount of ORSrequired(in ml) can also be calculated by multiplying the childs weight(in kg) times 75.
If the child wants more ORS than shown, give more.
For infants under6 months who are not breastfeed, also give 100-200 ml 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 10 minutes. Then continue, but more slowly.
Continue breastfeeding whenever the child wants.
10 -< 12 kg6 -< 10 kg< 6 kgWEIGHT
12 months up to
2 years
4 months up to
12 months
Up to 4 monthsAGE
DETERMINE AMOUNT OR ORS TO GIVE DURING FIRST 4 HOURS
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Plan B: Treat Some Dehydration with ORS
AFTER 4 HOURS:
Reassess the child and 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 4-hour treatment at home.
Give her enough ORS packets to complete rehydration. Also give her 2 packets asrecommended in Plan A.
Explain the 4 rules of home Treatment.
1. GIV EEXTRA FLUID
2. GIV EZINCSUPPLEMENTS (age 2months up to 5 years)
3. CON TINUEFEEDING (exclusive breastfeeding if age less than 6months
4. WH ENTO RETURN
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GIVE VITAMIN A
SUPPLEMENTATION
AS NEEDED
IMMUNIZE EVERY
SICK CHILD AS
NEEDED
GIVEMEBENDAZOLE/ALBE
NDAZOLE AS
NEEDED
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GIVE FOLLOW-UP CARE
Care for the child who returns for follow-up using all theboxes that match the childs previous classifications
If the child has any new problem, assess, classify and treat
the new problem as on the ASSESSAND CLASSIFYchart.
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PNEUMONIA
After2 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:
Ifchest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular chloramphenicol. Then refer URGENTLY to hospital.
Ifbreathing rate, fever, and eating are the same, change to the second-line antibiotic
and advise the mother to return in 2 days or refer. (If this child had measles within the
last 3 months, refer.)
Ifbreathing slower, less fever, or eating better, complete the 5 days of antibiotic.
SeeASSESS & CLASSIFYchart.
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PERSISTENT DIARRHEA
After 5 days:
Ask:
Has the diarrhea stopped?
How many loose stools is the child having per day?
Treatment:
Ifthe 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.
Ifthe diarrhea has stopped (child having less than 3 loose stools per day), tell the
mother to follow the usual recommendations for the childs age.
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DYSENTERY
After2 days:
Assess the child for cough or difficult breathing. > SeeASSESS & CLASSIFYchart.
Ask:
Are there fewer stools? Is there less abdominal pain?
Is there less blood in the stool? Is the child eating better?
Is there less fever?
Treatment:
If the child is dehydrated, treat dehydration.
ifnumber of stools, amount of blood in stools, fever, abdominal pain, oreating is the
same or worse:
Change to second-line oral antibiotic recommended for Shigella in your area. Give it for 5days. 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
Iffewer stools, less blood in the stools, less fever, less abdominal pain, and eating
better, continue giving the same antibiotic until finished.
Refer to
hospital
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MALARIA
If fever persists after2 days, or returns within 14 days:
Do a full assessment of the child. > See ASSESS & CLASSIFYchart.
Treatment:
If the child has any general danger signs or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE/MALARIA. If the child has any cause of fever other than malaria, provide treatment.
Ifmalaria 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 in 2 days if fever persists.
If fever persists after2 days treatment with second line oral antimalarial, refer with
blood smear for reassessment.
If fever has been present for 7 days, refer for assessment.
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FEVER-MALARIA UNLIKELY
If fever persists after2 days:
Do a full reassessment of the child. > SeeASSES & CLASSIFYchart.
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.
Ifmalaria is the only apparent cause of fever:
Take a blood smear.
Treat with the first-line oral antimalarial. Advise the mother to return again in 2 days ifthe fever persists.
If fever has been prevent for 7 days, refer for assessment.
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FEVER (NO MALARIA)
If fever persists after2 days:
Do a full assessment of the child. > SeeASSESS & CLASSIFYchart.
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 and the blood smear is positive or there is
no blood smear classify according to fever with Malaria Risk and treat accordingly.
If there has been no travel to malarious area or blood smear is negative:
If child has any general danger signs of stiff neck, treat as VERY SEVERE
FEBRILE DISEASE.
If the child has any apparent cause of fever, provide treatment.
If no apparent cause of fever, advice the mother to return again in 2 days if fever
persists.
If fever has been present for 7 days, refer for assessment.
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MEASLES WITH EYE OR MOUTH COMPLICATION
After2 days:
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth
Treatment for eyes Infection:
Ifpus is 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 mother correct treatment.
If thepus is gone but redness remains, continue the treatment.
Ifno pus or redness, stop the treatment.
Treatment for Mouth Ulcers:
Ifmouth ulcers are worse, or there is a very foul smell from the mouth, refer to
hospital.
Ifmouth ulcers are the same or better, continue using half-strength gentian violet
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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. 5C or above),treat as MASTOIDITIS.
Acute ear infection: If ear pain 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.
Encourage her to continue.
Ifno ear pain or discharge, praise the mother for her careful treatment. If shehas not yet finished th e 5 days of antibiotic, tell her to use all of its before
stopping .
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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 initialvisit to measure the childs weight gain.
ANEMIA
After 5 days:
Given iron. Advise mother to return in 14 days for more iron.
Continue giving iron every day for2 months with follow-up every 14 days.
If the child has any palmar pallor after2 months, refer for assessment.
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VERY LOW WEIGHT
After30 days:
Weight the child and determine if the child is still very low weight for age.
Reassess feeding. > See question at the top of the COUNSEL chart.
Treatment
If the child is no longer very low weight for age, praise the mother and encourageher 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 weightrefer the child.
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IF ANY MORE FOLLOW-UP VISITS ARE NEEDEDBASED ON THE INITIAL VISIT OR THIS VISIT,
ADVISE THE MOTHER OF THE
NEXT FOLLOW-UP VISIT
ALSO, ADVISE THE MOTHER
WHEN TO RETURN IMMEDIATELY.(See COUNSEL CHART.)
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FOOD
Assess the Childs Feeding
Ask questions about the childs usual feeding and feeding during this illness. Compare the
mothers answer to the FeedingRecommendations for the childs age in the box below.
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 or fluids?
What food or fluids?
How many times per day?
What do you use to feed the child?
If very low weight for age: How large are servings? Does the child receive his own
serving? Who feeds the child and how?
During this illness has the child s feeding charged? If yes, how?
COUNSEL THE MOTHER
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Counsel the Mother About Feeding Problems
If the mother reports difficulty with breastfeeding, assess breastfeeding.
(See YOUNG INFANT chart). As needed, show the mother correctpositioning 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 breastmilk that the
child needs.
Suggest giving more frequent, longer breastfeeds, day and night, andgradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother to:
Breastfeed as much as possible, including at night.
Make sure other milk is a locally appropriate breastmilk substitute, give
only when necessary. Make sure other milk is correctly and hygienically prepared and given in
adequate amounts.
Prepare only an amount of milk which the child can consume within an
hour. If there is some left-over milk, discard.
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If the mother is using a bottle to feed the child:
Recommended substituting a cup for bottle.
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 and encourage eating.
Give the child and adequate serving in a separate plate or bowl.
Observe what the child likes and consider these in the preparation of his/her
food.
If the child is not feeding well during the 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.
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FLUID
Advise the Mother to Increase FluidDuring Illness
FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed.
Increase fluid. For example, give soup, rice water, buko juice or clean water.
FOR CHILD WITH DIARRHEA:
Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on
TREAT THE CHILD chart.
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WHEN TO RETURN
NEXT WELL-CHILD VISIT
Advise mother when to return for next immunization according to immunization schedule.
30 daysVERY LOW WEIGHT FOR AGE
5 daysANEMIA
5 days
PERSISTENT DIARRHEA
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving
2 days
PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVER-MALARIA UNLIKELY, if fever persists
FEVER (NO MALARIA), if fever persists
MEASLES WITH EYE OR MOUTH COMPLICATIONS
DENGUE HEMORRHAGIC FEVER UNLIKELY, if fever persist
Return for
Follow-up in:If the child has:
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT
Advise the mother to come for follow-up at the earliest time listed for the childs problems.
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Any sick child Not able to drink or breastfeed
Becomes sicker
Develops a fever
If child has NO PNEUMONIA:
COUGH OR COLD, also return if:
Fast breathing
Difficult breathing
If child has diarrhea, also return if: Blood in stool
Drinking poorly
If child has FEVER:DENGUE HEMORRHAGIC FEVER
UNLIKELY,
Also return if:
Any sign of bleedingPersistent abdominal pain
Persistent vomiting
Skin petechiae
Advise mother to return immediately if the child has any of these signs:
WHEN TORETURN IMMEDIATELY
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Counsel the MotherAbout Her Own Health
If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection),
provide care for her or refer her 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 if needed.
Make sure she has access to:
Family Planning
Counseling on STD and AIDS prevention
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WEIGHT FOR AGE CHART