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- -~SICK YOUNG INFANT

AGED 1 WEEK TO 2 MONTHS
ASSESS, CLASSIFY, AND TREAT THE SICK YOUNG INFANT Assess, Classify, and Identify the Treatment Check for Possible Bacterial Infection Then Ask: Does the Young Infant have Diarrhea? Then Check for Feeding Problems or Low Weight Check the Young Infant's Immunization Status Assess Other Problems Treat the Young Infant and Counsel the Mother Oral Antibiotics Intramuscular Antibiotics To Treat Diarrhea, See TREAT THE CHILD Chart Immunize Every Sick Young Infant, as Needed Treat Umbilical Infections in the Health Center Treat Local Infections at Home Correct Positioning and Attachment for Breastfeeding Home Care for the Young Infant Give Follow-up Care for the Sick Young Infant Local Bacterial Infection Feeding Problem Low Weight Thrush RECORDING FORMS SICK YOUNG INFANT SICK CHILD WEIGHT-FOR-AGE CHART
'.1.

SICK CHILD AGED 2 MONTHS TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD Assess, Classify, and Identify the Treatment Check for General Danger Signs .................. Then Ask About the Main Symptoms: Does the child have cough or difficult breathing? TREAT THE CHILD, continued

2
2

Give Extra Fluid for Diarrhea and Continue Feeding Plan A: Treat Diarrhea at Home 12 Plan B: Treat Some Dehydration with ORS 12 Plan C 13
.

Doesthe child havediarrhea?

Does the child have fever? Classify malaria Classify measles Classify dengue Does the child have an ear problem? Then Check for Malnutrition and Anemia Then Check the Child's Immunization Status Then Check the Child's Vitamin A Status Assess Other Problems
TREA T THE CHILD

3
4 4 4 4 5 6 6 6 6

Immunize Every Sick Child, as Needed Give Every Sick Child Vitamin A, as Needed Give Follow-up Care
Pneumonia Persistent Diarrhea , Dysentery Malaria Fever: Malaria Unlikely Fever: No Malaria Measles with Eye or Mouth Complications Fever: Dengue Hemorrhagic Fever Unlikely Ear Infection Feeding Problem Anemia Very Low Weight

13 13
14 14 14 15 15 15 16 16 16 17 17 17

23 24 25 26

26

27 27 28 28 28 28 29 29 30 31 31 31

Teach the Mother How to Give Oral Drugs at Home Oral Antibiotics. Oral Antimalarial Paracetamol Vitamin A Iron ......... Mebendazole Teach the Mother How to Treat Local Infections at Home Treat Eye Infection with Tetracycline Eye Ointment Dry the Ear by Wicking Treat Mouth Ulcers with Gentian Violet Soothe the Throat and Relieve Cough with a Safe Remedy Give These Treatments in the Health Center Only Intramuscular Antibiotic Quinine for Severe Malaria Prevent Low Blood Sugar

7 8 8 8 8 8

COUNSEL THE MOTHER Food Assess the Child's Feeding Feeding Recommendations Counsel about Feeding Problems Fluid Increase Fluid during Illness

9 9 9 9

18 19 20

21

10 10 11

When to Return Advisethe MotherWhento Return to the HealthWorker Counsel the Mother about Her Own Health

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~

21

on the back cover

8

11 ORGANIZATION

WORLD HEALTH

Association of Deans

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22

of Nursing,Inc. DEPARTMENT HEALTH OF Republicof the Philippines

of Philippine Colleges

. .'. .' ~. .

ECD Project

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33 53

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

ASSESS
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this problem. if follow-up visit, use the follow-up instructions on the TREAT THE CHILD chart. if initial visit, assess the child as follows:

CLASSIFY
USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS.

IDENTIFY TREATMENT

ASK: Is the child not able to drink or

LOOK:

. .

breastfeed?

See if the child is abnormally sleepy or difficult to awaken.

Does the child vomit everything? Has the child had convulsions? (during the present illness)

AnYr&e1'l

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IF YES, ASK: For how long?

LOOK, LISTEN: . Count the breaths in one minute.

. .
If the child is:

Look for chest indrawing. Look and listen for stridor.

CHILD MUST BE CALM.

signor . Chestlndrawing ~( . Stridor';i'nc~lm

~ Givefirsl dqse of anapprop ~ Give VitarhjJt A. ".. ~ Treatthe;~hildtopre.;erillo ~ Refer URG~TL Y to hQ$pita ~ Give an appropriate antibiotic 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. ~ If coughing for more than 30 days, refer for assessment. ~ Soothe the throat and relieve the cough with safe remedy. ~ Advise mother when to return immediately. ~ Follow up in 5 days if not improving.

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.
.

Fastbreathing

PNEUMONIA

2 months up to 12 months old 12 months up

.
.

Fast breathing is:

50 breaths per minute or more
40 breaths per minute or more

No signs of pneumonia or very severe disease.

NO PNEUMONIA COUGH OR COLD

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Does Jhe child have diarrhea?
IF YES, ASK: LOOK AND FEEL:

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Forhowlong? Is there blood in the stool?

. Lookat the child'sgeneralcondition. Is the child:

- Abnormally sleepy or difficult to awaken? - Restlessand irritable?

for
DEHYDRATION

. Lookforsunkeneyes.

Offerthe childfluid. Is the child: - Notableto drink or drinkingpoorly? - Drinkingeagerly,thirsty?

Twoof the followingsigns: . Restless,irritable Sunkeneyes

. . .
.
. .

Drinks eagerly, thirsty

. Skinpinchgoes back veryslowly

SOME DEHYDRATION

. Pinch theskinoftheabdomen. Does itgoback:

-

~ Givefluid andfoodfor somedehydration(PlanB). ~ If child also has another severe classification: - Refer URGENTL hospital, with mother giving Yto frequent sips of ORSon the way. - Advise mother to continue breastfeeding. ~ Advisethe motherwhento returnimmediately. ~ Followup in 5 days if not improving. ~ ~ ~ ~ Givefluid and foodto treatdiarrheaat home(PlanA). GiveZincsupplements. Advisemotherwhento returnimmediately. Followupin 5 days if not improving.

Veryslowly(longerthan2 seconds)? - Slowly?

Not enough signs to classify as some or severedehydration

NO DEHYDRATION

Dehydration present

II

~ Treatdehydrationbeforereferralunlessthe child has anothersevereclassification. ~ Give Vitamin A. ~ ijf!fer to hospital. ~ Advise the mother on feeding a child who has PERSISTENT DIARRHEA. ~ Give Vitamin A. ~ Followup in 5.days. ~ Advise motherwhento returnimmediately.

No dehydration

PERSISTENT DIARRHEA

and if blood in stool

Blood in the stool

DYSENTERY

~ Treat for 5 days with an oral antibiotic recommended for Shigella in your area. ~ Follow up in 2 days. ~ Advise mother when to return immediately.

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

3
DANGER SIGNS, COUGH, DIARRHEA ASSESS AND CLASSIFY
_LY, FEVER: NO MALARIA

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3SESS AND CLASSIFY

FOLLOW-UP

UNSEL THE MOTHER

FOllOW-UP

THEN ASK: Does the child have feve.r?

(by history, or feels hot Or if temperature is 37.5C** or abov~)

Decide Malaria Risk

Ask: Does the child live in a malaria area? Has the child visited/travelled or stayed overnight in a malaria area in the past 4 weeks?

. .

MalariaRisk (including travel or overnightstay in malariaarea)

. Bloodsmear(+) If bloodsmearnotdone: . NOrunnynose,and NOmeasles, nd a

NOothercauses fever of

MALARIA

~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Treatthe child with an oral antimalarial. , Give onedoseof paracetamolin healthcenter for high fever (38.5Cor above). Advisemotherwhento returnimmediately. Followup in 2 daysif fever persists. If fever is presenteverydayfor morethan7 days,referfor assessment. Give onedoseof paracetamolin health centerfor high fever (38.5cor above). Advisemotherwhento returnimmediately. Followup in 2 daysif fever persists. If feveris presenteveryday for morethan 7 days,referfor assessment. Treatothercausesof fever.

If Yes to either, obtain a blood smear. THEN ASK: LOOK AND FEEL: Forhowlong hasthe child had' Lookor feel for stiff neck. fever? Lookfor runny nose. If more than 7 days, has the fever beenpresenteveryday? Has the child had measles Lookfor signs of MEASLES: within the last 3 months? - Generalrashesand - One of these: cough, runny nose, or red eyes

. Bloodsmear(-)or . Runnynoseor . Othercausesoffever . Measlesor

FEVER: MALARIA lINLIKELY

No MalariaRisk

a VERYSEVERE ~ Giveone dose of an appropriateantibiotic. ~ Treatthe child to prevent low blood sl1gar. FEBRILE ~ Giveone doseof par.acetamoln healthcenterfor high fever (38.5cor above). i DISEASE ~ Refer URGENTLY hospital. to

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

.
. .

.
Lookfor mouthulcers. Are they deep and extensive? Lookfor pusdrainingfromthe eyes. Lookfor cloudingof the cornea.

. diseaseof a veryseverefebrile Nosigns

FEVER: NO MALARIA

~ ~ ~ ~ ~

Give onedoseof paracetamolin health centerfor high fever (38.5cor above). Advisemotherwhento returnimmediately. Followup in 2 daysif the feverpersists. If feveris presenteverydayfor morethan7 days,referfor assessment. Treatother causesof fever. ~

..
.
. .

.......

. ulcers extensi~emouth Deepor

Cloudingof the corneaor

. Any dangersign

a ~ Give VitaminA. SEVERE, COMPLICATED ~ Give first dose of an appropriate antibiotic. MEASLES*** ~ If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment. ~ Refer URGENTLY hospital. to MEASLESWITH EYEOR MOUTH ~ If pus draining from the eye, apply tetracycline eye ointment. COMPLICATIONS'" ~ If mouthulcers, teachthe mother to treat with gentian "iolet.

Assess Dengue Hemorrhagic Fever ASK: LOOKAND FEEL: Hasthe child hadany bleeding' Look for bleeding from nose or fromthe noseor gums,or inthe gums. Look for skin petechiae. vomitusor stools? Hasthe child had black Feel for cold and clammy vomitus? extremities. Hasthe child had black Check for slow capillary refill. If stools? none of the aboveASK, LOOK,and . Hasthe child had persistent FEELsigns are present& the child abdominalpain? is 6 monthsor older &fever present Has the child had persistent for morethan 3 days. Performthe tourniquettest. vomiting?

. Pus drainingfromthe eye or . Mouth ulcers

~ Give Vitamin A.

. .

.
Assess DENGUE Hemorrhagic Fever

~ Followup in 2 days. ~ Advise motherwhen to return immediately.

.
.

Measlesnow or within the last 3 months

MEASLES

Give Vitamin A. ~ Advise motherwhen to return immediately.

~

. Bleedingfromnoseor gumsor . Bleedingin stoolsor vomitusor . BlackIIItoolsor vomitusor . S~inpetechiaeor extremitiesor . Coldandclammy . Capillaryrefillmorethan3 seconds or

~ If persistent vomiting or persistent abdominal pain or skin petechiae or positive tourniquet test are the only positive signs, give ORS(Plan B). SEVERE ~ If any other signs of bleeding is positive, give fluids rapidly, as in Plan C. DENGUE ~ Treat the child to prevent low blood sugar. HEMORRHAGIC ~ Refer all children URGENTLY hospital. to FEVER ~ DO NOTGIVEASPIRIN.

. .
. .

Persistent bdominal a painor Persistent omiting v or Tourniquet positive test No signsof severedengue ilemorrhaglc fever

FEVER: ENGUE ~ Advise motherwhen to return immediately. D HEMORRHAGIC ~ Follow up in 2 days if fever persistsor child shows signs of bleeding. FEVER UNLIKELY ~ DO NOTGIVEASPIRIN.

* If referral is not possible, see manage the child as described in Management of Childhood Illness, Treat the Child, Annex: When Referral is Not Possible, and WHO guidelines for inpatient care. ** These temperatures are based on axillary temperature. Rectal temperature readings are approximately a.5C higher. *** Other important complications of measles-pneumonia, stridor, diarrhea, ear infection, and malnutrition-are classified in other tables.

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Other Causes of Fever:

. . severe complicatedmeasles . measleswith eye or mouth complications . measles

pneumonia dysentery

. .
. .

severe dengue hemorrhagic fever

mastoiditis

acute ear infection abscess, cellulites, osteomyelites severe pneumonia or very severe disease

5
FEVER, MALARIA, MEASLES, EAR PROBLEM

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UNSEL THE MOTHER

FOLLOW-UP

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

MOTHER TO GIVE ORAL

Give an Appropriate Oral Antibiotics

~ FOR PNEUMONIA, ACUTE EAR INFECTION, VERY SEVERE DISEASE, MASTOIDITIS: FIRST-LINE ANTIBIOTIC COTRIMOXAZOLE SECOND-LINE ANTIBIOTIC: AMOXYCILLIN COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 days. AGE OR WEIGHT ADULT TABLET 80 mg trimethoprim + 400 mg sulphamethoxazole 1/2 SYRUP 40 mg trimethoprim + 200 mg sulphamethoxazole per 5 ml 5.0 ml AMOXYCILLIN Give three times dailyfor 5 days. TABLET 250 mg 1/2 SYRUP 125 mg per 5 ml 5ml

2 months up to 12 months (4 - <10 kg) 12 months up to 5 years (10-19 kg)

FOR DYSENTERY:

10.0 ml

10 ml

Give antibiotic recommended for Shigella in your area for 5 days. FIRST-LINE ANTIBIOTIC FOR SHIGELLA. COTRIMOXAZOLE SECOND-LINE ANTIBIOTIC FOR SHIGELLA NALIDIXIC ACID

COtRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 days. AGE OR WEIGHT 2 months up to 4 months (4-<6 kg) See doses 4 months up to 12 months (6 - <10 kg) 12 months up to 5 years(10- 19 kg) ~ FOR CHOLERA: Give an antibiotic recommended for Cholera in your area for 3 days. FIRST-LINE ANTIBIOTIC FOR SHIGELLA TETRACYCLINE SECOND-LINE ANTIBIOTIC FOR SHIGELLA COTRIMOXAZOLE TETRACYCLINE Above.

NALIDIXIC ACID Give four times daily for 5 days. SYRUP 250 mg/5 ml

1.25 ml (1/4 tsp) 2.5 ml (1/2 tsp) 5 ml (1 tsp)

~
AGE OR WEIGHT 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 5 years (10

Give four times daily for 3 days. CAPSULE (250 mg)

COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 days.

1/2 1

See doses Above.

- <19 kg)

MALNUTRITION ANEMIA, and IMMUNIZATION AND VITAMINA STATUS ANTIBIOTICS

_LY, FEVER: NO MALARIA

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)SESS AND CLASSIFY

FOLLOW-UP

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8

aTeACH THe MOTHeR TO Give ORAL DRUGS AT HOMe Followthe instructions belowfor every oral drug to be given at home. Also followthe instructions listed with each drug's dos

~ Give an Oral Antimalarial

FIRST-LINE ANTIMALARIAL: SECOND-LINE ANTIMALARIAL: ~ IF CHLOROQUINE: CHLOROQUINE, PRIMAQUINE, SULFADOXINE AND PYRIMETHAMINE ARTEMETER-LUMEFRANTIN E

~ Give Vitamin A
TREATMENT ~ Give one dose in the health center. SUPPLEMENT A TlON ~ Give one dose in health center if: If the child is six months of age or older, child has not received a dose of Vitamin A in the past six months.

Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of chloroquine. 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 not dangerous.

AGE

VITAMIN A CAPSULES 100,0001U 200,000 IU 1/2 capsule 1 capsule

~ IF SULFADOXINE + PYRIMETHAMINE: Give a single dose in the health center 2 hours before intake of Choroquine.
~ IF PRIMAQUINE: Give single dose on Day 4 for P. falciparum ~ IF ARTEMETER-LUMEFRANTINE CHLOROQUINE Give for 3 days TABLET (150 mg base) AGE 2 months up to 5 months (4 - <7 kg) 5 months up to 12 months
(7 - <10 kg)

6 months up to 12 months 12 months.up to 5 years

PRIMAQUINE Give daily for 14 days for P. vivax TABLET (15 mg base) SULFADOXINE + PYRIMETHAMINE Give single dose in health center TABLET (500 mg sulfadoxine) 25 mg pyrimethamine y" 3 monthsupto 4 months (4- <6kg) 4 months upto 12months (6-<10kg) 12months upto 3 years (10-<14kg) 1/2tablet

1 -

combination: Give for 3 days. PRIMAQUINE Give single dose in health center for P. falciparum TABLET (15 mg base) DAY 3

~ Give Iron
~ Give one dose daily for 14 days. IRON/FOLATEABLET T AGEORWEIGHT Ferroussulfate 200mg + 250mcgFolate (60mgelemental iron) IRONSYRUP Ferrous sulfate150mg per5 ml (6 mgelementalronperml) i 2.5ml(1/2tsp) 4 ml (3/4tsp) 5 ml(1tsp) 10ml(1112tsp) IRONDROPS Ferrous sulfate 25 mg I (25mgelementalronperml) i 0.6ml 1.0ml 1.5ml 2.0 ml

DAY 1

DAY 2

12 months up to 3 years (10-<14kg) 3 years up to 5 years (14 - <19 kg) See additional 1

y"

3 yearsupto 5years (14-19 kg)

1 tablet

handout for drug table on second line antibiotics.

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

PARACETAMOL AGE OR WEIGHT 2 months up to 3 years (4 - <14 kg) TABLET (500 mg) y" SYRUP (120 mg/5 ml) 5 ml (1 tsp) 10 ml (2 tsp)

~
~

Give Mebendazole/Albendazole
Give 500 mg Mebendazole/400 mg Albendazole as a single dose in the health center if the chileJis 12 months up to 59 months and has not had a dose in the previous 6 months, with the following dose. AGE OR WEIGHT 12 months up to 23 months 24 months up to 59 months Albendazole 400 mg tablet }2 1

Mebendazole500 mg tablet
1 1

3 years to 5 years (14 - <19 kg)

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TEACH THE MOTHE.R TO TREAT LOCAL INFECTIONS AT HOM.E

~

to the mother what the treatment is and why it should be given.

Dry the Ear by Wicking

~ ~

~ Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, strong tissue paper into a

. wick. . Remove the wick when wet. . Replace the wick with a clean one and repeat these steps
Place the wick in the child's ear. until ear is dry.

Treat Mouth Ulcers with Gentian Violet

~ Treat the mouth ulcers twice daily. Wash hands.

~
~

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 3 times daily Wash hands.

. . . bud.

Wash child's mouth clean using soft cloth wrapped around the finger and wet with salt water. Paint'the mouth with half-strength gentian violet, using cotton

. Wash hands again.

. . .
. . .

Ask child to close eyes.

Use clean cloth and water to gently wipe away pus.

~ Soothe the Throatand Relieve Cough

with a Safe Remedy
~

Then apply tetracycline eye ointment in both eyes 3 times daily.

Ask the child to look up. Squirt a small amount of oitment on the inside of the lower lid. Wash hands again.

Safe remedies to recommend:

.
.

Breastmilk for exclusively breastfed infant Tamarind, Calamansi and Ginger

~
~ ~ Treat until redness is gone. Do not use other eye ointments or drops, or put anything else in the eye.

Harmful remedies to discourage:

.
.

. Other cough syrups

9
cL Y, FEVER: NO MALARIA

Codeine cough syrup

Oral and nasal decongestants

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ORAL DRUGS LOCALINFECTIONS

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iSESS AND CLASSIFY UNSEL THE MOTHER L

FOLLOW-UP

10

GIVE THESE TREATMENTS IN HEALTH CENTER ONLY

~

lain to the mother why the drug is given.

. .

~ Give an IntramuscularAntibiotic
FOR CHILDREN BEING REFERRED WHO CANNOT TAKE ORAL ANTIBIOTIC: ~ Give the first dose of intramuscular chloramphenicol and refer child urgently to hospital. IF REFERRAL IS NOT POSSIBLE: ~ Repeat the chloramphenicol injection every 12 hours for 5 days. ~ Then change to an appropriate oral antibiotic to complete 10 days of treatment. CHLORAMPHENICOL Dose: 40 mg per kg Add 5.0 ml sterilewaterto vial containing 1,000mg = 5.6 ml at 180mg/ml 1.0 ml = 180 mg 1.5 ml = 270 mg 2 ml = 360 mg 2.5 ml = 450 mg 3.5 ml = 630 mg

Give Quinine for Severe Malaria

BEING REFERRED WITH A VERY SEVERE FEBRILE DISEASE/MALARIA:

FOR CHILDREN

~ Give first dose of intramuscular

QUININE and refer urgently to hospital.

IF REFERRAL IS NOT POSSIBLE: ~ Give first of intramuscular QUININE. ~ The child should remain lying down for one hour. ~ Repeat the QUININE injection at 4 and 8 hours later, and then every 12 hours until the child is able 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. AGE OR WEIGHT INTRAMUSCULAR QUININE 300 mg/ml* (in ml ampoules)

AGE OR WEIGHT

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 to 3 years (10 - <14 kg) 3 to 5 years (14 -19 kg)

4 months up to 12 months (6 - <10 kg) 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

0.3 ml 0.4 ml 0.5 ml 0.6 ml

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~ Treat the Child to Prevent Low Blood Sugar Level

~ 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 2QO-ml of clean water. cup

~ If the child is not able to swallow: Give 50 ml of milk or sugar water by nasogastric tube.

~ If the child is difficult to awaken or unconscious, start IV infusion: Give5 mllkgof 10%of dextrosesolution(D10)over a few minutes Or give 1 mllkg of 50% (D50)by slowpush

11
INTRAMUSCULARANTIBIOTIC INTRAMUSCULARQUININE LOW BLOOD SUGAR LEVEL
~ Y, rtVER:

NO MALARIJ.\

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FOLLOW-UP

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E EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING

:See FOOD advice on COUNSEL THE MOTHE,

~ Plan A: Treat Diarrheaat Home

Counsel the Mother on the 4 Rules of Home Treatment: Give Extra Fluid, Give Zinc Supplements, Continue Feeding, When to Return 1.
GIVE EXTRA FLUID (as much as the child will take)
~ TELL THE MOTHER: Breastfeed frequently and longer at each feeding. If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk. If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, or "buko juice"), or clean water.

~ Plan B: Treat Some Dehydration with ORS

Give in health center recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HOURS. AGE Up to 4 months 4 months up to 12 months 6 to -< 10 kg 400-700 12 months up to 2 years 10 to -< 12 kg 700-900 2 years up to' 5 years 12 to 19 kg 900-1400

WEIGHT AMOUNT (ml)

<6 kg 200-400

* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75. If the child wants more ORS than shown, give more. For infants under 6 months of age who are not breastfed, water during this period. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. but more slowly.

It is especially important to give ORS at home when: the child has been treated with Plan B or Plan C during the visit, or the child cannot return to a health center if the diarrhea gets worse.
~

also give 100-200 ml clean

TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME. SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: '
Up to 2 years 2 years or more Tell the mother: Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue qivinq extra fluid until the diarrhea stoDS. 50 to 100 ml after each loose stool 100 to 200 ml after each loose stool

Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, Continue breastfeecHng whenever the child wants.

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 her child to finish 4-hour 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:

2.

. .

GIVE ZINC SUPPLEMENTS

10 mg per day in infants
.

< 6 mos. for 10-14 days

20 mg per day in children 6 mos. - 5 years old for 10-14 days

See COUNSEL
THE MOTHER

3. 4.

CONTINUE FEEDING WHEN TO RETURN

chart

1. 2. 3. 4.

GIVE EXTRA FLUID

GIVE ZINC SUPPLEMENTS CONTINUE FEEDING KNOW WHEN TO RETURN

See Plan A for the recommended fluids

and . See the COUNSEL THE MOTHER chart.

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EXTRA FLUID FOR DIARRHEA AND CONTINUE FEE.DING

OhOOI1NSEL THlZlVIOTHER chart.

Plan C: Treat Severe

FOLLOW THE ARROWS.
START HERE
Can you give intravenous fluid immediately? (IV)

Dehydration

Quickly

IF ANSWER IS "YES," GO ACROSS. IF "NO," GO DOWN.

.
YES.

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

AGE Infants (under 12 months) NO

) *

First give 30 ml/kg in: 1 hour* 30 minutes*

Then give 70 ml/kg in: 5 hours 2 1/2 hours

Children (12 months up to 5 years)

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

. . .
Is IV treatment available nearby (within 30 minutes)? NO Are you trained to use a nasogastric (NG) tube for rehydration? NO YES.

Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 mllkg/hr) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify the dehydration. Then choose the appropriate plan (A, S, 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.

. (total of 120 mllkg). .

Start rehydration

by tube (or mouth) with ORS solution: give 20 mllkg/hr for 6 hours

Reassess the child every 1-2 hours:

" "

YES I.

Can the child drink?

. After 6 hours, reassess

NOTE:

- If there is repeated vomiting or increasing abdominal ditension, give more fluid slowly. - If hydration status is not improving after 3 hours, send the child for IV therapy.
the child. Classify dehydration. Then choose the appropriate

plan (A, S, or C) to continue treatment.

NO
Refer urgently to a hospital for IV or NG treatment.

If possible, observe the child at least 6 hours after rehydration

to be sure that the

mother can maintain hydration, giving the child ORS solution by mouth.

13

UNLIKELY, FEVER: NO MALARIA

,,'OJ\,:! ~vVMM~I'OjUI-\IIVI~;) ~

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I Iv;;)

PLANA, PLANS, PLAN C

FOllOW-UP

JUNSEl THE MOTHER

,SESS AND CLASSIFY

FOLLOW-UP

If
14

,~FO~LI-OW-UP CARE

PNEUMONIA

~ DYSENTERY
After 2 days:

After 2 days: Check the child for general danger signs.

Assess the child for cough or difficult breathing. Ask:

- Is the child's breathing slower? - Is there less fever? - Is the child eating better?

} See the ASSESS AND CLASSIFY chart.

Assess the child for diarrhea. > See Assess & Classify chart

Ask:
- Are there fewer stools? - Is there less blood in the stool?

- Is

there

less fever?

Treatment:

- Is there less abdominal pain? - Is the child eating better?

. Ifchest indrawing or a general danger sign, give a dose of second-line antibioticor intramuscular
chloramphenicol. Then refer URGENTLY to hospital. . If breathing 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.) If breathing slower, less fever, or eating better, complete the 5 days of antibiotic. If cough is more than 30 days, refer for assessment.

Treatment: . If the child is dehydrated, treat dehydration.

If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same or worse:

Change to second-line oral antibiotic recommended for 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 DIARRHEA
After 5 days: Ask: - Has the diarrhea stopped? - How many loose stools is the child having per day? Treatment:

. If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving the same antibiotic until finished.

. If the diarrhea has not stopped (child is still having less than 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 child's age.

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FOllOW-UP CARE
~ FEVER-MALARIA UNLIKELY
If fever persists after 2 days:

Do a full assessment 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/MALARIA. ~ If malaria 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 if the fever persists. - If fever has been present for 7 days, refer for assessment.

~ MALARIA
If fever persists after 2 days, or returns within 14 days: Do a full assessment of the child. > See ASSESS & CLASSIFY chart. Treatment: ~ If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE/MALARIA. ~ If the child has any cause of fever other treatment. than malaria, provide

~ FEVER (NO MALARIA)

If fever persists after 2 days:

Do a full assessment of the child. > See ASSESS & CLASSIFY chart. Make sure that there has been no travel to malarious area and overnight stay in malaria area. If there has been travel and overnight stay take blood smear, if possible. Treatment: ~ If there has been travel and overnight stay to a malarious area and the blood smear is positive or there is no blood smear

~ If malaria is the only apparent cause of fever. - Take a blood smear - Give second-line oral antimalarial without waiting for result of blood smear. - Advise mother to return if fever persists. - If fever persists after 2 days treatment with second-line oral antimalarial, refer with blood smear for reassessment. - If fever has been present for 7 days, refer for assessment.

- classify

according

to Fever with Malaria

Risk and treat

accordingly. ~ If there has been no travel to mfllarious area or blood smear is negative: - If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. - If the child has any apparent cause of1ever, provide treatment. - If no apparent cause of fever, advise the mother to return again in 2 days if fever persists. - If fever has been present for 7 days, refer for assessment.

PNEUMONIA, PERSISTENT DIARRHEA, DYSENTERY, MALARIA, FEVER: MALARIA

15
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UNLIKELY, FEVER: NO MALARIA

FOLLOW-UP

SESS AND CLASSIFY

UNSEL THE MOTHER

FOLLOW-UP

If

f
16

EFO
~

OW-UP CARE
~ FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
If fever persists after 2 days: Do a full assessment of the child. > See ASSESS & CLASSIFY chart. Do a tourniquet test. Assess for the other causes of fever.

Treatment: ~

~ MEASLES WITH EYE OR MOUTH COMPLICATIONS

After 2 days:

~ ~ ~

Ifthe child has any signs of bleeding, including skin petechiae or a positive tourniquet test, or signs of shock, or persistent abdominal pain or persistent vomiting. If the child has any other apparent cause of fever, provide treatment. If fever has been present for 7 days, refer for assessment. If no apparent cause of fever, advise the mother to return daily until the child has had no fever for least 48 hours. Advise mother to make sure child is given more fluids and is eating.

~
Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth. Treatment for Eye Infection: ~ If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct treatment.

~ EAR INFECTION
After 5 days: Reassess for ear problem. > See ASSESS & CLASSIFY chart. Measure the child's temperature. Treatment: ~ ~
~ ~

~ If pus is gone but redness remains, continue the treatment. ~ If no pus or redness, stop the treatment.
Treatment for Mouth Ulcers: ~ ~ If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If mouth ulcers are the same or better, continue using halfstrength gentian violet for a total of 5 days.

If there is tender swelling behind the ear or high fever (38.5C or above), treat as MASTOIDITIS.

Acute earinfection:if earpain or discharge persists,treatwith5 moredaysof thesame

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. 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.

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VE FOLLOW-UP CARE

~ ANEMIA
After 14 days:

~ Give iron. Atlvise mother to return in 14 days for more iron.

~ Continue giving iron every day for 2 months with follow-up every 14 days.

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.

0
~ If the child has any palmar pallor after 2 months, refer for assessment.

ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY. (See the COUNSEL THE MOTHER chart.)

17

MEASLES, EVER: ENGUE F D HEMORRHAGIC FEVER UNLIKELY, EARINFECTION, FEEDING PROBLEM, ANEMIA, VERYLOWWEIGHT,

ING RECOMMENDATIONS

UNSEL THE MOTHER

SESS AND CLASSIFY

FOllOW-UP

Jj

J
18

COUNSEL THE MOTHER

~ Assess the Child's Feeding

Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's 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 feed the child and how? During this illness, has the child's feeding changed? If yes, how?

~ Assess the Child's Care for Development

Ask questions about how mother cares for her child. Compare the mother's answers to the Recommendations for Care for Development.

ASK:

- How do you play with your child? - How do you communicate with your child?

Sample Feeding Problem

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. difficulty in breastfeeding child less than 4 months taking other milk/food use of breastmilk substitute/cow's milk/evap milk use of feeding bottles lack of active feeding not feeding well during illness complementary food not enough in quantity/quality/variety child 6 months above not yet given complementary foods infant not exclusively breastfed improper handling and use of breastmilk substitute

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l111J1l1l1J111l1l111I111J1l111l1l1lJ;J1l1l1Recommendations for Feeding and Care for Development

Birth up to 6 Months
6 months to 12 months 12 months to 2 years 2 years and older

. Exclusively breastfeed as often as the child

. .
.

Breastfeed as often as the child wants. Add any of the following:

/ .
Breastfeed as often as the child wants.

Give adequate amount of family foods at 3

meals every day.
Give twice daily nutritious foods, between

Lugawwith added oil, mashedvegetablesor

beans, steamed tokwa, flaked fish, pulverized roasted dilis, finely ground meat, egg yolk, bite-size fruits 3 times per day if breastfed 5 times per day if not breastfed

wants, day and night, at least 8 times in 24 hours.

Do not give other foods or fluids.

.
Play:

. Provide an area where the child could move, play,

and develop his senses of sight, touch, and hearing. " Have large, colorful things for your child to reach for and new things to see. Communicate:

. . .

Give adequate amount of family foods, such as: rice, camote, potato, fish, chicken, meat, monggo, steamed tokwa, pulverized roasted dilis, milk and eggs, dark-green, leafy and yellow vegetables (malunggay, squash), fruits (papaya, banana) Add oil or margarine. 5 times per day Feed the baby nutritious snacks like fruits.

meals such as: Boiled yellow camote, boiled yellow corn, peanuts, boiled saba, banana, taho, fruits, and fruit

juices.

Play:
Play:

. Help your child count, name, and compare

Play:

Give your child clean, safe household things to handle, bang, and drop.

Look into your child's eyes and smile at him or her. When you are breastfeeding, it is a good time to talk to your child and get a conversation going with sounds or gestures.

Give your child things to stack up, and to put into containers, and take out.

things. . Make simple toys for your child.

Communicate:

Communicate:
questions. Respond

Ask your child simple

to your child's attempts to talk.

Playgames like

"bye."

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.
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Encourage yourchild
to talk, and answer your child's questions. Teach your child stories, songs, and games.

e.~@
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Feeding Recommendations for a child who has PERSISTENT DIARRHEA ~ If still breastfeeding, give more frequent, longer breastfeeds, day and night. ~ If taking other milk such as milk supplements; Replace these with increased breastfeeding, or

Replace half the milk with nutrient-rich, semi-solid foods. Do not use condensed or evaporated filled milk. For other foods, follow the feeding recommendations for the child's age.

19
ASSESS FEEDING, FEEDINGRECOMMENDATIONS

COUNSEL THE MOTHER

iSESS AND CLASSIFY L

FOLLOW-UP

J1

J 20
@

~ 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:
~

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

Ifthe child is less than 6 months old and is taking other milk or foods:

-Build mother's
- Suggest - Breastfeed

confidence that she can produce all the breastmilk that the child needs. giving more frequent, longer breastfeeding, day and night, and gradually reducing other milk or foods.

If other milk needs to be continued, counsel the mother to: as much as possible, including at night.

- Make sure that other milk is a locally appropriate breastmilk substitute, give only when necesarry. - 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.

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

- Recommend

substituting

a cup for bottle.

- Show the mother how to feed the child with a cup.

~ Ifthe child is not being fed actively, counsel the mother to:

- Sit witbthechild

and encourage eating.

- Give the child an adequate serving in a separate plate or bowl. - Observe what the child likes and consider this in the preparation of his/her food.

~ Ifthe child is not feeding well during illness, counsel the mother to:

- Breastfeed

more frequently and longer if possible. - Use soft, varied, appetizing, favorite foods to encourage the child to eat as much as possible, and offer frequent small feeding. - 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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~ Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD: ~Breastfeed more frequently and longer at each feed. ~ Increase fluid. For example, give soup, rice water, buko juice or clean water. FOR CHILD WITH DIARRHEA: ~Giving an extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT Advisethe motherto comefor follow-upat the earliesttime listedfor the child'sproblems.
If the child has: PNEUMONIA DYSENTERY MALARIA,if the fever persists FEVER-MALARIAUNLIKELY,if the fever persists FEVER(NO MALARIA)if the fever persists MEASLESWITH EYEOR MOUTHCOMPLICATIONS DENGUEHEMORRHAGICFEVERUNLIKELY,if the fever persists PERSISTENTDIARRHEA ACUTE EAR INFECTION CHRONICEAR INFECTION FEEDINGPROBLEMS MANY OTHER ILLNESSES,if not improving ANEMIA VERY LOWWEIGHT FORAGE

Return for follow-up in:

2 days

WHEN TO RETURN IMMEDIATELY

Advise the mother to return immediately if the child has any of these signs:
Any sick child 5 days

Ifthe childhas NO PNEUMONIA: COUGHORCOLD,also returnif:

14 days 30 days If the child has Diarrhea, also return if:

. . . . .

Not able to drink or breastfeed Becomes sicker Develops a fever Fast breathing

If the childhasFEVER:DENGUE HEMORRHAGIC FEVERUNLIKELY,

also return if:

. . . .

Difficultbreathing Bloodin stool Drinkingpoorly

Any sign of bleeding Persistent abdominal pain

. Persistentvomiting . Skin petechiae .

Skin rash

21
FEEDING AND CARE FOR DEVELOPMENT, FEEDING PROBLEMS, FLUID, WHEN TO RETURN
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SSESS AND CLASSIFY

FOLLOW-UP

If

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22

~ Counsel the Mother about Her Own Health

~

If the mother is sick, provide care for her, or refer her for help. If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help. Advise her to eat well to keep her own strength and health. Check the mother's immunization status and give her Tetanus Toxoid if needed. Make sure she has access to:

. .

Family Planning Counseling on STD and AIDS prevention.

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ASSESS, CLASSIFY, AND TREAT THE SICK INFANT AGE 1 WEEK TO 2 MONTHS
I

ASSESS
ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE

CLASSIFY
USE All BOXES THAT MATCH THE INFANT'S SYMPTOMS AND PROBLEMS TO CLASSifY THE IllNESS.

IDENTIFY TREATMENT

Determine if this is an initial or follow-up visit for this problem. If follow-up visit, use the follow-up instructions in the follow-up section. If initial visit, assess the young infant as follows:

CHECK FOR POSSIBLE BACTERIAL INFECTION

ASK: Has the infant
had convulsions?

SIGNS

CLASSIFY AS

LOOK, LISTEN:

Count the breaths Repeat

in one minute.

the count if elevated. indrawing. flaring.

Look for chest Look for nasal

Look and listen for grunting.

CHILD MUST BECALM.

Classify ALL YOUNG INFANTS

. Con""Jlsions or
Fast breatbing (60 breClths;per minute or

,.

TREATMENT
. Give ,first dose of intramt1scalar antibiotics.
. Treat the chirtJto prevent low blood sugar. Advise m,pther how to keep the infant warm on the way to the I hospital.
**

more) or
Severe ch indrawing or Nasal flaring or Grunting or
Bulging fontanelle or

.
POSSIBLE SERIOUS
BACTERIAL INFECTION

. . .
. .

Pus draining from the ear or Umbilical rednes extending to the skin or

Look and feel for bulging fontanelle. Look for pus draining from the ear. Look at the umbilicus. Does the redness
Measure temperature

Fever (37.5C*or above, or feels hot) or low bodytemperature (less than 35.58*,or feels cold)or
pus?

. Refer URGENTLY to the hospital.

I!I

Is it red or draining to the skin?

extend

Many or severe skin pustules or Abnormly; sleepy or diffcUlt to awaken or Less Ulan normal movement.
temperature).

(or feel for fever

or low body

Look for skin pustules. See if the young difficult to awaken.

Are there many or severe sleepy or

pustules?

infant is abnormally

Red umbilicus or draining pus or Skin pustules

LOCAL
BACTERIAL INFECTION

. .

. Look at the young infant's movements.

Are they less than normal?
These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately a.sac higher. .. If referral is not possible, manage the child as described in Management of Childhood Illness. Treat the Child, Annex: Where Referral is Not Possible.

Give an appropriate oral antibiotic. Treat the local infection in the health center, and teach the mother to treat local infections at home. . Advise mother how to give home care
for young infant.

Follow up in 2 days.

l.-

23
MOTHER'S HEALTH BACTERIAL INFECTION

,\

ASSESS AND CLASSIFY

FOLLOW-UP

if

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24

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

. .

LOOK AND FEEL: Look at the young infant's general condition. Is the young infant: - Abnormally sleepy or difficult to awaken? - Restless or irritable?

for DEHYDRATION

Sunkeneyes . SkJ,n pinchgoes back veryslowly

. .

Two of the following signs: Abnormally sleepy or

difficult to awaken

seveRE DEHYDRATION

. Look for sunken eyes. . Pinch the skin of the abdomen.

Does it go back: - Very slowly (longer than 2 seconds )? - Slowly?

..

If infant does not have POSSIBLE SERIOUS BACTERIALINFECTION. or DYSENTER){: n - Giv~fluid for severe dehydration (Plan C) OR If infant also has a POSSIBLE SERIOUS BACTERIAL INFECTIONor DYSENTERY: - Refer URGENTLYto hospital, with mother giving frequent sips of ORS on the way. - Advise mother to continue breastfeeding. - Advise mother how to keep the young. infant warm on the way to the hospital. Give fluid for some dehydration (Plan B). If infant also has POSSIBLE SERIOUS BACTERIAL INFECTIONor DYSENTERY: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise mother to continue breastfeeding.
Give fluid to treat diarrhea at home (Plan A).

Two of the following signs: . Restless, irritable . . Sunken eyes Skin pinch goes back

. .

SOME
DEHYDRATION

slowly

Not enough signs to classify as some or severedehydration

. NO DEHYDRATION

Diarrhea

lasting for 14 days

or more

SEVERE, PERSISTENT DIARRHEA

If the young infant has dehydration, treat dehydration bW'ore referral unless the infant has also POSSIBLE SERIOUS BACTERIAL INFECTION. Refer to hospital.

and if blood in stool

. Blood

. DYSENTERY .

inthe stool

Refer URGENTLY to hospital, withamother giving frequent sips of ORS on the way. Advise mother to continue breastfeeding.

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THEN CHECK. FOR FEEDING PROBLEMS OR LOW WEIGHT:
IF YES, ASK:
Is there any difficulty feeding?

~~~uJl.1~~~

LOOK and FEEL:

Determine weight for age.

Classify FEEDING

Is the infant breastfed? If yes, how many times in 24 hours? Does the infant usually receive any other food or drink? If yes, how often?

WP

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@

--------------------------------------What do you use to feed the infant?

IF AN INFANT:

Has any difficulty feeding. Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to hospital:

. or .
.

Not well attached to breast or

Not sucking effectively

~ Advise the mother to breastfeed

as often and

for as long as the infant wants, day and night. . If not well attached or not sucking effectively, teach correct positioning and attachment.

. drinks or

Less than 8 breastfeeds in 24 hours or Receives other foods or Low weight for age or

FEEDING PROBLEM OR LOWWEIGHT

If breastfeeding less than 8 times in 24 hours, advise to increase frequency of breastfeeding.

Thrush (ulcers or white

patches in the mouth)

~ If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods and drinks, and using a cup: If not breastfeeding at all: Refer to breastfeeding counseling and possible relactation. Advise about the correct preparing of breastmilk substitutes, and using a cup. ~ If thrush, teach the mother to treat thrush at home.

ASSESS THE INFANT'S BREASTFEEDING: Has the infant breastfed in the previous hour? If the infant has not fed in the previous hours, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (If the infant was fed during the last hour, ask the mother if she can wait, and to tell you when the infant is willing to feed again.) Is the infant able to attach? no attachment at all not well attached good attachment

TO CHECK ATTACHMENT, LOOK FOR: Chin touching the breast Mouth wide open Lower lip turned outward More areola visible above than below the mouth (All these signs should present if the attachment is good.) be Is the infant sucking effectively (that is, slow, deep sucks, sometimes pausing)? not sucking at all not sucking effectively good effectively

.
8<

~ Advise the mother to give home care for the young infant. ~ Follow up any feeding problem or thrush in 2 days. ~ Follow up low weight for age in 14 days.

.
.
Not low weight for age,
and no other signs of inadequate feeding.

NO FEEDING PROBLEM

~ Advise mother to give home care for the young infant. ~ Praise the mother for feeding the infant well.

Clear a blocked nose if it interferes with breastfeeding. Look for ulcers or white patches in the mouth (thrush).

25
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DIARRHEA FEEDING PROBLEMS

IHKU~H

FOLLOW-UP

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:r THE YOUNG INFANT AND COUNSEL THE MOTHER

COTRIMOXAZOLE AMOXICILLIN COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) ~ Give two times daily for 5 days AMOXYCILLIN

~ Give an Appropriate OralAntibiotic

For local bacterial infection: First-line antibiotic: Second-line antibiotic:

Give three times daily for 5 days

TABLET 250 mg SYRUP 125 mg per 5 ml

AGE OR WEIGHT

ADULT TABLET
single strength (80 mg trimethoprim + 400 mg sulphamethoxazole)

SYRUP
40 mg trimethoprim + 200 mg sulphamethoxazole per 5 ml

Birth up to 1 month 3 kg)

1 to 2 months (3-4 kg) * Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.

1.25 ml* 2.5 ml

1.25 ml 2.5 ml

~ Give First Dose of Intramuscular Antibiotics

~

Give the first dose of both benzylpenicillin

and gentamicin intramuscular.

BENZYLPENICILLIN Dose: 50,000 units per kg Add 6 ml sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml To a vial of 600 mg (1,000,000 units): Add 3.6 ml sterile water = Add 2.1 ml sterile water = OR 4.0 ml at 250,000 units/ml 2.5 ml at 400,000 units/ml 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml 0.2 ml 0.4 ml 0.6 ml 0.8 ml 1.0 ml

GENTAMICIN Dose: 5 mg per kg WEIGHT Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml or

1 kg 2 kg 3 kg 4 kg 5 kg
* Avoid

0.5 ml* 1.0 ml* 1.5 ml* 2.0 ml* 2.5 ml*

using undiluted 40 mg/ml gentamicin.

Referral is the best option for a young infant classified with POSSIBLE SERIOUS BACTERIAL INFECTION. If referral is not possible, give benzylpenicillin and gentamicin for at least 5 days. Give benzylpenicillin every 6 hours plus gentamicin one dose daily.

27
IMMUNIZATION STATUS ANTIBIOTICS

THRUSH FOLLOW-UP

TREAT AND COUNSEL

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28

THE YOUNG INFANTAND COU

L THE MO

~ To treat Diarrhea, See TREAT THE CHILD chart.

~ Teach the Mother How to Treat Local Infections

at Home

~ Explain how the treatment is given. ~ Watch her as she does the first treatment in the health center. ~ Tell her to do the treatment twice daily. She should return to the health center if the infection worsens. To Treat Skin Pustules The mother should: ~ Wash hands. ~ Gently wash off pus and crusts with soap and water. ~ Dry the area. ~ Paint with gentian violet. ~ Wash hands.

To Treat Umbilical Infection

The mother should: ~ Wash hands. ~ Clean with 70% ethyl alcohol ~ Paint with gentian violet. ~ Wash hands.

To Treat Oral Thrush The mother should: ~ Wash hands.

(ulcers

or white patches in mouth)

~ Wash mouth with clean soft cloth wrapped around the finger and wet with salt water. ~ Paint the mouth with half-strength gentian violet. ~ Wash hands.

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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER ~
Teach Correct Positioning and Attachment for Breastfeeding
~ Show the mother how to hold her infant. - with the infant's head and body straight. - facing her breast, with infant's nose opposite her nipples - with infant's body close to her body - supporting infant's whQle body, not just neck and shoulders. ~ Show her how to help the infant to attach. She should: - touch her infant's lips with her nipple - wait until her infant's mouth is opening wide - move her infant quickly onto breast, aiming the infant's lower lip well below the nipple. ~ Look for signs of good attachment and effective sucking. If the attachment or sucking is good, try again.

~ Advise Mother to Give Home Care for the Young Infant

~ ~

FOOD FLUID

Breastfeed frequently, as often and for as long as the infant wants, day and night, during sickness and health.

WHEN TO RETURN

Follow-up Visit
Ifthe infant has: LOCAL BACTERIAL INFECTION ANY FEEDING PROBLEM THRUSH LOW WEIGHT FOR AGE
~

When to Return Immediately:

Return for follow-up in: 2 days Advise the mother to return immediately ifthe young infant has any of these signs:
Breastfeeding or drinking poorly Becomes sicker Develops a fever Fast breathing Difficult breathing Blood in stool

14days

MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES. In cool weather, cover the infant's head and feet, and dress the infant with extra clothing.

29
LOCAL INFECTIONS BREASTFEEDING HOME CARE

THRUSH FOLLOW-UP

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30

f
NT

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG IN

~ LOCAL BACTERIAL INFECTION

After 2 days: Look at the umbilicus. Is red or draining pus? Does redness extend to the skin? Look at the skin pustules. Are there many or severe pustules? Treatment ~ If the pus or redness remains or is worse, refer to hospital. ~ If the pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

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GIVE-FOLLOW UP CARE FOR THE SICK YOUNG INFANT

~ FEEDING PROBLEM
After 2 days: Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above. 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 young infant back again. If the young infant is low weight for age, ask mother to return in 14 days after the initial visit to measure the young infant's weight gain.

Exception: If you do not think that feeding will improve, or if young infant has loss weight, refer the child.

~ LOW WEIGHT
After 14 days: Weigh the young infant and determine if the infant is still low weight for age. Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above. If the infant is no longer low weight for age, praise the mother and encourage her to continue. If the young infant is still low weight for age, but is feeding well, praise mother. Ask her to come again within a month or when she returns for immunization. If the young infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she returns for immunization, if this is within 2 weeks). Continue to see the young infant every few weeks until infant is feeding well and gaining weight regularly or is no longer low weight for age.

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

~ ORAL THRUSH
After 2 days: Look for ulcers or white patches in the mouth (thrush). Reassess feeding. > See "Then Check for Feeding Problem or Low Weight" above. ~ If thrush is worse, or if the infant has problems with attachment or sucking, refer to hospital. ~ If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.

31
FEEDING PROBLEM, LOW WEIGHT FOR AGE, THRUSH FOLLOW~UP

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MANAGEMENT OFTHE SICKYOUNGINFANTAGE 1 WEEK UPTO 2 MONTHS

Date: Child's ame: N ASK:What retheinfant's roblems? a p ASSESS (Circle allsignspresent) Age:Sex:Weight: Initial visit: kg . Temperature: Follow-up visit: C

LL C)

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CLASSIFY

CHECK FOR POSSIBLE BACTERIAL INFECTION Has the infant had convulsions?

. . . . . .
. .
.

Count the breaths in one minute.

breaths

per minute. Repeat if elevatedFast Breathing? Look for severe chest indrawing. Look for nasal flaring. Look and listen for grunting. Look and feel for bulging fontanelle. Look for pus draining from the ear. Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin?

. . .
DOES THE YOUNG INFANT HAVE DIARRHEA? For how long? days Is there blood in the stool?

Fever (temperature 37.5C or above or feels hot) or low body temperature (below 35.5C or feels cool) . Look for skin pustules. Are there many or severe pustules? See if the young infant is abnormally sleepy or difficult to awaken. Look at the young infant's movements. Less than normal? YES_NOLook at the young infant's general condition. Is the infant: Abnormally sleepy or difficult to awaken Restless or irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

.
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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

-----------------------------------

times Does the infant usually receive any other foods or drinks? Yes If Yes, how often? . What do you use to feed the child?

. .
.

Is there

difficulty

feeding

Yes

Is the infant breastfed?

If Yes, how many times in 24 hours? -

Yes

No No -

Determine weight for age. Low -

Not low ('f) ('f)

No-

-----

If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to hospital: ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour?

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If infant has not fed in the previous hour, ask the mother to put her infant on her breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: - Chin touching breast Yes No- Mouth wide open Yes No- Lower lip turned outward Yes No- More areola above than below the mouth Yes No-

no attachment at all

not well attached

good attachment

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Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)?
not sucking at all not sucking effectively sucking effectively

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Look for ulcers or white patches in the mouth (thrush) Return for next immunization on:

CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS Circle immunization needed today.

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ASSESS OTHER PROBLEMS

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Giveany immunizations needed today: I='

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GROWTH CHART
Record the information along the month-of-weighing weight fever breastfeeding cough/cold line using the symbols below:

F B C CF D 01 A H 1

complementary diarrhea other illnesses Vitamin A given hospitalized

foods introduced

5-6 years
+2S0 Boys +250 Girls

4-5years

sign of injuries such as abrasions/hematoma

20 19

.2S0 Boy. -280 Girts

14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 I 1 I 1 1 I I 1 1 I I 1 I The child's weight should be between the ~reference~ curves. The plotted growth curve should go in an upward direction

A child who is... not gaining weight has a plotted growth curve that flattens off or looks like a flat line between the "reference" curves;

Distributed bye & E PublisJUni, Inc. 1672 Quezon Avenue, South Triangle. Quezon Cit)' Tel. NO's.929-1344/928-7298 E-mail: infQ.~cebookshop.com Website: www.cebookshop.com Showroom & Branches: Quezon Ave 1021928-7298Ioc.132 Dagupan 1075)522-3034 Cebu Quezon Ave. Ext (021927-6878 Tuguegarao 10781844-9583 Baguio 1074)446-6543 Naga 1054)811-2107 UE-Recto 1021735-3007 BacO'lod 1034)433-0187 Davao (082) 225-0159

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As a cfildgelsolder,

A child who is...

losing weight has a plott edgrDWt h curve that goes in a downward/declining direction between the ~reference" curves.
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IlO'-ilo (0331320-5079

Cagayan de Oro 108821272-2094

10321254-3487