Integrated Management of

Childhood Illness
 Causes of 10.5 million deaths among children <5
in developing countries, 1999

Pneumonia
One in every 18%
two child
deaths in
developing Malnutrition
countries are 54% Diarrhoea
due to just 15%
five
infectious
diseases and Measles
8%
malnutrition
HIV/AIDS Malaria
3% 7%
Source: EIP/WHO, 1999 data
 Distribution of deaths of children
<5 the world, 1990 and projected for 2020
The 5 main killers of
children: 1990 2020
ARI, diarrhoea,
measles, malaria
and malnutrition

55% 52%
Perinatal
conditions

Other 5% 7%
communicable
9% 18%
diseases 19% 11%
12%
Non-communicable
11%
diseases

Injuries
Objectives of the Global Child Health
Programme

• To reduce significantly global mortality and

morbidity associated with the major causes of
disease in children

• To contribute to healthy growth and

development of children
 IMCI CASE MANAGEMENT
PROCESS
• Assess by checking for danger signs (or
possible bacterial infection in a young
infant) asking questions about common
conditions, examining the child, and
checking nutrition and immunization
status. Ask other health problems
• Classify using a color-coded triage
system
 IMCI CASE MANAGEMENT
PROCESS
• Identify specific treatments
• Provide practical treatment instructions
including teaching how to give oral drugs, how
to feed and give fluids and how to treat local
infections at home
• Counsel to solve any feeding problems after
assessing feeding
• Give follow-up care when a child is brought
back as requested
The Integrated Case Management Process
Outpatient Health Facility
• check for danger signs
• assess main symptoms
• assess nutrition and Immunization status
and potential feeding problems
• Check for other problems
• classify conditions and
• identify treatment actions
Outpatient Health Facility

Urgent referral
Home
• pre-referral treatment Outpatient Health
Facility
• advise parents
• refer child Caretaker is
Treatment counselled on:
• treat local infection • home treatment
• give oral drugs • feeding &fluids
Referral facility • advise and teach • when to return
• emergency triage &
treatment caretaker • immediately
• Diagnosis & treatment • follow up • follow-up
• monitoring & ff-up
 Overall Case Management
Process
Outpatient
1 - assessment
2 - classification and identification of treatment
3 - referral, treatment or counseling of the child’s
caretaker (depending on the classification identified
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of patient
progress
 Target Groups
• Sick young infant
– 1 week up to 2 months

• Sick young children

– 2 months up to 5 years
 SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS

FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic

ASK THE CHILD’S AGE

IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years

USE THE CHART: USE THE CHART:

œ ASSESS, CLASSIFY AND TREAT œ ASSESS AND CLASSIFY THE SICK CHILD
THE SICK YOUNG INFANT TREAT THE CHILD
COUNSEL THE MOTHER
 SUMMARY OF ASSESS AND CLASSIFY

Ask the mother or caretaker about the child’s problem.

If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the
problem, give follow-up care according to PART VII)

Check for general danger

signs.

Ask the mother or caretaker about the four When a main symptom is present:
main symptoms: œ assess the child further for signs related to
œ cough or difficult breathing, the main symptom, and
œ diarrhoea, œ classify the illness according to the signs
œ fever, and œ ear problem which are present or absent.

Check for signs of malnutrition and anaemia and classify the child’s nutritional status

Check the child’s immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child

(PART V), and Counsel the Mother (PART VI)
Assessing the Sick Child
▪ Is the child able to drink
or breastfeed?
▪ Does the child vomit
General everything?
▪ Has the child had
Danger convulsions?
▪ See if the child is
Signs lethargic or unconscious
▪ Is the child convulsing
now?
 Updates on Convulsions

Convulsion is a danger sign only when:

Occurs in less than 6 months
More than one episode
Occurring for more than 15 minutes

This definition EXCLUDES SIMPLE

FEBRILE CONVULSIONS
Classifying and Treating Danger Signs
Checking the Main Symptoms
- cough and difficult breathing
- diarrhea
- fever
- ear problem
Checking the Main Symptoms
1. Cough or difficult breathing
3 clinical signs
– Respiratory rate
– Lower chest wall indrawing
– Stridor
Checking the Main Symptoms
2. Diarrhea
• Dehydration
– General condition
– Sunken eyes
– Thirst
– Skin elasticity
• Persistent diarrhea
• Dysentery
 Checking the Main Symptoms
3. Fever
• Stiff neck
• Risk of malaria and other endemic
infections, e.g. dengue hemorrhagic
fever
• Runny nose
• Measles
• Duration of fever (e.g. typhoid fever)
 Checking the Main Symptoms
4. Ear problems
• Tender swelling behind the ear
• Ear pain
• Ear discharge or pus (acute or
chronic)
 Checking Nutritional Status,
Feeding, Immunization Status
• Malnutrition
– visible severe wasting
– edema of both feet
– weight for age
• Anemia
– palmar pallor
• Feeding and breastfeeding
• Immunization status
 Assessing Other Problems
• Meningitis
• Sepsis
• Tuberculosis
• Conjunctivitis
• Others: also mother’s (caretaker’s) own
health




Assessing for Main Symptoms


❑Cough or difficult breathing

❑Diarrhea
❑Fever
❑Ear problems
 Cough or Difficult Breathing
This is the first of the 4 main symptoms. It is one of the most common infections among
children. Infections can occur in any part of the respiratory tract such as the nose,
throat, larynx, trachea, bronchi, and lungs. A child with cough or difficult breathing may
have pneumonia or a less serious respiratory infection. Bacteria and viruses can cause
pneumonia. In the Philippines, the most common bacterial cause of pneumonia is
Streptococcus pneumoniae. Children with bacterial pneumonia may die from hypoxia
(too little oxygen) or sepsis (generalized infection).

Most children with cough or difficult breathing have only mild infection. For
example, a child who has a cold may cough because of post-nasal discharge. Or the
child may have a viral infection of the bronchi called bronchitis. These children do not
need treatment with antibiotics. Their families can manage them at home.

In order to identify very sick children with cough or difficult breathing one
checks two clinical signs: fast breathing and chest indrawing
 Parts of the Respiratory System

•Nasal
passages
•Windpipe or
trachea
•Lungs
 Inside the alveolus

shows the
alveolus and its
relationship
with blood
vessels that
are involved in
the diffusion of
gases through
the respiratory
unit composed
of the following:
respiratory
bronchiole,
alveolar ducts,
atria and alveoli
 Cough or Difficult Breathing
ASK: Does the child have cough or difficult breathing?

If NO If YES

IF YES, ASK: LOOK, LISTEN, FEEL: Child

•For how long? •Count the breaths in one minute must
•Look for chest indrawing be calm
•Look and listen for stridor and wheezing

If the child is: Fast breathing is:

Ask about 2 mos – 12 mos. 50 breaths/min or more
next main 12 mos – 5 yrs 40 breaths/min or more
symptoms:
diarrhea,
fever, ear Classify child’s illness using the color-coded
problems classification table for cough or difficult breathing
Child with Chest Indrawing
Video of child with stridor
Stepwise approach for assessing and
classifying a wheezing child
Rationale for management of children
with wheeze
• Wheeze can cause fast breathing and or
chest indrawing
• Good response to inhaled bronchodilator
may cause fast breathing or chest indrawing
to disappear
• Only children with wheeze and signs of
pneumonia (fast breathing and/or chest
indrawing) need antimicrobials
• Wheezing without signs of pneumonia only
need bronchodilator treatment
 Cough or Difficult Breathing
SIGNS CLASSIFY AS IDENTIFY TREATMENT
•Any general danger ➢Give first dose of an
sign or SEVERE appropriate antibiotic
•Stridor in a calm child PNEUMONIA OR ➢Refer URGENTLY to hospital
VERY SEVERE
DISEASE

➢Give an appropriate oral

antibiotic for 5 days
➢Soothe the throat and relieve the
•Fast breathing PNEUMONIA cough with a safe remedy
•Chest indrawing ➢Advise mother when to return
immediately
➢Follow-up in 2 days

➢If coughing > 30 days, refer for

assessment
No signs of NO PNEUMONIA: ➢Soothe the throat and relieve the
pneumonia COUGH OR COLD cough with a safe remedy
or very severe ➢Advise mother when to return
immediately
disease
➢Follow-up in 5 days if not improving
 Treatment
Soothe the Throat, Relieve the Cough with a Safe Remedy
•Safe remedies to recommend:
Breastmilk for exclusively breastfed
infant; tamarind, calamansi, gingerwhich can be taken
liberally to induce coughing and expectoration of sticky
phlegm.

•Harmful remedies to discourage:

Codeine cough syrup
Other cough syrups
Oral and nasal decongestants
Antibiotic treatment for Pneumonia
AMOXICILLIN

• Children aged 2-59 months pneumonia (chest

indrawing and or high RR) should be treated with
oral amoxicillin of at least 40mg/kg/dose twice a
day for five days
• The evidence….
• Addo-yobo et al (2004 ) evaluated 1702 children
with severe pneumonia
• Oral amoxicillin (n=857) versus IV Penicillin
(n=485) for two days followed by oral amoxicillin
• After 48 hours, treatment failure for both arms was
19% and the risk difference was not significant
 More evidence…
• Atkinson et al (2007) conducted a study in 8
pediatric centers in England
• Exclusion criteria: wheeze, signs of shock and
pulmonary complications, O2 saturation < 85%
• 7 day treatment of oral amoxicillin (n=100) or IV
benzyl penicillin (n=103)
• Primary outcome was time for temp to be <38C for
24 continuous hours
• The study found equivalence between the two
treatment, with a median time of 1.3 days for fever
to go down
Why amoxicillin … not cotrimoxazole?
COTRIMOXAZOLE = PCP Pneumonia

• Oral amoxicillin is effective against both non-

severe and severe pneumonia in low HIV settings.
• In high HIV settings, oral amoxicillin is also
preferred because oral cotrimoxazole is
recommended for Pneumocystis Jirovecii
Pneumonia (PCP)
• Strauss et al (1998) studied 302 children with
severe pneumonia and compared oral cotri
(n=203) with oral amox (n=99). Higher treatment
failure rates were demonstrated in cotri group
(33%) compared to oral amox (18%)
 Benefits of current treatment for
pneumonia with chest indrawing
• Increased access to antibiotic care
• Number of referrals and hospital admissions will be
reduced and thus less risk for nosocomial
infections
• Better treatment compliance – home care,
antimicrobial given only twice a day for five days
• Cost effective – injectable antibiotics are more
expensive
• Oral amoxicillin is an effective and safe alternative
to parenteral antibiotics in low HIVsettings in
children with pneumonia (chest indrawing).
 Vitamin A Supplementation

for Severe Pneumonia or Very Severe Disease

100,000

200,000
DIARRHEA
Anatomy of the Gastrointestinal
System
 Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs,
ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHOEA?

If NO If YES

Does the child have diarrhoea?

IF YES, ASK: LOOK, LISTEN, FEEL:
œ For how long? œ Look at the child’s general condition.
Is the child:
œ Is there blood in the
stool Lethargic or unconscious?
Restless or irritable?
œ Look for sunken eyes.
Classify DIARRHOEA
œ Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

œ Pinch the skin of the abdomen.

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

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhoea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and
anaemia, immunization status and for other problems.
 DIARRHEA
Does the child have diarrhea?
IF YES, ASK:
• For how long?
• Is there blood in the stool?
LOOK, LISTEN, FEEL:
• Look at the child’s general
condition, is the child:
• Lethargic or unconscious?
cannot be consoled or calmed down. If
• Restless or irritable? he stops breastfeeding and he is restless
and irritable, then he has the sign.

• Look for sunken eyes

• Offer the child fluid. Is the Pinch the skin of the
child: abdomen
• Not able to drink or drinking poorly? Does it go back:
• Drinking eagerly, thirsty? Very slowly (> than 2 secs)?
Slowly?
A child is drinking poorly if the child is weak and cannot drink without help. He
may be able to swallow only if fluid is put in his mouth
 Clinical Types of Diarrhea


• Acute watery diarrhea ( includes cholera): lasts several

hours or days; main danger is dehydration
• Acute bloody diarrhea: “dysentery”; main dangers are
damage to intestinal mucosa, sepsis and malnutrition
• Persistent diarrhea: lasts 14 days or longer; main
dangers are malnutrition and serious non-intestinal
infection
• Diarrhea with severe undernutrition: main dangers are:
severe systemic infection, dehydration, heart failure,
vitamin and mineral deficiency

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
 Recognized Enteropathogens for Acute diarrhea
Viruses Bacteria Parasites
Rotavirus Escherichia coli Entamoeba hystolitica
Norwalk agent Enterotoxigenc* Giardia lamblia
Adenovirus Enteropathogenic* Strongyloides
Calicovirus Enteroinvasive* Trichuris trichuria
Coronavirus Enterohemorrhagic* Cryptosporidia
Astrovirus Enteroadherent
Vibrio cholerae*
Shigella*
Campylobacter jejuni
Staphylococcus aureus*
Clostridium dificile*
Clostridium perfringens*
Yersinia enterocolitica
Vibrio parahaemolytica
Aeromonas hydrophila
Bacillus cereus*

*These bacteria produce enterotoxins

Ghai. Understanding and Managing Acute Diarrhea in Infants and Young Children
All India Institute of Medical Science, New Delhi
 Notes on Diarrhea
Weight loss More severe,
Food intake more prolonged
Nutrient
& failure
to grow a more frequent
absorption
Nutrient a diarrhea

requirements
Diarrhea Malnutrition

Nutrient-Rich
foods
Video of Skin Pinching
 CLASSIFICATION TABLE FOR DEHYDRATION

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
Two of the following signs: If child has no other severe classification:
•Lethargic or unconscious — Give fluid for severe dehydration (Plan C).
•Sunken eyes SEVERE OR
•Not able to drink or drinking DEHYDRATION If child also has another severe classification:
poorly — Refer URGENTLY to hospital with mother giving
•Skin pinch goes back very frequent sips of ORS on the way.
slowly Advise the mother to continue breastfeeding
If child is 2 years or older and there is cholera in your
area, give antibiotic for cholera.

Two of the following signs: Give fluid and food for some dehydration (Plan B).
•Restless, irritable •If child also has a severe classification:
•Sunken eyes SOME — Refer URGENTLY to hospital with mother
•Drinks eagerly, thirsty DEHYDRATION giving frequent sips of ORS on the way.
•Skin pinch goes back slowly Advise the mother to continue breastfeeding
•Advise mother when to return immediately.
•Follow-up in 5 days if not improving.

Not enough signs to Give fluid and food to treat diarrhoea at home
classify as some or (Plan A).
severe dehydration. NO Advise mother when to return immediately.
DEHYDRATION Follow-up in 5 days if not improving.
A child who does not have two (2) or more signs in the pink or yellow row is classified as having NO DEHYDRATION.

This child needs extra fluid and foods to prevent dehydration. The three rules of home treatment are: 1) Give extra fluid,
2) Continue feeding, 3) Return immediately if the child develops danger signs
 

No Dehydration

 Some Dehydration
Signs of dehydration: The absence of lethargy, unconsciousness, restlessness,
irritability, sunken eyes, able to drink, skin pinch goes back immediately.
Severe Dehydration
 Updates on Diarrhea

• Use of low/reduced osmolarity Oral

Rehydration Salts (ORS)
• Providing children with zinc for 14
days:
− Children > 6 months 20 mg zinc
− Children < 6 months 10 mg of zinc
• Ciprofloxacin as first line drug for
bloody diarrhoea (dysentery)
Why the New Low Osmolarity ORS?

Compared to standard WHO/ORS, Meta-analysis

studies showed:
- Reduced volume of liquid stool output by
25 to 30%;
- Vomiting, frequently associated with
diarrhoea, is reduced by 30%;
- The need for unscheduled IV fluids is
reduced by more than 30%.
Composition of the old and 

reformulated ORS

 

Zinc and Diarrhea




• 24 RCTs ( n= 9128)
• Age ranged from 1 to 60 months
• 19 papers on acute diarrhea (1 with shigellosis)
• 5 papers on persistent diarrhea
• 7 on malnourished children; 4 only with male subjects
• Dose ranged from 5 to 45 mg
• Duration ranged from 7 days to 2 weeks or till recovery
Zinc promotes immunity, skin and mucosal resistance to infection, growth, and
development of the nervous system, important anti-oxidant and preserves cellular
membrane integrity.

At the level of gastrointestinal system, zinc restores mucosal barrier integrity and
enterocyte brush-border enzyme activity

it promotes the production of antibodies and circulating lymphocytes against intestinal

pathogens and has a direct effect on ion channels, acting as a potassium channel
blocker of adenosine 3-5-cyclic monophosphate- mediated chlorine secretion.

Lazzarini M, Ronfani L. Cochrane Database Sys Rev 2013

 Treatment of > 6 months old 

with Acute Diarrhea


• Duration: MD -10.44 hrs (-21.13 to 0.25)

= modestly decreased the duration by half a day
• Acute diarrhea persisting beyond 7 days: RR 0.73 (0.61
to 0.88)
= likelihood of prolonged diarrhea is decreased by 30%
• Duration if with Moderate Malnutrition: MD -26.98 hrs
(-14.92 to -39.34)
= decrease the duration by more than a day

Treatment:

- however, it can increase the risk of vomiting if the preparation is not palatable

- if given during diarrhea episodes, it can reduce the risk of recurrence by around

40% in the next 3-5 months

- it also reduces the risk of dying from diarrhea by 23%

 Role of Supplemental Zinc Therapy

1. Reduction in the severity and duration of
diarrhea:
– 12 studies examined impact of zinc on mgt of
acute diarrhea
• 11 showed reduction in duration of diarrheal episode
(8 of these stat. significant)
• 8 studies found reduction in stool output or frequency (
5 of these stat. significant)
– Conclusion: Zn supplementation
• 25% reduction of diarrhea
• 30% reduction in stool volume

Implementing the New Recommendations on the Clinical Management of Diarrhea WHO 2006
 Role of Supplemental Zinc Therapy

2. Prevention of subsequent episodes

of diarrhea
– 10 -20 mg of Zn per day for 10-14 days
reduces the number of diarrheal
episodes in the 2-3 months after
supplementation.
 TPA for No dehydration
• Counsel the mother on the 4 rules of
home treatment:
1. Give extra fluid
2. Give zinc supplements
3. Continue feeding
4. Advice when to return
 Treatment Plan A

Treat Diarrhea at home

1. Give extra fluid (as the child will take):

▪ Breastfeed frequently and for longer at each
feed
▪ If the child is exclusively breastfed, give ORS or
clean water in addition to breastmilk
▪ If the child is not exclusively breastfed, give
one or more of the ff: ORS solution, food-
based fluids (such as soup, rice water and
yoghurt drinks) or clean water

It is especially important to give ORS at home when:

•The child has been treated with Plan B or C during the visit
•The child cannot return to the clinic if the diarrhea gets worse
 Treatment Plan A

Treat Diarrhea at home – Rule # 1

• Teach the mother how to mix and give ORS, give

the mother 2 packets or ORS to use at home
• Show the mother how much fluid to give in
addition to the usual fluid intake:
▪ Up to 2 years : 50 to 100 ml after each loose stool
▪ 2 years or more: 100 to 200 ml after each loose stool
• Tell the mother to:
▪ Give frequent small sips from a cup
▪ If the child vomits, wait 10 minutes. Then continue but more slowly
▪ Continue giving extra fluid until the diarrhea stops
 Treatment Plan A

Treat Diarrhea at home – Rule # 2

2. Give zinc supplements

• Tell the mother how much zinc to
give:
▪Up to 6 months: ½ tablet (10 mg) per day
for 10-14 days
▪6 months and more: 1 tablet (20 mg) per
day for 1-14 days
• Show the mother how to give the
zinc supplements
 Treatment Plan A

Treat Diarrhea at home – Rule 3, 4

3. Continue feeding
See mother’s card
4 When to return
 No Dehydration
Tell the Mother:
(a) Breastfeed frequently and longer for each feed.
(b) If the child is exclusively breastfed, give ORS or clean water
in addition to breastmilk. it is important for this child to be
breastfed more frequently than usual. Also give ORS solution or
clean water. Breastfed children under 4 months should first be
offered a breastfeed, then given ORS.
(c) If the child is NOT exclusively breastfed, give 1 or more of
the following:
•ORS
•Food-based fluids
•Clean Water
In most cases a child who is not dehydrated does not really need ORS solution. Give
him extra food-based fluids such as soups, rice water or “am” and yoghurt drinks and
clean water (preferably given along with food).

 Fluid Management
What is an effective Home fluid?
• Safe when given in large volumes – avoid food that will have high
sugar content above 300mOsm/L, those with purgative action and
stimulants. Avoid very sweet tea, carbonated drinks, sweetened fruit
drinks, coffee
• Easy to prepare – not time consuming, ingredients are available and
inexpensive
• Acceptable – palatable, easy on the pocket, available
• Effective – should contain carbohydrate, protein, and some salt in the
right proportions
 Fluids 

NOT to be given
• Drinks sweetened with sugar
– Commercial carbonated beverages
– Commercial fruit juices
– Sweetened tea
• Other fluids to avoid
– Those with stimulant, diuretic and purgative effect
• Coffee
• Some medicinal teas or infusions

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
 No Dehydration
Treatment Plan A
Age Amount of Fluid Type of Fluid

< 2 yrs 50-100 ml (¼-½ cup) after each loose stool ORS, rice water, yogurt,
2-10 yrs 100-200 ml (½-1 cup) after each loose stool soup with salt

• Give frequent small sips from a cup.

• If the child vomits, wait 10 minutes. Then continue, but

more slowly.

• Continue giving extra fluids until the diarrhea stops.

 Some Dehydration
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then
continue, but more slowly.
• Continue giving extra fluids until the
diarrhea stops.
• Reassess after 4 hours and classify the
child for dehydration.
If the child’s eyes are puffy, it is a sign of overhydration. It is not a danger sign or a sign of hypernatremia. It is simply a sign
that the child has been rehydrated and does not need any more ORS solution at this time. The child should be given clean water or
breastmilk. The mother should give ORS solution according to Plan A when the puffiness is gone. If the child still has SOME
DEHYDRATION choose Plan B again. Begin feeding the child in the clinic. Offer food, milk or juice. After feeding the child, repeat
the 4-hour Plan B treatment. Offer food, milk and juice every 3 or 4 hours. Breastfed children should continue to breastfeed
frequently. If the clinic or health center is closing before you finish the treatment, tell the mother to continue treatment at home.

If worse, and the child now has SEVERE DEHYDRATION, you will need to begin Plan C.

 Some Dehydration
If the mother must leave before completing
treatment:
•show her how to prepare the ORS solution
at home.
•show her how much to give to finish the 4
hour treatment at home
•give her enough ORS packets to complete
rehydration.
Explain to her the 3 Rules of Home Treatment: 1) Give extra fluid; 2) Continue
feeding; 3) When to return
 Some Dehydration
Treatment Plan B
(Determine amount of ORS to be given in 4 hours)

Age Up to 4 mos 4mos - 12mos 12mos – 2years 2 years – 5years

< 6kg 6 - < 10kg 10 - <12kg 12-19kg

WEIGHT 200-400 400-700 700-900 900-1400
In ml
•The approximate amount of ORS can also be calculated by
multiplying the child’s weight (in kg) by 75.
• example, a child weighing 8 kg would need 600 ml of ORS solution in 4 hours. Notice that
this amount fits in the range given in the box. The box will save you this calculation.
Giving ORS solution should not interfere with a breastfed baby’s normal feeding. The mother
should pause to let the baby breastfeed whenever the baby wants to, then resume the ORS
solution. For infants under 6 months who are not breastfed, the mother should give 100-200
ml clean water during the first 4 hours in addition to the ORS solution. The breastmilk and
water will help prevent hypernatremia in infants.
 Severe Dehydration

Can you give Intravenous

fluids (IV) immediately?
Severely dehydrated children need to have water and salts quickly replaced.
Intravenous fluids are usually used for this purpose. Rehydration therapy
using IV fluids or using a nasogastric tube (NGT) is recommended ONLY for
children who has SEVERE DEHYDRATION. The treatment of the severely
dehydrated child depends on:

the type of equipment available at your clinic, or at a nearby clinic or hospital;

the training you have received; and whether the child can drink

 Severe Dehydration
Treatment Plan C
To treat severe dehydration (IV fluid: pLRS)

Age Initial Phase Subsequent Phase

(30 ml/kg) (70 ml/kg)

Infants (<12 mos) 1 hour * 5 hours

Older children 30 minutes* 2½ hours

*Repeat once if radial pulse is still very weak or

imperceptible.
During IV treatment, assess the child every 1-2 hours. Determine if the child is receiving
an adequate amount of IV fluid.
 Severe Dehydration
• Reassess the child every 1-2 hours. If
hydration status is not improving, give the
IV drip more rapidly.

• Also give ORS (5ml/kg/hr) as soon as the

child can drink.

• Reassess the infant after 6 hours & a child

after 3 hours. Classify dehydration.
Severe Dehydration

If trained to use a
nasogastric tube for
rehydration?
A nasogastric tube is a tube that is inserted into the nose down to the level
of the stomach. This access to the gastrointestinal system is another
option to rehydrate severly dehydrated children. Correct positioning of the
tube in the stomach is known by listening to the presence of abdominal
sounds after a small amount of air is introduced into the tube.

 Severe Dehydration
• Start hydration by tube (or mouth) with
ORS solution. Give (20ml/kg/hr) for 6
hours. (Total of 120ml/kg)
• Reassess the child every 2 hours.
– If there is repeated vomiting or increasing abdominal
distention, give the fluid more slowly.
– If hydration status is not improving after 3 hours,
send the child for IV therapy.
• After 6 hours, reassess the child. Classify
dehydration.
CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

•Treat dehydration before referral unless the

•Dehydration present SEVERE child has another severe classification.
PERSISTENT •Refer to hospital.
DIARRHOEA

•Advise the mother on feeding a child who

•No dehydration PERSISTENT has PERSISTENT DIARRHOEA.
DIARRHOEA •Follow-up in 5 days.
 Persistent Diarrhea
• After 5 days:
Ask:
• If the diarrhoea has NOT stopped (3 or
more stools) do a full reassessment, give
the treatment, then refer to hospital.

• If the diarrhoea has stopped (< 3 stools per

day) Tell the mother to follow the usual
feeding recommendations for the child’s
age.
1. Ask if the diarrhea has stopped and how many stools the child has per day.

1.1 If the diarrhea has NOT stopped (child is still having 3 or more loose
stools per day), do a full reassessment. This should include assessing the
child completely as

described on the ASSESS & CLASSIFY chart. Identify and manage any
problems that require immediate attention such as dehydration. Then refer the
child to the 

hospital.

1.2 If the diarrhea has stopped (child is having less than 3 loose stools per
day), instruct the mother to follow the feeding recommendations for the child’s
age. If the child is not normally fed in this way, you will need to teach the
mother/caretaker the following feeding recommendations:

(a) Breastfeed more frequently and for a longer time if possible

(b) Use nutritious, soft, varied, appetizing favorite foods to encourage

the child to eat as much as possible, and offer small feeding.

(c) Clear blocked nose if it interferes with feeding.

(d) Expect that appetite will improve as the child gets better.

(e) Add or mix with lugaw or rice, protein rich sources of food such
as flaked fish, chicken, pulverized roasted dilis, chopped meat, egg yolk,
steamed tokwa and munggo.

80
 CLASSIFICATION TABLE FOR DYSENTERY

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

•Treat for 5 days with an

•Blood in the oral antibiotic
stool DYSENTERY recommended for
Shigella in your area.
•Follow-up in 2 days.

One can assume that Shigella caused the dysentery because:

a) Shigella causes about 60% of dysentery cases seen in health centers.

b) Shigella causes nearly all cases of life-threatening dysentery.

c) Finding the actual cause of dysentery requires a stool culture. It can take at least 2
days to obtain the lab results.

 Antibiotics for Diarrhea

1. Shigella dysentery
2. Cholera
3. Laboratory proven cases of Amebiasis
4. Laboratory proven cases of Giardiasis
Indications for antimicrobial agents

• Bloody diarrhea – shigella, amoeba

• Cholera cases
• Diarrhea associated with serious non-
intestinal infections
• Other indications:
– Symptomatic Giardia duodenalis infection
– Severely malnourished children with
diarrhea

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
 Pathogen Antimicrobial % Resistance
2000 2002 2003 2004
Enteric Pathogens
Salmonella typhi Chloramphenicol 1.2 0 1 0
Cotrimoxazole 3.9 3 0 1
Ampicillin 3.6 2 0 1

Nontyphoidal Salmonella Chloramphenicol 24.1 16 21 18

Cotrimoxazole 30.6 15 31 20
Ampicillin 49.3 24 47 27
Ciprofloxacin 10.0 4 8 0
Shigella Ampicillin 47.8 78 50 50
Cotrimoxazole 81.0 73 78 67
Nalidixic acid 0 0 0 0
Ciprofloxacin 12 0
Vibrio cholerae 01 Tetracycline 6.9 1 0 2
Chloramphenicol 4.6 2 0 1
Cotrimoxazole 9.8 36 1 3
 Dangers of routinely giving
antimicrobial agents
• Will not hasten recovery of the patients
• May result to untoward effects such as:
– Suppression of gut flora
– Development of drug resistance
– Prolongation of the Salmonella carrier state
 “Antidiarrheal” drugs

• These agents have no practical

benefit and are NEVER indicated for
the treatment of acute diarrhea in
children
• Some of them are dangerous

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev.
WHO document 2005
 Dysentery
• After 2 days:
Ask:
• if the child is dehydrated, treat dehydration.

• if the number of stools, amount of stools,

fever, abdominal pain or eating is same or
worse: Change to 2nd line antibiotics & give
for 5 days. Advise to return in 2 days.
This slide shows the follow-up care for the mother who returns after 2 days.

1.Assess the child for diarrhea.

2.Ask the following questions:

a. Are there fewer stools?

b. Is there less blood in the stool?

c. Is there less fever?

d. Is there less abdominal pain?

e. Is the child eating better?

Treatment:

If there is any dehydration, treat it.

If the 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
the area. Give it for 5 days. Advise the mother to return in 2 days. If after being
treated with the second-line antibiotic for 2 days the child has still not improved, the
child may have amebiasis. This child may be treated with Metronidazole/Albendazole
(if it is available or can be obtained by the family) or referred for treatment. Amebiasis
can only be diagnosed with certainty when trophozoites of Entamoeba histolytica
containing red blood cells are seen in a fresh stool sample.

88
 Dysentery
• EXCEPTIONS:
If the child is less than 12 months old or
was dehydrated on the 1st visit or had
measles within the last 3 months. REFER
TO HOSPITAL.
If fewer stools, less blood in stools, less
fever, less abdominal pain & eating better,
continue antibiotics.
Thank you
Fever
 Assess FEVER
• A child has the main symptom of fever if:

– the child has history of fever

– the child feels hot
– the child has an axillary temperature of
37.5 or above
 Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk

Ask:
• Does the child live in a malaria area?

• Has the child visited malaria area in the past 3 weeks?

• Do a malaria test- if NO severe classification in fever cases with

malaria-risk; no obvious cause of fever

Then Ask: Look and Feel:

• For how long does the child has • Look and feel for stiff neck.
fever? • Look for runny nose

• If >7 days, has the fever been

present everyday? Look for signs of Measles:
• Generalized rash.
• One of these: cough, runny nose or
• Has the child had measles within red eyes
the last 3 months?
 Malaria Diagnosis

• Prompt parasitological confirmation by microscopy or

alternatively by Rapid Diagnostic Tests (RDTs) is
recommended in ALL patients suspected of malaria before
treatment is started.
 Clinical Benefits of Parasitological 

Based Diagnosis
• Supports the exclusion of malaria in the
differential diagnosis of febrile illness;
• Improves clinical management of non-malarial
illnesses;
• Reduces malaria over-diagnosis and
unnecessary antimalarial treatments;
• Improves rational use of antimalarials and
reduce the risk of adverse drug reactions;
• May improve adherence to treatment.
 Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

Classify Malaria Risk

(including travel to
FEVER malaria area)

Decide Malaria Risk:

No Malaria Risk

After the child has been assessed for fever (by history, feels hot or has a
temperature of 37.5°C or above) decide the malaria risk. This must include
asking whether the child lives in a malarious area or has been in a malaria risk
 Malaria Risk Areas
1. Palawan 11. Isabela
2. Davao Oriental 12. Cagayan
3. Davao del Norte 13. Quezon
4. Compostela Valley 14. Ifugao
5. Tawi-tawi 15. Zamboanga del Sur
6. Sulu 16. Bukidnon
7. Agusan del Sur 17. Misamis Oriental
8. Mindoro Occidental 18. Quirino
9. Kalinga Apayao 19. Mountain Province
10. Agusan del Norte 20. Basilan
Malaria Free:
- Catanduanes
- Leyte
- Cebu
 Classify FEVER
Malaria Risk
• Any general danger sign or VERY SEVERE
• Stiff Neck FEBRILE DISEASE/
MALARIA

Malaria Risk •Malaria test positive

(including travel to MALARIA
malaria area)

•Malaria test negative FEVER:

•Other causes of fever. MALARIA UNLIKELY

Classify
FEVER No Malaria Risk

• Any general danger sign or VERY SEVERE

• Stiff Neck FEBRILE DISEASE
No Malaria Risk

• No general danger sign FEVER:

•No stiff neck NO MALARIA
 Malaria Risk
• Any general danger •Pre-referral treatment includes rectal
sign or VERY SEVERE artesunate suppository or oral quinine and
• Stiff Neck FEBRILE IM Ampicillin and Gentamicin
DISEASE •Treat the child to prevent low blood sugar.
/MALARIA •Give one dose of Paracetamol in health center
for high fever (38.5C or above.)
•Send a blood smear with the patient.
•Refer URGENTLY to a hospital.

•Malaria Test •Treat the child with an oral antimalarial.

Positive •Give one dose of Paracetamol in health center
MALARIA for high fever (38.5C or above.)
•Advise mother when to return immediately.
•Follow up in 2 days if fever persists.
•If the fever is present every day for more than 7
days, refer for assessment.
 Malaria Risk
• Malaria Test • Give one dose of Paracetamol in
Negative health center for high fever (38.5C
• Other causes or above.)
of fever. FEVER: • Advise mother when to return
MALARIA immediately.
UNLIKELY • Follow up in 2 days if fever persists.
• If the fever is present every day for
more than 7 days, refer for
assessment.
•Treat other causes of fever.
 Treatment of Uncomplicated falciparum
malaria

} Artemisinin-based combination therapies (ACTs)

should be used in the treatment of uncomplicated
P. falciparum malaria
} ACTs should include at least 3 days of treatment
with an artemisinin derivative
 TREAT THE CHILD: 

Antimalarial Agents

• If the species of malaria is identified through blood

smear, give the following:
– P. falciparum – Artemisinin-based combination
therapies (ACTs) should be used in the treatment of
uncomplicated P. falciparum malaria

– P. vivax – first dose of Primaquine with Chloroquine

and give mother enough for one dose each day for
the next 13 days.
 TREAT THE CHILD: 

Antimalarial Agents

• If you do not have the blood smear or

you do not know which species of
malaria is present, treat as P. falciparum.

• Do not give Primaquine to children under

12 months of age. Don’t Give: < 1 year
 TECHNICAL UPDATES: 

Antimalarial Agents

TECHNICAL BASIS: Artemisinin Based Combination

Therapies
Based on available safety and efficacy data, the following
therapeutic options are available and have potential for
deployment (in prioritized order) if costs are not an issue:
• Arthemether – lumefantrine (Coarthem TM)
• Artesunate (3 days) + amodiaquine
• Artesunate (3 days) + SP in areas where SP remains high
• SP + Amodiaquine in areas where both SP and
Amodiaquine remain high. This mainly limited to West
Africa.
Malaria case management has been greatly affected by the emergence and
spread of chloroquine resistance. This was reported for almost all malaria
endemic countries of Africa. Sulfadoxine-pyrimethamine (SP) was, until
recently, seen as the obvious successor to Chloroquine. However, resistance
to SP is developing quickly even in its current use, thus reducing the useful
therapeutic use of this drug. Chloroquine and SP were the first line and second
line antimalarial drugs recommended in the IMCI guidelines of many countries.

Artemisinin based combination therapies have been shown to improve

treatment efficacy. The advantages of Artemisinin based combination therapy
(ACT) relate to the unique properties and mode of action of the artemisinin
components, which include rapid substantial reduction of the parasite biomass
and rapid resolution of clinical symptoms. Due to its very short half-life of
artemisinin derivatives, their use as monotherapy requires a multiple dose
seven-day regimen. Combination of one of these drugs with a longer half-life
“partner” anti-malarial drug allows a reduction in the duration of artemisinin
treatment, while at the same time enhancing efficacy and

reducing the likelihood of resistance development for the partner drug.

Artesunate used in combination therapy has been shown to delay the
development of resistance to its partner drug (mefloquine) in low malaria

105
 TECHNICAL UPDATES: 

Antimalarial Agents

• Administer intramuscular antibiotics if the child

cannot take an oral antibiotic to treat meningitis

• Rectal artesunate suppository or oral

quinine and IM Ampicillin and Gentamicin
for severe malaria

• Breastmilk or sugar to prevent low blood sugar.

Give an Intramuscular Antibiotic
A child may need an antibiotic before he
leaves for the hospital, if he/she:
– is not able to drink or breastfeed
– vomits everything
– has convulsions
– is abnormally sleepy or difficult to
awaken Lethargic
 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 breastmilk
substitute. If neither is available, give
sugar water. Give 30 – 50 ml of milk or
sugar water before departure.
 TREAT THE CHILD: 

To Prevent Low Blood Sugar
To make Sugar Water:
4tsp + 200mL H2O

•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 sugar water by nasogastric tube
before the child is referred to the hospital.
 TREAT THE CHILD: 

Paracetamol for High Fever
Paracetamol lowers a fever and reduces pain

PARACETAMOL
Tablet Syrup
Age or Weight
(500mg) (120mg/5ml)

2 months up to 3 years
1/4 5ml (1 tsp)
(4 - <14kg)
~125mg

3 years up to 5
1/2 10 ml (2 tsp)
years (14 – 19 kg)
~250mg

If the child has fever, give a dose or paracetamol in the health center. Give the mother
enough paracetamol for 1 day.

 No Malaria Risk
• Any general VERY SEVERE •Give first dose of appropriate antibiotics.
danger sign or FEBRILE •Treat the child to prevent low blood sugar.
• Stiff Neck DISEASE •Give one dose of Paracetamol in health
center for high fever (38.5C or above.)
•Refer URGENTLY to a hospital.

• No sign of FEVER: •Give one dose of Paracetamol in health

very severe NO MALARIA center for high fever (38.5C or above.)
febrile disease •Advise mother when to return immediately.
•Follow up in 2 days if fever persists.
•If the fever is present every day for more
than 7 days, refer for assessment.
 Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

Severe
Complicated
Measles

If the child has

measles now or Classify Measles with Eye
within the last FEVER or Mouth
three Complications

months:

Measles

If dengue Risk, classify page 77 of the module Assess

and Classify the Sick Child Age 2 months up to 5 years
Refer once again to the chart on FEVER. If the child has fever and measles now
or within the last three months classify child both for fever and measles. First
you classify the fever. Next you classify measles. If the child has no signs
suggesting measles, or has not had measles within the last 3 months, do not
classify measles.

Children with measles may have other serious complications of measles. These
include stridor in a calm child, severe pneumonia, severe dehydration, or severe
malnutrition. Some complications are due to bacterial infections. Others are
due to the measles virus, which causes damage to the respiratory and intestinal
tracts. Vitamin A deficiency contributes to some of the complications such as
corneal ulcer. Any Vitamin A deficiency is made worse by the measles
infection. Measles complications can lead to severe disease and death.

There are three possible classifications for measles: SEVERE COMPLICATED

MEASLES, MEASLES WITH EYE OR MOUTH COMPLICATIONS and
MEASLES.

113
Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

If the child has •Look for mouth

ulcers: are they If measles
measles now
deep and extensive now
or within the last
•Look for pus or within
three months:
draining from the last three
eye months,
•Look for clouding classify
of the cornea
 Measles
• Fever and generalized rash are the main signs of
measles.
• Highly infectious.
• Maternal antibody protects young infants against
measles for about 6 months. Then the protection
gradually disappears. Most cases occur in children
between 6 months and 2 years of age.
• Over crowding and poor housing increases the risk of
developing measles.
• Caused by a virus that infects the layers of cells that line
the lung, gut, eye, mouth and throat. The measles virus
damages the immune system for many weeks after the
onset of measles. This leaves the child at risk for other
infections.
 Measles
• Complications of measles occur in about 30% of
all cases
– diarrhea (including dysentery and persistent
diarrhea)
– pneumonia and stridor
– mouth ulcers
– ear infection
– severe eye infection (which may lead to corneal
ulceration and blindness)
• Encephalitis occurs in about 1/1000 cases. (look
for danger signs such as convulsions, abnormally
sleepy or difficult to awaken)
 Classify MEASLES Protects the mucosa,
All children should receive vitamin A immunomodulator and shortens cours
•Clouding of the SEVERE •Give Vitamin A
cornea COMPLICATED •Give first dose of an appropriate
•Deep extensive MEASLES antibiotics
mouth ulcers •If clouding of the cornea or pus
draining from the eye, apply
Tetracycline eye ointment
•Refer URGENTLY to the hospital

•Pus draining from MEASLES WITH EYE •Give Vitamin A

the eye OR MOUTH •Give first dose of an appropriate
•Mouth ulcers COMPLICATIONS antibiotics
•If pus draining from the eye, apply
Tetracycline eye ointment
•If mouth ulcers, teach the mother to
treat with gentian violet
•Follow up in two days

•Measles now or MEASLES •Give Vitamin A

within the last 3
months
Children with Measles
Koplik spots are small irregular, bright red spots with a white spot in the
center. These are inside the cheek during the early stages of the
measles infection
Koplik’s spots
 TREAT THE CHILD: 

Give Vitamin A
TREATMENT
• Give one dose of Vitamin A in the Health Center
SUPPLEMENTATION
• Give one dose of Vitamin A in the Health Center if:
– Child is 6 months of age or older
– Child has not received a dose of Vitamin A in the past 6 months

Vitamin A is given to a child with the following classifications:

1) SEVERE PNEUMONIA

2) VERY SEVERE DISEASE

3) MEASLES

4) SEVERE PERSISTENT DIARRHEA

5) PERSISTENT DIARRHEA

6)VERY LOW WEIGHT

7)SEVERE MALNUTRITION

Vitamin A helps resist the measles virus infection in the eye as well as in the layer of cells that line the lung, gut, mouth and throat. It may also help the
immune system to prevent other infections. Corneal clouding, a sign of Vitamin A deficiency, can progress to blindness if Vitamin A is not given. As

soon as the first dose is given refer the child urgently to the hospital.

For Treatment: A single dose of Vitamin A should be given to the child in the health center.

For Supplementation: Give 1 dose in the health center if the child is 6 months or older and the child has not received a dose of Vitamin A in the past 6
months.
 TREAT THE CHILD: 

Give Vitamin A

Vitamin A Capsule
AGE
100,000 IU 200,000 IU
2 – 6 months 50,000 IU
100,000
6 – 12 months 1 cap 1/2 cap
200,000
1 – 5 years 2 caps 1 cap

• 200,000 IU = 6 drops
• 100,000 IU = 3 drops
 Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)

1. Malaria
2. Measles

Severe DHF

3. Decide Dengue Risk:

Yes or No
Classify Fever; DHF
FEVER Unlikely
If Dengue Risk:

Torniquet Test 1.3gp

Torniquet Test 2.3gp
A child has the main symptom fever if: the child has a history of fever, or the
child feels hot or the child has an axillary temperature of 37.5° C or above.

Decide the malaria risk by asking if the child lives in a malarious area or has
been in a malaria risk area in the previous 3 weeks. If there is a malaria risk,
take a blood smear.

Then determine if the child has had fever, history of measles, stiff neck, runny
nose, signs suggesting measles and measles complications.

Then for all children with fever: decide the dengue fever risk and if there is
dengue risk assess for signs suggesting dengue hemorrahagic fever.

123
 Does the child have fever?

(by history, or feels hot or temperature 37.5C and above)
Decide Dengue Risk: Yes or No
If Dengue Risk:
Then Ask:
• Has the child had any
bleeding from the nose or
gums or in the vomitus or
stools?
• Has the child had black
vomitus or stools?
• Has the child had abdominal
pain?
• Has the child been vomiting?
Look and Feel:
• Look for bleeding from nose or
gums.
• Look for skin petechiae
• Feel for cold clammy
extremities.
If none of the above ASK or LOOK
and FEEL signs are present and
the
child is 6 months or older and fever
present for more than 3 days.
Perform Torniquet Test.
 Tourniquet Test
• Inflate blood pressure
cuff to a point midway
between systolic and
diastolic pressure for
5 minutes
• Positive test: 20 or
more petechiae per 1
inch² (6.25 cm²)
 Classify DENGUE HEMORRHAGIC
FEVER
•bleeding from the nose or
gums
•Bleeding in the vomitus or
stools
•Skin petechiae
•Cold clammy extremities
•Capillary refill more than 3
seconds
•abdominal pain or
•Vomiting or
•Positive torniquet test
•No signs of severe dengue
hemorrhagic fever
SEVERE DENGUE •If skin petechiae or abdominal pain or
HEMORRHAGIC vomiting or positive tourniquet test are
FEVER the only positive signs, give ORS
•If any other signs of bleeding are
present, give fluids rapidly as in Plan C
•Treat the child to prevent low blood
sugar
•Refer all children URGENTLY to the
hospital
•DO NOT GIVE ASPIRIN
FEVER; DENGUE •Advise mother when to return
HEMORRHAIC immediately
FEVER UNLIKELY •Follow up in 2 days if fever persists or
child shows signs of bleeding.
•DO NOT GIVE ASPIRIN
A child with fever when there is a risk of dengue should first be classified for malaria and measles.
Then you should classify for dengue hemorrhagic fever. If there is no risk of dengue you should not
classify for dengue.

In deciding if there is a dengue risk ask the following questions:

Has the child had any bleeding from the nose or gums, in the vomitus or in the stools since the
present illness started?

Has the child had black vomitus in this illness?

Has the child had black stools? (be cautious with this question if the child has taken chocolates or
ferrous sulfate preparations)

Has the child abdominal pain?

Has the child been vomiting?

Look for signs of bleeding and shock: bleeding manifestations, skin petechiae, signs suggesting
shock (cold clammy extremities, slow capillary refill and positive tourniquet test)

There are 2 possible classifications for dengue hemorrhagic fever: SEVERE DENGUE
HEMORRHAGIC FEVER and FEVER:DENGUE HEMORRHAGIC FEVER UNLIKELY

Classify the child as SEVERE DENGUE HEMORRHAGIC FEVER if a child has any of the following
signs: bleeding from the nose or gums or in the vomitus or stools, or black stools or vomitus, or skin
petechiae or shock (cold clammy extremities with or without slow capillary refill) or abdominal pain or
vomiting or a positive tourniquet test.

Classify the child as FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY if the child has none of the
signs needed for a classification of dengue.

127
 Dengue Hemorrhagic Fever
A child with dengue hemorrhagic fever or
dengue shock syndrome may present as
severely hypotensive with disseminated
intravascular coagulation (DIC).

Crystalloid fluid resuscitation and standard

DIC treatment are critical to the child's
survival.
Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension
usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well
beyond a normal duration of 2 seconds.

 Ear Problem
This is the last of the 4 main symptoms. A child with an ear problem may have an ear
infection. When a child has an ear infection, pus collects behind the eardrum and
causes pain and often fever. If the infection is not treated, the eardrum may perforate.
The pus discharges and the child feels less pain. The fever and other symptoms may
stop, but the child suffers from poor hearing because the eardrum has a hole in it.
Usually the eardrum heals by itself. At other times the discharge continues, the eardrum
does not heal, and the child becomes deaf in that ear.

Sometimes the infection can spread from the ear to the bone behind the ear (mastoids)
causing mastoiditis. Infection can also spread from the ear to the brain causing
meningitis. These are severe diseases. They need urgent attention and referral.

Ear infections rarely cause death. However, they cause many days of illness in children.
Ear infections are the main causes of deafness in developing countries and deafness
causes learning problems in school.

 Assess EAR PROBLEM

Then Ask: Does the child have an ear problem?
If YES, ASK:
• Is there ear pain?
• Is there ear discharge? If yes, for how long?
LOOK and FEEL:
• Look for pus draining from the ear.
• Feel for tender swelling behind the ear.
Ask about ear problem in ALL sick children.
 Classify EAR PROBLEM
•Tender swelling behind the MASTOIDITIS •Give the first dose of an appropriate
ear antibiotics
•Give first dose of Paracetamol for pain
•Refer URGENTLY to hospital

•Pus is seen draining from ACUTE EAR •Give an antibiotic for 5 days.
the ear and discharge is INFECTION (Amoxicillin)*
reported for less than 14 •Give Paracetamol for pain.
days, or •Dry the ear by wicking.
•Ear pain •Follow up in 5 days.

•Pus is seen draining from CHRONIC EAR •topical quinolone ear drops for at least
the ear and discharge is INFECTION two weeks
reported for 14 days or •Dry the ear by wicking.
more.
•Follow up in 5 days.

•No ear pain and no pus is NO EAR INFECTION •No additional treatment.
seen draining from the ear.

*Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high.
Rationale for using quinolone eardrops

• Review of systemic versus topical antibiotics

included 8 trials (474 participants) .
• Moderate quality evidence for higher rates of
treatment failure with systemic antibiotics
compared to topical quinolone
• Malawi study (2005) – compared hearing
thresholds for children treated with boric acid
compared with ciprofloxacin (quinolone ) and
showed a difference in mean improvement of 2.17
db at two weeks and 3.43 dbs at 4 weeks in favor
of ciprofloxacin
Malnutrition and Anemia
 Malnutrition
• Pathological state secondary to relative
or absolute deficiency or excess of one
or more essential nutrients
• It can also develop in children with diet
lacking in the recommended amounts of
essential vitamins and minerals( iron)
Nutritional Strategy for Screening and Triage for
Acute Malnutrition
 How to check for Anemia
(1) Look for palmar pallor

(2) Hold the child’s palm open by grasping it

gently form the side.

DO NOT STRETCH THE FINGERS

BACKWARDS
(This may cause pallor by blocking the
blood supply).
 How to check for anemia

(3) Compare the color of the child’s palm

with your own palm and with the palm of
other children.

Severe palmar pallor - very pale or white

Some palmar pallor - pale

Children with Anemia and
Malnutrition
 Conditions Predisposing to
Anemia

• infections

• hookworm and whipworm infections

• malaria
Counseling
 Good Communication
• Reassure mother that the child will
receive good care

• Success of home treatment depends on

how well you communicate with the
child’s mother

– needs to know how to give treatment

and understand the importance of
treatment
 Use Good Communication Skills

♥ASK and Listen to find out what the

child’s problems are and what the
mother is already doing
♥PRAISE the mother for what she has
done well
♥ADVISE her how to care for her child at
home
♥CHECK the mother’s understanding
 Advise mother how to care for her
child at home
When Teaching:
• Use words s/he understands
• Use teaching aids that are familiar
• Give feedback when s/he practices, praise
what was done well and make corrections
• Allow more practice, if needed
• Encourage the mother/caretaker to ask
questions and then answer all questions
 3 Basic Teaching Steps
1. Give information

1. Show an example

1. Let her practice

 Good Communication Skills
Check the mother’s understanding

♥ Avoid asking leading questions and

questions answerable with a simple yes
or no
♥ Good checking questions describe WHY,
HOW or WHEN she will give treatment
♥ Give the mother time to think and then
answer
♥ Praise the mother for correct answers
♥ If she needs it , give more information,
examples, or practice
Counsel the Mother
About Feeding
 How to breastfeed your baby
• Mother and baby should feel comfortable;

• Bring baby close to your body, level with

your breast. He should be lying chest to
chest, chin to breast. Tuck his lower arm
around you; and

• Encourage baby to open his mouth by

tickling his bottom lip with your nipple.
 


Correct Positioning
 How to breastfeed your baby
• When his mouth is wide open, guide
baby’s mouth to your breast. Your baby
must take in your nipple and some of the
darker part of your breast (the areola)
into his mouth
• As you breastfeed your baby, his mouth
should be wide and open and his bottom
lip curled back.
 How to breastfeed your baby
• Talk and try to have eye contact with
your baby while feeding.
• Communication is as vital as milk
itself
• If you need to remove baby’s mouth
from your breast, gently press down his
chin to break the suction.
Follow-up Care



 Immediate Follow up
Advise to return immediately if the child has any of these signs
Any sick child •Not able to drink or drink
or breastfeed
•Becomes sicker
•Develops a fever
If the child has no •Fast breathing
pneumonia: cough or cold, •Difficult breathing
also return if:
If the child has diarrhea, •Blood in stool
also return if: •Drinking poorly
 Follow-up visit table
If the child has: Return for follow-
up in:
Pneumonia 2 days
Dysentery
Malaria, if fever persists
Measles with eye or mouth complications

Persistent diarrhea 5 days

Acute ear infection
Chronic ear infection
Feeding problems
Any other illness, if not improving

Pallor 14 days

Very low weight for age 30 days

 Next well-child visit
• Advise when to return for the next
immunization according to the
immunization schedule
 Follow-up care
• If the child does not have a new problem,
use the IMCI follow-up instructions for
each specific problem:
– Assess the child according to the
instructions
– Use the information about the child’s
signs to select the appropriate
treatment
– Give the treatment
 Follow-up care

• See if the child is improving on the drug or

other treatment that was prescribed

• May need to try a second-line drug

Thank you!