IMCI

IMCI
INTEGRATED MANAGEMENT
OF CHILDHOOD ILLNESS
DISTANCE LEARNING COURSE
Module 1
General danger signs
for the sick child
WHO Library Cataloguing-in-Publication Data:
Integrated Management of Childhood Illness: distance learning course.
15 booklets
Contents: – Introduction, self-study modules – Module 1: general danger signs for the
sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing
– Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia
– Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child –
Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation:
introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance.
7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)
© World Health Organization 2014
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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD
n CONTENTS
Acknowledgements 4
1.1 Module overview 5
1.2 Checking all sick children for general
danger signs 8
1.3 Care when urgent referral is required 18
1.4 Using this module in your clinic 22
1.5 Review questions 23
1.6 Answer key 24
3
Acknowledgements
The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated
the development of these distance learning materials on the Integrated Management
of Childhood illness (IMCI), in an effort to increase access to essential health services
and meet demands of countries for materials to train primary health workers in
IMCI at scale. These materials are intended to serve as an additional tool to increase
coverage of trained health workers in countries to support the provision of basic
health services for children. The technical content of the modules are based on new
WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/
AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as
care for development.
Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent
Health (MCA) led the development of the materials with contributions to the content
from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg,
José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim,
Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well
as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African
Region of WHO.
A particular debt of gratitude is owed to the principal developer, Ms Megan Towle.
Megan helped in the design and content of the materials based on the field-test
experiences of the materials in South Africa. A special word of thanks is also due to
Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam
Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix
Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic
of Tanzania
WHO is grateful for the contribution of all external experts to develop the distance
learning approaches for IMCI including professor Kevin Forsyth, Professor David
Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open
University (UK), Aisha Yousafzai who reviewed the care for development section
of the well child care module, Amha Mekasha from Addis Ababa University and
Eva Kudlova, who have contributed to different sections of the distance learning
modules.
We acknowledge the help from Ms Sue Hobbs in the design of the materials.
Financial and other support to finish this work was obtained from both the MCA
and HIV departments of WHO.
4
1.1 MODULE OVERVIEW

During the first face-to-face meeting you learned that the IMCI process
always begins by checking all children for signs of serious illness.
In the sick child aged 2 months up to 5 years these are called general danger
signs. In this module you will learn about these signs
A sick child is 2 months up to 5 years of age.

This means the child has not had his 5th birthday.
Note that the signs of serious illness for the sick young infant (under 2 months of
age) are called general danger signs of serious disease. In Module 2 you will learn
more about these signs and care for the sick young infant.
MODULE LEARNING OBJECTIVES

After you study this module, you will know how to:
✔✔ Greet a caregiver and get important information for IMCI
✔✔ Recognize general danger signs in a sick child
✔✔ Provide urgent pre-referral treatment according to IMCI instructions
✔✔ Refer a child when danger signs are present
MODULE ORGANIZATION
This module is divided into the following sections:
✔✔ Greet the caregiver
✔✔ Check for general danger signs
✔✔ Care when urgent referral is required
WHERE DOES THIS MODULE FIT IN THE IMCI PROCESS?

This module will focus specifically on the first two steps in the IMCI process
– greeting and caregiver and checking for general danger signs. Look at the
chart below to identify these two steps; they are the first two boxes.
5
IMCI FOR THE SICK CHILD (2 months up to 5 years of age)
GREET THE CAREGIVER

ASK: child’s age (this chart is for sick child) ASK: initial or follow-up visit for problems?
ASK: what are the child’s problems? MEASURE: weight and temperature
CHECK FOR GENERAL DANGER SIGNS ASSESS MAIN SYMPTOMS

Even if present
•• Unable to drink or breastfeed •• Cough or difficult breathing •• Diarrhoea
•• Vomits everything •• Fever •• Ear problems
•• Convulsions •• Malnutrition and anaemia •• HIV status
•• Lethargic or unconscious •• Check immunizations •• Others
All danger
signs require
CLASSIFY
urgent referral
URGENT TREAT IN TREAT AT

REFERRAL CLINIC HOME
(RED) (YELLOW) (GREEN)
URGENT REFERRAL REQUIRED REFERRAL NOT REQUIRED REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral •• IDENTIFY TREATMENT •• IDENTIFY TREATMENT
treatment •• TREAT •• COUNSEL caretaker on
•• URGENTLY REFER •• COUNSEL caretaker home treatment
•• FOLLOW-UP CARE •• FOLLOW-UP CARE
WHAT SECTION OF THE IMCI RECORDING FORM IS USED

DURING THIS MODULE?
Review your IMCI recording form for the sick infant. The top portions of this
recording form are relevant to this module:
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Age: Weight (kg): Temperature (°C):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
For how long? ___ Days Count the breaths in one minute
___ breaths per minute. Fast breathing?
Look for chest indrawing
Look and listen for stridor
Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child:
Is there blood in the stool? 6
Lethargic or unconscious?
Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
BEFORE YOU BEGIN

What do you know now about general danger signs?
Before you begin studying this module, quickly practice your knowledge with the
questions below. Do not look up the answers. This is for your own exercise.
After you finish the module, you will answer the same questions. This will
demonstrate to you what you have learned during the course of the module!
Fill in the blanks:
1. If a child arrives at your clinic with a sign of serious illness, they should be
immediately referred. What are these signs?
a.
b.
c.
d.
Circle one answer for each question:
2. When is a child lethargic?
a. The child will not wake, even after shaking
b. The child is sleeping more often than usual, but will wake up if you set them
down to walk
c. The child is drowsy and will not follow movement or noise in the room
3. When is a child unconscious?
a. The child will not wake, even after shaking. However, his eyes might be open.
b. The child is drowsy and will not follow movement or noise in the room
c. The child is sleeping very deeply
4. If you identify a child with serious illness that requires referral, your course of
action is:
a. Stop your assessment of the child, and tell the caregiver they must hurry to
the hospital
b. Provide urgent treatments, prepare the caregiver for travel to the hospital,
and prepare supplies and a referral note
c. Keep the child at your clinic to monitor them and see if they will improve
during the course of the day, and then refer only when necessary
5. Why do some children require urgent referral?
a. The parents do not want to receive care in the clinic
b. It is quickest if the child receives important care at a different facility
c. They show signs of serious illness that require advanced care that is usually
available at a referral facility, like a hospital.
7
1.2 CHECKING ALL SICK CHILDREN FOR

GENERAL DANGER SIGNS
You will begin this module with a case study. This scene should be similar to
situations that you see in your clinic. After you read the case study, you will learn
how to: (a) greet the caregiver and get important information about the child, and
(b) check for general danger signs.
n OPENING CASE STUDY – LEBO

Lebo’s grandmother carries him into the clinic. Lebo does not look well. She has walked for one hour to the
clinic. She tells you that she is also taking care of 4 other grandchildren. Lebo is her youngest grandchild and
she is very worried about him. She says he is acting very unwell and has had a cough for 7 days.
The grandmother tells you as she sits down that Lebo’s mother died 2 months ago. She says she does not
know what caused the mother to die. Lebo’s father works away and does not come home, only once every
year or so. The grandmother is very worried about Lebo and very tired from her walking.
She tells you this is the first time she is bringing Lebo in to the clinic. You ask her how old Lebo is. She says he
is 19 months old. You ask Lebo’s grandmother her name. She tells you that her name is Nthabeleng.
WHAT IS THE FIRST THING YOU DO WHEN NTHABELENG

COMES TO THE CLINIC?
The first step in the IMCI process is to greet the caregiver and ask about the child.
Greeting the caregiver has two purposes.
First, greeting makes a caregiver feel welcome in the clinic. Greeting and
welcoming a caregiver is an important first step in building trust. It begins good
and caring communication.
Second, it helps you to gather important information about why the child is
coming to the clinic.
WHY IS GOOD COMMUNICATION WITH A CAREGIVER IMPORTANT?

Caregivers can be very stressed and emotional when a child is ill. It is important
for health workers to communicate concern and care for the child’s health, and the
family’s situation. Good communication helps to reassure the caregiver that her
child will receive good care.
When you treat the child’s illness later in the visit, you will need to teach and advise
the caregiver about caring for her sick child at home. Good communication and trust
is essential here. It is important to have good communication with the caregiver
from the beginning of the visit.
8
WHAT ARE GOOD COMMUNICATION SKILLS?

Good communication skills involve the following:
✔✔ LISTEN – Listen carefully to what the caregiver tells you. This shows you are
taking her concerns seriously.
✔✔ SIMPLIFY WORDS – Use words the caregiver understands. If she does not
understand what you ask her, she cannot give the information you need to assess
and classify the child correctly.
✔✔ GIVE HER TIME – Give the caregiver time to answer the questions. She might
need time to decide if a sign you are asking about is present.
✔✔ BE CLEAR – Ask additional questions when the caregiver is not sure about her
answer. If she is not sure that a certain symptom or sign is present, ask additional
questions. Help her make her answers clearer.
✔✔ PRAISE – Praise the caregiver for what she is doing right. This will reinforce
good practices.
WHAT IS THE IMPORTANT INFORMATION YOU GATHER

DURING A GREETING?
When you greet a caregiver you begin to ask important information about the child.
This will help you in your assessment.
Age
The child’s age determines which IMCI charts to use – the sick child or the young
infant.
Child’s problem
Another important piece of information is why the caregiver is bringing the child
to the clinic. By asking the caregiver about the problem, you can make note of the
symptoms or health problems that are worrying them. If necessary, you can ask
further detail. For example, you might ask how long the symptom has been present,
or if it has been getting worse.
You can also ask the caregiver how she has been addressing the health problem
thus far. This will give you background about previous care given in the home,
community, or other facilities.
Weight and temperature

Lastly, you will determine the child’s weight and temperature. Check if this is already
recorded on the child’s card. If not, weigh the child and measure his temperature
later when you assess and classify the child’s main symptoms. Do not undress or
disturb the child now.
Initial or follow up visit

You also want to know if this is the first visit for this problem, or if this is a follow-up
visit. These visits are different, so this is another important piece of information.
9
ASK: first time coming to the clinic for this problem?
YES NO
INITIAL VISIT FOLLOW-UP VISIT

ASSESS and CLASSIFY according to IMCI Give follow-up care according to IMCI
This is an initial visit if it is the child’s first for this episode of illness.
This is a follow-up visit if the child was seen a few days ago for the same problem.
You will learn more about what to do for follow-up visits in the later modules.
Watch “Introduction” on the IMCI DVD (disc 1)

This video will review the important steps of the IMCI greeting.
SELF-ASSESSMENT EXERCISE A
Complete this exercise, and try not to look back at the material. Remember that
you can check your answers to all of the self-assessment exercises at the end of
the module.
1. What charts will you use for this child? Check your answer.
Sick child Sick young infant

Sam is 6 weeks old
Mari is 2 months old
Jera is 4 years, 10 months
Thabo is 7 weeks old
Paulo is 3 years old

2. List the important pieces of information you gather during a greeting:
a.
b.
c.
d.
e.
f.
10
n LET US RETURN TO THE CASE OF LEBO

Which charts will you use for Lebo? If child is 2 MONTHS up to 5 YEARS
Nthabeleng said that Lebo is 19 months old, so you will
use charts for the sick child.
What is Lebo’s problem? Use the charts:
Nthabeleng tells you that Lebo has had a cough for 7 •• ASSESS & CLASSIFY SICK CHILD
days. She also says that he has not been eating well. •• TREAT THE CHILD
Nthabeleng is very worried about this. She says that in
the past two days, he cannot take anything at all and she says he is very weak. This is concerning to you.
Is Lebo coming for an initial or follow-up visit?

Nthabeleng told you that this is her first time bringing him to the clinic for this issue. This is an initial visit.
Lebo’s temperature and weight were recorded when he came into the clinic, he weighs 10 kg and his
temperature is 37 Celsius.
How will you fill out the top of Lebo’s recording form?

Name: Lebo Age: 19 mo Weight (kg): 10 kg 37 °C
Temperature (°C):
Ask: What are the child's problems? Cough, not feeding well (not eating for last 2 days) Initial Visit? X Follow-up Visit?
Danger sign when
AFTER GREETING THE CAREGIVER, HOW DO YOU BEGIN selecting
classifications
ASSESSING
DOES THE THE OR
CHILD HAVE COUGH CHILD?
DIFFICULT BREATHING? Yes __ No __
The first thing you check every sick child for is general danger signs. These signs
are critically important. If Lebo shows any one of these signs, he is in danger. He
needs urgent pre-referral treatment and immediate referral to the hospital.
Is there blood in the stool? Lethargic or unconscious?
For ALL sick children – askOffer
the the child fluid. Is the child:
caregiver about the child’s problems,
then
CHECK EVERY SICK CHILD FOR GENERAL
Drinking eagerly, thirsty? DANGER SIGNS
Very slowsly (longer then 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __
Decide malaria risk: High ___ NO
Low signs present
___ No___ Look or feel for stiff neck YES, one or more signs present
For how long? ___ Days Look for runny nose
If more than 7 days, has fever been present every Look for signs of MEASLES:
day? Generalized rash and
Has child had measels within the last 3 months? One of these: cough, runny Child requires
nose, or red eyes urgent referral.
Look for any other cause of fever.
Do malaria test if NO general danger sign Continue assessment quickly so
High risk: all fever cases
Low risk: if NO obvious cause of fever referral is not delayed.
Test POSITIVE? P. falciparum P. vivaxNEGATIVE?
If the child has measles now or within the Look for mouth ulcers.
last 3 months: If yes, are they deep and extensive?
CONTINUE ASSESSMENT: Look for
assess for pus draining
main from the eye.(cough
symptoms or difficult breathing,
Look for clouding of the cornea.
diarrhoea, fever,
DOES THE CHILD HAVE AN EAR PROBLEM? ear problems), check for malnutrition & anaemia, Yes __ No __
Is there ear pain? check immunization status,
Look HIV status,
for pus draining from theand
ear other problems
Is there ear discharge? Feel for tender swelling behind the ear
If Yes, for how long? ___ Days
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
AND ANAEMIA Determine WFH/L _____ Z score.
For children 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
If child has MUAC less than 115 mm or

11
Severe palmar pallor? Some palmar pallor?
Is there any medical complication?
WFH/L less than -3 Z scores or oedema of General danger sign?
Any severe classification?
both feet: Pneumonia with chest indrawing?
For a child 6 months or older offer RUTF to eat. Is the child:
Not able to finish or able to finish?
For a child less than 6 months is there a breastfeeding problem?
WHAT IS A GENERAL DANGER SIGN?

Assess and classify the sick child aged 2 m
A general danger sign is present if:
✔✔ Child is not able to drink or breastfeed

ASSESS
✔✔ Child vomitsAND CLASSIFY
everything
✔✔ Child has had more than one convulsion or prolonged convulsions,
or is convulsing ASSESS CLASSIFY
✔✔ Child is lethargic or unconscious
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE
HOW WILL YOU CHECK
Determine if this isFOR A GENERAL
an initial DANGER
or follow-up SIGN?
visit for this USE ALL BOXES THAT MATC
problem.
Assessing CHILD'S
for general danger signs involves four steps. You will ASK three SYMPTOMS AND PRO
questions
if follow-up
and LOOK to observe visit, use
the child’s the follow-up instructions
actions. TO CLASSIFY THE ILLNES
on TREAT THE CHILD chart.
Open your Chart Booklet to the chart for general danger signs. You will
if initial visit, assess the child as follows:
see these instructions:
CHECK FOR GENERAL DANGER SIGNS
Ask: Look: Any general danger sign P

Is the child able to drink or See if the child is lethargic V
breastfeed? or unconscious. D
Does the child vomit Is the child convulsing URGENT attention
everything? now?
Has the child had
convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatm
ASK – IS YOUR CHILD ABLE TO DRINK OR BREASTFEED?

A child has the sign not able to drink or breastfeed if the child is not able to suck or
swallow when offered a drink or breast milk.
When you ask the caregiver if the child is able to drink, make sure that
she understands the question. If she says that her child is not able to drink or
breastfeed, ask her to describe what happens when she offers the child something
to drink. For example, is the child able to take fluid into his mouth and swallow it?
If you are not sure about the caregiver’s answer, ask her to offer the child a drink
of clean water or breast milk. Look to see if the child is swallowing the water or Page 4 of 75
breast milk.
A child who is breastfed may have difficulty sucking when his nose is blocked. If the
child’s nose is blocked, clear it. If the child can breastfeed after the nose is cleared,
the child does not have the danger sign, “not able to drink or breastfeed.”
12
ASK – DOES YOUR CHILD VOMIT EVERYTHING?

A child who is not able to hold anything down at all has the sign “vomits everything”
– everything that goes down comes back up. A child who vomits everything will not
be able to hold down food, fluids, or oral drugs. A child who vomits several times
but can hold down some fluids does not have this general danger sign.
When you ask the question, use words that the caregiver understands. Give her
time to answer. If the caregiver is not sure if the child is vomiting everything, help
her to make her answer clear. For example, ask the caregiver how often the child
vomits. Also ask if each time the child swallows food or fluids, does the child vomit?
If you are not sure of the caregiver’s answers, ask her to offer the child a drink. See
if the child vomits.
ASK – HAS YOUR CHILD HAD CONVULSIONS?

Ask the caregiver if the child has had more than one convulsion, or prolonged
convulsions, during this current illness.
During a convulsion, the child’s arms and legs stiffen because the muscles are
contracting. The child may lose consciousness or not be able to respond to spoken
directions. Use words the caregiver understands. For example, the caregiver may
call convulsions “fits” or “spasms.”
LOOK – IS THE CHILD LETHARGIC OR UNCONSCIOUS?

A lethargic child is not awake and alert when she should be. The child is drowsy and
does not show interest in what is happening around her.
Often the lethargic child does not look at his caregiver or watch your face when
you talk, or will not respond if you clap or snap your fingers. The child may stare
blankly and appear not to notice what is going on around him.
An unconscious child cannot be wakened. He does not respond when he is touched,
shaken, or spoken to. Ask the caregiver if the child seems unusually sleepy or if she
cannot wake the child. Look to see if the child wakens when the caregiver talks or
shakes the child or when you clap your hands.
Watch “Demonstration: danger signs” (disc 1)

This video shows examples of children with general danger signs.
It is very useful to see these signs in the clinical setting.
WHAT DO YOU DO IF A CHILD SHOWS ONE OR MORE

GENERAL DANGER SIGNS?
A child with a general danger sign has a serious problem. Most children with a
general danger sign need urgent referral to hospital. The child might need lifesaving
treatment with injectable antibiotics, oxygen, or other treatments that may not be
available in your clinic.
13
If a child has a general danger sign, you must take

IMMEDIATE ACTION
1. Complete assessment immediately – the child has a severe problem. There
must be no delay in treatment.
2. Provide urgent pre-referral treatment
3. Refer child to hospital
DVD EXERCISE – GENERAL DANGER SIGNS

Watch “Assess general condition” (disc 1) to identify if the four children are
lethargic or unconscious. Write your answers and reasons below. The video will
review the correct answers with you.
Lethargic or unconscious? What are your reasons?
1
2
3
4
SELF-ASSESSMENT EXERCISE B (GENERAL DANGER SIGNS)

Check the boxes below if the sign is a general danger sign.
Is this a general danger sign?
The child is vomiting frequently. When you give milk, he holds it down.  YES  NO
The child will not take the mother’s breast.  YES  NO
The child lies in his caregiver’s arms. When you clap he follows you.  YES  NO
The child had convulsions last night and today. The child has been ill for 4 days.  YES  NO
The child’s eyes are open, but he is limp and will not respond to you.  YES  NO
The child will not move, but after efforts to wake him, he walks around.  YES  NO
SELF-ASSESSMENT EXERCISE C (SALINA)

Now you will practice on a case study. Read the following case study and complete
the recording form as instructed. Salina is 15 months old. She weighs 8.5 kg. Her
temperature is 38.5 °C. The health worker asked, “What are the child’s problems?”
The mother said, “Salina has been coughing for 4 days, and she is not eating well.”
This is Salina’s initial visit for this problem. The health worker checked Salina for
general danger signs. He asked, “Is Salina able to drink or breastfeed?” The mother
said, “No. Salina does not want to breastfeed.” The health worker gave Salina some
water. She was too weak to lift her head. She was not able to drink from a cup. Next
he asked the mother, “Is she vomiting?” The mother said, “No.” Then he asked, “Has
she had convulsions?” The mother said, “No.” The health worker looked to see if
Salina was lethargic or unconscious. When the health worker and the mother were
talking, Salina watched them and looked around the room.
14
Here is the top part of a Recording Form:

1. Write Salina’s name, age, weight and temperature in the spaces provided.
2. Write Salina’s problem on the line after the question “Ask-What are the child’s
problems?”
3. Tick (✓) whether this is the initial or follow-up visit for this problem.
4. Does Salina have a general danger sign? If yes, circle her general danger sign in
the box with the question, “Check for general danger signs.”
5. In the top row of the “Classify” column, tick either Yes or No if “Danger sign
present?”
Danger sign when
selecting
classifications
n Does Lebo show any general danger signs? Look and listen for wheezing
Youhow
For asklong?
if Lebo is able to drink or breastfeed,
___ Days and
Look Nthabeleng
at the childs generalsays, “no,Is not
condition. today, he is too tired.” You try
the child:
to give him some water from a cup but he is too weakand
Restless and does not swallow. You ask Nthabeleng if Lebo is
irritable?
vomiting, and she says “no.” You ask if LeboLook for sunken
is having eyes.
convulsions, and Nthabeleng says “no.”
You look at Lebo’s condition. He is not paying Drinking attention to you or Nthabeleng as you talk, and only stares
eagerly, thirsty?
ahead. You snap your fingers in front of his face, butskin
Pinch the heofdoes not look
the abdomen. Doesatit the fingers. You ask Nthabeleng to
go back:
bounce Lebo and speak to him, and when sheVery says slowsly (longer then 2 seconds)?
Slowly?
“Lebo! Lebo!” he does not look up at her.
Lebo is showing two general danger signs – he is unable to drink and lethargic. He needs to be
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
referred
For how long? immediately
___ Days to the hospital. Look for runny nose
Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes
Do malaria test if NO general danger sign
Name:
High risk:
Lebo
all fever cases Age: 19 mo Weight (kg): 10 kg 37 °C
Temperature (°C):

Low risk: if NO(Circle
obvious
Cough, not feeding well (not eating for last 2 days) Initial Visit? X
Ask: What are the child's problems? Follow-up Visit?
ASSESS all cause of fever
signs present) CLASSIFY
If the child hasTO
NOT ABLE measles
DRINK ORnow or within the
BREASTFEED Look for mouth
LETHARGIC ORulcers.
UNCONSCIOUS present?
last 3 months:
VOMITS EVERYTHING If yes, are they
CONVULSING NOW deep and extensive? Yes ___ No ___
CONVULSIONS Look for pus draining from the eye. Remember to use
Look for clouding of the cornea. Danger sign when
DOES THE CHILD HAVE AN EAR PROBLEM? selecting
Yes __ No __
Is there ear pain? Look for pus draining from the ear classifications
Is DOES
there ear discharge?
THE CHILD HAVE COUGH OR DIFFICULTFeel for tender swelling behind the ear
BREATHING? Yes __ No __
If Yes,For
forhow
howlong?
long?______ Days
Days Count the breaths in one minute
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema
___ breaths of bothFast
per minute. feet.
breathing?
Look for chest
Determine WFH/Lindrawing
_____ Z score.
AND ANAEMIA Look and listen for stridor
Lookfor
Look andpalmar
listen for wheezing
pallor.
DOES THE CHILD HAVE DIARRHOEA? Severe palmar pallor? Some palmar pallor? Yes __ No __
If childFor hashow long? ___ Days
MUAC less than 115 mm or Is Look
thereatany
themedical
childs general condition. Is the child:
complication?
Is there blood in the stool? Lethargicdanger
General or unconscious?
sign?
WFH/L less than -3 Z scores or oedema of Restless and irritable?
both feet: Look for sunken eyes.
Pneumonia with chest indrawing?
For a Not
child 6 months
able or drinking
to drink or older offer RUTF to eat. Is the child:
poorly?
Not able eagerly,
Drinking to finishthirsty?
or able to finish?
ForPinch
a child
the less
skin of 15
than
the6abdomen.
months isDoesthere a breastfeeding
it go back: problem?
CHECK FOR HIV INFECTION Very slowsly (longer then 2 seconds)?
Note mother's and/or child's HIV status Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Yes __ No __
Child'smalaria
Decide virological test: ___
risk: High NEGATIVE POSITIVE
Low ___ No___ NOTLook
DONE or feel for stiff neck
Child's
For howserological
long? ___test:
DaysNEGATIVE POSITIVE NOTLook
DONEfor runny nose
If mother is HIV-positive
If more and fever
than 7 days, has NO positive virological
been present Look for signs of MEASLES:
every test in child:
n What will you do for Lebo and Nthabeleng?

You tell Nthabeleng that you think Lebo needs further treatment at the hospital because he is unable to drink
and now acting very tired. You tell her that it is very important that he go to the hospital right away. You will
help arrange for her to get there.
She looks very scared and asks if Lebo will die like his mother. She says that this must be because of
something she has done. You affirm Nthabeleng and tell her that this is because Lebo is sick, not because of
her actions. You explain that the treatment in the hospital will be able to help. You reassure her that she was
a very good grandmother to bring Lebo to the clinic for care. She was very alert to notice that he was unwell.
You tell her that you will start some immediate treatment now so that he can be stable during the journey to
the hospital. Reassure her that you will help her, and that this treatment is very important.
You will then complete the assessment with Lebo and decide what pre-referral treatment is
necessary. Nthabeleng told you that Lebo has a cough. You have determined that he has two general
danger signs. You must complete his classification for the cough during your assessment to determine
necessary pre-referral treatment.
Now you will learn more about how to identify and administer pre-referral treatment.
HOW DOES THE ASSESSMENT CONTINUE AFTER CHECKING FOR

A child with any general danger sign needs URGENT attention. You should complete
the assessment and administer any pre-referral treatment immediately so that the
referral is not delayed.
For ALL sick children – ask the caregiver about the child’s problems, then
CHECK EVERY SICK CHILD FOR GENERAL DANGER SIGNS
NO signs present YES, one or more signs present
Child requires urgent referral.

Continue assessment quickly so
referral is not delayed.
CONTINUE ASSESSMENT: assess for main symptoms (cough or difficult breathing,

diarrhoea, fever, ear problems), check for malnutrition & anaemia,
check immunization status, HIV status, and other problems
You will learn much more about this assessment process in the following self-study
modules. For now, remember that you will follow the IMCI instructions through
this process. Your chart booklet walks you through these instructions.
16
First, assess for main symptoms

These are symptoms of the most common causes of illness and death in children
under five years. When a main symptom is present, a child could have a serious
illness. These symptoms include cough or difficult breathing (Module 3), diarrhoea
(Module 4), and fever (Module 5). A number of illnesses – including pneumonia,
malaria, or an infection – cause these symptoms.
Second, assess the child’s nutritional status

You have learned that undernutrition is a very common underlying cause of child
mortality. Even children with mild and moderate malnutrition have an increased
risk of death. When a caregiver brings her child to the clinic, it is usually because
the child has an acute illness.
A sick child can be malnourished, but you or the child’s family may not notice the
problem. The child may have no complaints that point to malnutrition or anaemia.
Module 6 discusses how to assess, classify, and treat malnutrition and anaemia.
Then check immunizations, HIV status, and other problems

Modules 7, 8, 9, and additional modules explain these assessments.
17
CLASSIFY IDENTIFY TREATMENT
Two of the following signs: Pink: If child has no other severe classification:
S Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
for DEHYDRATION Sunken eyes DEHYDRATION OR
1.3 CARE WHEN URGENT REFERRAL IS REQUIRED
Not able to drink or If child also has another severe
up
sifyvisit for this USE ALL BOXES
DIARRHOEA THAT MATCH THE
drinking poorly classification:
WHEN IS URGENT
Skin pinch goes back REFERRAL REQUIRED? Refer URGENTLY to hospital with
CHILD'S SYMPTOMS AND PROBLEMS mother giving frequent sips of ORS
very slowly.
p instructions TO Children
CLASSIFY withTHE general danger signs and/or
ILLNESS on the anywaycondition with a red
classification require urgent pre-referralAdvise the mother
treatment andtoreferral.
continue These
breastfeeding
follows: classifications indicate very serious illness. Review the CLASSIFY table for general
If child is 2 years or older and there is
danger signs below. This is a red classification.
cholera You will area,
in your alsogive
see antibiotic
the identified
for
cholera
treatments in the right-side TREAT column.
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for
Restless, irritable SOME some dehydration (Plan B)
Sunken eyes DEHYDRATION If child also has a severe classification:
Any general
Drinks danger
eagerly, sign
thirsty Pink: GiveRefer URGENTLY
diazepam to hospital
if convulsing nowwith
Skin pinch goes back VERY SEVERE mother
Quickly giving the
complete frequent sips of ORS
assessment
slowly. DISEASE Giveonany
thepre-referal
way treatment immediately
URGENT attention
Advise
Treat the mother
to prevent to continue
low blood sugar
Keepbreastfeeding
the child warm
AdviseURGENTLY.
Refer mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat
tention; complete the assessment and any
as some pre-referral treatment immediately so referral is not delayed.
or severe NO diarrhoea at home (Plan A)
Itdehydration.
is important to remember that once you have
DEHYDRATION
identified a general danger sign,
Advise mother when to return immediately
you must conduct the IMCI assessment and determine
Follow-up in 5any
dayspre-referral
if not improvingtreatment
so that you do not delay the referral.
Dehydration present. Pink: Treat dehydration before referral unless the
and if diarrhoea 14 SEVERE child has another severe classification
days or more
HOW DO YOU DETERMINE URGENT
PERSISTENT PRE-REFERRAL
Refer to hospital TREATMENT?
DIARRHOEA
Urgent pre-referral treatments are in bold print on the classification charts in your
chart booklet. Open your Yellow:
No dehydration. Advise the mother on feeding a child who has
classification tables: do you see the treatment identified
PERSISTENT PERSISTENT DIARRHOEA
in bold? For example, the DYSENTERY
DIARRHOEA classification belowand
Give multivitamins specifies ciprofloxacin
as a pre-referral treatment. minerals (including zinc) for 14 days
Follow-up in 5 days
Page 4 of 75
Blood in the stool. Yellow: Give ciprofloxacin for 3 days

and if blood in stool
DYSENTERY Follow-up in 2 days
These are specified because some treatments should not be given before referral.
Treatments that are not urgently needed will only delay referral. For example, do not
teach a caregiver how to treat a local infection or give immunizations before referral.
FLIP THROUGH YOUR CHART BOOKLET TO SEE THE

Page 6 of 75
PRE-REFERRAL TREATMENTS:
As you look through your charts, can you see the bold pre-referral treatments?
Look through each chart and identify the pre-referral treatments in bold. Here are
some examples of what you will see. You will learn more about the classifications
below in upcoming modules.
18
CLASSIFICATION PRE-REFERRAL TREATMENT IDENTIFIED

SEVERE PNEUMONIA or
Requires first dose of an appropriate antibiotic, treat for low blood sugar
VERY SEVERE DISEASE
PNEUMONIA First dose of oral amoxicillin
SEVERE or SOME DEHYDRATION Requires the caregiver to give frequent sips of ORS on the way to hospital, and continue
(with another severe classification) breastfeeding
Requires treatment for malaria, if necessary, and first doses of antibiotic and paracetamol
VERY SEVERE FEBRILE DISEASE
for high fever
MEASLES Requires treatment for malaria, if necessary, and first dose of paracetamol for high fever
SEVERE ACUTE MALNUTRITION Requires treatment for low blood sugar, keeping child warm, and first dose of antibiotic
Measles-related classifications Requires Vitamin A treatment, and treatment if complications
HOW DO YOU URGENTLY REFER THE CHILD?

There are four steps to referring a child or a sick young infant to hospital:
1. EXPLAIN to the caregiver the need for referral, and get her agreement to
take the child.
If you suspect that she does not want to take the child, find out why. Possible
reasons might be:
•• She thinks hospitals are places where people often die. She fears her child will
die there too.
•• She does not think that the hospital will help the child.
•• She cannot leave home and stay in the hospital to care for her child, if there is
no one to take care of her other children, or she is needed for farming, or she
may lose a job.
•• She does not have money to pay for transportation, hospital bills, medicines, or
food for herself during the hospital stay.
2. CALM the caregiver’s fears and help her resolve any problems.
For example: if the caregiver fears that her child will die at the hospital, reassure
her that the hospital has physicians, supplies, and equipment that can help cure
her child.
✔✔ Explain what will happen at the hospital and how that will help her child.
✔✔ If the caregiver needs help at home while she is at the hospital, ask questions
and make suggestions about who could help. For example, ask whether her
husband, sister or caregiver could help with the other children or with meals
while she is away.
✔✔ Discuss how she can travel to the hospital. Help arrange transportation if
necessary.
✔✔ You may not be able to help the caregiver solve her problems and be sure that she
goes to the hospital. However, it is important to do everything you can to help.
19
3. WRITE A REFERRAL NOTE for the caregiver to carry.

Tell her to give it to the health worker there. The note should include:
•• The name and age of the infant or child
•• The date and time of referral
•• Description of the child’s problems
•• The reason for referral (signs/symptoms for classification)
•• Treatment that you have given
•• Any other information that the hospital needs to know in order to care for the
child, such as earlier treatment of the illness or immunizations needed
•• Your name and the name of your clinic
4. GIVE SUPPLIES AND INSTRUCTIONS NEEDED to care for her child on the
way to the hospital:
If the hospital is far, give the caregiver additional doses of antibiotic and tell her
when to give them during the trip (according to dosage schedule on the TREAT
chart). If you think the caregiver will not actually go to the hospital, give her the full course
of antibiotics, and teach her how to give them.
✔✔ Tell the caregiver how to keep the young child warm during the trip.
✔✔ Advise the caregiver to continue breastfeeding.
✔✔ If the child has some or severe dehydration and can drink, give the caregiver
some ORS solution for the child to sip frequently on the way.
REMEMBER: any child with a general danger sign or

a serious classification requires urgent referral.
WHAT IF REFERRAL IS NOT POSSIBLE?

The best possible treatment for a child with a very severe illness is usually at a
hospital. Sometimes referral is not possible or not advisable. Distances to a hospital
might be too far; the hospital might not have adequate equipment or staff to care for
the child; transportation might not be available. Sometimes parents refuse to take
a child to a hospital, in spite of the health worker’s effort to explain the need for it.
If referral is not possible, you should do whatever you can to help the
family care for the child. If referral is not possible, continue with pre-
referral treatment until the child is able to leave for the hospital. If the
child improves on pre-referral treatment, initiate treatment in the clinic (e.g. the
YELLOW classification). Advise the caregiver on all available treatment.
To help reduce deaths in severely ill children who cannot be referred, you may need
to arrange to have the child stay in or near the clinic where he may be seen several
times a day. If not possible, arrange for visits at home. There is more information
about when a referral is not possible in the ANNEX.
20
When you can refer, remember to:

1. Explain to the mother
2. Calm fears
3. Write a referral note
4. Give supplies & instructions for journey
n How will you refer Lebo?

You have completed Lebo’s assessment. You give him the urgent pre-referral treatments indicated in bold
on the classification charts where you classified his other conditions.
You prepare the referral note for Nthabeleng and Lebo, give her the necessary instructions for treatment on
the way to the hospital.
She is nervous but you tell her that this treatment is urgent and should help Lebo, and that she is taking very
good care of him to be so alert and bring him to the clinic all herself. You tell her that she is being a very good
grandmother for taking him to the hospital for this treatment, and that it is very important for his health.
SELF-ASSESSMENT EXERCISE D
What will you do for the children who have general danger signs? Which
statements below are true, and which are false? If the statement is false, rewrite
it so that it is true.
1 Stop immediately and send the child to the hospital  TRUE  FALSE
Continue the assessment, determine pre-referral treatment, treat,
2  TRUE  FALSE
and refer.
Continue to assess the child and send child to hospital with referral
note about all of the treatments you identified.
If referral is not possible, there is nothing you can do. Send the child
home.
21
1.4 USING THIS MODULE IN YOUR CLINIC

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU HAVE
GAINED FROM THIS MODULE IN YOUR CLINIC?
Use your Chart Booklet and IMCI recording forms as you practice in the clinic. In
the coming days, you should focus on the clinical skills below.
Greeting
✔✔ Greet caregivers and use good communication skills to make them feel welcome
in the clinic.
✔✔ Ask for important information from the caregiver: child’s name, age, problems,
history, etc.
General danger signs

✔✔ Check all children for general danger signs
✔✔ Use your Chart Booklet when checking children to ensure that you ASK, LOOK,
and FEEL for all signs
✔✔ Record what you find on the IMCI recording form for sick children
✔✔ If the child has a general danger sign, classify as VERY SEVERE DISEASE
✔✔ If a child has a danger sign, practice preparing a caregiver for referral
Remember to use your logbook

n Now that you have completed the module, remember to complete your logbook for MODULE 1:
n Complete Module 1 exercises
n Record cases from your clinic as you check children for general danger signs
n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be
valuable notes to share with your study group and at the face-to-face meeting
22
1.5 REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT
Before you began studying this module, you practiced your knowledge. Now that
you have finished the module, answer the same questions and see how much you
have learned.
Fill in the blanks:
1. If a child arrives at your clinic with a sign of serious illness, they should be
immediately referred. What are these signs?
a.
b.
c.
d.
Circle one answer for each question:
2. When is a child lethargic?
a. The child will not wake, even after shaking
b. The child is sleeping more often than usual, but will wake up if you set them
down to walk
c. The child is drowsy and will not follow movement or noise in the room
3. When is a child unconscious?
a. The child will not wake, even after shaking. However, his eyes might be open.
b. The child is drowsy and will not follow movement or noise in the room
c. The child is sleeping very deeply
4. If you identify a child with serious illness that requires referral, your course of
action is:
a. Stop your assessment of the child, and tell the caregiver they must hurry to
the hospital
b. Provide urgent treatments, prepare the caregiver for travel to the hospital,
and prepare supplies and a referral note
c. Keep the child at your clinic to monitor them and see if they will improve
during the course of the day, and then refer only when necessary
5. Why do some children require urgent referral?
a. The parents do not want to receive care in the clinic
b. It is quickest if the child receives important care at a different facility
c. They show signs of serious illness that require advanced care that is usually
available at a referral facility, like a hospital.
Check your answers on the next page. How did you do? ............... complete out of 5.
Did you miss questions?
Turn back to the section recommended to re-read and practice the self-assessment exercises.
23
1.6 ANSWER KEY

NOTE: All video exercises discuss answers in the video.
REVIEW QUESTIONS
Did you miss the question? Return
QUESTION ANSWERS
to this section to read and practice:
1 Order of these 4 answers does not matter CHECKING ALL CHILDREN
1. Child is lethargic or unconscious
2. Child is vomiting everything
3. Child has had convulsions, or is
convulsing now
4. Child cannot breastfeed or drink
2 C CHECKING ALL CHILDREN
3 A CHECKING ALL CHILDREN
CARE WHEN URGENT REFERRAL IS
4 B
REQUIRED
CHECKING ALL CHILDREN, CARE WHEN
5 C
URGENT REFERRAL IS REQUIRED
EXERCISE A (GREETING & INTRODUCTION)

1. What charts will you use for this child?
Sick child Sick young infant
Sam is 6 weeks old ✘
Mari is 2 months old ✘
Jera is 4 years, 10 months ✘
Thabo is 7 weeks old ✘
Paulo is 3 years old ✘

2. Child’s name, child’s age, what the child’s problems are, if this is an initial or follow-
up visit, weight, and temperature. You can also get the caregiver’s name and
background information on the family or household situation. You can learn how the
caregiver has been trying to address the child’s problem up to now. This greeting is
important to build rapport and trust with good communication skills. This will help
you get more information from the caregiver.
EXERCISE B (GENERAL DANGER SIGNS)

Is this a general danger sign?
The child is vomiting frequently. When you give milk, he holds it down. ✘ NO
The child will not take the mother’s breast. ✘ YES
The child lies in his caregiver’s arms. When you clap he follows you. ✘ NO
The child had convulsions last night and today. The child has been ill for 4 days. ✘ YES
The child’s eyes are open, but he is limp and will not respond to you. ✘ YES
The child will not move, but after efforts to wake him, he walks around. ✘ NO
24
EXERCISE C (SALINA)

Name: Salina Age: 15 months Weight (kg): 8.5 kg 38.5 °C
Temperature (°C):
Ask: What are the child's problems? Cough for 4 days, not eating well Initial Visit? ✓ Follow-up Visit?
VOMITS EVERYTHING CONVULSING NOW ✓
Yes ___ No ___
Danger sign when
selecting
classifications
EXERCISE D Look for chest indrawing
1. FALSE. Actual true statement is: Continue the assessment quickly, identify all pre-
For how long? ___referral
Days treatments needed, treat,
Look and
at the refer urgently.
childs general condition. Is the child:
2. TRUE. Continue the assessment, determine
Restless pre-referral treatment, treat, and refer.
and irritable?
3. FALSE. Actual true statement Offer theis: You
child fluid.should deliver the necessary pre-referral
Is the child:
treatment before they leave yourDrinking
clinic eagerly,
for thethirsty?
hospital.
4. FALSE. Actual true statementVery is: You can
slowsly provide
(longer then 2 essential
seconds)? care (further discussed in
Slowly?
Annex), work with the family to encourage
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)them to go to the hospital, or bring the childYes __ No __
near
Decide malaria risk: High ___to the___clinic
Low No___to monitor treatment and
Look or feel for stiffprogress.
neck
Low risk: if NO obvious cause of fever
Look for pus draining from the eye.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
If child has MUAC less than 115 mm or Is there any medical complication?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on:
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ________________
Hep B1 Hep B2 Hep B3 (Date)
Hep B0
RTV-1 RTV-2 RTV-3
Pneumo-1 Pneumo-2 Pneumo-3 25
ISBN 978 92 4 150682 3
IMCI
Module 2
The sick young infant
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT
n CONTENTS
Acknowledgements 4
2.1 Module Overview 5
PART I. Assess, classify, and treat the sick young infant 9
2.2 Introduction to sick young infant 10
2.3 Assess a sick young infant for signs of serious disease 12
2.4 Assess & classify jaundice 22
2.5 Assess & classify diarrhoea in young infant 27
2.6 Treat the young infant requiring urgent referral 30
2.7 Treat the young infant not requiring urgent referral 35
2.8 Provide follow-up care for the sick young infant 39
PART II. Feeding problems and counselling the caregiver 42
2.9 Assess feeding problems or low weight 43
2.10 Check immunizations 54
2.11 Counsel the caregiver on feeding 56
2.12 Counsel the caregiver on infant care 65
2.15 Answer key 71
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
2. 1 MODULE OVERVIEW
As you learned in your first face-to-face meeting, young infants up to 2 months
of age have special characteristics that must be considered when classifying their
health conditions.

✔✔ Assess a young infant for very severe disease and local bacterial infection
✔✔ Recognize the clinical signs for assessing jaundice
✔✔ Check for a feeding problem or low weight
✔✔ Assess breastfeeding
✔✔ Classify a young infant for very severe disease and local bacterial infection using
IMCI charts
✔✔ Classify for jaundice and diarrhoea using IMCI charts
✔✔ Provide pre-referral treatment to a young infant with very severe disease
✔✔ Treat a young infant with oral or intramuscular antibiotics
✔✔ Teach correct positioning and attachment for breastfeeding
✔✔ Teach the mother how to express breast milk and feed the infant by a cup
✔✔ Teach the caregiver to treat local bacterial infections and thrush at home
✔✔ Give follow-up care for the sick young infant
MODULE ORGANIZATION: WHY IS THIS MODULE SPLIT INTO PARTS?

Module 2 is a very large module because there is a lot to learn about care for the sick young
infant. As such, the module is split into two parts. Each contains the following sections:
PART I
This part focuses on how to assess, classify, treat, and provide follow-up care for
the young infant’s common symptoms.
n SPECIAL CARE FOR YOUNG INFANTS
n IMCI TOOLS FOR THE SICK YOUNG INFANT
n ASSESS & CLASSIFY THE SICK YOUNG INFANT
n TREAT THE SICK YOUNG INFANT
n FOLLOW-UP
PART II
As infant feeding is such an important part of care, this part focuses on feeding
and how to counsel the caregiver.
n ASSESS & CLASSIFY FEEDING PROBLEMS OR LOW WEIGHT
n COUNSEL THE CAREGIVER ON INFANT FEEDING
n COUNSEL THE CAREGIVER ON INFANT CARE
5
WHAT DOES THE IMCI PROCESS LOOK LIKE FOR THE

SICK YOUNG INFANT?
You learned in your 1st face-to-face meeting that IMCI for the sick young infant
follows the same major steps of the IMCI process for the sick child. However, IMCI
for the sick young infant has some different signs and symptoms to assess.
Some treatments are also age-appropriate. A flow chart for using IMCI for the sick
young infant is below:
IMCI FOR THE SICK YOUNG INFANT (up to 2 months of age)
GREET THE CAREGIVER

ASK: child’s age (this chart is for sick young infant) ASK: initial or follow-up visit for problems?
ASK: what are the infant’s problems? MEASURE: weight and temperature
ASSESS MAIN SYMPTOMS

ASSESS FOR •• Jaundice
Even if present
GENERAL DANGER SIGNS •• Diarrhoea
•• HIV status or mother’s HIV status
for very severe disease
•• Feeding problem and growth
•• Check immunizations
•• Assess other problems and mother’s health
All danger
signs require
urgent referral CLASSIFY


WHAT JOB AIDS WILL YOU USE DURING THIS MODULE?

You have two aids for using IMCI with the sick young infant:
n IMCI CHART BOOKLET – YOUNG INFANT SECTION is an excellent reference
tool. It provides instructions for assessing, classifying, and treating the sick
young infant. It also includes instructions for counselling the caregiver and
providing follow-up care.
6
n RECORDING FORM FOR SICK YOUNG INFANT follows the charts for the
sick young infant. This form is below. It can also be found in your logbook.
WHAT RECORDING FORM IS USED FOR THIS MODULE?
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS

Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?
CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
Is the infant having difficulty in feeding? Count the breaths in one minute. ___ breaths per minute
Has the infant had convulsions? Repeat if elevated: ___ Fast breathing?
Look for sever chest indrawing.
Look and listen for grunting.
Look at the umbiculus. Is it red or draining pus?
Fever (temperature 38°C or above fells hot) or
low body temperature (below 35.5°C or feels cool)
Look for skin pustules. Are there many or severe pustules?
Movement only when stimulated or no movement even when
stimulated?
THEN CHECK FOR JAUNDICE
When did the jaundice appear first? Look for jaundice (yellow eyes or skin)
Look at the young infant's palms and soles. Are they yellow?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___
DIARRHOEA? move only when stimulated?
not move even when stimulated?
Is the infant restless and irritable?
Very slowly?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
If the infant has no indication to refer urgently to hospital Determine weight for age. Low ___ Not low ___
Is there any difficulty feeding? Yes ___ No ___ Look for ulcers or white patches in the mouth (thrush).
Is the infant breastfed? Yes ___ No ___
If yes, how many times in 24 hours? ___ times
Does the infant usually receive any other foods or
drinks? Yes ___ No ___
If yes, how often?
What do you use to feed the child?
Note mother's and/or child's HIV status:
If mother is HIV positive and and NO positive virological test in young infant:
Is the infant breastfeeding now?
Was the infant breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and infant on ARV prophylaxis?
ASSESS BREASTFEEDING
Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her
infant to the 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 ___
not well attached good attachment
Is the infant sucking effectively (that is, slow deep sucks, sometimes
pausing)?
not sucking sucking effectively
effectively
BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U immunization on:
OPV-0 OPV-1 OPV-2 vitamin A to ________________
mother (Date)
ASSESS OTHER PROBLEMS: Ask about mother's own health
7
BEFORE YOU BEGIN

What do you know now about managing sick young infants?
Before you begin studying this module, quickly practice your knowledge with the
questions below. Do not look up the answers. This is for your own exercise.
Circle one answer for each question.
1. Why do young infants require different care than sick children?
a. Young infants are much quicker to recover from illness because they are
young.
b. Young infants show signs of illness differently. They can also become ill and
die from an infection very quickly.
c. Young infants very rarely get sick.
2. Which of the following is important care for a young infant?
a. Keeping the infant loosely bundled so he can begin to move his arms and legs
b. Keeping the umbilical cord moist so that it falls off quickly
c. Keeping the infant warm through skin-to-skin care
3. What are the feeding recommendations for sick young infants?
a. Exclusive, on-demand breastfeeding for at least 6 months
b. Breastfeeding and additional sources of fluid, like water, to hydrate
c. Soft complementary foods as soon as the child is ready
4. What are signs that a young infant is seriously ill and needs urgent referral and
care?
a. Breathing more than 60 breaths per minute
b. Skin pustules
c. Some jaundice, where the eyes are yellow but not the palms or soles
5. A young infant presents at your clinic, and his caregiver says the infant has been
feeding well, but in the past 2 days is unable to breastfeed at all. What actions
will you take?
a. Counsel the caregiver on positioning and attachment so that the infant can
breastfeed better.
b. The infant is seriously ill if they are unable to feed. You must urgently refer.
c. Recommend that the caregiver give other safe fluids by cup.
8
PART I
Assess, classify,
and treat the sick
young infant
9
2.2 INTRODUCTION TO SICK YOUNG INFANT

WHY ARE YOUNG INFANTS SPECIAL?
Young infants differ from older infants and children in the ways they show signs
of infection:
n They become ill and die very quickly from serious A young infant is a child
bacterial infections. Severe infections are the most up to 2 months of age.
common serious illness during first 2 months of life.
If 2 months old or above,
n Special risk for low birth weight infants: Infants she or he is considered
under 2.5 kilograms at birth are low weight. Infections a sick child.
are particularly dangerous in low birth weight infants.
This means the infant had low weight at birth, due
either to poor growth in the womb or to prematurity (being born early).
n Infants often show only general signs when seriously ill, such as difficulty
in feeding, reduced movements, fever or low body temperature.
n Newborn infants are often sick from conditions related to labour and
delivery. Newborns with any of these conditions require immediate
attention. Some infants are premature, or born before 37 weeks of pregnancy.
They may have trouble in breathing due to immature lungs. These conditions
include birth asphyxia, birth trauma, preterm birth, and early-onset infections
such as sepsis from premature ruptured membranes.
IMPORTANT!
Young infants can become sick and die very quickly.
WHAT ARE YOUNG INFANTS’ SPECIAL CARE REQUIREMENTS?

Young infants have important care requirements to protect them from infection
during the first months of life. This care includes:
•• EXCLUSIVE, ON-DEMAND BREASTFEEDING, which provides young infants
with the nutrients and antibodies they require for healthy growth, development,
and immune function
•• KEEPING INFANTS WARM, particularly through methods like skin-to-skin
contact
•• MAINTAINING GOOD HYGIENE by washing hands every time before holding
an infant, and keeping the umbilical cord area clean, which is vulnerable to
infection
•• IMMUNIZING a young infant on schedule
•• SEEKING IMMEDIATE CARE IF THERE ARE SIGNS OF SEVERE DISEASE
As you have learned, the IMCI process (ASSESS, CLASSIFY, TREAT) is the same
for young infants and children. However, as infants have some special care
requirements, they are assessed for specific symptoms and signs.
10
IMPORTANT CARE FOR YOUNG INFANTS

n Exclusive breastfeeding
n Keep warm
n Keep umbilical cord clean
n Wash hands before holding
n Immunize on schedule
Complete this exercise, and try not to look back at the material. Remember that
you can check your answers to all of the self-assessment exercises at the end of
the module.
1. Are these statements true or false? If they are false, write out the correct
statement.
a. Young infants are up to 2 months of age TRUE FALSE
b. Young infants have a different section of charts because they have a separate
IMCI process that is entirely different from the process for the sick child.
TRUE FALSE
c. Severe infections are the most serious illness in the
first two months of life TRUE FALSE
d. Young infants and children are very similar in how
they show signs of illness. TRUE FALSE
e. Sami is 2 months old. He is considered a sick young infant. TRUE FALSE
2. You have learned that there is special care that is particularly important for
young infants. Tick (✔) the measures below that are important care for infants.
 Skin-to-skin contact (kangaroo care) to keep the infant warm
 Give water regularly to keep infant hydrated
 Seek care immediately if infant develops signs of serious illness
 Change gowns before holding young infant
 Exclusive, on-demand breastfeeding
 Give all immunizations at birth, and never again
 Give immunizations on schedule
 Wash hands before handling the young infant
 Rub the young infant with oils, lotion, or vasoline to keep skin moist
11
2.3 ASSESS A SICK YOUNG INFANT FOR SIGNS OF

SERIOUS DISEASE
n OPENING CASE – MIMI

A young caregiver, Biya, comes into your clinic on Tuesday morning with her small young infant, a little girl
named Mimi. Biya is very concerned because Mimi is her first child, and is very precious to the family. Mimi
was born 6 weeks ago.
Biya tells you that during the weekend she noticed Mimi was not taking the breast as often as she normally
did. She got worried and wanted to take Mimi to the nearby health centre on Monday. Biya herself had an
appointment scheduled for Tuesday for follow-up care on the pregnancy.
Biya’s husband and caregiver told her to wait and take Mimi on Tuesday to the schedule appointment so that
they do not have to pay for the transport twice. Biya is now very worried because she thinks Mimi is getting
worse with the feeding.
HOW WILL YOU GREET BIYA WHEN SHE ENTERS THE CLINIC?
Greeting the caregiver is an important first step in obtaining appropriate
information about the sick infant, and why they are coming to the clinic. You will
greet the caregiver and obtain the same information as you would with the sick child.
First, this greeting helps to create a welcoming environment, and build
trust with caregivers. You can review communication skills in INTRODUCTION
PART 2: Introduction to IMCI.
Second, it allows you to gather important information about the infant:
✔✔ ASK: what is the child’s name?
✔✔ ASK: how old is Mimi? This determines the charts to use.
✔✔ ASK: what is Mimi’s problem? Is this the first time you
are coming to the clinic for this problem?
✔✔ MEASURE: Mimi’s weight and temperature, which will
be used during the assessment.
Next, you will assess Mimi for signs of severe disease
or local infection. You will check every sick young infant
for these signs. This is similar to checking every sick
child for the general danger signs, which was discussed in
Module 1.
12
WHEN DO YOU CHECK EVERY SICK YOUNG INFANT FOR SIGNS OF

SEVERE DISEASE?
The first part of your assessment is checking for signs of severe illness. Every sick
young infant is checked for signs of very severe disease, especially a serious
infection.
For ALL sick young infants – ask the caregiver about the infant’s problems, then
ASSESS EVERY YOUNG INFANT FOR SIGNS OF SEVERE DISEASE
AND LOCAL INFECTION
NO signs present YES, one or more signs present
Young infant requires urgent referral.

Continue assessment quickly
so referral is not delayed.
CONTINUE ASSESSMENT: assess for jaundice, diarrhoea, check HIV status, check
feeding problems and low weight, check immunization status, and other problems
WHY DO YOU CHECK EVERY SICK YOUNG INFANT FOR

SIGNS OF SEVERE DISEASE?
Young infants can become sick and die very quickly from serious bacterial
infections such as pneumonia, sepsis, and meningitis. The signs of very severe
disease also identify young infants who have other serious conditions like severe
birth asphyxia and complications of preterm birth.
If you find a reason that a young infant needs urgent referral, you should
complete the assessment quickly and refer the infant to the hospital.
13

HOW WILL YOU ASSESS FOR SEVERE DISEASE AND
LOCAL INFECTION?

When you assess by looking for signs of severe disease, you will ask questions of

the caregiver, and
also make your own observations. These are detailed in your
ASSESS chart.

Review your ASSESS chart for very severe disease and local bacterial

infection. Itincludes the instructions below. It is important to assess the signs in
the order on
the chart. The young infant should be calm.

For the first two signs (fast breathing and severe lower chest indrawing):

the young infant must be calm, and may be asleep. If the infant is awake, observe
his or her movements.
To assess the next few signs, you will pick up the infant and then undress him,
look at the skin all over his body and measure his temperature. If the infant was
sleeping earlier, by this time he or she will probably be awake. Then you can see and
observe his or her movements.
ASK: IS YOUR BABY HAVING DIFFICULTY IN FEEDING?

Any difficulty that the caregiver mentions is important. A young infant who was
feeding well earlier but is not feeding well now may have a serious infection. A
newborn that has not been able to feed since birth may be premature or may have
complications such as birth asphyxia. These infants who are either not able to
feed or are not feeding well should be referred urgently to hospital.
The caregiver may also mention difficulties such as: her infant feeds too frequently
(or not frequently enough), she does not have enough milk, her nipples are sore,
or she has flat or inverted nipples. You will assess these difficulties later during
breastfeeding assessment.
14
ASK: HAS YOUR BABY HAD CONVULSIONS [FITS]?

Use words the caregiver understands. For example, the caregiver may know
convulsions as “fits” or “spasms”.
During a convulsion, the young infant’s arms and legs may become stiff. The infant
may stop breathing and become blue. Many times there may only be rhythmic
movements of a part of the body, such as rhythmic twitching of the mouth or
blinking of eyes. The young infant may lose consciousness.
LOOK: DOES THE SICK INFANT HAVE FAST BREATHING?

Count the breathing rate as you would in an older infant or young child. Young
infants usually breathe faster than older infants and young children. The breathing
rate of a healthy young infant is commonly more than 50 breaths per minute.
Therefore, 60 breaths per minute or more is the cut-off used to identify fast breathing
in a young infant.
If the first count is 60 breaths or more, repeat the count. This is important
because the breathing rate of a young infant is often irregular. The young infant
will occasionally stop breathing for a few seconds, followed by a period of faster
breathing. If the second count is also 60 breaths or more, the young infant has fast
breathing.
Fast breathing in a sick young infant is

60 or more breaths per minute
LOOK: DOES THE INFANT HAVE SEVERE CHEST INDRAWING?

The infant has chest indrawing if the lower chest wall (lower ribs) goes IN
when the infant breathes IN. Chest indrawing occurs when the infant needs to
make a greater effort than normal to breathe in.
In normal breathing, the whole chest wall (upper and lower) and the abdomen move
OUT when the infant breathes IN. When chest indrawing is present, the lower chest
wall goes IN when the infant breathes IN.
Only severe chest indrawing is a
serious sign in a young infant. Mild
chest indrawing is normal in a young
infant because the chest wall is soft.
Severe chest indrawing is very deep and
easy to see, and is a sign of pneumonia.
For chest indrawing to be present, it
must be visible and present all the time
you are observing the infant.
The child breathing in The child breathing in

WITHOUT chest indrawing WITH chest indrawing
15
MEASURE TEMPERATURE OR FEEL THE INFANT: FEVER OR LOW

BODY TEMPERATURE?
The thresholds for fever in the YOUNG INFANT chart are based on axillary
temperature. Axillary temperature is measured in the armpits. The thresholds
for rectal temperature are approximately 0.5 °C higher. If you do not have a
thermometer, feel the infant’s abdomen or armpit and determine if it feels hot or
unusually cool.
Fever is defined as 37.5 °C or above (axillary). Fever is uncommon in the first
two months of life. If a young infant has fever, this may mean the infant has very
severe disease. Fever may be the only sign of a serious bacterial infection.
Low body temperature is below 35.5 °C (axillary). Young infants can also
respond to infection by dropping their body temperature. This is called hypothermia.
What is FEVER = 37.5 °C or above

What is LOW BODY TEMPERATURE= below 35.5 °C
(axillary temperature)
LOOK AT THE UMBILICUS: IS IT RED OR DRAINING PUS?

The umbilical cord usually separates one to two weeks after birth. The wound heals
within 15 days. Redness of the end of the umbilicus, or pus draining from the
umbilicus, is a sign of umbilical infection. Recognizing and treating an infected
umbilicus early are essential to prevent sepsis.
LOOK FOR SKIN PUSTULES

Skin pustules are red spots or blisters that contain pus. Examine the skin on the
entire body. If you see pustules, is it just a few pustules or are there many? A severe
pustule is large or has redness extending beyond the pustule. Many or severe
pustules indicate a serious infection.
LOOK AT THE YOUNG INFANT’S MOVEMENTS

Young infants often sleep most of the time, and this is not a sign of illness. Observe
the infant’s movements while you do the assessment. If a young infant does not wake
up during the assessment, ask the caregiver to wake him. An awake young infant
will normally move his arms or legs or turn his head several times in a minute if
you watch him closely.
If the infant is awake but has no spontaneous movements, gently stimulate the
young infant. If the infant moves only when stimulated and then stops moving, or
does not move at all, it is a sign of severe disease. An infant who cannot be woken
up even after stimulation should also be considered to have this sign.
16
Watch “Demonstration: assessment of sign young infant” (disc 2)

This reviews all steps in assessing for serious disease or possible
bacterial infection.
SELF-ASSESSMENT EXERCISE B
Answer the questions below about assessing for signs of serious illness.
Remember that an answer key for all self-assessment exercises is at the end of
this module.
1. How many breaths per minute is fast breathing in an infant?
2. How do you decide if an infant has fast breathing?
3. How will you measure temperature in a young infant?
4. What temperature is a fever in a young infant?
5. What temperature is considered low body temperature?
6. Which of the following statements about signs of severe disease or bacterial

infection are true? Which are false? Circle your answer. If false, write the correct
statement.
a. Chest indrawing is identified when an infant is
breathing OUT. TRUE FALSE
b. A healthy umbilicus is often red, and sometimes drains pus. TRUE FALSE
c. Any difficulty with feeding in an important issue for
young infants.
TRUE FALSE
d. Only severe chest indrawing is a serious sign in infants,
as mild chest indrawing is normal in young infants. TRUE FALSE
17
n How do you assess Mimi?

Mimi weighs 3.1 kg, and when you ask, Biya tells you her birth weight was 3.5 kg. Mimi’s axillary temperature
is 34.7 degrees Celsius.
Biya tries several times to put Mimi on the breast but Mimi did not attach at all. Biya says that she has had no
convulsions. You count 45 breaths per minute, and because Mimi did not exceed 60 breaths per minute, you
do not need to repeat the count.
You observe Mimi’s breathing, her lower chest wall moves in quite severely when Mimi breathes in. She does
not have skin pustules. The umbilicus is not red or draining pus. When you move Mimi’s arm to stimulate her
movements, Mimi drops the arm when you release it.
n Does Mimi have any signs of serious illness?

You recognize four serious signs in Mimi.
1. First, she is having difficulty breastfeeding.
2. Second, she has a low body temperature. Her temperature of 34.7 degrees is less than 35.5 degrees
Celsius.
3. Third, you observe severe chest indrawing.
4. Fourth, you see that her movements are reduced.
n How will you fill OF

MANAGEMENT in Mimi’s recording
THE SICK form?INFANT AGED UP TO 2 MONTHS
YOUNG
Mimi
Name: Age: 6 weeks Weight (kg): 3.1 Temperature (°C):34.7
Not breastfeeding well
Ask: What are the infant's problems?:
ASSESS (Circle all signs present)
Initial Visit? X Follow-up Visit?
CLASSIFY

Is the infant having difficulty in feeding? 45
Count the breaths in one minute. ___ breaths per minute
stimulated?
You have recorded these signs on your form.Look
Youat will learn
the young now
infant's about
palms classifying
and soles. these signs and identifying
Are they yellow?
treatment.
Very slowly?
Slowly?
If yes, how often?
18
HOW WILL YOU CLASSIFY SIGNS OF SERIOUS ILLNESS IN A

SICK YOUNG INFANT?
Open you classification table for severe disease or local bacterial infection. You
will observe that there are three classifications for the signs of serious disease or
local infection:
1. VERY SEVERE DISEASE
2. LOCAL BACTERIAL INFECTION
L BACTERIAL INFECTION
3. SEVERE DISEASE OR LOCAL INFECTION UNLIKELY
Any one of the following Pink: Give first dose of intramuscular antibiotics
Classify ALL YOUNG signs VERY SEVERE Treat to prevent low blood sugar
INFANTS Not feeding well or DISEASE Refer URGENTLY to hospital **
Convulsions or Advise mother how to keep the infant
Fast breathing (60 breaths warm on the way to the hospital
per minute or more) or
Severe chest indrawing or
Fever (37.5°C* or above)
or
Low body temperature
(less than 35.5°C*) or
Movement only when
stimulated or no movement
at all.
Umbilicus red or draining Yellow: Give an appropriate oral antibiotic
pus LOCAL Teach the mother to treat local infections at home
Skin pustules BACTERIAL Advise mother to give home care for the young
INFECTION infant
Follow up in 2 days
None of the signs of very Green: Advise mother to give home care.
severe disease or local SEVERE DISEASE
bacterial infection OR LOCAL
INFECTION
UNLIKELY
Now you will read more about the three classifications and the treatments identified
for each.
What happens if you see signs from multiple classifications?

When you find signs from different boxes, you always classify with the more severe classification.
For example:
You assess signs from RED and YELLOW ➞ classify RED
You assess signs from YELLOW and GREEN ➞ classify YELLOW
REMEMBER! Colour-coded classifications tell where care to be given.

resholds for rectal temperature readings are approximately 0.5°C higher.
RED = refer urgently
f Childhood Illness, Management of the sick young infant module, Annex 2 "Where referral is not possible".
YELLOW = treat in clinic
GREEN = home treatment
Page 43 of 75
19
VERY SEVERE DISEASE (RED)

Remember that the presence of only one sign is enough to classify as very
severe disease. A young infant with severe signs may have a serious disease
and be at high risk of death. A young infant with any sign of very severe disease
needs urgent referral to hospital. Before referral, give a first dose of intramuscular
antibiotics.
The infant may have complications of preterm birth (very low birth weight or birth
asphyxia), or may have a serious infection. The serious infection may be pneumonia,
sepsis or meningitis. It is difficult to distinguish between these conditions in a
young infant. Fortunately, it is not necessary to make this distinction in order to
make initial management decisions.
What are your actions?

Treat to prevent low blood sugar by giving breast milk or sugar water if it is not
possible to give breast milk. If the young infant is not able to feed, give breast milk
by nasogastric tube. Malaria is unusual in infants of this age, so no treatment is
required for possible severe malaria.
Advising the caregiver to keep her sick young infant warm is very important.
Young infants have difficulty maintaining their body temperature. Low temperature
alone can kill young infants.
If one or more severe signs is present, classify as severe
LOCAL BACTERIAL INFECTION (YELLOW)

Young infants with this classification typically have an infected umbilicus or
a skin infection.

Treatment includes giving an appropriate oral antibiotic at home for 5 days. The
caregiver will treat the local infection at home and give home care. She should return
for follow-up in 2 days to be sure the infection is improving. Bacterial infections
can progress rapidly in young infants.
SEVERE DISEASE OR LOCAL INFECTION UNLIKELY (GREEN)

Young infants with this classification have none of the signs of very severe disease
and local bacterial infection.

Advise the caregiver to give homecare to the young infant.
20
n How will you classify Mimi?

You identified four serious signs when you assessed Mimi: difficulty feeding, low body temperature, severe
chest indrawing, and reduced movements.
Mimi shows at least one sign of serious disease. You will classify her as having very severe disease, the red
L INFECTION classification that requires urgent referral.
Any one of the following Pink: Give first dose of intramuscular antibiotics
YOUNG signs VERY SEVERE Treat to prevent low blood sugar
Not feeding well or DISEASE Refer URGENTLY to hospital **
Convulsions or Advise mother how to keep the infant
Fast breathing (60 breaths warm on the way to the hospital
per minute or more) or
Severe chest indrawing or
Fever (37.5°C* or above)
or
Low body temperature
(less than 35.5°C*) or
Movement only when
stimulated or no movement
at all.
Umbilicus red or draining Yellow: Give an appropriate oral antibiotic
pus LOCAL Teach the mother to treat local infections at home
INFECTION infant
Follow up in 2 days
None of the signs of very Green: Advise mother to give home care.
severe disease or local SEVERE DISEASE
bacterial infection OR LOCAL
INFECTION
UNLIKELY
You will record this classification

MANAGEMENT OF THE on her recording
SICK YOUNGform:
INFANT AGED UP TO 2 MONTHS
Mimi
Name: Age: 6 weeks Weight (kg): 3.1 Temperature (°C):34.7
Not breastfeeding well
Ask: What are the infant's problems?:
CLASSIFY

Has the infant had convulsions? Repeat if elevated: ___ Fast breathing? Very severe
disease
Look at the umbiculus. Is it red or draining pus? (red)
stimulated?
n Mimi has a severe classification:Look
whatat the do
youngyou
infant'sdo next?
palms and soles. Are they yellow?
You learned earlier that if you find a reason thatmove
DIARRHOEA? a young infant
only when needs urgent referral, you should complete
stimulated?
the assessment quickly and refer the infant toinfant
Is the therestless
hospital.
and irritable?
You will continue to assess and classify MimiPinch
for jaundice,
the skin of thediarrhoea, HIV
abdomen. Does it gostatus,
back: feeding problem or low
Very slowly?
weight, and immunization status. However, youSlowly?
can postpone the breastfeeding assessment, as it takes some
THEN
time. CHECK
You FOR FEEDING
can always PROBLEM
continue OR LOW
this process WEIGHT
after the infant’s most immediate problems have been resolved.
al temperature readings are approximately 0.5°C higher.
ness, Management ofIfthe
yes, sick young
how many timesinfant module,
in 24 hours? Annex 2 "Where referral is not possible".
___ times
21
If yes, how often?
CHECKPage 43 of 75
FOR HIV INFECTION
2.4 ASSESS & CLASSIFY JAUNDICE

Now that you have checked all young infants for signs of severe disease, you will
continue your assessment. You will now assess for main symptoms. The first
is jaundice.
For ALL sick young infants – ask the caregiver about the infant’s problems, check for
signs of serious disease or local infection, then: LOOK: IS THE INFANT JAUNDICED?
NO YES
Classify the jaundice using the colour-

coded classification table for jaundice
CONTINUE ASSESSMENT: assess for diarrhoea, check HIV status, check feeding
problems and low weight, check immunization status, and other problems
WHAT IS JAUNDICE?
Jaundice is a yellow discoloration of skin in young infants.
Many normal babies may have jaundice during the first week of life. This is
common for small babies less than 2.5 kg at birth or born before 37 weeks gestation.
This jaundice usually appears on the third or fourth day of life and occurs because
the infant’s liver is not fully mature to eliminate the bilirubin formed in the body.
This type of jaundice is mild and disappears before the age of two weeks in full term
and by the age of three weeks in preterm babies. It does not need any treatment.
However, some signs indicate severe jaundice that requires urgent care.
WHEN IS JAUNDICE NOT NORMAL, BUT SIGN OF A

SEVERE PROBLEM?
Jaundice that appears on the first day of life is always due to an underlying
disease. Deep jaundice that extends to the palms and soles can be severe and
requires urgent treatment.
Jaundice that persists beyond the age of two weeks needs further
investigation. If not treated, it may damage the young infant’s brain.
Jaundice needs special attention when it:

✔✔ Appears within 24 hours of birth
✔✔ Remains beyond 2 weeks of age
22
HOW WILL YOU ASSESS FOR JAUNDICE IN A SICK YOUNG INFANT?

When you assess for jaundice, you observe the child for yellow discoloration in the
skin.
Open to your ASSESS chart for jaundice. It contains these instructions for ASSESS
that you will now read about below:
CHECK FOR JAUNDICE
If jaundice present, ASK: LOOK AND FEEL: Any jaun

When did the jaundice Look for jaundice (yellow than 24 h
appear first? eyes or skin) CLASSIFY Yellow pa
Look at the young infant's JAUNDICE any age
palms and soles. Are they
Jaundice
yellow?
24 hours
Palms an
yellow
LOOK: FOR YELLOW SKIN

It is important to look for jaundice in natural light. To look for jaundice, press the
infant’s skin over the forehead with your fingers to blanch. Remove your fingers and No jaund
look for yellow discoloration. If there is yellow discoloration, the infant has jaundice.
LOOK: AT THE INFANT’S PALMS AND SOLES OF THE FEET

THEN of
To assess for severity ASK: Doesrepeat
disease, the young infant
the above have diarrhoea*?
process on the hands and soles
of the infant’s feet. Press the infant’s skin on palms and soles with your fingers.
IF YES, LOOK AND FEEL: Two of the
Remove your fingersLookandatlook
the for yellow
young discoloration.
infant's As before, yellow discoloration
general condition: Movem
Infant's
is your indication that themovements
infant has jaundice. Classify stimula
Does the infant move on his/her own? DIARRHOEA for movem
Does the infant not move even when stimulated but DEHYDRATION Sunke
ASK: WHEN DID JAUNDICE then stops? APPEAR? Skin p
Does the infant not move at all? very s
Remember that the timing of the jaundice, and the infant’s age, is very important
for this assessment.Look for sunken eyes.
Jaundice that appears Veryonslowly
the (longer
first day
thanof life is always due to an underlying
2 seconds)? Two of the
disease. Deep jaundice that extends to the palms and soles can be severe and
or slowly? Restle
Sunke
requires urgent treatment.
Skin p
Jaundice that persists beyond the age of two weeks needs further slowly
investigation. If not treated, it may damage the young infant’s brain.
Not enoug
as some o
dehydratio
* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more wate
The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
Page 44 of
23
HOW WILL YOU CLASSIFY JAUNDICE IN A SICK YOUNG INFANT?

Review your jaundice classification table in your Chart Booklet. What do you observe
about the classifications and treatments? There are three classifications for jaundice:
1. SEVERE JAUNDICE
2. JAUNDICE
3. NO JAUNDICE
Any jaundice if age less Pink: Treat to prevent low blood sugar
than 24 hours or SEVERE Refer URGENTLY to hospital
LASSIFY Yellow palms and soles at JAUNDICE Advise mother how to keep the infant
JAUNDICE any age warm on the way to the hospital
Jaundice appearing after Yellow: Advise the mother to give home care for the
24 hours of age and JAUNDICE young infant
Palms and soles not Advise mother to return immediately if palms
yellow and soles appear yellow.
If the young infant is older than 14 days, refer
to a hospital for assessment
Follow-up in 1 day
No jaundice Green: Advise the mother to give home care for the
NO JAUNDICE young infant
SEVERE JAUNDICE (RED)

?
A young infant who is less than 24 hours of age and has jaundice should be classified
as SEVERE JAUNDICE.
Two of the following signs: Any young infant who
Pink: has has
If infant yellow palms
no other and
severe soles is also
classification:
Movement only when SEVERE Give fluid for severe dehydration (Plan C)
assify
classified as having SEVEREDEHYDRATION
stimulated or no
jaundice. OR
ARRHOEA for movement at all If infant also has another severe
DEHYDRATION classification:
What Sunken
are your
eyesactions?
Skin pinch goes back Refer URGENTLY to hospital with
Beforevery
referral,
slowly. the infant will require treatment forgiving
mother low blood
frequentsugar,
sips ofand
ORS the
on
the way
caregiver will be advised on keeping the infant warm.
Advise the mother to continue
breastfeeding
Two of the following signs: Yellow: Give fluid and breast milk for some
JAUNDICE (YELLOW)
Restless and irritable dehydration (Plan B)
SOME
YoungSunken
infantseyeswith jaundiceDEHYDRATION
over 24 hours oldIfand without
infant has anyyellow palms and soles
severe classification:
be classified as having JAUNDICE. If an infant
shouldslowly. with JAUNDICE is older
mother giving frequent sips of ORS on
than 14 days, refer to a hospital for assessment. the way
breastfeeding
What are your actions? Advise mother when to return immediately
At the end of the assessment you will advise the caregiver on home care and when
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
to return immediately.
as some or severe continue breastfeeding (Plan A)
NO
dehydration. DEHYDRATION Advise mother when to return immediately
NO JAUNDICE (GREEN)
A young infant who has no jaundice gets the classification NO JAUNDICE.
al pattern and are many and watery (more water than fecal matter).
not diarrhoea.
You will advise the caregiver on home care at the end of your assessment.
Page 44 of 75
24
SELF-ASSESSMENT EXERCISE C
Answer the following questions about assessing and classifying jaundice.
1. Are these statements true or false? If false, write the statement out correctly.
a. Jaundice is a yellow discolouration of the skin. TRUE FALSE
b. Yellow soles and palms are normal in young infants. TRUE FALSE
c. Many babies may have jaundice in the first week of life,
especially if they are low birth weight or premature. TRUE FALSE
d. Jaundice in a young infant less than 24 hours old is
very serious. TRUE FALSE
e. To assess for jaundice of the skin, soles, or palms,
blanch the skin and look for discolouration. TRUE FALSE
f. It is best to look for jaundice indoors under a lamp TRUE FALSE
g. Jaundice that persists beyond 2 weeks requires further
investigation. TRUE FALSE
2. Match the signs below with the correct classification. Each “signs” box should
be matched with a classification.
SIGNS CLASSIFICATION
a. Precious is 14 days old. Her skin is not discoloured. Her
SEVERE JAUNDICE
palms and soles are normal.
b. Kai was born last night, less than 24 hours ago. His skin
JAUNDICE
is very yellow.
c. Sal is 2 weeks old. She has yellow discolouration of the

NO JAUNDICE
skin and eyes. Her palms and soles are not yellow.
3. Biki is 21 days old. He has yellow skin, but his palms and soles are not yellow.
How would you classify Biki? What action would you take for Biki?
25
n How did you assess and classify Mimi for jaundice?

When you press Mimi’s skin in the natural light, you see that it is yellow. When you examine her palms and
soles, and compare the colour to her caregiver, you see they are also yellow. You ask Biva when this yellow
colouring appeared. She says she did not really notice it, so she is not sure.
Mimi shows a sign of SEVERE JAUNDICE, because her yellow palms and soles. This is a red classification, and
will need to be referred urgently.
Any jaundice if age less Pink: Treat to prevent low blood sugar
Yellow palms and soles at JAUNDICE Advise mother how to keep the infant
DICE any age warm on the way to the hospital
Jaundice appearing after Yellow: Advise the mother to give home care for the
Palms and soles not Advise mother to return immediately if palms
yellow and soles appear yellow.
Follow-up in 1 day
n How will you assess and classify Mimi on your recording form?

Name: Mimi Age: 6 weeks Weight (kg): 3.1 Temperature (°C): 34.7
Not breastfeeding Initial Visit? X
Pink: well
Ask: What are the infant's problems?: Follow-up Visit?
Two(Circle
ASSESS of the following
all signs present) signs: If infant has no other severe classification:
CLASSIFY

CHECKMovement
FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
only when SEVERE Give fluid for severe dehydration (Plan C)
Is the infant having difficulty in feeding? Count the breaths in one minute. 45 ___ breaths per minute
stimulated
Has the or no
infant had convulsions? DEHYDRATION
Repeat if elevated: ___ Fast breathing? OR Very severe
movement at all Look for sever chest indrawing.
If infant also has another severe disease
HYDRATION Sunken eyes Look at the umbiculus. Isclassification:
it red or draining pus? (red)
very slowly. mother
Look for skin pustules. Are there giving
many or severe frequent sips of ORS
pustules? on
Movement only when stimulated theor no
waymovement even when
stimulated?
THEN CHECK FOR JAUNDICE Advise the mother to continue
When did the jaundice appear first? Look for jaundice (yellow eyesbreastfeeding
or skin)
Severe jaundice
Not known
Look at the young infant's palms and soles. Are they yellow? (red)
TwoTHE
DOES of the following
YOUNG INFANTsigns:
HAVE Yellow:Look at the young infant'sGivegeneralfluid andDoes
condition. breast milk for someYes ___ No ___
the infant:
Restless and irritable SOME not move even when dehydration
stimulated? (Plan B)
Sunken eyes DEHYDRATION
Is the infant restless and If
n This is a severe classification – what actions will you take? infant has any severe classification:
irritable?
Skin pinch goes back Pinch the skin of the abdomen. Refer URGENTLY
Does it go back: to hospital with
You have identified two RED classifications for Mimi:
slowly. one for signsmother
Very slowly? of severe disease
giving and onesips
frequent for jaundice.
of ORS Youon
Slowly?
know that you should continue the assessment quickly before you
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT the refer.
way
If the infant has no indication to refer urgently to hospital Determine weight for age. LowAdvise
___ Not lowthe
___ mother to continue
YouIswill make note of the identified pre-referral
there any difficulty feeding? Yes ___ No ___
treatments
Look for ulcers for
or white patches severe
in the jaundice: Before you refer Mimi,
mouth (thrush).
breastfeeding
you Iswill need
the infant to treat
breastfed? Yesher
___ for low blood sugar, and advise Biya on how to keep Mimi warm on the way to the
No ___
If yes, how many times in 24 hours? ___ times Advise mother when to return immediately
hospital
Does thewithinfantextra
usuallyblankets or skin-to-skin
receive any other foods or contact.
drinks? Yes ___ No ___ Follow-up in 2 days if not improving
NowIfNot youenough
yes, will
how move
often? to the next main symptom, diarrhoea.
What do you use tosignsfeed theto classify Green:
child? Give fluids to treat diarrhoea at home and
CHECKas some FOR HIV or severe
INFECTION NO continue breastfeeding (Plan A)
dehydration.
Mother's HIV test: NEGATIVE POSITIVE DEHYDRATION
NOT DONE/KNOWN Advise mother when to return immediately
If breastfeeding: Is the mother and infant on ARV prophylaxis? 26
e many and watery (more
Has the water than infecal
infant breastfed matter).
the previous hour? If the infant has not fed in the previous hour, ask the mother to put her
2.5 ASSESS & CLASSIFY DIARRHOEA IN YOUNG INFANT
YOU WILL LEARN ABOUT DIARRHOEA IN MODULE 4

You will learn about assessing and classifying for diarrhoea in Module 4. The assessment process is similar
with the sick child. You can review this material now to be familiar with signs when you practice assessing a
sick young infant in your clinic.
DVD EXERCISE – ASSESSING & CLASSIFYING GEMMA

Watch “Case study – Gemma” on DVD disc 2 to assess and classify Gemma for signs
of severe disease and local infection, and diarrhoea.
As you watch the video, use the recording form below to assess and classify. The
video will review the classifications with you.

stimulated?
Very slowly?
Slowly?
If yes, how often?
27
pausing)?
Complete the two case studies below. Read the case information, and complete
the recording form as you greet, ask information, assess, and classify.
1. HENRI. Henri was born 6 hours ago at home. His weight is 3.0 kg. His axillary
temperature is 36.5 °C. He is brought to the health facility because he did not
cry immediately after birth and is having difficult breathing. The health worker
first checks the young infant for signs of VERY SEVERE DISEASE and LOCAL
BACTERIAL INFECTION. The father says that the young infant has not had
convulsions and has not yet been fed. The health worker counts 74 breaths per
minute. He repeats the count. The second count is 70 breaths per minute. He finds
that the young infant has severe chest indrawing. The young infant moves only
when he is stimulated. The umbilicus is normal, and there are no skin pustules.
There is no jaundice. Henri does not have diarrhoea.

stimulated?
Very slowly?
Slowly?
If yes, how often?
28
pausing)?
effectively
2. SASHI. Sashi is 1 week old. Her weight is 3.4 kg. Her axillary temperature is
37 °C. Her caregiver brought her to the clinic because she has a rash. The health
worker assesses for signs of very severe disease and local bacterial infection.
Sashi’s caregiver says that there were no convulsions and that the infant is feeding
well. Sashi’s breathing rate is 55 per minute. She has no chest indrawing. Her
umbilicus is normal. The health worker examines her entire body and finds a red
rash with a few skin pustules on her buttocks. She is awake and has spontaneous
movements. She has neither jaundice nor diarrhoea.

stimulated?
Very slowly?
Slowly?
If yes, how often?
pausing)?
effectively
mother (Date)
ASSESS OTHER PROBLEMS: 29
Ask about mother's own health
2.6 TREAT THE YOUNG INFANT REQUIRING

URGENT REFERRAL
HOW DO YOU KNOW WHEN A YOUNG INFANT REQUIRES
URGENT REFERRAL?
A young infant with any severe classification (RED) needs to be urgently referred.
GREET THE CAREGIVER


Even if present
All danger
signs require


WHAT CLASSIFICATIONS REQUIRE URGENT REFERRAL OF

A YOUNG INFANT?
If the infant has any of the following classifications (RED) they require urgent
referral:
•• VERY SEVERE DISEASE
•• SEVERE JAUNDICE
•• SEVERE DEHYDR ATION in some cases: the infant with SEVERE
DEHYDRATION needs rehydration with IV fluids. If you can give IV therapy,
you can treat in clinic and do not need to refer. If you cannot give IV therapy
30
you must refer urgently. If the infant has SEVERE DEHYDRATION and another
severe classification, they must be referred.
WHAT DOES THE YOUNG INFANT REQUIRE BEFORE REFERRAL?

Before urgently referring a young infant to hospital, give all appropriate pre-referral
treatments. Urgent pre-referral treatments are in bold print on the chart.
Some treatments should not be given before referral because they are
not urgently needed and would delay referral. For example, do not teach a
caregiver how to treat a local infection before referral. Do not give immunizations
before referral.
HOW DO YOU GIVE PRE-REFERRAL TREATMENTS?

The TREAT THE YOUNG INFANT charts in your Chart Booklet include instructions
on how to give the following pre-referral treatments:
✔✔ VERY SEVERE DISEASE: Give first dose of intramuscular antibiotics, treat to
prevent low blood sugar, and teach caregiver how to keep child warm
✔✔ SEVERE JAUNDICE: give all pre-referral treatments as for VERY SEVERE
DISEASE except the first dose of intramuscular antibiotics
✔✔ Give an appropriate oral antibiotic. If the infant needs an oral antibiotic
for LOCAL BACTERIAL INFECTION and has not received intramuscular
antibiotics, give a first dose of oral antibiotic before referral.
✔✔ SEVERE DEHYDRATION and VERY SEVERE DISEASE: teach caregiver to give
frequent sips of ORS on the way, and advise caregiver to continue breastfeeding.
Now you will read more about these pre-referral treatments.
How will you treat to prevent low blood sugar?

Your treatment and instructions to the caregiver will depend if the infant is able
to feed and swallow. If the infant is:
1. ABLE TO BREASTFEED, ask caregiver to breastfeed
2. UNABLE TO BREASTFEED, BUT ABLE TO SWALLOW
✔✔ Give 20–50 ml (10 ml/kg) expressed breast milk before departure
✔✔ If not possible, give 20–50 ml (10 ml/kg) sugar water (to make, dissolve 4 level
teaspoons of sugar, or 20 grams, in a 200 ml cup of clean water)
3. UNABLE TO SWALLOW, give 20–50 ml (10 ml/kg) of expressed breast milk
or sugar water by nasogastric tube
REVIEW: TREAT TO PREVENT LOW BLOOD SUGAR

✔✔ Can breastfeed: ask caregiver to breastfeed
✔✔ Can’t breastfeed, but can swallow: give expressed breast milk or sugar water
✔✔ Can’t swallow: give expressed breast milk or sugar water by nasogastric tube
31
How will you give the first dose of intramuscular antibiotics?

Young infants get two intramuscular antibiotics:
1. Gentamicin and
2. Ampicillin
WHY ARE TWO INTRAMUSCULAR ANTIBIOTICS GIVEN?

Young infants with VERY SEVERE DISEASE are often infected with a broader range
of bacteria than older infants. The combination of Gentamicin and Ampicillin is
effective against this broader range of bacteria. Use the table in your Chart Booklet
to find dose instructions.
HOW DO YOU USE GENTAMICIN?

Read the vial of Gentamicin to determine its strength. Check whether it should
be used undiluted or should be diluted with sterile water. When ready to use, the
strength should be 10 mg/ml. Choose the dose from the row of the table that is
closest to the infant’s age and weight.
HOW DO YOU USE AMPICILLIN?

To use a vial of 250 mg Ampicillin, add 1.3 ml sterile water. This will give 250 mg
TREAT AND COUNSEL
per 1.5 ml solution. Choose the dose from the row of the table that is closest to the
infant’s weight.
TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER
If you have a vial with a different amount of Gentamcin or Ampicillin, or if you use a
different amount of sterile water than described here, the dosing table on the YOUNG
Give First Dose of Intramuscular Antibiotics
INFANT chart will not be correct. In that situation, carefully follow the manufacturer’s
directions for adding sterile water and recalculate the doses.
Give first dose of ampicillin intramuscularly and
Give first dose of gentamicin intramuscularly.
AMPICILLIN
Dose: 50 mg per kg GENTAMICIN
To a vial of 250 mg
Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml
WEIGHT
OR
Add 1.3 ml sterile water = 250 mg/1.5ml Add 6 sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml
AGE <7 days AGE >= 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
1.5-<2 kg 0.5 ml 0.9 ml* 1.3 ml*
2-<2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
2.5-<3 kg 0.8 ml 1.4 ml* 2.0 ml*
3-<3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
3.5-<4 kg 1.1 ml 1.9 ml* 2.8 ml*
4-<4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
* Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give
ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3 times daily to
infants one week or older. Give gentamicin once daily.
↺
What if the caregiver is not going to take the infant to the hospital?
If an infant with VERY SEVERE DISEASE cannotPage 49 of 75
go to a hospital, it is possible to continue
treatment using these intramuscular antibiotics.
32
How will you keep an infant warm?

Keeping an infant warm is very important care during travel to the hospital.
Advise the caregiver to provide skin to skin contact, or keep the infant covered as
much as possible at all times. Dress with extra clothing – hat, gloves, socks – and
wrap in a soft dry cloth and cover with a blanket.
KEEP INFANT WARM ON WAY TO HOSPITAL

✔ Skin to skin contact
✔ Extra clothing or wrapping
Then you refer the young infant:

There are some steps to follow as you prepare to refer. You can also refer to MODULE
1.
1. REFERRAL NOTE
Prepare a referral note and explain to the caregiver the reason you are referring
the infant.
2. TEACH ABOUT CARE
Teach her anything she needs to do on the way, such as keeping the young infant
warm, breastfeeding, and giving sips of ORS.
3. EXPLAIN IMPORTANCE, ESPECIALLY FOR YOUNG INFANTS
In addition, explain that young infants are particularly vulnerable. When they
are seriously ill, they need hospital care and need to receive it promptly. Many
cultures have reasons NOT to take a young infant to hospital. If this is the case,
you will have to address these reasons and explain that the infant’s illness can
best be treated at the hospital.
What if the caregiver is not going to take the infant to the hospital?
If the caregiver is not going to take the infant to hospital, follow the guidelines:
where referral is not possible, located in the Annex.
33
n How will you treat and refer Mimi?

As you classified Mimi, you identified immediate pre-referral treatment for Mimi. These were the bold
treatments in the classification charts:
1. Give first dose of intramuscular antibiotics ➞ for SEVERE DISEASE classification
2. Treat to prevent low blood sugar ➞ for SEVERE DISEASE and SEVERE JAUNDICE classifications
3. Advise caregiver to keep infant warm on way to hospital ➞ for SEVERE DISEASE and SEVERE
JAUNDICE classifications
n How will prepare Mimi’s intramuscular antibiotic?

Mimi weighs 3.1 kg. You use the chart in your Chart Booklet to determine the appropriate antibiotic dosages
for the given formulations:
✔✔ Ampicillin: 1.0 ml
✔✔ Gentamicin: 2.4 ml
n Next, how will you treat Mimi to prevent low blood sugar?
You use the instructions in your Chart Booklet to decide on this treatment. Mimi cannot breastfeed, but she
can swallow.
You ask Biya to express breast milk into a cup, and measure just over 30 ml to give Mimi. You should give
10 ml per kg, and Mimi weighs 3.1 kg. If Biya needed help on learning how to express breast milk, you have
instructions for this counselling in the next sections.
If Biya was unable to express breast milk, the other way you could treat Mimi’s low blood sugar is by giving
the same amount (31 ml) of sugar water.
n Next, how you will prepare Mimi to keep Biya warm?

You also teach Biya how to keep Mimi warm on the way to the hospital. You ask Biya to put Mimi’s hat
and socks on, and you show her how to rewrap the blanket to keep Mimi covered.
n Finally, how you will prepare Mimi for referral?

Finally, you prepare a referral note for Biya. You explain to Biya that Mimi needs to go to the hospital
urgently to receive treatment for her severe signs, and so that she can begin feeding again.
You ask Biya if her husband and caregiver will let her go to the hospital. She is worried that they will be upset
about the transportation costs. However because Mimi stopped feeding today and is looking so serious, she
thinks they will support her.
34
2.7 TREAT THE YOUNG INFANT NOT REQUIRING

URGENT REFERRAL
WHAT YOUNG INFANTS DO NOT REQUIRE REFERRAL?

Yellow and green colour-coded classifications do not require referral. They
can be treated in the clinic or home. In the sick young infant section of the chart
booklet, the TREAT charts give instructions about treatment.
GREET THE CAREGIVER


Even if present
All danger
signs require


35
HOW WILL YOU DETERMINE REQUIRED TREATMENTS?

As you ASSESS and CLASSIFY, you will:
1. Record identified treatments for each classification, using your use recording
form
2. After you complete the assessment, determine the integrated treatment
3. Provide necessary treatments in the clinic, as necessary
4. Advise the caregiver on home treatment, and when to return to the clinic
WHAT IS INCLUDED IN THESE TREATMENTS?

You will learn more about the following treatments in this section:
✔✔ Oral antibiotics
✔✔ Treating local infections
✔✔ Treating dehydration and diarrhoea
✔✔ Managing jaundice
How do you determine an appropriate antibiotic treatment?

Use the chart in your Chart Booklet to identify recommended antibiotic for local
bacterial infection.
When deciding on antibiotics:
1. Determine the appropriate local first and second line antibiotics
2. Determine the dose based on the young infant’s weight
CO-TRIMOXAZOLE
AMOXICILLIN
(trimethoprim/suphamethoxazole)
Give two times daily for 5 days
ADULT TABLET single PEDIATRIC TABLET SYRUP TABLET SYRUP
AGE or WEIGHT
strength (80/400 mg) (20/100 mg) (40/200 mg) (250 mg) (125 mg/5 ml)
Birth to 1 month
½a 1.25mla 1/4 2.5 ml
(under 4 kg)
1 to 2 months
1/4 1 2.5 ml ½ 5 ml
(4 to under 6 kg)
Avoid giving Cotrimoxazole to a young infant less than 1 month of age who is premature or jaundiced. Give this infant Amoxicillin instead.
a
HOW WILL YOU ADMINISTER ANTIBIOTIC TREATMENTS?

You will give the first dose in the clinic. Then you will teach the caregiver
how to continue the treatment at home. Follow the steps in the Chart Booklet
for teaching a caregiver how to give an oral antibiotic at home. That is, teach her
how to measure a single dose.
Show her how to crush a tablet and mix it with breast milk. Guide her as needed to
give the first dose, and teach her the schedule. Watch the caregiver and ask checking
questions to be sure she knows how to give the antibiotic. We will learn more about
good counselling skills in the next section.
36
How will you manage jaundice?

Young infants with JAUNDICE need home care just like those without any problem.
They do not need any medication.
However, the caregiver needs to be counselled to return immediately if
palms and soles appear to be yellow. Also, you should follow up infants with
jaundice in 1 day to assess if jaundice is worsening. If the young infant is older than
14 days, refer to hospital for assessment.
What local infections can be treated at home?

There are three types of local infections in a young infant that a caregiver can treat
at home:
✔✔ An umbilicus which is red or draining pus,
✔✔ Skin pustules, or
✔✔ Oral thrush
Twice each day, the caregiver should clean the infected area and then apply gentian
violet. Half-strength gentian violet must be used in the mouth.
HOW DO YOU TEACH THE CAREGIVER TO TREAT LOCAL INFECTIONS

AT HOME?
Explain and demonstrate the treatment to the caregiver. Then watch her and guide
her as needed while she gives the treatment.
Remember to send supplies home with the caregiver. If the caregiver will
treat skin pustules or umbilical infection, give her a bottle of full strength (0.5%)
gentian violet. If the caregiver will treat thrush, give her a bottle of half-strength
(0.25%) gentian violet.
Discuss when the caregiver should return to the clinic. She should return
for follow-up in 2 days, or sooner if the infection worsens. She should stop using
gentian violet after 5 days. Ask her checking questions to be sure that she knows
to give the treatment twice daily and when to return.
37
SELF-ASSESSMENT EXERCISE E
Return to Sashi and Henri’s recording forms that you used earlier in this module.
Review the classifications on the recording form, to remind you of the infant’s
condition. You will now decide on treatments required. Refer to the YOUNG INFANT
chart as needed. For each infant, decide how to answer the following questions. Write
your complete answers below, including specific treatments (e.g. schedule, dosing).
a. Should the infant be urgently referred? What pre-referral treatments are
required?
b. If the infant does not need to be urgently referred, write all recommended
treatments and advice for the caregiver.
1. HENRI:
2. SASHI:
38
2.8 PROVIDE FOLLOW-UP CARE FOR THE

SICK YOUNG INFANT
WHY IS FOLLOW-UP CARE SO IMPORTANT FOR THE YOUNG INFANT?
Follow-up visits are especially important for a young infant because they progress
quickly in their illness. During a follow-up visit, you will do two things.
1. RE-ASSESS the conditions that you classified and treated during the initial
visit. Are these conditions:
 Improving?
 The same?
 Worsening?
2. RE-ASSESS USING IMCI TO IDENTIFY NEW ISSUES, if there are any. You
will use a second recording form for this visit.
WHEN SHOULD AN INFANT COME FOR A FOLLOW-UP VISIT?

The time required for a follow-up visit is established for all conditions. You will
record this follow-up date on the recording form and advise the caregiver.
RETURN FOR FOLLOW-UP VISIT

If the infant has… Return for first follow-up in…
✔ Jaundice 1 day
✔ Local bacterial infection
✔ Thrush 2 days
✔ Diarrhoea
WHERE ARE THE INSTRUCTIONS FOR FOLLOW-UP VISITS?

Your Chart Booklet has charts with instructions for follow-up care for each
condition. These charts follow the section on treatment. These instructions will
re-assess by ASKING, LOOKING, FEELING, and LISTENING.
You will now learn the instructions from these charts. As you read this section,
follow along in your Chart Booklet.
LOCAL BACTERIAL INFECTION (follow-up 2 days)

A young infant classified with local bacterial infection should return for follow up
in 2 DAYS. At the follow-up, you will:
✔✔ LOOK at the umbilicus. Is it red or draining pus?
✔✔ LOOK for skin pustules. Are they less in number? Are they drying up?
 UMBILICUS PUS/REDNESS OR SKIN PUSTULES ARE IMPROVED

Tell the caregiver to complete the 5 days of an antibiotic that she was given
during the initial visit. Improved means there is less pus and redness has reduced.
39
Similarly, if skin pustules have improved, which means they are less in number
and are drying up, tell the caregiver to continue giving the antibiotic. Emphasize
that it is important to continue giving the antibiotic even when the infant
is improving. She should also continue treating the local infection at home for 5
days. This includes cleaning the area and applying gentian violet.
  UMBILICUS PUS/REDNESS OR SKIN PUSTULES ARE

SAME OR WORSE
The infant is not improving, or is getting worse. Refer the infant to hospital if skin
pustules or umbilicus is the same or worse than before.
JAUNDICE (follow-up 1 day)

An infant with jaundice should return in 1 DAY. During the follow-up visit:
✔✔ LOOK for jaundice – are palms and soles yellow?
 JAUNDICE HAS STARTED DECREASING

Reassure the caregiver and ask her to continue home care. Ask her to return for
follow-up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.
 JAUNDICE HAS NOT DECREASED, BUT PALMS & SOLES

NOT YELLOW
Advise the caregiver on home care and ask her to return for follow up in 1 day.
 PALMS AND SOLES ARE YELLOW

This child is getting worse. The child needs urgent referral to the hospital.
THRUSH (follow-up 2 days)

When a young infant who had thrush returns for follow-up in 2 DAYS, you will:
✔✔ LOOK for ulcers or white patches in mouth (thrush)
✔✔ Reassess the infant’s feeding
  THRUSH IS BETTER OR SAME, AND THE INFANT

IS FEEDING WELL
Continue treatment with half-strength gentian violet. Stop using gentian violet
after 5 days.
 THRUSH IS WORSE, OR PROBLEMS ATTACHING OR SUCKLING

Refer to hospital. It is very important that the infant be treated so that he can
resume good feeding as soon as possible.
40
n How will you provide follow-up care to Mimi?

Now you will return to Mimi and her caregiver, Biya. You referred Mimi urgently for signs of severe disease,
and for jaundice. Biya was very worried about Mimi, especially because she was not feeding. She assured you
that she would take Mimi to the hospital.
n So what happened to Mimi?

Biya took Mimi to the nearby district hospital, and she was admitted to the newborn care ward.
Mimi was given intravenous fluids and parenteral antibiotics. She was put in a warm room. After some time
in the hospital, she started to suck well. Her body temperature returned to 37.0 degrees, which is safe for a
young infant. Mimi was discharged after 5 days stay in the hospital.
Two days later, Biya brought Mimi for her follow-up appointment at the clinic. How will you provide follow-up
care to Mimi? How will you counsel Biya?
SELF-ASSESSMENT EXERCISE F
You will return to Sashi’s case to discuss follow-up care for this infant.
Sashi is 1 week old. The health worker classified her as having LOCAL BACTERIAL
INFECTION because she had some skin pustules on her buttocks. Her caregiver
got pediatric tablets of cotrimoxazole to give at home, and learned how to clean
the skin and apply gentian violet at home. She has returned for a follow-up visit
after 2 days. Sashi has no new problems. At this clinic, local bacterial infections are
treated with co-trimoxazole.
1. How would you reassess Sashi?
When you look at the skin of her buttocks, you see that there are fewer pustules
and less redness.
2. What treatment does Sashi need now?
41
PART II
Feeding
problems and
counselling
the caregiver
42
2.9 ASSESS FEEDING PROBLEMS OR LOW WEIGHT

WHY IS FEEDING SO IMPORTANT FOR THE YOUNG INFANT?
Adequate feeding is essential for the infant’s health, growth and development.
Poor feeding during infancy increases the risk of infection and death. It also
impairs growth and may have lifelong effects such as increasing the risk of poor
development, or obesity.
WHEN DO YOU NEED TO ASSESS A YOUNG INFANT’S FEEDING?

You will assess feeding in all young infants except those that have severe
classifications.
For ALL sick young infants - ask the caretaker about the infant’s problems, check for
signs of serious disease or local infection, assess for jaundice and diarrhoea, then
FOR ALL YOUNG INFANTS THAT DO NOT REQUIRE URGENT REFERRAL
ASK: DOES THE INFANT HAVE ANY PROBLEMS FEEDING?
NO YES
1. ASSESS & CLASSIFY

feeding problems and low weight
CHECK immunization status and other problems. Assess the mother’s health.
WHY DO SOME YOUNG INFANTS HAVE FEEDING PROBLEMS?

Some feeding and weight problems are associated with prematurity (born before
37 weeks of pregnancy), or low birth weight.
A low birth weight baby (LBW) is small for gestational age. He did not grow
well enough in the uterus during pregnancy. LBW babies are more likely to have
breathing and feeding problems and develop infection and die than babies with a
normal birth weight.
LBW babies who survive are likely to have more medical and developmental
problems than normal term babies. Some communities believe that these babies
are born to die. As a health worker you have important role
to change this belief and help caregivers and family members
to provide the extra care the LBW baby needs.
LOW BIRTH WEIGHT = under 2500 grams (2.5 kg)

VERY LOW BIRTH WEIGHT = under 1500 grans (1.5 kg)
43
WHAT ARE CRITICAL FEEDING RECOMMENDATIONS

FOR YOUNG INFANTS?
The best way to feed a child from birth to 6 months is to breastfeed
exclusively. There are two important things to emphasize about this breastfeeding:
EXCLUSIVE BREASTFEEDING means that the child takes only breast milk and
no additional food, water, or other fluids. Medicines and vitamins are exceptions.
Exclusive breastfeeding reduces the risk of diarrhoea and pneumonia as well as the
risk of mortality.
BREASTFEEDING ON DEMAND means children at this age should receive breast
milk as often as they want, day and night. This will be at least 8 times in 24 hours.
ALL INFANTS UP TO 6 MONTHS SHOULD BREASTFEED:

n EXCLUSIVELY: infant takes only breast milk and nothing else
n ON DEMAND: as often as they want, day and night
n AT LEAST 8 TIMES IN 24 HOURS
WHAT WILL YOU RECOMMEND TO A CAREGIVER WHO IS NOT

BREASTFEEDING?
If a child under 6 months old is receiving food or fluids other than breast
milk, encourage and help the caregiver to gradually change back to more or exclusive
breastfeeding.
Suggest giving more frequent, longer breastfeeds, day and night. As breastfeeding
increases, the caregiver should gradually reduce other milk or food. Since this is an
important change in the child’s feeding, be sure to ask the caregiver to return for
follow-up in 5 days. She will need your help and support.
If the caregiver is HIV positive, she will need separate advice. This is discussed
in your modules on feeding recommendations and HIV/AIDS.
HOW WILL YOU ASSESS FOR FEEDING PROBLEMS

AND LOW WEIGHT?
You will assess every young infant for feeding problems and low weight,
except those who have severe classifications.
The assessment has two parts. You will now learn about each part of the assessment:
PART A: IF INFANT HAS FEEDING PROBLEM PART B:

ASSESS FOR FEEDING OR BREASTFEEDS LESS THAN ASSESS
PROBLEM OR LOW WEIGHT 8 TIMES IN 24 HOURS BREASTFEEDING
HIV-exposed infants not breastfeeding have a separate assessment you will read later.
44
PART A. ASSESS FOR FEEDING
Has the infant had convulsions?
Look for sever PROBLEM
chest indrawing. OR LOW WEIGHT
Repeat if elevated: ___ Fast breathing?

This first part of the assessmentFever (temperature 38°C or above fells hot) or
will give you an overall picture of the infant’s feeding
and identify any issues. You will also determine if the infant is low weight for age.
stimulated?
THEN CHECKWHO DO YOU
FOR JAUNDICE ASSESS FOR FEEDING PROBLEMS AND LOW WEIGHT?
Every sick young infant is assessed foryoung
Look at the feeding problems
infant's palms orAre
and soles. low
theyweight.
yellow? The only
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant:
exception is young infants with move
a severe classification. These infants should beYes ___ No ___
DIARRHOEA? only when stimulated?
referred immediately. not move even when stimulated?
LOCATE THIS ASSESSMENT ON YOUR RECORDING FORM: Very slowly?
Slowly?
If yes, how often?
CHECK FOR HIV INFECTION THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
HOW WILL YOU ASSESS?
Mother's HIV test: NEGATIVE Use this table
POSITIVE NOT for all young infants except HIV-exposed young infants not breastfed because their mother f
DONE/KNOWN
Child's virological test: NEGATIVE the mother has
POSITIVE NOTchosen
DONE formula feeding. For these HIV-exposed non-breastfed young infants use the following
Open test:
Child's serological to your chartNON-breastfed
NEGATIVE booklet to
POSITIVE NOTreview
DONE the instructions in the ASSESS chart:
infants.
If an infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL: Not well attached to
ASSESS BREASTFEEDING Is the infant breastfed? If Determine weight for age. or
Has the infant breastfed in the previous hour?yes, how Ifmany times
the infant hasin not
24 fed Look
in the previous hour,
for ulcers Classify
ask the mother
or white to putFEEDING
her Not suckling effectiv
hours? infant to the breast. Observe the in
patches breastfeed
the mouthfor 4 minutes.
Less than 8 breastfe
Is the
Does the infant infant able to attach?
usually (thrush).To check attachment, look for:
24 hours or
receive any other Chin touching
foods or breast: Yes ___ No ___
Mouth wide open: Yes ___ No ___ Receives other food
drinks? If yes, how often? drinks or
If yes, what do you
Moreuse to above than below the mouth: Yes ___ No ___
areola Low weight for age
feed the infant? not well attached good attachment Thrush (ulcers or w
Is the infant sucking effectively (that is, slow deep sucks, sometimes patches in mouth).
pausing)?
effectively
CHECK THE ASK: ISIMMUNIZATION
CHILD'S THERE ANYSTATUS
DIFFICULTY FEEDING? needed today)
(Circle immunizations Return for next
BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2
200,000 I.U immunization on:
Any difficulty that the caregiver mentions is important. mother
This caregiver may need (Date)
ASSESS counselling
OTHER or specific help with
PROBLEMS: a difficulty.
Ask about mother's own health
If a caregiver says that the infant is not able to feed, you will assess
breastfeeding or watch her try to feed the infant with a cup to see what she means
by this. An infant who is not able to feed may have a serious infection or other life-
threatening problem and should be referred urgently to hospital.
ASK: IS THE INFANT BREASTFEEDING? HOW MANY TIMES IN THE Not low weight for a
LAST 24 HOURS? no other signs of
inadequate feeding.
The recommendation is that the young infant be breastfed as often and for as long
as the infant wants,ASSESS
day and night. This should be 8 or more times in 24 hours.
BREASTFEEDING:
Has the infant breastfed in the previous hour?
If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes. Page 71 of 75
(If the infant was fed during the last hour, ask the mother
45when the infant is willing to
if she can wait and tell you
feed again.)
Is the infant well attached?
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
ASK: DOES THE INFANT RECEIVE OTHER FOOD OR DRINKS?

IF YES, HOW OFTEN?
A young infant should be exclusively breastfed. Find out if the young infant is
receiving any other foods or drinks such as other milk, juice, tea, thin porridge,
dilute cereal, or even water. Ask how often he receives it and the amount. You need
to know if the infant is mostly breastfed, or mostly fed on other foods.
DETERMINE WEIGHT FOR AGE

Some young infants who are low weight for age were born with low birth weight.
Some did not gain weight well after birth. Use a weight for age chart in the IMCI
Chart Booklet. You will find the intersection of the lines for the child’s weight and
age. You will determine if this point is considered low weight for age.
IMPORTANT TIPS FOR YOUR WEIGHT-FOR-HEIGHT CHART:
✔✔ FIND THE LOW WEIGHT FOR AGE LINE: you will use this line to determine
if young infants are low weight for age. Do not use the line for very low weight
for age, which is used for older infants and children.
✔✔ AGES ARE IN WEEKS: because the young infant is under 2 months (8 weeks) old.
The weight for age chart for children 2 months and older is labelled in months.
✔✔ SAME FOR BOYS AND GIRLS: The chart for young infants is the same for boys
and girls. In older children there are separate charts for boys and girls.
EXAMPLE: A young infant is 6 weeks old and weighs 3 kg. Here is how the health worker checked if the
infant was low weight for age:
LOW WEIGHT FOR

AGE LINE use for
young infants
1. Locate the
infant’s weight:
3 kg
2.
SUMMARY: The star is the point where the lines Locate
for age and weight meet. The point is BELOW infant’s
the low weight for age line. age:
6 weeks
THE INFANT IS LOW WEIGHT FOR AGE
46
LOOK FOR ULCERS OR THRUSH

Young infants may also have ulcers or white patches in the mouth.
It is important to treat these infections so that the young infant
feeds well.
Look for thrush. Look inside the mouth at the tongue and
inside of the cheek. Thrush looks like milk curds on the inside
of the cheek, or a thick white coating of the tongue. Try to wipe
the white off. The white patches of thrush will remain.
SELF-ASSESSMENT EXERCISE G
Practice assessing and classifying young infants for feeding problems.
1. What are three very important recommendations you will give to caregivers
about the best way to feed a young infant from 0–6 months?
2. TRUE OR FALSE: a young infant with severe jaundice should be assessed for
feeding problems and low weight.
3. Practice charting weight for age in young infants:

Is this infant low weight for age?
WEIGHT AGE
YES NO
a. 2.5 kg 1 month
b. 3 kg 2 weeks
c. 4 kg 8 weeks
d. 3.2 kg 4 weeks
e. 4.5 kg 3 weeks
f. 3.3 kg 2 weeks
g. 3.1 kg 7 weeks

4. What is low birth weight?
5. What is very low birth weight?
You have finished learning how to assess an infant for feeding problems. Now you will
learn about part 2 of the assessment. This is an assessment of breastfeeding, when needed.
47
stimulated?
PART B. ASSESS BREASTFEEDING
WHEN WILL YOU ASSESS HOW AN INFANT IS BREASTFEEDING?
Very slowly?
You need to assess breastfeeding Slowly?
if the infant:
If the infant has no ✔ Doestonot
✔indication referneed
urgentlyurgent
to hospitalreferral
Determine weight for age. Low ___ Not low ___
✔✔ Is feeding less than 8 times in 24 hours
Does the infant usually receive any other foods THEN
or CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
drinks? Yes ___✔✔NoMixed
___ feeding: is Use taking other food or drinks
this table for all young infants except HIV-exposed young infants not breastfed because their mother follows the
If yes, how often? the mother has chosen formula feeding. For these HIV-exposed non-breastfed young infants use the following table "THE
What do you use✔✔ toIffeed
thethecaregiver’s
child? answers indicate
NON-breastfed infants. difficulty with breastfeeding
CHECK FOR HIV INFECTION If an infant has no indications to refer urgently to hospital:
Note mother's and/or
✔✔ Ischild's
low HIV status: for age (remember that this is often due to low birthweight, and
weight
Ask: LOOK, LISTEN, FEEL:
low
Child's virological birthweight
test: infants
NEGATIVE POSITIVE are
NOTespecially
DONE likely to have breastfeeding problems) Not well attached to breast Ye
Child's serological test: NEGATIVE Is the infant
POSITIVE NOTbreastfed?
DONE If Determine weight for age. or
yes, how
If mother is HIV positive and and NO positive virological many
test timesinfant:
in young in 24 Look for ulcers or white Classify FEEDING Not suckling effectively or
Is the infant breastfeeding now? hours? patches in the mouth Less than 8 breastfeeds in
LOCATE THIS ASSESSMENT ON YOUR RECORDING FORM:
Does
Was the infant breastfeeding at the time of test or 6the infantbefore
weeks usuallyit? (thrush). 24 hours or
receive
If breastfeeding: Is the mother and infant on ARV any other foods or
prophylaxis? Receives other foods or
drinks? If yes, how often?
ASSESS BREASTFEEDING drinks or
If yes, what do you use to Low weight for age or
feed the infant? Thrush (ulcers or white
Is the infant able to attach? To check attachment, look for: patches in mouth).
pausing)?
effectively
mother (Date)
HOW WILL YOU ASSESSAsk
BREASTFEEDING?
about mother's own health
ASSESS OTHER PROBLEMS:
Assessing breastfeeding requires careful observation. Review your chart booklet.
Not low weight for age and G
The ASSESS chart provides the following instructions: no other signs of
inadequate feeding.
ASSESS BREASTFEEDING:
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother
if she can wait and tell you when the infant is willing to
feed again.)
Mouth wide open
Page 71 of 75
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep
sucks, sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
* Unless not breastfeeding because the mother is HIV positive.
Now you will learn what to look for in this assessment.

Page
48
ASK: HAS THE INFANT BREASTFED IN THE PREVIOUS HOUR?

IF YES, ask the caregiver to wait and tell you when the infant is willing to
feed again. In the meantime, complete the assessment by checking the infant’s
immunization status. You may also decide to begin any treatment that the infant
needs, such as giving an antibiotic for local bacterial infection or ORS solution for
some dehydration.
IF INFANT HAS NOT BREASTFED IN PAST HOUR, he may be willing to
breastfeed. Ask the caregiver to put her infant to the breast. Observe a whole
breastfeed if possible, or observe for at least 4 minutes. Sit quietly and watch the
infant breastfeed.
LOOK: IS THE INFANT ABLE TO ATTACH?

You will look for four signs of good attachment to assess this. You will determine
if the infant is well attached, not well attached, or not attaching at all.
WHAT ARE THE SIGNS OF GOOD ATTACHMENT?

The infant is well attached if you see all four signs of good attachment:
1. Chin touching breast, or very close
2. Mouth wide open
3. Lower lip turned outward
4. More areola visible above than below the mouth
Good attachment Poor attachment
WHEN IS THE INFANT NOT WELL ATTACHED?

The infant is not well attached if you see any of the four signs of poor
attachment:
1. Chin not touching breast
2. Mouth not wide open, lips pushed forward
3. Lower lip turned in, or
4. More areola (or equal amount) visible below infant’s mouth than above it
If a very sick infant cannot take the nipple into his mouth and keep it there
to suck, he has no attachment at all, and is not able to breastfeed at all.
49
WHAT HAPPENS IF AN INFANT IS NOT WELL ATTACHED?

If an infant is not well attached, it may cause pain or damage to the nipples. Or
the infant may not remove breast milk effectively, which may cause engorgement
of the breast.
The infant may be unsatisfied after breastfeeds and want to feed very often or for a
very long time. The infant may get too little milk and not gain weight, or the breast
milk may dry up. All these problems may improve if attachment can be improved.
SELF-ASSESSMENT EXERCISE H
Circle the signs of good attachment. Cross-out the signs of poor attachment.
Chin away from breast Mouth wide open
More areola visible above than below mouth Lower lip turned outward
Narrow mouth with lips pushed forward Chin touching breast
Equal amount areola visible below/above mouth Lower lip turned in
LOOK TO SEE IF THE INFANT IS SUCKLING EFFECTIVELY

The infant is suckling effectively if he suckles with slow deep sucks and sometimes
pauses. You may see or hear the infant swallowing. If you can observe how the
breastfeed finishes, look for signs that the infant is satisfied. If satisfied, the infant
releases the breast spontaneously (that is, the caregiver does not cause the infant
to stop breastfeeding in any way). The infant appears relaxed, sleepy, and loses
interest in the breast.
An infant is not suckling effectively if he is taking only rapid, shallow sucks.
You may also see indrawing of the cheeks. You do not see or hear swallowing. The
infant is not satisfied at the end of the feed, and may be restless. He may cry or try
to suckle again, or continue to breastfeed for a long time.
An infant who is not suckling at all is not able to suck breast milk into his mouth
and swallow. Therefore he is not able to breastfeed at all. If a blocked nose seems to
interfere with breastfeeding, clear the infant’s nose. Then check whether the infant
can suckle more effectively.
SELF-ASSESSMENT EXERCISE I
Match signs with how well the infant is suckling.
a. Unable to suck breast milk.
SUCKLING EFFECTIVELY
Nose is not blocked.
b. Suckles deeply, sometimes pausing.
NOT SUCKLING EFFECTIVELY
Releases on own when satisfied.
c. Rapid, shallow sucks. Cannot hear swallowing.
NOT SUCKLING AT ALL
Cheeks draw in. Restless.
Watch “Demonstration: breastfeeding assessment” (disc 2)

In this video you will see all steps in breastfeeding assessment, and
examples of good attachment and suckling.
50
HOW WILL YOU CLASSIFY FEEDING PROBLEMS & LOW WEIGHT?

Open to your classification table for feeding problems and low weight. What do you
W WEIGHT FOR AGE observe? There are two possible classifications for feeding problem or low weight:
d young infants not breastfed because their mother follows the national recommendations to avoid all breastfeeding or when
1. FEEDING
exposed non-breastfed young infants PROBLEM
use the following or LOW
table "THEN WEIGHT
CHECK (YELLOW)
FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in
ital:
2. NO FEEDING PROBLEM (GREEN)
Not well attached to breast Yellow: If not well attached or not suckling effectively,
or FEEDING teach correct positioning and attachment
Classify FEEDING Not suckling effectively or PROBLEM If not able to attach well immediately, teach
Less than 8 breastfeeds in OR the mother to express breast milk and feed by
24 hours or LOW WEIGHT a cup
Receives other foods or If breastfeeding less than 8 times in 24 hours,
drinks or advise to increase frequency of feeding. Advise
Low weight for age or the mother to breastfeed as often and as long as
Thrush (ulcers or white the infant wants, day and night
patches in mouth). If receiving other foods or drinks, counsel the
mother about breastfeeding more, reducing other
foods or drinks, and using a cup
If not breastfeeding at all*:
Refer for breastfeeding counselling and
possible relactation*
Advise about correctly preparing breast-milk
substitutes and using a cup
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise 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 Green: Advise mother to give home care for the young
no other signs of NO FEEDING infant
inadequate feeding. PROBLEM Praise the mother for feeding the infant well
WHY IS NOT ABLE TO FEED NOT ON THIS CLASSIFICATION CHART?

The first and most severe classification, NOT ABLE TO FEED, was assessed
when you checked for signs of serious disease or possible local infection.
As such, this classification is not included on the classification chart for feeding
problem or low weight for age.
If the infant was NOT ABLE TO FEED, it was a severe classification (RED) because
this infant has a life-threatening problem. The infant requires the same urgent pre-
referral as SEVERE DISEASE, and then must be urgently referred.
Page 46 of 75
51
FEEDING PROBLEM OR LOW WEIGHT (YELLOW)

The classification of is feeding problem or low weight includes infants who are low
weight for age or infants who have some sign that their feeding needs improvement.
They are likely to have more than one of these signs.

Advise the caregiver of any young infant in this classification to breastfeed as
often and for as long as the infant wants, day and night. Short breastfeeds are an
important reason why an infant may not get enough breast milk. The infant should
breastfeed until he is finished.
Teach each caregiver about any specific help her infant needs, such as better
positioning and attachment for breastfeeding, or treating thrush.
NO FEEDING PROBLEM (GREEN)

A young infant classified as having no feeding problem is exclusively and frequently
breastfed. Not low weight for age means that the infant’s weight for age is not below
the line for “Low Weight for Age”.

The infant’s caregiver may still require counselling on good feeding to ensure that
the infant gains weight properly.
n How did you assess and classify Mimi’s feeding?

Biya breastfeeds Mimi. She explained earlier that she came to the clinic because Mimi had not been feeding
well for the past few days, and since this morning she was not taking the breast at all.
When you ask Biya to try and breastfeed, Mimi will not attach. This is a severe sign, as you classified earlier for
SEVERE DISEASE (RED).
You are not able to assess breastfeeding with Biya because Mimi will not take the breast. You checked Mimi
for thrush and ulcers, and she has none.
n Is Mimi low weight for her age?

Mimi is 6 weeks old and weighs 3.1 kg. Biya has told you that she is at a lower weight now than she was at
birth.
Mimi is low weight for age, because her weight falls below the low weight for age line used for young infants.
52
WHAT IF THE INFANT DOES NOT TAKE ANY BREAST MILK?

If the infant takes no breast milk, you will skip the previous two-part assessment.
You will instead complete a different assessment.
You will assess what the caregiver is feeding, and how. You will also use this chart
when an HIV positive
THEN caregiver
CHECK FORhas chosen
FEEDINGnotPROBLEM
to breastfeed.
OR LOW WEIGHT FOR AGE in NON-breastfed inf
Use this chart for HIV EXPOSED infants when the national authorities recommend to avoid all breast
What does the ASSESS chart
indications lookurgently
to refer like fortothis assessment?
hospital:
Ask: LOOK, LISTEN, FEEL: Milk incorrec

What milk are you giving? Determine weight for age. unhygienica
How many times during Look for ulcers or white Classify FEEDING
Giving inapp
the day and night? patches in the mouth replacemen
How much is given at (thrush).
Giving insuf
each feed?
replacemen
How are you preparing
the milk? An HIV posi
mixing brea
Let mother demonstrate or
feeds before
explain how a feed is
prepared, and how it is Using a feed
given to the infant. Low weight
Are you giving any breast Thrush (ulc
milk at all? patches in m
What foods and fluids in
Not low wei
addition to replacement
no other sig
feeds is given?
inadequate
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
W WEIGHT FOR AGE in NON-breastfed infants

onal authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding AND the infant has no
You will CLASSIFY with the following chart:
Milk incorrectly or Yellow: Counsel about feeding
unhygienically prepared or FEEDING Explain the guidelines for safe replacement
Classify FEEDING PROBLEM feeding
Giving inappropriate
replacement feeds or OR Identify concerns of mother and family about
LOW WEIGHT feeding.
Giving insufficient
replacement feeds or If mother is using a bottle, teach cup feeding
An HIV positive mother
mixing breast and other
feeds before 6 months or
Using a feeding bottle or
infant
Low weight for age or Follow-up any feeding problem or thrush in
Thrush (ulcers or white 2 days
patches in mouth). Follow-up low weight for age in 14 days
no other signs of NO FEEDING infant
inadequate feeding. PROBLEM Praise the mother for feeding the infant well
Please refer to the HIV module for more information on assessing and
classifying. The HIV module also contains information for counselling HIV-positive Page 47 of
women on infant feeding.
53
2.10 CHECK IMMUNIZATIONS

WHY ARE IMMUNIZATIONS IMPORTANT?
Immunizations help protect young infants from infections that can be especially
dangerous at their young age. Health workers have an important responsibility
to ensure that young infants are on schedule with their immunizations, and to
counsel caregivers about the importance of immunizations on schedule. See Module
8 for more details.
HOW WILL YOU CHECK IMMUNIZATION STATUS?

You will check immunization status by examining:
✔✔ Has the young infant received all the immunizations recommended for
his age?
✔✔ Does the young infant need any immunizations today?
CK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN
WHAT IMMUNIZATIONS ARE SCHEDULED FOR YOUNG INFANTS?
The immunization schedule relevant for young infants includes:
HEDULE: AGE VACCINE VITAMIN A

Birth BCG OPV-0 Hepatitis B0 200 000 IU to the mother within 6
weeks of delivery
6 weeks DPT+HIB-1 OPV-1 Hepatitis B1
10 weeks DPT+HIB-2 OPV-2 Hepatitis B2
doses on this visit.

ts unless being referred.Remember that you should not give OPV 0 to an infant who is more than 14 days old.
Therefore,
ker when to return for the if an infant has not received OPV 0 by the time he is 15 days old, you should
next dose.
wait to give OPV until he is 6 weeks old. Then give OPV 1 together with DPT 1.
When included in the National Immunization schedule, give three doses of Hepatitis B
and three doses of Haemophilus influenzae type b (Hib) vaccine; at 6 weeks, 10 weeks and
OTHER PROBLEMS 14 weeks, just like DPT.
HOW DO YOU MANAGE ANY REQUIRED IMMUNIZATIONS?

Administer any immunizations that the young infant needs today. Tell the caregiver
when to bring the infant for the next immunizations, and record this on your
recording form. If young infant is going to be referred, do not immunize
before referral.
54
Page 48 of 75
SELF-ASSESSMENT EXERCISE J
Decide if the infant needs any immunizations today, and which ones.
What does the infant need today, if
AGE STATUS
anything? How will you handle the case?
16 days Received BCG
7 weeks Received DPT-1, HIB-1
4 weeks Received BCG, OPV-0
MANAGEMENT OF THE
Received SICK
BCG, OPV-0.YOUNG
Infant is INFANT AGED UP TO 2 MONTHS
8 weeks
being urgently referred today.
FINALLY,
CHECK FOR YOU WILL
SEVERE DISEASE ASSESS
AND LOCAL FOR OTHER
BACTERIAL PROBLEMS:
INFECTION
Has the infant had convulsions? Repeat
Assess any other problems that the if elevated: ___
caregiver Fast breathing?
mentions or that you observe. Refer to
other guidelines on treatment of those problems. If you think the infant has a serious
problem, or if you do not know Fever (temperature 38°C or above fells hot) or
how to help the infant, refer the infant to hospital.
WHAT WILL YOU ASK THE CAREGIVER ABOUT HER OWN HEALTH?
stimulated?
This can provide valuable background
When did the jaundice appear first?
information about the caregiver, the child’s
Look for jaundice (yellow eyes or skin)
health status, and the householdLook at the youngThis
situation. infant'sinformation
palms and soles. Are theyallow
will yellow? you to better
counsel the caregiver.
Assessing a caregiver’s well-being should
Look for sunken eyes. include the following:
✔✔ Preventing and detecting postpartum Very slowly? complications (e.g. infections, bleeding,
Slowly?
THEN CHECKanaemia) FOR FEEDING PROBLEM OR LOW WEIGHT
Determine weight for age. Low ___ Not low ___
If the infant has
✔no ✔ Preventing
indication to refer or managing
urgently to hospital anaemia (iron and folic acid supplementation)
Look for ulcers or white patches in the mouth (thrush).
Is there any difficulty feeding? Yes ___ No ___
✔ Providing
✔breastfed?
Is the infant Yes ___information
No ___ and counselling on nutrition, safe sex and family planning
✔ ✔ Providing contraception
If yes, how✔ ✔ Planning postnatal care, including advice on danger signs and emergency
often?
preparedness
✔✔and/or
Note mother's Promoting use of insecticide treated nets
child's HIV status:
n How will you manage immunizations for Mimi today?
You have classified Mimi with several severe signs, and she requires urgent referral.
Mimi is due for her immunizations at 6 weeks: DPT-1 + HIB-1, OPV-1, and Hepatitis B1. You will not give Mimi
these immunizations now, because it will delay Is thereferral.
infant able You willToinclude
to attach? a notelook
check attachment, about
for: these immunizations
on her referral note so the staff can decide what to give her.
Biya told you when she arrived that she had made an appointment
More areola above than below for her own
the mouth: post-natal
Yes ___ No ___ care. Your first
priority is to stabilize Mimi for severe signs, and then you will assess Biya’s health. The recording
Is the infant sucking effectively (that is, slow deep sucks, sometimes form gives
you space to make notes from this assessment. pausing)?
effectively
mother (Date)
n How will you fill out this section of Mimi’s recording form?
55
2.11 COUNSEL THE CAREGIVER ON FEEDING
REFRESH!
In the introduction to these self-study modules, you learned some important
communications skills when counselling caregivers. Refer to PART 1 of this book to review these
good communications skills.
WHY IS COUNSELLING A CAREGIVER ABOUT THE YOUNG INFANT

SO CRITICAL?
Counselling the caregiver is a vital component of IMCI for the sick young infant.
You learned at the beginning of this module that young infants have special
characteristics, and require certain care for disease protection, healthy growth, and
development. Families need to fully understand these important care measures.
WHAT ARE THE MOST IMPORTANT MESSAGES ABOUT THE YOUNG

INFANT?
✔✔ BREASTFEED – caregivers should breastfeed exclusively and on demand
✔✔ KEEP INFANTS WARM – especially low weight infants
✔✔ WASH HANDS – before handling infants
✔✔ KEEP UMBILICAL CORD CLEAN
✔✔ BRING INFANT TO CLINIC IMMEDIATELY – if infant shows any signs of
severe disease or local infection
You will learn how to counsel on breastfeeding in this section (2.2.3).

In the next section (2.2.4) you will learn how to counsel on these other care measures.
HOW WILL YOU COUNSEL A CAREGIVER ABOUT FEEDING?

Feeding is a very important topic to counsel the caregiver about. There are four
particularly critical topics you must cover, including:
1. Correct positioning and attachment for breastfeeding
2. Expressing breast milk
3. Feeding by cup
4. Addressing other feeding problems
You will read more about these four topics in the following pages.
56
FEEDING #1
HOW WILL YOU TEACH CORRECT BREASTFEEDING POSITIONING
AND ATTACHMENT?
If the young infant is not correctly positioned or attached, they are not feeding
optimally.
WHAT ARE THE REASONS FOR POOR ATTACHMENT OR INEFFECTIVE

SUCKLING?
There are several reasons that an infant may be poorly attached or not able to suckle
effectively. Perhaps the infant was small and weak, or there was a delay starting
to breastfeed. The child may have had bottle feeds, especially in the first few days
after delivery. His caregiver may be inexperienced, or had some difficulty like flat
nipples and nobody was there to help or advise her.
HOW WILL YOU TEACH A CAREGIVER TO IMPROVE POSITIONING

AND ATTACHMENT?
If in your assessment of breastfeeding you found any difficulty with attachment or
suckling, help the caregiver position and attach her infant better.
Make sure that the caregiver is comfortable and relaxed, for example, sitting on a
low seat with her back straight. Then follow the steps in the box below.
TEACH CORRECT POSITIONING & ATTACHMENT FOR BREASTFEEDING

Show her how to hold her infant:
✔✔ With the infant’s head and body in line
✔✔ With the infant approaching breast with nose opposite to the nipple
✔✔ With the infant held close to the caregiver’s body
✔✔ With the infant’s whole body supported, 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 her breast, aiming the infant’s lower lip well below the nipple
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good,
try again.
57
WHAT ARE GOOD PRACTICES WHEN OBSERVING A BREASTFEED?

Always observe a caregiver breastfeeding before you help her, so that you understand
her situation clearly. Do not rush to make her do something different.
ENCOURAGE
If you see that the caregiver needs help, first say something encouraging, like: “She
really wants your breast milk, doesn’t she?”
GIVE POSITIVE SUGGESTIONS

Then explain what might help and ask if she would like you to show her. For example,
say something like, “Breastfeeding might be more comfortable for you if your young
infant took a larger mouthful of breast. Would you like
me to show you how?” If she agrees, you can start to
help her.
DO NOT TAKE OVER

As you show the caregiver how to position and attach
the infant, be careful not to take over from her. Explain
and demonstrate what you want her to do. Then let the
caregiver position and attach the infant herself.
CHECK & CORRECT

Then look for signs of good attachment and effective
suckling again. If the attachment or suckling is not
good, ask the caregiver to remove the infant from her Infant ready to attach. Nose is opposite nipple,
mouth is open wide.
breast and to try again.
ONCE THE INFANT IS WELL POSITIONED, WHAT INFORMATION IS

IMPORTANT?
When the infant is suckling well, explain to the caregiver that it is important to
breastfeed long enough at each feed. She should not stop the breastfeeding before
the infant wants to.
“Demonstration: teach correct positioning & attachment” (disc 2)

This video shows examples of good and poor positioning, and
instructions on how to show the caregiver how to position properly.
58
Feeding #2
HOW WILL YOU TEACH A CAREGIVER TO EXPRESS BREAST MILK?
All health workers who care for breastfeeding caregivers and young infants should be
able to teach caregivers how to express their milk. Expressing breast milk is usually
required for feeding infants who do not suck effectively, but can swallow well. This
is often the case of low birth weight babies. Expressing milk is also useful to:
➞ Relieve engorgement,
➞ Feed a sick young infant who cannot suckle enough,
➞ Keep up the supply of breast milk when a caregiver or young infant is ill, or
➞ Leave breast milk for a young infant when his caregiver goes out or to work
WHAT IS THE BEST WAY TO EXPRESS MILK?

Hand expression is the most useful way to express milk. It needs no appliance, so a
woman can do it anywhere, at any time. It is easy to hand express when the breasts
are soft. It is more difficult when the breasts are engorged and tender. As such, teach
a caregiver how to express her milk in the first or second day after delivery. Do not
wait until the third day, when her breasts are full.
Many caregivers are able to express plenty of breast milk using different
techniques. If a caregiver’s technique works for her, let her continue to do it that
way. But if a caregiver is having difficulty expressing enough milk, teach her a more
effective technique.
HOW SHOULD YOU SHOW A WOMAN HOW TO EXPRESS?

A woman should express her own breast milk. The breasts are easily hurt if
another person tries. If you are showing a woman how to express, show her on your
own body as much as possible, while she copies you. If you prefer not to use your
own body, use a model breast, or practice on the soft part of your arm or cheek. If
you need to touch her to show her exactly where to press her breast, be very gentle.
WHEN SHOULD A CAREGIVER START TO EXPRESS MILK?

A caregiver should start to express milk on the first day, within six hours of
delivery if possible. She may only express a few drops of colostrum at first, but it
helps breast milk production to begin, in the same way that a young infant suckling
soon after delivery helps breast milk production to begin.
She should express as much as she can as often as her young infant would
breastfeed. This should be at least every 3 hours, including during the night. If
she expresses only a few times, or if there are long intervals between expressions,
she may not be able to produce enough milk.
59
WHAT IF A CAREGIVER IS EXPRESSING MORE THAN

HER INFANT NEEDS?
If a caregiver is expressing more than her low birth weight young infant needs, let
her express the second half of the milk from each breast into a different container.
Let her offer the second half of the expressed breast milk first. Her young infant
gets more hind milk, which helps him to get the extra energy that he needs. This
helps a young infant to grow better.
WHAT ARE THE STEPS FOR TEACHING HOW TO EXPRESS

BREAST MILK?
PREPARATIONS
1. Choose a cup, glass or jug with a wide mouth. Wash the cup in soap and water.
Pour boiling water into the cup, and leave it for a few minutes. Boiling water will
kill most of the germs. Pour water out of cup when ready to express milk.
2. Wash hands thoroughly
3. Get comfortable
WHEN READY TO EXPRESS MILK

4. Hold a wide necked container under nipple and areola
5. Place thumb on top of the breast and the first finger on the underside of the
breast so they are opposite each other (at least 4 cm from the tip of the nipple). See
illustration below.
6. Compress and release the breast tissue between her finger and thumb a few
times – see illustration below. If the milk does not appear she should re-position
her thumb and finger closer to the nipple and compress and release the breast as before.
7. Compress and release all the way around the breast, keeping her fingers the same
distance from the nipple. See illustration below. Be careful not to squeeze the
nipple or to rub the skin or move her thumb or finger on the skin.
8. Express one breast until the milk just drips, then express other breast until the
milk just drips.
9. Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes. Stop
expressing when the milk no longer flows but drips from the start.
EXPRESSING BREAST MILK BY HAND

1. Place thumb on top of breast, 2. Compress and release the breast tissue. 3. Compress and release all the way
and first finger on underside. around the breast. Keep fingers the
same distance from nipple.
60
Feeding #3
HOW WILL YOU TEACH A CAREGIVER TO FEED BY CUP?
If a young infant cannot breastfeed, he should be fed expressed breast milk by a
cup. If the caregiver cannot or has chosen not to breastfeed, the infant should be
fed a breast milk substitute by a cup.
TEACH THE CAREGIVER HOW TO FEED BY A CUP

✔✔ Put a cloth on the infant’s front to protect his clothes as some milk can spill
✔✔ Hold the infant semi-upright on the lap
✔✔ Put a measured amount of milk in the cup
✔✔ Hold the cup so that it rests lightly on the lower lip
✔✔ Tip the cup so that the milk just reaches the infant’s lips
✔✔ Allow the infant to take the milk himself. DO NOT pour the milk into the
infant’s mouth.
WHY IS CUP FEEDING SAFER THAN BOTTLE FEEDING?

✔✔ Cups are easy to clean with soap and water, if boiling is not possible.
✔✔ Cups are less likely than bottles to be carried around for a long time, which gives
bacteria time to breed
✔✔ A cup cannot be left beside a young infant, for the young infant to feed himself.
The person who feeds a young infant by cup has to hold the young infant and
look at him, and give him some of the contact that he needs.
✔✔ A cup does not interfere with suckling at the breast.
✔✔ A cup enables a young infant to control his own intake.
WHY IS CUP FEEDING PREFERABLE TO SPOON FEEDING?

➤ Spoon feeding takes longer
➤ Caregivers often find spoon feeding difficult, especially at night
➤ You need 3 hands to spoon feed: to hold the infant, the cup of milk, and the
spoon
➤ Some caregivers give up spoon feeding before the young infant has had enough
➤ Some spoon-fed babies do not gain weight well.
However, spoon feeding is safe if a caregiver prefers it, and if she gives the young
infant enough. Also, if a young infant is very ill, for example with difficult breathing,
it is sometimes easier to feed him with a spoon for a short time.
SUMMARY OF FEEDING TIPS: Feeding from a cup is safer than a bottle.

Cups are often easier to use than spoons, though spoons are safe.
61
Feeding #4
WHEN WILL YOU COUNSEL A CAREGIVER ABOUT OTHER
FEEDING PROBLEMS?
➤ If a caregiver is breastfeeding less than 8 times in 24 hours:
Advise her to increase the frequency of breastfeeding. The caregiver should
breastfeed as often and for as long as the infant wants, day and night.
➤ If the infant receives other foods or drinks:
Counsel the caregiver about breastfeeding more, reducing the amount of
the other foods or drinks, and if possible, stopping altogether. Advise her to
feed the infant any other drinks from a cup, and not from a feeding bottle.
➤ If a caregiver does not breastfeed at all:
Consider referring her for breastfeeding counselling and possible re-
lactation. If the caregiver is interested, a breastfeeding counsellor may be able
to help her to overcome difficulties and begin breastfeeding again.
Advise a caregiver who does not breastfeed about choosing and correctly preparing
an appropriate breastmilk substitute. Also advise her to feed with a cup, and not
a bottle.
SELF-ASSESSMENT EXERCISE K
Practice what you have learned on counselling a caregiver about infant feeding.
1. Are the following statements TRUE or FALSE?
a. Spoon feeding is not safe TRUE FALSE
b. Cup feeding is the preferred method of feeding TRUE FALSE
c. Bottle feeding is unsafe TRUE FALSE
d. Cup feeding is preferred over spoon feeding TRUE FALSE
e. Bottle feeding is most recommended for young infants
to practice suckling TRUE FALSE
2. Srilekha is unsure how to hold her infant while breastfeeding. How will you show
her how to hold?
3. Yoonhee is unsure how to help her infant attach. What should she do?
4. How frequently should a caregiver breastfeed in 24 hours?

5. Jaya breastfeeds but also gives her 4-month old some watery porridge. What do
you recommend for her feeding?
62
Follow-up
WHEN SHOULD A CAREGIVER FOLLOW-UP ABOUT THESE
FEEDING PROBLEMS?
Young infants are asked to return sooner than older infants and young children.
This is because they should be growing quickly, and are at higher risk if they do not
gain weight. Quick follow-up is especially important if you are recommending a
change in the way the infant is fed.
FEEDING PROBLEM OR THRUSH (FOLLOW-UP 2 DAYS)

When a young infant who had a feeding problem returns for follow-up in 2 days:
✔✔ Refer to the young infant’s chart or follow-up note for a description of the
feeding problem found at the initial visit and previous recommendations.
✔✔ ASK: how have you carried out these recommendations? Did you have
problems?
What actions will you take?

Counsel the caregiver about new or continuing feeding problems. Refer to the
recommendations in the box “Counsel the Caregiver About Feeding Problems” on
the COUNSEL chart and the box “Teach Correct Positioning and Attachment for
Breastfeeding” on the YOUNG INFANT chart.
For example, you may have asked a caregiver to stop giving an infant water or juice
in a bottle, and to breastfeed more frequently and for longer. You will assess how
many times she is now breastfeeding in 24 hours and whether she has stopped
giving the bottle. Then advise and encourage her as needed.
LOW WEIGHT FOR AGE (FOLLOW-UP 14 DAYS)

When a young infant classified as low weight for age returns in 14 DAYS, you will:
✔✔ Determine if the young infant is still low weight for age.
✔✔ Reassess his feeding by asking the questions the ASSESS box.
✔✔ Assess breastfeeding if the young infant is breastfed.
 NO LONGER LOW WEIGHT

Praise the caregiver for feeding the infant well. Encourage her to continue feeding
the infant as she has been or with any additional improvements you have suggested.
  STILL LOW WEIGHT, BUT FEEDING WELL

Praise the caregiver. Ask her to have her infant weighed again within a month or
when she returns for immunization. You will want to check that the infant continues
to feed well and continues gaining weight. Many young infants who were low birth
weight will still be low weight for age, but will be feeding and gaining weight well.
63
 STILL LOW WEIGHT, AND STILL HAS FEEDING PROBLEM

Counsel the caregiver about the problem. Ask the caregiver to return with her infant
again in 14 days. Continue to see the young infant every few weeks until you are sure
he is feeding well and gaining weight regularly or is no longer low weight for age.
 LOST WEIGHT, NO WEIGHT GAIN IN 14 DAYS

This young infant should be referred to the hospital. This is also the case if you
think the problem will not improve.
64
2.12 COUNSEL THE CAREGIVER ON INFANT CARE

AFTER FEEDING, WHAT TOPICS WILL YOU DISCUSS
WITH A CAREGIVER?
You will advise a caregiver on other important care for infants. To review these topics:
1. Keeping an infant warm
2. Maintaining good hygiene
3. When to follow-up
Infant care #1
WHY IS IT IMPORTANT TO KEEP AN INFANT WARM AT HOME?
It is important to maintain the body temperature of the newborn between 36.5 and
37.4 °C. Low temperature in the newborn has an adverse impact on the sick newborn
and increases the risk of death. Low birth weight infants need greater attention to
temperature care than those infants who do have not low birth weight.
WHAT ARE GOOD PRACTICES FOR KEEPING AN INFANT WARM?

There are several practices you should advise:
•• Keep the infant in her bed in a warm room – with room temperature at least 25oC
•• Avoid bathing the low weight infant
•• Keep the infant dry at all times
•• Periodically feel the hands and feet of the infant to make sure that they are warm.
Skin-to-skin contact is the best way to re-warm the infant if the hands and
feet are cold, and to prevent the infant getting cold.
HOW DOES SKIN-TO-SKIN CONTACT WORK?

Skin-to-skin contact can be provided by the caregiver or any adult. The adult body
will transfer heat to the newborn. To keep the infant in skin-to-skin contact in the
clinic, provide privacy to the caregiver and request her to sit or recline comfortably.
1. Undress infant gently, except for cap, nappy and socks.
2. Place infant against the caregiver’s bare chest in an upright and
extended posture, between her breasts.
3. Turn infant’s head to one side to keep airways clear.
4. Cover the infant with caregiver’s blouse or gown. Then wrap
caregiver-baby pair with an extra blanket or shawl.
5. Breastfeed the young infant frequently.
65
If skin-to-skin contact is not possible, dress and wrap the young infant ensuring
that head, hands and feet are also well covered. Hold the young infant close to
the caregiver’s body, in a room warmed by a heating device. Ask the caregiver to
breastfeed the young infant frequently.
Infant care #2
HOW WILL YOU COUNSEL ON GOOD HYGIENE CARE?
There are two very important hygiene practices when caring for a young infant:
n WASH HANDS every time before handling the infant

Counsel the caregiver on the importance of washing hands before handling the
infant. Emphasize that everyone in the household who handles the young infant should
follow this practice. Everyone in the household must also wash hands after going
to the toilet.
Demonstrate to the caregiver how to properly wash hands with soap and water. This
should emphasize the correct length of time, and scrubbing nails.
n KEEP UMBILICAL CORD CLEAN

Cleaning the umbilical cord and area around it is an essential care practice. This
area is particularly vulnerable to infection in the first weeks of a young infant’s life.
The cord must be kept clean and dry until the stump falls off. If rubbing
alcohol is available, this may help keep the stump dry and hygienic. This alcohol is
very dangerous to drink and families must be careful in storing it away. If rubbing
alcohol is not available, the caregiver should use clean water and soap to gently clean.
With good cord care, the umbilical cord usually separates one to two weeks
after birth. The wound often heals within 15 days. Even if it appears to be about
to fall, advise parents they should not remove the stump.
Infant care #3
HOW WILL YOU COUNSEL ON WHEN TO BRING THE INFANT BACK
TO THE CLINIC?
Tell the caregiver when to return for a follow-up visit and when to return
immediately. These are different visits, so you must explain them fully to the
caregiver.
FOLLOW-UP VISIT is arranged to check on the conditions that you classified today.
INFANT CLASSIFIED AS: RETURN FOR FOLLOW-UP VISIT IN:
✔ Jaundice 1 day
✔ Local bacterial infection ✔ Thrush
2 days
✔ Feeding problem ✔ Diarrhoea
✔ Low weight for age 14 days
66
RETURNING IMMEDIATELY is required when young infant starts showing signs

of serious illness. These signs are very important and caregivers should know
them.
RETURN IMMEDIATELY if the infant:
✔ Breastfeeds poorly ✔ Feels unusually cold
✔ Reduces activity ✔ Is breathing fast or having difficulty breathing
✔ Becomes sicker ✔ Difficult breathing
✔ Develops a fever ✔ Palms and soles appear yellow
Teach the caregiver about these signs. Use the caregiver’s card to explain the
signs. Ask her checking questions to be sure she knows when to return immediately.
SELF-ASSESSMENT EXERCISE L
In this exercise, you will use the case study SASHI from earlier in this module.
Use Sashi’s recording form for this activity. Refer to the YOUNG INFANT chart
as needed.
Review the infant’s assessment findings, classifications, and treatments needed.
Answer the additional questions below about treating each case.
1. In addition to treatment with antibiotics, Sashi needs treatment at home for her
local infection, that is, the pustules on her buttocks. List below the steps that
her caregiver should take to treat the skin pustules at home.
2. How often should her caregiver treat the skin pustules?
3. Sashi also needs “home care for the young infant.” What are the 3 main points
to advise the caregiver about home care?
4. What would you tell Sashi’s caregiver about when to return?
67

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE FROM THIS
MODULE IN YOUR CLINIC?
Use your Chart Booklet and IMCI recording forms for the sick young infant as you
practice in the clinic. In the coming days, you should focus on the clinical skills below.
PART I
GREETING
✔✔ Greet caregivers and use good communication skills to make them feel welcome
✔✔ Ask for important information from the caregiver: infant’s name, age, problems,
history, temperature, and weight
CHECK ALL YOUNG INFANTS FOR SIGNS OF SERIOUS ILLNESS

✔✔ Assess if the infant is having difficulty feeding
✔✔ Look for severe chest indrawing
✔✔ Count breathing – is the young infant breathing too fast?
✔✔ Look at the umbilicus for signs of infection
✔✔ Look for skin pustules
✔✔ Assess the young infant’s movements
✔✔ Determine if the young infant has had convulsions
ASSESS & CLASSIFY THE SICK YOUNG INFANT

✔✔ Check all infants for jaundice, and assess and classify
✔✔ Check all infants for diarrhoea, and assess and classify
TREAT THE SICK YOUNG INFANT

✔✔ Provide pre-referral treatments in classification tables and prepare referral notes
✔✔ Treat infants to prevent low blood sugar
✔✔ Provide antibiotics and care for local infections
PART II
ASSESS & CLASSIFY THE SICK YOUNG INFANT
✔✔ Assess all infants for feeding problems and low weight, and classify
✔✔ Assess breastfeeding – look for signs of good attachment and positioning
✔✔ Check for immunizations
✔✔ Check for other problems, or any health problems the caregiver is having
68
COUNSEL A CAREGIVER ON FEEDING

✔✔ Counsel a caregiver on correct positioning and attachment for breastfeeding
✔✔ Teach a caregiver to express breast milk
✔✔ Teach a caregiver to feed by cup
✔✔ Counsel a caregiver on other feeding problems
COUNSEL ABOUT INFANT CARE

✔✔ Counsel about keeping an infant warm
✔✔ Show caregivers how to provide skin-to-skin care
✔✔ Counsel on hygiene and demonstrate good handwashing
✔✔ Counsel caregivers on when to return to the clinic for follow-up
✔✔ Counsel caregivers on the signs for immediate return to the clinic
Remember to use your logbook for MODULE 2:

n Complete logbook exercises, and bring completed to the next meeting
n Record cases on IMCI recording forms, and bring to the next meeting
valuable notes to share with your study group and facilitator.
69

MANAGING SICK YOUNG INFANTS?
Before you began studying this module, you practiced your knowledge on with
several multiple-choice questions. Now that you have finished the module, you
will answer the same questions. This will help demonstrate what you have learned.
Circle the best answer for each question.
1. Why do young infants require different care than sick children?
a. Young infants are much quicker to recover from illness because they are
young.
b. Young infants show signs of illness differently. They can also become ill and
die from an infection very quickly.
c. Young infants very rarely get sick.
2. Which of the following is important care for a young infant?
a. Keeping the infant loosely bundled so he can begin to move his arms and legs
b. Keeping the umbilical cord moist so that it falls off quickly
c. Keeping the infant warm through skin-to-skin care
3. What are the feeding recommendations for sick young infants?
a. Exclusive, on-demand breastfeeding for at least 6 months
b. Breastfeeding and additional sources of fluid, like water, to hydrate
c. Soft complementary foods as soon as the child is ready
4. What are signs that a young infant is seriously ill and needs urgent referral and
care?
a. Breathing more than 60 breaths per minute
b. Skin pustules
c. Some jaundice, where the eyes are yellow but not the palms or soles
5. A young infant presents at your clinic, and his caregiver says the infant has been
feeding well, but in the past 2 days is unable to breastfeed at all. What actions
will you take?
a. Counsel the caregiver on positioning and attachment so that the infant can
breastfeed better.
b. The infant is seriously ill if they are unable to feed. You must urgently refer.
c. Recommend that the caregiver give other safe fluids by cup.
Turn back to the section to re-read and practice the exercises.
70
2.15 ANSWER KEY

REVIEW QUESTIONS
Did you miss the question?
QUESTION ANSWER
Return to this section to read and practice:
1 B PART I INTRODUCTION TO SICK YOUNG INFANT
2 C PART I INTRODUCTION TO SICK YOUNG INFANT
3 B II COUNSEL THE CAREGIVER ON FEEDING
4 A PART I ASSESS & CLASSIFY FOR SIGNS OF SERIOUS DISEASE
ASSESS & CLASSIFY FEEDING PROBLEMS OR LOW
5 B PART II
WEIGHT
EXERCISES PART I
EXERCISE A
1. Are these statements true or false? If they are false, write out the correct statement.
a. TRUE Young infants are up to 2 months of age.
b. FALSE. Correct: The IMCI process is the same for both the sick young infant and
the sick child. They require separate charts because some signs and symptoms
are age-specific.
c. TRUE Severe infections are the most serious illness in the first two months of life.
d. FALSE. Correct:Young infants show signs of illness very differently than older
infants or children. This is why they are assessed for different signs and symptoms.
e. FALSE. Correct: Sami is a sick child. Young infants are up to 2 months, so this does
not include a child that is 2 months old.
2. Correct special care measures:
➝ Skin-to-skin contact (kangaroo care) to keep the infant warm
➝ Seek care immediately if infant develops signs of serious illness
➝ Exclusive, on-demand breastfeeding
➝ Give immunizations on schedule
➝ Wash hands before handling the young infant
EXERCISE B
1. 60 breaths or more per minute, counted twice.
2. Make sure infant is calm. Count breathing. If over 60 breaths per minute, count a
second time to confirm.
3. Taking axillary (armpit) temperature, feeling the infant, or rectal temperature
(temperature thresholds are .5 degrees higher)
4. 37.5 or more degrees Celsius
5. Below 35.5 degrees Celsius
71
6. If false, write the correct statement.

a. FALSE Correct statement: Chest indrawing is identified when the infant breathes IN.
In normal breathing, when the infant breathes IN, the abdomen and chest wall move
out. With chest indrawing, the chest wall moves IN.
b. FALSE Correct statement: If the umbilicus is red or draining pus, it is a sign of infection.
c. TRUE
d. TRUE
EXERCISE C
1. Answers below:
a. T
b. F
c. T
d. T
e. T
f. F
g. T
2. Answers below:
a. NO JAUNDICE (GREEN)
b. SEVERE JAUNDICE (RED)
c. JAUNDICE (YELLOW)
3. Biki has jaundice after 14 days of life. He should be referred for assessment.
EXERCISE D
1. Henri:

Name: Henri Age: 6 hours Weight (kg): 3.0 Temperature (°C): 36.5

Ask: What are the infant's problems?: Difficult breathing, did not cry after birth Initial Visit? ✗ Follow-up Visit?
Has the infant had convulsions? 70
Repeat if elevated: ___ Fast breathing?
Look and listen for grunting. Very severe
Look at the umbiculus. Is it red or draining pus? disease
Fever (temperature 38°C or above fells hot) or (red)
stimulated?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___ ✗
Very slowly?
Slowly?
If yes, how often?
72
2. Sashi:

Name: Sashi Age: 1 week Weight (kg): 3.4 Temperature (°C): 37
Rash
Ask: What are the infant's problems?: Initial Visit? ✗ Follow-up Visit?
Look and listen for grunting. Local infection
Look at the umbiculus. Is it red or draining pus? (yellow)
stimulated?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___ ✗
Very slowly?
Slowly?
EXERCISE
Is there any difficulty feeding? EYes ___ No ___
If yes, how many HENRI:
1. times Henri___
in 24 hours? must
timesbe urgently referred. You classified him as VERY SEVERE DISEASE.
drinks? Yes ___ NoHe ___requires the following pre-referral treatments:
If yes, how often?
What do you use to✔ ✔ First
feed dose of intramuscular antibiotics: AMPICILLIN 1.0 ml and GENTAMICIN 1.6 ml
the child?
Note mother's and/or✔ ✔ Treat
child's HIV to prevent low blood sugar (you will need to determine if he can breastfeed
status:
or swallow)
✔✔ Advise
If mother is HIV positive and and NOcaregiver how to
positive virological testkeep Henri
in young infant:warm on way to hospital
Was the infant SASHIE: Sashie
2. breastfeeding was
at the time classified
of test or 6 weeksLOCAL
before it?INFECTION. She does not need to be urgently
referred. She requires the following treatments:
✔✔ Give an oral antibiotic,Ifinfant
the infant has not fed in the previous hour, ask the mother to put her
and preferably
to syrupthesobreastfeed
the breast. Observe that she for can drink it. If you have
4 minutes.
COTRIMOXAZOLE, she will require
Is the 1.25 ml
infant able syrup,
to attach? twice
To check a daylookfor
attachment, for:5 days. If you
have AMOXICILLIN, she will Mouth require 2.5 ml syrup, twice
wide open: Yes ___ No ___ a day for 5 days.
✔✔ You will give the first dose in
Morethe clinic
areola and
above thanthen counsel
below the the___caregiver
mouth: Yes No ___ how to
give the remaining dosesIs–the
twice a day for 5 days. You will teach her how to give
infant sucking effectively (that is, slow deep sucks, sometimes
(GIVE INFORMATION, SHOW HER HOW TO DO IT AS YOU GIVE THE FIRST DOSE,
pausing)?
AND ASK HER TO SHOW YOU HOW SHE WILL DO IT). You will confirm that she
effectively
CHECK THE CHILD'Sunderstands
IMMUNIZATION STATUS
by using (Circle immunizations
checking questions. needed today) Return for next
OPV-0 OPV-1 ________________
✔✔ You will OPV-2
teach the caregiver how to treat the skin vitamin A to
pustules. She should do the
mother (Date)
treatment twice a day for
ASSESS OTHER PROBLEMS: Ask 5 days.
about Sheown
mother's will:health
wash hands, gently wash the pus and
crusts with soap and water, dry the area, paint the skin with gentian violet (.5%),
and then wash her hands again.
✔✔ You will counsel her to follow-up for the local infection in 2 DAYS.
✔✔ You will review the signs that the caregiver must watch for, and return
immediately.
73
Page 71 of 75
EXERCISE F
1. You will reassess by looking at the skin pustules. Decide if there are many or severe
pustules. See if the redness and pus of the pustules is improved.
2. Tell Sashi’s caregiver that the infection is improving, but that she must complete
the 5 days of antibiotic. She should also continue cleaning the skin and applying
gentian violet on those days.
EXERCISES PART II
EXERCISE G
1. Exclusive breastfeeding is recommended until at least 6 months of age. The three
points are:
a. Exclusive: no other fluids or foods are given, only breastmilk
b. On demand: the infant should breastfeed whenever he wants, day and night
c. The infant should breastfeed at least 8 times in 24 hours
2. FALSE – the infant has a severe classification (RED) and requires urgent referral, so
you will skip the feeding and low weight assessment.
3. Answers below:
a. YES
b. NO
c. YES
d. YES
e. NO
f. NO
g. YES
4. Low birth weight is when a baby weighs less than 2.5 kg (2500 grams) at birth.
5. A very low birth weight baby weighs less than 1.5 kg (1500 grams) at birth.
EXERCISE H
Circle the signs of good attachment. Cross-out the signs of poor attachment:
Chin away from breast Mouth wide open
More areola visible above than below mouth Lower lip turned outward
Chin touching breast Narrow mouth with lips pushed forward
Equal amount areola visible below/above mouth Lower lip turned in
EXERCISE I
a. Not suckling at all
b. Suckling effectively
c. Not suckling effectively
74
EXERCISE J
What does the infant need today, if
AGE STATUS
anything? How will you handle the case?
16 days Received BCG None, appointment for 6 weeks of age
7 weeks Received DPT-1, HIB-1 OPV1, Hep B 1
4 weeks Received BCG, OPV-0 None, give appointment for 6 weeks
Received BCG, OPV-0. Infant is No vaccines now. Urgently transfer to
8 weeks
being urgently referred today. hospital.
EXERCISE K
1. Are the following statements TRUE or FALSE?
a. FALSE
c. TRUE
d. TRUE
e. TRUE
f. FALSE
2. Show Srilekha how to hold her infant:
✔✔ With the infant’s head and body in line
✔✔ With the infant approaching breast with nose opposite to the nipple
✔✔ With the infant held close to the caregiver’s body
✔✔ With the infant’s whole body supported, not just neck and shoulders
3. Show Yoonhee how to help her infant attach:
✔✔ Touch her infant’s lips with her nipple
✔✔ Wait until her infant’s mouth is opening wide
✔✔ Move her infant quickly onto her breast, aiming the infant’s lower lip well below
the nipple
4. At least 8 times in 24 hours
5. Jaya should:
✔✔ Breastfeed more (on demand, at least 8 times in 24 hours)
✔✔ Stop the porridge and breastfeed exclusively – determine why she began giving
porridge and what issues she is having with feeding
EXERCISE L
1. Steps that her caregiver should take to treat the skin pustules at home:
a. Wash hands
b. Gently wash off pus and crusts with soap and water
c. Dry the area
d. Paint with gentian violet
e. Wash hands
2. Twice each day
75
3. The 3 main points to advise the caregiver about home care are:
a. Food/Fluids: Breastfeed frequently, as often and for as long as the infant wants,
day and night, during sickness and health
b. When to return
c. Make sure the young infant stays warm at all times
4. Return in 2 days for follow-up (to be sure the skin pustules are improving). Return
immediately if Sashie is breastfeeding poorly, becomes sicker, develops a fever,
breathing becomes fast or difficult, or if there is blood in her stool.
76
ISBN 978 92 4 150682 3
IMCI
Module 3
Cough or
difficult breathing
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING
n CONTENTS
Acknowledgements 4
3.2 Introduction to cough or difficult breathing 7
3.3 Assess a child for cough or difficult breathing 9
3.4 Classify cough or difficult breathing 15
3.5 Treat the child with cough or difficult
breathing 21
3.6 Counsel the caregiver 28
3.7 Provide follow-up care for cough or
difficult breathing 35
3.8 Using this module in your clinical practice 38
3.10 Answer key 40
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
3.1 MODULE OVERVIEW

A cough or difficult breathing is a common reason why a mother will bring a child
to your clinic. The problem may be a mild cold, or it may be a serious problem like
pneumonia. How can you tell the difference? How should you treat the child? How
should you counsel the mother? The choices may seem confusing, but this self-
learning module will help you make the correct decisions.
For ALL sick children – ask the caregiver about the child’s problems,
check for general danger signs, and then ASK:
DOES THE CHILD HAVE A COUGH OR DIFFICULT BREATHING?
NO YES
ASSESS & CLASSIFY the child using

the colour-coded classification charts
for cough or difficult breathing.
CONTINUE ASSESSMENT: assess for main symptoms (next is diarrhoea), check for
malnutrition & anaemia, check immunization status, HIV status, and other problems

After you study this module, you will be able to:
✔✔ Assess cough or difficult breathing using the IMCI Chart Booklet
✔✔ Recognize main clinical signs of cough or difficult breathing
✔✔ Classify cough or difficult breathing
✔✔ Treat a child with cough or difficult breathing according to IMCI guidelines
✔✔ Counsel caregiver on home care
✔✔ Give appropriate follow‐up care for a child with cough or difficult breathing
YOUR RECORDING FORM
Look
NOT ABLE TO DRINKat
ORyour IMCI recording form
BREASTFEED for the
LETHARGIC sick child. This
OR UNCONSCIOUS section deals with this present?
module:
Danger sign when
selecting
classifications
5
Slowly?
MODULE ORGANIZATION
This module follows the major steps of the IMCI process:
✔✔ Assess cough or difficult breathing
✔✔ Classify cough or difficult breathing
✔✔ Treatment for cough or difficult breathing
✔✔ Counsel caregiver on home care (oral antibiotics, safe remedies)
✔✔ Follow-up care for cough or difficult breathing
BEFORE YOU BEGIN

What do you know now about managing cough or difficult breathing?
Before you begin studying this module, quickly practice your knowledge with these
multiple-choice questions.
1. What clinical signs can help you identify if a child has pneumonia?
a. Wet cough
b. Fast breathing
c. Chest indrawing
2. If a child has pneumonia, how will you treat?
a. Oral antibiotics
b. Honey
c. Paracetamol
3. Why is it important to correctly identify and manage pneumonia?
a. Pneumonia is very common, but it is not so serious for children
b. Pneumonia is a major killer of children under 5 around the world, and it
requires early management
c. Children with pneumonia need to be isolated from all other family members
4. Chest indrawing is when:
a. The lower ribs move in when the child breathes out
b. The lower ribs move in when the child breathes in
c. The lower ribs are always pushed in, no matter if the child is breathing in or out
5. Children who have a cough, but do not show signs of pneumonia, should
immediately receive an antibiotic:
a. TRUE
b. FALSE
6. The following is a good checking question: “how will you prepare a safe home
remedy for cough?”
a. TRUE
b. FALSE
demonstrate to you what you have learned during the module!
6
3.2 INTRODUCTION TO COUGH OR

DIFFICULT BREATHING
Consider a typical case that you might see in your practice. Imagine the situation.
This will help you start thinking about the problem of a child with a cough or
difficult breathing.
n OPENING CASE STUDY – JACOB

Amira lives in a village two hours walk away from the regional health centre. She arrives at your clinic and
carefully takes Jacob off her back. She presents him to you with a look of panic on her face. She tells you that
Jacob is not feeling well and she is worried about him.
Amira watches her children carefully. She has been noticing for the last 3 days that Jacob does not seem to
be himself. He is 6 months of age and has been started on some solids, but is now refusing to take these
solids. He is also not breastfeeding as much as he was.
Amira is quite worried and scared to tell her husband. She decides to walk the two hours to the local health
clinic carrying Jacob on her back. Amira had three other children. However, one died at three weeks of age
from an illness she is not sure about.
Her husband is often away. When he is home he sometimes is violent towards the children, especially if they
are crying and seem to be unwell. Amira thinks he may be frightened that another child will die.
She is unsure about whether she should attend the clinic. She decides that this is the best thing. She just
hopes that Jacob gets well and her husband does not find out.
n Greet Amira at the clinic

First, you praise Amira for bringing Jacob to the clinic. You tell her that you know it is a long walk and she
must be tired. Compliment her on the wisdom of her decision and her effort in bringing Jacob to the clinic.
Reassure her that she did the right thing to help her child.
This conversation with Amira will establish good communications between you and the mother. That
is important, because she will have a lot of responsibility for Jacob’s care. You want her to trust you and
understand your directions.
You have learned from Amira that the child’s name is Jacob, and he is 6 months old. She is concerned
because he is not feeding well.
When you ask more about this, Amira tells you that she has noticed that Jacob starts to breastfeed and then
pulls off the breast and seems to pant for air before going back for a further suckle. She has noticed that his
stomach seems to be going in and out quite quickly.
This is her initial visit to the clinic for this problem. Jacob weighs 5kg and his temperature is 37 degrees.
7
n Next, check Jacob for general danger signs

Amira has told you that Jacob is not eating solids well, and he is taking the breast less than he used to. You
ask her if he is still able to drink or breastfeed. She says yes, he will take the breast, but he does not drink well.
He does not vomit. He has had no convulsions.
You look at Jacob’s condition. He appears very tired, but lifts his hand to Amira. His eyes look up to Amira and
follow you when you snap your fingers.
Here is how you would complete Jacob’s recording form thus far:

Name: Jacob Age: 6 mo Weight (kg): 5 kg Temperature (°C): 37 °C
Ask: What are the child's problems? Not feeding well (not taking other foods, not taking Initial Visit? X Follow-up Visit?
ASSESS (Circle all signs present) breast well), rapid breathing CLASSIFY
VOMITS EVERYTHING CONVULSING NOW X
Yes ___ No ___
Danger sign when
selecting
classifications
Jacob shows no general danger signs. You will now assess for cough or difficult
breathing.
Slowly?
8
Hep B0
RTV-1 RTV-2 RTV-3
3.3 ASSESS A CHILD FOR COUGH OR DIFFICULT

BREATHING
WHY ARE WE CONCERNED ABOUT COUGH OR
DIFFICULT BREATHING?
Jacob reminds us that many problems can occur
nose
at any site in the respiratory system. Here is a
simple illustration to remind you of the different throat epigottis
parts of the respiratory system. ribs larynx
You will go step-by-step through the process of lungs trachea

assessing, classifying, and treating respiratory bronchi
infections.
You will use the story of Jacob and his mother
Amira as an example.
The respiratory tract
WHAT CAUSES COUGH OR DIFFICULT BREATHING?

Many children who come to your clinic with a cough or difficult breathing may have
mild respiratory infections. They may have a cold or bronchitis. These children are
not seriously ill and do not need antibiotics, they can be treated at home.
However, some children with cough or difficult breathing may have
pneumonia or another serious respiratory infection. You have learned that
pneumonia is one of the greatest causes of child mortality in the world.
Children can die from bacterial pneumonia because they can’t get enough oxygen
(hypoxia) or they get a generalized infection (sepsis). Most pneumonia in
developing countries is caused by bacteria and can be treated with antibiotics.
HOW CAN YOU IDENTIFY PNEUMONIA?

Pneumonia is a serious respiratory infection. You can identify children with
pneumonia by checking for two clinical signs. When children develop pneumonia,
their lungs become stiff. These two signs help show how stiff the lungs have become.
1. FAST BREATHING: is one of the body’s responses to stuff lungs and hypoxia.
2. CHEST INDRAWING: develops when the lungs become even stiffer as the
pneumonia becomes more severe.
HOW WILL YOU ASSESS A CHILD FOR COUGH OR

This assessment will examine how quickly the child is breathing, the noises he is
making as he breaths, and how much difficult he appears to have while breathing.
9


ASK: DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

Difficult breathing is any unusual pattern of breathing. Caregivers describe this

in different ways. They may say that their child’s breathing is “fast” or “noisy” or

“interrupted.” If a mother answers no, look to see if you think the child has cough
or difficult breathing.

If the child does not have a cough or difficult breathing, move
to the next

symptom: diarrhoea. You do not need to assess the child further for cough or

difficult breathing.

IF YES: Open to your ASSESS chart for cough or difficult breathing. You will see

the following instructions. You will learn now about the signs discussed
in this
ASSESS chart.

ASK: FOR HOW LONG?
A cough or difficult breathing that lasts for more than 14 days may indicate
tuberculosis, asthma, whooping cough, or some other problem.
LOOK: DOES THE CHILD HAVE FAST BREATHING?

As you have learned, fast breathing is one sign of pneumonia in a child.
How do you determine if a child is breathing faster than he or she normally
should be? You count the number of breaths the child takes per minute to determine
if fast breathing is present. To count the breaths per minute, use a watch with a
second hand or a digital watch. Look for the breathing movement anywhere on the
child’s chest or abdomen.
The number of breaths for ‘fast breathing’ depends on the child’s age.
Younger children normally have higher rates of breathing than older children.
10
It is very important that the child is calm and still. If the child is moving or
crying, you will not be able to get an accurate count of breaths. Ask the mother to
help keep her child calm.
FAST BREATHING
2 months up to 12 months = 50 or more breaths per minute
DVD EXERCISE – FAST BREATHING

Watch “Count respiratory rate” (disc 1) to practise identifying fast breathing. It
is very useful to practice counting with a video. The video will review answers
with you.
What did you find?
CHILD 1: breaths/minute. Is this fast?  YES  NO
CHILD 2: breaths/minute. Is this fast?  YES  NO
Remember that all self-assessment exercise answers at in a key at the end of
this module.
Let us practise what we have learned about cough or difficult breathing thus far.
1. What are two clinical signs that help you identify children with pneumonia?
2. Do the following children have fast breathing? Tick your answers.
a. 3 years, 36 breaths per minute  YES  NO

b. 12 months, 50 breaths per minute  YES  NO
c. 6 months, 45 breaths per minute  YES  NO
d. 3 months, 57 breaths per minute  YES  NO
3. Julie arrives at your clinic with her mother. You begin by gathering important
information about the child. You check Julie for danger signs, and she has none.
What do you do next?
a. ASK:
b. LOOK:
4. When you ask Julie’s mother, she says Julie has no cough or difficult breathing.
You watch Julie, and she seems to be breathing regularly. What do you do next?
11
LOOK: FOR CHEST INDRAWING

Chest indrawing occurs when the child needs to make a greater effort than normal
to breathe in. You will look for chest indrawing when the child breathes IN.
In normal breathing, the whole chest wall (upper and lower) and the abdomen
move OUT when the child breathes IN. The child has chest indrawing if the
lower chest wall (lower ribs) goes IN when the child breathes IN. Review
the photo below.
For chest indrawing to be present, it must be visible and present all the
time you are observing the child. If you still do not see the lower chest wall go
IN when the child breathes IN, the child does not have chest indrawing.
Here are some helpful tips to look for chest indrawing:
✔✔ Ask the caregiver to lift the child’s shirt, if you did not when you counted breaths.
✔✔ If the child’s body is bent at the waist, it is hard to see the lower chest wall move.
Ask the caregiver to change the child’s position so he is lying flat in her lap.
REMEMBER! When do you look for chest indrawing? When the child breathes IN
NORMAL: when child breathes IN, chest wall moves OUT
CHEST INDRAWING: when child breathes IN, chest wall moves IN
12
DVD EXERCISE – CHEST INDRAWING

Watch “Assessing indrawing” (disc 1). It is very useful to practise with a video.
Record your answers as you watch. It will review the answers at the end. Do these
children have chest indrawing?
CHILD 1  YES  NO CHILD 4  YES  NO
CHILD 3  YES  NO
LOOK AND LISTEN FOR STRIDOR

Stridor is a harsh noise made when a child breathes IN. It
occurs when the larynx, trachea, or epiglottis is swollen. Stridor is present when
These conditions are often called croup. This swelling the child breathes IN
interferes with air entering the lungs. If the swelling blocks It is a harsh noise caused
the child’s airway, it can be life threatening. when swelling interferes
To look and listen for stridor, look to see when the with air entering the lungs.
child breathes IN. Then listen for stridor. Put your ear near
the child’s mouth because stridor can be difficult to hear.
Sometimes you will hear a wet noise if the child’s nose is blocked. Clear the nose,
and listen again.
Be sure to look and listen for stridor when the child is calm. A child who
is not very ill may have stridor only when he is crying or upset. However, a child
who is calm and also has stridor has a dangerous situation. You may only hear a
wheezing noise when the child breathes OUT – this is not stridor.
DVD EXERCISE – STRIDOR

Watch “Assessing stridor” (disc 1) to practise identifying stridor. It is very useful
to practice with a video. The video will review answers with you. Do you hear
stridor in these children?
CHILD 3  YES  NO
LOOK AND LISTEN FOR WHEEZING

Wheeze is a high-pitched whistling or musical sound heard at the end of the
breathing OUT. The child’s small air passages narrow to cause wheezing.
To hear wheezing, put your ear near to the child’s mouth when the child is calm.
Look at the child’s breathing while you listen to check that the sound mainly occurs
when the child breathes out.
If the child has wheezing and either fast breathing or chest indrawing:
you need to perform an additional assessment. Give a trial of rapid acting inhaled
bronchodilator for up to three times 15–20 minutes apart. Count the breaths and
look for chest indrawing again. Then classify the problem.
13
Watch “Demonstration: cough or difficult breathing” (disc 1)

This video will review all steps in assessing for cough or difficult
breathing. It is very useful to see these signs in the clinical setting.
n Now you will return to Jacob’s case. How will you assess him for
cough or difficult breathing?
You have already assessed Jacob for general danger signs, and found that he did not have any.
Next, you will assess Jacob for cough or difficult breathing. You ask Amira if Jacob has a cough or difficult
breathing. She is confused when you say “difficult breathing,” so you explain it as breathing that is fast, noisy,
or interrupted.
Amira says yes, she thinks Jacob has been breathing fast. He also moves away from the breast to take breaths.
She says he did not do this in the past.
You ask Amira how long this issue has been present. She says 1 week. You remember that a cough or difficult
breathing that lasts for more than 14 days may indicate tuberculosis, asthma, whooping cough, or some
other problem.
Based on Amira’s answers, you will need to assess Jacob for a cough or difficult breathing. You think there
may be a respiratory problem.
You hold up Jacob’s shirt and count his breaths in one minute. When he is calm, he is breathing 70 breaths
MANAGEMENT
per OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
minute. He coughs frequently.
Then
Name:you look at his lower chest wall for indrawing.
Age: When Jacob breathes
Weight (kg):in, his lower chest wall and
Temperature (°C):
abdomen move out. You listen for stridor when Jacob breathes in, and you do not hear any harsh
Ask: What are the child's problems? Initial Visit? noise.
Follow-up Visit? You
also do not hear wheezing when he breathes out.
Does Jacob
NOT have
ABLE TO fast
DRINK breathing?
OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
Does he have indrawing or stridor?
Danger sign when
Here is how you would complete Jacob’s recording form for cough or difficult breathing: selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? X No __
Yes __
7 Days
For how long? ___ Count the breaths in one minute
70 breaths per minute. Fast
___ breathing? Yes
Look for chest indrawing No
Look and listen for stridor No
Look and listen for wheezing No
You Iswill now learn how to classify the signs youLethargic
there blood in the stool?
checked Jacob for.
or unconscious?
Slowly?
Test POSITIVE? P. falciparum P. vivaxNEGATIVE? 14
3.4 CLASSIFY COUGH OR DIFFICULT BREATHING

Now you will learn how to classify using the signs you assessed for. There are three
possible classifications for a child with cough or difficult breathing:
1. SEVERE PNEUMONIA OR VERY SEVERE DISEASE
2. PNEUMONIA
3. COUGH OR COLD
Open your chart booklet: what does the classification table look like?
Any general danger sign Pink: Give first dose of an appropriate

ify or SEVERE antibiotic
GH or Stridor in calm child. PNEUMONIA OR Refer URGENTLY to hospital**
CULT VERY SEVERE
ATHING DISEASE
Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
Fast breathing. PNEUMONIA If wheezing (even if it disappeared after
rapidly acting bronchodilator) give an inhaled
bronchodilator for 5 days****
If chest indrawing in HIVexposed or infected
child, give first dose of amoxicillin and refer to
hospital.
If coughing for more than 2 weeks or if
having recurrent wheezing, refer for further
assessment or consider TB or asthma
Follow-up in 3 days
No signs of pneumonia or Green: If wheezing (even if it disappeared after
very severe disease. COUGH OR COLD rapidly acting bronchodilator) give an inhaled
Soothe the throat and relieve the cough with a
safe remedy
If coughing for more than 2 weeks or if having
recurrent wheezing, refer for assessment for
TB or asthma
* If pulse oximeter is available, determine oxygen saturation and refer if < 90%.
** If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the
Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care.
*** Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried.
REMEMBER!
Classifications are colour-coded, and identify treatments:
RED = refer urgently
r if < 90%.
YELLOW = treat in clinic
ated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient
GREEN = home treatment
athing but no chest indrawing in low HIV settings.
butamol may be tried.
Page 5 of 75
15
VERY SEVERE PNEUMONIA OR VERY SEVERE DISEASE (RED)

A child with cough or difficult breathing and any general danger sign or stridor
(in a calm child) is classified as having SEVERE PNEUMONIA OR VERY SEVERE
DISEASE. The child may have another serious acute lower respiratory infection such
as bronchiolitis, pertussis, or a wheezing problem.

A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is
seriously ill. He or she needs urgent referral to a hospital for treatments such as
oxygen, a bronchodilator, or injectable antibiotics. Before the child leaves, give the
first dose of an appropriate antibiotic. The antibiotic helps prevent severe pneumonia
from becoming worse. It also helps treat other serious bacterial infections such as
sepsis or meningitis.
PNEUMONIA (YELLOW)
A child with cough or difficult breathing who has fast breathing and or chest
indrawing is classified as having PNEUMONIA. This child should not have a general
danger sign, or stridor.

A child with PNEUMONIA needs treatment with oral amoxicillin for 5 days. You
will begin this treatment in the clinic, and it will continue at home. Later in this
section, you will read about how to identify and give an antibiotic. You will also
learn how to teach caregivers to give treatments at home. If the child has wheezing,
this will require treatment with an inhaled bronchodilator. If the child is HIV
exposed or infected and chest indrawing, she needs give the first dose of
amoxicillin and refer to the hospital.
COUGH OR COLD (GREEN)

A child with cough or difficult breathing but none of the signs already discussed
– general danger signs, chest indrawing, stridor when calm, or fast breathing – is
classified as COUGH OR COLD.

A child with COUGH OR COLD does not need an antibiotic. The antibiotic will
not relieve the child’s symptoms. It will not prevent the cold from developing
into pneumonia. Instead, give the mother advice about good home care, like safe
remedies.
A child with a cold normally improves in one to two weeks. However, a child who
has a chronic cough lasting more than 2 weeks, he/she may have tuberculosis,
asthma, whooping cough or another problem. A child with a chronic cough needs
to be referred to hospital for further assessment.
16

How will you classify Jacob?
n Name: Age: Weight (kg): Temperature (°C):
You observed
ASSESS (Circle allone
signs sign in Jacob – fast breathing. You counted 70 breaths per minute. For his age,
present) 50 breaths
CLASSIFY
orCHECK
more is
FORconsidered
GENERALfast. Fast breathing
DANGER SIGNS is a sign used to classify pneumonia (yellow). He didGeneral
not show
danger sign
any NOT ABLE
signs TO DRINK
from OR BREASTFEED
the SEVERE PNEUMONIA or VERY LETHARGIC DISEASE (red) classification, like stridor orpresent?
OR UNCONSCIOUS
SEVERE a general
danger sign.
Danger sign when
You will write your classification on the recording form: selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? X No __
Yes __
7 Days
70 breaths per minute. Fast
___ breathing? Yes
Look for chest indrawing No Pneumonia
Look and listen for stridor No
Look and listen for wheezing No
n What doinyou
Is there blood do after classifying Jacob’s
the stool? cough?
In a normal scenario, you will then begin to ASSESS Jacob
Look for sunken eyes.for the next main symptom, diarrhoea, until you
are done with the full assessment. Offer the child fluid. Is the child:
Then you will review all of the treatments you have Drinkingidentified
eagerly, thirsty?for his various classifications, and decide on his
integrated treatment. You will learn more about giving treatment,
Very slowsly (longer then 2 seconds)?counselling Amira, and providing
follow-up care in the following sections. Slowly?
Asmalaria
n Decide a practice exercise,
risk: High ___ Low ___ No___consider a second scenario with Jacob:
Look or feel for stiff neck
Look for runny nose
For how long? ___ Days
Look for signs of MEASLES:
HowIf more
wouldthanyou have
7 days, classified
has fever differently
been present every if you had heard a harsh noise while Jacob sat with Amira? Jacob’s
Generalized rash and
day?
first Has
sign, fast breathing, is a sign used
child had measels within the last 3 months? to classify
One PNEUMONIA
of (yellow
these: cough, runny nose, or classification).
red eyes The second sign,
stridor, is a sign of SEVERE PNEUMONIA or Look forSEVERE
VERY any other DISEASE
cause of fever.
(red classification).
There
Low risk:are
if NOoften
obviouscases
cause ofwhen
fever you will find signs from several classifications. In these situations, you
always classify with the most severe classification. So in a scenario where you assess one sign from a yellow
classification,
If the child has and another
measles nowsign from athe
or within red classification, you would use the red classification. This signifies
Look for mouth ulcers.
SEVERE illness and requires urgent pre-referralIftreatment,
last 3 months: yes, are they deep
andandthen
extensive?
referral.
Hep B0
RTV-1 RTV-2 RTV-3 17
Pneumo-1 Pneumo-2 Pneumo-3
Open your Chart Booklet. Review the classification table for cough or difficult
breathing.
1. Match the boxes below. Each “signs” box should be matched with one
classification.
Sal is 9 months old and has a cough. You count 45 breaths SEVERE PNEUMONIA or
per minute. No chest indrawing or stridor. VERY SEVERE DISEASE
Linus is 3 months old, and you could 65 breaths in one

minute. When he breathes in, has had convulsions during PNEUMONIA
current illness.
Jojo is 3 years old. You count 56 breaths in one minute.

COUGH OR COLD
No indrawing or stridor.
2. Are these statements true or false? If false, write the statement as correct.
a. You should look for chest indrawing when the child
TRUE FALSE
breathes OUT.
b. Fast breathing in a child 12 months and older is 40 or
TRUE FALSE
more a minute.
c. Chest indrawing is a sign of pneumonia. TRUE FALSE
d. If a child has a cough but no other signs, they probably
TRUE FALSE
have pneumonia.
e. A child with chest indrawing will always also have fast
TRUE FALSE
breathing.
f. Chest indrawing is when the lower ribs move IN when
TRUE FALSE
the child breathes IN
g. A child 2 up to 12 months has fast breathing if more
TRUE FALSE
than 45 breaths a minute.
h. A child with chest indrawing has a higher risk of death
from pneumonia than a child with fast breathing and TRUE FALSE
no chest indrawing.
i. Difficult breathing can also be described as noisy,
TRUE FALSE
interrupted, or fast.
j. If a child has cough, fast breathing, and vomits
TRUE FALSE
everything, he is classified as PNEUMONIA (YELLOW)
18
EXAMPLE EXERCISE: CLASSIFYING

Read this case study and see how the health worker classified this child’s illness.
Aziz is 18 months old. He weighs 11.5 kg. His temperature is 37.5 °C. His mother
brought him to the clinic because he has a cough. She says he is having trouble
breathing. This is his first visit for this illness. The health worker checked Aziz for
general danger signs. Aziz is able to drink. He has not been vomiting. He has not
had convulsions. He is not lethargic or unconscious. The health worker asked “How
long has Aziz had this cough?” His mother said he had been coughing for 6 or 7
days. Aziz sat quietly on his mother’s lap. The health worker counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. He thought,
“Since Aziz is over 12 months of age, the cut-off for determining fast breathing is
40. He has fast breathing.” The health worker did not see any chest indrawing. He
did not hear stridor. Here is how the health worker recorded Aziz’s case information
and signs of illness:

Name: Aziz Age: 18 mo Weight (kg): 11.5 kg Temperature (°C): 37.5 °C
Ask:
What are the child's problems?
CLASSIFY
Yes ___ No ___
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? X
Yes __ No __
41 breaths per minute. Fast breathing?
___
To classify Aziz’s illness, the health
Restless andworker
irritable? looked at the classification.
1. First, he checked to see if Aziz
Offerhad anyfluid.
the child ofIsthe signs in the pink row. He thought,
the child:
“Does Aziz have any general danger
Drinking eagerly, thirsty? he does not. Does Aziz have any
signs? No,
HEN ASK ABOUT MAIN SYMPTOMS: Pinch the skin of the abdomen. Doesdoes
it go back:
oes the child have cough or of the other
difficult signs in this row? No,
breathing? he does not.” Aziz
not have any signs for
severe classification. Slowly?
yes, ask: DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)
Look, listen, feel: Yes __ No __
Pink:
2. High
Next, the___health Any general danger sign Give first d
For how long? Decide malaria risk:Count ___ Low No___ worker looked at for
Look or feel thestiffyellow
neck
the Classify Look for runny nose or SEVERE antibiotic
For how long? ___ row.
breaths inHe thought, “Does Aziz have signs in the
Days
COUGH Look
or for signs of MEASLES: Stridor in calm child. PNEUMONIA OR Refer URGE
If more than 7 days, has fever been present every
day? oneyellow
minute*.row? He has DIFFICULT
fast breathing.”
Generalized rash and VERY SEVERE
Look forwithin the last 3 months?BREATHINGOne of these: cough, runny nose, or red eyes
Has child had measels DISEASE
3. The health Look for any other cause of fever.
Do malaria test if NOchest
general danger signworker classified Aziz as having Chest indrawing or Yellow: Give oral A
indrawing.
High risk: all fever casesPNEUMONIA. He wrote PNEUMONIA on the Fast breathing. PNEUMONIA If wheezing
Lookcause
Low risk: if NO obvious and of fever
Recording Form. rapidly actin
Test POSITIVE? P.listen for P. vivaxNEGATIVE?
falciparum bronchodila
If the child hasstridor.measles now or within the Look for mouth ulcers. If chest indr
last 3 months:Look and If yes, are they deep and extensive? child, give fi
listen for Look for pus draining from the eye.
hospital.
wheezing. Look for clouding of the cornea.
If coughing
DOES THE CHILD HAVE AN EAR CHILDPROBLEM? Yes __ No __
having recu
MUST BE
Is there ear discharge? Feel for tender swelling behind the ear assessment
CALM
If Yes, for how long? ___ Days 19 Advise moth
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. Follow-up in
Green:
For children 6 months or older measureNo signs
MUAC of pneumonia
____ mm. or If wheezing
Look for palmar pallor. very severe disease. COUGH OR COLD rapidly actin
Severe palmar pallor? Some palmar pallor? bronchodila
Read the following case study and answer the questions.
Gyatsu is 6 months old and weighs 5.5 kg. His temperature is 38 °C. His mother said
he has had cough for 2 days. The health worker checked for general danger signs.
The mother said that Gyatsu is able to breastfeed. He has not vomited during this
illness. He has not had convulsions. Gyatsu is not lethargic or unconscious.
The health worker said to the mother, “I want to check Gyatsu’s cough. You said
he has had cough for 2 days now. I am going to count his breaths. He will need to
remain calm while I do this.” The health worker counted 58 breaths per minute. He
did not see chest indrawing or hear stridor.
1. Record Gyatsu’s signs on the Recording Form below.

Danger sign when
selecting
classifications
2. To classify Gyatsu’s illness, look at the
Restless and classification
irritable? table for cough or difficult
breathing in your chart booklet. Look
Offer the childat the
fluid. topchild:
Is the row (is pink in the Chart Booklet).
a. Does Gyatsu have a generalDrinking
danger sign?
eagerly, thirsty?  YES  NO
b. Does he have chest indrawing or stridor
Very slowsly (longer when calm?
then 2 seconds)?  YES  NO
Slowly?
c. Will you classify SEVERE PNEUMONIA OR Yes __ No __
VERY SEVERE DISEASE? Look for runny nose  YES  NO
day? 3. If he does not have the severeGeneralized
classification,
rash and look at the middle row (yellow on
Chart). Look for any other cause of fever.
a. Does Gyatsu have fast breathing?
High risk: all fever cases  YES  NO
b. How
Test POSITIVE? P. falciparum would you classify Gyatsu’s illness? Write on the Recording Form.
P. vivaxNEGATIVE?
20pallor.
Look for palmar
3.5 TREAT THE CHILD WITH COUGH OR DIFFICULT

BREATHING
REFRESH: WHAT DOES THE ‘IDENTIFY TREATMENT’ COLUMN
IN THE CLASSIFICATION TABLE EXPLAIN?
The classification table identifies three pieces of critical information:
1. Appropriate treatment for each classification
2. Where treatment is given: either in a second-level facility (RED), at the clinic
(YELLOW), or at home (GREEN)
3. Pre-referral treatments: are identified clearly (in bold), and are required if
child needs urgent referral
WHAT TREATMENTS ARE IDENTIFIED FOR COUGH

OR DIFFICULT BREATHING?
Open your classification chart. What treatments are listed in the “IDENTIFY
TREATMENT” column for cough or difficult breathing? There are three
treatments that you will learn about in this section:
✔✔ Oral antibiotics (amoxicillin)
✔✔ Remedy for soothing sore throats
✔✔ Inhaler treatment if wheezing
CLASSIFY IDENTIFY TREATMENT

Any general danger sign Pink: Give first dose of an appropriate
or SEVERE antibiotic
Stridor in calm child. PNEUMONIA OR Refer URGENTLY to hospital**
VERY SEVERE
DISEASE
Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
Fast breathing. PNEUMONIA If wheezing (even if it disappeared after
rapidly acting bronchodilator) give an inhaled
If chest indrawing in HIVexposed or infected
child, give first dose of amoxicillin and refer to
hospital.
If coughing for more than 2 weeks or if
having recurrent wheezing, refer for further
assessment or consider TB or asthma
Follow-up in 3 days
No signs of pneumonia or Green: If wheezing (even if it disappeared after
very severe disease. COUGH OR COLD rapidly acting bronchodilator) give an inhaled
safe remedy
If coughing for more than 2 weeks or if having
recurrent wheezing, refer for assessment for
TB or asthma
21
Follow along with your Chart Booklet TREAT THE CHILD section. This section
of charts provides detailed instructions for providing each of these listed treatments.
HOW WILL YOU GIVE ORAL ANTIBIOTICS?

It is important to review some general instructions on giving antibiotics
with integrated management, as this is the first time you are learning about
antibiotic use within IMCI. You will refer back to this information when later
Modules discuss antibiotic treatment.
You will see in your TREAT THE CHILD section that there are instructions for giving
antibiotics for various classifications that require antibiotics. These are listed below.
In this section you will learn about antibiotics for PNEUMONIA.
n SEVERE PNEUMONIA OR VERY SEVERE DISEASE
n PNEUMONIA
n SEVERE DEHYDRATION with cholera in the area
n DYSENTERY
n VERY SEVERE FEBRILE DISEASE
n SEVERE COMPLICATED MEASLES
n MASTOIDITIS
n ACUTE EAR INFECTION
HOW DO YOU SELECT THE APPROPRIATE ANTIBIOTIC?

Many health facilities have more than one type of antibiotic. You must learn to
select the most appropriate antibiotic for the child’s illness. Some important
instructions for giving antibiotics include:
n GIVING FIRST LINE: Give the “first-line” oral antibiotic if it is available. It has
been chosen because it is effective, easy to give and inexpensive.
n GIVING SECOND LINE: You should give the “second-line” antibiotic only if the
first-line antibiotic is not available, or if the child’s illness does not respond to
the first-line antibiotic.
n ORAL ANTIBIOTICS: If the child is able to drink, give an oral antibiotic. The
appropriate oral antibiotic for each illness varies by country. The antibiotics
recommended in your country are on your TREAT THE CHILD chart.
INTEGRATED MANAGEMENT: GIVING ANTIBIOTICS

n GIVE FIRST LINE antibiotics
n GIVE SECOND LINE only if first line not available, or if child does not respond to first.
n WHERE CHILD HAS TWO+ CLASSIFICATIONS REQUIRING ANTIBIOTICS treat with one antibiotic for
both classifications if possible
22
WHAT IF THE CHART IDENTIFIES MORE THAN ONE ILLNESS

REQUIRING ANTIBIOTICS?
MULTIPLE ILLNESSES, ONE ANTIBIOTIC: Sometimes one antibiotic can be
given to treat more than one illness. For example, a child with DYSENTERY and
ACUTE EAR INFECTION can be treated with a single antibiotic, co-trimoxazole,
if the first-line antibiotic for an ACUTE EAR INFECTION (co-trimoxazole) is also
a first- or second-line antibiotic for DYSENTERY. NOTE: when treating a child
with more than one illness requiring the same antibiotic, do not double the
size of each dose or give the antibiotic for a longer period of time.
MULTIPLE ILLNESSES, MULTIPLE ANTIBIOTICS: Sometimes more than
one antibiotic must be given to treat multiple health problems. For example, the
antibiotics used to treat PNEUMONIA may not be effective against DYSENTERY in
your country. Here, a child who needs treatment for DYSENTERY and PNEUMONIA
must be treated with two antibiotics.
How do you decide on the appropriate dosage?
The TREAT THE CHILD chart has the schedule and dose for giving antibiotics.
SCHEDULE tells you how many days and how many times each day to give the
antibiotic. Most antibiotics should be given for 5 days. Only cholera cases receive
antibiotics for 3 days. The number of times to give the antibiotic each day varies
depending on the type of antibiotic.
CORRECT DOSAGE of the antibiotic is determined by:
1. Identify the column of the type of tablets or syrup available in your clinic.
2. Choose the row for the child’s weight or age. Use weight over age.
3. The correct dose is listed at the intersection of the column and row.
AMOXICILLIN *
Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION
AGE OR WEIGHT
TABLET SYRUP
(250 mg) 250 mg/5 ml
2 months up to 12 months (4 – <10 kg) 1 5 ml
12 months up to 3 years (10 – <14 kg) 2 10 ml
3 years up to 5 years (14 – 19 kg) 3 15 ml
* Amoxicillin is now the first-line drug of choice i the treatment of pneumonia due to its efficacy and increasing high resistance to
cotrimoxazole.
CRUSHING OR BREAKING TABLETS: If a tablet has to be crushed before it is

given to a child, add a few drops of clean water and wait a minute or so. This softens
the tablet to make it easier to crush.
23
HOW ARE ANTIBIOTICS GIVEN FOR PNEUMONIA?

If the child is classified as SEVERE PNEUMONIA, the first dose of the antibiotic
should be given before urgent referral. If the classification is PNEUMONIA, you
will give the first dose of oral amoxicillin in the clinic and teach the caregiver
how to give the remaining 5 days of treatment at home. Amoxicillin is now the
recommended first-line antibiotic to treat pneumonia due to its efficacy, and the
increasing resistance to cotrimoxazole.
Now that you have learned how to give oral antibiotics, you will examine other
treatments required for cough or difficult breathing classifications.
HOW WILL YOU GIVE AN INHALER FOR WHEEZING?

If the child has wheezing and will require an inhaler treatment in the clinic or at
home, review the TREAT THE CHILD chart for inhaled salbutamol for wheezing.
•• From salbutamol metered dose inhaler (100 μg/puff) give 2 puffs.
•• Repeat up to 3 times every 15–20 minutes before classifying pneumonia.
A spacer is a way of delivering the bronchodilator medicines effectively into the
lungs. A spacer works as well as a nebuliser if correctly used. No child under 5
should be given an inhaler without a spacer.
If commercial spacers are not available, spacers can be easily made with a
drink bottle (500 ml) or something similar. Using a sharp knife, cut a hole in
the bottle base in the same shape as the mouthpiece of the inhaler. Cut the bottle
between the upper quarter and the lower ¾. Disregard the upper quarter of the
bottle. Cut a small V in the border of the large open part of the bottle to fit to the
child’s nose and be used as a mask. Flame the edge of the cut bottle with a candle
or a lighter to soften it. In a small baby, a mask can be made by making a similar
hole in a plastic (not polystyrene) cup.
To use an inhaler with a spacer:
✔✔ Remove the inhaler cap. Shake the inhaler well.
✔✔ Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
✔✔ The child should put the opening of the bottle into his mouth and breath in and
out through the mouth.
✔✔ A carer then presses down the inhaler and sprays into the bottle while the child
continues to breath normally.
✔✔ Wait for three to four breaths and repeat.
✔✔ For younger children place the cup over the child’s mouth and use as a spacer
in the same way.
✔✔ If a spacer is being used for the first time, prime with 4-5 extra puffs from the
inhaler.
24
WHAT IS A SOOTHING REMEDY FOR THE THROAT?

Find this chart in your TREAT charts. To soothe the throat or relieve a cough, use
a safe remedy. Such remedies can be homemade, given at the clinic, or bought at a
pharmacy. It is important that they are safe. Homemade remedies are as effective as
those bought in a store. Your TREAT THE CHILD chart recommends safe, soothing
remedies for children with a sore throat or cough. If the child is exclusively breastfed,
do not give other drinks or remedies. Breastmilk is the best soothing remedy for
an exclusively breastfed child.
Harmful remedies may be used in your area. If so, they should be recorded in
the box. Never use remedies that contain harmful ingredients, such as atropine,
codeine or codeine derivatives, or alcohol. These items may sedate the child. They
may interfere with the child’s feeding. They may also interfere with the child’s
ability to cough up secretions from the lungs.
Medicated nose drops (that is, nose drops that
contain anything other than salt) should also SOOTHING REMEDIES
not be used. SAFE HARMFUL
When explaining how to give the safe ✔ Breastmilk ✔ Atropine or codeine

remedy, it is not necessary to watch the ✔ ✔ Alcohol
mother practice giving the remedy to the ✔ ✔
child. Exact dosing is not important with this ✔ ✔
treatment.
DVD EXERCISE – CASE STUDY ‘BEN’

Watch ‘Case study Ben’ (disc 1). Watching this case is a great way to practice.
As you watch the video, complete the recording form below as you would a
normal case. Does Ben present with any general danger signs? How do you classify?
AN IMPORTANT NOTE: videos are used to show signs.

The classification discussed at the end of the video may not be accurate due
to recent technical updates.

Danger sign when
selecting
classifications
25
Answer the following questions about the treatments you have read about.
1. Are these statements true or false? Circle your answer.
a. You should give a child the first-line antibiotic, unless
it is unavailable or the child has not responded to it. TRUE FALSE
b. If a child has more than one illness that requires
antibiotics, if possible, give one antibiotic for more than
one illness. TRUE FALSE
c. If a child can drink, it is preferable to give syrup
antibiotics. TRUE FALSE
d. If a child has two illnesses that require the same
antibiotic, you should, just double the dosage or put
the child on the treatment for 10 days instead of 5. TRUE FALSE
2. How often should you give amoxicillin for pneumonia?
3. What is the correct dosage for the following oral treatments? Refer to your dosage
chart for pneumonia. Write out the medicine and concentration, and its dosage
and schedule.
a. Child is 3 months old, weighs 5 kg, and can drink. You have amoxicillin syrup
in your clinic.
b. Child is 9 months old, and you have amoxicillin tablets.
c. Child is 13 months old, and 8 kg. She can drink. You have amoxicillin syrup
in your clinic.
d. Child is 4 years. You have amoxicillin tablets in the clinic.
4. What is meant by a “safe” remedy? Give an example.
5. Give at least 2 examples of remedies that are not safe.
26
n Now you will return to Jacob. What treatments are identified?

Review your classification table in your Chart Booklet. The TREATMENT column
instructs on the appropriate treatment for each classification. You have classified
Jacob’s problem as PNEUMONIA:
The classification chart instructed that the correct treatments are:
•• An oral antibiotic
•• Soothe the throat and relieve the cough with a safe remedy
•• Advise Amira when to return: 3 days for PNEUMONIA, or immediately if he
worsens
n How will you give Jacob the oral antibiotics?

First, you prescribe amoxicillin in syrup form. Jacob is able to drink, so an oral
antibiotic is given. Amoxicillin is an appropriate first-line in your clinic.
Second, you must determine Jacob’s dosage. Jacob is 6 months old, and
weighs 5 kg. What is the correct dosage? The chart determines that the correct
dosage for Jacob is 5 ml of syrup (250 mg/5 ml), given twice a day for 5 days.
AMOXICILLIN *
TABLET SYRUP
AGE OR WEIGHT
(250 mg) 250 mg/5ml
2 months up to 12 months (4 up to 10 kg) 1 5 ml
12 months up to 5 years (10–19 kg) 2 10 ml
You also designate a safe remedy for cough in your area. Breast milk will be
an important remedy for Jacob because he is breastfed.
In the next section, you will learn more about how you will counsel Amira on
why the antibiotic is important to treat Jacob’s pneumonia. You will counsel her
on how she will give it in the home. You will also counsel her on giving the throat
remedy. You will explain to Amira why the antibiotic is important to treat Jacob’s
pneumonia.
27
3.6 COUNSEL THE CAREGIVER

WHY MUST YOU COUNSEL THE CAREGIVER?
As you will remember from previous lessons, this is an important opportunity to
counsel home treatment, feeding, care in the home, and when to return to the clinic.
You will counsel the caregiver on all relevant treatment and health conditions after
you have assessed, classified, and decided on treatment for all conditions.
AS A REVIEW, WHAT ARE GOOD COMMUNICATION SKILLS

DURING COUNSELLING?
For the full discussion on communication skills when using IMCI, refer back to
your section on “Good communication and counselling skills” in INTRODUCTION
PART 1. Quickly review these good skills that you have learned about.
APAC PROCESS
Used as you assess, classify, treat, and counsel:
 ASK and LISTEN to find out what the child’s problems are and what the caregiver
is already doing for the child.
 PRAISE the caregiver for what she has done well.
 ADVISE her how to care for her child at home.
 CHECK the caregiver’s understanding, using checking questions
THREE BASIC TEACHING STEPS

For example, Jacob’s pneumonia requires oral antibiotic given at home. What should
you remember as you teach Amira how to give this treatment?
1. GIVE INFORMATION – use words the caregiver understands, and focus on the
most important messages
2. SHOW AN EXAMPLE – using familiar objects as teaching aids
3. LET HER PRACTICE – affirm, give feedback, and allow for more practice as
needed
HOW WILL YOU COUNSEL A CAREGIVER ABOUT COUGH OR

There are several topics relevant to cough or difficult breathing. You will read more
about these topics below. They include:
 Giving oral antibiotics in the home
 Giving soothing remedies in the home
 How to use an inhaler if necessary for wheezing
 When to return immediately
 When to follow-up
28
GIVING ORAL MEDICINES AT HOME:

Your TREAT THE CHILD charts include instructions for counselling a caregiver on
giving oral medicines at home. The oral medicines listed on the chart are given for
different reasons, in different doses and on different schedules. However, the way
to give each drug is similar.
Pneumonia requires antibiotics given at home. However, as this is the first time
we are dealing with giving an oral drug, we will review the basic steps of
teaching caregivers to give oral medicines. If a caregiver learns how to give a
drug correctly, then the child will be treated properly.
The important points to remember are:
 DETERMINE APPROPRIATE MEDICINES & DOSAGE – for child’s weight
and age
 EXPLAIN TREATMENT – tell caregiver why you are giving the drug to the child
 DEMONSTRATE how to measure a dose
 LET HER PRACTICE- watch the caregiver practice measuring a dose by herself.
Tell her what she has done correctly when she measures the dose, or crushes a
tablet. If she measured the dose incorrectly, show her again how to measure it.
 ASK CAREGIVER TO GIVE FIRST DOSE to the child
 EXPLAIN DRUG CAREFULLY, THEN LABEL AND PACKAGE – Tell the mother
how much of the drug to give her child. Tell her how many times per day to give
the dose.
Tell her when to give it (such as early morning, lunch, dinner, before going to bed)
and for how many days. Write the information on a drug label. This is an example:
29
HOW DO YOU LABEL AND PACKAGE A DRUG?

To write information on a drug label, be sure to write the instructions clearly so
that a literate person is able to read and understand them:
1. Write the full name of the drug.
2. Write the total amount of tablets, capsules, or syrup to complete the course
of treatment.
3. Write the daily dose and schedule. For example: ½ tablet twice daily for 5 days.
 Write the correct dose for the patient to take. For example, the number of
tablets, capsules, drops, or spoonfuls.
 Write when to give the dose. For example, early morning, lunch, dinner,
before going to bed.
EXAMPLES OF DRUG LABELS:
Li, Jung 17-02-96 Agar, MAnu 17-02-96

Iron Syrup 14 ml Vitamin A 1 capsule
/1 4 tsp. 1
Give /1 4 teaspoon Give vitamin A capsule
one time per day tomorrow
4. To package the drug, put the total amount of each drug into its own labelled
drug container. Use clean containers. This could be an envelope, paper, tube,
or bottle. It is important to keep medicines clean. After you have labelled and
packaged the drug, give it to the mother.
TIPS FOR DRUG LABELS

 REPEAT IF MORE THAN ONE DRUG – give, collect, count, and package each drug separately
 EMPHASIZE COURSE OF TREATMENT – explain that all the tablets or syrup must be used to finish the
course of treatment, even if the child gets better.
 CHECK CAREGIVER’S UNDERSTANDING – ask checking questions to make sure she understands how to
treat her child. In some clinics, a drug dispenser has the task of teaching the caregiver to give treatment
and checking the caregiver’s understanding. If this is your situation, teach the skills you are learning here
to that dispenser.
30
WHEN TO RETURN FOR FOLLOW-UP CARE:

The TREATMENT column in your chart booklet designates how soon the child
should return for follow-up.
A child with PNEUMONIA Follow-up in 3 days

A child with COUGH OR COLD Follow-up in 5 days if not improving
WHEN TO RETURN IMMEDIATELY:

You should always counsel the caregiver on looking for signs that they should bring
the child immediately to the clinic.
Turn to INTRODUCTION PART 2 to review these signs.
WHEN TO RETURN IMMEDIATELY

Advise the caregiver to return immediately if the child has any of these signs:
Any sick child ✔ Not able to drink or breastfeed
✔ Becomes sicker
✔ Develops a fever
If child has COUGH OR COLD ✔ Fast breathing
✔ Difficult breathing
Rewrite the following questions as good checking questions.
1. Do you remember when to give the amoxicillin?
2. Do you understand how much amoxicillin syrup to give your child?
3. Did the nurse explain to you how to use an inhaler?
4. Do you know how to make a remedy for the throat?
31
Review the case below on treating with antibiotics.
Nurse Aluka gives some oral antibiotics to a mother for her child, Maria Balana.
Before he explains how to give them, Aluka asks the mother if she knows how to
give her child the medicine. The mother nods her head yes. So Aluka gives her the
antibiotics and says good-bye.
1. If a mother tells you that she already knows how to give a treatment, what should
you do?
2. How would you fill out this drug label? You have classified the child’s respiratory
condition as PNEUMONIA. Maria Balana is 4 months old. You have adult co-
trimoxazole tablets (80/400 mg) in your clinic.
3. When should a child classified as COUGH OR COLD return immediately to the

clinic?
4. When should they follow-up on the cough or cold?
32
n How will you counsel Amira about Jacob’s pneumonia?

Amira hovers over you and asks what you have found. You explain to her what
you have observed and what you think it means. You explain to Amira that Jacob
is breathing faster than he normally should, and that you think he has pneumonia.
Amira becomes very panicked and says that Jacob is going to die. She says that
she must run home with him in case he dies away from home and her husband
will be furious with her. You ask Amira to sit down and you try to calm her. You ask
her why she is so afraid. She says it is because her other child died so young.
You explain that pneumonia is an infection, but there is treatment for him to take.
You will be able to give this treatment at home. You will teach her steps to care for
the pneumonia at home.
n How you will begin to explain treatment?

You emphasize that it is really important that Jacob receives appropriate
treatment for his pneumonia. Without treatment, he could become very ill. You
reassure her that you will tell her all of the steps for the treatment Jacob needs.
This will help ensure that Jacob will get better.
Amira starts to settle and her face relaxes a little. However, she is still worried
about Jacob and worried about her husband’s response. You explain to her that
this infection can be treated but that it will take some time. She will need to give
Jacob antibiotics on a regular basis.
You also encourage Amira to bring Jacob’s father to the clinic if he wishes to have
further questions answered. You encourage Amira to discuss these things with
Jacob’s father and ask him to help with Jacob’s treatment.
n As a reminder, you want to counsel Amira on these topics

relevant to Jacob’s pneumonia:
 Giving oral antibiotics in the home
 Giving soothing remedies in the home
 When to return immediately
 When to return for follow-up
n How will you teach Amira about home treatment?

You have already identified that Jacob needs an oral antibiotic for 5 days.
He will receive it twice a day. You will also teach Amira how to make and give a
safe remedy for sore throat. You also explain to her that the medicine you are
giving needs to be taken regularly. Explain that it will take a few days for Jacob to
improve. Remind her that you must see Jacob again to watch his progress.
33
n How will you explain antibiotic treatment?

Jacob will get his first dose of antibiotic in the clinic. This provides a good
teaching opportunity for you to instruct Amira on the correct way to give
her son the antibiotic at home.
You show Amira how to measure the correct dose of the syrup. You ask her to
practice measuring it while you watch. Then, you ask her to give the first dose to
Jacob in the clinic. You praise her for doing a good job.
You give her a bottle of the syrup and remind her that she must give it to Jacob
twice a day for the full 5 days. Even if Jacob gets better before the 5 days are up,
she must continue the treatment. You label the syrup and give her the package.
n What will you tell Amina about follow-up?

You again praise her for being such a good mother and bringing in her sick child
for treatment. You encourage her to continue breastfeeding, as that is the best
way to soothe her son if his throat is sore.
Then, you ask Amira to bring Jacob back in 3 days to check on his condition. You
record this date on Jacob’s recording form. Then you will take Amira’s Mothers
Card and review the signs that she should be aware of for immediate return to the
clinic.
Amira still seems fearful, but very reluctantly agrees with the plan that you have
discussed together. She puts Jacob onto her back and walks off back to her
village. You watch her go and wonder what will happen.
n Now you will learn how to provide follow-up care for

respiratory illnesses:
A few days later you are sitting in your busy clinic room when you see Amira
coming to the door. As she unbundles Jacob, you notice that this time her face is
less fearful. You also see that her husband is with her, as he has decided to come
to the clinic to talk with you.
How will you provide care to Jacob? You will learn about follow-up for cough or
difficult breathing in the next section.
34
3.7 PROVIDE FOLLOW-UP CARE FOR COUGH OR

DIFFICULT BREATHING
REFRESH: WHAT ARE THE STEPS TO PROVIDING FOLLOW-UP CARE?
During a follow-up visit, you will do two things.
FIRST, YOU ASSESS PREVIOUS CLASSIFICATIONS

✔ You will check the child for general danger signs.
✔ You will assess for cough or difficult breathing. You will ASK:
1. Is the child breathing slower than on his first visit?
2. Is there less fever?
3. Is the child eating better?
✔ You will assess if the child’s respiratory condition is:
 IMPROVING
 THE SAME
 WORSENING
SECOND, YOU WILL USE IMCI TO FULLY RE-ASSESS THE CHILD

Second, you will use IMCI to reassess the child using IMCI to see if there are any
new issues. You will use a second recording form for this visit.
WHEN SHOULD A CHILD WITH COUGH OR DIFFICULT BREATHING

RETURN FOR FOLLOW-UP?
A child with PNEUMONIA should follow-up in 3 days. A child with COUGH OR
COLD should follow-up in 5 days if not improving. You have read in the box above
about what signs you will ask in the follow-up visit. You will use these to decide if
the child is improving, worsening, or the same.
 CHILD HAS A GENERAL DANGER SIGN

The child is getting worse. This child needs urgent referral to a hospital.
 CHEST INDRAWING OR BREATHING RATE, FEVER, AND EATING ARE SAME

The signs may not be exactly the same as 3 days before – but the child is not worse,
and not improving. This child needs urgent referral to a hospital.
 CHILD IS BREATHING SLOWER AND WITHOUT CHEST INDRAWING, EATING

BETTER, AND LESS FEVER
The child is improving. The child may cough, but most children who are improving
will no longer have fast breathing. The fever is lower or completely gone.
Tell the mother that the child should finish taking the 5 days of the antibiotic.
Review with her the importance of finishing the entire 5 days.
35
n How will you provide follow-up care for Jacob?

Amira has returned to the clinic with her husband. Amira looks more relaxed.
You welcome Amira and her husband and praise them for bringing Jacob back
for a follow-up visit. Amira tells you that she has been giving her son his antibiotic
regularly, as you discussed.
Amira says that Jacob seems to be better.
You check Jacob over and ask the appropriate questions for a pneumonia follow-
up visit:
•• Is Jacob breathing slower than on his first visit?
•• Is there less fever?
•• Is he eating better?
You notice that Jacob is coughing much less. His breathing rate is now 40 breaths
per minute. Amira says that he is eating better. He will take solid foods and is
breastfeeding better now.
 THE CHILD IS BREATHING SLOWER AND EATING BETTER
Jacob is improving. You tell his parents that he is much better. They are relieved
and thank you for the help.
n What actions will you take?

You remind Amira that Jacob should finish taking 5 days of the antibiotic.
Review with her the importance of finishing the entire 5 days. And again, praise
the parents for their good care of Jacob.
REMEMBER!
If child needs follow-up for more than one condition, they should
come at the earliest definite follow-up.
36
Read the following case study. Answer the questions about how you would
manage the case. Refer to any of the case management charts as needed.
Pandit’s mother has brought him back for follow-up. He is one year old. Three days
ago he was classified as having PNEUMONIA and you gave him amoxicillin. You
ask how he is doing and if he has developed any new problems. His mother says
that he is much better.
1. How would you reassess Pandit today? List all the signs you would look at and
write the questions you would ask his mother.
When you assess Pandit, you find that he has no general danger signs. He is still
coughing and he has now been coughing for about 10 days. He is breathing 38 breaths
per minute and has no chest indrawing and no stridor. His mother said that he does
not have fever. He is breastfeeding well and eating some food. He was refusing all
food before. He was playing with his brother this morning.
2. Based on Pandit’s signs today, what actions will you take?
37
3.8 USING THIS MODULE IN YOUR CLINICAL PRACTICE

How will you begin to apply the knowledge you have gained from this module
in managing children with cough or difficult breathing? In the coming days,
you should focus on these key clinical skills and using your Chart Booklet and
recording form. Practicing will help you better understand the clinical signs needed
to assess and classify these children.
ASSESS
✔✔ Ask caregivers if their children have a cough or difficult breathing, and for how
long. Explain difficult breathing if they do not understand.
✔✔ Look at the children’s chests to identify difficult breathing.
✔✔ Count the number of breaths in one minute. Decide if it is fast breathing.
✔✔ Watch children’s chest walls. See how in normal children the chest wall and
abdomen move out when the child breathes in.
✔✔ Identify chest indrawing – the lower chest wall moves in when child breathes in.
✔✔ Listen for the different noises of breathing – do you hear stridor or wheezing?
CLASSIFY
✔✔ Use your chart booklet to classify the signs you identify in children
✔✔ Record your classifications and appropriate treatment on your recording form.
TREAT
✔✔ Determine the appropriate treatment for a respiratory classification.
✔✔ Determine the correct type and dosage of antibiotic.
✔✔ Determine safe remedies in your area.
COUNSEL
✔✔ Use the key communication skills (APAC, 3 teaching steps) as you counsel
caregivers.
✔✔ Teach a caregiver how to give the antibiotic at home.
✔✔ Teach a caregiver about making or buying and giving a safe remedy for sore
throat or cough.
✔✔ Counsel about when to return for follow-up on this respiratory condition.
✔✔ Counsel about when to return immediately.
FOLLOW-UP
✔✔ Re-assess the child’s previous classification
✔✔ Determine how you will manage

38

MANAGING COUGH OR DIFFICULT BREATHING?
several questions. Now that you have finished the module, you will answer the same
questions. This will help demonstrate what you have learned.
1. What clinical signs can help you identify if a child has pneumonia?
a. Wet cough
b. Fast breathing
c. Runny nose
2. If a child has pneumonia, how will you treat?
a. Oral antibiotics
b. Honey
c. Paracetamol
3. Why is it important to correctly identify and manage pneumonia?
a. Pneumonia is very common, but it is not so serious for children
b. Pneumonia is a major killer of children under 5 around the world, and it
requires early management
c. Children with pneumonia need to be isolated from all other family members
4. Chest indrawing is when:
a. The lower ribs move in when the child breathes out
b. The lower ribs move in when the child breathes in
c. The lower ribs are always pushed in, no matter if the child is breathing in or
out
5. Children who have a cough, but do not show signs of pneumonia, should
immediately receive an antibiotic:
a. TRUE
b. FALSE
6. The following is a good checking question: “how will you prepare a safe home
remedy for cough?”
a. TRUE
b. FALSE
39
3.10 ANSWER KEY

REVIEW QUESTIONS
Did you miss the question? Return to this section
QUESTION ANSWER
to read and practice:
1 B INTRODUCTION, ASSESS
2 A TREAT
3 B INTRODUCTION
4 B ASSESS
5 B CLASSIFY, TREAT
6 A COUNSEL
EXERCISE A (ASSESS)
1. Fast breathing, chest indrawing.
2. Answers below
a. 3 years, 36 breaths per minute NO
b. 12 months, 50 breaths per minute YES
c. 6 months, 45 breaths per minute NO
d. 3 months, 57 breaths per minute YES
3. Answers below:
a. ASK: does the child have cough or difficult breathing?
b. LOOK: do you notice any issues with breathing?
4. Continue to the next assessment, for diarrhoea.
EXERCISE B (CLASSIFY)
1. Signs below are matched with the appropriate classification.
Sal is 9 months old and has a cough. You count 45 breaths
COUGH OR COLD
per minute. No chest indrawing or stridor.
Linus is 3 months old, and you could 65 breaths in one

SEVERE PNEUMONIA or
minute. When he breathes in, has had convulsions during
VERY SEVERE DISEASE
current illness.
Jojo is 3 years old. You count 56 breaths in one minute.

PNEUMONIA
No indrawing or stridor.
2. Answers below. If the statement is false, a correct statement is provided.

a. FALSE: You look for chest indrawing when the child breathes IN.
b. TRUE
c. TRUE
d. FALSE: If a child shows no signs, they are classified as COUGH OR COLD.
e. FALSE: A child with chest indrawing may not have fast breathing.
f. TRUE
40
g. FALSE: Fast breathing in this age group 50 or more breaths per minute.
h. TRUE
i. TRUE
j. FALSE: Classify as SEVERE PNEUMONIA OR VERY SERIOUS DISEASE. This child
shows signs from two classifications. Fast breathing is a sign of PNEUMONIA
(yellow). He also has a general danger sign (red classification). When a child
presents with signs from different boxes, you always classify with the more severe.
EXERCISE C (GYATSU)
1. Form below:

Name: Gyatsu Age: 6 months Weight (kg): 5.5 kg Temperature (°C): 38 °C
What are the child's problems? Cough
Ask: for 2 days Initial Visit? ✓ Follow-up Visit?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___✓
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes ✓
__ No __
2 Days
___
Look for chest indrawing Pneumonia
2. theTo
Is there blood in classify
stool? Gyatsu’s illness, look at the
Lethargic classification table for
or unconscious? cough or difficult
breathing in your chart booklet. Look at irritable?
Restless and the pink (or top) row.
a. NO Offer the child fluid. Is the child:
b. NO Drinking eagerly, thirsty?
c. NO Pinch the skin of the abdomen. Does it go back:
Slowly?
3. If he does not have the severe classification, look at the yellow (or middle) row.
a. NO
b. PNEUMONIA
EXERCISES D
Do malaria test if NO general danger sign (TREATMENT)
High risk: all fever1.
cases
Answers below:
a. TRUE
If the child has measles
b. TRUEnow or within the Look for mouth ulcers.
last 3 months: c. TRUE If yes, are they deep and extensive?
d. FALSE Look for clouding of the cornea.
2. 5 days, 2 times a day
If Yes, for how3.
long? ___ Days
What is the correct dosage for the following oral treatments?
AND ANAEMIA a. 5 ml (250 mg/5 ml), two times Determine WFH/L
a day, for_____
fiveZdays
score.
b. 1 tablet (250 mg), two times
Look aforday, for
palmar five days
pallor.
c. 10 ml (250 mg/5 ml), two times Severe a palmar
day, forpallor? Some
five days palmar pallor?
d. 3 tablets (250 mg), two times a day,
General for sign?
danger five days
WFH/L less than -3 Z scores or oedema of
41 or older offer RUTF to eat. Is the child:
For a child 6 months
4. Many safe remedies are locally specific and recorded in your chart booklet. Remedies
can be homemade, given at clinic, or bought at pharmacy. Breast milk is best remedy
for exclusively breastfed child – do not give other drinks or remedies.
5. Many unsafe remedies are locally specific and recorded in your chart booklet. Other
harmful remedies contain atropine, codeine or codeine derivatives, or alcohol. These
items may sedate the child. They may interfere with the child’s feeding. They may also
interfere with the child’s ability to cough up secretions from the lungs. Medicated
nose drops (that is, nose drops that contain anything other than salt) should also
not be used.
EXERCISE E (COUNSEL)
ANSWERS: questions should now be open-ended, and begin with how, what,
why, when, where, or how. You should not be able to answer them ‘yes’ or ‘no’.
Some examples are below, but you will have your own questions.
1. Do you remember when to give the amoxicillin? When will you give the amoxicillin?
2. Do you understand how much syrup to give your child? How much syrup will you
give your child?
3. Did the nurse explain to you how to give an inhaler? How will you give the inhaler?
4. Do you know how to make a remedy for the throat? How will you make a remedy
for the throat at home?
EXERCISE F (COUNSEL)
1. Ask the mother to show you how to measure the dosage, and tell you the schedule
for the antibiotic. If she is incorrect, give her information, and demonstrate for her.
If she does indeed know the information and measures the dosage correctly, ask
her to give the first dose so you can observe.
Maria 05/02/03
Amoxicillin 10 tablets
Give 1 tablet, two times a

day, for 5 days
2. They must return immediately if breathing becomes fast or difficult.

3. They should return for a follow-up visit in 5 days, only if the cough is not improving.
42
EXERCISE G (PANDIT)
1. List all the signs you would look at and write the questions you would ask his mother:
1. Is he able to drink or breastfeed?
2. Does he vomit everything?
3. Has he had convulsions?
4. See if he is lethargic or unconscious.
5. Is he still coughing? How long has he been coughing?
6. Count the breaths in one minute.
7. Look for chest indrawing.
8. Look and listen for stridor.
9. Is he breathing slower?
10. Is there less fever?
11. Is he eating better?
2. Tell his mother that he is improving nicely. She should continue giving him the
pills as she has been until they are all gone. You should ask her checking questions
about how she has been giving the treatment. If you notice any issues, or she has
any concerns and questions, address this.
43
ISBN 978 92 4 150682 3
IMCI
Module 4
Diarrhoea
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA
n CONTENTS
Acknowledgements 4
4.2 Introduction to diarrhoea 8
4.3 Assess a sick young infant & child for diarrhoea 10
4.4 Classify diarrhoea & dehydration 17
4.5 Treat the child with diarrhoea 23
4.7 Provide follow-up care for diarrhoea 42
4.10 Answer key 47
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
4.1 MODULE OVERVIEW

Diarrhoea is likely a very common problem in the children you see at your clinic.
Diarrhoea can be serious – and even lead to death.
check for general danger signs, assess for cough or difficult breathing, then ASK:
DOES THE CHILD HAVE DIARRHOEA?
NO YES

the colour-coded classification charts
for dehydration & diarrhoea.
CONTINUE ASSESSMENT: assess for main symptoms (next is fever), check for
malnutrition & anaemia, check immunization status, HIV status, other problems
NOTE ON DIARHOEA IN SICK YOUNG INFANT: In Module 2, you were told to

refer to this module to assess and classify diarrhoea in sick young infants. The
IMCI process is similar for the two. There are some important distinctions, which
you will learn about in the module.

✔✔ Define the types of diarrhoea and levels of dehydration
✔✔ Recognize clinical signs of dehydration
✔✔ Assess diarrhoea in sick children
✔✔ Assess dehydration in young infants and sick children
✔✔ Classify diarrhoea and severity of dehydration using IMCI charts
✔✔ Provide Plans A, B, and C for dehydration
✔✔ Counsel the caregiver about home treatment for diarrhoea and dehydration
5
Danger sign when
YOUR RECORDING FORM selecting
classifications
Look at your IMCI recording form for the sick child. This section deals with thisYes __
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? No __
module:
Slowly?
MODULE ORGANIZATION
Has child hadThis module
measels follows
within the the major stepsOne
last 3 months? of the IMCI
of these: process:
cough, runny nose, or red eyes
✔ ASSESS DIARRHOEA and DEHYDRATION IN SICK CHILD
✔cases
High risk: all fever
Test POSITIVE?✔ P.✔falciparum
ASSESSP.DEHYDRATION
vivaxNEGATIVE? IN SICK YOUNG INFANT
✔✔ CLASSIFY DIARRHOEA and DEHYDRATION
✔✔ CLASSIFY DEHYDRATION IN SICK YOUNG INFANT
✔✔ TREAT DIARRHOEA
✔ COUNSEL
✔FOR
THEN CHECK CAREGIVER ONLook
ACUTE MALNUTRITION 4 RULES OF
for oedema HOME
of both feet. TREATMENT
✔✔ FOLLOW-UP CARE FOR DIARRHOEA
BEFORE
WFH/L less than YOUorBEGIN
-3 Z scores oedema of General danger sign?
both feet:
What do you know now about managingPneumonia withdiarrhoea?
chest indrawing?
Before you begin studying this module, quickly
Not able to practice
finish or able to finish? your knowledge with these
CHECK FORmultiple-choice
HIV INFECTION questions.
Circle
Mother's HIV test: theNEGATIVE
best answer POSITIVEfor each question.
NOT DONE/KNOWN
1. How can diarrhoea kill children?
Was the child a. Children
breastfeeding lose
at the timevaluable fluids,
of test or 6 weeks salts,
before it? and sugars, which can cause shock to vital
organs
BCG b. ChildrenDPT+HIB-2
DPT+HIB-1 lose valuableDPT+HIB-3
nutrients because
Measles1 they cannot
Measles 2 eat Vitamin A immunization on:
Hep B0
c. B1Diarrhoea
Hep Hepcauses
B2 liverHepfailure
B3 (Date)
RTV-1 RTV-2 RTV-3
2. Pneumo-1
What are critical treatments
Pneumo-2 for children with diarrhoea and dehydration?
Pneumo-3
a. Oral antibiotics
b. Oral rehydration therapy and zinc
c. Paracetamol for discomfort
Page 65 of 75
6
3. What is persistent diarrhoea?

a. When a child frequently has diarrhoea over a period of 1 month, and is ill as
a result
b. When a child has several episodes of diarrhoea a day
c. When a child has an episode of diarrhoea lasting 14 days or more, which is
particularly dangerous for dehydration and malnutrition
4. Critical messages for caregivers about diarrhoea and dehydration include:
a. The child must receive increased fluids, ORS, zinc, and regular feeding
b. The child requires ORS, but should receive less food in order to reduce the
diarrhoea
c. The child should immediately receive antibiotics to stop the diarrhoea
5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She
has diarrhoea. You observe a significant loss of skin elasticity. How will you
manage Nidhi?
a. Nidhi requires ORS immediately, as she is dehydrated.
b. These are common signs of diarrhoea, as the child’s body is exhausted.
c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV
or nasogastric tube.
7
4.2 INTRODUCTION TO DIARRHOEA
n OPENING CASE STUDY – MARY

It is a busy afternoon in your clinic. A young mother comes into your clinic room, carrying a small girl. She
says her daughter, Mary, has diarrhoea. You ask the mother’s name, and she says Ana. Ana says that Mary
usually eats porridge and milk, but that she has had bad diarrhoea in the past few days. Ana tried giving
more porridge but Mary is still sick. Ana thought it was a bad stomach from spoiled milk, and that it would
pass.
However, the diarrhoea has remained for several days now, and now Mary looks unwell. Ana fears that Mary
is getting worse, and is feeling guilty that she did not come to the clinic sooner. Ana works in the mornings,
and lives some distance from the clinic. By the time she commutes into the city for her work duties, she does
not have very much time in the day to bring Mary in. She says she is worried that her family will blame her for
working at the job and letting Mary get more and more sick.
WHAT IS DIARRHOEA?
Diarrhoea occurs when stools contain more water than normal, and are loose or
watery. In many regions diarrhoea is defined as three or more loose or watery stools
in a 24-hour period. Children between the ages of 6 months and 2 years often have
diarrhoea. It is more common in settings of poor sanitation and hygiene, including
a lack of safe drinking water.
WHAT ARE THE TYPES OF DIARRHOEA IN CHILDREN?

Most diarrhoea that causes dehydration is loose or watery. Cholera is one example,
though only a small proportion of all loose or watery diarrhoeas are due to cholera.
n ACUTE DIARRHOEA is an episode of diarrhoea that lasts less than 14 days.
Acute watery diarrhoea causes dehydration and contributes to malnutrition.
The death of a child with acute diarrhoea is usually due to dehydration.
n PERSISTENT DIARRHOEA lasts 14 days or more. Up to 20% of episodes of
diarrhoea become persistent, and this often causes nutritional problems and
contributes to death in children.
n DYSENTERY is diarrhoea with blood in the stool, with or without mucus. The
most common cause of dysentery is Shigella bacteria. Amoebic dysentery is
not common in young children. A child may have both watery diarrhoea and
dysentery.
WHAT ARE THE TYPES OF DIARRHOEA IN YOUNG INFANTS?

A young infant has diarrhoea if the stools have changed from the usual pattern, and
are many and watery. This means more water than faecal matter. The normally
frequent or semi-solid stools of a breastfed baby are not diarrhoea.
8
n How do you greet Ana and begin the assessment?

You praise Ana for bringing in her daughter. You tell her that diarrhoea can be a serious problem for young
children, but that there are ways to help her daughter get better. You explain that you will check her
condition and decide the best treatment. Ana seems relieved.
You ask Mary’s age. Ana tells you that she is 9 months old. You ask Ana if there are other problems besides
the diarrhoea. She says no. This is their first time coming to the clinic for this diarrhoea. You take Mary’s
weight, 8.2 kg, and temperature, 37 degrees Celsius.
n You will check Mary for general danger signs.

First, you check Mary for general danger signs. Ana tells you that Mary is able to drink milk and take porridge.
She does not vomit. She has not had convulsions. You watch Mary. She looks very tired in Ana’s arms, but she
watches you as you speak. When you reach out to her to take her hand, she grabs your finger. Does Mary
have any general danger signs?
n Next, you will assess Mary for cough or difficult breathing.

Now you check Mary for cough or difficult breathing. You ask Ana if Mary has had a cough, or any fast or
noisy breathing. Ana says that Mary had a cough about 2 months ago, but it has cleared up.
This is how you will complete Mary’s recording form thus far:

Name: Mary Age: 9 mo Weight (kg): 8.2 kg Temperature (°C): 37 °C
Ask: What are the child's problems? Diarrhoea for several days Initial Visit? X Follow-up Visit?
CLASSIFY
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
NowIs you willinassess
there blood the stool?Mary
for the next main Lethargic
symptom, diarrhoea. This is
or unconscious? also the problem that her
mother brought her to the clinic for. Look for sunken eyes.
Slowly?
THEN CHECK FOR ACUTE MALNUTRITION 9
Look for oedema of both feet.
4.3 ASSESS A SICK YOUNG INFANT & CHILD

FOR DIARRHOEA
You have a very important job to do in helping a child with diarrhoea. This module
will guide you through the process of assessing, classifying, and treating by the
type of diarrhoea and the severity of dehydration.

First, you will ASK all caregivers if the child has diarrhoea. You might need to explain
diarrhoea as loose, watery stools if the caregiver needs clarification. Be sure to use
words for diarrhoea that the mother understands.
NO diarrhoea, ask about the next main symptom, fever. You do not need to further
assess.
YES or reported earlier that diarrhoea was the reason for coming to the clinic,
record her answer. You will then assess in two parts:
1. Type of diarrhoea: especially if it is persistent, or dysentery
2. Signs of dehydration
Open to your ASSESS chart for diarrhoea, which includes the assessment for both
diarrhoea and dehydration. It contains the following instructions, which you will
now learn about.
Does the child have diarrhoea?
Two of the
If yes, ask: Look and feel:
Letharg
For how long? Look at the child's general
for DEHYDRATION Sunken
Is there blood in the stool? condition. Is the child:
Not able
Lethargic or
Classify DIARRHOEA drinking
unconscious?
Skin pin
very slo
Offer the child fluid. Is the
child:
Not able to drink or
drinking poorly?
Drinking eagerly,
thirsty?
Two of the
Pinch the skin of the
Restless
abdomen. Does it go back:
Sunken
Very slowly (longer
Drinks e
than 2 seconds)?
Skin pin
Slowly?
slowly.
The ASSESS chart for the sick young infant is slightly different. There is some
additional detail to examine about the infant’s movements. It also does not test how Not enough
well the child drinks. Review the ASSESS chart for the sick young infant as well. as some or
dehydration
Dehydra
and if diarrhoea 14
days or more
10 No dehy
DIARRHOEA: SICK CHILD

ASK: FOR HOW LONG?
Diarrhoea which lasts 14 days or more is persistent diarrhoea. Give the mother
time to answer the question. She may need time to recall the exact number of days.
ASK: IS THERE BLOOD IN THE STOOL?

Ask the mother if she has seen blood in the stools at any time during this episode of
diarrhoea. As we previously reviewed, dysentery is diarrhoea with blood in the stool,
with or without mucus. The most common cause of dysentery is Shigella bacteria.
Dysentery will require specific treatments.
DEHYDRATION: SICK CHILD & YOUNG INFANT

WHAT IS DEHYDRATION?
Diarrhoea can be a serious problem – and even lead to death – if child
becomes dehydrated. Dehydration is when the child loses too much water and salt
from the body. This causes a disturbance of electrolytes, which can affect vital organs.
A child who is dehydrated must be treated to help restore the balance of water and
salt. Many cases of diarrhoea can be treated with Oral Rehydration Salts (ORS),
a mixture of glucose and several salts. ORS and extra fluids can be used as home
treatment to prevent dehydration. Low osmolarity ORS should be used to treat
dehydration.
HOW WILL YOU ASSESS DEHYDRATION?

There are several signs that help you decide the severity of dehydration. When a
child becomes dehydrated, he is at first restless or irritable. As the body loses fluids,
the eyes may look sunken, and skin loses elasticity. If dehydration continues, the
child becomes lethargic or unconscious.
LOOK: AT THE CHILD’S GENERAL CONDITION

When you checked for general danger signs, you checked to see if the child was
lethargic or unconscious. If the child is lethargic or unconscious, he has a general
danger sign. Remember to use this general danger sign when you classify the child’s
diarrhoea.
A child is classified as restless and irritable if s/he is restless and irritable all the
time or every time s/he is touched and handled. If an infant or child is calm when
breastfeeding but again restless and irritable when he stops breastfeeding, s/he has
the sign restless and irritable. Many children are upset just because they are in the
clinic. Usually these children can be consoled and calmed, and do not have this sign.
FOR THE YOUNG INFANT: watch the infant’s movement. Does he move on his own? Does the infant only
move when stimulated, but then stops? Is the infant restless and irritable?
11
LOOK FOR SUNKEN EYES

The eyes of a child who is dehydrated may look sunken. Decide
if you think the eyes are sunken. Then ask the mother if she
thinks her child’s eyes look unusual. Her opinion can help
you confirm.
NOTE: In a severely malnourished child (see Module 6) who
is wasted, the eyes may always look sunken, even if the child
is not dehydrated. Still use the sign to classify dehydration.
DVD EXERCISE – SUNKEN EYES

Watch “Assess sunken eyes” (disc 1). It is very useful to practice with a video. Record
your answers as you watch, and the video will review them. Do these children
have sunken eyes?
CHILD 1  YES  NO CHILD 3  YES  NO CHILD 5  YES  NO
CHILD 2  YES  NO CHILD 4  YES  NO CHILD 6  YES  NO
LOOK: TO SEE HOW THE CHILD DRINKS

Ask the mother to offer the child some water in a cup or spoon. Watch the child drink.
A child is not able to drink if he is not able to suck or swallow when offered a drink.
A child may not be able to drink because he is lethargic or unconscious.
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.
A child has the sign drinking eagerly and acts thirsty if it is clear that the child
wants to drink. Look to see if the child reaches out for the cup or spoon when you
offer him water. When the water is taken away, see if the child is unhappy because
he wants to drink more. If the child takes a drink only with encouragement and
does not want to drink more, he does not have the sign drinking eagerly, thirsty.
FEEL: BY PINCHING THE SKIN OF THE ABDOMEN

This skin pinch tests is an important tool for testing dehydration. When a child is
dehydrated, the skin loses elasticity. To assess dehydration using the skin pinch:
1. ASK the mother to place the child on the examining table so that the child is flat
on his back with his arms at his sides (not over his head) and his legs straight.
Or, ask the mother to hold the child so he is lying flat on her lap.
2. USE YOUR THUMB AND FIRST FINGER to locate the area on the child’s
abdomen halfway between the umbilicus and the side of the abdomen. Do not
use your fingertips because this will cause pain. The fold of the skin should be
in a line up and down the child’s body.
3. PICK UP all the layers of skin and the tissue underneath them.
4. HOLD the pinch for one second. Then release it.
12
5. LOOK to see if the skin pinch goes back very slowly (more than 2 seconds),
slowly, (less than 2 seconds, but not immediately), or immediately. If the skin
stays up for even a brief time after you release it, decide that the skin pinch goes
back slowly. The photographs below show you how to do the skin pinch test and
what the skin looks like when the pinch does not go back immediately.
Skin pinch Skin pinch going back very slowly
NOTE: The skin pinch test is not always an accurate sign. In a child with severe
malnutrition, the skin may go back slowly even if the child is not dehydrated. In a
child is overweight or has oedema, the skin may go back immediately even if the child
is dehydrated. However you should still use it to classify the child’s dehydration.
13
DVD EXERCISE – SKIN PINCH

Watch “Assess skin pinch” (disc 1) to see how skin pinches look. How do you assess
the 5 children in the video? Record your answers, and the video will review
answers with you.
1 2 3 4 5
VERY SLOWLY
SLOWLY
IMMEDIATELY

Watch “Demonstration: assess and classify diarrhoea” (disc 1)

This video reviews all steps in assessing diarrhoea.
It is useful to see in a clinical setting.

n How will you assess Mary’s diarrhoea?
Ana has already
Ask: What reported
are the child's problems?that Mary has diarrhoea. You ask Ana how many days she
Initial has had diarrhoea,
Visit? and
Follow-up Visit?
she tells you 3 days. You ask Ana if there is blood in her daughter’s stool, and she tells you no.
CHECK
Now youFOR
willGENERAL DANGER
examine Mary’s SIGNS She seems restless and irritable, especially when you touch
condition. Generalher.
danger
Yousign
begin to examine
VOMITS Mary for signs of dehydration.
EVERYTHING You check
CONVULSING NOW to see if she has sunken eyes, and it appears
Yes ___ Nothat
___
sheCONVULSIONS
does. Ana agrees that her daughter’s eyes look unusual. You offer her some water to drink and noticeto use
Remember
how she responds. She drinks the water eagerly. Danger sign when
selecting
Next, you give Mary a pinch test to determine how dehydrated she is. You ask Ana to place Mary classifications
on the
DOES THE table
examining CHILDso HAVE
thatCOUGH ORon
she is flat DIFFICULT
her backBREATHING?
with her arms at her sides, and her legs straight. You
Yesdo
__ pinch
No __
theFor
skinhow long? ___ Days
of Mary’s abdomen, and it goes backCount in 1the breaths in one minute
second.
How will you record these signs on Mary’s
Look andrecording
listen for stridor form?
DOES THE CHILD HAVE DIARRHOEA? X No __
Yes __
For how long? ___3 Days Look at the childs general condition. Is the child:
Slowly?
Decidein
malaria Look or feel for stiff neck
Then the risk:
nextHigh ___ Low you
section, ___ No___
will learn how to assess Mary’s diarrhoea using the signs you have assessed.
Look for runny nose
On Ifthe
morenext
than 7page
days, has
youfever been
will present
have theevery
opportunity to practice assessing signs in two case studies.
day?
Is there ear discharge? 14
Feel for tender swelling behind the ear
Read the case study below. Assess and classify the child’s diarrhoea and
dehydration.
Maya is at the clinic today because she has had diarrhoea for 4 days. She is 25 months
old. She weighs 9 kg. Her temperature is 37.0 °C. Maya has no general danger signs.
She does not have cough or difficult breathing. The health worker said to the mother,
“When Maya has diarrhoea, is there any blood in the stool?” The mother said,
“No.” The health worker checked for signs of dehydration. Maya is not lethargic or
unconscious. She is not restless or irritable. Her eyes are not sunken. Maya drinks
eagerly when offered some water. Her skin pinch goes back immediately. Record
Maya’s signs and classify them.

Danger sign when
selecting
classifications
Slowly?
both feet: 15
Read the case study below. Assess and classify the child’s diarrhoea and
dehydration.
Rana is 14 months old. She weighs 12 kg. Her temperature is 37.5 °C. Rana’s mother
said the child has had diarrhoea for 3 weeks. Rana does not have any general danger
signs. She does not have cough or difficult breathing. The health worker assessed
her diarrhoea. He noted she has had diarrhoea for 21 days. He asked if there has
been blood in the child’s stool. The mother said, “No.” The health worker checked
Rana for signs of dehydration. The child is irritable throughout the visit. Her eyes
are not sunken. She drinks eagerly. The skin pinch goes back immediately. Record
Rana’s signs and classify.

Danger sign when
selecting
classifications
Slowly?
both feet: 16
4.4 CLASSIFY DIARRHOEA & DEHYDRATION

HOW WILL YOU CLASSIFY FOR MAIN SYMPTOM DIARRHOEA?
This main symptom has more than one classification table in the ASSESS AND
CLASSIFY charts. You will now classify both diarrhoea and dehydration. When
classifying:
✔✔ All children with diarrhoea are classified for dehydration
✔✔ If the child has had diarrhoea for 14 days or more, classify for persistent
diarrhoea
✔✔ If the child has blood in the stool, classify the child for dysentery

HOW DO YOU CLASSIFY DEHYDRATION?
There are three possible classifications for the type of diarrhoea. These are:
1. SEVERE DEHYDRATION
2. SOME DEHYDRATION
3. NO DEHYDRATION
Open your Chart Booklet to the dehydration classification table. What do you
observe? You will now read about these classifications and identified treatments.
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
sify DIARRHOEA
very slowly. mother giving frequent sips of ORS
on the way
breastfeeding
cholera in your area, give antibiotic for
cholera
Drinks eagerly, thirsty Refer URGENTLY to hospital with
Skin pinch goes back mother giving frequent sips of ORS
slowly. on the way
breastfeeding
as some or severe NO diarrhoea at home (Plan A)

days or more PERSISTENT Refer to hospital
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
DIARRHOEA 17 Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days
SEVERE DEHYDRATION (RED)

Classify as SEVERE DEHYDRATION if the child has two or more of the following
signs: lethargic or unconscious, not able to drink or drinking poorly, sunken eyes,
or very slow skin pinch.

Any child with dehydration needs extra fluids. A child classified with SEVERE
DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids. The box
“Plan C: Treat Severe Dehydration Quickly” on the TREAT chart describes
how to give fluids to severely dehydrated children. You will learn more about
Plan C in the next section.
SOME DEHYDRATION (YELLOW)

If the child does not have signs of SEVERE DEHYDRATION, look at the next row.
Does the child have signs of SOME DEHYDRATION? If the child has two or more
of the following signs – restless, irritable; drinks eagerly, thirsty; sunken eyes; skin
pinch goes back slowly – classify as SOME DEHYDRATION.

If a child has one sign in the red (top) row and one sign in the yellow (middle)
row, classify the child in the yellow row (SOME DEHYDRATION). A child who
has SOME DEHYDRATION needs fluid, foods, and zinc supplements. Treat the
child with ORS solution. In addition to fluid, the child with SOME DEHYDRATION
needs food. Breastfed children should continue breastfeeding. Other children should
receive their usual milk or some nutritious food after 4 hours of treatment with ORS.
The treatment is described in the box “Plan B: Treat Some Dehydration with
ORS”. You will learn more about ORS and zinc supplements in the next section.
NO DEHYDRATION (GREEN)
A child who does not have two or more signs in the red or yellow row is classified
as having NO DEHYDRATION. This child needs extra fluid and foods to prevent
dehydration.
The four rules of home treatment are:
1. Give extra fluid
2. Give zinc supplements
3. Continue feeding
4. Return immediately if the child develops danger signs, drinks poorly, or has
blood in stool

The treatment box called “Plan A: Treat Diarrhoea At Home” describes what
fluids to teach the mother to give and how much she should give. A child with NO
DEHYDRATION also needs food and zinc supplements. You will learn more about
Plan A and zinc in the next section.
18
breastfeeding
as some or severe IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA
NO diarrhoea at home (Plan A)
After you classify dehydration,

Pink:
classify the child for persistent diarrhoea if the child
Dehydration present. Treat dehydration before referral unless the
and if diarrhoea 14 has had diarrhoea for 14 daysSEVERE
or more. Then child
you has
classify
anotherfor dysentery.
severe classification
DIARRHOEA
DIARRHOEA:
TwoNo
ofdehydration.
SICK Yellow:
the following signs:
CHILD
Pink: Advise the mother
If child has no otheronsevere
feeding a child who has
classification:
Lethargic or unconscious PERSISTENT
Give fluid DIARRHOEA
for severe dehydration (Plan C)
HOW DO YOU CLASSIFYPERSISTENT
DYSENTERY
SEVERE IN A CHILD?
for DEHYDRATION Sunken eyes DIARRHOEA
DEHYDRATION Give multivitamins and OR
If the
Notchild has
able to diarrhoea
drink or and any blood in the minerals
stool,
If childyou
also will
hasclassify
(including zinc) for as
another 14 DYSENTERY.
severe
days
Follow-up in 5 days
sify DIARRHOEA Review the classification table in your Chart Booklet. Refer URGENTLY to hospital with
Skin pinch goes back
Blood in the stool. Yellow: Giveonciprofloxacin
the way for 3 days
DYSENTERY Follow-up inthe
Advise mother to continue
2 days
breastfeeding
A child with dysentery should be treated for cholera
dehydration. You should
in your area, also give
give antibiotic foran
cholera
antibiotic recommended for Shigella in your area. Finding the actual cause of the
dysentery
Restless,requires
irritable a stool culture
SOME
for which itsome
can dehydration
take at least
(Plan2B)
days to obtain the
laboratory results. You willDEHYDRATION
Sunken eyes assume Shigella isIfthe
childcause because:
also has a severe classification:
✔ Shigella
Skin pinchcauses
✔Page 6 of 75 about 60% of dysentery casesmother
goes back seen ingiving
clinics.
frequent sips of ORS
slowly. on the way
✔✔ Shigella causes nearly all cases of life-threatening
Advisedysentery.
the mother to continue
breastfeeding
HOW DO YOU CLASSIFY PERSISTENT Follow-up
DIARRHOEA in 5 days ifIN
notA CHILD?
improving
IfNot
theenough
childsigns to classify
has had Green:
diarrhoea for 14 days orGive
more,fluid,you
zinc supplements,
will classifyand
forfood to treat
persistent
as some or severe NO diarrhoea at home (Plan A)
diarrhoea.
dehydration. Health workers often mismanage
DEHYDRATION Advisepersistent diarrhoea,
mother when to so these
return immediately
instructions are important: Follow-up in 5 days if not improving

DIARRHOEA
DIARRHOEA Give multivitamins and
Follow-up in 5 days

SEVERE PERSISTENT DIARRHOEA
DYSENTERY (RED)
Follow-up in 2 days
If a child has had diarrhoea for 14 days or more and also has some or severe
dehydration, is classified SEVERE PERSISTENT DIARRHOEA. Children who are
classified with SEVERE PERSISTENT DIARRHOEA should be referred to hospital.

Treat the child’s dehydration before referral unless the child has another severe
Page 6 of 75
classification. Treating dehydration in children with another severe disease can be
difficult. These children should be treated in a hospital. These children need special
attention to help prevent loss of fluid. They may need a change in diet. They may
also need laboratory tests to identify the cause of the diarrhoea.
19
PERSISTENT DIARRHOEA (YELLOW)

A child who has had diarrhoea for 14 days or more and who has no signs of
dehydration is classified as having PERSISTENT DIARRHOEA.

Special feeding is the most important treatment for persistent diarrhoea.
DVD EXERCISE – JOSH CASE STUDY

Watch “Case study Josh” (disc 1). This is a great way to practice assessing and
classifying a child for general danger signs, respiratory problems, and diarrhoea.
As you watch the video, complete the recording form below as you would a normal
case. Assess and classify using this form and your Chart Booklet.
Does Josh present with any general danger signs? How do you classify Josh for
respiratory illness? How do you classify Josh’s diarrhoea?

Danger sign when
selecting
classifications
Slowly?
Has child had Answer One of these: cough, runny nose, or red eyes
the
measels within the questions
last 3 months? below about assessing and classifying diarrhoea and
dehydration.
1. How many signs are needed to classify a child with SOME DEHYDRATION?
2. Give two signs that may indicate that aofchild
Look for clouding has SEVERE
the cornea. DEHYDRATION.
20
3. What type of ORS should be used to treat dehydration?
4. Which children need zinc supplements?
5. What are the 4 rules of home treatment of diarrhoea?

Ask: What are theAssess
child's problems?
and classify dehydration in these children. Be sure to Initial Visit?
circle the signs Follow-up Visit?
you
use to classify.
1. PANO has had diarrhoea forCONVULSING
VOMITS EVERYTHING five days. He
NOWhas no blood in the stool. He is irritable.
Yes ___ No ___
CONVULSIONS
His eyes are sunken. His father and mother also think that Pano’s eyes are sunken. Remember to use
Danger sign when
The health worker offers Pano some water, and the child drinks eagerly. When selecting
classifications
the health worker pinches the skin on the child’s abdomen, it goes back slowly.
Record the child’s signs and classification for dehydration on the Recording
Form. Look for chest indrawing
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Not able to drink or drinking poorly?
Name: Age: Weight (kg):
Very slowsly (longer then 2 seconds)? Temperature (°C):
Ask: What are the child's problems? Slowly? Initial Visit? Follow-up Visit?
CHECK FORrisk:
Decide malaria GENERAL DANGER
High ___ Low SIGNS
___ No___ Look or feel for stiff neck General danger sign
NOT ABLE
For how TO___
long? DRINK
DaysOR BREASTFEED Look for runnyOR
LETHARGIC nose
UNCONSCIOUS present?
VOMITS 2.
EVERYTHING
If more than JANE has had diarrhoea
7 days, has fever been present every for 3 days. There
Look for signs ofNOW
CONVULSING was
MEASLES: no blood in the stool. The child
Yes ___ No ___
CONVULSIONS
day? Generalized rash and Remember to use
was not lethargic or unconscious.
Has child had measels within the last 3 months? One ofShe was
these: notrunny
cough, irritable
nose, or or
red restless.
eyes Her eyes were
Danger sign when
sunken. She Lookbut
was able to drink, for any
sheother
wascause
notof fever.
thirsty. The skin pinch went back selecting
High risk: all fever cases classifications
immediately.
DOES
Low risk:THE
if NO CHILD HAVE
obvious cause of COUGH
fever OR DIFFICULT BREATHING? Yes __ No __
TestFor how long?P.___
POSITIVE? Days
falciparum Count the breaths in one minute
P. vivaxNEGATIVE?
Record the child’s signs and
___ classification forbreathing?
dehydration on the Recording
If the child has measles now or within the Lookbreaths perulcers.
for mouth minute. Fast
last 3 months: Form. If yes, are they deep and extensive?
Look
Look and listen forofwheezing
for clouding the cornea.
DOES
DOES THE
THE CHILD
CHILD HAVE
HAVE DIARRHOEA?
AN EAR PROBLEM? Yes
Yes __
__ No
No __
__
For howear
Is there long? ___ Days
pain? Look
Look at
forthe
puschilds general
draining fromcondition.
the ear Is the child:
Is
Is there
there blood in the stool?
ear discharge? FeelLethargic
for tenderorswelling
unconscious?
behind the ear
If Yes, for how long? ___ Days Restless and irritable?
Slowly?
Any severe classification? Yes __ No __
both
Decidefeet:
malaria risk: High ___ Low ___ No___ Look or feel for stiff
Pneumonia withneck
chest indrawing?
For how long? ___ Days Look
For for runny
a child noseor older offer RUTF to eat. Is the child:
6 months
If more than 7 days, has fever been present every Look for 21
signs of MEASLES:
day? For aGeneralized rash
child less than 6 and
months is there a breastfeeding problem?
CHECK FOR HIV INFECTION Look for any other cause of fever.
Do malaria test if NO
Note mother's general
and/or danger
child's sign
HIV status
Mother's
High risk: HIV
all fever test:
cases NEGATIVE POSITIVE NOT DONE/KNOWN
Child's
Low risk: if NOvirological
obvious causetest: ofNEGATIVE
fever POSITIVE NOT DONE
n How Any
willjaundice
you classify
if age lessMary’s
Pink:diarrhoea? Treat to prevent low blood sugar
Y Mary has had diarrhoea
Yellow palms and forsoles
3 days,
at which is an acute episode
JAUNDICE of diarrhoea.
Advise mother howShetodoes
keepnot
thehave persistent
infant
JAUNDICE diarrhoea,any
which
age lasts 14 days or more. She does not havewarm
dysentery,
on theasway
there
to is nohospital
the blood in the stool.
Every childJaundice appearingisafter
with diarrhoea Yellow:for dehydration.
also classified Advise the mother to give home care for the
Palms and soles not
will you classify Mary’s dehydration? Advise
n How yellow mother to return immediately if palms
and soles appear yellow.
When you assessed Mary, you observed the following signs:
— She has sunken eyes Follow-up in 1 day
— SheNois jaundice
eager to drink Green: Advise the mother to give home care for the
— Her skin pinch goes back slowly
With these signs, you classify Mary with SOME DEHYDRATION. Look at your classification table. What do you
observe about the identified treatments for this classification?
Two of the following signs: Pink: If infant has no other severe classification:
Movement only when SEVERE Give fluid for severe dehydration (Plan C)
stimulated or no DEHYDRATION OR
EA for movement at all If infant also has another severe
DEHYDRATION Sunken eyes classification:
very slowly. mother giving frequent sips of ORS on
the way
breastfeeding
Two of the following signs: Yellow: Give fluid and breast milk for some
Restless and irritable SOME dehydration (Plan B)
Sunken eyes DEHYDRATION If infant has any severe classification:
slowly. mother giving frequent sips of ORS on
the way
breastfeeding
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO continue breastfeeding (Plan A)
You tell Ana that Mary has some dehydration. It is not serious enough to send her to the hospital. You can
n and are many andbegin
watery (more water
treatment at than fecal matter).
the clinic, and she can continue treatment at home. Ana looks relieved.
rhoea.
You will now learn more about treatment in the next section.
Page 44 of 75
22
4.5 TREAT THE CHILD WITH DIARRHOEA

Children with diarrhoea are treated for dehydration. They are also treated for their
diarrhoea, if they have persistent diarrhoea or dysentery.
WHAT TREATMENTS ARE IDENTIFIED FOR DIARRHOEA AND

DEHYDRATION?
Open your classification tables for dehydration, persistent diarrhoea, and
dysentery and review the “IDENTIFY TREATMENT” columns. The colour-coded
classifications also indicate where the treatment can be delivered – by urgent
referral, at the clinic, or at home.
Identified treatments are listed below. These are all new treatments, so you
will learn about all of them in this section:
✔✔ Plans A, B, and C for giving fluids and food
✔✔ Giving ORS for dehydration
✔✔ Zinc supplementation
✔✔ Ciproflaxacin for dysentery

HOW DO YOU TREAT DEHYDRATION?
When you classified the severity of dehydration, you identified the appropriate
treatment to replenish fluids or prevent dehydration.
There are three plans to provide fluid and replace water and salts lost in diarrhoea:
n PLAN A – treat diarrhoea at home
n PLAN B – treat SOME DEHYDRATION with low osmolarity oral rehydration
salts (ORS)
n PLAN C – treat SEVERE DEHYDRATION quickly with intravenous (IV) fluids
In the following pages, you will now learn how to give Plans A, B, and C.
PLAN C (SEVERE DEHYDRATION)

Urgent treatment
PLAN B (SOME DEHYDRATION)

Treat at clinic
PLAN A (NO DEHYDRATION)

Treat at home
23
PLAN C (SEVERE DEHYDRATION)

Urgent treatment
HOW IS PLAN C GIVEN?

Severely dehydrated children and young infants need to have water and salts quickly
replaced. Plan C requires rapid hydration using IV fluids or a nasogastric (NG)
tube.
It is important to note that rehydration therapy using IV fluids or using a
nasogastric (NG) tube is recommended only for children who have SEVERE
DEHYDRATION.
WHERE IS PLAN C GIVEN?

Open to Plan C in your Chart Booklet. There
is a flow chart determining where is the safest
place to treat the severely dehydrated child.
You will observe that the treatment of
the severely dehydrated child depends on:
n Type of available equipment at your clinic
or at a nearby clinic or hospital,
n Training you have received
n If the child can drink
IN YOUR CLINIC, WHERE IS THE SAFEST PLACE TO GIVE PLAN C?

This is important for you to determine based on available equipment and your
training. If you cannot give IV or NG fluid and the child cannot drink, refer
the child urgently to the nearest hospital that can give IV or NG treatment.
If IV (intravenous) treatment is available within a 30-minute drive, refer urgently
to hospital for treatment with IV fluids. On the way to hospital, have the mother
offer frequent sips of ORS to her sick child.
Are you able to provide Plan C in your clinic?

If not, where will you refer?
24
PLAN B (SOME DEHYDRATION)

Treat at clinic
A child or young infant with some dehydration needs fluid, zinc supplemen-
tation, and food. You will give zinc just as you will for Plan A.
HOW IS PLAN B GIVEN?

Plan B begins with a 4-hour treatment period at the clinic. During the 4
hours, the mother slowly gives a recommended amount of ORS solution. If a child
who has SOME DEHYDRATION needs treatment for other problems, you should
start treating the dehydration first. Then provide the other treatments.
After the 4 hours, you will reassess and classify the child’s dehydration. If the
signs are gone, put the child on Plan A for home treatment. If there is still some
dehydration, the child repeats Plan B. If the child now has SEVERE DEHYDRATION,
put the child on Plan C.
WHAT HAPPENS IF A CHILD HAS A SEVERE CLASSIFICATION AND

NEEDS PLAN B?
A child who has a severe classification and SOME DEHYDRATION needs urgent
referral to hospital.1 Do not try to rehydrate the child before he leaves. Quickly
give the mother some ORS solution. Show her how to give frequent sips to child on
the way to the hospital.
HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS

IN THE CLINIC?
Now study Plan B in your TREAT THE CHILD section. It contains the following
instructions:
1. DETERMINE AMOUNT of ORS to give during first 4 hours.
Use the chart in Plan B to determine how much ORS to give. To find the
recommended amount, look below the child’s weight (or age only if the weight
is not known). The child will usually want to drink as much as he needs. If the
child wants more or less than the estimated amount, give him what he wants.
The mother should also breastfeed whenever the baby wants to, then resume
the ORS solution.
2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Find a comfortable place in the clinic for the mother to sit with her child. Tell
her how much ORS solution to give over the next 4 hours. Show her the
amount in units that are used in your area. If the child is less than 2 years,
show her how to give a spoonful frequently. If the child is older, show her how
to give frequent sips from a cup. Sit with her while she gives the child the
first few sips from a cup or spoon. Ask her if she has any questions.
The exception is a child with the severe classification, SEVERE PERSISTENT DIARRHOEA. This child should
1
be rehydrated then referred.
25
REFRESH: how do you decide amount of ORS to give?

1. Use chart in Plan B with child’s weight
2. If no chart, multiple child’s weight (kg) by 75 (Example: 8 kg child x 75 ml = 600 ml)
WHAT WILL YOU DO WHILE THE MOTHER GIVES ORS FOR 4 HOURS?
n Show the caregiver where to wash her hands, and where she can change the
child’s nappy or where the child can use a toilet.
n Check with the mother from time to time to see if she has problems. If
the child is not drinking the ORS solution well, try another method of giving
the solution. You may try using a dropper or a syringe without the needle.
n This also provides valuable time to teach the mother about care for
her child. The first concern is to rehydrate the child. When the child is
obviously improving, the mother can turn her attention to learning. Teach her
about mixing and giving ORS solution (Plan A).
n It is a good idea to have printed information that the mother can study
while she is sitting with her child. Posters on the wall can also reinforce this
information.
TIPS FOR THE YOUNG INFANT

During the first 4 hours of rehydration, encourage the mother to pause to breastfeed the infant whenever
the infant wants, then resume giving ORS. Give a young infant who does not breastfeed an additional
100–200 ml clean water during this period.
26
HOW WILL YOU REASSESS THE CHILD AFTER 4 HOURS?

After four hours you will reassess the child using the ASSESS AND CLASSIFY chart.
Classify the dehydration. Choose the appropriate plan to continue treatment. If the
child is not taking the ORS solution, or seems to be getting worse, reassess
before four hours.
Depending on your classifications, you will take further action:
n If the child has NO DEHYDRATION, move to Plan A. Counsel on home care.
n If the child has SOME DEHYDRATION, choose Plan B again. Begin feeding
the child in clinic. Offer food, milk, or juice. Continue to breastfeed frequently
if child is breastfed.
n If the child is worse and now has SEVERE DEHYDRATION, begin Plan C.
If the child’s eyes are puffy, it is a sign of overhydration. It is not a danger sign
or a sign of hypernatraemia. 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, and ORS according to Plan A when the puffiness is gone.
WHAT HAPPENS IF A CAREGIVER MUST LEAVE BEFORE

FINISHING 4 HOURS OF ORS?
1. Show the caregiver how to prepare ORS solution and have her practice.
2. Show her how much ORS to give to complete the 4-hour treatment at home.
3. Give her packets to complete rehydration PLUS 2 more packets as recommended
in Plan A.
4. Explain 4 rules of home treatment
27
Answer the following questions about PLAN B for dehydrated children.
1. The following children are classified SOME DEHYDRATION. Write the range
of amounts of ORS solution each child is likely to need in the first 4 hours of
treatment:
Name Age or Weight Range of Amounts of ORS Solution
a. Andras 3 years
b. Gul 10 kg
c. Nirveli 7.5 kg
d. Sami 11 months

2. Vinita is 5 months old and has diarrhoea. She is classified as SOME
DEHYDRATION. There is no scale for weighing Vinita at the small clinic. Vinita’s
mother died during childbirth, so Vinita has been taking infant formula. The
grandmother has recently started giving cooked cereal as well.
a. Vinita should be given ml of
during the first hours of treatment. She should also be given ml
of during this period.
b. What should the grandmother do if Vinita vomits during the treatment?
c. When should the health worker reassess Vinita?
d. When Vinita is reassessed, she has NO DEHYDRATION. What treatment

plan should Vinita be put on?
3. Yasmin is 9 months old and weighs 8 kg. Her mother brought her to the clinic
with diarrhoea. The health worker assesses Yasmin as SOME DEHYDRATION.
The health worker chooses Plan B. He asks if Yasmin still breastfeeds. Her mother
says that she breastfeeds several times each day. She also eats 3 meals each day
of rice along with vegetables, pulses, and sometimes bits of meat.
a. Approximately how much ORS solution should Yasmin’s mother give her
during the first 4 hours?
b. During the first 4 hours of treatment, should Yasmin eat or drink anything
in addition to the ORS solution? If so, what?
c. After 4 hours of treatment, the health worker reassesses Yasmin. She is still
classified as SOME DEHYDRATION. What is the appropriate plan to continue
her treatment?
28
PLAN A (NO DEHYDRATION)

Treat at home
A child with diarrhoea but no dehydration requires fluid, zinc, and food to prevent
dehydration. This child can be treated at home with Plan A.
WHAT IS PLAN A?
Plan A is based on the four rules of home treatment. These are critical for you
to remember. Plan A requires you to counsel the child’s mother about the 4 rules
of home treatment. As such, your teaching and advising skills are an important
part of Plan A.
Plan A is also an important treatment plan because eventually, all children
with diarrhoea will require Plan A. Children with diarrhoea who come to a
health worker with NO DEHYDRATION are put on Plan A right away. Child with
more serious dehydration will first be treated with Plan B or C, and then they will
be put on Plan A.
WHAT ARE THE 4 RULES OF HOME TREATMENT?

The four rules of home treatment are very important to remember:
1. Give extra fluid – as much as the child will take
2. Give zinc
3. Continue feeding
4. When to return (for a follow-up visit, or immediately if danger signs develop)
Now you will learn more about the four rules of home treatment. Open to Plan A
in your Chart Booklet to read along with the instructions.
RULE 1: GIVE EXTRA FLUID

Tell the caregiver to give as much fluid as the child will take. It is very
important for the child to have extra fluid – as much as the child will take. The
purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to
prevent dehydration. The critical action is to give more fluid than usual, as soon as
the diarrhoea starts.
HOW SHOULD THE CAREGIVER GIVE EXTRA FLUID?

Tell the mother that breastfeeding should continue, with the addition of ORS and
clean water. If the child is exclusively breastfed, it is important for this child to be
breastfed more frequently than usual. Breastfed children under 4 months should
first be offered a breastfeed then given ORS.
If the child is not being breastfed, the child should receive ORS solution, food-
based fluids (soup, rice water, yoghurt drinks), and clean water. In your country,
the national programme for diarrhoeal disease control may have specified several
food-based fluids to use at home.
29
TIPS FOR THE YOUNG INFANT

n If infant is exclusively breastfed, it is important not to introduce a food-based fluid.
n If infant will be given ORS solution at home, you will show how much ORS to give the infant after each
loose stool. Mother should first offer a breastfeed, then give ORS.
HOW WILL YOU TEACH THE CAREGIVER TO MIX ORS?

Teach the caregiver how to mix and give ORS. Ask the caregiver to practice doing
it as you observe. The steps for making ORS are (follow along in drawings below):
✔✔ Wash your hands with soap and water
✔✔ Pour all the powder from one packet into a clean container. Use any available
container, such as a jar, bowl or bottle.
✔✔ Measure 1 litre of clean water (or correct amount for packet used). It
is best to boil and cool the water, but if this is not possible, use the cleanest
drinking water available.
✔✔ Pour the water into the container. Mix well until the powder is completely
dissolved.
✔✔ Taste the solution so you know how it tastes.
The caregiver should mix fresh ORS every day, in a clean container. She
should keep the container covered. She should throw away any solution remaining
from the day before.
1 litre
bottle
HOW WILL THE CAREGIVER GET ORS TO USE IN THE HOME?

Give the caregiver 2 packets of ORS to use at home. Show her how much fluid should
be given in addition to the usual fluid intake:
n Up to 2 years: 50–100 ml after each loose stool
n 2 years or older: 100–200 ml after each loose stool
HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS?

Finally, give the caregiver instructions for giving ORS:
1. Give frequent small sips from a cup
2. If child vomits, wait 10 minutes. Then continue, but more slowly.
3. Continue giving extra fluid until the diarrhoea stops
30
WHEN IS ORS ESPECIALLY IMPORTANT?

It is especially important to give ORS at home when:
✔✔ Child was treated with Plan B or C during this visit – in other words, the child has
just been rehydrated and needs ORS to prevent dehydration from coming back
✔✔ Child cannot return to the clinic if the diarrhoea gets worse – for example, if the
family lives far away or the mother has a job that she cannot leave
RULE 2: GIVE ZINC SUPPLEMENTS

Zinc treatment can considerably reduce the duration and severity of a child’s
diarrhoeal episode. It is also shown to decrease stool output and decrease the
need to hospitalize a child with diarrhoea.
Zinc is only given to children 2 months up to 5 years. This box describes how
much zinc to give a child with diarrhoea. Review this information in Plan A in your
Chart Booklet.
GIVE ZINC SUPPLEMENTS (one tablet is 20 mg zinc)

Remind the caregiver to give zinc supplements for the full 14 days
Tell the caregiver how much zinc to give
Up to 6 months: ½ tablet per day, for 14 days
6 months or older: 1 tablet per day, for 14 days
Show the caregiver how to give zinc supplements
Infants: dissolve the tablet in a small amount of breast milk, ORS, or clean water in a small cup or spoon
Older children: tablets can be chewed or dissolved in small amount of clean water in a cup or spoon
RULE 3: CONTINUE FEEDING

You will learn more about special feeding recommendations if the child has
persistent diarrhoea.
31
RULE 4: WHEN TO RETURN

You have learned the signs when a caregiver should return immediately to a health
worker.
Tell the mother of any sick child that the signs to return are:
•• Not able to drink or breastfeed
•• Becomes sicker
•• Develops a fever
If the child has diarrhoea, also tell the mother to return if the child has:
•• Blood in stool
•• Drinking poorly – also includes not able to drink or breastfeed
Answer the following questions about PLAN A for children with diarrhoea.
1. At your clinic, what are the recommended fluids for children with diarrhoea with
NO DEHYDRATION?
2. Somi is a 4-year-old boy who has diarrhoea. He has no general danger signs. He
was classified as having diarrhoea with NO DEHYDRATION and NO ANAEMIA
AND NOT VERY LOW WEIGHT. He will be treated according to Plan A.
a. What are the 4 rules of home treatment of diarrhoea?
b. What fluids should the health worker tell his mother to give?
3. Kasit is a 3-month-old boy who has diarrhoea. He has no general danger signs.
He was classified as NO DEHYDRATION and NO ANAEMIA AND NOT VERY
LOW WEIGHT. He is exclusively breastfed. What should the health worker tell
his mother about giving him extra fluids?
32
4. For which children with NO DEHYDRATION is it especially important to give

ORS at home?
5. The following children came to the clinic because of diarrhoea. They were
assessed and found to have no general danger signs. They were classified as NO
DEHYDRATION. Write the amount of extra fluid that the mother should give
after each stool.
Name Age Amount of extra fluid to give after each loose stool
a. Kala 6 months
b. Sam 2 years
c. Kara 15 months
d. Lalita 4 years

DIARRHOEA: SICK CHILD

Treatment is required for children who have persistent diarrhoea or dysentery.
HOW WILL YOU TREAT SEVERE PERSISTENT DIARRHOEA?

Children with this classification have persistent diarrhoea (14 days or longer) and
signs of dehydration. These children should be referred to hospital. They need special
attention to prevent fluid loss. You should treat dehydration before referral, unless
child has another severe classification.
HOW WILL YOU TREAT PERSISTENT DIARRHOEA?

Children with this classification have persistent diarrhoea (14 days or longer)
and no signs of dehydration. Special feeding is the most important treatment
for persistent diarrhoea with no signs of dehydration. Children with persistent
diarrhoea may have difficulty digesting milk other than breastmilk. They
need to temporarily reduce the amount of other milk in their diet.
Special feeding advice for a child with PERSISTENT DIARRHOEA includes:
✔✔ If still breastfeeding, give more frequent, longer breastfeeds, day and night.
✔✔ If taking other milk:
— Replace with increased breastfeeding, OR
— Replace with fermented milk products, such as yogurt, OR
— Replace half the milk with nutrient-rich semi-solid food.
✔✔ For other foods, follow feeding recommendations for the child’s age: give small,
frequent meals (at least 6 times a day), and avoid very sweet foods or drinks.
The child also should receive zinc for 14 days. The child should follow up in 5
days.
33
HOW WILL YOU TREAT DYSENTERY?

Children with dysentery should receive ciprofloxacin for 3 days (or another oral
antibiotic recommended for Shigella in your area). The box “Give an Appropriate
Oral Antibiotic” on the TREAT THE CHILD chart tells the recommended antibiotics.
Refer to Module 3 to review counselling the caregiver on oral medicines. They
should also receive zinc supplements. Zinc should be given in the same way that
you learned previously in Plans A and B. Treat dehydration as classified. Children
should follow-up for the dysentery in 2 days.
WHEN SHOULD ANTIBIOTICS BE USED FOR DIARRHOEA?

Antibiotics are not effective in treating most diarrhoea. They rarely help
and make some children sicker. Unnecessary use of antibiotics may increase the
resistance of some pathogens. In addition, antibiotics are costly. Money is often
wasted on ineffective treatment. Therefore, do not give antibiotics routinely. The
only types of diarrhoea that should be treated with antibiotics are DYSENTERY
and diarrhoea with SEVERE DEHYDRATION with cholera in the area.
34
Answer the questions below about treatment for diarrhoea and dehydration.
1. How will you give zinc supplements to a 4 month old infant, weight 7.3 kg, with
SOME DEHYDRATION?
2. How will you give zinc supplements to a 37 month old infant, weight 12 kg, with
NO DEHYDRATION?
3. How would you treat a 9 month old, weighing 8.3 kg, with a classification of
DYSENTERY?
4. How would you treat a 36 month old, weighing 15 kg, with a classification of
DYSENTERY?
5. How would you treat a 7 month old with SEVERE PERSISTENT DIARRHOEA?
6. You are talking with the mother of a 15-month-old child who is no longer
breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feedings
of cow’s milk and 1 meal of family foods each day. His diet has not changed during
the diarrhoea. Which of the following are appropriate to say when counselling
this mother? Tick appropriate comments.
 a. You were right to keep feeding your child during the diarrhoea. He needs
food to stay strong.
 b. Your child needs more food each day. Try to give him 3 family meals plus
2 feedings between meals.
 c. Cow’s milk is very bad for your child.
 d. Your child may be having trouble digesting the cow’s milk, and that may
be the reason that the diarrhoea has lasted so long.
 e. Give your child yoghurt instead of milk (until follow-up visit in 5 days).
Or give only half the usual milk and increase the amount of family foods
to make up for this.
35
Lethargic or unconscious SEVERE
IMCI DISTANCE Give 4.
LEARNING COURSE | MODULE fluid for severe dehydration (Plan C)
DIARRHOEA
RATION Sunken eyes DEHYDRATION OR
EA
n What treatment will Mary require?
on the way
Mary has an acute episode of diarrhoea lasting for 3 days, and there is no blood in the stool, so you did not
classify her for persistent diarrhoea or dysentery.
breastfeeding
You classified Mary’s dehydration as SOME DEHYDRATION. Review If childwhat
is 2treatments
years or older and there
were identified foris
SOME
DEHYDRATION. cholera in your area, give antibiotic for
cholera
Skin pinch goes back mother giving frequent sips of ORS
slowly. on the way
breastfeeding
as some or severe NO DEHYDRATION
You will remember from this section that SOME diarrhoea at Plan
requires home (Plan
B for A) foods, and zinc. Plan
fluids,
Bdehydration. DEHYDRATION
will require Ana to give ORS to Mary Advise
for 4 hours in the clinic, mother
then you will when to return
re-assess Mary’simmediately
dehydration.
Open your Chart Booklet to review Plan B. Follow-up in 5 days if not improving
The steps of Plan B are:
1. Determine the amount of ORS to give for the first 4 hours in the clinic. Mary is 8 kg and 9 months old.
rhoea 14 SEVERE child has another severe classification
We review the chart in Plan B and decide that she should receive between 450 and 800 ml of ORS. If we
more PERSISTENT Refer to hospital
had calculated with the second method, multiplying her weight 8 kg by 75 ml, we would have calculated
DIARRHOEA
560 ml, which is within the chart range.
2. Teach Ana how to give the ORS solution. You explain to Ana that Mary has diarrhoea with some
dehydration. She needs fluids and food. You ask Ana to stay at the clinic to give Mary ORS solution. Show
DIARRHOEA Give multivitamins and
Ana how much ORS to give from a cup.
You take Ana to a corner where she can sit with Mary andFollow-up in 5 You
give the ORS. daysshow her where you can wash
her hands, and where she can change Mary or use the toilets. You make sure she is comfortable. She does
not have any questions for you, but it worried about staying too late at the clinic because her husband
Blood
will in the
worry. Youstool. Yellow:
assure her that she can give all of the ORSGive
now, ciprofloxacin forwork
and then you will 3 days
with her to decide
od in stool about treatment later tonight at home. Ana props Mary on her lap. She slowly begins to give her ORS
from a cup. You also encourage Ana to breastfeed if Mary wants to.
3. After 4 hours, you reassess Mary. She had NO DEHYDRATION. Her diarrhoea continued, but you think
that she is ready to go home on Plan A. Plan A will also include giving zinc and food.
Page 6 of 75
36

Good teaching and advising skills are particularly important when treating
dehydration and diarrhoea. As you read in the previous section on treatment, the
caregiver gives many of the treatments in the clinic or at home. This requires you
to teach them how to give the treatment.
WHAT ARE THE 4 RULES OF HOME TREATMENT?

It is very important to counsel caregivers on the 4 rules of home treatment.
This is required for Plan A. Child classified with NO DEHYDRATION need Plan A.
After children who required Plan B or C have completed this plan, they will also
require Plan A at home.
1. Give extra fluid – as much as the child will take
2. Give zinc
3. Continue feeding
4. When to return (for a follow-up visit, or immediately if danger signs
develop)
RULE 1. How will you counsel a caregiver to give extra fluid?

You will tell a caregiver that during illness, a child loses fluid due to fever, fast
breathing, or diarrhoea. The child will feel better and stay stronger if he drinks
extra fluid to prevent dehydration. Extra fluid is especially important for children
with diarrhoea.
FIRST, TELL THE CAREGIVER TO GIVE AS MUCH FLUID AS THE

CHILD WILL TAKE.
The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus
to prevent dehydration. The critical action is to give more fluid than usual as
soon as the diarrhoea starts. More fluid can be given by:
•• Breastfeeding more frequently, and for longer feeds. If the child is exclusively
breastfed, also give ORS or clean water in addition.
•• If child is not breastfed, increase fluid with food-based fluids (soup, rice water,
yoghurt drinks), or ORS
•• ORS is especially important at home if the child was treated on Plan B or C, or
if the child cannot return to the clinic if the diarrhoea gets worse
SECOND, teach the caregiver how to mix and give ORS.

Review these teaching steps in the previous TREAT section. Ask the caregiver to
practice doing it as you observe. You will review these steps, which are also discussed
in Plan B in the previous section:
1. Wash hands with soap and water
2. Pour the ORS powder into a clean container
37
3. Measure 1 litre of water (or specified amount). It is best to boil and cool water.
4. Pour the water into the container with the powder. Mix and taste.
5. Give solution to the child slowly, by cup. If the child vomits, wait for 10 minutes
and then continue more slowly.
6. Always make fresh ORS solution each day. Keep the solution covered.
RULE 2. How will you counsel a caregiver to give zinc?

Your TREAT chart and the previous section describe how much zinc to give a child
with diarrhoea. Zinc is only given to children 2 months up to 5 years.
Show the mother how to give the zinc to her baby with diarrhoea. For
example, infants can be given the tablet dissolved in a small amount of expressed
breast milk ORS, or clean water in a cup. Older children can chew the tablet or take
it in a small amount of clean water.
The mother should give her child the first zinc supplement. If a child is 2
months up to 6 months, he can have half a 20 mg tablet daily for 14 days. A child
6 months or older can take a whole 20 mg tablet. Explain how she will continue
to give this treatment for 14 days. Check her understanding with checking
questions, and answer any problems she has.
RULE 3. How will you counsel a caregiver to continue feeding?

The caregiver should continue feeding, as explained in the previous TREAT section.
You will also remember that children with persistent diarrhoea have
special feeding needs. If may be difficult for these children to digest milk other
than breast milk. Caregivers need to temporarily reduce the amount of other milk
in the child’s diet. To make up for this reduction, the child must take more breast
milk or other foods. Continue other foods appropriate for the child’s age. The child
with persistent diarrhoea should be seen again in 5 days for follow-up, and will be
given further feeding instructions during this visit.
RULE 4. How will you counsel a caregiver to return to clinic?

You will advise on follow-up care as you would with all other conditions.
Remember that if the child is required to follow up for more than one
illness, they should return for follow-up at the earliest definite date. The child
should follow up:
Immediately if  The child is not able to breastfeed or drink
 Becomes sicker
 Develops a fever
 Has blood in the stool
In 3 days if The child has dysentery
In 5 days if The child has persistent diarrhoea
38
SELF-ASSESSMENT EXERCISE H
Complete this case study.
CASE STUDY: Health worker Basaka must teach a mother to prepare ORS solution
for her child with diarrhoea. First he explains how to mix the ORS, then he shows
her how to do it. He asks the mother, “Do you understand?” The mother answers
“yes”. So Basaka gives her 2 ORS packets and says good-bye.
1. What are the four rules of home treatment that must be explained to the mother?
2. What information did Basaka give the mother about the task?
3. Did he show her an example?
4. Did he ask her to practice?
5. How did Basaka check the mother’s understanding?
6. Did Basaka check the mother’s understanding correctly?
7. How would you have checked the mother’s understanding?
39
SELF-ASSESSMENT EXERCISE I
Answer these questions about counselling a caregiver.
1. A 4-year-old boy has diarrhoea. He has no general danger signs. He was classified
with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT.
The health worker has taught his mother Plan A and given her 2 packets of ORS
to use at home. Tick all the fluids that the mother should encourage her son to drink
as long as the diarrhoea continues.
 Tea that the child usually drinks with meals
 Fruit juice that the child usually drinks each day
 Water from the water jug. The child can get water whenever he is thirsty.
 ORS after each loose stool
 Yoghurt drink when the mother makes some for the family
2. A mother brought her 11-month-old daughter, Aviva, to the clinic because she
has diarrhoea. Aviva usually eats cereal and bits of meat, vegetables and fruit.
Her mother has continued to breastfeed her as well. The mother says she lives
far from the clinic and might not be able to come back for several days, even if
the child gets worse.
The health worker assesses Aviva and finds she has no general danger signs and
no other disease classifications. He classifies her as NO DEHYDRATION. He
decides Aviva needs treatment according to Plan A.
a. Should the health worker give this mother ORS packets to take home? If so,
how many one-litre packets should he give?
b. What should the mother do if the child vomits while being fed the solution?
c. How long should Aviva’s mother continue giving extra fluid?
d. The health worker will tell the mother to continue feeding Aviva. He will
also teach her the signs to return immediately. What signs should the health
worker teach Aviva’s mother?
3. Which of the following is the best checking question after advice about increasing
fluids during diarrhoea? (Tick one.)
a.  Do you remember some good fluids to give your child?
b.  Will you be sure to give your child extra fluid?
c.  How much fluid will you give your child
40
n What do you advise Ana about home treatment?

You classified Mary with SOME DEHYDRATION and gave her Plan B in the clinic. You re-assessed after Ana
had been giving her ORS for 4 hours, and Mary showed signs of NO DEHYDRATION.
You will now counsel Ana on home treatment of diarrhoea with Plan A. You give Ana a Mothers’ Card to
take home. This card reminds her of important information like what fluids and food to give her child.
n What are the 4 rules of home treatment you will teach Ana?
1. You tell Ana to give extra fluid, as much as Mary will take.
This will include breast milk, clean water, ORS, or food-based fluids such as soup, rice water, yogurt drinks.
You ask Ana which of these options she will use to give Mary more fluid. Ana says that Mary takes rice
water well, and she will still breastfeed. She will also try to get some yogurt from a neighbour who makes
some. You remind Ana to breastfeed as often as Mary will.
You previously taught Ana how to make the ORS when you were preparing it in the clinic. You ask her
checking questions to make sure she remembers how to make it.
— You ask, “How much clean water do you need for 1 packet of ORS?” Ana says, “1 litre.”
— You ask, “How will you give the ORS?” Ana says, “With a cup, as she sits in my lap.”
— You also ask Ana, “How often will you give ORS?” “What will you do if Mary vomits?”
You remind Ana that if Mary vomits, she should wait 10 minutes, then continue again, but more slowly.
You give Ana 2 packets of ORS to take home.
2. You advise Ana how to give Mary zinc tablets.
Mary is 9 months old, so she will take 1 full tablet a day for 14 days. You show Ana how to dissolve the
tablet in a spoon with breast milk or clean water. You explain why you are giving zinc to Ana, that it is a
good nutrient for the body that will help with Mary’s diarrhoea.
3. You advise Ana to continue feeding, and that Mary should get between 50–100 ml of solution after
each loose bowel movement.
4. You advise Ana to return to the clinic immediately if Mary develops the following: she is not able
to breastfeed or drink, she becomes sicker, she develops a fever, she has blood in the stool. You use Ana’s
Mother’s Card to demonstrate these signs. Mary does not have other illnesses that require specific follow-
up, or else you would have given them a specific date to return.
Your conversation with Ana also gives her a chance to ask questions. Your checking questions gave you an
idea of how much she understands home treatment. After you talk with Ana, you feel confident that she
understands home treatment, and you say goodbye to her and Mary.
41
4.7 PROVIDE FOLLOW-UP CARE FOR DIARRHOEA

DO YOU REMEMBER THE STEPS FOR PROVIDING FOLLOW-UP CARE?
First, you will re-assess your earlier classifications. Is the child:
 Improving?
 The same?
 Worsening?
Second, you will reassess the child using IMCI to see if there are any new issues.
You will use a second recording form for this visit.
DIARRHOEA IN SICK YOUNG INFANT (FOLLOW-UP 2 DAYS)

When an infant with diarrhoea follows-up in 2 DAYS, you will:
✔✔ ASK – Has the diarrhoea stopped?
 DIARRHOEA HAS STOPPED

Tell the mother to continue exclusive breastfeeding. If the infant’s signs are
improving, tell the mother to continue giving the infant the fluids and breastfeeding
according to plan A.
  DIARRHOEA HAS NOT STOPPED

If the diarrhoea has not stopped, reassess the young infant for diarrhoea. Classify
the dehydration and select a fluid plan.
If the signs are the same or worse, refer the infant to hospital. If the young
infant has developed fever, give intramuscular antibiotics before referral, as for
VERY SEVERE DISEASE.
PERSISTENT DIARRHOEA (FOLLOW-UP 5 DAYS)

First you will ASK:
✔✔ Has the diarrhoea stopped?
✔✔ How many loose stools is the child having per day?
 DIARRHOEA HAS STOPPED (less than 3 stools/day)

Tell the mother to follow the usual feeding recommendations for the child’s age.
If the child is not normally fed in this way, you need to teach her the feeding
recommendations on the COUNSEL chart.
 DIARRHOEA HAS NOT STOPPED (more than 3 stools/day)

Do a full reassessment of the child. Identify and manage any problems that require
immediate attention such as dehydration. Then refer the child to hospital.
42
DYSENTERY (FOLLOW-UP 3 DAYS)

First you will ASK:
✔✔ Are there fewer stools?
✔✔ Is there less blood in the stool?
✔✔ Is there less fever?
✔✔ Is there less abdominal pain?
✔✔ Is the child eating better?
 FEWER STOOLS, LESS BLOOD IN STOOLS, LESS FEVER, LESS ABDOMINAL

PAIN, AND EATING BETTER
The child is improving on the antibiotic ciprofloxacin. Usually all of these signs will
diminish if the antibiotic is working. If only some signs have diminished, use your
judgment to decide if the child is improving. Tell the mother to finish the 3 days of
the ciprofloxacin prescribed. Review with the mother the importance of finishing
the antibiotic.
 CHILD IS DEHYDRATED
Use the classification table to classify the child’s dehydration. Select the appropriate
fluid plan and treat the dehydration.
 MORE STOOLS, BLOOD IN STOOLS, FEVER, ABDOMINAL PAIN, AND EATING

IS SAME OR WORSE
The child is not improving on the antibiotic. Stop the first antibiotic and give the
second-line antibiotic recommended for Shigella for 5 days. Refer to TREAT chart.
Antibiotic resistance of Shigella may be causing the lack of improvement. Advise
the caretaker to return in 2 days.
✔✔ Give the first dose of the new antibiotic in the clinic.
✔✔ Teach the caregiver how and when to give the antibiotic and help her plan how
to give it.
✔✔ Advise the caregiver to bring the child back again after two more days.
What actions will you take on the follow-up visit in 2 days?
If the child has received the second-line antibiotic for two days, and has not improved,
the child may have amoebiasis. This child may be treated with metronidazole if it
is available or can be obtained by the family, or referred for treatment. Amoebiasis
can only be diagnosed with certainty when trophozoites of E. histolytica containing
red blood cells are seen in a fresh stool sample.
REFER if the non-improving child has any of these 3 high-risk factors:

1. Less than 12 months old, or
2. Was dehydrated on the first visit, or
3. Had measles within the last 3 months,
43
n How do you provide Mary with follow-up care?

You classified Mary with SOME DEHYDRATION, and she received Plan B in the clinic. Then you re-assess her,
and classified with NO DEHYDRATION. You counselled her mother Ana on Plan A home treatment, and sent
them home.
Ana and Mary were only supposed to return for follow-up if Mary’s dehydration and diarrhoea did not
improve. You are pleased that Mary does not return to the clinic for follow-up. You hope this means that the
fluid plan worked, and Mary was no longer dehydrated and acting unwell.
Answer questions for this case about follow-up of DYSENTERY or PERSISTENT
DIARRHOEA.
Details about this clinic: This clinic refers children with severe dehydration because
health workers cannot give IV or NG therapy. A hospital nearby can give IV therapy.
Evaristo was brought for follow-up of PERSISTENT DIARRHOEA after 5 days. He
is 9 months old and weighs 6.5 kg. His temperature is 36.5 °C today. He is no longer
breastfed. His mother feeds him cereal twice a day and gives him a milk formula 4
times each day. When you saw him last week, you advised his mother to give him
only half his usual amount of milk. You also advised the mother to replace half the
milk by giving extra servings of cereal with oil and vegetables or meat or fish added.
1. What is your first step for reassessing Evaristo?
2. Evaristo’s mother says the diarrhoea has not stopped. What do you do next?
You do a complete reassessment of Evaristo, as on the ASSESS & CLASSIFY chart.

You find that Evaristo has no general danger signs. He has no cough. When you
reassess his diarrhoea, his mother says that now he has had diarrhoea for about
3 weeks. There is no blood in the stool. Evaristo is restless and irritable. His eyes
are not sunken. When you offer him some water, he takes a sip but does not seem
thirsty. A skin pinch goes back immediately. Evaristo’s mother tells you that he has
no other problems.
3. Is Evaristo dehydrated?
4. How will you treat Evaristo?
5. If your reassessment found that Evaristo had some dehydration, what would
you have done before referral?
44

How will you begin to apply the knowledge you have gained from this module
in managing children with diarrhoea? In the coming days, you should focus on
these key clinical skills. Practicing these skills in your clinic, and using your IMCI
job aids, will allow you to observe and better understand the signs needed to assess
and classify a child with dehydration and diarrhoea.
ASSESS
✔✔ Assess children for diarrhoea – how long has the diarrhoea lasted? Is there blood
in the stool?
✔✔ Assess children for signs of dehydration, including sunken eyes, skin pinches,
the child’s condition, and the child’s willingness and ability to drink.
✔✔ Practice giving children skin pinches and assessing if it returns very slowly,
slowly, or immediately.
✔✔ Practice observing children’s conditions (restless, irritable, unconscious,
lethargic) and willingness to drink.
CLASSIFY
✔✔ Use your chart booklet to classify the signs of dehydration
✔✔ Classify if a child has persistent diarrhoea or dysentery
TREAT
✔✔ Determine if children need Plans A, B, or C.
✔✔ Determine how you will give Plan C in your facility – what equipment do you
have for intravenous fluid? Is there a facility within a 30 minute drive that can
give this fluid? Are you trained to use Naso-Gastric tubes for rehydration?
✔✔ Advise a caregiver on giving Plan B in your facility. Determine correct amount of ORS.
✔✔ Advise a caregiver about giving Plan A. Focus on the 4 rules of home treatment.
COUNSEL
✔✔ Teach a caregiver how to make and give ORS. Determine the amounts required.
✔✔ Advise a caregiver on giving extra fluid and continue breast feeding in the home.
✔✔ Advise a caregiver on giving zinc, and show them how to give tablets. Advise on
how often zinc should be given.
✔✔ Advise a caregiver on continued feeding, especially for children with persistent
diarrhoea.
✔✔ Counsel a caregiver about when to return for follow-up for diarrhoea or
dehydration.
✔✔ Counsel a caregiver about when to return immediately.

45

MANAGING DIARRHOEA AND DEHYDRATION?
several questions. Now that you have finished the module, you will answer the same
questions. This will help demonstrate what you have learned.
1. How can diarrhoea kill children?
a. Children lose valuable fluids, salts, and sugars, which can cause shock to vital
organs
b. Children lose valuable nutrients because they cannot eat
c. Diarrhoea causes liver failure
2. What are critical treatments for children with diarrhoea and dehydration?
a. Oral antibiotics
b. Oral rehydration therapy and zinc
c. Paracetamol for discomfort
3. What is persistent diarrhoea?
a. When a child frequently has diarrhoea over a period of 1 month, and is ill as
a result
b. When a child has several episodes of diarrhoea a day
c. When a child has an episode of diarrhoea lasting 14 days or more, which is
particularly dangerous for dehydration and malnutrition
4. Critical messages for caregivers about diarrhoea and dehydration include:
a. The child must receive increased fluids, ORS, zinc, and regular feeding
b. The child requires ORS, but should receive less food in order to reduce the
diarrhoea
c. The child should immediately receive antibiotics to stop the diarrhoea
5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She
has diarrhoea. You observe a significant loss of skin elasticity. How will you
manage Nidhi?
a. Nidhi requires ORS immediately, as she is dehydrated.
b. These are common signs of diarrhoea, as the child’s body is exhausted.
c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV
or nasogastric tube.
46
4.10 ANSWER KEY

REVIEW QUESTIONS
QUESTION ANSWER
1 A INTRODUCTION
2 B CLASSIFY, TREAT
3 C CLASSIFY
4 A TREAT, COUNSEL THE CAREGIVER
5 C CLASSIFY, TREAT
EXERCISE
Name:
A (MAYA)
Ask: What are the child's problems?
Age: Weight (kg):
Initial Visit?
Temperature (°C):
Follow-up Visit?
MANAGEMENT
OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS CLASSIFY
NOTMaya
Name: ABLE TO DRINK OR BREASTFEED Age: 25 mo
LETHARGIC Weight (kg): 9 kg
OR UNCONSCIOUS 37 °C
present?
Temperature (°C):
VOMITS
Ask: EVERYTHING
What are the child's problems? CONVULSING NOW
Initial Visit? X Yes ___
Follow-up No ___
Visit?
CONVULSIONS
Diarrhoea
Remember
CLASSIFY to use
Danger sign when
selecting
classifications
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ X
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
CONVULSIONS Yes __ Noto__
Remember use
For how long? ___ Days Count the breaths in one minute Danger sign when
___ breaths per minute. Fast breathing? selecting
Look for chest indrawing classifications
DOES THE CHILD HAVE COUGH OR DIFFICULTLook BREATHING?
and listen for wheezing X
Yes __ No __
X
Yes __ No __
4
Is there blood in the stool? No Lethargic or unconscious?
No
Restless and irritable?No
DOES THE CHILD HAVE DIARRHOEA? Offer the child fluid. Is the child: Yes __ No __
For how long? ___ Days LookNotat able
the childs
to drink general condition.
or drinking Is the child:
poorly?
No visible
Drinking eagerly, Yes
thirsty? dehydration
Restless
Pinch the skin and
of theirritable?
Slowly?
Decide malaria risk: High ___ Low ___ No___
Yes __ No __
EXERCISE
Name:
Ask:If What
more are than Bthe
7(RANA)
days,
child'shas fever been present every
problems?
Age:
Slowly?
Weight (kg):
Initial Visit?
Temperature (°C):
Follow-up Visit?
day? (Circle all signs present) Generalized rash and
ASSESS
Has child had measels within the last 3 months?
One
Look for
Look
of
or feel
these:
anyfor
cough,
stiffcause
other
runny
neck of fever.
nose, or red eyes Yes __ No __
CLASSIFY
CHECK
Do malariaFOR test if GENERAL
NO general danger DANGERsign SIGNS General danger sign
Look for runny nose
Rana
For how
HighNOT
Name:
If
risk:ABLE
more
long?
all fever
than
TO___
14 mo
7
cases
days,
DaysOR BREASTFEED
DRINK 12 kg
has fever been
37.5 °C
present every
LETHARGIC
Age: for signsOR
Look
UNCONSCIOUS
of MEASLES: Weight (kg): present?
Temperature (°C):
Ask:VOMITS
Lowday?Whatif are
Diarrhoea
risk:
CONVULSIONS
ASSESS
EVERYTHING

NO the child's
obvious cause
(Circle all signs present)
X
problems?
of fever
CONVULSING NOW
Generalized rash and Initial Visit? Yes ___
Follow-up No ___
Visit?

TestHasPOSITIVE?
child hadP. falciparum
measels withinP.the
vivaxNEGATIVE?
last 3 months? One of these: cough, runny nose, or red eyes Remember
CLASSIFY to use
Look for any other cause of fever. Danger sign when
CHECK
If
Dothe
malaria childFOR
testhas GENERAL
if NOmeasles
general dangerDANGER
nowsign SIGNS
or within the Look for mouth ulcers. General danger
selecting
sign
HighNOT risk: ABLE
all fever TOcases
DRINK OR BREASTFEED LETHARGIC
If yes, are ORtheyUNCONSCIOUS
deep and extensive? present?
last 3 months: classifications
VOMITS EVERYTHING
CONVULSING
Look NOW from the eye.
for pus draining X
Yes ___ No ___
DOES THE CHILD HAVE COUGH OR DIFFICULTLook
CONVULSIONS BREATHING?
for clouding of the cornea. Yes __ Noto__
Remember use
TestForPOSITIVE? P. falciparum P. vivaxNEGATIVE?
DOEShow THE long?CHILD___ DaysHAVE AN EAR PROBLEM? Count the breaths in one minute Danger
Yes __sign
No when
__
If the
Is therechild ear haspain?measles now or within the
Look for mouth
___ breaths perulcers.
minute. Fast breathing?
Look for pus draining from the ear selecting
lastIs 3theremonths: LookIf yes, are they
for chest deep and extensive?
indrawing classifications
ear discharge? Feel for tender swelling behind the ear
Look for
andpus draining
listen from the eye.
for stridor
DOESIf Yes,THE for how CHILDlong? HAVE
___ DaysCOUGH OR DIFFICULT BREATHING?
Look for
andclouding
listen forofwheezing
the cornea. X
Yes __ No __
THENFor how CHECK long? FOR
___ DaysACUTE MALNUTRITION Look
Count the breaths in one feet.
for oedema of both minute
DOES
AND
THE
ANAEMIA
CHILD HAVE AN EAR PROBLEM? Determine
DIARRHOEA? WFH/L _____ Z
___ breaths per minute. Fast breathing? score. X
Yes __ No __
Is
For there
howear 21
long? pain?
___ Days Look
For for puschilds
at the
Lookchildren
for chest6draining
months from
general
indrawing
the ear
condition.
or older Is the
measure child:____ mm.
MUAC
Is there ear blood discharge? No
in the stool? Feel
Look for tender
Lethargic
Look for
andpalmar
orswelling
listen for
No
unconscious?
pallor.
stridor
behind the ear
Look
Restlesspalmar
Severe Yes
and irritable?Some palmar pallor?
and listen for pallor?
wheezing
THEN CHECK FOR ACUTE MALNUTRITION Look for sunken
oedema eyes.
of complication?
both feet.
If childTHE
DOES has CHILD MUAC HAVE less than 115 mm or
DIARRHOEA? Is there
Offer
any medical
the child fluid._____
Is the Zchild: Yes __ No __
Determine WFH/L score.
AND ForANAEMIA
WFH/L howlesslong? than
___ -3DaysZ scores or oedema of Look
General
Not
For Anyat the
able
children
danger
childs
tomonths
6 drink
sign?
general
oror condition.
drinking
older Is the
poorly?
measure child:____ mm.
MUAC
Some
both feet:
Is there blood in the stool? Look
severe
Lethargic
Drinking
for palmar
Pneumonia
classification?
or pallor. Yes
unconscious?
eagerly,
with chestthirsty?
indrawing?
dehydration
Restless
Pinch the skinandof irritable?
the
Severe palmar
For a child 6 months orabdomen.
pallor? offerDoes
olderSome palmar
RUTF it go back:
pallor?
to eat. Is the child:
If child has MUAC less than 115 mm or Is Not able to finish or able to2finish?
Very
there slowsly
any medical (longer then
complication? seconds)?
Offer the
Slowly? child fluid. Is the child:
WFH/L less than -3 Z scores or oedema of For aGeneral
child lessdanger
than 6sign? months is there a breastfeeding problem?
CHECK
both feet: FOR HIV INFECTION Any severe classification? Yes __ No __
Drinking
Pneumonia eagerly, thirsty?
Decide
Notemalaria
mother's risk: High child's
and/or ___ Low HIV___ No___
status Look or feel for with chest indrawing?
stiff neck
Pinch the
For a child skin
6 monthsof the abdomen. Does it go back:
NOTLook for runny noseor older offer RUTF to eat. Is the child:
ForMother's
If more
how long?
than
Child's
HIV___ Days NEGATIVE POSITIVE
test:
7 days, has
virological test:fever been present
NEGATIVE every
POSITIVE NOTLookDONE
47
DONE/KNOWN
Veryable
Not slowsly
for signsto of (longer
finish thento2finish?
or able
MEASLES:
seconds)?
Slowly?
For aGeneralized
child less than 6 months is there a breastfeeding problem?
day? Child's serological test: NEGATIVE POSITIVE NOT DONE rash and
CHECK FOR HIV INFECTION Yes __ No __
IfHas child
mother ishad measels
HIV-positive within
and NO thepositive virological test in child:One of these: cough, runny nose, or red eyes
last 3 months?
Decide
Note malaria
mother's risk: High child's
and/or ___ Low HIV ___ No___
status Look or feel
Look for anyfor stiffcause
other neck of fever.
Is the child breastfeeding
Do malaria test if NO general danger sign now?
ForMother's
how the
Was long? HIV___
child Days NEGATIVE
test:
breastfeeding POSITIVE
at the time NOTLook
of test or 6 weeks
for runny nose
DONE/KNOWN
before it?
High risk: all fever cases Look for signs of MEASLES:
If more than
Child's 7 days,
virological has fever
test: been
NEGATIVE present every
POSITIVE
If breastfeeding: Is the mother and child on ARV prophylaxis? NOT DONE
Low risk: if NO obvious cause of fever Generalized rash and
EXERCISE C (CLASSIFY)
1. 2 SIGNS from any of the following – sunken eyes, restless/irritable, drinks eagerly/
thirsty, and slow skin pinch (faster than 2 seconds, but not immediate).
2. 2 SIGNS from any of the following – lethargic/unconscious, sunken eyes, not able
to drink/drinking poorly, very slow skin pinch (over 2 seconds)
3. Low osmolarity ORS.
MANAGEMENT
4. ChildrenOF
withTHE SICK
diarrhoea CHILD
that do AGED
not require 2 MONTHS
immediate referral – thatUP TO 5with
is, children YEARS
Name: diarrhoea and some or no dehydration.
Age: Children with persistent
Weight (kg): diarrhoea receive
Temperature (°C):
zinc for 14 days. Zinc supplements are a very important part of treating diarrhoea.
5. 4 rules DANGER
CHECK FOR GENERAL of home SIGNS
treatment of diarrhoea: General danger sign
1. Give extra fluid
VOMITS EVERYTHING – as muchCONVULSING
as the child
NOWwill take Yes ___ No ___
2. Give zinc Danger sign when
3. Continue feeding selecting
classifications
4. When to return (for a follow-up visit, or immediately if danger signs develop)
EXERCISE D
MANAGEMENT OF(CLASSIFY)
THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
3. PANO Look and listen for stridor
Name: Look
Age: and listen for wheezing Weight (kg): Temperature (°C):
Ask:
DOES What are the
THE child'sHAVE
CHILD problems?
DIARRHOEA? Initial Visit? Follow-upX
Yes __Visit?
No __
ASSESS (Circle
For how 5
long?all___
signs present)
Days Look at the childs general condition. Is the child: CLASSIFY
Is thereFOR
CHECK blood GENERAL No
in the stool? DANGER SIGNS Lethargic or unconscious? No General danger sign
NOT ABLE TO DRINK OR BREASTFEED Restless and
LETHARGIC OR irritable?
UNCONSCIOUS Yes present?
VOMITS EVERYTHING Look for sunkenNOW
CONVULSING eyes.
Yes ___ No ___
CONVULSIONS
Some
Remember to use
Drinking eagerly, thirsty? Yes dehydration
Danger sign when
Pinch the skin of the abdomen. Does it go back: selecting
Very slowsly (longer then 2 seconds)? classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Slowly? Yes Yes __ No __
For how long? ___ Days Count the breaths in one minute Yes __ No __
Decide malaria risk: High ___ Low ___ No___ ___ breaths
Look perstiff
or feel for minute.
neckFast breathing?
Look for
Look for runny
chest indrawing
nose
Look for
andsigns
listenoffor stridor
4. JANE
If more than 7 days, has fever been present every Look
Look and listen for
MEASLES:
wheezing
DOES THEhad
Has child CHILDmeaselsHAVE
within DIARRHOEA?
the last 3 months? One of these: cough, runny nose, or red eyes X
Yes __ No __
For howtest
Do malaria long? 3 ___general
if NO Days danger sign Look for anychilds
at the othergeneral
cause ofcondition.
fever. Is the child:
No
Is there blood in the stool?
Lethargic or unconscious? No
Restless and irritable? No
Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Offer the child fluid. Is the child:
Not
No dehydration
If the child has measles now or within the Look forable
mouth to drink or drinking poorly?
ulcers.
Drinking
If yes, are eagerly,
they deepthirsty?
and extensive?
last 3 months: Pinchfor
thepus
skin of the abdomen. Does it go back:
Look draining from the eye.
LookVery slowsly (longer
for clouding then 2 seconds)?
of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Slowly? Yes __ No __
Is there ear pain? Look for pus draining from the ear Yes __ No __
Is there
Decide malariaear discharge?
risk: High ___ Low ___ No___ Lookfor
Feel or tender
feel forswelling
stiff neckbehind the ear
IfFor
Yes,
how forlong?
how long? ___ Days
___ Days Look for runny nose
THENIf moreCHECK EXERCISE
FORhas
than 7 days, ACUTE E (PLAN B)
MALNUTRITION
fever been present every Look for
Look for oedema
signs of MEASLES:
of both feet.
day? Generalized
Determine WFH/L rash and Z score.
_____
AND ANAEMIA 1. Answers below:
Has child had measels within the last 3 months? For One of these:
children cough,
6 months runnymeasure
or older nose, or MUAC
red eyes
____ mm.
Look for
Look for palmar
any other cause of fever.
pallor.
High risk: all fever cases Name Age or Weight Severe Rangepalmarofpallor?
Amounts
Some of ORSpallor?
palmar Solution
If
Lowchild
risk: ifhas MUACcause
NO obvious less ofthan
fever115 mm or Is there any medical complication?
a. Andras 3 years 900–1400
General ml
danger sign?
WFH/L less than
Test POSITIVE? -3 Z scores
P. falciparum or oedema of
P. vivaxNEGATIVE? Any severe classification?
both b. Gul 10 kg 750 ml or 700–900 ml
If the feet:
child has measles now or within the Look for mouth with
Pneumonia ulcers.
chest indrawing?
last 3 months: c. Nirveli 7.5 kg For aIfchild
yes, 6are
562.5 they
months
ml ordeep andoffer
or 400–700
older extensive?
RUTF
ml to eat. Is the child:
LookNotforable
pustodraining
finish orfrom
ablethe
to eye.
finish?
d. Sami 11 months Look
For for400–700
a child less thanofml
clouding 6the cornea.
months is there a breastfeeding problem?
DOES THE
CHECK FORCHILD HAVE AN EAR PROBLEM?
HIV INFECTION Yes __ No __
Is there
Note ear pain?
mother's and/or child's HIV status Look for pus draining from the ear
Is there ear discharge?
Mother's HIV test: NEGATIVE POSITIVE NOTFeel for tender swelling behind the ear
DONE/KNOWN
If Yes, for how
Child's long? ___
virological test:Days
NEGATIVE POSITIVE NOT DONE
THENChild's
CHECK FOR test:
serological ACUTE MALNUTRITION
NEGATIVE POSITIVE NOT Look
DONE for oedema of both feet.
AND If mother
ANAEMIA Determine WFH/L _____ Z score.
is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now? For children 6 months or older measure MUAC ____ mm.
Was the child breastfeeding at the time of test or 6 weeks Look
before 48
for palmar
it? pallor.
If breastfeeding: Is the mother and child on ARV prophylaxis? Severe palmar pallor? Some palmar pallor?
If child has
CHECK THEMUAC CHILD'S lessIMMUNIZATION
than 115 mm orSTATUSIs(Circle there anyimmunizations needed today)
medical complication? Return for next
WFH/L
BCG less than -3 Z scores or
DPT+HIB-1 oedema of DPT+HIB-3
DPT+HIB-2 General danger sign?
Measles1 Measles 2 Vitamin A immunization on:
OPV-0feet: OPV-1 OPV-2 OPV-3 Any severe classification? Mebendazole ________________
both
Hep B0 Hep B1 Hep B2 Hep B3 Pneumonia with chest indrawing? (Date)
2. Answers below:
a. Vinita should be given 400–700ml of low osmolarity ORS solution during the
first 4 hours of treatment. She should also be given 100–200 ml of clean water
during this period.
b. She should wait 10 minutes before giving more ORS solution. Then she should
give Vinita the ORS solution more slowly.
c. After Vinita is given ORS solution for 4 hours on Plan B
d. Because Vinita has been reassessed as NO DEHYDRATION, she should be put on
Plan A.
e. 2 one-litre packets
f. To continue treatment at home, the grandmother should give Vinita 50–100 ml
of ORS solution after each loose stool.
3. Answers below:
a. 400–700 ml of ORS solution
b. Yes, Yasmin should breastfeed whenever and as much as she wants.
c. Because Yasmin is still classified as SOME DEHYDRATION, she should continue
on Plan B.
EXERCISE F (PLAN A)
1. Answers will vary
2. Somi answers:
a. Give extra fluid, Give zinc, Continue feeding, Advise when to return
b. ORS solution, food-based fluids (such as soup, rice water, yoghurt drinks), clean
water
3. The health worker should tell Kasit’s mother to breastfeed him more frequently
than usual. The health worker should also tell the mother that after breastfeeding,
she should give Kasit ORS solution or clean water.
4. Children who have been treated with Plan B or Plan C during the visit, or children
who cannot return to a clinic if the diarrhoea gets worse.
5. Answers below:
a. Kala 6 months 500–100 ml
b. Sam 2 years 100–200 ml
c. Kara 15 months 50–100 ml
d. Lalita 4 years 100–200 ml
49
EXERCISE G (TREAT)
1. 10 mg (1/2 of a 20 mg tablet) once each day for 14 days. Tablet should be crushed
and dissolved in breast milk, ORS, or clean water. It is important to give zinc for all
14 days.
2. 20 mg tablet given once each day for 14 days. Tablets can be chewed or dissolved
in fluid. It is important to give zinc for all 14 days.
3. Give 1ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days
4. Give 3ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days
5. Start treatment for dehydration, give Vitamin A dose, teach mother to give
frequent sips of ORS on the way, give other urgent pre-referral treatment as other
classifications require, and refer URGENTLY.
6. Correct answers are A, B, D, E
EXERCISE H (CASE STUDY COUNSEL)

1. Rules are:
a. GIVE EXTRA FLUID: Explain what extra fluids to give. Since the child is being
treated with Plan B during this visit, the mother should give ORS at home. Explain
how much ORS solution to give after each loose stool.
b. CONTINUE FEEDING: Instruct her how to continue feeding during and after
diarrhoea.
c. GIVE ZINC: explain dosing and schedule for 14 days of zinc, how to give, why it
is given
d. WHEN TO RETURN: Teach her the signs to bring a child back immediately.
2. How to mix ORS into water. He did not include what containers to use, what ratio of
packets and water, how to give the ORS to her child, or instructions for frequency
of treatment.
3. YES
4. NO
5. WITH A YES/NO QUESTION (“DO YOU UNDERSTAND?”). THIS IS NOT A CHECKING
QUESTION.
6. NO. THE QUESTION DOES NOT SHOW IF THE CAREGIVER LEARNED.
7. CHECKING QUESTION –for example “How will you prepare the ORS for your child?”
EXERCISE I (CASE STUDY COUNSEL)

1. All five answers should be checked.
2. Aviva answers:
a. YES, 2 PACKETS
b. The mother should wait 10 minutes before giving more fluid. Then she should
give the solution more slowly.
c. Aviva’s mother should continue giving extra fluid until the diarrhoea stops
d. Drinking poorly or not able to drink or breastfeed, Becomes sicker, Develops a
fever, Blood in stool
3. Only C “How much fluid will you give your child?” is a good checking question
50
EXERCISE J (EVARISTO FOLLOW-UP)

1. Ask: Has Evaristo’s diarrhoea stopped? How many loose stools is he having per day?
2. Reassess Evaristo completely as described on the ASSESS & CLASSIFY chart. Treat
any problems that require immediate attention. Then refer him to hospital.
3. NO
4. Refer him to a hospital. He does not need any treatments before he leaves.
5. Rehydrate him according to Plan B before referral.
51
ISBN 978 92 4 150682 3
IMCI
Module 5
Fever
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER
n CONTENTS
Acknowledgements 4
5.2 Introduction to fever 8
5.3 Assess a child for fever 13
5.4 Classify fever 21
5.5 Treat the child with fever 29
5.7 Provide follow-up care 40
5.10 Answer key 48
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
5.1 MODULE OVERVIEW

A fever can have many causes. Fever can be the only sign of a sick child, or it
may be combined with other problems. It is important to keep the big picture in
mind as you manage the child with fever. You will have to do a careful assessment
to determine how serious the problem is. This module will teach you how to do this
assessment.
check for general danger signs, assess for cough or difficult breathing, assess
diarrhoea and dehydration, then DETERMINE: DOES THE CHILD HAVE A FEVER?
NO YES

the colour-coded classification
charts for fever.
CONTINUE ASSESSMENT: check for malnutrition & anaemia, check immunization

status, HIV status, and other problems

✔✔ Determine if a child has fever by measuring temperature, history, or feeling
✔✔ Determine a child’s malaria risk
✔✔ Recognize the clinical signs of severe febrile disease
✔✔ Identify clinical signs of measles and complications from measles
✔✔ Classify fever using IMCI charts
✔✔ Classify measles and measles with complications
✔✔ Give oral antimalarials
✔✔ Give appropriate treatments for measles
✔✔ Counsel on home treatment and follow-up care for children with fever
✔✔ Provide follow-up to children with fever
5
IMCI DISTANCELook and listenCOURSE
LEARNING for stridor| MODULE 5. FEVER
YOUR RECORDING FORM Restless and irritable?
Look at your IMCI recording form for the sick child. This section
deals with this
module: Drinking eagerly, thirsty?
Slowly?
MODULE ORGANIZATION
✔✔ Assess fever Severe palmar pallor? Some palmar pallor?
✔✔ Classify
WFH/L less than fever
-3 Z scores or oedema of General danger sign?
✔✔ Treat fever For a child 6 months or older offer RUTF to eat. Is the child:
✔✔ Counsel caregiver on homeForcare
a child less than 6 months is there a breastfeeding problem?
Note mother's✔ ✔ Follow-up
and/or care for fever
child's HIV status
✔ ✔ Module contents
BEFORE YOU BEGIN
CHECK THE What doIMMUNIZATION
CHILD'S you know now about(Circle
STATUS managing fever? needed today)
immunizations Return for next
OPV-0 Before
OPV-1 you begin studying this
OPV-2 module, quickly practice your knowledge
OPV-3 with these
Mebendazole ________________
Hep B0 multiple-choice questions.
RTV-1 RTV-2 RTV-3
1. Which of the following children has a fever that requires further investigation?
a. Imrana has an axillary temperature of 37 °C
b. Joy’s mother says she has been feeling very hot for the pastPage 65 of 75
three days
c. Samuel’s face is very flushed and red
2. What are common causes of fever that often kill children?
a. Local infection and malaria
b. Meningitis and influenza
c. Measles and malaria
6
3. What would you give to children with high fever?

a. Paracetamol
b. Amoxicillin or another antibiotic
c. Fluids
4. What is recommended treatment for malaria?
a. Chloroquine
b. Artemisinin-based combination therapies
c. Paracetamol
5. Traci has a fever, generalized rash, runny nose, and mouth ulcers. How you would
you classify?
a. She shows signs local infections of the skin
b. She shows clinical signs of AIDS
c. Measles with mouth complications
7
5.2 INTRODUCTION TO FEVER

Now you will consider a typical case that you might see in your practice – imagine the
situation. This will help you start thinking about the problem of a child with a fever.
n OPENING CASE STUDY – SAMI

It is a hot day in your clinic, and the waiting room is crowded with mothers. Miriam comes into your clinic
with her son, Sami. He has been complaining of being “hot” for a few days, she says.
Sami sits next to Miriam but does not look very energetic. He is a quiet boy, and when you ask him how he is
feeling, he puts his head into his mother’s skirt. He continues to lie on her lap and looks unwell. You are not
yet sure if he is feeling unwell because of the heat, or if he has a fever. You know there are several causes for
fever.
WHEN DOES A CHILD HAVE THE MAIN SYMPTOM FEVER?

The child has a history of fever
n The child feels hot
n The child has an axillary (underarm) temperature of 37.5 °C (38 °C rectal) or
above
WHAT CAUSES FEVER IN CHILDREN?

A child with fever may have malaria, measles or another severe disease – like
meningitis, septicaemia and very severe pneumonia.
Signs of some very severe diseases may be general and non-specific. For a
health worker it is very important to identify key symptoms and signs of the diseases
that may cause the child’s death very quickly. Therefore all sick children with those
signs should be referred to the hospital for further assessment and treatment.
Other bacterial infections causing fever include pneumonia, acute ear infection,
streptococcal sore throat, dysentery, local bacterial infection, typhoid, and urinary
tract infection. Or, a child with fever may have a simple cough or cold or other viral
infection.
All health workers should know how to assess a child for common childhood
causes of fever: malaria and measles. These are two major killers of children
under five in the world. In malaria risk areas, malaria is still a major cause of fever
and death in children although measles has been on the decline due to successful
measles immunization.
Malaria and measles are common causes of fever, and two major killers of children.
8
WHAT CAUSES MALARIA?

Malaria is caused by parasites in the blood called plasmodia. These parasites are
transmitted when an infected female anopheline mosquitoes bite humans. Four
species of plasmodia can cause malaria. The most dangerous type is Plasmodium
falciparum. Signs of falciparum malaria include shivering, sweating and vomiting.
Another parasite species that commonly causes malaria is called Plasmodium vivax.
This rarely causes very severe illness or death, but Plasmodium vivax contributes
to malaria morbidity in some countries.
Malaria may occur throughout the year or during the rainy season in some countries.
It is important to know which species of Plasmodium is in your country and area of work.
It is also important to know when during the year it occurs.
HOW CAN MALARIA CAUSE ILLNESS AND DEATH IN CHILDREN?

In areas with very high malaria transmission, malaria is a major cause of
death in children. A case of uncomplicated malaria can develop into severe malaria
as soon as 24 hours after the fever first appears. Severe malaria is malaria with
complications such as cerebral malaria, severe anaemia, or presence of any other
general danger sign. The child can die if he or she does not receive urgent treatment.
WHAT ARE SIGNS OF MALARIA?

Fever is the main symptom of malaria. It can be present all of the time, or it
can go away and return at regular intervals.
Signs of malaria can overlap with signs of other illnesses. For example:
✔✔ A child may have malaria and a cough with fast breathing, a sign of pneumonia.
This child needs treatment for both malaria and pneumonia.
✔✔ Children with malaria may also have diarrhoea. They need an antimalarial and
treatment for the diarrhoea.
✔✔ A child with malaria may have chronic anaemia (with no fever) as the only sign
of illness. You will read more about anaemia in MODULE 6.
HOW DO YOU CONFIRM MALARIA?

If a child has a fever due to malaria, malaria parasites
or malaria antigens should be present in the blood How do you determine fever?
when it is tested to confirm malaria infection. •• History of fever
If the child does not have malaria parasites present, •• Feels hot
then it is unlikely that the fever is due to malaria. The
•• Axillary temperature 37.5 °C
child should be assessed for other possible causes of or above
fever.
9
BESIDES MALARIA, WHAT ARE OTHER CAUSES OF FEVER?

If a child with fever does not show signs of malaria parasites, it is unlikely that the
fever is not due to malaria. The child should be assessed for other possible cause
of fever.
There are three major categories of children with fever:
1. FEVER WITH LOCALISING SIGNS
A child might have an apparent bacterial cause of fever such as pneumonia,
dysentery, acute ear infection, sore throat, meningitis, and local infection that
has localising signs. Signs of local infection may be refusal to use a limb, hot
tender swelling, tenderness, or red tender skin.
2. FEVER WITHOUT LOCALISING SIGNS
A child might also have fever due to bacterial infection with no localising signs
like septicaemia, typhoid fever, urinary tract infection, HIV infection and miliary
tuberculosis. These infections are difficult to diagnose without use of laboratory
tests and therefore children suspected of having these conditions should be
referred to hospital for assessment.
3. FEVER WITH A RASH
Fever with a rash is commonly caused by measles. It can also be other simple viral
infections, or infections like meningococcal meningitis and dengue haemorrhagic
fever.
WHAT CAUSES MEASLES?

Measles is caused by a virus that infects the skin and layer of cells that line the
lung, gut, eye, mouth, and throat.
Measles is highly infectious. Most cases occur in children between 6 months
and 2 years of age. The measles virus damages the immune system for many
weeks after the onset of measles. This leaves the child at risk for other infections.
Complications of measles occur in about 30% of all cases.
WHAT ARE SIGNS OF MEASLES?

Fever and a generalized rash are the main signs of measles. Sometimes measles
presents with eye and mouth complications.
WHY DOES MEASLES CONTRIBUTE TO MALNUTRITION?

Measles contributes to malnutrition because it causes diarrhoea, high fever, and
mouth ulcers. These problems interfere with feeding. Malnourished children are
more likely to have severe complications due to measles. This is especially true
for children who don’t have enough vitamin A. One in ten severely malnourished
children with measles may die. For this reason, it is very important to help the
caregiver to continue to feed her child during measles.
10
n How will you greet Miriam and begin the assessment?

You praise Miriam for bringing Sami to the clinic. You tell her that she has been attentive to listen to her son’s
complaints and to bring him in. She tells you Sami is 3 years old, so you know you will be using the sick child
charts.
You ask her to tell you more about Sami’s problem, “feeling hot,” and what she has done for the problem so
far. Miriam tells you that he handles the heat well, so you do not think that he is only talking about the heat
outside. She says his body feels warm. She has tried to put cool, wet rags on his chest and head, she says, but
they have not helped him.
You ask if this is the first time she is coming to the clinic for this, and she says yes. You take Sami’s
temperature under his armpit, and it is 38.6 degrees. He does has a fever, because his temperature is over
37.5 degrees. He weighs 12 kg.
n Next, you will check for general danger signs:

You ask Miriam if Sami is able to eat and drink, and she says yes. She says he is not vomiting, and has not had
convulsions. You watch Sami. He acts very tired – he continues to lay his head on his mother’s lap – but he
watches you as you talk. He holds the material of Miriam’s skirt and plays with it. Does Sami have any general
danger signs?
n Next, you assess for cough or difficult breathing and diarrhoea:

You will now assess Sami for the first two main symptoms, cough or difficult breathing and diarrhoea. You ask
Miriam if Sami has had a cough. She says no.
You ask if he has diarrhoea, and she says that he has been having loose stools. She says this has been a
problem for the last week. You ask if there is blood in the stool and she says no.
Then you assess Sami’s dehydration. Sami does not look restless or irritable. You look for sunken eyes, but
Sami’s look normal. You pour Sami a glass of water from a pitcher on the counter, and offer it to him. He is
shy to take it, but Miriam asks him to take it and drink. He drinks eagerly. You ask Miriam to set Sami on the
examination table and lay down with his hands to his sides. You tell them that you will pinch Sami’s skin, but
it will not hurt. The skin returns immediately.
n How will you classify Sami’s diarrhoea and dehydration?

You classify that Sami does not have persistent diarrhoea (lasting longer than 14 days) or dysentery (blood in
the stools).
Sami has diarrhoea, but not enough signs to classify any dehydration. You determine that you will counsel
Miriam on Plan A for home treatment of diarrhoea.
11
n How will you complete Sami’s recording form thus far?

Name: Sami Age: 3 years Weight (kg): 12 kg Temperature (°C): 38.6 °C
Ask: What are the child's problems? Feels hot Initial Visit? X Follow-up Visit?
CLASSIFY
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
DOES THE CHILD HAVE DIARRHOEA? X
Yes __ No __
7
Restless and irritable? Diarrhoea, no
dehydration
Drinking eagerly, thirsty? (Plan A)
Slowly?
Look for runny nose
n Now you will learn to assess Sami for the next main symptom, fever.
ThisHas
was also
child had his complaint,
measels and
within the last you have
3 months? already
One ofdetermined by taking
these: cough, runny hiseyes
nose, or red temperature that he has a fever.
Hep B0
RTV-1 RTV-2 RTV-3
12
Page 65 of 75
5.3 ASSESS A CHILD FOR FEVER

First, determine if the child has a fever.
A child has the symptom of fever if:

•• Has a history of fever
•• Feels hot
•• Has an axillary (underarm) temperature of 37.5 °C (38 °C rectal) or above
If you do not have a thermometer, feel the child’s stomach or axilla (underarm)
and determine whether the child feels hot. Ask the caregiver: “Does the child have
fever?” The child has a history of fever if the child has had any fever with this illness.
History of fever is enough to assess the child. If the child has a history of fever, you
will assess even if his current temperature is not 37.5 °C or above, or he does not feel
hot now. If the child has no fever, ask about the next main symptom, ear problem.

NO fever, ask about the next main symptom using the IMCI process.
YES fever is present, you will assess in three parts:
1. Determine if malaria risk is high or low
2. Assess for causes of fever
3. Assess for complications from measles, if child shows signs of measles or has
had measles
Open your chart booklet to the ASSESS chart for fever. The top part of the box
describes how to assess for causes of fever. These include signs of malaria, measles,
meningitis and other causes. The bottom part of the box describes how to assess
the child for signs of measles complications, if the child has measles now or within
the last 3 months.
13
HOW WILL YOU ASSESS FOR CAUSES OF FEVER?

You will now read about
Does theassessing
child have forfever?
causes of fever, the top part of the ASSESS
chart: (by history or feels hot or temperature 37.5°C* or above)
If yes: Any genera

Decide Malaria Risk: high or low Stiff neck.
Then ask: Look and feel: Classify
FEVER High or Low
For how long? Look or feel for stiff neck.
Malaria Risk
If more than 7 days, has Look for runny nose.
fever been present every Look for any other cause
day? of fever**.
Has the child had measles Look for signs of Malaria test
within the last 3 months? MEASLES.
One of these: cough,
runny nose, or red
eyes.
Do a malaria test: If NO general danger sign or stiff
neck
In all fever cases if High malaria risk. Malaria test
In Low malaria risk if no obvious cause of fever present. and/or
Other caus
PRESENT.
MALARIA RISK
HOW WILL YOU DECIDE MALARIA RISK?
To classify and treat children with fever, you must know the malaria risk in your area. Any genera
If the child has measles Look for mouth ulcers. or
Most national malaria
now orcontrol programmes
within the last 3 define areas of malaria risk
Are they deep and
as follows:
If MEASLES now or within Clouding of
months: extensive? last 3 months, Classify Deep or ext
•• HIGH MALARIA RISK: in area where more than 5% of fever cases in children
Look for pus draining from ulcers.
2 to 59 months are attributable to malaria.
the eye.
Look for clouding of the
•• LOW MALARIA RISK: in area where fewer than 5% of fever cases in children
cornea.
Pus drainin
2 to 59 months are attributable to malaria, but where the risk is not negligible. or
Mouth ulcer
•• NO MALARIA RISK: malaria transmission does not normally occur in the area,
and imported malaria is uncommon.
Measles no
HOW IS MALARIA RISK DETERMINED? the last 3 m
Malaria risk depends on:

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C hig
n How prevalent malaria is in your area – this is called malaria endemicity
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower ab
n Extent of malaria control
*** If no malariain
testthe country
available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause o
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - a
Risk also varies by:
n Region, because malaria risk can change across a local area or across a country
Page 7 of
n Season, because the breeding conditions for mosquitoes are limited or absent
during the dry season, and as a result, malaria risk is usually low during dry
season
14
WHAT IS THE MALARIA RISK IN YOUR AREA?

Find out the risk of malaria for your area. If the risk changes according to
season, be sure you know when the malaria risk is high and when the risk is low. If
you do not have information telling you that the malaria risk is low in your area,
always assume that children under 5 years of age who have fever are at high risk
for malaria.
ASK the caregiver: “Has the child travelled during the past two weeks and,
if so, where?” Some families in low risk areas may have travelled to areas where
there is a malaria risk. If a caregiver in a low malaria risk area tells you she has
travelled with the child to an area where you know there is a high malaria risk, you
will assess the child according to a high risk area.
WHAT IS THE MALARIA RISK IN YOUR AREA?

Does it change by season?
Are there other nearby regions that people travel to that have a higher malaria risk?
WHY DOES MALARIA RISK MATTER FOR IMCI?

Depending on the local malaria risk, you may do a malaria test for the child. It is
not possible to clinically distinguish fever caused by malaria from other causes of
fever because there are many causes of fever. To be sure that a child with a fever
or history fever has a malaria infection, you need to do a malaria test.
To avoid a large number of children being treated for malaria when in fact they
have another febrile illness, children should first be tested for malaria to determine
treatment. Testing for malaria will also help to distinguish malaria caused by
P.  falciparum or P. vivax. As you learned earlier, P. falciparum is more dangerous.
WHEN WILL YOU DO A MALARIA TEST: HIGH MALARIA RISK?

Here the chance of the child’s fever attributable to malaria is very high. A malaria
test should be done in all children with a fever or history of fever with no
general danger sign or stiff neck. Do not do a malaria test if a child has a danger
to avoid delay in referral but give pre-referral antimalarial and antibiotic treatment,
and refer urgently.
WHEN WILL YOU DO A MALARIA TEST: LOW MALARIA RISK?

The chance of malaria causing the child’s fever is low. There is an even lower chance
of malaria if the child has signs of another infection that can cause fever. A malaria
test should be done if the child with fever has no general danger signs and
no apparent cause of fever.
15
HOW WILL DETERMINE WHICH MALARIA TEST TO USE?

There are two ways of doing a malaria test:
1. Examining a blood slide for malaria parasites using a microscope
2. Using a Rapid Diagnostic Test (RDT) to check blood for malaria antigens
HOW WILL YOU RECORD A MALARIA TEST RESULT?

To do a malaria test, take a blood smear if you have a microscope in the clinic, or
check the blood by using an RDT. The malaria test result will determine whether
a child has malaria parasites requiring treatment or not. Always check the quality
of your blood slides if using microscopy or RDTs to ensure that the test results are
reliable.
Circle the results of the test on the recording form:
n POSITIVE – if there are malaria parasites or RDT is positive. Note if it is
P.  falciparum or P. vivax if able to do so especially when using microscopy.
n NEGATIVE – If there are no parasites seen by microscopy, or RDT is negative
CAUSES OF FEVER
ASK: HOW LONG HAS THE CHILD HAD FEVER?
Most fevers due to viral illnesses go away within a few days. If the fever has been
present for more than 7 days, ask if the fever has been present every day. A fever
that has been present every day for more than 7 days can mean that the
child has a more severe disease such as typhoid fever. Refer this child for
further assessment.
ASK: HAS THE CHILD HAD MEASLES WITHIN THE LAST 3 MONTHS?
Measles damages the child’s immune system and leaves the child at risk for other
infections for many weeks. A child with fever and a history of measles within the
last 3 months may have an infection, such as an eye infection, due to complications
of measles.
LOOK OR FEEL FOR STIFF NECK

A stiff neck may be a sign of meningitis, cerebral malaria or another very severe
febrile disease. It requires urgent treatment with injectable antibiotics and
referral to a hospital.
WATCH THE CHILD: While you talk with the caregiver during the assessment, look
to see if the child moves and bends his or her neck easily when looking around. If
the child is moving and bending his or her neck, the child does not have a stiff neck.
TEST THE CHILD: If you did not see any movement, or if you are not sure, draw
the child’s attention to his or her umbilicus or toes. For example, you can shine a
flashlight on the toes or umbilicus or tickle the toes to encourage the child to look
down. Look to see if the child can bend his or her neck when looking down at his
or her umbilicus or toes.
16
FEEL FOR STIFF NECK: If you still have not seen the child
bend his or her neck himself, ask the caregiver to help you
lay the child on his or her back. Lean over the child, gently
support the child’s back and shoulders with one hand. With
the other hand, hold the child’s head.
Then carefully bend the head forward towards the child’s
chest. If the neck bends easily, the child does not have stiff
neck. If the neck feels stiff and there is resistance to bending,
the child has a stiff neck. Often a child with a stiff neck will
cry when you try to bend the neck.
DVD EXERCISE – NECK STIFFNESS

Watch “Assess neck stiffness” (disc 2). It is very useful to practice with a video.
Record your answers as you watch, and the video will review them. Do these
children have stiff necks?
LOOK FOR RUNNY NOSE

When malaria risk is low, a child with fever and an obvious cause of fever like a runny
nose (common cold), pneumonia or ear infection does not need a malaria test. This
child’s fever is probably caused by a common cold or pneumonia or ear infection.
LOOK FOR OTHER SIGNS OF FEVER

Assess the child for signs of other non-apparent bacterial infection. Look for local
tenderness, oral sores, refusal to use a limb, hot tender swelling, red tender skin or
boils, lower abdominal pain, or pain on passing urine in older children.
LOOK FOR SIGNS SUGGESTING MEASLES

There are two categories of signs suggesting measles. First, the child should have
a generalized rash. They should also show one of the following: cough, runny
nose, or red eyes.
Generalized rash
In measles, a red rash begins behind the ears and on the neck. It spreads to the face.
During the next day, the rash spreads to the rest of the body, arms and legs. After
4 to 5 days, the rash starts to fade and the skin may peel.
Some children with severe infection may have more rash spread over more of the
body. The rash becomes more discoloured (dark brown or blackish), and there is more
peeling of the skin. A measles rash does not have vesicles (blisters) or pustules. The
rash does not itch.
Do not confuse measles with other common childhood rashes such as chicken pox,
scabies, or heat rash. Chicken pox rash is a generalized rash with vesicles. Scabies
occurs on the hands, feet, ankles, elbows, buttocks and axilla (underarm). It also
17
itches. Heat rash can be a generalized rash with small bumps and vesicles, which
itch. A child with heat rash is not sick.
Does the child have fever?
(by history or feels hot or temperature 37.5°C* or above)
Cough, runny nose, or red eyes
To classify a childIf yes:
as having measles, the child with fever must have a generalized Any genera
rash AND one ofDecide Malaria Risk:
the following high or
signs: low runny nose, or red eyes.
cough, Stiff neck.
Then ask: Look and feel: Classify
The child has “red eyes” if there High or Low
For how long? is redness inLook
the white part
or feel for stiffof the eye.
neck. In a healthy
FEVER
Malaria Risk
If more
eye, the white part of the than
eye 7isdays, has whiteLook
clearly andfornot
runny nose.
discoloured.
fever been present every Look for any other cause
day? of fever**.
Has the child had measles Look for signs of Malaria test P
Watch “Assess
within the lastand classify fever”
3 months? (disc 2)
MEASLES.
This video reviews all steps of assessing fever.rash
Generalized IMPORTANT:
and note that
this video does not include a malaria test. Doing a
One of these: cough, malaria test with
microscopy or RDT is a recent technical update.
runny nose, or red
eyes.
Do a malaria test: If NO general danger sign or stiff
neck
In all fever cases if High malaria risk. Malaria test
COMPLICATIONS
In LowFROM MEASLES
malaria risk if no obvious cause of fever present. and/or
Other cause
WHEN WILL YOU ASSESS FOR COMPLICATIONS FROM MEASLES? PRESENT.
If the child has measles now or has had measles within the last 3 months,
you will assess if the child has mouth or eye complications.
This assessment follows instructions on the lower portion of the fever ASSESS chart:
Any genera
If the child has measles Look for mouth ulcers. or
now or within the last 3 Are they deep and If MEASLES now or within Clouding of
months: extensive? last 3 months, Classify Deep or ext
Look for pus draining from ulcers.
the eye.
Look for clouding of the
cornea.
Pus draining
or
Mouth ulcer
WHAT ARE MEASLES WITH COMPLICATIONS?

Children with measles may have other serious complications of measles. Measles Measles no
complications can lead to severe disease and death. Classifying complications the last 3 mo
will allow you to better treat the child with measles.

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C high
Complications include stridor in a calm child, severe pneumonia, severe dehydration,
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abd
or severe malnutrition. Some complications of measles are due to bacterial infections.
*** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause o
Others are due to the measles virus, which causes damage to the respiratory and
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - a
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.
Page 7 of 7
Now you will learn about assessing for these clinical signs.
18
LOOK FOR MOUTH ULCERS

Look inside the child’s mouth for mouth ulcers. Ulcers are
painful open sores on the inside of the mouth and lips or
the tongue. They may be red or have white coating.
In severe cases, they are deep and extensive. A child
with measles who has mouth ulcers will find it difficult to
drink or eat.
Mouth ulcers are different than the small spots called
Koplik spots. Koplik spots occur in the mouth inside the
cheek during early stages of the measles infection. Koplik
spots are small, irregular, bright red spots with a white spot in the centre. They do
not interfere with drinking or eating. They do not need treatment.
LOOK FOR CLOUDING OF THE CORNEA

The cornea is usually clear. When clouding of the cornea is
present, the cornea may appear clouded or hazy. The cornea
may look the way a glass of water looks when you add a small
amount of milk. The clouding may occur in one or both eyes.
Corneal clouding is a dangerous condition. It may be
the result of vitamin A deficiency that has been made worse
by measles. If the corneal clouding is not treated, the cornea
can ulcerate and cause blindness. A child with clouding
of the cornea needs urgent treatment with vitamin A.
A child with corneal clouding may keep his or her eyes
tightly shut when exposed to light. The light may cause
irritation and pain to the child’s eyes. To check the child’s eye, wait for the child
to open his or her eye. Or gently pull down the lower eyelid to look for clouding.
If there is clouding of the cornea, ask the caregiver how long the clouding
has been present. If the caregiver is certain that clouding has been there for some
time, ask if the clouding has already been assessed and treated at the hospital. If it
has, you do not need to refer this child again for corneal clouding.
LOOK FOR PUS DRAINING FROM THE EYE

Pus draining from the eye is a sign of conjunctivitis.
Conjunctivitis is an infection of the conjunctiva, the inside
surface of the eyelid and the white part of the eye.
If you do not see pus draining from the eye, look for
pus on the conjunctiva or on the eyelids. Often the pus
forms a crust when the child is sleeping and seals the eye
shut. You can gently open the eye, making sure that your
hands are clean.
Wash your hands after examining the eye of any child with pus draining from the
eye.
19
n How will you assess Sami for fever?

When you took Sami’s temperature, you saw that he does have a temperature higher than normal, 38.6 °C.
A fever is anything higher than 37.5 degrees. You ask Miriam about his symptoms. She tells you that Sami has
been “hot”. He does not have a history of fever.
Sami has the symptom fever, so you will now assess for its causes.
First, you determine that Sami and his family live in a high risk malaria area. You ask how long Sami has
MANAGEMENT
been OF THE
feeling hot, and Miriam says 2 SICK CHILD
days. This is underAGED
the 7 day2threshold
MONTHS UPindicate
that may TO 5 YEARS
a more serious
disease, and would require referral.
You continue
ASSESS (Circle allto watch
signs Sami
as he rests on his mother’s lap. He is able to move his neck
present) well. Just CLASSIFY
to check,
you tap Sami’s
CHECK feet andDANGER
FOR GENERAL ask him SIGNS
to look down. He bends his neck well to look down. Sami doesGeneral not have
dangerasign
present?
runny
NOTnose. You
ABLE TO ask OR
DRINK to BREASTFEED
examine him and survey his body
LETHARGIC for any signs of bacterial infection, like tenderness,
OR UNCONSCIOUS
swelling, or red skin. He has none.
Danger sign when
Now you will do a malaria test. You remember that all children in a high malaria risk area with a fever, without
selecting
classifications
a general danger sign or stiff neck, should take a malaria test. You have RDT available at the clinic. Sami’s test is
positive for
For how P. falciparum.
long? ___ Days This is the more dangerous parasite.
Count the breaths You mark this on his recording form.
in one minute
You ask Miriam if Sami has had measles within Lookthe pastindrawing
for chest three months. She does not understand when you ask
about measles, so you explain some of the symptoms Look and listen forawheezing
– rash, runny nose, or red eyes, for example. She has
already mentioned that Sami has not had a cough. She says no, he has not shown any of these signs. Yes __ If
NoSami
__
did show signs
Is there blood of stool?
in the measles today, or Miriam reported
Lethargicthat he has had measles within the past three months,
or unconscious?
you would have assessed for complications affecting his eyes
Look for sunken eyes. or mouth. You would have assessed for mouth
ulcers, clouded cornea, and pus draining from the
Offer eye.fluid. Is the child:
the child
n How will you record your assessment on Sami’s form? Pinch the skin of the abdomen. Does it go back:
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) X
Yes __ No __
X
2
One of these: cough, runny nose, or red eyes
Malaria RDT
Do malaria test if NO general danger sign positive
(P. falciparum)
You Is there ear discharge?
Ifwill
Yes,now
for howlearn how
long? ___ to
Days classify Sami’s fever. Feel for tender swelling behind the ear
BCG
OPV-0
DPT+HIB-1
OPV-1
DPT+HIB-2
OPV-2
DPT+HIB-3
OPV-3
20
Measles1 Measles 2 Vitamin A
Mebendazole
immunization on:
________________
Hep B0
RTV-1 RTV-2 RTV-3
5.4 CLASSIFY FEVER

If the child has fever and no signs of measles, classify the child for fever only. If the
child has signs of both fever and measles, classify the child for fever and for measles.
CAUSES OF FEVER
HOW DO YOU CLASSIFY FEVER?
You will classify based on the signs you have assessed, and the results of the malaria
test if you conducted. There are three classifications for fever. These are:
1. VERY SERIOUS FEBRILE DISEASE
2. MALARIA
3. FEVER: NO MALARIA
Any general danger sign or Pink: Give first dose of artesunate or quinine for
Stiff neck. VERY SEVERE severe malaria
Classify FEBRILE DISEASE Give first dose of an appropriate antibiotic
FEVER High or Low
Treat the child to prevent low blood sugar
Malaria Risk
Give one dose of paracetamol in clinic for
high fever (38.5°C or above)
Refer URGENTLY to hospital
Malaria test POSITIVE.*** Yellow: Give recommended first line oral
MALARIA antimalarial
Follow-up in 3 days if fever persists
If fever is present every day for more than 7
days, refer for assessment
Malaria test NEGATIVE Green: Give one dose of paracetamol in clinic for
and/or FEVER: high fever (38.5°C or above)
Other cause of fever NO MALARIA Give appropriate treatment for any other cause
PRESENT. of fever
Any general danger sign Pink: Give Vitamin A treatment

or SEVERE Give first dose of an appropriate
If MEASLES now or within VERY SEVERE FEBRILE
Clouding of cornea or
DISEASE
COMPLICATED
(RED) antibiotic
last 3 months, Classify Deepwith
or extensive MEASLES**** If clouding of neck
the cornea or pus draining
A child fever mouth
and any general danger sign or a stiff should be classified
ulcers. from the eye, apply tetracycline eye
as having very severe febrile disease. A childointment
with fever and any general danger
sign or stiff neck may have meningitis, sepsis, or severe
Refer malaria
URGENTLY (including cerebral
to hospital
Pus draining
malaria) from the
if there is eye Yellow:
malaria Give Vitamin
risk. It is not possible A treatmentbetween these
to distinguish
or MEASLES WITH EYE If pus draining from the eye, treat eye
severe diseases
Mouth ulcers. without laboratory tests.
OR MOUTH infection with tetracycline eye ointment
COMPLICATIONS**** If mouth ulcers, treat with gentian violet
What are your actions? Follow-up in 3 days
Measles now or within Green: Give Vitamin A treatment
A child classified
the last 3 months. as having very severe febrile disease needs urgent pre-referral
MEASLES
treatment and referral. You will learn about pre-referral treatment in the next
section.
temperature readings are approximately 0.5°C higher.
t tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
ALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.
ridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.
21
Page 7 of 75
MALARIA (YELLOW)
A child with a fever, a positive malaria test, and NO general danger sign or stiff
neck is classified as having MALARIA. This is the same for both high and low risk
malaria areas.

It is critical to provide antimalarial treatment for the child. You will also give
paracetamol for high fever. This child should be followed up in 3 days. Remember
that if the fever has been present for longer than 7 days, the child should be referred.
FEVER: NO MALARIA (GREEN)

In a low malaria risk area, a child with a malaria test negative or no other clinical
signs of other possible infection is classified as having FEVER: NO MALARIA.

If the child’s fever is 38.5 °C, give paracetamol. You will also treat for any other
causes of fever. If the fever has been present every day for more than 7 days, refer
for assessment. If the fever persists for 2 days, the caregiver should return.
Answer the questions below about assessing and classifying fever.
1. Should all children with a fever be classified for fever?
2. When will you conduct a malaria test?
3. Which signs indicate that a child has VERY SEVERE FEBRILE DISEASE?
4. Reba has a positive P. vivax test and no general danger signs or stiff neck. She
has a temperature of 38 degrees Celsius.
a. How will you classify?
b. Reba requires oral antimalarials and paracetamol. TRUE or FALSE

5. TRUE or FALSE: a child lives in a low malaria risk area. You will never need to
conduct a malaria test for this child.
22
Malaria test POSITIVE.*** Yellow: Give recommended first line oral
MALARIA antimalarial
MEASLES & COMPLICATIONS days, refer for assessment
HOW DO YOU CLASSIFY
and/or MEASLES?
FEVER: high fever (38.5°C or above)
You previously learned that a child who has aoffever
PRESENT. fever and measles now or within the
last 3 months is classified both for fever and measles.
Advise Open
mother when yourimmediately
to return classification
chart for measles: If fever is present every day for more than 7

If MEASLES now or within Clouding of cornea or COMPLICATED antibiotic
last 3 months, Classify Deep or extensive mouth MEASLES**** If clouding of the cornea or pus draining
ointment
Pus draining from the eye Yellow: Give Vitamin A treatment
or MEASLES WITH EYE If pus draining from the eye, treat eye
Mouth ulcers. OR MOUTH infection with tetracycline eye ointment
Follow-up in 3 days
Measles now or within Green: Give Vitamin A treatment
the last 3 months. MEASLES
temperature readings are approximately 0.5°C higher.
SEVERE
t tender swelling; red tender skin or boils; lower COMPLICATED MEASLES
abdominal pain or pain on passing urine (RED)
in older children.
ALARIA; Low malaria risk AND NOA
obvious
childcause
withofany
fever - classifydanger
general as MALARIA.
sign, clouding of cornea, or deep or extensive mouth
ridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.
ulcers should be classified as having SEVERE COMPLICATED MEASLES.
WhatPage 7 of 75
are your actions?
This child needs urgent treatment and referral to hospital. Before referral, the child
requires Vitamin A treatment and the first dose of an appropriate oral antibiotic.
If there is clouding of the cornea, or pus draining from the eye, apply tetracycline
ointment. If it is not treated, corneal clouding can result in blindness. Ask the
caregiver if the clouding has been present for some time, and if it was assessed and
treated at the hospital. If it was, you do not need to refer the child again for this
eye sign.
MEASLES WITH EYE OR MOUTH COMPLICATIONS (YELLOW)

If the child has pus draining from the eye, or mouth ulcers that are not deep
or extensive, classify the child as having MEASLES WITH EYE OR MOUTH
COMPLICATIONS.

A child with this classification does not need referral. However, early identification
and treatment of measles complications can prevent many deaths. Treat the child
with vitamin A. It will help correct any vitamin A deficiency and decrease the
severity of the complications. Teach the caregiver to treat the child’s eye infection
or mouth ulcers at home. Treating mouth ulcers helps the child resume normal
feeding more quickly.
23
MEASLES (GREEN)
A child with measles now or within the last 3 months and with none of the
complications listed in the top or middle row of the table is classified as MEASLES.
Give the child vitamin A to help prevent measles complications. All children with
measles should receive vitamin A.
n How will you classify Sami’s fever?

You assessed that Sami had a fever by taking his temperature, which was 38.6 degrees. You know his family
lives in a high risk area, so you will use the high malaria risk charts.
Sami did not show signs of a stiff neck. He did not show any general danger signs when you checked him
earlier. Sami had a positive malaria test with the RDT. He did not have a runny nose. He did not have any signs
of other causes of fever. Miriam said that he has not had measles.
n How will you classify Sami?

You classify Sami as having MALARIA. This classification identifies the appropriate treatments, which we will
discuss in the next section.
You will not need to classify Sami for measles. This is because Miriam reported that Sami did not have
measles within the past three months, and he did not show any signs of measles today.
Now you will practice assessing and classifying two case studies for fever and measles. You will be given an
example case to review before you do the two exercises. Then you will learn about appropriate treatments
for febrile disease, malaria, fever, complicated measles, and measles.
Answer the questions below about assessing and classifying measles.
1. When should a child be classified for measles?
2. When you assess a child with fever for measles, what signs will you look for?
3. Allan has a fever and deep, extensive ulcers. How will you classify?
4. Which signs indicate that a child has MEASLES WITH COMPLICATIONS?
24
SELF-ASSESSMENT EXAMPLE
This example will show you how to assess and classify illness in a child with fever.
After this example, you will have two self-assessment exercises to complete
yourself.
Paulo is 10 months old. He weighs 8.2 kg. His temperature is 37.5 °C. His mother
says he has a rash and cough. The health worker checked Paulo for general danger
signs. Paulo was able to drink, was not vomiting, did not have convulsions and was
not lethargic or unconscious. The health worker next asked about Paulo’s cough.
The mother said Paulo had been coughing for 5 days. He counted 43 breaths per
minute. He did not see chest indrawing. He did not hear stridor when Paulo was
calm. Paulo did not have diarrhoea.
Next the health worker asked about Paulo’s fever. The malaria risk is high. The
mother said Paulo has felt hot for 2 days. Paulo did not have a stiff neck. He has
had a runny nose with this illness, his mother said. Paulo had a positive RDT test
for P. falciparum malaria parasites.
Paulo has a rash covering his whole body. Paulo’s eyes were red. The health worker
checked the child for complications of measles. There were no mouth ulcers. There
was no pus draining from the eye and no clouding of the cornea.
1. To classify Paulo’s fever, the health worker looked at the table for
classifying fever:
— He checked to see if Paulo had any of the signs in the pink row. He thought,
“Does Paulo have any general danger signs? No, he does not. Does Paulo have
a stiff neck? No, he does not. Paulo does not have any signs of VERY SEVERE
FEBRILE DISEASE.”
— Next, the health worker looked at the yellow row. He thought, “Paulo has
a fever. His temperature measures 37.5 °C. He also has a history of fever
because his mother says Paulo felt hot for 2 days. He classified Paulo as having
MALARIA.
2. Because Paulo had a generalized rash and red eyes, Paulo has signs
suggesting measles. To classify Paulo’s measles, the health worker looked
at the classification table for classifying measles:
— He checked to see if Paulo had any of the signs in the pink row. He thought,
“Paulo does not have any general danger signs. The child does not have
clouding of the cornea. There are no deep or extensive mouth ulcers. Paulo
does not have SEVERE COMPLICATED MEASLES.”
— Next the health worker looked at the yellow row. He thought, “Does Paulo
have any signs in the yellow row? He does not have pus draining from the
eye. There are no mouth ulcers. Paulo does not have MEASLES WITH EYE
OR MOUTH COMPLICATIONS.”
— Finally the health worker looked at the green row. Paulo has measles, but he
has no signs in the pink or yellow row. The health worker classified Paulo as
having MEASLES.
25
3. Here is how the health worker recorded Paulo’s case information and
signs of illness.

Name: Paulo Age: 10 mo Weight (kg): 8.2 kg Temperature (°C): 37.5 °C
What are the child's problems? Rash, cough
Ask: Initial Visit? X Follow-up Visit?
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
4 Days
___
Look for chest indrawing cough or cold
Yes __ No __
Slowly?
Yes __ No __
X
For how long? ___ 2 Days Look for runny nose
Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Malaria
Look for pus draining from the eye. Measles
Are ___
If Yes, for how long? there
Daysany parts of this form that are confusing to you?
THEN CHECK Revisit
FOR ACUTE MALNUTRITION
the ASSESS section toLook for oedema of both feet.
review clinical signs. You learned that the first step
is to determine the malaria risk. Then6 months
For children you will assess
or older measurefor
MUACcauses of fever. If the
____ mm.
child shows signs of measles, orSeverehas palmar
had measles
pallor? Some within the past 3 months, you
palmar pallor?
will less
If child has MUAC assess for115
than complications.
mm or Is there any medical complication?
Revisit the CLASSIFY section Any
to severe
see howclassification?
you will classify with different tables,
depending on the malaria risk.
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3
26
Hep B0
RTV-1 RTV-2 RTV-3
Record Kareem’s signs and classify all signs assessed on the recording form.
Kareem’s case is from an area of high malaria risk.
Kareem is 5 months old. He weighs 5.2 kg. His axillary temperature is 37.5 °C. His
mother said he is not eating well. She said he feels hot, and she wants a health worker
to help him. Kareem is able to drink, has not vomited, does not have convulsions,
and is not lethargic or unconscious. Kareem does not have a cough, said his mother.
He does not have diarrhoea.
Because Kareem’s temperature is 37.5 °C and he feels hot, the health worker
assessed Kareem further for signs related to fever. It is the rainy season, and the
risk of malaria is high. The mother said Kareem’s fever began 2 days ago. He has
not had measles within the last 3 months. He does not have stiff neck, his nose is
not runny, and there are no signs suggesting measles. He had a positive RDT test
for P. falciparum.

Danger sign when
selecting
classifications
Slowly?
27
Record Dolma’s signs and classify all signs assessed on the recording form.
Dolma’s case is from an area of low malaria risk.
Dolma is 12 months old. She weighs 7.2 kg. Her axillary temperature is 36.5 °C. Her
mother brought Dolma to the health centre today because she feels hot. Dolma has
no general danger signs. She does not have cough or difficult breathing. When asked
about diarrhoea, the mother said, “Yes, Dolma has had diarrhoea for 2 to 3 days.” She
has not seen any blood in the stool. Dolma has not been lethargic or unconscious.
Her eyes are not sunken. She drinks normally. Her skin pinch returns immediately.
The health worker said, “You brought Dolma today because she feels hot. I will check
her for fever.” The risk of malaria is low. Her mother said that Dolma has felt hot
for 2 days. She has not had measles within the last 3 months. There is no stiff neck
and no runny nose. Dolma has a dry, generalized rash. She also has red eyes. She
has a negative malaria test.

Danger sign when
selecting
classifications
Slowly?
28
5.5 TREAT THE CHILD WITH FEVER

HOW WILL YOU TREAT FEVER?
Return to your classification charts for fever and measles. What treatments do you
see in the IDENTIFY TREATMENT columns?
You will review several treatments for fever and malaria in this section:
As you read more about each, follow along with your TREAT THE CHILD charts.
✔✔ Give quinine or artesunate for severe malaria
✔✔ Give paracetamol
✔✔ Give first-line oral antimalarials
✔✔ Give Vitamin A treatment
Some treatments are require counselling the caregiver, so you’ll read in
the next section:
✔✔ Apply eye ointment
✔✔ Treat with gentian violet
You will see that some identified treatments that have been previously
discussed:
✔✔ Give antibiotics
✔✔ Treat for low blood sugar
MALARIA
HOW WILL YOU GIVE QUININE OR ARTESUNATE FOR
SEVERE MALARIA?
A child with VERY SEVERE FEBRILE DISEASE may have severe malaria. To kill
malaria parasites as quickly as possible, give a quinine injection before referral.
Artesunate suppositories are the preferred antimalarials because they are
effective in most areas of the world and they act rapidly.
Possible side effects of a quinine injection are a sudden drop in blood pressure,
dizziness, ringing of the ears, and a sterile abscess. If a child’s blood pressure drops
suddenly, the effect stops after 15–20 minutes. Dizziness, ringing of the ears and
abscess are of minor importance in the treatment of a very severe disease. Use the
table in TREAT chart to determine the dose. Use the child’s weight, if the child can
be weighed.
29
HOW WILL YOU GIVE FIRST-LINE ORAL ANTIMALARIALS

FOR MALARIA?
ACT (artemisinin-based combination therapies) are recommended for treating malaria
WHO now recommends the use of artemisinin-based combination therapies

(ACT), which have been shown to improve treatment efficacy. The advantages
of ACT are that it can very quickly reduce the number of malarial parasites and
improve the symptoms.
WHAT ACTS ARE RECOMMENDED?

The antimalarials to be used for treatment of malaria will depend on the national
policy guidelines. There are several ACT options available. Based on available data
on safety, efficacy, and cost, the following therapies are recommended in prioritized
order:
1. artemether-lumefantrine (CoartemTM)
2. artesunate (3 days) plus amodiaquine
3. artesunate (3 days) plus SP in areas where SP efficacy remains high
4. SP plus amodiaquine in areas where efficacy of both amodiaquine and SP remain
high (this is mainly limited to countries in West Africa).
You will now read the instructions and dosing for two common treatments – numbers
1 and 2 from above. This information is also in your Chart Booklet.
ORAL ARTESUNATE – LUMEFANTRINE (AL)

1. First dose in clinic: Give the first dose of Artesunate – lumefantrine (AL) in
the clinic and observe for one hour. If child vomits within an hour repeat the
dose.
2. Continued doses at home: The second dose is given at home after 8 hours.
Artesunate – lumefantrine (AL) should be taken with food. Then twice daily for
further two days as shown below:
AL TABLETS
(20 mg artemether and 120 mg lumefantrine)
WEIGHT (age) 0h 8h 24h 36h 48h 60h
5–15 kg (2 mo under 3 years) 1 1 1 1 1 1
15–24 kg (4–8 years) 2 2 2 2 2 2
25–34 kg (9–14 years) 3 3 3 3 3 3
Over 34 kg (over 14 years) 4 4 4 4 4 4
30
ORAL ARTESUNATE PLUS AMODIAQUINE (AS+AQ)

This is currently available as a fixed-dose formulation with tablets containing
25/67.5 mg, 50/135 mg or 100/270 mg of artesunate and amodiaquine. Blister
packs of separate scored tablets containing 50 mg of artesunate and 153 mg base
of amodiaquine, respectively, are also available.
1. First dose in clinic: Give first dose in the clinic and observe for an hour, if a
child vomits within an hour repeat dose.
2. Continued doses at home: The child will then require a dose every day for the
following two days as per the table below using the fixed dose combination:
AS+AQ (Fixed Dose formulation tablets)
WEIGHT (age) DAY 1 DAY 2 DAY 3
5 up to 10 kg 1 tablet 1 tablet 1 tablet
(2 mo up to 1 year) (25 mg AS/67.5 mg AQ) (25 mg AS/67.5 mg AQ) (25 mg AS/67.5 mg AQ)
10 up to 18 1 tablet 1 tablet 1 tablet
(1–5 years) (50 mg AS/135 mg AQ) (50 mg AS/135 mg AQ) (50 mg AS/135 mg AQ)
18 up to 36 kg 1 tablet 1 tablet 1 tablet
(6–13 years) (100 mg AS/270 mg AQ) (100 mg AS/270 mg AQ) (100 mg AS/270 mg AQ)
36 kg or more 2 tablets 2 tablets 2 tablets
(14 years or older) (100 mg AS/270 mg AQ) (100 mg AS/270 mg AQ) (100 mg AS/270 mg AQ)
31
Answer the following questions about oral antimalarials treatment.
1. Why are chloroquine and Sulfadoxine-pyrimethamine (SP) no longer the first-line
and second-line antimalarial medicines recommended in the IMCI guidelines of
many countries?
2. What does the WHO recommend for oral antimalarial treatment?
3. Explain how the following children should receive treatment:

a. 10 kg child, 6 months old, AL (20 mg/120 mg):
b. 12 kg child, AS+AQ:
c. 33 kg child, 12 years old, AL (20 mg/120 mg):
4. What special instructions are given with AL?
32
FEVER
HOW WILL YOU GIVE PARACETAMOL FOR HIGH FEVER
(OVER 38.5 DEGREES OR ABOVE)?
Paracetamol lowers a fever and reduces pain. If a child has high fever, regardless
of the classification, give one dose of paracetamol in clinic. See the TREAT THE
CHILD charts for doses.
MEASLES
HOW WILL YOU GIVE VITAMIN A TREATMENT?
Vitamin A is given to a child with MEASLES or SEVERE MALNUTRITION. Vitamin
A is available in capsule and syrup. Use the child’s age to determine the dose. Give
2 doses.
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.
Give the first dose to the child in the clinic. Give the second dose to the mother
to give her child the next day at home. If the vitamin A in your clinic is in capsule
form, make sure the child swallows it whole. If the child is not able to swallow a
whole capsule or needs only part of the capsule, open the capsule. Tear off or cut
across the nipple with a clean tool. If the vitamin A capsule does not have a nipple,
pierce the capsule with a needle.
Record the date each time you give vitamin A to a child. This is important. If you give
repeated doses of vitamin A in a short period of time, there is danger of an overdose.
HOW WILL YOU TREAT LOCAL INFECTIONS?

Local infections include the eye infection and mouth ulcers that measles
might cause. You will learn more in the next section about teaching a caregiver
to treat eye infection with tetracycline eye ointment and treat mouth ulcers with
gentian violet.
Some treatments for local infections cause discomfort. Children often resist having
their eyes, ears or mouth treated. Therefore, it is important to hold the child still.
This will prevent the child from interfering with the treatment. However, do not
attempt to hold the child still until immediately before treatment.
If the child is not being referred, and if the child has eye infection, ear infection,
mouth ulcers, cough or sore throat, teach the child’s mother or caregiver to treat
the infection at home.
If the child will be referred, and the child needs pre-referral treatment with
tetracycline eye ointment, clean the eye gently. Pull down the lower lid. Squirt the
first dose of tetracycline eye ointment onto the lower eyelid. The dose is about the
size of a grain of rice.
33
n How will you treat Sami?

You have classified Sami’s fever as MALARIA. The classification table identifies the following treatments for
Sami:
✔✔ Antimalarials
✔✔ One dose paracetamol in clinic for high fever – Sami will need this, because his fever is 38.6 degrees.
Paracetamol is recommended for 38.5 degrees and above.
✔✔ You will advise Miriam when to return immediately and when to follow-up
You explain to Miriam that you think Sami has malaria, but that he can easily be treated with an oral
medication. You also tell her that you will also give him some medicine to bring down his high fever. This
should help him start to feel better.
n How will you give Sami paracetamol?

You will refer to your TREAT THE CHILD chart about pain relief medications to determine the dosage of
paracetamol. Sami is 3 years old and 12 kg. What dosage will you give?
WEIGHT AGE PARACETAMOL (120 mg/5 mls)

12 up to 14 kg 2 up to 3 years 7.5 ml
You decide that Sami needs 7.5 ml of 120 mg/5 mls paracetamol. You give this to him now. Miriam looks
very relieved and holds Sami’s hands. She asks how she will be able to give the antimalarials. She says she
is nervous to do this and will need instructions, and she is worried about harming Sami with medication
because he is grown. You tell her that you will walk her through this all.
n How will you give Sami antimalarials?

You stress that it will be very important for her to give him the medication properly at home. You have
Artesunate-lumefantrine (AL) in the clinic so you will explain how to give this medication. What dosage of AL
tablets (20 mg artemether and 120 mg lumefantrine) will you give him?
AL tablets (20 mg artemether and 120 mg lumefantrine)

WEIGHT (age) 0h 8h 24h 36h 48h 60h
5–15 kg (2 mo under 3 years) 1 1 1 1 1 1
You will give the first dose of AL in the clinic and observe for one hour. You show Miriam how to
measure the dosage, and give Sami the medication. You ask her to practice, and then you ask her to give
the first dose in the clinic. You explain that you will watch him for 1 hour to make sure he does not vomit the
medication up.
Sami does not vomit, so you do not need to repeat the dose. You instruct Miriam to give the second dose at
home in 8 hours. You tell her to give the same dose twice each day for the next two days. AL should be given
with food.
Sami will then require additional tablets for the next two days. This is shown in the table above.
You will learn in the next section how to counsel further Miriam about Sami’s care and when to return to the
clinic, and you will check her understanding.
34

DO YOU REMEMBER THE IMPORTANT STEPS WHEN
COUNSELLING A CAREGIVER?
Review the topics that you will always discuss with a caregiver:
In this section, you will learn about home treatments for fever and measles,
and when a child should return to the clinic. The good communication skills
you have learned previously are very important for the teaching you will be doing.
HOME TREATMENTS
Giving oral medicines, treating local infections
FEEDING & FLUIDS

Feeding problems, during illness, breastfeeding
FOLLOW-UP
WHEN TO RETURN
IMMEDIATELY
CAREGIVER’S HEALTH and OTHER CARE
HOW WILL YOU COUNSEL ON GIVING ORAL ANTIMALARIALS?

Antimalarials will be given with the same steps that we reviewed for oral medicines
in Module 4 on cough or difficult breathing. Let us review the steps for counseling
a caregiver about giving oral medicines at home:
1. DETERMINE APPROPRIATE MEDICINES & DOSAGE – for child’s weight
and age. You will determine this based on oral antimalarials in your country.
2. EXPLAIN TREATMENT – tell caregiver what the drug is, and why you are
giving it. Explain the treatment steps as described in the appropriate TREAT
THE CHILD box.
3. DEMONSTRATE how to measure a dose
4. LET HER PRACTICE – watch the caregiver practice measuring a dose by herself
5. ASK CAREGIVER TO GIVE FIRST DOSE to the child
6. EXPLAIN DRUG CAREFULLY, THEN LABEL AND PACKAGE – you would
also give the caregiver a tube of tetracycline ointment for the eyes or a small
bottle of gentian violet for mouth ulcers.
7. CHECK UNDERSTANDING
35
HOW WILL YOU TREAT EYE INFECTIONS WITH TETRACYCLINE

EYE OINTMENT?
If the child will be URGENTLY referred, clean the eye gently.
Pull down the lower lid. Squirt the first dose of tetracycline
eye ointment onto the lower eyelid. Dose size = grain of rice
If the child is not being referred, teach the caregiver to

apply the tetracycline eye ointment. Refer to the TREAT
THE CHILD chart and give the caregiver the following information.
The dose is about the size of a grain of rice.
GIVE INFORMATION. Tell the caregiver:
✔✔ Treat both eyes to prevent damage to the eyes
✔✔ Wash her hands before and after treating the eye.
✔✔ Clean the child’s eyes immediately before applying the tetracycline eye ointment.
Use a clean cloth to wipe the eye.
✔✔ The ointment will slightly sting the child’s eye
✔✔ Repeat the process (cleaning the eye and applying ointment) 3 times per day – in
the morning, at mid-day and in the evening.
DEMONSTRATE how to treat the eye.
✔✔ Wash your hands
✔✔ Hold down the lower lid of 1. Give information
your eye. Point to the lower
lid. Tell the caregiver that
this is where she should
apply the ointment. Tell her
2. Show an example
to be careful that the tube
does not touch the eye or lid. 3. Let caregiver practise
✔✔ Have someone hold the child
still.
✔✔ Wipe one of the child’s eyes
with the cloth. Squirt the ointment onto the lower lid. Make sure the caregiver
sees where to apply the ointment and the correct dose (rice grain).
ASK CAREGIVER TO PRACTICE cleaning and applying the eye ointment into
the child’s other eye. Observe and give feedback as she practices.
When she is finished, give her the following additional information.
•• Treat both eyes until the redness is gone from the infected eye. The infected eye
is improving if there is less pus in the eye or the eyes are not stuck shut in the
morning.
•• Do not put any other eye ointments, drops or alternative treatments in the
child’s eyes. They may be harmful and damage the child’s eyes. Putting harmful
substances in the eye may cause blindness.
•• After 2 days, if there is still pus in the eye, bring the child back to the clinic.
36
Then give the caregiver the tube of ointment to take home. Give her the
same tube you used to treat the child in the clinic. Before the caregiver leaves, ask
checking questions about treating the eye. For example, ask: “Will you treat one
or both eyes?” or “How much ointment you will put in the eye?”
HOW WILL YOU TREAT MOUTH ULCERS WITH GENTIAN VIOLET?

Treating mouth ulcers controls infection and helps the child to eat. Teach the
caregiver to treat mouth ulcers with half-strength gentian violet (.25%), which
should be used in the mouth, not full-strength (0.5%).
1. GIVE INFORMATION. Tell the caregiver:
✔✔ A child will start eating normally sooner if she paints the mouth ulcers in her
child’s mouth. It is important that the child eats.
✔✔ Clean the child’s mouth. Wrap a clean soft cloth around her finger. Dip it in salt
water. Wipe the mouth.
✔✔ Use a clean cloth or a cotton-tipped stick to paint gentian violet on the mouth
ulcers. The gentian violet will kill germs that cause the ulcers. Put a small amount
of gentian violet on the cloth or stick. Do not let the child drink the gentian violet.
✔✔ Treat the mouth ulcers 2 times per day, in the morning and evening.
✔✔ Treat the mouth ulcers for 5 days and then stop.
2. SHOW how to wrap a clean cloth around your finger, dip it into salt water, and
wipe the child’s mouth clean. Then paint half of the child’s mouth with half-
strength gentian violet.
As you have read, some treatments for local infections
cause discomfort. The drawing on the right shows a good
position for holding a child. Tilt the child’s head back when
applying eye ointment or treating mouth ulcers. Do not attempt
to hold the child still until immediately before treatment.
3. ASK CAREGIVER TO PRACTICE. Watch her wipe the child’s
mouth clean and paint the rest of the ulcers with gentian violet.
Comment on the steps she did well and those that need to be
improved.
Give the caregiver a bottle of half-strength gentian violet
to take home. Tell her to return in 2 days for follow-up. Also
tell her that she should return to the clinic earlier if the mouth
ulcers get worse or if the child is not able to drink or eat.
Before the caregiver leaves, ask checking questions. If she anticipates any
problems providing the treatment, help her to solve them. For example, ask:
“What will you use to clean the child’s mouth?”
“When will you wash your hands?”
“How often will you treat the child’s mouth?”
“For how many days?”
37
WHEN SHOULD A CHILD WITH FEVER RETURN TO THE CLINIC?

MALARIA … in 3 days if the fever persists
FEVER: NO MALARIA … in 2 days if the fever persists
MEASLES … in 2 days
Any sick child Should return immediately if they:

✔ are not able to drink or breastfeed
✔ become sicker
Answer the following questions about counselling a caregiver about fever.
1. What are the 3 basic teaching steps?
2. What are important instructions for the caregiver about treating the eye with
ointment? List 5 that you can think of from the information you provide the
caregiver, and when you would demonstrate how to put the ointment on.
3. When should children with FEVER: NO MALARIA return for follow-up? Pick
the best answer below.
a. The next day
b. 3 days, after antimalarials are finished
c. 2 days, if the fever persists
4. When should children with measles and eye or mouth complications return for
follow-up? Pick the best answer below.
a. The next day
b. 4 days, if signs of measles (rash, runny nose, red eyes) persist
c. 3 days
38
n How will you counsel Miriam?

Now you will review how to counsel Miriam about home care to treat Sami’s malaria.
Sami will need oral antimalarials for his malaria. You will give AL. Let us review the treatment guidelines for
AL now:
AL is given twice daily for 3 day.
He weighs 12 kg, so give Sami tablets of AL for 3 days. He should get 1 tablet (Artemether-lumefantrine) at
the clinic, another dose after 8 hours on the first day, then 1 tablet twice daily on the second and third day.
n What important information does Miriam require?

You tell Miriam that Sami will need to take the medication for 3 days, and explain how she will give 1 tablet 8
hours after the first dose given at the clinic, and then 1 tablet twice daily for the next two days.
Demonstrate how to give Sami the medication, and ask her to practice measuring the dosage.
You tell Miriam to watch Sami carefully for 30 minutes after she gives the AL. If he vomits within 30 minutes,
she should repeat the dose. She will need to return to the clinic for extra doses.
You will also need to counsel Miriam on Plan A for home treatment of diarrhoea.
n How will you check that Miriam understands?

You finish by asking checking questions about the home treatment.
You ask, “How will you give the tablets? What is the schedule?”
You ask, “What should you do after giving the tablets to Sami?”
You ask, “How will you mix the ORS?”
You ask, “How will you give the zinc?”
Miriam answers the questions well.
n When should Sami return?

You tell Miriam that she should bring Sami back in 3 days if his fever continues, or in 5 days if his diarrhoea
is continuing. You take Miriam’s Mother’s Card and review when she should bring Sami back immediately if
danger signs develop.
Miriam takes the AL tablets, zinc supplements, and two packets of ORS. She thanks you for your help.
39
5.7 PROVIDE FOLLOW-UP CARE

Open your Chart Booklet and review the boxes on follow-up care. What do
you observe? You will use these instructions when a child returns for a follow-up
visit for a persistent fever, measles, or other cause of fever. The follow-up boxes also
describe treatment.
REMEMBER!
If a fever has been present for 7 days or longer, refer the child for
assessment. This child may have typhoid fever or another serious infection
requiring additional diagnostic testing and special treatment.
FEVER: NO MALARIA
HOW DO YOU FOLLOW UP ON FEVER IF PERSISTS AFTER 3 DAYS?
If this child returns for follow-up after 3 days because the fever persists, follow the
instructions below.
1. Do a full reassessment of the child, assessing for other causes of fever
2. Do a malaria test with RDT or microscopy
 MALARIA TEST IS POSITIVE

Treat with recommended first-line oral antimalarial. Advise the caregiver to return
again in 3 days if the fever persists.
 CHILD HAS ANOTHER CAUSE OF FEVER, BESIDES MALARIA

If the child has any cause of fever other than malaria, provide treatment for that
cause.
 CHILD HAS GENERAL DANGER SIGN(S) OR STIFF NECK

If the child has any general danger signs or stiff neck, treat as described on the
chart for VERY SEVERE FEBRILE DISEASE. Refer to the previous page to review
this treatment.
MALARIA
HOW WILL YOU FOLLOW-UP MALARIA (IF FEVER PERSISTS 3 DAYS)?
Any child classified as having MALARIA should return for follow-up if the fever
persists for 3 days. If a child classified with MALARIA returns with a fever within
14 days of receiving treatment, you will provide the same follow-up care.
40
If a child returns because the fever persists after 3 days, or within 14 days:
✔✔ Do a full reassessment of the child, assessing for other causes of fever
If the child also had measles or any other cause of fever at the initial visit, the
fever may be due to the measles or another cause. This will require further
assessment and possible laboratory investigations. It is very common for the
fever from measles to continue for several days. Therefore, the persistent fever
may be due to the measles rather than to resistant malaria.
 CHILD HAS GENERAL DANGER SIGN(S) OR STIFF NECK

If the child has any general danger signs or stiff neck, treat as described on the chart
for VERY SEVERE FEBRILE DISEASE. Refer urgently to hospital.
If the child has already been on an antibiotic, the illness worsening to very severe
febrile disease might mean there is a bacterial infection that is not responsive
to this antibiotic. Give a first dose of the second-line antibiotic or intramuscular
chloramphenicol.
If the child cannot take an oral antibiotic because he has repeated vomiting, is
lethargic or unconscious, or is not able to drink, give intramuscular chloramphenicol.
Also give intramuscular chloramphenicol if he has a stiff neck.
✔✔ Do a malaria test with RDT or microscopy
It is very unusual for the fever due to malaria to persist for 3 days after the initial
visit or fever to return within 14 days of receiving ACT treatment. Therefore, a
blood test using microscopy should be done to confirm that malaria parasites are
resistant to the first-line ACT antimalarial before giving an effective second-line
ACT treatment.
 MALARIA TEST POSITIVE

Treat with second-line oral antimalarial. Ask the caregiver to return again in 3
days if the fever persists. If second line oral antimalarial is not available, refer the
child to hospital.
Note: If a child had a positive malaria test on the initial visit, the commonly used
HRP-2-based RDT tests will remain positive for even up to 3 weeks after effective
treatment. Therefore only microscopy should be used to identify malaria parasites
on follow up after initial treatment malaria. HRP-2 based RDT tests should not be
repeated if fever persists or returns within 14 days. Check on the type of RDT you use
in your clinic and how long the test remains positive.
 CHILD HAS ANOTHER CAUSE OF FEVER, BESIDES MALARIA

If the child has any cause of fever other than malaria, provide treatment for that
cause. For example, give treatment for the ear infection or refer for other problems
such as urinary tract infection or abscess.
41
Read about Lin, who is returning for follow-up for MALARIA. Answer the questions.
In this clinic, Artemether-lumefantrine (AL) is the first-line oral antimalarial (20 mg
artemether and 120 mg lumefantrine). Artesunate plus Amodiaquine is the second-line
oral antimalarial.
Lin’s mother has brought him back to the clinic because he still has fever. The risk
of malaria is high. Two days ago he was given AL for MALARIA. He was also given
a dose of paracetamol. His mother says that he has no new problems, just the fever.
He is 3 years old and weighs 14 kg. His axillary temperature is 38.5 °C.
1. How would you reassess Lin?
When you reassess Lin, he has no general danger signs. He has no cough and no
diarrhoea. He has now had fever for 4 days. He does not have stiff neck. There is no
runny nose or generalized rash. Microscopy slide for malaria parasites is positive.
He has no ear problem. He is classified as having NO ANAEMIA AND NOT VERY
LOW WEIGHT. There is no other apparent cause of fever.
2. How would you treat Lin? If you would give a drug, specify the dose and schedule.
Read about Sindi, who is returning for follow-up for MALARIA. Answer the
questions.
Sindi’s mother has come back to the clinic because Sindi still has a fever. Three days
ago she had a positive rapid malaria test and was given treatment for MALARIA.
Her mother says that she is sicker now, vomiting and very hot. Sindi is 18 months
old and weighs 11 kg. Her axillary temperature is 39 °C today.
When you assess Sindi, her mother says that yesterday she could drink, but she
vomited after eating. She did not always vomit after drinking a small amount. She
has not had convulsions. She will not wake up when her mother tries to wake her.
She is unconscious. Her mother says that she does not have a cough or diarrhoea.
She has now had fever for 5 days. She does not have stiff neck, runny nose or
generalized rash.
3. How will you manage Sindi?
42
MEASLES
HOW WILL YOU FOLLOW-UP ON MEASLES WITH COMPLICATIONS
(IN 2 DAYS)?
When a child who was classified as having MEASLES WITH EYE OR MOUTH
COMPLICATIONS returns for follow-up in 2 days, you will check the eyes and
mouth. You will select treatment based on the signs.
Follow these instructions:
1. Look for red eyes and pus draining from the eyes
2. Look at mouth ulcers
3. Smell the mouth
EYE INFECTIONS
 NO PUS OR REDNESS
Stop the treatment. Praise the caregiver for treating the eye well. Tell her the
infection is gone.
 PUS IS GONE, BUT REDNESS REMAINS

Continue the treatment. Tell the caregiver that the treatments are helping.
Encourage her to continue giving the correct treatment until the redness is gone.
 PUS IS STILL DRAINING FROM EYE

Ask the caregiver to describe or show you how she has been treating the eye infection.
If she has brought the tube of ointment with her, you can see whether it has been
used.
There may have been problems so that the caregiver did not do the treatment
correctly. For example, she may not have treated the eye three times a day, or she
may not have cleaned the eye before applying the ointment, or the child may have
struggled so that she could not put the ointment in the eye.
If the caregiver has not correctly treated the eye, ask her what problems
she had in trying to give the treatment. Teach her any parts of the treatment
that she does not seem to know. Discuss with her how to overcome difficulties she
is having. Finally, explain to her the importance of the treatment. Ask her to return
again if the eye does not improve. However, if you think that the caregiver still will
not be able to treat the eye correctly, arrange to treat the eye each day in clinic or
refer the child to a hospital.
If the caregiver has correctly treated the eye infection for 2 days and there
is still pus draining from the eye, refer the child to a hospital.
43
MOUTH ULCERS
 ULCERS ARE WORSE, OR VERY FOUL SMELL FROM MOUTH
Refer to hospital. The mouth problem may prevent the child from eating or drinking
and may become severe. A very foul smell may mean a serious infection. Mouth
problems could be complicated by thrush or herpes, which is the virus which causes
cold sores.
  ULCERS ARE SAME or BETTER

Ask the caregiver to continue treating the mouth with half-strength gentian
violet for a total of 5 days. She should continue to feed the child appropriately to
make up for weight lost during the acute illness and to prevent malnutrition.
Review with the caregiver when to seek care and how to feed her child as described
on the COUNSEL THE MOTHER chart. Tell her that attention to feeding is especially
important for children who have measles because they are at risk of developing
malnutrition.
The child with measles continues to have increased risk of illness for
months, it is important that the caregiver know the signs to bring the
child back for care. Children who have measles are at increased risk of developing
complications or a new problem. This is due to immune suppression that occurs
during, and following, measles.
n How will you provide follow-up for Sami?

You classified Sami’s fever as MALARIA, and gave Miriam AL tablets to give to Sami for 3 days. You counselled
her on how to safely give this treatment at home, and instructions on when to return to the clinic if the fever
continued.
Fortunately, you did not see Miriam or Sami in the days following their visit, which hopefully means
the medication worked well and Sami’s fever reduced within 3 days.
As you instructed Miriam how to give the medication, and how to monitor Sami closely, this would have well-
equipped her to deliver the medication and not return to the clinic with concern over these common issues.
n What if Sami had come to the clinic for follow-up?

However, in the case that Sami’s fever had continued for 3 days, and Miriam had returned to the clinic, you
would have needed to do a full re-assessment.
As you reassess a child in this situation, look for the cause of the fever, possibly pneumonia, meningitis,
measles, ear infection, or dysentery. Also consider whether the child has any other problem that could cause
the fever, such as tuberculosis, urinary tract infection, osteomyelitis or abscess.
44

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU
HAVE GAINED FROM THIS MODULE IN MANAGING CHILDREN
WITH FEVER?
In the coming days, you should focus on these key clinical skills. Practicing these
skills will help you to better understand how to use IMCI for fever and measles.
MALARIA & MEASLES

✔✔ Determine if your area is high or low malaria risk. Does this change by season?
Are there nearby areas that are of a different risk setting – in case any of your
patients travel from there, or recently travelled?
✔✔ Determine what capacity you have to do malaria tests in your facility (e.g.
microscopy or Rapid Diagnostic Tests). What tests are available, and what is
the procedure?
✔✔ If you have a case of measles, what are the national reporting procedures for
measles outbreaks (if any)?
ASSESS
✔✔ Determine if children have fever by taking their temperature, feeling if they are
hot, or examining their history of fever.
✔✔ Look and feel children for stiff neck
✔✔ Look for runny nose
✔✔ Look for signs of measles – generalized rash, cough, runny nose, or red eyes
✔✔ Look for signs of complications from measles – mouth ulcers, pus draining from
eye, and clouded cornea
CLASSIFY
✔✔ Use your chart booklet to classify fever in high and low malaria risk areas
✔✔ Use your chart booklet to classify any complications if children have measles,
or have had measles within the past 3 months
TREAT
✔✔ Determine how to give urgent treatment for very severe febrile disease
✔✔ Determine what antimalarials you have available to you. Determine what dosages
you have, and which are appropriate for certain weight/age groups
✔✔ Practice giving oral antimalarials
✔✔ Practice giving paracetamol for high fever
✔✔ Practice giving Vitamin A treatment
COUNSEL
✔✔ Teach a caregiver how to give antimalarials, eye ointment, and violet gentian
✔✔ Counsel a caregiver about when to return for follow-up for fever or complications
✔✔ Counsel a caregiver about when to return immediately
45

46

MANAGING FEVER?
1. Which of the following children has a fever that requires further investigation?
a. Imrana has an axillary temperature of 37 °C
b. Joy’s mother says she has been feeling very hot for the past three days
c. Samuel’s face is very flushed and red
2. What are common causes of fever that often kill children?
a. Local infection and malaria
b. Meningitis and influenza
c. Measles and malaria
3. What is a critical treatment for reducing high fever in children?
a. Paracetamol
b. Amoxicillin or another antibiotic
c. Fluids
4. What is recommended treatment for malaria?
a. Chloroquine
b. Artemisinin-based combination therapies
c. Paracetamol
5. Traci has a fever, generalized rash, runny nose, and mouth ulcers. How you would
you classify?
a. She shows signs local infections of the skin
b. She shows clinical signs of AIDS
c. Measles with mouth complications
47
5.10 ANSWER KEY

REVIEW QUESTIONS
QUESTION ANSWER
1 B INTRODUCTION, ASSESS
2 C INTRODUCTION
3 A CLASSIFY, TREAT
4 B TREAT
5 C ASSESS, CLASSIFY
EXERCISE A (ASSESS & CLASSIFY)

1. YES. Children who have a fever AND signs of measles will also be assessed for measles.
2. In high risk areas, all children with fever; in low risk areas, any child without another
clear cause of fever
3. Fever and any general danger sign OR stiff neck
4. Reba answers:
a. MALARIA
b. FALSE: she requires oral antimalarials, but not paracetamol because her fever is
not high fever (38.5 degrees C)
5. FALSE. The child may require a malaria test in two scenarios: (a) the child has no other
clear cause of fever, or (b) if the child travelled to a high risk malaria area within 2
weeks.
EXERCISE B (ASSESS & CLASSIFY)

1. If the child has a fever and shows signs of measles now, or has had measles in the
last 3 months.
2. First you look for a generalized rash. If this is present, the child should also have one
of the following signs: cough, runny nose, or red eyes.
3. SEVERE COMPLICATED MEASLES
4. Signs of measles, and also pus draining from eye or mouth ulcers
48
EXERCISE C (KAREEM)

Name: Kareem Age: 5 mo Weight (kg): 5.2 kg Temperature (°C): 37.5 °C
What are the child's problems? Not eating well, feels hot
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
Yes __ No __
Slowly?
Yes __ No __
X
Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Malaria
High risk: all fever cases positive
Low risk: if NO obvious cause of fever P. falciparum
Hep B0 49
RTV-1 RTV-2 RTV-3
EXERCISE D (DOLMA)

Name: Dolma Age: 12 mo Weight (kg): 7.2 kg Temperature (°C): 36.5 °C
What are the child's problems? Feels hot
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
4 Days
___
Yes __ No __
2-3 Days
For how long? ___ Look at the childs general condition. Is the child:
Diarrhoea, no
Not able to drink or drinking poorly? dehydration
Slowly?
Yes __ No __
X
Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Measles
(Date)
Hep B0 Hep B1 Hep B2 Hep B3
50
RTV-1 RTV-2 RTV-3
EXERCISE E (TREAT)
1. Resistance to chloroquine is emerging and growing, and now resistance to SP is
growing as well.
2. WHO now recommends the use of artemisinin-based combination therapies (ACT),
which have been shown to improve treatment efficacy. The advantages of ACT are
that it can very quickly reduce the number of malarial parasites and improve the
symptoms.
3. Explain how the following children should receive treatment:
a. 10 kg child, 6 months old, AL (20 mg/120 mg): 1 tablet given twice a day for next
two days (at 0 hours, 12, 24, 36, 48, and 60)
b. 12 kg child, AS+AQ: 1 tablet (50 mg AS/135 mg AQ) each day for 3 days
c. 33 kg child, 12 years old, AL (20 mg/120 mg): 4 tablets given twice a day for next
two days (at 0 hours, 12, 24, 36, 48, and 60)
4. First dose in clinic, and observe for 1 hour. If child vomits within the hour, repeat
the dose. Give second dose at home 8 hours later. Must be taken with food.
EXERCISE F (COUNSEL)
1. Give information, 2. demonstrate, 3. ask caregiver to practice
2. Answers can include any of the following tips:
✔✔ Dose of tetracycline eye ointment is the size of a grain of rice
✔✔ Treat both eyes
✔✔ Wash hands before and after treating eye
✔✔ Clean child’s eyes before applying ointment – use a clean cloth to wipe the eye
✔✔ Do not touch the tube to the eye or lid when applying the ointment
✔✔ Put the ointment in the lower lid of the eye. Hold the lid down.
✔✔ Apply dose of ointment 3 times per day – in the morning, afternoon, and evening
✔✔ Treat until redness is gone from eyes
✔✔ If pus remains after 2 days, return to clinic
✔✔ Do not put other drops, ointments, or treatments in the eye. They might harm
the child’s eyes.
3. B: 3 days if fever persists
4. C: 3 days
EXERCISE G (FOLLOW-UP)
1. Today you will test Lin again for malaria, and assess for other causes of fever using
the instructions in your charts.
2. Lin has tested positive for malaria again. You will need to give him the second-line
treatment, which is Artesunate plus Amodiaquine. You will give him the first dose
in the clinic: 1 tablet (50 mg AS/135 mg AQ). He will require the same dose, once
daily, for the next two days.
3. Do a full reassessment as on the ASSESS & CLASSIFY chart. You classify as VERY SEVERE
FEBRILE DISEASE. Sindi must be referred urgently because she has a general danger
sign. You will give the first doses of an antimalarial, the first dose of an appropriate
antibiotic, and one dose of paracetamol. You also need to treat for low blood sugar,
but Sindi is unconscious. If you can provide by NG tube you will. Refer urgently.
51
ISBN 978 92 4 150682 3
IMCI
Module 6
Malnutrition
and anaemia
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA
n CONTENTS
Acknowledgements 4
6.2 Opening case study 8
6.3 Introduction to malnutrition 10
6.4 Assess malnutrition 13
6.5 Classify malnutrition 27
6.6 Treat malnutrition 31
6.7 Assess & classify anaemia 36
6.8 Treat anaemia 40
6.9 Provide follow-up care for nutrition 44
6.12 Answer key 49
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
6.1 MODULE OVERVIEW

As malnutrition is an underlying cause of much illness, this is a very important
assessment. Review the chart below to refresh on when this assessment comes in
the IMCI process:
check for general danger signs, assess and classify for main symptoms, then
CHECK ALL CHILDREN FOR MALNUTRITION AND ANAEMIA
ASSESS & CLASSIFY nutrition status for all children.
CHECK immunization status and other problems. Assess caregiver’s health.

✔✔ Explain why it is necessary to check all children for malnutrition and anaemia
✔✔ Determine weight for height/length
✔✔ Measure a child’s mid-upper arm circumference (MUAC)
✔✔ Recognize clinical signs of severe acute malnutrition
✔✔ Conduct an appetite test for child with acute malnutrition
✔✔ Recognize clinical signs of anaemia
✔✔ Classify malnutrition and anaemia using IMCI charts
✔✔ Provide ready-to-use therapeutic foods (RUTF) and counsel the caregiver on
giving
✔✔ Distribute iron and mebendazole
✔✔ Counsel caregivers on home treatments
✔✔ Follow-up a child with malnutrition or anaemia according to IMCI guidelines
5
Has child had measels within One of these: cough, runny nose, or red eyes
IMCItheDISTANCE
last 3 months?
LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA
YOUR
If the child has RECORDING
measles now or within FORM
the Look for mouth ulcers.
Look at your IMCI recording form
Look forfor
pus the sick
draining fromchild.
the eye. This section deals with this
module:
MODULE ORGANIZATION
Is the childThis modulenow?
breastfeeding follows the IMCI process. It will first discuss IMCI for malnutrition:
If breastfeeding: Is the mother
✔✔ CHECK ALL andCHILDREN
child on ARV prophylaxis?
FOR MALNUTRITION AND ASSESS
BCG ✔ CLASSIFY MALNUTRITION
✔DPT+HIB-1 DPT+HIB-2 DPT+HIB-3
Mebendazole ________________
OPV-0 OPV-1 OPV-2 OPV-3
Hep B0
✔ TREAT
✔RTV-1 MALNUTRITION
RTV-2 RTV-3
Then it will discuss IMCI for anaemia:
✔✔ CHECK ALL CHILDREN FOR ANAEMIA
✔✔ CLASSIFY ANAEMIA
✔✔ TREAT ANAEMIA Page 65 of 75
And finally you will learn how to provide follow-up care for nutrition concerns:
✔✔ FOLLOW-UP CARE FOR NUTRITION
6
BEFORE YOU BEGIN

What do you know now about managing malnutrition and anaemia?
Circle the best answer:
1. When is it necessary to check a child for malnutrition and anaemia?
a. Check if the child appears low weight for age
b. Check every child for malnutrition and anaemia, as sometimes problems go
unnoticed
c. Check if the caregiver tells you about a feeding problem
2. Sami has a MUAC measurement of 112 mm. What does this tell you?
a. Sami is healthy
b. 112 mm is low weight, so you will advise on feeding recommendations
c. Sami is showing a sign of severe acute malnutrition
3. A child with anaemia needs:
a. Vitamin A
b. Iron
c. Glucose
4. Traci shows oedema in her feet. What are your actions?
a. Sit Traci and elevate her legs, to drain the swelling
b. Advise Traci’s mother to cut down the salts and fats in her child’s diet
c. Urgently refer, as this is a sign of severe malnutrition
5. What is palmar pallor?
a. A sign of anaemia
b. A sign of local infection
c. A sign of severe wasting
6. What is marasmus?
a. A common skin infection in malnourished children
b. A type of malnutrition where the child is very thin and lacks fat
c. A type of malnutrition where the child has a puffy moon face and thin hair
7. Which of the following in an important measurement of wasting?
a. Weight-for-age
b. Percentage weight gain since last visit
c. Weight-for-height (or length)
7
6.2 OPENING CASE STUDY

This will help you start thinking about the problem of a child with malnutrition
or anaemia.
n OPENING CASE STUDY – NOAH

A young mother, Rachel, brings in her child Noah on a quiet morning in your clinic. You invite them into your
clinic room. Rachel sits Noah on her lap.
Rachel looks tired, and you ask how she came to the clinic this morning. She said she had to wait for a bus to
come. It took a long time. The trip to the clinic is on a rough road and it is hot, so she does not feel very well.
She said she was worried about Noah getting sicker during the long trip.
Then, you examine Noah for possible signs of malnutrition or anaemia. You notice that his skin is very pale.
You look at the skin of his palm and see that it is very pale. You tell Rachel that you are concerned that her
son may have a nutritional deficiency. He can be treated, but she will have to learn about home care.
n First, you gather important information in the greeting.

You praise Rachel for bringing Noah in, especially because the trip is difficult and costs her money. You tell
her that you were good to bring him in, and he is in an important age of growth and development, so it is
good that we make sure he is healthy.
You ask how old Noah is, and Rachel tells you he is 2 years old and 4 months. You ask what his problem is,
and she tells you that he has had a cough for 3 days. You ask about the initial visit, and she says that this is
their first time to the clinic for the cough. Noah weighs 12.7 kg and his temperature is 37 degrees Celsius.
n Next, you check for general danger signs.

You ask Rachel if Noah is able to drink, and she says yes, with no trouble. He is not vomiting. He has not had
convulsions. You look at Noah’s condition, and he is sitting on Rachel’s lap and kicking his legs against her
skirt. He coughs and looks around the room. Does Noah have any general danger signs?
n Then you will assess Noah for main symptoms.

You will first check for cough or difficult breathing. Rachel already identified Noah’s problem as a cough that
has lasted for 3 days. You count Noah’s breaths in one minute. You count 35 breaths. You check for chest
indrawing and stridor. Noah’s chest wall and abdomen move out when he breathes IN, and you hear no harsh
noises.
How will you assess Noah’s cough? Noah shows no signs of pneumonia. You tell Rachel that you think
Noah’s cough is a cold, and can be treated at home with a safe remedy to soothe the throat and cough. You
tell her that you will teach her about this later.
8
Then you ask Rachel if Noah has had diarrhoea, and she says no. You move to the next symptom, fever.
Noah’s temperature is below the 37.5 degree point for fever. You ask if Noah has felt hot, or if he has had a
fever recently. Rachel says no.
You have assessed Noah for the symptoms we have learned about so far.
n How will you complete Noah’s recording form thus far?

Name: Noah Age: 26 mo Weight (kg): 12.7 kg Temperature (°C): 37 °C
Ask: What are the child's problems? Cough Initial Visit? X Follow-up Visit?
CLASSIFY
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
3
35
___ breaths per minute. Fast breathing? No
Look for chest indrawing Cough or cold
Yes __ No __
Slowly?
Yes __ No __
Nowday?you will learn how to check Noah for malnutrition and anaemia. You check
every child for these
conditions.
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 9
Mebendazole
immunization on:
________________
Hep B0
RTV-1 RTV-2 RTV-3
6.3 INTRODUCTION TO MALNUTRITION

WHY DO YOU CHECK EVERY CHILD FOR MALNUTRITION?
You have previously learned that malnutrition is a major
underlying cause of death and illness in children. Even
children with mild and moderate malnutrition have an increased
risk of death.
You will check all sick children for signs suggesting
malnutrition. This is a very important part of the clinic
visit. A caregiver may bring her child to clinic because the child
has an acute illness. The child may not have specific complaints
that point to malnutrition or anaemia. However, a child can be
malnourished, but you or the child’s family may not notice the
problem.
WHY IS IT SO IMPORTANT TO IDENTIFY CHILDREN WITH

MALNUTRITION?
A child with malnutrition has a higher risk of many types of disease and death.
Even children with mild and moderate malnutrition have an increased risk of death.
More than one out of three child deaths are linked to malnutrition.
Identifying children with malnutrition and treating them can help prevent many
severe diseases and death. Some malnutrition cases can be treated at home. Severe
cases need referral to hospital for special feeding, blood transfusion for severe
anaemia, or specific treatment of a disease contributing to malnutrition.
You have a chance to make a real difference in a child’s health by assessing,
classifying, and treating malnutrition and anaemia.
WHAT CAUSES MALNUTRITION?

There are several causes of malnutrition. They may vary from country to country.
A child whose diet lacks recommended amounts of essential vitamins,
minerals, or other nutrients can develop malnutrition. The child may not
be breastfeeding efficiently or eating enough of the recommended amounts of
nutrients, like proteins and calories. They might not get enough specific vitamins,
such as vitamin A, or minerals, such as iron.
A child who has had frequent illnesses, HIV infection, or tuberculosis can also
develop acute malnutrition. The child’s appetite decreases, and the food that the
child eats is not used efficiently.
Now you will read more about severe acute malnutrition.
Malnutrition develops when a child’s diet lacks amounts of essential vitamins,

minerals and other nutrients. Illness and disease can often cause malnutrition.
10
WHAT IS SEVERE ACUTE MALNUTRITION (SAM)?

One type of malnutrition is severe acute malnutrition (SAM). Severe acute
malnutrition develops when the child is not getting enough energy or protein and
other nutrients from his food to meet his nutritional needs.
You will learn to assess a child for severe acute malnutrition in the next section. It
is also helpful to be aware of common clinical signs of SAM.
Some clinical signs of a child with severe acute malnutrition can include:
•• The child may become severely wasted (a sign of marasmus)
•• The child may develop oedema (a sign of kwashiorkor)
This child is showing clinical signs of malnutrition

like:
•• Very thin body with reduced subcutaneous fat,
especially on the arms, legs, and buttocks
•• The belly may be distended
•• The face may appear the same
This child is showing clinical signs of malnutrition

like:
•• Thin, sparse and pale (yellowish or reddish)
hair that easily falls out
•• Dry, scaly skin especially on the arms and legs
•• A puffy or “moon” face
•• Swelling of ankles and/or feet
In the next section you will learn how to assess for severe acute malnutrition using
IMCI.
11
Answer these questions about what you have read about malnutrition and
anaemia.
1. What is malnutrition?
2. Why do you check every child for malnutrition and anaemia?
3. Are the following signs common presentations of severe acute malnutrition?
Answer true or false.
1. Puffy face TRUE FALSE
2. Distended abdomen TRUE FALSE
3. Extremely thin body TRUE FALSE
4. Oedema of the feet TRUE FALSE
5. Scaly skin on legs TRUE FALSE
6. Rash on belly TRUE FALSE
7. Lack of fat on buttocks and arms TRUE FALSE
8. Child is crying from hunger TRUE FALSE
9. Thin hair that may fall out TRUE FALSE
12
6.4 ASSESS MALNUTRITION

HOW DO YOU CHECK FOR MALNUTRITION?
The assessment for malnutrition includes many important steps. This section
is structured to help you learn each step in order. Open your ASSESS chart for
malnutrition. What instructions do you observe?
THEN CHECK FOR ACUTE MALNUTRITION
CHECK FOR ACUTE MALNUTRITION Oed

LOOK AND FEEL: Classify OR
Look for signs of acute malnutrition NUTRITIONAL WF
STATUS sco
FOR ALL CHILDREN: Look for oedema of both feet.
MU
FOR ALL CHILDREN: Determine WFH/L** ___ z-score.
(6 m
FOR CHILDREN 6 MONTHS AND OLDER: Measure
MUAC*____ mm. AND a
follow
If MUAC less than 115 mm, or WFH/L less than -3 z-
score, or oedema of both feet: Med
pre
FOR ALL CHILDREN check if there is a medical
Bre
complication:
(up
Any general danger sign
Not
Any severe classification
note
Pneumonia with chest indrawing
(6 m
ADDITIONALLY FOR CHILDREN UP TO 6 MONTHS:
Does the child have a breastfeeding problem?*** MU
mm
ADDITIONALLY FOR CHILDREN UP TO 6 MONTHS:
WF
Offer the child RUTF**** to finish within 30 minutes
sco
Does the child finish all the RUTF or not?
AND
No
WHY ARE THERE SOME AGE DIFFERENCES IN THE ASSESS CHART? No
Severely malnourished infants under 6 months of age need special care. They should pro
mon
always be treated in inpatient care until full recovery. Remember that children under Abl
6 months are assessed differently than children 6 months and older. For example, amo
mon
MUAC cannot be used for children less than 6 months.
MU
to 1
NOW YOU WILL LEARN HOW TO ASSESS: WF
-2
You will now learn more about these instructions. We will think about the oed
malnutrition assessment in two parts.
First, you will assess for severe acute malnutrition (SAM): MU
WF
n PART 1: ASSESS FOR SAM or m
of b
Second, if there is SAM, you will assess for complications:
n PART 2: WHEN SAM, ASSESS FOR COMPLICATIONS
* MUAC is Mid-Upper Arm Circumference is measured using MUAC tape in a child 6 months or older.
**WFH/L is Weight-for- height / Weight-for- Length is determined using the WHO growth standards charts.
***Refer to the FEEDING PROBLEM classification (yellow) for the sick young infant.
****RUTF is Ready-to-Use Therapeutic Food for therapeutic feeding and conducting the appetite test for children
Page 9 of
13
PART 1: ASSESS FOR SAM
STEP 1: LOOK AND FEEL FOR OEDEMA OF BOTH FEET

The first step when assessing for SAM is looking and feeling for oedema of both feet.
WHAT IS OEDEMA?
Oedema is when an unusually large amount of fluid gathers in the child’s tissues.
The tissues become filled with the fluid and look swollen or puffed up. If a child has
oedema of both feet they should be referred to inpatient care.
HOW WILL YOU ASSESS FOR OEDEMA?

LOOK and FEEL to determine if the child has oedema of both feet. Using your
thumbs, press the topside of both feet simultaneously for 3 seconds on the top side
of each foot. The child has oedema if a dent remains in the child’s foot when you
lift your thumb. See the photo below as an example:
PHOTO: UNICEF
REMEMBER! Oedema of both feet means severe acute malnutrition.

ALL CHILDREN WITH OEDEMA OF BOTH FEET SHOULD BE REFERRED TO A HOSPITAL.
14
STEP 2: MEASURE WEIGHT-FOR-HEIGHT OR LENGTH

By comparing a child’s weight to his/her height or length, you can measure how
thin the child is. If the weight-for height or length is low, the child is wasted. This
is an important measurement of acute malnutrition. You have also learned wasting
is an important sign of marasmus.
WHY USE WEIGHT-FOR-HEIGHT?

You might be familiar with other ways to measure a child’s growth, like weight-for-
age, or height-for-age. These measurements do not indicate acute malnutrition in
the same way that weight-for-height does. You will learn about these other ways
to measure growth in the WELL CHILD CARE module.
WHAT IS THE DIFFERENCE BETWEEN LENGTH AND HEIGHT?

There is an important difference between height and length for you to remember.
They are measured differently for certain age groups.
n LENGTH is measured when the child is lying down. This is used for children
below 2 years of age or if the child is too weak to stand.
n HEIGHT is measured when the child is standing upright. This is used for all
other children.
NOTE: the height of a child is 0.7 cm shorter than length. Therefore in case
you measure a child 2 years or older using length instead of height, subtract
0.7 cm from the measurement.
HOW WILL YOU MEASURE A CHILD’S LENGTH?

Remember that length is used for children under 2 years, or those too weak to stand.
One assistant should hold the child’s head over the ears and with straight arms.
The measurer hold one hand on the child’s knees keeping the legs straight and the
other on the foot-place to read the length. The child should lie flat on the board.
Once you have measured the child’s length, you will use the weight and length
to calculate a child’s Z-score
15
HOW WILL YOU MEASURE A CHILD’S HEIGHT?

Remember that height is used for children 2 years and older. The assistant should
hold the child’s knees to keep the legs straight with one hand, and the other hand
on the shins to keep the heels against the back and base of the board. The measurer
should hold one hand the child’s chin and the other on the head-piece to read the
height. The child’s eyes should the in horizontal level and the body flat against the
board.
Once you have measured the child’s height, you will use the weight and height
HOW DO YOU CALCULATE A CHILD’S Z-SCORE?

Once you have the child’s weight and height/length, you will calculate their Z-score.
This is basically a score comparing the weight-for-height/length of children across
the world. Children with low Z-scores have low weight-for-height/length. The Z-score
does not require any math. You will use an easy chart, which you can refer to
your IMCI Chart Booklet.
1. THERE ARE SEPARATE CHARTS FOR HEIGHT (2 to 5 years) and LENGTH
(birth to 2 years)
16
2. DETERMINE WHICH CHART TO USE BASED ON THE CHILD’S SEX

It is important to note that there are two separate charts for females and males.
They cannot be used interchangeably.
3. MARK THE INTERSECTION OF THE CHILD’S WEIGHT AND HEIGHT

Next you will find the intersection of the weight and height. The numbers for
weight (kg) run up the chart, and guiding lines run across the chart. The
numbers for height (cm) are along the bottom of the chart, and the guiding
lines run up the chart.
Let us review an example. Ben is 10.5 kg and 82 cm. See how we find the
intersection:
1. Locate the child’s

weight: 10.5 kg
2.
Locate
child’s
height:
82 cm
17
4. USE THE INTERSECTION POINT TO FIND THE Z-SCORE

Think about the Z-scores like zones between two lines. Look at the figure below.
You should be most worried about any weight-for-height intersection points that
fall:
✔ Between the -2Z and -3Z lines, like the circle below. This is moderate
malnutrition.
✔ Below the -3Z line, like the star below. This is severe malnutrition.
Between -2Z and -3Z is

moderate malnutrition
Below -3Z is
severe malnutrition
WHAT DO YOU DO AFTER CALCULATING A CHILD’S Z-SCORE?

Children above the -2Z score are not malnourished. However you should
routinely check children because their nutrition status can change rapidly.
If children are between -2Z and -3Z, or below -3Z, you will use this information
to classify their acute malnutrition. You will learn this in the next section.
REMEMBER! WFH/L below -3Z means severe acute malnutrition
18
Plot weight and height on the chart. Use a dot that is very clear. Determine the
Z score.
1. 76 cm, 9 kg
2. 80 cm, 7.5 kg
3. 90 cm, 11.2 kg
4. 93 cm, 11 kg
5. 85 cm, 12 kg
19
STEP 3: MEASURE MUAC (only for children 6–59 months)

WHAT IS MUAC?
The measurement around the middle of a child’s upper arm is an
important indicator of acute malnutrition in a child. This is called
mid-upper arm circumference (MUAC). The MUAC strip is a flexible
measuring tape that measures in millimetres (mm).
MUAC can only be used for children 6–59 months.
HOW DO YOU READ THE MUAC STRIP?

Examine your own MUAC strip, and refer to the picture below. The
first thing you should note about your MUAC strip is that there
are three different colours: green, yellow, and red to note danger of child’s MUAC.
There are two important pieces of the MUAC strip you should note in the picture
above. The first is the slit where you will insert the MUAC strip. The next is the
window where you will read the child’s MUAC in mm.
Children with a MUAC less than 115 mm have severe acute malnutrition.
This measurement is red on the MUAC strip. These children need special treatment.
HOW DO YOU MEASURE THE CHILD’S MUAC?

The steps and the figure below explain how to measure the child’s MUAC.
•• Find the mid-point of the child’s upper arm between the shoulder and elbow.
•• Use MUAC tape to mark the midpoint on the child’s arm.
•• Hold the large end of the strap against the arm at the midpoint of the arm.
•• Put the other end of the strap around the child’s arm. Thread the end up through
the second small slit in the strap. The end will come from behind.
•• Pull both ends until the strap fits closely. It should not be so tight that it makes
folds in the skin. It should also not be too loose.
•• Gently press the window. At the marks note the measurement and colour.
REMEMBER! MUAC below 115 mm (RED) means severe acute malnutrition
20
SIGNS OF SEVERE ACUTE MALNUTRITION: A REVIEW

BELOW ARE THE SIGNS OF A CHILD LESS THAN 6 MONTHS
WITH SAM:
•• Infant has oedema of both feet
•• Weight-for-length is less than 3 z-score
BELOW ARE THE SIGNS OF A CHILD 6 MONTHS AND OLDER

WITH SAM:
•• Child has oedema of both feet
•• Weight-for-height/length is less than 3 z-score
•• MUAC is 115 mm or below
WHAT DO YOU DO IF ANY OF THESE SIGNS ARE PRESENT?

If any signs are present, you will look for other clinical complications. You will learn
about these next.
WHAT IF NO SIGNS OF SAM ARE PRESENT?

If none of the three signs above are present, you will move to CLASSIFY the child’s
nutrition status using your IMCI charts.
REMEMBER! IF ANY OF THE SIGNS OF SEVERE ACUTE MALNUTRITION ARE PRESENT,

YOU WILL LOOK FOR OTHER CLINICAL COMPLICATIONS.
Exercises on signs of severe acute malnutrition.
1. What is the child’s Z-score? Tick the correct box.
Below Between Between Between Between
Child is: -3 -3 and -2 -2 and -1 -1 and 0 0 and 3
a. Boy, 18 months, length 75 cm, weight 8.5 kg

b. Boy, 30 months, height 118 cm, weight 22 kg
c. Girl, 11 months, length 70 cm, weight 6 kg
d. Girl, 27 months, weight 11 kg, height 95 cm
e. Boy, 7 months, length 60 cm, weight 5 kg
f. Girl 32 months, length 111 cm, weight 14.5 kg
g. Boy, 26 months, weight 14.5 kg, height 113 cm
h. Girl, 32 months, height 111 cm, weight 16.5 kg
i. Girl, 20 months, length 100 cm, weight 14.5 kg

21
2. Which of the children above are moderately malnourished based on their

Z-scores?
3. Which of the children above have severe acute malnutrition based on their
Z-scores?
4. Do the children below have signs of severe acute malnutrition? Tick YES or NO.
If NO, answer why not.
TICK: WRITE:
Signs of No signs
Child is: If no, why not?
SAM of SAM
a. Child’s MUAC is 112 mm

b. Child has Z-score between -2 and -3
c. Child has a swollen right foot and is very skinny
d. Child is too weak to stand
e. Child’s MUAC is 113.5
f. Child has oedema of both feet
g. MUAC is 120 mm and child is irritable

5. What clinical sign does this picture show?
22
PART 2: WHEN SAM, ASSESS FOR COMPLICATIONS
IF CHILD IS UNDER 6 MONTHS:

If the child is under 6 months, you will do two steps:
1. Check the child for medical complications. These are discussed below.
2. Check the child for a breastfeeding or feeding problem. Refer to the sick
young infant assessment chart for FEEDING PROBLEM.
WHEN WILL YOU CHECK A CHILD FOR CLINICAL COMPLICATIONS?

If the child has the following complications, it must be noted for their assessment:
•• General danger sign or sign of severe illness, done at the beginning of ASSESS
•• Any severe (red) classification
•• Pneumonia with chest indrawing
IF CHILD IS 6 MONTHS AND OLDER:

If the child is 6 months and older, you will do two steps:
1. Check the child for medical complications, as was described above.
2. Conduct an appetite test with RUTF.
WHEN WILL YOU CONDUCT AN APPETITE TEST?

Review your ASSESS chart again. You just learned how to check children with signs
of SAM for other clinical complications. Additionally, if these children are 6 months
or older, you will also need to conduct an appetite test.
If a child is 6 months or older, and shows signs of severe acute malnutrition, you
should conduct an appetite test. You will assess appetite by giving the child some
Ready-to-use Therapeutic Food (RUTF) to try at the site.
HOW WILL YOU PREPARE TO GIVE A CHILD AN APPETITE TEST?

A child may refuse to eat RUTF because it is unfamiliar and because the child is in
a strange environment. In this case, the caregiver should move to a quiet, private
area and slowly encourage the child to take the RUTF. The health worker will also
need to move to this area, because you must observe the child eating the RUTF
before classifying.
23
HOW WILL YOU CONDUCT AN APPETITE TEST?

To carry out the appetite test, it is important to follow the steps listed below:
1. The appetite test should be conducted in a separate quiet area.
2. Explain to the caregiver the purpose of the appetite test. Explain how it will be
carried out.
3. The caregiver should wash her hands.
4. The caregiver should sit comfortably with the child on his lap. She should offer
the RUTF from the packet, or put a small amount on her finger and give it to the
child.
5. The caregiver should offer the child the RUTF gently, encouraging all the time.
If the child refuses, then the caregiver should continue to quietly encourage the
child. She can take time for the test. The child must not be forced to take the
RUTF.
6. The child needs to be given plenty of water from a cup as he/she is taking the
RUTF.
HOW DOES A CHILD ‘PASS’ THE APPETITE TEST?

To pass the test, the child must eat the RUTF quantities in table below within 30
minutes.
Minimum RUTF amount child should eat within 30 minutes to pass the appetite test
Number of sachets the child should consume willingly during
the test (sachets = 500 Kcal, or 92 g)a
Weight of the child Minimum Maximum
< 4 kg 1/8 1/4
4 up to 6.9 kg 1/4 1/3
7 up to 9.9 kg 1/3 1/2
10 up to 14.9 kg 1/2 3/4
15 kg and above 3/4 1 or above
Note: quantities should be adjusted if RUTF is available in containers or in packaging with different weights.
a
ARE THERE ANY TIMES WHEN AN APPETITE TEST SHOULD NOT

BE CONDUCTED?
There are some scenarios where the child is showing signs of severe malnutrition but
does not need an appetite test. If a child has any general danger signs, the appetite
test is not done. The appetite test is also not done in children who have pneumonia,
persistent diarrhoea, dysentery, measles, or malaria. If RUTF is not available for
an appetite test, refer.
24
Complete the exercises below on steps you will take with children who have
signs of SAM.
1. What are the three signs of severe acute malnutrition?
1.
2.
3.
2. When evaluating a SAM child for hypothermia, how will you evaluate if the child
has a low body temperature?
3. Are the following true or false statements? Circle your answer. If false, write the
correct statement.
a. Aram is 5 months old, and has a z-score of less than -3.
You will immediately begin an appetite test. TRUE FALSE
b. A child must consume the RUTF within 30 minutes
for an appetite test, so the caregiver should rush the
child to finish quickly. TRUE FALSE
c. Masha’s blood sugar level is 52.5 mg/dL.
She is hypoglycaemic. TRUE FALSE
d. Shock is an important clinical complication of SAM
to evaluate for. TRUE FALSE
4. Boniface weighs 9.9 kg. What is the minimum amount of the RUTF sachet he
should consume to pass an appetite test?
25
n How will you assess Noah for acute malnutrition?

You have completed Noah’s IMCI assessment up to malnutrition. You know that you need to check all
children for these conditions. First you will check Noah for the three signs of severe acute malnutrition. You
check Noah for oedema of both feet. You see no swelling. Noah’s weight is 12.7 kg, which you measured at
the beginning of the visit using a solar scale. He was able to stand on this himself for measurement. Noah’s
height is 104 cm. What is Noah’s Z-score?
You measure his MUAC, which is 116 cm. While you measure his MUAC, you encourage Rachel to keep him
calm on her lap. Then you explain to Rachel that you need to measure his height. You ask for her help in
doing so, and she agrees. You explain each step as you go.
n Does Noah have any signs of severe acute malnutrition?

Let us review the results of checking Noah for signs of severe acute malnutrition:
1. There is no oedema of both feet
2. WFH z-score is -3Z: this qualifies as SAM
3. MUAC is 116 cm: this is above the 115 cm required for SAM
Noah is showing at least one sign of SAM because he has a WFH Z-score under -3Z. Now you will need to
evaluate him for medical complications. As he is over 6 months of age, you will also conduct an appetite test.
n How will you check Noah for other medical complications?

You check Noah for common medical complications in children with malnutrition, including shock,
hypothermia, hypoglycemia, and infections. Earlier in your assessment you classified Noah’s cough as COUGH
OR COLD, and not an acute respiratory infection like pneumonia. You do not see any medical complications.
n How will you conduct an appetite test for Noah?

Noah weighs 12.7 kg, so here is the amount of minimum RUTF he must eat during the appetite test. You will
give him about 30 minutes.
Minimum RUTF amount child should eat within 30 minutes to pass the appetite test
Number of sachets the child should consume willingly during
the test (sachets = 500 Kcal, or 92 g)a
Weight of the child Minimum Maximum
10 up to 14.9 kg 1/2 3/4
You explain to Rachel that you want to see how strong Noah’s appetite is. Your clinical space is quiet, so you
have Rachel and Noah sit on the side. Rachel washes her hands. You explain to Rachel how to give the RUTF
directly from the packet, and how to encourage Noah. You emphasize that she should not force Noah. You
also provide a cup of water for her to give Noah. He slowly takes the RUTF and about 20 minutes into the test,
he has eaten over ½ of the sachet. You tell Rachel that he has done a good job eating, and he does not need
to anymore.
Now you will learn how to classify Noah based on his signs.
26
6.5 CLASSIFY MALNUTRITION

HOW DO YOU CLASSIFY SIGNS OF MALNUTRITION?
After you complete the assessment for malnutrition, you will classify. There are
FOUR classifications for malnutrition:
1. COMPLICATED SEVERE ACUTE MALNUTRITION
2. UNCOMPLICATED SEVERE ACUTE MALNUTRITION
3. MODERATE ACUTE MALNUTRITION
4. NO MALNUTRITION
Oedema of both feet, Pink: Give first dose appropriate antibiotic

OR COMPLICATED Treat the child to prevent low blood
ONAL WFH/L less than -3 Z SEVERE ACUTE sugar
score, OR MALNUTRITION Keep the child warm
MUAC less than 115 mm Refer URGENTLY to hospital
(6 months or older)
AND any one of the
following:
Medical complication
present, OR
Breastfeeding problem
(up to 6 months), OR
Not able to finish the
noted amount of RUTF
(6 months and older)
MUAC less than 115 Yellow: Give oral antibiotics for 5 days.
mm, OR UNCOMPLICATED Give ready-to-use therapeutic food for a
WFH/L less than-3 Z SEVERE ACUTE child aged 6 months or more
score MALNUTRITION Re-establish effective breast feeding for a
child aged less than 6 months
AND Counsel the mother on how to feed the
No medical complication child.
No breastfeeding Assess for possible TB infection
problem (under 6 Advise mother when to return immediately
months) Follow up in 7 days
Able to finish the noted
amount of RUTF (6
months and older)
MUAC between 115 up Yellow: Assess the child's feeding and counsel the
to 125 mm, OR MODERATE ACUTE mother on the feeding recommendations.
WFH/L between -3 and MALNUTRITION If feeding problem, follow up in 7 days
- 2 Z scores and no Assess for possible TB infection.
oedema of both feet Advise mother when to return immediately
Follow-up in 30 days
MUAC over 125 mm, OR Green: If child is less than 2 years old, assess the
WFH/L Z scores are -2 NO ACUTE child's feeding and counsel the mother on
or more and no oedema MALNUTRITION feeding according to the feeding
of both feet recommendations
If feeding problem, follow-up in 7 days
in a child 6 months or older.

Now you will read about each of these classifications.
he WHO growth standards charts.
ung infant.
conducting the appetite test for children with severe acute malnutrition.
Page 9 of 75 27
COMPLICATED ACUTE SEVERE MALNUTRITION (RED)

Remember that signs of severe acute malnutrition that you have assessed for
include MUAC less than 115 mm, weight-for-height lower than -3 Z, or include
oedema of both feet.
The child is classified as COMPLICATED SEVERE ACUTE MALNUTRITION when
they have severe acute malnutrition and one of the following complications:
•• At least one medical complication, including any general danger sign, any
severe classification, or pneumonia with chest indrawing
•• No appetite, determined failed appetite test in a child 6 months or older
•• A feeding problem in children under 6 months according to the FEEDING
PROBLEM classification for the young infant

Children classified as having SEVERE COMPLICATED MALNUTRITION are at high
risk of death from pneumonia, diarrhoea, measles, and other severe diseases. These
children need urgent referral to hospital where their treatment can be carefully
monitored. They may need special feeding, antibiotics or blood transfusions.
Before the child leaves for hospital you should give:
•• The first dose of amoxicillin
•• 50 ml of 10% glucose or sucrose solution; if you do not have solution this is
one rounded teaspoon of sugar in three tablespoons of water
•• Keep the child warm
UNCOMPLICATED SEVERE ACUTE MALNUTRITION (YELLOW)

If the child has at least one sign of severe acute malnutrition, but passed the appetite
test or does not other signs of complication, they are classified as UNCOMPLICATED
SEVERE ACUTE MALNUTRITION.

These children need urgent treatment-based RUTF, deworming, and oral
antibiotics. These children are at risk of death from serious diseases. Check if the
child is at high risk of HIV infection, whether s/he has been vaccinated for measles,
and test for malaria.
You will learn how to provide treatment-based RUTF later in this module. You
will also learn how to counsel the caregiver on giving RUTF. A child with SEVERE
UNCOMPLICATED MALNUTRITION should return for follow-up after 1 week.
28
MODERATE ACUTE MALNUTRITION (YELLOW)

If the child’s weight-for-age is between -3 and -2 Z-score or MUAC between 115 and
125, classify as MODERATE ACUTE MALNUTRITION.

A child classified as having MODERATE ACUTE MALNUTRITION has a higher risk
of severe disease. Assess the child’s feeding and counsel the caregiver about feeding
her child according to the recommendations in the FOOD box on the COUNSEL
chart and in the WELL CHILD CARE module. You should also consider screening
the child for HIV and TB and same medications as above.
If the child has a feeding problem, they should follow-up in 5 days. If there is no
feeding problem, the child should follow-up in 30 days.
NO ACUTE MALNUTRITION (GREEN)

If the child has a weight-for-age over -2 Z-scores, and has no other signs of
malnutrition, classify as NO ACUTE MALNUTRITION. If the child is less than
2 years of age, assess the child’s feeding. Children less than 2 years of age have a
higher risk of feeding problems and malnutrition than older children. Counsel the
caregiver about feeding her child according to the recommendations in the FOOD
box on the COUNSEL chart and in the WELL CHILD CARE module.
n How will you classify Noah’s malnutrition?

Noah shows one sign of SAM, a WFH Z score under -3Z. He does not have oedema or any clear medical
complications. He passed his appetite test. You classify him as UNCOMPLICATED SEVERE ACUTE
MALNUTRITION (yellow).
n What treatments are identified for Noah?

Noah needs immediate treatment, as he is at risk of death from serious diseases given his nutrition status.
You identify his treatments for this classification as:
✔✔ Treatment-based RUTF
✔✔ Deworming
Now you will learn how to provide these treatments to Noah.
29
Practice classifying malnutrition.
1. How will you classify the following children? Tick the appropriate box.
Complicated Uncomplicated
Moderate acute No acute
severe acute severe acute
malnutrition malnutrition
a. Child has MUAC

of 112 mm and no
complications
b. Child has WFH z-score
less than -3 and failed
the appetite test
c. Child has MUAC of 112
mm
d. Child has MUAC of 117
mm and no oedema
e. Child’s WFH z-score is
between -1 and -2
f. Child has WFH z-score
between -3 and -2
g. Child has MUAC of 113
mm and is showing
signs of shock
h. Child is less than 6
months, has lost weight
and not breastfeeding
effectively
2. You classify a child as UNCOMPLICATED SEVERE ACUTE MALNUTRITION.

What are the primary treatments you have identified for this classification?
3. When will you advise this child to return for follow-up?
30
6.6 TREAT MALNUTRITION

WHAT TREATMENTS ARE IDENTIFIED FOR MALNUTRITION?
Review your classification table for malnutrition. It identifies the following
treatments:
Oedema of both feet, Pink: Give first dose appropriate antibiotic

OR COMPLICATED Treat the child to prevent low blood
WFH/L less than -3 Z SEVERE ACUTE sugar
score, OR MALNUTRITION Keep the child warm
MUAC less than 115 mm Refer URGENTLY to hospital
(6 months or older)
AND any one of the
following:
Medical complication
present, OR
Breastfeeding problem
(up to 6 months), OR
Not able to finish the
noted amount of RUTF
(6 months and older)
MUAC less than 115 Yellow: Give oral antibiotics for 5 days.
mm, OR UNCOMPLICATED Give ready-to-use therapeutic food for a
WFH/L less than-3 Z SEVERE ACUTE child aged 6 months or more
score MALNUTRITION Re-establish effective breast feeding for a
child aged less than 6 months
AND Counsel the mother on how to feed the
No medical complication child.
No breastfeeding Assess for possible TB infection
problem (under 6 Advise mother when to return immediately
months) Follow up in 7 days
Able to finish the noted
amount of RUTF (6
months and older)
MUAC between 115 up Yellow: Assess the child's feeding and counsel the
to 125 mm, OR MODERATE ACUTE mother on the feeding recommendations.
WFH/L between -3 and MALNUTRITION If feeding problem, follow up in 7 days
- 2 Z scores and no Assess for possible TB infection.
oedema of both feet Advise mother when to return immediately
MUAC over 125 mm, OR Green: If child is less than 2 years old, assess the
WFH/L Z scores are -2 NO ACUTE child's feeding and counsel the mother on
or more and no oedema MALNUTRITION feeding according to the feeding
of both feet recommendations
arts.
or children with severe acute malnutrition.

31
Page 9 of 75
You have already learned about several of the treatments listed in this chart:
➞ Give all children oral antibiotics for 5 days (Module 3)
➞ Treat for low blood sugar if child is being referred (Module 1)
The treatments that you will read about now include:
➞ Give RUTF to children with UNCOMPLICATED SEVERE ACUTE MALNUTRITION
(yellow)
➞ How to manage children with severe acute malnutrition AND dehydration, as
dehydration should be managed differently when the child has malnutrition
(also refer to Module 4)
Counselling on feeding problems is discussed in module 8, care of the well child
HOW WILL YOU GIVE RUTF?

A child classified as UNCOMPLICATED SEVERE ACUTE MALNUTRITION must
receive RUTF. The caregivers will provide RUTF. RUTF is the only food that thin
children need for their recovery. If the child is young and still breastfeeding, this
should continue.
It is important to remember that RUTF is a therapeutic treatment and
must be given in correct quantity. Quantities of RUTF are given according to
the child’s weight, in the table:
Weight of the RUTF paste RUTF Sachetsa (500 Kcal sachets, or 92 g)

child (kg) grams per day grams per week sachets per day sachets per week
4.0–4.9 190 1300 2 14
5.0–6.9 230 1600 2½ 18
7.0–8.4 280 1900 3 21
8.5–9.4 320 2300 3½ 25
9.5–10.4 370 2600 4 28
10.5–14.9 400 2800 4½ 32
15.0–19.9 450 3200 5 35
20.0–29.9 550 3900 6 40
Note: quantities should be adjusted if available in containers or in packaging with different weights.
a
HOW WILL YOU COUNSEL THE CAREGIVER ABOUT GIVING RUTF?

You will start a child immediately on RUTF, and the caregivers will continue the
treatment. There are several key messages for the caregiver about RUTF:
•• Wash hands before giving RUTF
•• Sit with child on the lap and gently offer the RUTF
•• Encourage the child to eat the RUTF without forced feeding
32
•• Give small, regular meals of RUTF, and encourage child to eat often (5-6 meals
per day)
•• If still breastfeeding, should continue by offering breast milk first before every
RUTF feed
•• Offer plenty of clean water, to drink from a cup, when the child is eating the RUTF
WHEN SHOULD THE CHILD RECEIVING RUTF RETURN

FOR FOLLOW-UP?
A child with UNCOMPLICATED SEVERE MALNUTRITION should return for
follow-up after 1 week. Advise the caregiver to return immediately if the child does
not eat RUTF.
WHEN SHOULD THE CHILD STOP RUTF?

RUTF should be given until the weight-for-height is above -2 z scores for 2
consecutive visits OR there is 15% weight gain. The child should be well and alert.
If the child presents with oedema, he will lose weight as the swelling goes down
and he begins to improve. RUTF should not be stopped until the child has achieved
weight gain as described above, AND the oedema has disappeared and been gone
for at least two weeks.
RUTF is stopped after the child gains appropriate weight,

AND there have been no signs of oedema for at least 2 weeks.
33
Answer the following questions about RUTF treatment.
1. How much RUTF should the following children be given for a week’s supply?
a. 3.7 kg, paste available
b. 16.7 kg, sachets available
c. 7.8 kg, sachets available
d. 11.6 kg, paste available
2. When should the child receiving RUTF follow-up?
3. List three important counselling messages about providing RUTF at home:

1.
2.
3.
4. List three checking questions to see if the caregiver understands how to provide
home treatments:
1.
2.
3.
5. Should the following children stop RUTF? Tick your answer.
CONTINUE RUTF STOP RUTF
a. Tsepi (boy) now weighs 13.5 kg, and is 96 cm
in height. Last visit he weighed 13 kg.  
b. Rakim’s weight has changed from 20.5 kg to 23 kg.  
c. Angie (girl) weighs 15.5 kg and is 109 cm in height.
Last visit she weighed 14.5.  
d. Sheena’s weight has changed from 32.5 kg to 38.0 kg.  
e. Maria (girl) now weighs 17.2 kg and is 116 cm in
height. Last visit she weighed 17.3 kg.  
34
HOW YOU MANAGE CHILDREN WITH SAM AND DEHYDRATION?

In Module 4 you have learned to assess for dehydration. If a child has severe acute
malnutrition and signs of dehydration, they must be managed differently. There are
two classifications for dehydration. Let us revisit these and the actions to be taken.
SEVERE DEHYDRATION
All children with severe dehydration should be urgently referred.
SOME DEHYDRATION
If the child has some dehydration they can be treated in the health facility. Children
with SAM and some dehydration should not be treated with normal ORS.
This is because normal ORS has high sodium and low potassium content, which is
not suitable for severely malnourished children.
n Treating dehydration in children with SAM

PREFERRED: ReSoMal
If available, give ReSoMal 5 ml/kg every 30 minutes the first 2 hours, and 5-10 ml/kg per hour for the next 4-10
hours on alternate hours with RUTF.
IF ReSoMal NOT AVAILABLE: ½ STRENGTH ORS
If ReSoMal is not available prepare half strength ORS with concentrated electrolyte/mineral solution in same
doses as ReSoMal.
NEITHER AVAILABLE: REFER
If ReSoMal is not available and half strength ORS cannot be prepared, urgently refer to the nearest hospital.
HOW LONG WILL YOU GIVE RESOMAL OR HALF STRENGTH ORS?

A child with SAM and some dehydration cannot be sent home before
improvement is seen. The child should be assessed every 30 minutes for the first
2 hours and every hour for the next 4–10 hours.
If the child improves the caregiver can be sent home with ReSoMal/half strength
ORS for two days. She should give 50–100 ml after each loose stool. Tell the caregiver
to return urgently if the child is not improving and to come back for follow-up after
the two days.
If the child is deteriorating or not improving she/he should urgently be referred.
You have completed assessing, classifying, and treating malnutrition.

Now you will learn about the IMCI process for anemia.
35
6.7 ASSESS & CLASSIFY ANAEMIA

WHAT IS ANAEMIA?
Anaemia is a reduced number of red cells or a reduced amount of haemoglobin
in each red cell. Iron deficiency anaemia is considered to be the most common
cause of anaemia, but other causes include deficiencies in folate, Vitamin B12, and
Vitamin A. Besides iron deficiency, a child can also develop anaemia as a result of:
✔✔ Infections
✔✔ Parasites, such as hookworm or whipworm, that can cause blood loss from
the gut
✔✔ Malaria, which can destroy red cells rapidly. Children can develop anaemia if
they have repeated episodes of malaria or if malaria was inadequately treated.
The anaemia may develop slowly. Often, anaemia in these children is due to both
malnutrition and malaria.
HOW DO YOU CHECK FOR ANAEMIA?

Open your ASSESS chart for anaemia. What instructions do you observe?
THEN CHECK FOR ANEAMIA
Check for aneamia Do a malaria test Severe

Decide Malaria Risk: High or If high malaria risk and
Low some pallor present Classify
Look for palmar pallor. Is it: ANEAMIA Classification
arrow Some
Severe palmar pallor?
Some palmar pallor?
HOW WILL YOU DETERMINE MALARIA RISK?

Before you begin, determine is the malaria risk is high or low. Remember that No pal
you learned about high and low risk malaria areas in the beginning of Module 5 on
Fever. It is also important to remember that a child can live in a low risk area, but
you need to check if the child has travelled to a high risk area. You will do a malaria
test if the child has high malaria risk and shows sign of some pallor.
* If malaria test not available in malaria high risk, give oral antimalarial.
** If child has severe acute malnutrition, DO NOT give iron.
HOW WILL YOU LOOK FOR PALMAR PALLOR?
Pallor is unusual paleness of the skin, and is a sign of
anaemia. Palmar pallor means it is identified in the palm
of the hand.
LOOK at the skin of the child’s palm. Hold the child’s palm
open by grasping it gently from the side. Do not stretch the
fingers backwards. This may cause pallor by blocking the
blood supply. Compare the colour of the child’s palm with
your own palm and with the palms of other children.
The child has some palmar pallor if the skin of the child’s palm is pale. The child
has severe palmar pallor if the skin of the palm is very pale or so pale that it
looks white. A good example of severe palmar pallor is in the picture to the right.
36
HOW DO YOU CLASSIFY SIGNS OF ANAEMIA?

What do you observe about the classification chart for anaemia? You will see how
palmar pallor is the important sign. There are 3 classifications for anaemia. These are:
1. SEVERE ANAEMIA
2. ANAEMIA
3. NO ANAEMIA
Severe palmar pallor Pink: Refer URGENTLY to hospital

SEVERE
assify ANAEMIA
NEAMIA Classification
arrow Some pallor Yellow: Give iron**
ANAEMIA Give oral antimalarial if malaria test postive*
Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according to
the feeding recommendations
ial.
SEVERE ANAEMIA (RED)
A child with severe palmar pallor has severe anaemia and should be referred urgently.
ANAEMIA (YELLOW)
A child with some palmar pallor should be classified as having ANAEMIA. The
child should be given iron. Asses for malaria with in all children with some
palmar pallor.
In addition, the anaemia may be due to malaria, hookworm, or whipworm.
If the child’s malaria test is positive, you should give oral antimalarials. Hookworm
and whipworm infections contribute to anaemia because the loss of blood from the
gut results in iron deficiency. Give the child mebendazole only if there is hookworm
or whipworm in the area. Only give mebendazole if the child with anaemia is 1 year
or older and has not had a dose of mebendazole in the previous 6 months. You can
review the dosage in your TREAT charts. You will also learn more about deworming
in in the WELL CHILD CARE module.
NO ANAEMIA (GREEN)
If the child has no palmar pallor, classify the child as having no anaemia and not
very low weight. Children less than 2 years of age have a higher risk of feeding
problems and malnutrition than older children do. If the child is less than 2 years
of age, assess the child’s feeding.
Page 10 of 75
37
Watch “Assess for malnutrition, anaemia, & ear problems” (disc 2)

This video clip reviews all steps of assessing for malnutrition and
anaemia. You will return to watch the ‘ear problems’ portion.
NOTE: video also covers feeding problems, which you will learn about
in the WELL CHILD CARE module.
Answer the following questions about malnutrition and anaemia.
1. Match the following key terms with their definitions. These are important
concepts for nutrition.
MATCH THIS TERM … … WITH A DEFINITION
Anaemia A food product that is used for the safe therapeutic

feeding of SAM children.
Oedema A sign that is identified by looking at a child’s palm.
Pallor A reduced number of red cells or a reduced amount
of haemoglobin in each red cell, caused by not
eating foods rich in iron, folate, Vitamin 12 and A;
parasites, malaria; or other infections.
RUTF Unusual paleness of the skin, and a sign of anaemia.
Palmar pallor When an unusually large amount of fluid gathers in
the child’s tissues. The tissues become filled with the
fluid and look swollen or puffed up.
2. Ned has severe palmar pallor – his hands are nearly white. How will you classify
him?
3. You classify a child as SOME PALMAR PALLOR. What treatments are identified
for this classification?
4. Lisa has been classified as SOME DEHYDRATION and SEVERE ACUTE

MALNUTRITION. How will you take action now?
a. Give ORS and zinc as per the diarrhoea charts
b. Give ReSoMal in the clinic
c. Advise the caregiver on how to give half strength ORS and RUTF at home
38
n How will you check Noah for anemia?
Danger sign when
selecting
You take Noah’s hands and survey his palms. You fold his fingers back and tell Rachel that you want to
classifications
compare
DOES THE theCHILD
colorHAVE
of their palms.
COUGH ORRachel also BREATHING?
DIFFICULT puts her hand out. Noah’s palms are quite a bit paler
Yes than his
__ No __
For how long?
mother’s. They___are
Days
pale, but not white. Count the breaths in one minute
How will you classify Noah? Look and listen for stridor
Noah
DOESdid THE show
CHILD someHAVE palmar pallor, a sign of anemia. You review your classification chart for anemia
DIARRHOEA? Yes __and
No __
classify Noah with SOME ANAEMIA (YELLOW). IfLethargic
his palmar pallor was severe--that is, his hands were white--
or unconscious?
you would have classified him with SEVERE ANAEMIA. Restless and irritable?
n How does Noah’s recording form look now? Not able to drink or drinking poorly?
Slowly?
Decide Noah
Name: malaria risk: High ___ Low ___ No___ Age: 26 mo
Weight (kg): 12.7 kg Temperature (°C): 37 °C
Look for runny nose Initial Visit? X
Ask:ForWhat
howare
long?
the ___ Days
child's problems?
Cough Look for signs of MEASLES:
Follow-up Visit?
If more(Circle
ASSESS than 7alldays,
signshas fever been
present) present every

CLASSIFY
CHECK
Has childFOR hadGENERAL
measels withinDANGER SIGNS
the last 3 months? One of these: cough, runny nose, or red eyes General danger sign
NOT ABLE Look for any other cause of fever. present?
Do malaria test TO DRINK
if NO ORdanger
general BREASTFEED
sign LETHARGIC OR UNCONSCIOUS
VOMITS EVERYTHING
CONVULSING NOW X
Yes ___ No ___
Danger sign when
Test POSITIVE? P. falciparum P. vivaxNEGATIVE? selecting
If the child has measles now or within the Look for mouth ulcers. classifications
If yes, are they deep and extensive?
last
DOES 3 months:
THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Look for pus draining from the eye. X
Yes __ No __
14
For how long? ___ Days Countfor
Look
35
theclouding
breathsofinthe
onecornea.
minute
DOES THE CHILD HAVE AN EAR PROBLEM?
___ breaths per minute. Fast breathing? No Yes __ No __
Is there ear pain?
Look
Cough or cold
Look for
andpus draining
listen from the ear
for stridor
Is there ear discharge? Feel
Lookfor
andtender
listenswelling behind the ear
for wheezing
For how
AND
long? ___
ANAEMIA
Days
<-3z
Look at the childs general condition. Is the child:
Determine WFH/L _____ Z score. Uncomplicated
Is there blood in the stool? Lethargic or unconscious? 116
severe acute
Look for palmar pallor. malnutrition
Drinking eagerly, thirsty? Some anaemia
both feet: Pinch the skin of the abdomen. Does it go back:
Slowly?
For a child less than 6 months is there a breastfeeding problem? Yes __ No __
Decide malaria Look or feel for stiff neck
CHECK FORrisk: HIVHigh ___ Low ___ No___
INFECTION
For how long? and/or
___ Days Look for runny nose
Note mother's child's HIV status
If more than 7 days, Look for signs of MEASLES:
Mother's HIV test:has fever been present
NEGATIVE every
POSITIVE NOT DONE/KNOWN
HasChild's
child had measelstest:
within the last 3 months? One of these: cough, runny nose, or red eyes
serological NEGATIVE POSITIVE NOT DONE
Do malaria
If mothertest if NO general
is HIV-positive danger
and sign virological test in child:
NO positive
Is the
High risk: child breastfeeding
all fever cases now?
Was
Low risk: theobvious
if NO child breastfeeding
cause of feverat the time of test or 6 weeks before it?
CHECK THE CHILD'S IMMUNIZATION STATUS Look (Circle immunizations needed today) Return for next
If the child has measles now or within the for mouth ulcers.
If yes, are they deep and extensive?
last 3 months: OPV-1
OPV-0 OPV-2 OPV-3 Mebendazole ________________
Hep B1 Hep B2 Hep Look
B3 for clouding of the cornea. (Date)
Hep B0
DOES THE CHILD RTV-1
HAVE AN RTV-2 RTV-3
EAR PROBLEM? Yes __ No __
Pneumo-1
Is there ear pain? Pneumo-2 Pneumo-3
Look for pus draining from the ear
Page 65 of 75
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN 39
6.8 TREAT ANAEMIA

WHAT TREATMENTS ARE IDENTIFIED FOR ANAEMIA?
Review your classification table for anaemia. What treatments do you identify?
Severe palmar pallor Pink: Refer URGENTLY to hospital

SEVERE
ANAEMIA
sification
w Some pallor Yellow: Give iron**
ANAEMIA Give oral antimalarial if malaria test postive*
Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months
NO ANAEMIA child's feeding and counsel the mother according to
the feeding recommendations
The identified treatments you have already learned about include:

➞ Give oral antimalarials – you learned steps in Module 5
Some new important treatments are identified here. You will learn more
about these in Module 9 (well child care):
➞ Give iron
➞ Give mebendazole if child is over one year: a dose of 500 mg is given to children
age 12–59 months, every 6 months.
As you read about these treatments, follow along in your TREAT THE CHILD section
of your chart booklet.
Counselling on feeding problems is discussed in module 9 on well child care.
Page 10 of 75
40
HOW WILL YOU GIVE IRON?

A child with SOME PALMAR PALLOR may have anaemia. A child with anaemia needs
iron. Give syrup to the child under 12 months of age. If the child is 12 months or
older, give iron tablets. Iron should not be given if the child is also receiving RUTF
for severe acute malnutrition, since there is adequate iron and folic acid in RUTF
to treat mild anaemia and folate deficiency. Remember to test all children for
malaria.
It is important you counsel the caregiver on continuing regular iron
treatments at home. Give the caregiver enough iron for 14 days. Tell her to give
her child one dose daily for the next 14 days. Ask her to return for more iron in
14 days. You should also tell her that the iron may make the child’s stools black.
Sometimes this scares caregivers and they might stop the treatment if they do not
expect it. It is also important to tell the caregiver to keep the iron out of reach of
the child. An overdose of iron can be fatal or make the child very ill.
Iron/folate tablet grams per day Iron syrup sachets per day
Ferrous sulfate 200 mg + 250 µg folate Ferrous fumarate 100 mg per 5 ml
Age or weight (60 mg elemental iron) (20 mg elemental iron per ml)
2– 4 mths or 4–6 kg 1 ml (< ¼ tsp.)
4 –12 mths or 6–10 kg 1.25 ml (¼ tsp.)
12 mths–3 yrs or 10–14 kg ½ tablet 2 ml (< ½ tsp.)
3–5 years or 14–19 kg ½ tablet 2.5 ml (½ tsp.)
Note: Children with Severe Acute Malnutrition and on RUTF should not be given iron
HOW WILL YOU GIVE MEBENDAZOLE?

If the child is 1 years of age or older and has not had a dose of mebendazole
in the past 6 months, the child should also be given a dose of mebendazole for
possible hookworm or whipworm infection. These infections contribute to anaemia
because of iron loss through intestinal bleeding. If hookworm or whipworm is a
problem in your area: an anaemic child 2 years of age or older needs mebendazole.
Give 500 mg mebendazole as a single dose in the clinic. Give either one 500 mg tablet
or five 100 mg tablets. Refer to the dosage chart below, and to your TREAT charts.
HOW WILL YOU GIVE ORAL ANTIMALARIALS?

If a child with pallor has a positive malaria test, the child should also be given an oral
antimalarial. This is done even if the child does not have a fever. Refer to Module 5
on Fever to refresh your skills on giving oral antimalarials.
41
n What treatments do you identify for Noah?

You have 3 classifications for Noah: COUGH OR COLD (green), UNCOMPLICATED SEVERE ACUTE
MALNUTRITION (yellow), and SOME ANAEMIA (yellow). Using your classification tables, you have identified
the following treatments:
✔✔ Home remedy for cough
✔✔ RUTF home treatment
✔✔ Mebendazole: if Noah hasn’t had within 6 months
You will not give iron because Noah is taking RUTF
n What treatments will you provide Noah today?

Of the treatments you have identified for Noah, you will give him the following today:
✔✔ Oral antibiotics: initiate today for 5 days following guidelines in TREAT charts
✔✔ RUTF home treatment: Noah weighs 12.7 kg, and you have sachets of RUTF available, so he requires 32
sachets for the week’s supply. He needs to consume 4 ½ sachets a day.
✔✔ Mebendazole: Noah hasn’t had within 6 months, so you will give him a dose of 500 mg today according
to your TREAT charts.
First, you explain to Rachel your concerns with Noah. You explain that you think his cough is not showing
signs of severe infection, but that she will need to keep an eye on it. You also tell her that Noah’s weight is
low and that getting him to a higher weight is very important to improve his nutrition and protect his body
from other serious diseases. Malnutrition seriously weakens children’s bodies. Rachel looks very frightened
by this but you reassure her that the RUTF treatment, and making some changes to his regular diet, should
help this.
n How will you counsel Rachel?

There are five key topics that you need to counsel Rachel on today:
1. Home care for cough, including a safe local remedy for cough
2. Providing oral antibiotics for 5 days, including the dosage and schedule
3. Providing RUTF at home, including the dosage, schedule, and how to give. You will also explain the
special tips below:
•• Wash hands before giving RUTF
•• Sit with child on the lap and gently offer the RUTF
•• Encourage the child to eat the RUTF without forced feeding
•• Give small, regular meals of RUTF
•• Encourage child to eat 5–6 meals per day
•• Offer plenty of clean water from a cup when the child is eating the RUTF
4. Feeding recommendations for his age, which you will learn about in module 8
5. When to return to the clinic
42
n How will you help teach Rachel?

Here you remember your 3 basic teaching steps: give information, demonstrate, and allow Rachel to practice.
You do this now to show her how to give the RUTF safely from the sachet, and providing water in a cup to
drink.
n When should Rachel and Noah return to the clinic?

You explain to Rachel the signs that she should look for that would require Noah to come back to the clinic
immediately. This includes the signs you normally discuss in your Chart Booklet, but in Noah’s case this also
includes if he does not eat RUTF. You also tell her to return to the clinic in 7 days or sooner in 5 days if Noah’s
cough does not improve. In 7 days you need to check Noah’s weight and nutrition status.
n You check Rachel’s understanding with checking questions

✔✔ How will you prepare a safe cough remedy at home?
✔✔ How will you provide the RUTF to Noah?
✔✔ What are important things to remember about giving RUTF while at home?
✔✔ What kinds of foods and servings can you provide to Noah, can you give me an example of one day’s
feeding schedule?
✔✔ When will you come back to the clinic with Noah?
Rachel seems a little confused when she tries to explain how to provide RUTF. However, she remembers
the tips well, especially about not giving the RUTF to others in the house. You again explain RUTF to Rachel,
demonstrate how to feed from the sachet, and let her practice. When you ask checking questions again, you
are satisfied with her responses.
n Reassuring Rachel
Rachel says she is worried she will forget to do something for Noah, because he has many treatments. You
help her by providing a dosage schedule for her to reference. You reassure Rachel that she is a good mother
for noticing Noah’s illness and bringing him to the clinic, and that they treatments should help him quickly.
Rachel collects her things and leaves the clinic with Noah.
43
6.9 PROVIDE FOLLOW-UP CARE FOR NUTRITION

WHEN WILL CHILDREN FOLLOW-UP FOR PROBLEMS RELATED
TO NUTRITION?
Notice that there are several different follow-up times related to nutrition. You will
read about each of these follow-up visits in this section.
➞ Follow-up in 1 week: the child classified as UNCOMPLICATED SEVERE ACUTE
MALNUTRITION that is receiving RUTF
➞ Follow-up in 5 days: See module 8 for more information on feeding problems.
If a child has a feeding problem and you have recommended changes in feeding,
to see if the caregiver has made the changes. You will counsel more if needed.
➞ Follow up in 14 days:
•• If a child is classified as MODERATE ACUTE MALNUTRITION
•• If a child has pallor, to give more iron.
PALLOR (follow-up 14 days)

During this visit, follow these instructions:
✔✔ Give the caregiver iron for the child. Advise her to return in 14 days for
more iron.
✔✔ Continue to give the caregiver iron when she returns every 14 days for 2
months.
✔✔ If the child still has palmar pallor after 2 months, refer the child for
assessment.
UNCOMPLICATED SEVERE ACUTE MALNUTRITION

(follow-up 1 week)
The child should return to the facility every week to have a health check-up and to
receive their supply of RUTF. During each follow-up visit, the health worker at the
clinic should assess the following:
1. Measure weight and MUAC at each visit. Measure height every four weeks.
Determine WFH z-score at every visit.
2. Check for oedema of both feed
3. Vital signs (temperature, pulse, respiration rate) and medical check
4. Appetite test with RUTF
5. Provide RUTF ration and review counselling messages with caregiver
44
 NO LONGER SEVERELY MALNOURISHED

The child has improvements in MUAC and/or weight-for-height/length. Praise the
caregiver. Continue with RUTF until the weight for length/height is above
-2Z or the child has gained 15 % weight.
 STILL SEVERELY ACUTE MALNOURISHED

This child still has very low weight for height. Children who fail to respond to the
treatment could be followed-up at home to determine the family circumstances
and if there are concerns with the care or sharing of food. Ask the caregiver to
come back after one week.
After one month of non-response to treatment, these children should be
referred for further medical review and laboratory tests as required to diagnose
underlying illnesses. Some of the potential problems are:
COMMON PROBLEMS IN MANAGEMENT OF MALNUTRITION

Problems related to the quality ✔ Inappropriate evaluation of health condition, or missed medical complication
of treatment ✔ Poorly conducted appetite test
✔ Inadequate instructions given to parent/caregiver on home care
✔ Inaccurate quantity of RUTF is given to child
✔ Protocol for routine medicines is not followed
✔ Health facility is a long distance from the patient’s home
Problems related to the home ✔ Low frequency of visits to the health facility
environment or child ✔ Insufficient RUTF given to child, or RUTF sharing with family members
✔ Inadequate intake of routine medicines
✔ Sharing of the family food
✔ Micronutrient deficiency
✔ Malabsorption
✔ Psychological trauma
✔ Infection/underlying disease
✔ Unwilling parent/caregiver
 IF CHILD CONTINUES TO LOSE WEIGHT

Refer the child to hospital or to a feeding programme.
REMEMBER!
A child can be discharged from outpatient malnutrition treatment if:
•• No signs of oedema for at least two weeks
•• He/she has gained 15 %
•• He/she is above -2 Z score for two consecutive visits
45
n How will you provide follow-up care for Noah?

Rachel returns with Noah in 7 days, as you discussed during the initial visit. You are happy to see her. During
this visit you will do an IMCI assessment and check for:
✔✔ If any new symptoms or signs are present
✔✔ If his cough is improving, the same, or worse
✔✔ If his weight is improving, the same, or worse
✔✔ If his palmar pallor has improved
✔✔ You will also discuss any issues Rachel has had with the treatments. You will check to be sure she’s
provided all of the medications according to schedules.
n How will you re-assess Noah?

In your IMCI re-assessment, you find the following:
1. Noah has no new symptoms.
2. Noah’s cough has cleared.
3. Noah’s weight is now 13 kg. He is still 104 cm tall. His MUAC is 117 cm. His new z-score is slightly between
-2 and -3, which is positive news. Although he has improved you will continue the treatment with RUTF. In
order to stop RUTF, Noah needs to have a z-score higher than -2Z for 2 consecutive visits. He will need to
continue taking RUTF in the same amounts, 4 ½ sachets a day.
4. Noah’s palms look improved. You reclassify as NO ANAEMIA.
n How will you treat Noah and counsel Rachel?

Rachel needs to continue providing RUTF treatment to Noah. You give her new supplies, and ask her
to explain how she has been providing the RUTF. You also ask her to demonstrate for you. You are pleased.
Rachel also needs to continue recommended feeding practices for Noah. You discuss the average day of food
she has provided to Noah in the past week. You ask her about any foods that you recommended in the last
visit, but that she was not able to give. You discuss if they are too expensive, or not available, and reasonable
other options.
You praise Rachel for the progress so far. You counsel her on continuing this important nutrition for Noah.
She seems a little worried that he needs to continue the RUTF. She was hoping he would be all better by now.
You explain that gaining weight needs time, and a lot of nutrition. You encourage her to continue giving as
she has.
n When should Rachel and Noah return to the clinic?

You also counsel on when to return to the clinic next: either immediately, or in 1 week.
46

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU HAVE
GAINED FROM THIS MODULE IN MANAGING CHILDREN WITH
MALNUTRITION AND ANAEMIA?
skills and using your job aids will help you to better understand how to use IMCI
for malnutrition and anaemia.
ASSESS & CLASSIFY

✔✔ What commonly causes malnutrition in your country?
✔✔ Does malnutrition change by season? By region?
✔✔ Check every child for malnutrition.
✔✔ Look for oedema of both feet.
✔✔ Determine children’s weight for height or length.
✔✔ Determine a child’s z-score using growth charts.
✔✔ Measure the child’s MUAC and determine if less than 115mm
✔✔ If child has severe acute malnutrition, check for medical complications.
✔✔ Conduct appetite test for children over 6 months.
✔✔ Check every child for anaemia by looking for palmar pallor.
✔✔ Use your chart booklet to classify malnutrition.
✔✔ Use your chart booklet to classify anaemia.
TREAT
✔✔ Treat children with severe malnutrition for low blood sugar.
✔✔ Give RUTF to children with severe malnutrition.
✔✔ Give iron to children with anaemia.
✔✔ Give mebendazole.
✔✔ Determine feeding recommendations for your area (also refer to Module 8)
✔✔ Determine the nutritional resources in your area. Is there nutrition counselling
at your clinic or in an organization nearby? Where can you refer families for food
support? What services in your area work on issues related to food and nutrition?
COUNSEL
✔✔ Counsel a caregiver on providing RUTF safely at home.
✔✔ Counsel a caregiver on feeding recommendations.
✔✔ Use clinic resources to teach a caregiver about nutrition and food. Also refer to
module 8.
FOLLOW-UP
✔✔ Use IMCI instructions for follow-up of classifications of malnutrition and/or
anaemia.

47

MANAGING MALNUTRITION AND ANAEMIA?
Now that you have finished the module, you will answer the same questions from
the beginning of the module. This will help demonstrate what you have learned.
Circle the best answer.
1. When is it necessary to check a child for malnutrition and anaemia?
a. Check if the child appears low weight for age
b. Check every child for malnutrition and anaemia, as sometimes problems go
unnoticed
c. Check if the caregiver tells you about a feeding problem
2. Sami has a MUAC measurement of 112 mm. What does this tell you?
a. Sami is healthy
b. 112 mm is low weight, so you will advise on feeding recommendations
c. Sami is showing a sign of severe acute malnutrition
3. A child with anaemia needs:
a. Vitamin A
b. Iron
c. Glucose
4. Traci shows oedema in her feet. What are your actions?
a. Sit Traci and elevate her legs, to drain the swelling
b. Advise Tracy’s mother to cut down the salts and fats in her child’s diet
c. Urgently refer, as this is a sign of severe malnutrition
5. What is pallor palmar?
a. A sign of anaemia
b. A sign of local infection
c. A sign of severe wasting
6. What is marasmus?
a. A common skin infection in malnourished children
b. A type of malnutrition where the child is very thin and lacks fat
c. A type of malnutrition where the child has a puffy moon face and thin hair
7. Which of the following in an important measurement of wasting?
a. Weight-for-age
b. Percentage weight gain since last visit
c. Weight-for-height (or length)
48
6.12 ANSWER KEY

REVIEW QUESTIONS

QUESTION ANSWER
1 B INTRODUCTION
2 C ASSESS MALNUTRITION
3 B TREAT ANAEMIA
4 C ASSESS MALNUTRITION, TREAT MALNUTRITION
5 A ASSESS ANAEMIA
6 B INTRODUCTION TO MALNUTRITION
7 C ASSESS MALNUTRITION
EXERCISE A (INTRODUCTION)
1. Malnutrition develops when a child’s diet is missing amounts of essential vitamins,
minerals and other nutrients. There are many types of malnutrition. The causes vary
by country.
2. Malnutrition is an underlying cause in up to 35% of childhood deaths around the
world. However, children might not present with specific complaints that suggest
malnutrition or anaemia. It is possible that you or the child’s family might not even
notice or know that the child is malnourished or anaemic. This is why it is important
to check every child.
3. Answers below:
a. Puffy face TRUE
b. Distended abdomen TRUE
c. Extremely thin body TRUE
d. Oedema of the feet TRUE
e. Scaly skin on legs TRUE
f. Rash on belly FALSE
g. Lack of fat on buttocks and arms TRUE
h. Child is crying from hunger FALSE
i. Thin hair that may fall out TRUE
49
EXERCISE B (PLOT WEIGHT FOR HEIGHT)

1. 76 cm, 9 kg: Between 0 and -1
2. 80 cm, 7.5 kg: Below -3
3. 90 cm, 11.2 kg: Between -1 and -2
4. 93 cm, 11 kg: Between -2 and -3
5. 85 cm, 12 kg: Between 0 and 1
EXERCISE C (ASSESS)
1. Answers below
Below Between Between Between Between
Child is: -3 -3 and -2 -2 and -1 -1 and 0 0 and 3
a. Boy, 18 months, length 75 cm, weight 8.5 kg X

b. Boy, 30 months, height 118 cm, weight 22 kg X
c. Girl, 11 months, length 70 cm, weight 6 kg X
d. Girl, 27 months, weight 11 kg, height 95 cm X
e. Boy, 7 months, length 60 cm, weight 5 kg X
f. Girl 32 months, length 111 cm, weight 14.5 kg X This one is a trick! She is
32 months but you are given
length (presumably because
she was too weak to stand),
so you need to subtract
0.7 cm for her height.
g. Boy, 26 months, weight 14.5 kg, height 113 cm X
h. Girl, 32 months, height 111 cm, weight 16.5 kg X
i. Girl, 20 months, length 100 cm, weight 14.5 kg X
2. Which of the children above are moderately malnourished based on their Z-scores?
D, E, F
3. Which of the children above have severe acute malnutrition based on their Z-scores?
C, G
50
4. Answers below:
TICK: WRITE:
Signs of No signs
Child is: If no, why not?
SAM of SAM
a. Child’s MUAC is 112 mm X

b. Child has Z-score between -2 and -3 X Must be below -3 for SAM
c. Child has a swollen right foot and is very skinny X SAM sign is oedema of both
feet
d. Child is too weak to stand X Child could be weak for
many other reasons, this is
not alone a sign of SAM
e. Child’s MUAC is 113.5 X
f. Child has oedema of both feet X
g. MUAC is 120 mm and child is irritable X MUAC must be under 115
mm
5. Oedema of both feet. This is a sign of SAM, and especially, kwashiorkor.
EXERCISE D (ASSESS)
1. Signs:
1. MUAC at or less than 115 mm
2. Weight-for-height/length z-score less than -3
3. Oedema of both feet
2. Low body temperature is under 35 °C under-arm, or rectal under 35.5 ° or very cold
hands and feet
3. Are the following true or false statements?
a. FALSE: cannot give appetite test to child under 6 months old
b. FALSE: child should be encouraged, but not forced to consume
c. TRUE
d. TRUE
4. The minimum is 1/3 of a 92 g sachet of RUTF, to be eaten within 30 minutes.
51
EXERCISE E (CLASSIFY)
1. Answers below:
Complicated Uncomplicated
Moderate acute No acute
severe acute severe acute
a. Child has MUAC

of 112 mm and no X
complications
b. Child has WFH z-score
less than -3 and failed X
the appetite test
c. Child has MUAC of 112
mm
X
d. Child has MUAC of 117
mm and no oedema
X
e. Child’s WFH z-score is
between -1 and -2
X
f. Child has WFH z-score
between -3 and -2
X
g. Child has MUAC of 113
mm and is showing X
signs of shock
h. Child is less than 6
months, has lost weight
and not breastfeeding
X
effectively
2. These children need urgent treatment-based RUTF, deworming, Vitamin A, and

second line oral antibiotics. These children are at risk of death from serious diseases.
Check if the child is at high risk of HIV infection, whether s/he has been vaccinated
for measles, and test for malaria.
3. A child with SEVERE UNCOMPLICATED MALNUTRITION should return for follow-up
after 1 week.
52
EXERCISE F (TREAT)
1. RUTF amounts below:
a. 3.7 kg, paste available – 900 grams paste
b. 16.7 kg, sachets available – 35 sachets (92 g each)
c. 7.8 kg, sachets available – 21 sachets (92 g each)
d. 11.6 kg, paste available – 2800 grams paste
2. Should follow-up in 1 week
3. Could include the following messages:
✔✔ RUTF is a special therapeutic food for thin children only. It should not be shared.
✔✔ RUTF is the only food that thin children need for their recovery.
✔✔ For young children who are breastfeeding, continue breastfeeding.
✔✔ Always give plenty of clean water to the child to drink when giving RUTF.
✔✔ Wash hands before feeding the child.
4. Focus on counselling messages above, (b) start with who, what, why, when, where,
or how.
5. Answers below:
CONTINUE STOP WHY?
a. Tsepi (boy) now weighs 13.5 kg, Has been above -2 z-score
and is 96 cm in height. Last visit X for two consecutive visits
he weighed 13 kg.
b. Rakim’s weight has changed from Has not achieved 15%
X
20.5 kg to 23 kg. weight gain
c. Angie (girl) weighs 15.5 kg and Is not above -2 z-score
is 109 cm in height. Last visit she X
weighed 14.5.
d. Sheena’s weight has changed Has achieved 15% weight
X
from 32.5 kg to 38.0 kg. gain
e. Maria (girl) now weighs 17.2 kg Has not been above -2
and is 116 cm in height. Last visit X z-score for two consecutive
she weighed 17.3 kg. visits
53
EXERCISE G (ASSESS)
1. TERMS ARE MATCHED WITH CORRECT DEFINITION BELOW:
Anaemia A reduced number of red cells or a reduced amount of haemoglobin
in each red cell, caused by not eating foods rich in iron, parasites,
malaria, or other infections.
Oedema When an unusually large amount of fluid gathers in the child’s
tissues. The tissues become filled with the fluid and look swollen
or puffed up.
Pallor Unusual paleness of the skin, and a sign of anaemia.
RUTF A food product that is used for the safe therapeutic feeding of SAM
children.
Palmar pallor A sign that is identified by looking at a child’s palm.
2. SEVERE PALMAR PALLOR. Requires referral.
3. Treatments for SOME PALMAR PALLOR include:
✔✔ Give Iron
✔✔ Oral antimalarials (if test positive)
✔✔ Mebedenazole or other deworming treatment (if child older than one year)
54
ISBN 978 92 4 150682 3
IMCI
Module 7
Ear problems
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS
n CONTENTS
Acknowledgements 4
7.2 Introduction to ear problems 7
7.3 Assess an ear problem 10
7.4 Classify an ear problem 12
7.5 Treat an ear problem 17
7.6 Counsel a caregiver about an ear problem 19
7.7 Provide follow-up care 27
7.10 Answer key 31
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
7.1 MODULE OVERVIEW

Ear problems are a common presentation at health clinics. You will check all children
for ear problems.
check for general danger signs, assess and classify for main symptoms, then
ASK: DOES THE CHILD HAVE AN EAR PROBLEM?
NO YES

Name: Age: theWeight
colour-coded
(kg): classification
Temperature (°C):
chart for ear problems.
CLASSIFY
CONVULSIONS CONTINUE ASSESSMENT: check for malnutrition and anaemia, check immunizationRemember to use
status, HIV status, and other problems Danger sign when
selecting
classifications
MODULE LEARNING OBJECTIVES ___ breaths per minute. Fast breathing?
After you study this module, you
Lookwill be able
and listen to:
for stridor
DOES THE CHILD HAVE
Explain DIARRHOEA?
why it is necessary to check all children for ear problems. Yes __ No __
Explain why ear problems can cause long-term
Restless and irritable?ear damage and deafness.
Recognize tender swelling, theOffer
clinical
the childsign ofthemastoiditis.
fluid. Is child:
Determine if an ear infection isPinch
chronic or acute.
the skin of the abdomen. Does it go back:
Classify ear problems using IMCISlowly?
charts.
Counsel
Decide malaria risk: High ___ caregivers
Low ___ No___on wicking Look an ear
or feeldry.
for stiff neck
If more than 7Follow-up
days, has feverwith a child
been present with earLook
every for signs of according
problems MEASLES:
to IMCI guidelines.
day?
YOUR RECORDING FORM
Low risk: if NO obvious
Lookcause of feverIMCI recording form for the sick child. This section deals
at your with this
module:
5
MODULE ORGANIZATION
✔✔ Assess all children for ear problems
✔✔ Classify ear problems
✔✔ Treat ear problems
✔✔ Counsel caregiver on home treatment for ear problems
✔✔ Follow-up care for ear problems
✔✔ Module contents
BEFORE YOU BEGIN

What do you know now about managing ear problems?
Select the best answer for each question:
1. What is mastoiditis?
a. Infection of the ear drum, which can cause deafness
b. Infection that has spread from the ear to the brain
c. Infection of the bone behind the ear
2. What is a clinical sign of mastoiditis?
a. A lot of pus is seen draining from the ear
b. Tender swelling behind the ear
c. The ear has a very terrible smell
3. Why are ear problems important in IMCI?
a. Ear problems are a common health issue in children, and can cause deafness
and serious infection
b. Ear problems are a major killer of children
c. Ear problems are sign of serious brain or bone infections
4. What is an acute ear infection?
a. When one point of the ear (like the ear lobe) has a local infection
b. When the child is experiencing ear pain, and pus is draining from the ear
c. When the child has had pus draining from the ear for over a month
5. What is an important care measure for ear infections?
a. Regularly wicking the ear to keep it dry
b. Rinsing out the ear with saline water
c. Antiseptic ointment
6
7.2 INTRODUCTION TO EAR PROBLEMS

This will help you start thinking about the problem of a child with an ear problem.
n OPENING CASE STUDY – TELISA

Sara has brought in her daughter Telisa to your clinic. Telisa and Sara live some distance from the clinic. They
travelled this morning by taxi and walking. Telisa is a small girl, and she looks very tired. Her mother, Sara, sits
down and puts Telisa on her lap. She takes a strip of cloth out of her bag, pours some water into it, and holds
the rag on Telisa’s neck. She says Telisa has been feeling hot.
WHY DO YOU CHECK EVERY CHILD FOR EAR PROBLEMS?

Ear problems are a common complaint when children and caregivers come to the
clinic. Ear infections rarely cause death. However, they cause many days of illness
in children.
Ear infections are the main cause of deafness in developing countries, and
deafness causes learning problems in school. It is very important to assess, classify,
and treat an ear problem to prevent pain in the short term, and more serious
consequences in the long-term.
WHAT IS AN EAR INFECTION?

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 burst. 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.
Eardrums can burst if ear infections are not treated.

This causes long-term ear and hearing damage.
WHEN DOES AN EAR PROBLEM CAUSE SEVERE DISEASES?

Sometimes the infection can spread from the ear to the bone behind the ear (the
mastoid) causing mastoiditis. Infection can also spread from the ear to the brain
causing meningitis. These are severe diseases. They need urgent attention and
referral.
7
n How will you begin to assess Telisa?

First, you gather important information in the greeting. Sara tells you that Telisa is 3 years old. Telisa was
weighed in triage, and she weighs 13 kg. You take her temperature. It is 37.5 °C.
You ask Sara what Telisa’s problem is. Sara says that she came to the clinic today because Telisa has felt hot
for the last 3 days. Telisa also woke the past 2 nights complaining of ear pain. You praise Sara for bringing
Telisa into the clinic.
n Next, you check for general danger signs.

You ask Sara “is Telisa is able to drink?” She says yes, with no trouble. Telisa is not vomiting. Telisa has not had
convulsions. You look at Telisa’s condition. She is sitting on Sara’s lap and looking around the room. She is
holding onto her mother’s arm. Does Telisa have any general danger signs?
n Next, you will assess Telisa for main symptoms.

You ask if Telisa has a cough or any difficult breathing. Sara says no. Telisa does not have diarrhoea. Sara has
already said that Telisa has been feeling hot. Her temperature is also 37.5 °C, which is fever. You will assess
and classify Telisa for fever.
n Then you will assess Telisa’s fever.

You assess Telisa for fever because she has a temperature, and Sara says she feels hot. You ask how long Telisa
Any general
has been danger
feeling hot. Hersign Pink:
or says
mother Give risk
3 days. There is no malaria firstfor
dose of artesunate
this area. orifquinine
You ask Sara for
they have
Stiff neck. VERY SEVERE
travelled to another area in the last month. She says no. severe malaria
FEBRILE DISEASE Give first dose of an appropriate antibiotic
or Low You look to see if Telisa has signs of meningitis. You watch Telisa
Treattothe
seechild
if she to
moves her head
prevent and neck.
low blood sugarShe
ria Risk is sitting quietly. You ask her to look down at her mother’s shoes.
Give She
one bends
dose ofover easily to lookindown
paracetamol clinicatfor
the
shoes. high fever (38.5°C or above)
You check for runny nose, generalized rash, and red eyes. You ask Telisa’s mother if she has had measles in
Malaria test POSITIVE.*** Yellow: Give recommended
the last 3 months, and she says no. Given that there is no clear source of fever, you first line
quickly dooral
a malaria test to
rule out malaria. The result is negative. MALARIA antimalarial
n How will you classify Telisa’s fever? high fever (38.5°C or above)
Telisa is not in an area of malaria risk. She does not have anyFollow-up
signs of measles. She
in 3 days does not
if fever have a general
persists
danger sign, or stiff neck. If fever is present every day for more than 7
and/or FEVER: high fever (38.5°C or above)
PRESENT. of fever

ow or within Clouding of cornea or COMPLICATED antibiotic
Classify Deep or extensive mouth MEASLES**** If clouding of the cornea or pus draining
ointment
Pus draining from the eye Yellow: Give Vitamin A treatment
or MEASLES WITH EYE8 If pus draining from the eye, treat eye
Mouth ulcers. OR MOUTH infection with tetracycline eye ointment
Follow-up in 3 days
n How will you record your assessment thus far?

Name: Telisa Age: 3 years Weight (kg): 13 kg Temperature (°C): 37.5 °C
Ask: What are the child's problems? Feels hot, complaining of ear pain Initial Visit? X Follow-up Visit?
CLASSIFY
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
Yes __ No __
Slowly?
Yes __ No __
X
3
Fever,
Do malaria test if NO general danger sign no malaria
YouIfhave
Yes, forassessed Telisa
for the symptoms we have learned about so far. Now you will learn how to check
how long? ___ Days
Telisa
THENfor the next
CHECK FOR main
ACUTEsymptom: Look forYou
ear problems.
MALNUTRITION check
oedema of bothevery
feet. child for an ear problem.
Hep B0
RTV-1 RTV-2 RTV-3
Page 65 of 75
7.3 ASSESS AN EAR PROBLEM

ASK: DOES THE CHILD HAVE AN EAR PROBLEM?
Be sure to ask this question for all sick children who come to your clinic for care.
NO If the caregiver says NO, continue your assessment to malnutrition and
anaemia.
YES If the caregiver answers YES to your question about her child’s ear problem,
continue:
HOW DO YOU ASSESS FOR AN EAR PROBLEM?

To determine if a child has an ear problem, you should ask, look, and feel. Open
your ASSESS chart for ear problems. It has these instructions, which you will now
read about:
Does the child have an ear problem?
If yes, ask: Look and feel: Tender swel

Is there ear pain? Look for pus draining from ear.
Is there ear discharge? the ear. Classify EAR PROBLEM
If yes, for how long? Feel for tender swelling
Pus is seen
behind the ear.
the ear and
reported for
days, or
ASK: DOES THE CHILD HAVE EAR PAIN? Ear pain.
Ear pain can mean that the child has an ear infection. If the caregiver is not sure Pus is seen
the ear and
that the child has ear pain, ask if the child has been irritable and rubbing his ear.
reported for
more.
ASK: IS THERE DISCHARGE FROM THE EAR? No ear pain a
No pus seen
Use words the caregiver understands. If the caregiver answers “yes,” ask how long the ear.
the child has had the discharge. Give her time to answer the question. She may
need to remember when the discharge started. You will classify and treat the ear
problem depending on how long the ear discharge has been present.
n Ear discharge reported for 2 weeks or more (with pus seen draining from the
ear) is treated as a chronic ear infection.
n Ear discharge reported for less than 2 weeks (with pus seen draining from the
ear) is treated as an acute ear infection.
LOOK: IS THERE PUS DRAINING FROM THE EAR?

Look inside the child’s ear to see if pus is draining. That is a sign of infection, even
if the child is not feeling any pain. Draining pus is a sign of infection.
FEEL: IS THERE TENDER SWELLING BEHIND THE EAR?

If both tenderness and swelling are present, the child may have mastoiditis,
a deep infection in the mastoid bone. Feel behind both ears. Compare them and
decide if there is tender swelling of the mastoid bone. In infants, the swelling may be
above the ear. Do not confuse this swelling of the bone with swollen lymph nodes.
10
Answer the following questions about assessing an ear problem.
1. Ear problems can be the result of:
a. Acute or chronic ear infections
b. Mastoiditis
c. Fever
2. What is mastoiditis? What signs you will look for to see if the child has
mastoiditis?
4. What is a chronic ear infection?
11
7.4 CLASSIFY AN EAR PROBLEM

HOW DO YOU CLASSIFY AN EAR PROBLEM?
There are four classifications for an ear problem. In order of seriousness, they are:
1. MASTOIDITIS
2. ACUTE EAR INFECTION
3. CHRONIC EAR INFECTION
4. NO EAR INFECTION
Open to your classification chart for ear problems. What do you see?
Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
ear. MASTOIDITIS Give first dose of paracetamol for pain
Classify EAR PROBLEM Refer URGENTLY to hospital
Pus is seen draining from Yellow: Give an antibiotic for 5 days
the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR
the ear. INFECTION
Now you will read more about each of these classifications.
MASTOIDITIS (RED)
If a child has tender swelling behind the ear, classify the child as having
MASTOIDITIS.

Refer to hospital urgently. This child needs treatment with injectable antibiotics
(ceftriaxone). He may also need surgery. Before the child leaves for hospital, give the
first dose of the antibiotic and give one dose of paracetamol if the child is in pain.
ACUTE EAR INFECTION (YELLOW)

If you see pus draining from the ear and discharge has been present for less than
two weeks, classify the child’s illness as ACUTE EAR INFECTION.
If the caregiver says that the child has ear pain, ask whether the pain wakes
the child at night. If the child is able to tell you that the ear is hurting or if the child
is distressed with pain or the caregiver tells you the child has been distressed with
pain earlier, classify as ACUTE EAR INFECTION.
However if the only history is that the child seems to have been scratching or pulling
the ear but otherwise does not appear to be in pain, do not classify. Explain to the
caregiver that children often rub their ears and it is not always a sign of ear pain.
Page 8 of 75
12

Give a child with an ACUTE EAR INFECTION amoxycillin for 5 days. Antibiotics
for treating pneumonia are also effective against the bacteria that cause most ear
infections. Give paracetamol to relieve the ear pain (or high fever). If pus is draining
from the ear, dry the ear by wicking.
The child should be seen again after 5 days if there is still pain or if the ear is still
discharging. A follow-up visit after 14 days must be scheduled for all children with
ACUTE EAR INFECTION.
CHRONIC EAR INFECTION (YELLOW)

If you see pus draining from the ear and discharge has been present for two
weeks or more, classify the child’s illness as CHRONIC EAR INFECTION.

Most bacteria that cause CHRONIC EAR INFECTION are different from those
causing acute ear infections. Do not give antibiotics to a child with a chronic ear
infection. Appropriate drops (usually acetic acid) if available, are instilled into the
ear after drying the ear by wicking whenever pus can be seen.
The most important and effective treatment for CHRONIC EAR INFECTION is to
keep the ear dry by wicking. You will learn to teach the caregiver how to do this in
the COUNSEL section.
NO EAR INFECTION (GREEN)

If there is no ear pain (or pain that does not wake the child at night) and no pus is
seen draining from the ear, the child’s illness is classified as NO EAR INFECTION.

The child needs no additional treatment.
An infant or small child that is irritable and slightly feverish – but does not have
ear pain – may have an ear infection, but is unable to locate the pain. This child will
have a fever for which no cause is obvious, so you will ask the caregiver to bring the
child back after two days if there is no improvement. One reason for doing this is
because by then there may be pus draining from the ear.
13
IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS Danger sign when
selecting
classifications
n How will you assess and classify Telisa for ear problems? Look and listen for stridor
You
DOEShave THE assessed
CHILD HAVE and classified
DIARRHOEA?Telisa for general danger signs, cough or difficult breathing, diarrhoea, Yes __ No and
__
fever. Next you will ask
about the next main symptom, ear problems.
Telisa’s mother has already mentioned
that an ear problem is part of the reason they came Restlesstoandthe clinic today.
irritable?
n How will you assess Telisa’s ear problem? Not able to drink or drinking poorly?
Sara said she came to the clinic because Telisa Very
has slowsly
ear pain.(longerThe
then child cried most of the night because her ear
2 seconds)?
hurt. You ask if there is discharge coming from Slowly?
Telisa’s ear. Sara says there has been discharge on and off for
about a year. You look but you do not see any
pus draining from the child’s ear. You feel behind Telisa’s
ears.
YouFor
feel tender swelling
how long? ___ Days behind one ear. Look for runny nose
n How will you classify Telisa’s ear problem?
You
Highhave fever cases one clinical signs from your assessment: tender swelling behind
risk: allidentified the ear. Telisa’s mother
says there has been discharge in the past, but you do not see any.
lastHow
n will you complete this section
3 months: ofareTelisa’s
If yes, recording
they deep and extensive? form?
n With these signs, how will you classify? Look for palmar pallor.
You classify
If child as MASTOIDITIS.
has MUAC Inmm
less than 115 theor
next section
Is thereyou will learn
any medical about identified treatments.
complication?
Tender swelling behind the Pink: For a child 6 months or older Give first
offer RUTFdose
to eat. Isof
thean appropriate antibiotic
child:
ear. MASTOIDITIS Not able to finish orGive first dose of paracetamol for pain
able to finish?
PROBLEM Refer URGENTLY to hospital
Pus is seen
Mother's draining
HIV test: from POSITIVE
NEGATIVE
Yellow:NOT DONE/KNOWN Give an antibiotic for 5 days
the earvirological
Child's and discharge is POSITIVE
test: NEGATIVE ACUTE EAR
NOT DONE Give paracetamol for pain
If reported for lessand
mother is HIV-positive than 14 virologicalINFECTION
NO positive test in child: Dry the ear by wicking
days, or breastfeeding now?
Is the child
Follow-up in 5 days
Ear pain.
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today)
Yellow: Return for next
Pus is seen draining from Measles1
Dry the Measles
ear by2 wicking
Vitamin A immunization on:
the ear and
OPV-0 discharge isOPV-2
OPV-1 CHRONIC
OPV-3 EAR Treat with topical quinolone eardrops
Mebendazole for 14 days
________________
B1 days orHep B2
Hep14 Hep B3 (Date)
Hep reported
B0 for INFECTION Follow-up in 5 days
RTV-1 RTV-2 RTV-3
more. Pneumo-1 Pneumo-2 Pneumo-3
the ear. INFECTION
Page 65 of 75
14
How will you classify the following children?
1. You can see pus draining from Ben’s ear. His grandmother tells you it has been
happening for about 3 months.

2. Leboheng is not able to sleep because he says his ears hurt. There has been
discharge for less than 1 week.

3. Akiiki has a fever. You feel swelling behind her ear, and she cries when you touch
this area.

4. Khotso wakes up at night crying because his right ear hurts.
5. Jamie says that his ears hurt. He does not wake up at night from pain. You do
not see discharge. You ask the mother if there is pus draining from the ear. She
says no.

15
Record Dana’s signs of ear problem and classify them on the Recording Form.
Dana is 18 months old. She weighs 9 kg. Her temperature is 37 °C. Her mother said
that Dana had discharge coming from her ear for the last 3 days. Dana does not have
any general danger signs. She does not have cough or difficult breathing. She does not
have diarrhoea and she does not have fever. The health worker asked about Dana’s
ear problem. The mother said that Dana does not have ear pain, but the discharge
has been coming from the ear for 3 or 4 days. The health worker saw pus draining
from the child’s right ear. She did not feel any tender swelling behind either ear.

Danger sign when
selecting
classifications
Slowly?
CHECK FOR HIV INFECTION 16
7.5 TREAT AN EAR PROBLEM

HOW WILL YOU TREAT AN EAR PROBLEM?
Open to your ear problem classification table. What treatments are identified in
the TREATMENT column?
➞ Give ceftriaxone IM – you learned about this in Module 3
➞ Give paracetamol – you learned about in Module 5
➞ Give amoxicillin – you learned about giving oral drugs in Module 3
➞ Teach the to wick the ear
➞ Give recommended ear drops
You will read more about counselling on wicking the ear in the next section. Now
let us return to Telisa’s case to determine what treatment she requires.
n What treatment does Telisa require?

You have classified Telisa’s ear problem as MASTOIDITIS. This is a red classification. It requires urgent referral.
n What
Tenderurgent
swelling pre-referral treatments are required
behind the Pink: fordose
Give first Telisa?
of an appropriate antibiotic
ear. MASTOIDITIS Give first dose of paracetamol for pain
Review what you have classified Telisa with today:
PROBLEM Refer URGENTLY to hospital
•• FEVER and Yellow:
Pus is seen draining from Give an antibiotic for 5 days
the ear and discharge is
•• MASTOIDITIS ACUTE EAR Give paracetamol for pain
Whatdays,
pre-referral
or treatments are identified in bold in these classification tables?
Follow-up in 5 days
Ear pain.
Tender swelling
Pus is seen behind
draining the Pink:
from Yellow: Give
Dry thefirst
eardose of an appropriate antibiotic
by wicking
ear.
the ear and discharge is MASTOIDITIS
CHRONIC EAR Give
Treat with topicalof
first dose paracetamol
quinolone forfor
eardrops pain
14 days
PROBLEM Refer URGENTLY
reported for 14 days or INFECTION Follow-up in 5 daysto hospital
more.
the ear pain
No ear and and
discharge is Green:
ACUTE EAR Give paracetamol for pain
No treatment
reported for less
No pus seen than from
draining 14 INFECTION
NO EAR Dry the ear by wicking
days, or
the ear. INFECTION Follow-up in 5 days
Ear pain.
These are the required pre-referral treatments before you send Telisa to the hospital:
reported
1. Give for 14 daysantibiotic
an appropriate or INFECTION Follow-up in 5 days
more.
2. Give first dose of paracetamol
the ear. INFECTION
17
n How will you prepare Telisa and Sara for referral?

You will prepare a referral note for Sara to carry with her to the hospital. You will also counsel Sara on why
Telisa must be referred.
Sara is confused when you tell her Telisa must go to the hospital. She says that all children have fevers and ear
problems. She did not think that this was so serious. She is worried that her husband will not want her to go
to the hospital today. He already did not think that it was necessary to come today. He said that all children
have pain in their ears and it goes away. It is a small issue. She says that Telisa is moving around fine, besides
the ear pain.
n How will you address Sara’s concerns?
You explain to Sara that yes, ear problems are often common with children. You explain that Telisa has a
problem in her ear that is now outside of her ear, in the bone. You explain that this is serious and must be
treated.
Sara still seems unsure.
You explain more. If the ear problem is not treated, it could cause more damage. It could cause damage
to her ears, and damage her ability to hear properly. It could also spread to other parts of her body, like
her brain. You tell Sara that this is why Telisa has a fever and is feeling hot. Her body is trying to fight the
infection.
Sara now looks panicked and afraid. You tell her not to be afraid, but that you are telling her these things so
she understands what is causing Telisa’s ear problem. You are firm and tell Sara that if she goes immediately
to the hospital, they can provide more care for Telisa. They will treat the infection.
18
7.6 COUNSEL A CAREGIVER ABOUT AN EAR PROBLEM

WHAT ARE GOOD COMMUNICATION SKILLS FOR HOME
TREATMENT?
Good communication is critical when teaching a caregiver about home treatment. It
is also important to never be judgemental when speaking to the caregiver. Remember
the APAC process when you are counselling:
ASK questions to find out what the caregiver is already doing for the child.
PRAISE the caregiver for what she has done well.
ADVISE her how to treat the child at home. Use the teaching steps below.
CHECK the caregiver’s understanding
WHAT ARE THE IMPORTANT STEPS WHEN TEACHING A CAREGIVER?

1. GIVE INFORMATION – about a home treatment. Ask checking questions to
make sure she understood the information. She needs to know:
a. How to give the treatment
b. Hot much to give 1. Give information
c. For how long to give the
treatment
d. Why the treatment is
important, and what the 2. Show an example
drugs will be doing. 3. Let caregiver practise
2. SHOW AN EXAMPLE – for
example, how to hold the
child still and wick the ear.
It may be enough to ask the caregiver to describe how she will do the task at
home.
3. LET HER PRACTICE – ask the caregiver to do the task while you watch. For
example, have the caregiver wick the child’s ear. Letting a caregiver practice is
the most important part of teaching a task.
HOW WILL YOU COUNSEL THE CAREGIVER TO WICK THE EAR?

To teach a caregiver how to dry the ear by wicking, first tell her it is important to keep
an infected ear dry to allow it to heal. Then show her how to dry wick her child’s ear.
As you wick the child’s ear dry, tell the caregiver to:
•• Use clean, absorbent cotton cloth or soft strong tissue paper for making a wick.
Paper towels used in some clinics are also suitable. Do not use a cotton-tipped
applicator, a stick or flimsy paper that will fall apart in the ear.
•• Clean the child’s ear with the wick and then place a clean wick in the child’s ear
until the wick is wet.
19
•• Replace the wet wick with a clean one.

•• Repeat these steps until the wick stays dry. Then the ear is dry.
Observe the caregiver as she practises
Give feedback. When she is finished, give her the following information.
What is important information for wicking the ear?

•• Wick the ear dry 3 times daily.
•• Use this treatment for as many days as it takes until the wick no longer gets
wet when put in the ear, and no pus drains from the ear.
•• Do not place anything (oil, fluid, or other substance) in the ear between dry
wicking treatments. Recommended ear drops (1% acetic acid) can be used if these
are available. If these ear drops are not available, then none should be used. Do
not plug the ear – it needs air to dry out. Do not allow the child to go swimming.
No water should get in the ear.
HOW WILL YOU CHECK TO BE SURE THE CAREGIVER

UNDERSTANDS?
If the caregiver thinks she will have problems wicking the ear dry, help her solve
them. Ask checking questions, such as:
•• “What materials will you use to make the wick at home?”
•• “How many times per day will you dry the ear with a wick?”
•• “What else will you put in your child’s ear?”
COUNSEL ON WHEN TO RETURN

For an ACUTE or CHRONIC EAR INFECTION, the child should follow-up in 14
days.
Any sick child should return immediately if they:
✔✔ Not able to drink or breastfeed
✔✔ Become sicker
✔✔ Vomiting everything
✔✔ Convulsions
20
Answer the following questions about treatment.
1. Paracetemol is given when a child’s temperature is what degrees?
2. How often should a caregiver wick the ear dry?
3. What is important information to tell a caregiver about wicking an ear?
4. When should a child with an ear infection return for follow-up?
INTRODUCTION TO EXERCISE: You are going to read about four important skills
when counselling a caretaker. These skills focus on building a caregiver’s confidence.
This is important for a caregiver to feel confident, informed, and supported when
caring for a child and providing treatment and good feeding.
In the following pages, there will be a section explaining each skill. It will be followed
by a set of exercises about the skill you just read about. You will begin with skill 1 below.
Skill 1: Acknowledge how the caregiver thinks and feels.

What is this skill?
It is important not to disagree with a caregiver; it is also important not to agree
with a mistaken idea. You may want to suggest something quite different. That
may be quite difficult if you have already agreed with her. Instead you just accept
how she thinks or feels. This means responding in a neutral way, and not agreeing
or disagreeing.
Example: Many caregivers have the idea that ‘My milk is weak and thin.’ What are
the possible ways you can respond to this?
Inappropriate response: ‘Oh no milk is never weak and thin’
Agreeing: ‘Yes, thin and weak milk can be a problem’
Accept: ‘I see, you are worried about your milk’ or ‘Ah-ha’
Reflecting back and giving simple responses are useful ways to show acceptance.
These are also good listening and learning skills.
Example: It is important to accept how the caregiver feels. You let her know that
you understand the emotions she is feeling about her child’s health. For example,
a caregiver might say ‘My baby has a cold and blocked nose and just cries all the
time.’ Which response accepts how the caregiver feels?
•• Don’t worry, your baby is doing very well.
•• You are upset about him, aren’t you?
•• Don’t cry, it’s not serious. He will soon be better.
21
The second response here recognizes how the caregiver feels: she is upset and
worried. On the other hand, the first and third responses do not accept how she
feels. Instead they seem to argue against her.
SKILL 1 EXERCISE:
For each of the following scenarios write another response that shows you accept
what the caregiver thinks or feels.
CAREGIVER SAYS: HEALTH WORKER RESPONSE:
1. ‘It is so hot that I am giving him water.’
2. ‘I am so worried because he refuses
to take any porridge, he just wants to
breastfeed.’
3. ‘I am giving him some porridge in a
bottle, and he really likes it.’
4. Mother is HIV positive: ‘He cries so
much at night I have to breastfeed him
or else he will wake the whole family.’
5. Caregiver of an 11-month old baby: ‘I
never give him egg or meat, he will get
an allergy’
6. ‘My child does not want to eat. I have
to close his nose and put food into his
mouth.’
Skill 2: Recognize and praise what a caregiver and

baby are doing right.
What is this skill?
We are trained to look for problems. This means that we see only what we think
people are doing wrong, and try to correct them. If you tell a caregiver she is doing
something wrong, you make her feel bad, and that reduces her confidence. As
counsellors we must look for what caregivers and babies are doing right. We must
recognize what they do right and then we should praise or show approval of the
good practices.
Praising good practices has these benefits:
•• It builds a caregiver’s confidence,
•• Encourages her to continue those good practices and
•• Makes it easier for her to accept suggestions later.
Example: You are weighing a baby together with his caregiver. He is exclusively
breastfed. He has gained some weight in the last month, however his growth line
shows that he is growing too slowly. Which of these remarks will help build the caregivers
confidence?
•• ‘Your baby’s growth line is going up too slowly’
•• ‘I don’t think your baby is gaining enough weight’
•• ‘Your baby gained weight last month just on your breastmilk’
22
SKILL 2 EXERCISE
In the scenarios bellows, there are three responses that are good things to say
to the caregiver. Tick the response that best praises the caregiver.
1. A mother has started bottle-feeding her baby by day while she is at work. She
breastfeeds as soon as she gets home, but the baby does not want to suckle as
much as he did before.
 You are very wise to breastfeed whenever you are at home.
 It would be better if you gave him artificial feeds by cup and not by bottle
 Babies often do stop wanting breastfeeds when you start giving bottles.
2. A 15 month old child is breastfeeding and having thin porridge and sometimes
tea and bread. He has not gained weight for 6 months and is thin and miserable.
 He needs to eat a more balanced diet.
 It is good that you are continuing to breastfeed him at this age, as well as
giving him other food.
 You should be giving him more than breastmilk and thin porridge at this age.
In the scenarios below, write your own response to the caregiver.
3. A 3 month old is completely bottle fed, and has diarrhoea. The growth chart
shows that he weighed 3.5 kg at birth. He has gained only 200 grams in the last
two months. The bottle smells very sour.
4. Neera comes to the clinic to learn how to take her 3 month old baby off the
breast. She is HIV positive and is going back to work soon. She is breastfeeding
and giving him bottles, which Neera is refusing, so she asks you to advise her.
Neera is alert and active.
23
Skill 3: Give a little relevant information

Caregivers often need information about feeding, but it is important to give
information that is relevant to her situation now. Try to give her only one or two
pieces of information at a time, especially if the caregiver is tired and has already
received a lot of advice. Give information in a positive way, so that it does not sound
critical, or make the caregiver feel she is doing something wrong. This is especially
important if you want to correct a mistaken idea. Wait until you have built the
caregiver’s confidence by accepting what she says, and praising what she does well.
SKILL 3 EXERCISE
Read each scenario below. Which response gives information that is more
relevant? Tick your answer.
1. Lerato is 2 months old, breastfeeding exclusively, and gaining weight happily.
Now she suddenly seems hungry, and she wants to feed more often. Her caregiver
thinks that she does not have enough milk.
 Oh, Lerato is growing well. Don’t worry about your breastmilk supply. It is best
to breastfeed exclusively for 6 months, and then you can start complementary
feeds.
 Lerato is growing fast. Healthy babies have these hungry times when they
grow fast. Lerato’s growth chart shows she is getting all the breastmilk she
needs. She will settle in a few days.
2. Joseph is 3 months old. His mother recently started giving him some bottle
feeds in addition to breastfeeding. The baby has started having diarrhoea. She
asks you if she should stop breastfeeding.
 It is good that you asked before deciding. Diarrhoea usually stops sooner if
you continue breastfeeding.
 Oh no, don’t stop breastfeeding. He may get worse if you do that.
3. You are talking with the mother of a 15 month old child who is no longer
breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feeds
of cow’s milk and 1 meal of family foods each day. His diet has not changed since
the diarrhoea started.
 Your child needs more food each day. Try to give him 3 family meals plus 2
feedings between meals.
 Give your child amasi or yoghurt instead of milk (until the follow-up visit in
5 days). Or give only half the usual milk and increase the amount of family
foods to make up for this
24
Skill 4: Use simple language

Health workers often use technical terms when they talk to caregivers, and
caregivers do not understand them. It is important to use simple familiar terms to
explain things to caregivers.
SKILL 4 EXERCISE:
Restate the following advice in simpler words:
1. Give foods that are high in energy and nutrient content in relation to volume
2. Consider starting a ‘safe transition’
3. When your baby suckles, prolactin is released which makes breasts secrete more
milk.
Skill 5: Make one or two suggestions, not commands

When you counsel a caregiver, you suggest what she could do. Then she can decide if
she will try it or not. This leaves her feeling in control, and helps her to feel confident.
You must be careful not to tell or command her to do something. This does not help
her feel confident. Commands use the imperative form of verbs (give, do, bring)
and words like always, never, must, should be avoided.
Suggestions include:
•• Have you considered…?
•• Would it be possible…?
•• What about trying…to see if it works for you?
•• Would you be able to?
•• Have you thought about…? Instead of …?
•• You could choose between… and ….
•• Usually… sometimes… often..
25
SKILL 5 EXERCISE
Rewrite the following as suggestions, not commands
1. Use a cup to feed your baby.
2. Do not give cereal or juice as a substitute for milk if your baby is under 6 months
old.
3. Give your child 5 meals a day and add a teaspoon of oil to each feed.
4. Never give your baby water; he does not need it if he is breastfeeding.
5. Always remember to give the child his own serving.
6. You must wash your hands before preparing the formula.
26
7.7 PROVIDE FOLLOW-UP CARE

WHEN WILL CHILDREN FOLLOW-UP FOR ACUTE EAR INFECTIONS?
If the child has an ACUTE EAR INFECTION:
➞ Follow-up in 5 days: If discharge persists
➞ Follow up in 14 days: If discharge does not persist
If the child has a CHRONIC EAR INFECTION, they will follow-up in 14 days. During
a follow-up visit, follow the instructions in the follow-up box of the Chart Booklet.
Reassess the child for ear problem and check for fever. Then select treatment based
on the child’s signs.
REMEMBER! If you feel tender swelling behind the ear:

The child may have developed mastoiditis. If there is a high fever (axillary temperature of
38.5 °C or above), the child may have a serious infection. A child with tender swelling behind
the ear or high fever has become worse, and thus needs URGENT REFERRAL.
ACUTE EAR INFECTION (follow-up 5 days if persists)

 NO EAR PAIN OR DISCHARGE
Praise the caregiver. Advise her to come back to the clinic immediately if the ear
becomes painful or starts to discharge again.
 EAR PAIN OR DISCHARGE PERSISTS

If ear pain or discharge persists after 5 days of antibiotics treat with 5 additional
days of the same antibiotic. Continue wicking if ear discharge is still present.
Ensure the caregiver is properly wicking. Ask the following, and correct if
necessary:
•• To describe or show you how she wicks the ear
•• How frequently the ear is wicked
•• What problems are faced when wicking, and discuss how to overcome them
Discuss with her the importance of keeping the ear dry so that it will
heal. Encourage her to continue wicking the ear. Show her how to give ear drops,
if available. Explain that drying is the only effective therapy for a draining ear.
Hearing loss could occur if the ear is not wicked.
Ask the caregiver to return in 5 days so that you can check whether the
ear infection is improving. It is important that the child has a follow-up visit to
ensure that mastoiditis has not developed and to ensure that the ear is being wicked
(if ear discharge). After 2 weeks of adequate wicking, refer if discharge persists.
REFER if no improvement after 14 days despite ear drops and adequate
wicking.
27
CHRONIC EAR INFECTION (follow-up 14 days)

 NO EAR PAIN OR DISCHARGE
Praise the caregiver. Advise her to come back to the clinic immediately if the ear
becomes painful or starts to discharge again.
 EAR PAIN OR DISCHARGE PERSISTS

Check that the caregiver is wicking the ear correctly, using the steps above. Explain
the importance of properly wicking the ear.
Review in 14 days. If no improvement (persistent pain or offensive discharge or
reduced hearing), refer.
 NO IMPROVEMENT DESPITE EAR DROPS AND ADEQUATE WICKING

If there is no improvement despite proper care, refer the child.
28

HOW WILL YOU BEGIN TO PRACTICE THIS MODULE IN YOUR CLINIC?
skills and using your job aids will help you to better understand how to use IMCI
for ear problems.
ASSESS
✔✔ Check every child for malnutrition and anaemia.
✔✔ Look for draining pus.
✔✔ Feel for tender swelling behind the ear.
✔✔ Ask how long the ear has been draining, in order to determine if the infection
is acute or chronic.
CLASSIFY
✔✔ Use your chart booklet to classify ear problems.
✔✔ Identify any pre-referral treatments if required.
TREAT & COUNSEL

✔✔ Give paracetamol for high fever.
✔✔ Give amoxicillin for infection.
✔✔ Give ceftriaxone IM if required before an urgent referral.
✔✔ Teach a caregiver to wick the ear dry. Demonstrate and let her practice. Give
feedback.
FOLLOW-UP
✔✔ Follow the IMCI instructions for follow-up with children who were classified
with ear problems.

29

MANAGING EAR PROBLEMS?
1. What is mastoiditis?
a. Infection of the ear drum, which can cause deafness
b. Infection that has spread from the ear to the brain
c. Infection of the bone behind the ear
2. What is a clinical sign of mastoiditis?
a. A lot of pus is seen draining from the ear
b. Tender swelling behind the ear
c. The ear has a very terrible smell
3. Why are ear problems important in IMCI?
a. Ear problems are a common health issue in children, and can cause deafness
and serious infection
b. Ear problems are a major killer of children
c. Ear problems are sign of serious brain or bone infections
a. When one point of the ear (like the ear lobe) has a local infection
b. When the child is experiencing ear pain, and pus is draining from the ear
c. When the child has had pus draining from the ear for over a month
5. What is an important care measure for ear infections?
a. Regularly wicking the ear to keep it dry
b. Rinsing out the ear with saline water
c. Antiseptic ointment
30
7.10 ANSWER KEY

REVIEW QUESTIONS
QUESTION ANSWER
1 C INTRODUCTION, ASSESS
2 B ASSESS
3 A INTRODUCTION
4 B CLASSIFY
5 A CLASSIFY, TREAT, COUNSEL
EXERCISE A
1. A and B
2. Mastoiditis is a deep infection in the mastoid bone, which is behind the ear. You will
look for tenderness and swelling behind the ear at the mastoid bone. This might be
a sign of mastoiditis. It is important not to confuse this swelling of the bone with
swollen lymph nodes.
3. A chronic infection is when there has been discharge from the ear for longer than
2 weeks.
4. An acute ear infection has had discharge for less than 2 weeks.
31
EXERCISE B

Name: Dana Age: 18 months Weight (kg): 9 kg Temperature (°C): 37 °C
What are the child's problems? Discharge from ear for three days
Yes ___ No ___
Danger sign when
selecting
classifications
Yes __ No __
Yes __ No __
Slowly?
Yes __ No __
DOES THE CHILD HAVE AN EAR PROBLEM? X
Yes __ No __
Is there ear pain? Look for pus draining from the ear Yes Acute ear
3-4
If Yes, for how long? ___ Days infection
EXERCISE C Severe palmar pallor? Some palmar pallor?
If child has MUAC less thanEAR
1. CHRONIC 115 INECTION
mm or Is there any medical complication?
2. ACUTE EAR INECTION Any severe classification?
3. MASTOIDITIS Not able to finish or able to finish?
4. ACUTE EAR INECTION
5. NO EAR INFECTION
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 32
Mebendazole
immunization on:
________________
Hep B0
RTV-1 RTV-2 RTV-3
EXERCISE D
1. 38.5 degrees C or more
2. They should wick the ear 3 times a day, for as many days as necessary until the ear
is dry and no pus drains from the ear.
3. Some important information is:
a. Use clean, absorbent cotton cloth or soft strong tissue paper for making a wick.
Paper towels used in some clinics are also suitable. Do not use a cotton-tipped
applicator, a stick or flimsy paper that will fall apart in the ear.
b. Clean the child’s ear with the wick and then place a clean wick in the child’s ear
until the wick is wet.
c. Replace the wet wick with a clean one.
d. Repeat these steps until the wick stays dry. Then the ear is dry.
4. In 14 days
EXERCISE E
Skill 1: Acknowledge how the caregiver thinks and feels
TO ANSWER: For each case, write a response that acknowledges or accepts how the
caregiver thinks or feels.
1. Caregiver: “It is so hot that I am giving him water”
Health worker: I can understand that you want to give him water
when it is so hot.
2. Caregiver: “I am so worried – he refuses to take any porridge,
he just wants to breastfeed.”
Health worker: I can see that you are worried that he does not want
to eat porridge.
3. Caregiver: “I am giving him some porridge in a bottle, and
he really likes it.”
Health worker: He certainly seems to like porridge in the bottle, or
Many caregivers put porridge into the babies’
bottles.
4. HIV positive mother: “He cries so much at night, I have to breastfeed
him or else
he will wake the whole family.”
Health worker: It is very considerate of you not to want to wake the
family when you get up to prepare a feed.
5. Caregiver of an 11 month old: “I never give him egg or meat, he will get an
allergy.”
Health worker: Yes, it is a common belief that giving infants meat or
eggs cause an allergy.
6. Caregiver: “My child does not want to eat. I have to close his
nose and put food into his mouth.”
Health worker: It can be very frustrating when a child does not
want to eat.
33
Skill 2: Recognize and praise what a mother and baby are doing right
TO ANSWER: In stories 1 and 2, there are three responses. They are all things you might
want to say. Tick the response that praises what the mother is doing right. For stories
3 and 4, write a praising response of your own.
1. A mother has started bottle-feeding her baby by day while she is at work. She
breastfeeds as soon as she gets home, but the baby does not want to suckle as
much as he did before.
— You are very wise to breastfeed whenever you are at home
— It would be better if you gave him artificial feeds by cup and not by bottle
— Babies often do stop wanting breastfeeds when you start giving bottles
2. A 15 month old child is breastfeeding, having thin porridge and sometimes tea and
bread. He has not gained weight for 6 months and is thin and miserable.
— He needs to eat a more balanced diet
— It is good that you are continuing to breastfeed him at this age, as well as giving him
other food
— You should be giving him more than breastmilk and thin porridge at this age
3. A 3 month old is completely bottle fed, and has diarrhoea. The growth chart shows
he weighed 3.5 kg at birth, and he has only gained 200 grams in the last two months.
The bottle smells very sour. It is good that you brought the Growth Chart today,
so that we can see how he is growing.
4. Neera comes to the clinic to learn how to take her 3 month old off the breast. She
is HIV positive and going back to work soon. She is breastfeeding and giving him
bottles, which he is refusing, so she asks you to advise. The baby is alert and active. It
is good of you to bring your bright baby boy to get advice on the feeding difficulty.
Skill 3: Give a little relevant information

1. Lerato is growing fast. Health babies have these hungry times when they grow fast.
Lerato’s Growth Chart shows that she is getting all the breastmilk she needs. She
will settle in a few days.
2. It is good that you asked before deciding. Diarrhoea usually stops sooner if you
continue breastfeeding.
3. Your child needs more food each day. Try to give him 3 family meals plus 2 feedings
between meals.
34
Skill 4: Use simple language

TO ANSWER: Restate the following advice in simpler words:
•• Give foods that are high in energy and nutrient content in relation to volume.
NEW: It is important to give him food which helps him to grow without making him feel
too full.
•• Consider starting a “safe transition”.
NEW: It is time for us to think about getting him used to other milk as you stop
breastfeeding.
•• When your baby suckles, prolactin is released which makes breasts secrete more milk.
NEW: Every time your baby suckles your breast makes more milk.
Skill 5: Make one or two suggestions, not commands

TO ANSWER: Rewrite as suggestions rather than commands (you can use your own
language):
•• Use a cup to feed your baby.
NEW: You may wish to try feeding him with a cup.
•• Do not give cereal or juice as a substitute for milk if your baby is under 6 months old.
NEW: Once your baby is 6 months old you could think about giving him some cereal
and a little juice.
•• Give your child 5 meals a day and add a teaspoon of oil to each feed.
NEW: As your child is growing he needs more food. Five meals a day with a little oil
added to each meal should be just right for him.
•• Never give your baby water; he does not need it if he is breastfeeding.
NEW: Babies don’t need extra water as long as they are fully breastfed.
•• Always remember to give the child his own serving.
NEW: By always giving your child his own serving you can see exactly how much he is
eating.
•• You must wash your hands before preparing the formula.
NEW: It is advisable for you to wash your hands before preparing the formula.
35
ISBN 978 92 4 150682 3
IMCI
Module 8
HIV/AIDS
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n CONTENTS
Acknowledgements 4
8.2 Basic information about HIV 9
8.3 HIV testing 16
8.4 Assess & classify a sick child 24
8.5 Assess & classify a sick young infant 31
8.6 Prophylaxis and other preventative measures 36
8.7 Counsel HIV-infected mothers about infant feeding 47
8.8 Antiretroviral treatment 63
8.9 Providing follow-up care 91
8.11 Answer key 111
ANNEXES
Annex 1 Clinical staging 121
Annex 2 Treatment dosing tables 123
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
8.1 MODULE OVERVIEW

This module will teach you how IMCI can assist in providing critical HIV/AIDS care,
treatment, support, and prevention.
Worldwide, 3.4 million children were living with HIV in 2011
First, this module will explain basic information about HIV and how children are
infected. This information will help you better manage children with suspected or
confirmed infection. Next, you will learn how to assess and classify HIV in young
infants and children. You will learn how to provide follow-up care for exposed
and infected children. The module will also explain how to counsel HIV-positive
mothers about safe feeding, and methods for further preventing illness in exposed
and infected children. Lastly, you will learn how to provide antiretroviral treatment
and provide follow-up.
MODULE OBJECTIVES
✔✔ Explain in basic terms how HIV affects the immune system
✔✔ Explain how children are infected with HIV
✔✔ Assess and classify a child for HIV
✔✔ Assess and classify a young infant for HIV
✔✔ Provide follow-up care to HIV exposed and infected children that are not on ART
✔✔ Counsel an HIV-infected mother about safe infant feeding, and preventing
common illnesses in infants and young children exposed to, or infected with,
HIV through cotrimoxazole prophylaxis, ARV prophylaxis, immunization, and
Vitamin A supplementation
✔✔ Explain and provide the recommended ARV regimens for children
✔✔ Explain the criteria for initiating ART in children at first-level facilities
✔✔ Describe the WHO paediatric clinical staging process
✔✔ Identify the possible side effects of ARV drugs and explain the management of
possible side effects
✔✔ Counsel the caregiver on giving ART and adherence
✔✔ Explain the principles of good follow-up care
✔✔ Provide chronic care for children with confirmed HIV infection and on ART
5
MODULE ORGANIZATION
This module is divided into multiple sections:
1. BASIC INFORMATION ABOUT HIV
2. HIV TESTING
3. ASSESSING & CLASSIFYING A CHILD FOR HIV
4. ASSESSING & CLASSIFYING A YOUNG INFANT FOR HIV
5. PROPHYLAXIS AND PREVENTIVE MEASURES
6. COUNSELLING THE HIV-POSITIVE MOTHER ABOUT INFANT FEEDING
7. ANTIRETROVIRAL THERAPY (ART)
8. PROVIDING FOLLOW-UP CARE
WHY IS THE IMCI STRATEGY USED WITH HIV?

Children with suspected or confirmed HIV infection have special needs. Therefore
they need to be cared for differently from children who are not infected.
As you have learned, the IMCI strategy is designed to help health workers identify
common health problems in children. It also helps identify underlying issues, like
malnutrition and HIV.
WHERE DOES HIV FIT IN THE IMCI PROCESS?

You have learned that for every sick child or young infant, you check for signs of
serious illness, assess and classify main symptoms, and check for malnutrition and
feeding problems. Next, you will ASSESS and CLASSIFY for HIV using the same
process.
CHECK for general danger signs or signs of serious illness
ASSESS & CLASSIFY main symptoms
CHECK for malnutrition of feeding problems
CHECK for HIV infection
CHECK immunizations and for other problems
6
WHAT IMCI TOOLS WILL YOU USE?

For this module, you will continue to use work aids provided earlier in the course:
1. IMCI Chart Booklet for HIV settings
2. IMCI recording forms for sick young infant and sick child
You will also have additional work aids that are specific to HIV/AIDS care:
3. ART initiation form for the sick child (2 months up to 5 years)
4. ART follow-up form for the sick child (2 months up to 5 years)
Open your chart booklets now to review each of these tools. Identify the recording
forms you will use for each set of charts.
BEFORE YOU BEGIN

What do you know now about managing HIV care?
1. A child is under 16 months old. What HIV test should be used for this child,
and why?
a. Serological tests, because it can detect if virus antibodies are present
b. Virological (PCR) tests, because it can actually detect the virus
c. Serological tests now, but after the child is 18 months, confirm with a PCR
2. What follow-up treatments are critical for HIV-exposed and infected infants
and children?
a. Cotrimoxazole prophylaxis
b. Paracetamol
c. Amoxicillin
3. What is the overall risk of a mother transmitting HIV to her child during
pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used
during prevention of mother-to-child transmission?
a. 70%
b. 10%
c. 35%
4. A 2-month breastfeeding baby has a positive virological (PCR) test. Is the child
HIV infected?
a. Yes, HIV-infected
b. No, HIV negative
c. Possibly, he is HIV exposed
5. When is an HIV-positive child or infant eligible for ART?
a. If a child has stage 2 HIV infection
b. Any child under five with confirmed HIV infection
c. Children over 5 years old with a count less than 350 cells per mm3
7
6. If a mother is HIV-positive, but the child is not confirmed with HIV infection,
what is the recommended feeding practice?
a. Exclusive breastfeeding as long as the child wants
b. Breastfeeding and also formula, in order to provide additional nutrition
c. Exclusive breastfeeding until 12 months
8
8.2 BASIC INFORMATION ABOUT HIV
What are the learning objectives for this section?

After you study this section, you will know how to:
•• Explain in basic terms how HIV affects the immune system
•• Explain how HIV is transmitted to infants and children
WHAT IS THE IMMUNE SYSTEM?

Every healthy person has a strong system to defend the body against diseases. This
defence system is called the immune system.
White blood cells are an important part of this defence system. They protect the
body against all kinds of diseases. They can be thought of as the “soldiers” of the body.
HOW DO WHITE BLOOD CELLS ACT AS “SOLDIERS”?

Lymphocytes are one type of white blood cell in the body.
Some of these lymphocytes have a marker on their surface CD4 lymphocytes warn
called CD4. Therefore they are called CD4 lymphocytes. These your immune system that
CD4 lymphocytes are responsible for warning your immune there are germs trying to
system that there are germs trying to invade the body. invade the body.
HIV (Human Immunodeficiency Virus) is a virus that HIV infects cells of the
immune system. Its
infects and takes over cells of the immune system. Although
main target is the CD4
HIV infects a variety of cells, its main target is the CD4
lymphocyte.
lymphocyte.
HOW DO VIRUSES INFECT THESE CELLS?

The human body is made of millions of different cells. Each body cell is able to make
new cell parts, in order to stay alive and to reproduce.
Viruses take advantage of this ability. They hide their own material in the centre
of the cell, called the nucleus. When the cell tries to make its own new parts, it
also makes new copies of the virus. When the HIV virus infects CD4 lymphocytes,
HIV uses the CD4 cell to make new copies of the HIV virus. These copies go on to
infect other cells.
WHAT DOES HIV DO TO CD4 LYMPHOCYTES?

CD4 cells infected with HIV are not able to work very well. They die early. When
the immune system loses these CD4 cells, the immune system becomes weaker.
This makes children (and adults) much more likely to develop illness from the
types of germs that would not normally cause them to be ill, or to be more sick
with common germs.
These infections are called opportunistic infections. They take the opportunity
of the body’s defence system being weak to flourish.
9
Figure 1 summarizes what happens to HIV after it enters a human cell.
Figure 1. HIV entering the cell and making new copies
HIV attacks many CD4 cells. The infected CD4 cell will first produce many new copies of the virus, and
then die.
The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and
then die.
This goes on and on – more CD4 cells are destroyed, and more copies of HIV are made.
10
HOW IS HIV MONITORED ONCE IT INFECTS THE BODY?

When a person gets infected with the HIV, the virus will start to
attack his/her immune system. Since HIV mostly attacks CD4 CD4 counts tell
cells, there is a measurement of the number of CD4 cells in an HIV- you how healthy a
infected person’s blood. This is a good way of checking how well person’s immune
their defence system is still working. This is called a CD4 count. system is.
HOW DOES HIV AFFECT ADULTS?

During the first years following infection, an adult’s immune system can still
function quite well, even though the HIV virus is slowly damaging the immune
system. The infected adult will have no symptoms, or only minor symptoms such
as swollen lymph nodes or mild skin diseases. At this stage, most adults do not
even know that are infected with HIV.
Usually after several years, the adult’s immune system gets more and more damaged
and weaker. The person becomes vulnerable to germs and diseases that they normally
fight off. These infections are called ‘opportunistic infections’ because they take
advantage of the weak immune system to cause disease.
In adults it usually takes around 7–10 years after the initial infection with HIV before
the person becomes ill and develops serious sickness from HIV. HIV is considered
to have progressed to AIDS when these sicknesses occur and a CD4 count
reaches below a certain number.
HOW DOES HIV AFFECT CHILDREN DIFFERENTLY THAN ADULTS?

HIV infection progresses much more rapidly in children as compared to adults. The
course of HIV infection is different in children than in adults because children’s
immune systems are not yet well developed.
HIV seems to damage the immune system more easily in children. This is
especially true if the child is infected with HIV while in the mother’s womb, or at
the time of delivery.
Children are also more susceptible to common infections or unusual
opportunistic infections. In the same way as adults, when the child’s immune
system gets damaged it becomes weak. Children can get sick from germs that do
not usually cause serious disease. For example, a child may normally have candida
bacteria living in the mouth. However, when the immune system
is damaged, the candida causes mouth ulcers or soreness. This is
HIV can usually
called oral thrush.
weaken or destroy
As the damage to the immune system gets worse, children the immune system
become highly vulnerable to life-threatening illnesses such as in children much
PCP pneumonia, unusual cancers (lymphoma), recurrent bacterial more quickly.
infections, and HIV brain damage (encephalopathy). These are Children progress
considered AIDS-defining diseases because they are often seen once from HIV to AIDS
a child’s immune system is not performing well due to HIV infection. more rapidly.
As the HIV disease progresses, a child’s CD4 percent or total

count gets less. Figure 2 illustrates how HIV attacks our health.
11
Figure 2. How HIV attacks the body
1. The CD4 cell is a kind of white blood cell. The CD4 2. Problems like cough try to attack our body, but the
is the friend of our body. CD4 fights them to defend the body, his friend.
body CD4
3. Problems like diarrhoea try to attack our body, but 4. Now, HIV enters and starts to attack the CD4.
CD4 fights them to defend the body.
5. The CD4 notices he cannot defend himself against 6. Soon, CD4 loses his force against HIV.
HIV!
7. CD4 loses the fight. The body remains without 8. Now the body is alone without defence. All
defence. kinds of problems, like cough & diarrhoea, take
advantage and start to attack the body.
9. In the end, the body is so weak that all the diseases can attack without difficulty.
12
HOW ARE CHILDREN INFECTED WITH HIV?

Mother-to-child transmission of HIV (MTCT) is the main way that young
children are infected with HIV. This is also called vertical transmission.
Other ways in which children can get HIV are sexual abuse, unsafe injections, or
blood transfusion with blood products that are infected with HIV.
HOW DOES MOTHER-TO-CHILD TRANSMISSION OF HIV OCCUR?

Mother-to-child transmission (MTCT) is when an HIV infected woman passes the
virus to her baby. This can happen without the mother’s knowledge is she does
not know her status. HIV can be transmitted from mother to child during several
methods, and times:
1. Pregnancy (in utero)
2. Labour and delivery (peri or intrapartum)
3. Breastfeeding (postpartum)
Not all HIV infected women will automatically transmit the virus to their
child.
WHAT IS THE RISK OF MOTHER-TO-CHILD TRANSMISSION?

Look at the diagram below. This will be an example. Consider 20 babies born to 20
HIV-infected women. If nothing is done to prevent HIV transmission in these 20
babies, then approximately 7 of the 20 women will transmit HIV to their infants
during pregnancy, labour, delivery, or breastfeeding. This means that the overall
risk of MTCT is about 35%.
This is visualized in the picture below, where 7 of 20 of babies are shaded. Of these
7 babies, it is estimated that about 4 of them (or 20% of the total infection risk)
would be infected during pregnancy, labour, or delivery. The remaining 3 babies (or
about 15% of the total infection risk) would be infected during breastfeeding. This
risk is decreased if the mother or child receives ART prophylaxis.
If 20 women
4 (20%)
deliver
3 (15%)
babies without any intervenKon
to reduce
infected
during
mother-‐to-‐child
infected
during
HIV transmission:

pregnancy, breast-
How labout
m any
or on a
delivery
verage will be infected? 7 out of 20
feeding
PREGNANCY BREASTFEEDING NOT INFECTED

& DELIVERY 3 out of 20 13 out of 20
4 out of 20 13
Why does transmission risk change during pregnancy, delivery, and

breastfeeding?
The risk of transmission during pregnancy is low, as the placenta
Exclusive
protects the developing baby. During labour and delivery the risk is breastfeeding
increased through sucking, absorbing, or aspirating blood or cervical fluid. reduces the
Mixed feeding, compared to exclusive feeding, may increase risk of HIV
transmission.
the risk of HIV transmission. Studies have shown that exclusive
breastfeeding carries a smaller risk of HIV transmission when compared
with mixed feeding. This is due to potential damage to the lining of the infant’s
gut by food particles or the introduction of an allergen or bacteria that causes
inflammation. This can lead to easier access of the HIV virus from the mother’s
breast milk into the infant’s blood.
IMPORTANT NOTE ABOUT MOTHER-TO-CHILD TRANSMISSION

The term mother-to-child transmission is used in this document because the source of the child’s HIV
infection is the mother. Use of the term mother-to-child transmission does not imply blame, whether or
not a woman is aware of her own infection status.
A woman can acquire HIV through unprotected sex with an infected partner, or by receiving contaminated
blood through non-sterile instruments or medical procedures.
WHAT DOES IT MEAN TO BE ‘HIV EXPOSED’?

For the purposes of this course, HIV-exposed infants are born to women who are
known to be HIV-infected. HIV-exposed infants or children cannot be considered
HIV-positive or HIV-negative until their status is confirmed with an appropriate
HIV test.
WHAT HAPPENS IF HIV-INFECTED CHILDREN ARE UNTREATED?

If untreated, three-quarters (75%) of children who are infected through MTCT will
develop problems from HIV and will die before the age of five.
For children who are infected through mother-to-child transmission and who do
not receive any antiretroviral treatment or cotrimoxazole prophylactic therapy:
about one-third will die by one year of age, and half will die by two years of age.
Many of these infant deaths occur at home before presentation to health care
facilities. Children with HIV infection can develop severe illness very quickly.
They may not present with the classic picture of chronic wasting and decline that is
commonly seen in adults with HIV or AIDS. HIV/AIDS is rapidly fatal in children
– this is why early HIV diagnosis essential.
14
HOW CAN DEATHS FROM HIV BE PREVENTED IN CHILDREN?

Important interventions to reduce the risk of children dying from HIV includes:
1. Early diagnosis of HIV
2. Initiating Antiretroviral Therapy (ART)
3. Initiating other prophylaxis and treatments
Infants are most at risk of developing serious complications and dying from HIV
infection – therefore it is most important that these children are identified, and
placed on treatment. You will now read more in the following sections about
each of these points for preventing deaths: early diagnosis through HIV
testing, prophylaxis, treatments, and ART.
SELF-ASSESSMENT EXERCISE A – HIV TERMS

Define the following terms in a way that you would explain to a caretaker.
1. Immune system:
2. CD4:
3. Opportunistic infection:
15
8.3 HIV TESTING

•• Explain the types of HIV tests available in your country
•• Interpret the tests based on a child’s age, breastfeeding status, and mother’s
status
16
n OPENING CASE STUDY – PETER

Peter is 6 months old. His mother, Lungile, brought him to your clinic because he had cough for the last
3 days. Peter has no general danger signs. He breathes 54 per minute but he has no chest indrawing and
no stridor or wheeze. He has no diarrhoea, fever, or ear problems. His weight is 7.2 kg. His temperature is
37.5 degrees. Lungile is worried. She was recently told she has HIV. She is receiving care at another clinic.
How will you assess and classify Peter?

First, you know that you will use the sick child charts because Peter is between 2 months and 5 years of
age. You record Peter’s important information at the top of the recording form. You assess his cough: he has
fast breathing but no other signs. You classify as PNEUMONIA. You do not classify for diarrhoea, fever, or ear
problems. He is not low weight for age. Lungile tells you she breastfed Peter until he was 4 months old.
How will you record this information on Peter’s recording form?

Danger sign when
selecting
classifications
Slowly?
Lungile
bothhas told you she is HIV-infected. Now you will learn about HIV tests used for sick children and
feet:
infants in your country. For a child 6 months or older offer RUTF to eat. Is the child:
Mother's HIV test: NEGATIVE POSITIVE
Child's virological test: NEGATIVE POSITIVE 17
NOT DONE/KNOWN
NOT DONE
WHY DOES HIV TESTING IMPORTANT FOR IMCI?

In order to assess and classify a child for HIV, you need to know if he or she has
already had an HIV test.
Open your chart booklet and review the ASSESS and CLASSIFY table for
HIV. You will see there are two sets of charts. These are based on whether or not
the child has been tested for HIV. You will now learn about HIV tests, and then you
will continue on to assessing and classifying.
WHEN IS IT NECESSARY TO TEST A CHILD FOR HIV?

You will encourage HIV testing for:
■■ All children born to an HIV-infected mother
■■ All children that do not have a known test result, and you do not know the
mother’s status
■■ In a high HIV setting, every child who is sick should be tested for HIV
WHAT ARE HIV TESTS?

Different tests are available to diagnose HIV infection. It is first important to
understand the different tests – some detect antibodies, and others detect the virus
itself. The results from these two tests are understood differently. Review these two
test types in the table:
What does the test detect? How can you interpret the test?
SEROLOGICAL TESTS These tests detect antibodies HIV antibodies pass from the mother to the child. Most
including rapid tests made by immune cells in response antibodies have gone by 12 months of age, but in some
to HIV. instances they do not disappear until the child is 18 months
of age.
They do not detect the HIV virus
itself. This means that a positive serological test in children under
the age of 18 months is not a reliable way to check for
infection of the child.
VIROLOGICAL TESTS These tests directly detect the Positive virological (PCR) tests reliably detect HIV infection
including DNA or RNA presence of the HIV virus or at any age, even before the child is 18 months old.
PCR products of the virus in the blood.
If the tests are negative and the child has been
breastfeeding, this does not rule out infection. The baby
may have just become infected. Tests should be done six
weeks or more after breastfeeding has completely stopped –
only then do the tests reliably rule out infection.
Now you will read more about these tests and their relevance for different age groups:
children under 18 months, and 18 months or older.
18
WHAT TEST SHOULD BE USED IF THE CHILD IS 18 MONTHS OR OLDER?

You will use a serological test to determine the HIV status of a child 18 months
or older. If the serological test is positive it confirms the child’s status as HIV-
infected.
WHAT TEST SHOULD BE USED IF THE CHILD IS UNDER

18 MONTHS OLD?
A virological test (PCR) is the only reliable method to determine the child’s HIV
status below 18 months of age. It detects the actual virus in the child’s blood.
Remember that serological tests do not determine HIV status in this age
group. This is because the test may detect antibodies that might have passed from
the mother through the placenta. Therefore a positive serological test may only
tell you that the child has been exposed to HIV, rather than that the child is HIV-
infected.
THERE ARE TWO SCENARIOS FOR CHILDREN UNDER 18 MONTHS:

This depends on the availability of PCR in your country:
1. IF PCR or other virological TEST IS AVAILABLE, TEST FROM 4–6 WEEKS OF
AGE
+ A POSITIVE result means that the child is infected, as it detects the actual
presence of HIV in the child
– A NEGATIVE result means that child is not infected, but could become
infected if they are still breastfeeding
2. IF PCR or other virological TEST IS NOT AVAILABLE, USE A SEROLOGICAL
TEST
+ A POSITIVE result is consistent with the fact that the child has been exposed
to HIV, but does not tell us if the child is definitely infected. All HIV-exposed
infants should be tested using PCR or other virological test.
– A NEGATIVE result usually means the child is not infected. A negative test
is also useful because it usually excludes HIV infection from the mother, as
long as the child has not breastfed for more than 6 weeks.
HOW WILL YOU INTERPRET A SEROLOGICAL TEST IN A CHILD

UNDER 18 MONTHS?
As you have read, the breast milk of an HIV-positive mother can transmit HIV. You
see in the chart that this affects how you will interpret test results.
Is child breastfeeding? POSITIVE (+) test NEGATIVE (-) test

NOT BREASTFEEDING, and HIV exposed and/or HIV infected – HIV negative
has not in last 6 weeks Manage as if they could be infected. Repeat Child is not HIV infected
test at 18 months.
BREASTFEEDING HIV exposed and/or HIV infected – Child can still be infected by breastfeeding.
Manage as if they could be infected. Repeat Repeat test once breastfeeding has been
test at 18 months or once breastfeeding has discontinued for more than 6 weeks.
been discontinued for more than 6 weeks.
19
REVIEW THE EARLY INFANT DIAGNOSIS

ALGORITHM BELOW:
Review This
the flow
early
chartsinfant
help youdiagnosis algorithm
make decisions about thebelow:
testing course of action for
This flow cchildren under
harts help you 18 months.
make It provides
decisions about tsome more cspecifics
he testing ourse of inaction
addition for ctohildren
the under
18 months. information you
It provides readm
some on thespecifics
ore previousin
page.
addition to the information you read on the
previous page.
HIV-‐exposed Infant or child <18 months
Conduct diagnostic v iral testa
Viral test available Viral test not available
Positive Negative
Infant/child is likely infected Never breastfed Ever breastfed or currently
breastfeeding
<24 months: immediately Infant/child is Infant /child remains at risk Regular and periodic
start ARTb uninfected for acquiring HIV infection clinical monitoring

until complete cessation of
And repeat viral test
breastfeedingc
to confirm infection
Infant/child develops signs or symptoms Infant remains well and reaches 9 months of age
suggestive of HIV
Conduct HIV antibody test at

Viral test not available approximately 9 months of age
Viral test available Positive

Negative

Negative Positive
Viral test not available
assume infected if sick
assume uninfected if well
Infant/child is infected

sick
well
HIV unlikely unless still

Start ARTb breastfeedingc
And repeat viral test to confirm
infection

Repeat antibody test at 18 months of age

and/or 6 weeks after cessation of
breastfeeding

a
For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant

diagnosis.
b
Start ART, if indicated, without delay. At the same time, retest to confirm infection.
c
The risk of HIV transmission remains as long as breastfeeding continues.
20
dIMCI SELF-‐STUDY MODULES | World Health Organization 16

WHAT MOTHERS NEED TO BE COUNSELLED FOR THEIR CHILD’S

HIV TEST?
Many mothers, and even health workers, are reluctant to discuss HIV.
However, HIV is present in the community and the problem will not be solved as
long as there is secrecy surrounding the topic. The mother of a child classified as
HIV EXPOSED will need to be counselled about an HIV test for the child. These
children all require HIV tests and re-classification based on these tests.
WHAT INFORMATION SHOULD BE PROVIDED TO THE MOTHER?

When you have identified a young infant or child who is in need of HIV testing you
should provide the mother with information:
•• Explain why it is important to test the child (e.g. status is unknown).
•• Help the mother to understand that the reason for HIV testing is so that the
child can receive treatment that will improve his quality of life. He should have
antibiotics to prevent infections, vitamin supplementation, regular growth
monitoring, treatment of any illnesses, and antiretroviral therapy if needed. If
the child is less than about 2 years, counsel on infant feeding.
HOW CAN YOU HELP ADDRESS A CAREGIVER’S CONCERNS?

Once you have explained, allow the mother to ask questions and address her
concerns. If she agrees to the test, arrange it in the normal way at your clinic.
Since the most common route of HIV infection for a child is by mother-to-child
transmission, you may need to discuss testing her and her partner as well perhaps
even before testing the child.
Mother-to-child transmission presents a number of barriers to testing of
the child. HIV may provoke feelings of guilt on the part of the mother, as well as
fears of rejection by and of the child and of revealing their own HIV status and how
they were infected. All health workers must be equipped with the knowledge and
ability to discuss HIV, ask questions and give appropriate counselling.
WHAT SHOULD A HEALTH WORKER DO IF A MOTHER REFUSES

TESTING?
If a mother does not agree to test the child, the health worker should listen to
and address her concerns and reasons against testing. The health worker may be
considered an advocate for the child and negotiate with the parent or carer in the
child’s best interest. Reassurances should be made regarding treatment, care, support
and/or preventive interventions that the child may benefit from once diagnosed. It
may help for the parent/carer to express their concerns without the child’s presence.
WHAT STEPS SHOULD BE TAKEN AFTER TESTING?

After testing, make an appointment for a review of the results and post-test
counselling. If a serological test has been performed, do the post-test counselling
immediately if this is agreeable to the mother. Maintain privacy and confidentiality
so that the mother can discuss her concerns freely.
21
After you explain information, allow the mother to ask questions.

Address her concerns.
SELF-ASSESSMENT EXERCISE B – HIV TESTING

Complete the following questions to practice what you have learned about HIV
tests.
1. What is the difference between an HIV virological (PCR) test and an HIV
serological test?
2. What test would you use to confirm HIV infection in a child under the age of 18
months?
3. A 20 month old baby has a positive virological (PCR) test. Is the child HIV
infected?
4. A 2 month old breastfeeding baby has a positive HIV serological test. Is the child
HIV infected?
5. A 2 month old baby has a positive virological (PCR) test. Is the child HIV infected?
6. A 21 month child has a negative serological test. Child has not breastfed since
he was 6 months old. Is the child HIV infected?
7. An 18 month old breastfeeding child has a positive HIV serological test. Is the
child HIV infected?
8. A 9 month old breastfeeding baby has a negative virological (PCR) test. Is the
child HIV infected?
9. A 9 month old baby has a negative virological (PCR) test. The baby last breastfed
3 months ago. Is the child confirmed HIV negative?
10. A 16 month old child has a negative serological test. The child is not breastfeeding.
Is the child confirmed HIV negative?
22
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?

Review the main points from this section. Reading this summary, and completing
the self-assessment exercises in the module, are important for learning.
1. HIV testing is essential for assessing and classifying a child for HIV
You will assess a child based on his HIV tests and clinical signs.
2. A positive serological HIV test cannot confirm HIV infection for children
below 18 months. This is because the test shows the presence of antibodies
– and children under 18 months can still have antibodies from their mothers.
However, a negative test is useful because it usually excludes HIV infection from
the mother, so long as the child has not been breastfed for more than 6 weeks.
3. A positive serological HIV test cannot confirm HIV infection for children
below 18 months. This is because the test shows the presence of antibodies,
and children under 18 months may have antibodies present from their mothers.
4. Breastfeeding matters
A child can be infected with HIV through breast milk. An HIV test can only be
confirmed once a child has stopped breastfeeding for at least 6 weeks.
23
8.4 ASSESS & CLASSIFY A SICK CHILD

•• Assess a sick child for HIV by using their test results or clinical signs of HIV
•• Classify a sick child for HIV
IN SUMMARY, HOW DO YOU KNOW WHEN A CHILD IS

HIV INFECTED?
In the last section you learned about HIV testing, and how to interpret results by
age group and by breastfeeding status. These test results will determine how you
assess and classify the child or sick young infant.
SUMMARY: how do you know when a child is HIV infected?

n POSITIVE VIROLOGICAL (PCR) TEST at any age with a confirmatory test
n POSITIVE SEROLOGICAL TEST at 18 months or older with a confirmatory test
Remember that test results are not confirmed unless child has not been breastfeeding for at least 6 weeks. Children
can still be infected by breastfeeding.
HOW WILL YOU USE TEST RESULTS TO ASSESS?

To ASSESS a child for HIV, you will use: (a) test results, if available, and (b) clinical
signs. The first step in assessing is to determine whether or not there are test results
available for the child or mother. This will help determine your steps for ASSESSING.
For ALL sick children – ask the caretaker about the child’s problems, check for
general danger signs, assess for cough or difficult breathing, assess for diarrhoea,
assess for ear problem, check for malnutrition and anaemia, and then:
ASK: HAS THE CHILD or MOTHER BEEN TESTED FOR HIV INFECTION?
YES, test results available NO test results available
Assess for HIV infection Check for features of HIV
CLASSIFY the child using the colour-coded charts
Check immunization status, assess feeding, other problems and mother’s health
24
HOW WILL YOU ASSESS FOR HIV INFECTION?

THEN CHECK
Open to your ASSESS chart forFOR HIV.HIV INFECTION
It contains these instructions, starting with
ASK: Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step an
Positive viro
ASK child
Classify OR
Has the mother and/or IF YES: Then note HIV
status Positive ser
child had an HIV test? mother's and/or child's a child 18 m
HIV status:-
Mother's HIV
status: POSITIVE or
NEGATIVE
Mother HIV
Child's HIV status:
negative vir
Virological test child breast
POSITIVE or NEGATIVE only stoppe
Serological test weeks ago
POSITIVE or NEGATIVE
O
Mother HIV
IF NO: Mother and child
not yet test
status unknown, then TEST
mother. O
If positive, then test the Positive ser
child. a child less
If mother is HIV positive and child is negative or old
unknown, ASK: Negative HI
Was the child breastfeeding at the time or 6 weeks or child*
before the test?
If breastfeeding ASK: Is the mother and child on ARV
prophylaxis?
* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical s
On the following** pages,
If virological
you test
willislearn
negative, repeat
about testof
each 6 weeks
theseafter the breatfeeding has stopped; if serological test is positiv
instructions.
ASK: HAS THE MOTHER AND/OR THE CHILD HAD AN HIV TEST?
Remember that this is sensitive information, and that it is important to ensure
confidentiality.
All mothers should have been offered testing during their pregnancy. Ask the mother
if she has had an HIV test. If the mother has had a test, ask her what the result was.
YES the mother or child has had an HIV test. Record the test results:
1. Mother’s HIV status: POSITIVE or NEGATIVE
Remember that a mother may have tested negative in the past, and could now
be HIV infected. The more recent the test, the more likely it is to be accurate.
2. Child’s HIV status:
a. Virological test POSITIVE or NEGATIVE Page 11 of
b. Serological test POSITIVE or NEGATIVE
25
NO test result is available for mother or child. Conduct an HIV test:

If there is no test available, you will test the mother. If the test is POSITIVE, then
test the child. You learned in Section 3 of this module about the types of HIV tests
available in your country. Remember tests are different depending on the child’s age:
•• child 18 months or older: you will use a serological test. If the test is positive
it confirms the child’s status as HIV-infected.
•• child under 18 months: a virological test (PCR) is the only reliable method to
determine the child’s HIV status. It detects the actual virus in the child’s blood.
IF MOTHER IS HIV POSITIVE AND CHILD IS NEGATIVE OR UNKNOWN

In this situation, you must ask more about the child’s feeding status. You remember
that breast milk can transmit HIV. As a result, a child who has initially tested
negative may still develop HIV infection.
It is therefore important to know if the child was breastfeeding or had been breastfed
in the six weeks before the test was done. Six weeks is considered the “window
period” or time during which a patient may test negative even though they
are infected.
In order to better understand the child’s feeding status, you will ask the following
questions and record responses:
1. If a previous test was done, was the child breastfeeding at the time or the test?
Was the child breastfeeding in the 6 weeks before the test?
2. Is the child breastfeeding now?
3. If the child is breastfeeding, ASK: is the mother and child on ARV prophylaxis?
You will learn more about ARV prophylaxis in section 9.6.
REMEMBER! Child must not have breastfed within six weeks of a test in
order for it to be confirmed negative.
26
WITH HIV RESULTS AVAILABLE, CLASSIFY THE CHILD:

Once you have the child or mother’s test results, you can classify according to the
result. Open to the classification table. There are three classifications:
1. CONFIRMED HIV INFECTION
2. HIV EXPOSED
3. HIV INFECTION UNLIKELY
already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
Positive virological test in Yellow: Give cotrimoxazole prophylaxis*

child CONFIRMED HIV Give HIV care and initiate ART treatment
Classify OR INFECTION Assess the child’s feeding and provide
HIV appropriate counselling to the mother
status Positive serological test in
a child 18 months or older Advise the mother on home care
Refer for TB assessment and INH preventive
therapy
Follow-up regularly as per national guidelines
Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
child breastfeeding or if recommended
only stopped less than 6 Do virological test to confirm HIV status**
weeks ago Assess the child’s feeding and provide
OR appropriate counselling to the mother
Mother HIV-positive, child Advise the mother on home care
not yet tested Follow-up regularly as per national guidelines
OR
Positive serological test in
a child less than 18 months
old
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
or child* HIV INFECTION
UNLIKELY
* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available,
offer HIV testing for child.
old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
CONFIRMED
eatfeeding has stopped; if serological test is positive, doHIV INFECTION
a virological test as soon(YELLOW)
as possible.
A child with a positive HIV test should be classified as CONFIRMED HIV
INFECTION. This means a positive serological test for a child 18 months or older.
Virological tests confirm HIV in all children. These children should be provided
cotrimoxazole prophylaxis (you will learn about eligibility in 9.6), HIV care and
ART, and other counselling.
HIV EXPOSED (YELLOW)

Children born to HIV-positive women are HIV EXPOSED and could possibly have
HIV. This classification is used for three different scenarios:
1. Mother is HIV-positive and the child has a negative virological test, but the child
is still breastfeeding or stopped less than 6 weeks ago. Due to the breastfeeding,
the child still risks exposure, or the negative status cannot yet be confirmed.
Page 11 of 75
2. Mother is HIV-positive and child has not yet tested.
3. The child is less than 18 months old and has a positive serological test. Remember
that this child’s status can only be confirmed with a virological test.
27
These children require cotrimoxazole prophylaxis and ARV prophylaxis (as

recommended). The child should receive a virological test to confirm status.
If this test is negative, it must be repeated after breastfeeding has stopped for 6
weeks in order to be confirmed.
HIV INFECTION UNLIKELY (GREEN)

If mother or child has a negative test, the child is classified HIV NEGATIVE. You will
treat, counsel, and follow-up existing conditions according to your IMCI assessment.
SELF-ASSESSMENT EXERCISE C – ASSESS & CLASSIFY SICK CHILD

Are these statements about assessing and classifying true or false?
a. A 10-month old has a positive virological test. She stopped

breastfeeding 30 days ago. She should be classified as TRUE FALSE
CONFIRMED HIV INFECTION.
b. A 9 month old child is still breastfeeding has tested
negative with a PCR test. He should be classified as HIV TRUE FALSE
INFECTION UNLIKELY.
c. A 9 week old child is clinically well. His mother is HIV-
infected. The child has not been tested yet, so you conduct
TRUE FALSE
a serological test. The result is positive. He should be
classified as CONFIRMED HIV INFECTION.
d. You send for a PCR test for a 16 month old. The results
are positive. He stopped breastfeeding when he was 12
TRUE FALSE
months old. He should be classified as CONFIRMED HIV
INFECTION.
e. A 4 month old was born to an HIV-infected mother. He is
breastfeeding. You provide a serological test, and the result TRUE FALSE
is positive. He should be classified as HIV EXPOSED.
f. An 8 month old child born to an HIV-infected mother
comes to the clinic. Her mother says she was tested
2 months ago. You see the PCR results, and they are TRUE FALSE
negative. The child is still breastfeeding. She should be
classified as HIV INFECTION UNLIKELY.
g. A 36 month old child has a positive serological HIV test.
TRUE FALSE
She should be classified as CONFIRMED HIV INFECTION.
28
n How will you assess Peter for HIV?

First, you review the ASSESS table in the sick child charts. You ask Lungile is Peter is breastfeeding. She says
yes. She has also already told you that she has been tested for HIV and is infected. She did not receive any
ART prophylaxis for PMTCT.
You
already enrolled in HIV ask
care, goiftoPeter has
the next been
step tested,forand
and assess sheand
mouth says
gumno. You counsel Lungile on testing Peter for HIV, and the
condition.
importance of identifying children who are exposed or infected with HIV. You provide a serological test. The
result is positive.
HIV n How willPositive
you classify Peter?
serological test in appropriate counselling to the mother
status
Lungile is HIV positive, and Peter has a negative serologicalRefer
test.for
HeTBisassessment
6 monthsand
old.INH
You classify him as HIV
preventive
EXPOSED. therapy
OR
old
Remember thator child*
you cannot confirm Peter’s HIV status until he has stopped breastfeeding for at least
HIV INFECTION
UNLIKELY
6 weeks. His status must be confirmed with a virological test as long as he is under 18 months of age.
In section 6 you will learn how to give prophylaxis to Peter. In section 7 you will learn about feeding
recommendations for Peter. In section 8 and subsequent sections you will learn about follow-up care,
old and to children 1- including ART
4 years old at WHO initiation if the2,child
clinical stages 3 and is confirmed
4 regardless positive.
of CD4 Withorthe
percentage classification
at any HIVCD4
WHO stage and EXPOSED,
<25% Peter will
eatfeeding has stopped;follow-up with
if serological testyou monthly.
is positive, do a virological test as soon as possible.

1. You will use HIV test results from a child and mother to assess and
classify a child’s HIV status. You will use test results from a mother and/
or child to classify the child’s HIV status. The first course of action is to test
the mother if you do not have her test results. If she is positive, then you will
test the child. It is important to maintain confidentiality of the test results of
mothers and children. If the HIV status of the mother or child is unknown, the
care provider should offer HIV testing especially if the child has malnutrition,
pneumonia, diarrhoea, chronic cough or other symptoms that may suggest HIV/
AIDS. This is referred as provider-initiated testing and counseling.
2. Children
Page 11 of 75 can be infected with HIV while breastfeeding. Test results cannot
be confirmed unless the child has not breastfed for 6 weeks or more. This is an
important window.
29
3. Virological tests must be used to confirm the status of a child under 18

months. Children under 18 months require confirmation by PCR (virological)
testing. Remember it is different for children older than 18 months: these
children can be confirmed with a serological test. The second important point
is that test results cannot be confirmed unless the child has not breastfed for 6
weeks or more.
30
8.5 ASSESS & CLASSIFY A SICK YOUNG INFANT

•• Explain how assessing and classifying for HIV is different for a young infant
•• Assess and classify a young infant using the chart booklet
WHEN WILL YOU ASSESS AND CLASSIFY A YOUNG INFANT FOR HIV?
Review what you have learned so far about assessing and classifying the sick young
infant.
For ALL sick young infants – ask the caretaker about the infant’s problems,
check for signs of possible bacterial infection and jaundice, assess for diarrhoea, then:
ASK: HAS INFANT BEEN TESTED FOR HIV?
YES NO
Assess for HIV infection Assess based on mother’s status
CLASSIFY the young infant’s HIV status using the colour-coded charts
NEXT: assess for feeding problems or low weight, check immunizations,

consider special risk factors, and assess mother’s health and other problems
HOW IS ASSESSING AND CLASSIFYING A YOUNG INFANT

DIFFERENT THAN A CHILD?
Assessing and classifying the sick young infant for HIV differs from the
classification for an older child. It is not possible to classify the sick young infant
for SYMPTOMATIC HIV INFECTION because infants usually do not show signs
and symptoms of HIV like children.
Young infants with HIV infection usually do not have any
signs and symptoms directly related to HIV infection – Young infants usually do
this does not mean that they may not become ill, but rather that not have signs directly
they will develop signs and symptoms of common childhood related to HIV.
illnesses such as pneumonia or diarrhoea. As a result, the As a result, classifications
assessment and classification of HIV infection in young infants use HIV test results.
is based on HIV test results.
31
WHY IS EARLY IDENTIFICATION SO IMPORTANT WITH

YOUNG INFANTS?
It is very important that young infants with HIV are identified early. These infants
may look well, but can become ill and die very quickly. PCR virological testing is
now available in many regions – this helps to identify HIV-infected children
early. All children born to HIV-infected mothers should be tested for HIV infection
using a virological test.
We have to ensure that all exposed babies are identified and tested, and that test
results come back to the clinic and are communicated to the caregiver. Counselling
of the mother or caregiver before and after the test is a key part of this process.
Early identification allows the infant to benefit from ART and other treatments.
HOW WILL YOU ASSESS THE YOUNG INFANT FOR HIV?

Review the ASSESS chart. What instructions do you see?
ASSESS YOUNG INFANT FOR HIV
ASK: HAS THE MOTHER AND/OR YOUNG INFANT HAD AN HIV TEST?
YES test available: note the mother’s and/or young infant’s HIV status
1. Mother’s HIV status: serological test POSITIVE or NEGATIVE
Remember that a mother may have tested negative in the past, and could now be HIV
infected. The more recent the test, the more likely it is to be accurate.
2. Young infant’s HIV status:
a. Virological test POSITIVE or NEGATIVE
b. Serological test POSITIVE or NEGATIVE
32
If mother is positive and no positive virological test in child, ASK about

feeding status:
As you know, the child’s status cannot be confirmed until breastfeeding has stopped
for at least 6 weeks. Therefore you should ask the mother this important information:
•• Is the young infant breastfeeding now?
•• Was the young infant breastfeeding at the time of the test or before it?
•• Are the mother and young infant on ARV prophylaxis?
NO test available, so mother and young infant status unknown:
If the mother and young infant test results are not known, you will perform an HIV
test for the mother. If it is positive, perform a virological test for the young infant.
HOW WILL YOU CLASSIFY THE YOUNG INFANT FOR HIV?

After you ASSESS for rest results, you will classify. There are three classifications:
2. HIV EXPOSED
already enrolled in HIV care, go to the next step and assess for mouth and gum condition.

HIV appropriate counselling to the mother
status Positive serological test in

OR
old
or child* HIV INFECTION
UNLIKELY
* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available,
offer HIV testing for child.
old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
CONFIRMED
eatfeeding has stopped; if serological test is positive, doHIV INFECTION
a virological test as soon(YELLOW)
as possible.
If the young infant has a positive virological (PCR) test, she is classified as
CONFIRMED HIV INFECTION. Remember that a virological test must be used
because a serological test does not confirm HIV infection in children less than
18 months of age. Children with this classification should receive cotrimoxazole
prophylaxis from age 4–6 weeks. All young infants with CONFIRMED HIV
33
INFECTION are eligible to receive ART and HIV care. You will learn about this in
the upcoming sections of this module.
HIV EXPOSED (YELLOW)

The young infant is classified as HIV EXPOSED if one of the following scenarios
is true:
•• If the mother is HIV-infected and the young infant’s virological is negative, but
he is still breastfeeding or stopped breastfeeding less than 6 weeks ago. The
infant is still exposed to HIV during breastfeeding.
•• If the mother is HIV infected and no test result is available for the infant.
•• If the infant has a positive serological test.
The HIV EXPOSED child should receive cotrimoxazole prophylaxis from age 4–6
weeks. ARV prophylaxis should be given per national recommendations. Remember
that the child’s status must be confirmed after he has stopped breastfeeding for
at least 6 weeks.
HIV INFECTION UNLIKELY (GREEN)

The child is classified HIV INFECTION UNLIKELY if the mother has a negative HIV
test, or the young infant has a negative test and was not breastfed for six weeks
before the test was done. These infants can be followed up routinely. Cotrimoxazole
prophylaxis can be stopped, if it had been previously started.
SELF-ASSESSMENT EXERCISE D – CLASSIFY

Classify the following sick young infants and children for HIV status.
1. 7 week old child. Mother HIV-positive.
2. 8 week old girl. Abandoned at birth, now formula feeding.
PCR done at six weeks was negative.
3. 6 week old with positive PCR test.
4. 7 week old, status unknown. Mother tested negative.
5. 12 month old, status unknown. Grandmother brings child to
clinic. Child has positive serological test.


1. If the mother and young infant do not have test results, you will begin
by testing the mother.
If the mother is HIV positive, this means the young infant has been exposed.
You will then test the young infant. If the mother is HIV negative, HIV infection
in the young infant is unlikely.
2. Young infants can be infected with HIV while breastfeeding.
Test results cannot be confirmed unless the young infant has not breastfed for
6 weeks or more. This is an important window.
34
3. Virological tests must be used to confirm the status of young infant.

Young infants are under two months of age. You remember that children under
18 months require confirmation by PCR (virological) testing.
4. Any child or young infant with symptoms suggestive of HIV infection,
offer HIV testing.
35
8.6 PROPHYLAXIS AND OTHER PREVENTIVE

MEASURES

After you study this section, you will know how to prevent HIV infection and other
common illnesses in infants and young children classified for HIV by:
•• Providing prophylactic ARVs
•• Providing cotrimoxazole prophylaxis
•• Providing isoniazid preventive therapy to address TB and HIV co-infection
•• Ensuring complete immunizations
•• Providing Vitamin A supplementation and regular deworming
•• Monitor HIV-infected children to ensure timely ART initiation
WHY IS THIS CARE IMPORTANT FOR HIV-EXPOSED AND

INFECTED CHILDREN?
You learned in the introduction of this module that HIV attacks a child’s immune
system. Because of this, children and infants become very vulnerable to infections
that may not usually make them so sick.
There are many important treatments for preventing and managing these
opportunistic infections. Several types of prophylaxis and other preventive
measures seek to keep a child’s immune system strong.
WHAT TYPES OF PROPHYLAXIS ARE GIVEN?

There are a number of prophylaxis and preventive measures for children and infants
who are HIV exposed and infected.
In this section you will read about the following measures:
•• PROPHYLACTIC ARVs
•• COTRIMOXAZOLE PROPHYLAXIS
•• ISONIAZID PREVENTIVE THERAPY
These important prophylactic measures are discussed in the well child care module:
•• IMMUNIZATIONS
•• VITAMIN A SUPPLEMENTATION
WHY ARE THESE TYPES OF PROPHYLAXIS IMPORTANT?

Prophylactic ARVs (nevirapine and zidovudine prophylaxis) can help in preventing
HIV infection in young infants. The other types of prophylaxis in this list prevent and
manage common opportunistic infections like tuberculosis, pneumonia, and other
bacterial infections. Routine care like immunizations, Vitamin A, and deworming are
important measures for HIV-exposed and HIV-infected children to prevent illness.
36
How will you give ARV prophylaxis?

Nevirapine (NVP) or zidovudine (AZT) are provided to HIV-exposed infants to
minimize mother-to-child transmission of HIV (PMTCT) until 4 to 6 weeks of age.
Open your chart booklet to the ‘TREAT’ charts to find instructions for PMTCT
prophylaxis:
BREASTFEEDING REPLACEMENT FEEDING

6 weeks of infant prophylaxis 4–6 weeks of infant prophylaxis with
with once-daily NVP once-daily NVP (or twice-daily AZT)
It is important to note that if a mother is found to be positive very late in pregnancy,

during labour, or during breastfeeding, and begins ART at this time, the ARV
prophylaxis for the child might need to be extended to 12 weeks.
The recommendations above are for both Option B+ and Option B PMTCT national
policies. The Option B+ policy says that every HIV-infected pregnant or breastfeeding
woman in high HIV settings should receive triple ART during this period, and
then continue on lifelong ART. The Option B policy says that HIV-infected women
receiving ART will stop at the end of breastfeeding transmission risk.
WHAT IS THE DRUG DOSAGE FOR PMTCT PROPHYLAXIS

IN YOUNG INFANTS?
The same ‘TREAT’ chart for PMTCT prophylaxis includes dosing information for
NVP and AZT. There are very important points about prophylaxis:
✔✔ Consider the infant’s birth weight if under 6 weeks old
✔✔ Monitor the infant’s age and change dosing as they age
What is cotrimoxazole prophylaxis?

Regular prophylaxis with Trimethoprim-sulfamethoxazole (TMP/SMX), also known
as cotrimoxazole, provides a simple, inexpensive, and effective strategy to prevent
illness. Cotrimoxazole prophylaxis provided to children with suspected or confirmed
HIV infection will decrease sickness and death due to PCP, other common bacterial
infections, and malaria.
WHY IS COTRIMOXAZOLE PROPHYLAXIS IMPORTANT?

Cotrimoxazole prophylaxis can reduce the mortality of HIV-infected children by
up to 40%. Infants and children with suspected or confirmed HIV infection may
acquire severe pneumonia and other serious infections at an early age. Often this
occurs before their HIV status has been confirmed.
Cotrimoxazole prophylaxis is given to HIV-exposed and infected children to

reduce the risk of infection, and lower mortality.
37
One serious life-threatening form of pneumonia is caused by an organism called

pneumocystis jirovecii (previously carinii). This is commonly called PCP. This is a
common cause of death in HIV-infected children, in particular young infants. The
risk of PCP is decreased if the child takes regular daily cotrimoxazole prophylaxis.
WHO SHOULD RECEIVE COTRIMOXAZOLE PROPHYLAXIS?

The table below reviews when certain classifications of infants and children should
begin cotrimoxazole.
THESE YOUNG INFANTS… SHOULD START… WHY?

CONFIRMED HIV INFECTION From 4–6 weeks Infant is HIV infected
HIV EXPOSED From 4–6 weeks Infant is born to HIV infected mother and exposed to HIV
THESE CHILDREN… SHOULD START… WHY?

CONFIRMED HIV INFECTION
As soon as possible Child is HIV infected
Less than 12 months old
These children are eligible:
1. When at WHO clinical stages
2-3-4, regardless of CD4%
CONFIRMED HIV INFECTION
2. When CD4% less than 25%, This is regardless of whether the child is on ART or not.
12 months up to 5 years
no matter what stage
Refer to Annex 1 to learn about
staging.
HIV EXPOSED As soon as possible Child is exposed to HIV
Children in this age category use adult prophylaxis
Over 5 years of age Follow adult guidelines
guidelines.
WHAT DOSE OF COTRIMOXAZOLE WILL YOU GIVE FOR

PROPHYLAXIS?
The details for cotrimoxazole prophylaxis in HIV-exposed and infected children
and infants are summarized below.1 You can also review in your TREAT charts,
TREAT WITH ORAL ANTIBIOTIC. See Annex 2 for a more information on dosing.
NOTE that if the HIV-infected child qualifies for cotrimoxazole and ART
simultaneously, start cotrimoxazole first.
COTRIMOXAZOLE DOSAGE – SINGLE DOSE PER DAY

Drug: Cotrimoxazole (Trimethoprim-sulfamethoxazole or TMP/SMX)
Syrup Adult Tablet Single Strength Paediatric Tablet Single Strength
Age
40 mg TMP/200 mg SMX per 5 ml 80 mg TMP/400 mg SMX 20 mg TMP/100 mg SMX
Less than 6 months 2.5ml – 1 tablet
6 months up to 5 years 5 ml 1/2 tablet 2 tablets
5 to 14 years 10 ml 1 tablet 4 tablets
Over 15 years NIL 2 tablets –
Revised WHO guidelines for cotrimoxazole prophylaxis in HIV-exposed and HIV-infected children in resource-
1
limited countries, Geneva, May 10–12, 2005.
38
HOW LONG DO CHILDREN RECEIVE COTRIMOXAZOLE

PROPHYLAXIS?
Cotrimoxazole prophylaxis is one of the medications an exposed or infected child
will need to take for a long time. Even with increasing access to ART, cotrimoxazole
prophylaxis is very important.
NOTE that it is recommended that infants with confirmed HIV infection
in resource-limited settings should continue cotrimoxazole indefinitely.
WHEN SHOULD COTRIMOXAZOLE PROPHYLAXIS BE STOPPED?

•• HIV IS RULED OUT
When children and infants classified as HIV EXPOSED are confirmed HIV-
negative, and the mother is no longer breastfeeding
•• SEVERE DRUG REACTIONS
Severe toxicity can include Steven Johnson syndrome or severe pallor. This child
should be referred to second level for assessment and for an alternate drug. If
you are unsure about whether to stop cotrimoxazole, refer the child to second
level for assessment and advice.
HOW CAN A HEALTH WORKER SUPPORT ADHERENCE TO

COTRIMOXAZOLE?
To make sure the caretaker and/or child are able to adhere to cotrimoxazole, they
will need counselling and support. Several counselling sessions will be required in
order to ensure that the issue of prophylaxis has been discussed with the caretaker
and that they have fully understood and agreed to adhere to the treatment. You
will learn more about chronic follow-up care for HIV-infected children in Section
11 of this module.
39
SELF-ASSESSMENT EXERCISE E – COTRIMOXAZOLE

Answer the following questions about cotrimoxazole prophylaxis.
1. What children should receive cotrimoxazole prophylaxis?
2. At what age should cotrimoxazole prophylaxis be started?
3. What are possible serious side effects of cotrimoxazole prophylaxis?
4. Should the following infants be receiving cotrimoxazole? If they should be

receiving it, write down the correct dose in the last column.
Should child receive If YES, what
cotrimoxazole? is the daily dose?
a. 6 week HIV-exposed girl, PCR not

available yet  YES  NO .......................
b. 6 month old HIV-exposed girl. PCR
positive, not yet on ART.  YES  NO .......................
c. 7 month old HIV-exposed girl. PCR
negative at 6 months of age. Stopped
breastfeeding at 3 months.  YES  NO .......................
d. 4 month old boy who started on
ART today  YES  NO .......................
e. 2 week old boy, HIV exposed, PCR
test not sent yet  YES  NO .......................
f. 8 month old HIV-exposed boy, breast-
feeding. PCR negative when tested at
six weeks.  YES  NO .......................
g. 3 year old girl, clinical stage 3  YES  NO .......................
h. 2 month old girl with SEVERE
PNEUMONIA, and has tested PCR
positive.  YES  NO .......................
i. 9 month old boy classified as HIV
EXPOSED. His caregiver declines testing.  YES  NO .......................
j. 4 year old boy with HIV infection,
CD4% is 45%  YES  NO .......................
5. When should cotrimoxazole prophylaxis be stopped?
40
WHAT IS ISONIAZID PREVENTIVE THERAPY (IPT)?

IPT is an important intervention for preventing and reducing active tuberculosis
(TB) in children living with HIV. IPT is an important part of a comprehensive
package of care for children and infants living with HIV. IMPORTANT NOTE:
You will initiate IPT in your facility only if your facility can do investigations to
identify tuberculosis cases.
WHY IS IPT FOR HIV-INFECTED CHILDREN AND INFANTS

IMPORTANT?
TB is a major cause of illness and death in children living with HIV. This is even
true in children who are on ART. Increasing levels of co-infection with TB and
HIV in children have been reported from resource-limited countries. Of children
infected with TB living in resource-limited countries, 10% to 60% are also
infected with HIV.
HIV infection has an impact on the entire cycle of TB infection and disease. HIV
increases a child’s susceptibility to tuberculosis infection, it increases the risk of
rapid progression to TB disease, and it increases the risk of TB reactivation in older
children with latent TB.
WHO SHOULD RECEIVE ISONIAZID PREVENTIVE THERAPY?

You will only consider isoniazid preventive therapy for children and infants who
are confirmed with HIV infection. IPT is also identified in your HIV classification
tables in the TREATMENT column.
IF THE HIV-INFECTED INFANT or CHILD IS: ACTIONS TO TAKE:

EXPOSED TO TB
Begin IPT for 6 months. See next page for dosage of isoniazid
This means the child has been exposed to TB through
(INH) for preventive therapy in HIV co-infections.
household contacts, but has no evidence of active disease.
NOT EXPOSED TO TB
This includes children over 12 months living with HIV, Begin IPT for 6 months. This is part of a comprehensive
including those previously treated for TB, who are not likely package of HIV care. See next page for dosage.
to have active TB and are not known to be exposed to TB.
1. Begin TB treatment immediately
DIAGNOSED WITH TB
2. Start ART as soon as tolerated within the first 8 weeks of
This includes any child with active TB disease
TB therapy, no matter the CD4 count and clinical stage
WHAT IS THE DOSAGE FOR ISONIAZID PREVENTIVE THERAPY?

The recommended dose of isoniazid (INH) for preventive therapy in HIV co-
infections is a daily dose of 10 mg per kg, with a maximum daily dose of 300 mg/
day. This dosage is given for 6 months. See Annex 2 for a more information on
dosing.
DOSE: 10 mg/kg (maximum daily dose 300 mg)  for 6 months
41
How will you give immunizations to HIV-exposed

and infected infants?
You have learned about giving immunizations in MODULES 2 and 7. You should
also always follow the national guidelines for immunizations. However, there are
important differences specific for infants who are HIV-exposed or infected.
GIVE ROUTINE EPI VACCINES ACCORDING TO NATIONAL SCHEDULES

All HIV-exposed infants and children should receive all EPI vaccines, including Hib
and pneumococcal vaccine, as early in life as possible, according to the recommended
national schedule.
POSSIBLE ADDITIONAL DOSE OF HIB

Haemophilus influenza type b (Hib) has been shown to be an important cause
of childhood meningitis and a major cause of bacterial pneumonia in children.
HIV appears to be a risk factor for developing invasive disease due to H. influenzae
type B, especially bacteremic pneumonia. Hib vaccine is recommended for use in
national childhood immunization programmes in all countries, including in HIV-
infected children. The vaccine is generally administered along with DTP vaccines
during infancy.
The need and timing for an additional dose in the second year of life in children
in developing countries is not well-defined. However, an additional dose may be
particularly useful in HIV-infected children even in developing countries.
BCG VACCINATION
New findings indicate a high risk of disseminated BCG disease developing in HIV-
infected infants. However, it is difficult to identify infants infected with HIV at
birth. Therefore, the BCG vaccination may need to be given at birth to all infants
regardless of HIV exposure, in areas with high endemicity of tuberculosis and
populations with high HIV prevalence.
YELLOW FEVER
Infants with symptomatic HIV infection should NOT receive yellow fever vaccines.
DO NOT VACCINATE SEVERELY ILL CHILDREN

As for any severely ill child at the time of immunization, severely ill HIV-infected
children should NOT be vaccinated.
How will you provide Vitamin A supplementation?

Young infants and children infected with HIV should follow the same Vitamin A
supplementation protocol as for uninfected young infants and children. It is best
that the Vitamin A doses are synchronised with immunization visits or campaigns.
Remember to make sure that children with HIV infection also receive routine
deworming treatments. This is further described in the module on well child care.
42
SELF-ASSESSMENT EXERCISE F – INTEGRATED TREATMENT

You will again practice integrated treatment, a skill you have learned throughout
your modules. In the cases below, the child also has an HIV-related classification.
How will you treat or follow-up?
1. How would you treat a child with the classifications: HIV EXPOSED and
PNEUMONIA?
2. When should you follow-up a child with the classifications: PERSISTENT

DIARRHOEA and HIV EXPOSED?
3. How would you treat a child with the classifications: PNEUMONIA (wheeze
present) and HIV EXPOSED?
4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA
and CONFIRMED HIV INFECTION? The child’s father has active TB and has
just begun treatment.
5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC
EAR INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and
CONFIRMED HIV INFECTION?
43
n Now you will return to Peter. What will you do during your first visit?
During your first visit with Peter, you classified him with PNEUMONIA and HIV EXPOSED. These are both
yellow. You identify treatments in your chart booklet:
PNEUMONIA • Give oral amoxicillin for 5 days HIV • Give cotrimoxazole

Yellow • If wheezing (even if it disappeared after EXPOSED prophylaxis
rapidly acting bronchodilator) give an inhaled Yellow • Start or continue ARV as
bronchodilator for 5 days** recommended
• Soothe the throat and relieve the cough with a • Do virological test to
safe remedy confirm HIV status**
• If coughing for more than 2 weeks or if having • Assess the child’s feeding
recurrent wheezing, refer for assessment for TB and provide appropriate
or asthma counseling to the mother
• Consider HIV infection • Advise the mother on home
• Advise mother when to return immediately care
• Follow-up in 3 days • Follow-up regularly
EPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

You know that Peter requires an oral antibiotic for pneumonia, and cotrimoxazole for HIV exposure. Your first
step is to manage these two treatments.
OME 1. Amoxycillin: Peter requires an appropriate oral antibiotic for 5 days for PNEUMONIA. He will receive
be given
TEPS IDENTIFIED Give
at amoxycillin
ON an
for 5Appropriate
THE ASSESSOral
days at the appropriate
AND Antibiotic
dosage for a six month old. This is indicated by the arrow. You
CLASSIFY CHART
will assess Peter’s cough again during the follow-up visit in 3 days.
FOR PNEUMONIA, ACUTE EAR INFECTION:
dosage table. FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
AMOXICILLIN*
HOME
or weight. Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION
to be given at Give AGE
anorAppropriate
WEIGHT
OralTABLET
Antibiotic SYRUP
250 mg 250mg/5 ml
2 months up to 12 months (4 - <10 kg) 1 5 ml
g's dosage table. FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
12 months up to 3 years (10 - <14 kg) 2 10 ml
AMOXICILLIN*
he 3 years up to 5 years (14-19 kg) 3 15 ml
ge drug.
or weight. * Amoxicillin is now the first-line drug of choice
Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION
in the treatment of pneumonia due to its efficacy and increasing high resistance
AGE or WEIGHT
ach drug to cotrimoxazole . TABLET SYRUP
FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED250 mg
CHILD: 250mg/5 ml
nish the course of ANTIBIOTIC FOR PROPHYLAXIS:
2 months up to 12 monthsOral Cotrimoxazole
(4 - <10 kg) 1 5 ml
2. Cotrimoxazole prophylaxis: After Peter completes 5 days of oral antibiotics for pneumonia, you
12 months up to 3 years (10 - <14 kg) 2COTRIMOXAZOLE 10 ml
determine he needs
3 years further
up to antibiotic
5 years (14-19 kg) treatment(trimethoprim
for
3 another cause. If he does not,
+ sulfamethoxazole) 15 ml he can begin
e the drug.
e each drug
cotrimoxazole prophylaxis
* Amoxicillin for HIV
is now the first-line exposure.
drug Give
of choice The
once
in the aappropriate
day starting
treatment at 4-6daily
of pneumonia duedose
weeks of
to age for
to: a 6
its efficacy month
and old
increasing isresistance
high indicated
to cotrimoxazole . All infants HIV exposed untill definitly ruled out
with the arrow:
AGE
All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease
FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED CHILD:
o finish the course of ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole All infants or children with CD4 < 25%
Syrup Paediatric COTRIMOXAZOLE
tablet Adult tablet
c. (40/200 mg/5ml) (Single strength 20/100 +mg)
(trimethoprim (Single strength 80/400 mg)
sulfamethoxazole)
Less than 6 months 2.5 ml Give once a1day starting at 4-6 weeks of age to:
6 months up to 5 years 5 ml 2 exposed untill definitly ruled out 1/2
All infants HIV
AGE give Ciprofloxacine
FOR DYSENTERY All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine All infants or children with CD4 < 25%
CIPROFLOXACINE
Syrup Paediatric tablet Adult tablet
AGE Give 15mg/kg two times daily for 3 days
(40/200 mg/5ml) (Single
250 mg strength
tablet 20/100 mg) (Single strength
500 mg tablet 80/400 mg)
Less than 6 months
Less than 6 months 2.5 ml 1/2 1 1/4
6 months up to 5up
6 months years
to 5 years 5 ml 1 2 1/2 1/2
FORFOR DYSENTERY give Ciprofloxacine
CHOLERA:
FIRST-LINEANTIBIOTIC
FIRST-LINE ANTIBIOTIC:FOR
OralCHOLERA:
Ciprofloxacine
____________________________________________________
3. SECOND-LINE
You will ANTIBIOTIC
advise Lungile FORaCHOLERA:
on: ____________________________________________________
throat remedy, feeding advice, to follow-up for the PNEUMONIA
CIPROFLOXACINE
AGE ERYTHROMYCIN Give 15mg/kg two times daily for 3 days
TETRACYCLINE
in 3 days, when to return for HIV test results, and when
250 mg tablet to return immediately. You will check
500 mg tablet
Give four times daily for 3 days Give four times daily for 3 days
immunizations, vitamin A, and deworming.
Less
AGE orthan 6
WEIGHTmonths 1/2 1/4
6 months up to 5 years TABLET 1 TABLET 1/2
FOR CHOLERA: 250 mg 250 mg
FIRST-LINE
2 years up toANTIBIOTIC
5 years (10FOR
- 19 CHOLERA:
kg) ____________________________________________________
1 1
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
44
ERYTHROMYCIN TETRACYCLINE ↺
Give four times daily for 3 days Give four times daily for 3 days
AGE or WEIGHT
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1
Page 15 of 75

n What
care will you provide when Peter returns for follow-up?

Your classification of PNEUMONIA requires follow-up in 3 days.

n Lungile brings Peter in 3 days for PNEUMONIA follow-up:

You re-assess Peter’s PNEUMONIA and do another full IMCI assessment.

Peter’s breathing has slowed to 45 breaths per minute. His pneumonia is improving. You ask Lungile to

continue giving the cotrimoxazole until it is complete. You remind her to provide additional food. You
completea
full IMCI assessment and there are no new problems. You as happy to see that Peter is improving,

and Lungile is relieved.

n What other
care does Peter require?

You will remember that you have classified Peter as HIV EXPOSED. As Lungile is HIV-infected, you must

counsel her on feeding Peter. You will learn about this in the next section.

45

Review the main points from this section. Reading this summary, and completing
the self-assessment exercises in the module, are important for learning.
1. Cotrimoxazole prophylaxis is very important to reducing mortality in
HIV-exposed and infected children and infants
n All young infants with confirmed HIV infection, from 4–6 weeks of age
n All young infants who are HIV-exposed, from 4–6 weeks of age
n All children who are HIV-infected and under 12 months old
n All children who are HIV-infected, from 12 months and up to 5 years of age,
who are at clinical stages 2, 3, or 4, or have a CD4% of under 25%.
n All children classified as HIV EXPOSED
2. Antiretroviral prophylaxis is an important measure in preventing
mother-to-child transmission in young exposed infants
The intervention depends on whether or not the child is breastfeeding. If the
child is breastfeeding, 6 weeks of once-daily NVP is recommended. If the child
is receiving replacement feeding, 4–6 weeks of once-daily NVP is recommended
(or twice-daily AZT).
3. Isoniazid preventive therapy is an important measure to protect children
and young infants who are HIV-infected children from tuberculosis.
Therapy lasts for 6 months. If a child has active TB they require TB treatment.
4. Routine care is critical for keeping HIV-exposed and infected infants
and children healthy
This includes timely immunizations, deworming, and Vitamin A.
46
8.7 COUNSEL HIV-INFECTED MOTHERS ABOUT

INFANT FEEDING

•• Explain your national guidelines on infant feeding, depending on if countries
recommend: (a) HIV-infected mothers receive ARVs while breastfeeding their
infants or (b) HIV-infected mothers should avoid all breastfeeding and use
infant milk formulas.
•• Describe feeding options for HIV exposed and infected children, including the
advantages and disadvantages of each option
•• Explain the nutritional needs of infants at different ages, and
recommendations to meet those needs: 0 to 6 months, 6 to 12 months, 12 to
24 months
WHAT FEEDING TOPICS ARE COVERED IN THIS SECTION?

This section includes a number of important discussions when considering safe
infant feeding for HIV-exposed and infected children.
1. Feeding options and considerations for HIV-infected mothers
2. Feeding recommendations for HIV-exposed children up to 24 months
a. If national recommendations are breastfeeding with ARV interventions
b. If national recommendations are no breastfeeding
3. Counselling on feeding problems that you might see in HIV-infected children
4. Counselling the mother on stopping breastfeeding
5. Counselling the mother on her own health
WHY DO HIV-INFECTED MOTHERS NEED SPECIAL COUNSELLING

AND SUPPORT?
Infant feeding counselling and support are critical for preventing mother-to-child
HIV transmission. You have learned about the risks of mother-to-child transmission
during pregnancy, labour, delivery, and through breastfeeding.
HIV-infected mothers need special counselling and support around infant feeding
and their own health. Remember that counselling on infant feeding options requires
skill and practice. This section provides you with the knowledge you will need to
give HIV-infected mothers basic information about safer infant feeding.1
This section assumes that you have completed the Counsel the Mother module of the IMCI case management
1
course. It does not provide you with all the skills you need to counsel pregnant or newly-delivered HIV-positive
women on infant feeding options. If you regularly need to counsel pregnant women on infant feeding options,
you should participate in one of the courses that include HIV and infant feeding counselling, for example the
WHO/UNICEF Infant and Young Child Feeding Counselling: An Integrated Course.
47
WHAT ARE IMPORTANT DEFINITIONS FOR FEEDING PRACTICES?

There are two key feeding practices to understand: exclusive breastfeeding, and
mixed feeding.
EXCLUSIVE BREASTFEEDING: giving the child breast milk and nothing more until 6 months
MIXED FEEDING: is giving the child breast milk and other foods or fluids
WHAT ARE THE FEEDING RECOMMENDATIONS FOR WOMEN WHO

DO NOT KNOW THEIR STATUS?
Women who do not know their HIV status should be encouraged to have an HIV test.
WHAT ARE THE FEEDING RECOMMENDATIONS FOR

HIV-UNINFECTED WOMEN?
All women who are HIV-negative or who do not know their HIV status should be
counselled to exclusively breastfeed their babies for the first six months of life,
then introducing complementary feeds and continuing with breastfeeding for up
to two years or beyond.
WHAT ARE THE FEEDING RECOMMENDATIONS FOR

HIV-INFECTED WOMEN?
All HIV-infected women should be informed on national recommendations for
HIV and infant feeding as part of antenatal and postnatal care. Informing mothers
about feeding recommendations can help improve HIV-free survival of HIV-exposed
infants.
WHO guidelines state that national health authorities should decide if health
services will principally counsel and support HIV-infected mothers in one of two
strategies that will most likely give infants the greatest chance of HIV-free survival:
1. BREASTFEED AND RECEIVE ARV INTERVENTIONS, OR

2. AVOID ALL BREASTFEEDING
This decision should be based on international recommendations and should
consider:
✔✔ Socio-economic and cultural contexts of the populations served by maternal
and child health services
✔✔ Availability and quality of health services
✔✔ Local epidemiology including HIV prevalence among pregnant women
✔✔ Main causes of maternal and child undernutrition, and infant and child mortality
48
WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND

RECEIVE ART: what are important considerations when discussing
feeding options?
There are advantages and disadvantages associated with the respective infant
feeding practices available to the HIV-infected mother. These are described in the
table on the next page.
WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND

RECEIVE ART: What happens if the mother will not breastfeed?
In exceptional circumstances when the mother cannot breastfeed or is unwilling
to breastfeed, refer to feeding counsellors.
WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THE MAIN

FEEDING OPTIONS AVAILABLE TO HIV-INFECTED MOTHERS?
The table below summarizes the major advantages and disadvantages of two feeding
practices: exclusive breastfeeding, and using commercial formula. Please read this
table to further your understanding of these feeding options. You can also discuss these
advantages and disadvantages while you counsel mothers about feeding their child.
PRACTICE ADVANTAGES DISADVANTAGES

Exclusive What are the advantages of breast milk? What are the disadvantages of exclusive breastfeeding?
breastfeeding ✔✔ Is the perfect food for babies ✔✔ As long as a mother is breastfeeding, her baby is exposed
✔✔ Protects babies from many serious to HIV
diseases ✔✔ People may pressure her to give water, other liquids,
✔✔ Gives babies all of the nutrition and or food to the baby while she is breastfeeding. This
water they need practice, known as mixed feeding, increases the risk of HIV
✔✔ Is free, always available, and does not transmission, diarrhoea, and other infections
need any special preparation ✔✔ The mother will need support to exclusively breastfeed
until it is possible for the mother to use another feeding
What are the advantages of exclusive
option
breastfeeding?
✔✔ It may be difficult if the mother works outside the home
✔✔ Exclusive breastfeeding for the first few
and cannot take the baby with her
months lowers the risk of passing
HIV, compared to mixed feeding
✔✔ People will not ask why the mother is
breastfeeding
✔✔ Exclusive breastfeeding protects the
mother from getting pregnant again
too soon
Commercial What are the advantages of formula? What are the disadvantages of formula?
infant ✔✔ Giving only formula carries no risk of ✔✔ Formula does not contain antibodies. These are
formula transmitting HIV to the baby substances that protect the baby from serious infections
✔✔ Most of the nutrients a baby needs ✔✔ A formula-fed baby is more likely to get seriously sick
have already been added to the from diarrhoea, chest infections and malnutrition
formula ✔✔ To prepare formula there is a need for a sustainable
✔✔ Others can help feed the baby supplies of fuel and clean water (brought to a rolling boil)
✔✔ People may wonder why the mother is not breastfeeding
✔✔ Formula takes time to prepare – bottle feeds should be
made up fresh each time
✔✔ Formula is expensive
✔✔ The mother will need support to exclusively and safely
formula feed
✔✔ Need to learn how to feed by cup
✔✔ The mother may get pregnant again too soon
49
WHAT ARE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN IF GUIDELINES ARE BREASTFEEDING AND ARVS?
This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12 months, and 12–24 months. It also reviews safe
transition from exclusive breastfeeding to replacement feeding.
CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES RECOMMEND BREASTFEEDING AND ARVS
UP TO 6 MONTHS OF AGE 6 UP TO 12 MONTHS 12 MONTHS UP TO 2 YEARS STOPPING BREASTFEEDING

•• BREASTFEED •• BREASTFEED as often as the •• COMPLEMENTARY FOODS. STOPPING BREASTFEEDING means
EXCLUSIVELY as often infant wants Give adequate servings of changing from all breast milk to none.
as the infant wants, day the following foods, or family This should happen gradually over
•• COMPLEMENTARY FOODS.
and night. Feed at least foods, 5 times a day: one month. Plan in advance for a safe
Give 3 adequate servings of
8 times in 24 hours. transition.
nutritious complementary
•• DO NOT GIVE OTHER foods, plus one snack, per 1. HELP MOTHER PREPARE:
FOODS OR FLUIDS. day. Each meal should be ¾ Mother should discuss and plan in
Mixed feeding increases cup. 1 cup = 250 ml. advance with her family, if possible
the risk of mother-to- •• IF BREASTFEEDING give •• Express milk and give by cup
•• This should include protein,
child HIV transmission adequate servings of •• Find a regular supply or formula
and mashed fruits and
50
when compared to complementary foods 3 times or other milk (e.g. full cream cow’s
vegetables. If possible, give
exclusive breastfeeding per day, plus snacks. milk)
an additional animal-source
food, such as liver or meat. •• IF NOT BREASTFEEDING •• Learn how to prepare a store milk
also give about 500 ml safely at home
Foods can include:
(1–2 cups) or full cream milk 2. HELP MOTHER MAKE
or infant formula per day. TRANSITION:
Give milk with a cup. Do not •• Teach mother to cup feed
use a bottle. If no milk is
•• Clean all utensils with soap and

available, give 4–5 feeds per water
day. •• Start giving only formula or cow’s
milk once baby takes all feeds by
cup
3. STOP BREASTFEEDING
COMPLETELY:
Express and discard enough breast
milk to keep comfortable until
lactation stops.
REVIEWING FEEDING RECOMMENDATIONS CHART
Breastfeeding and ARVs

WHAT ARE THE KEY RECOMMENDATIONS FOR MOTHERS?
In settings where national authorities recommend breastfeeding and ARV
interventions for HIV-infected mothers, there are two scenarios: either the infants
have been confirmed with HIV infection, or they are not infected or their status
is unknown.
IF INFANTS ARE CONFIRMED HIV INFECTED:

These mothers should follow standard feeding recommendations, like any other
child. Important points in these recommendations include:
✔✔ Exclusively breastfeed infants for the first 6 months of life
✔✔ Introduce appropriate complementary foods at 6 months, and
✔✔ Continue breastfeeding up to two years or beyond – that is, as per the
recommendations for the general population
IF INFANTS ARE HIV EXPOSED:

These mothers should:
✔✔ Exclusively breastfeed infants for the first 6 months of life
✔✔ Introduce appropriate complementary foods at 6 months
✔✔ Continue breastfeeding for the first 12 months of life
✔✔ Breastfeeding should then only stop once a nutritionally adequate and safe diet
without breastmilk can be provided.
WHAT IF ARVS ARE NOT IMMEDIATELY AVAILABLE

TO THESE WOMEN?
Mothers known to be HIV-infected should be provided with lifelong antiretroviral
therapy or antiretroviral prophylaxis interventions to reduce HIV transmission
through breastfeeding according to WHO recommendations.
When antiretroviral drugs are not immediately available to HIV-infected mothers,
breastfeeding may still provide their infants with a greater chance of HIV-free
survival. In circumstances where ARVs are unlikely to be available, such as acute
emergencies, breastfeeding of HIV-exposed infants is also recommended to increase
survival.
51
WHAT ARE IMPORTANT FOR COUNSELLING HIV-INFECTED WOMEN

WHO BREASTFEED?
There are some important issues for HIV-infected women to be counselled on, and
for you to remember as a health worker.
✔✔ When HIV-positive mothers decide to stop breastfeeding at any time, infants
must be provided with safe and adequate replacement feeds to enable normal
growth and development
✔✔ Skilled counselling and support in appropriate infant feeding practices
✔✔ ARV interventions to promote HIV-free survival of infants should be available
to all pregnant women and mothers. Refer to your section on prophylaxis.
Later in this section you will review more information on counselling a
mother as she stops breastfeeding.
Refer to MODULE 2 on the sick young infant to review what you have learned about
counselling a mother on breastfeeding. When you follow-up with a mother, here
are some important items to counsel on, or check:
✔✔ Check that she breastfeeds exclusively and gives no other milk, water, or food
✔✔ Help her with any feeding problem she may report, such as “not enough milk”,
“baby crying a lot”, or sore nipples.
✔✔ Check if she breastfeeds as often as the baby wants and for as long as the baby
wants
✔✔ Observe a breastfeed and check the mother’s breasts, as required
✔✔ Check that the mother is receiving ART or ARV prophylaxis. Check drug
adherence.
✔✔ Check the health of the mother and that she has had a CD4 count in the last 6
months.
52
WHAT ARE THE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN, IF

NATIONAL GUIDELINES ARE INFANT FORMULA?
This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12
months, and 12–24 months.
CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES

RECOMMEND INFANT FORMULA ONLY
UP TO 6 MONTHS OF AGE 6 UP TO 12 MONTHS 12 MONTHS UP TO 2 YEARS

FORMULA FEED GIVE MILK. Give about 1–2 COMPLEMENTARY FOODS.
EXCLUSIVELY. Do not give cups (250–500 ml) of infant Give adequate servings of
any breast milk. Other foods or formula or boiled (then cooled) the following foods, or family
fluids are not necessary. full cream milk. Give milk with a foods, 5 times a day:
cup, not a bottle.
Prepare correct strength and
amount just before use. Use COMPLEMENTARY FOODS.
milk within two hours. Discard Start by giving 2–3 tablespoons
any left over – a fridge can of food 2–3 times a day.
store formula for 24 hours. Gradually increase to ½ cup
(1 cup = 250 ml) at each meal,
Cup feeding is safer than bottle
and to 3–4 meals a day.
feeding. Clean the cup and
utensils with hot soapy water. SNACKS. Offer 1–2 snacks
each day when the child seems GIVE MILK. Give about 500 ml
Give the following amounts
hungry. For snacks give small (1–2 cups) or full cream milk or
of formula up to 6 times per
chewable items that the child infant formula per day. Give
day:
can hold. Let your child try to milk with a cup. Do not use a
AGE AMOUNT x eat the snack. bottle.
(months) TIMES PER DAY
This should include protein,
0 up to 1 60 ml x 8
and mashed fruits and
1 up to 2 90 ml x 7 vegetables. If possible, give an
2 up to 3 120 ml x 6 additional animal-source food,
such as liver or meat.
3 up to 4 120 ml x 6
These foods can include:
4 up to 5 150 ml x 6
5 up to 6 150 ml x 6
* EXCEPTION: heat-treated
breast milk can be given
53
Infant formula
WHAT ARE IMPORTANT REMINDERS ABOUT REPLACEMENT
FEEDING?
When you counsel and caretaker on formula feeding, and provide follow-up care in
subsequent visits, there are important practices to check.
You can ask checking questions about how feeds are being measured, prepared,
and given. Based on what the caregiver explains, you might also ask him/her
to demonstrate for you. Give appropriate feedback. If there are any problems,
demonstrate how to prepare safely and give the feed to the baby.
This is important to check the following:
✔✔ Only replacement feeding is being given, never breastmilk or unsafe fluids
✔✔ Appropriate volume and number of feeds
✔✔ Correct measurement of milk and other ingredients
✔✔ Feeds prepared cleanly and safely (e.g. boiling and cooling milk)
✔✔ Fresh feeds given each time
✔✔ Cup feeds are given for safety
✔✔ Use of hot soapy water for cleaning utensils and cup
All HIV-infected or exposed children

WHAT ARE IMPORTANT POINTS ABOUT GIVING CHILDREN FAMILY
FOODS AND SNACKS?
When children begin taking family foods, meals should contain foods that provide
energy such as a staple, but should be combined with other foods to provide enough
of the other essential nutrients such as protein, vitamins and iron.
Good snacks provide both energy and nutrients. Examples of good snacks are:
yoghurt and other milk products; bread or biscuits spread with butter, margarine,
nut paste or honey; fruit; bean cakes; cooked potatoes. Poor value snacks are ones
that are high in sugar but low in nutrients. Examples of these are fizzy drinks (sodas),
sweet fruit drinks, sweets, salty items, and sweet biscuits.
HOW SHOULD FEEDING CHANGE DURING ILLNESS?

Parents and caregivers should increase the amount of fluids they give to children
during illnesses and encourage the child to eat soft, varied, appetizing favourite
foods. After illness, parents and caregivers should give food more often than usual
and encourage the child to eat more. Remember that PERSISTENT DIARRHOEA
has specific feeding recommendations.
54
WHAT ARE SPECIAL FEEDING PROBLEMS HIV-INFECTED CHILDREN

MIGHT HAVE?
HIV-infected children may experience special feeding problems. These may require
further interventions for nutrition or care. In addition to special feeding problems,
HIV-related illnesses like tuberculosis and diarrhoea occur in malnourished
children. They have severe consequences because they can cause appetite loss, weight
loss, and acute malnutrition.
CHILD HAS CLINICAL CONDITIONS THAT AFFECT THEIR NUTRITION

Some clinical conditions may affect the HIV-infected child’s nutrition status. It is
important to identify local nutrient-rich foods that are available and affordable
and to advise the mother on how to increase the energy content of foods. Always
advise the mother to continue feeding and continue giving fluids during any illness.
CLINICAL SITUATION CONSEQUENCE WHAT ACTION SHOULD YOU TAKE?

Recurrent or chronic ✔ Increased metabolic Offer feeds more frequently than before:
infection needs 1. The chronic infection should be treated.
✔ Significantly higher 2. If the child is breastfeeding breastfeed at least 8 times in 24 hours
caloric demands 3. If the child is on complementary foods, offer small meals at least 5
times a day. Increase the energy value of these feeds by adding oil
or nuts.
4. Follow the recommendations in IMCI chart booklet
Intestinal infections ✔ Increased nutrient 1. These infections should be treated appropriately.
requirements 2. Follow the same feeding recommendations for the child with
✔ Impaired absorption recurrent or chronic infection
and loss of appetite 3. Treat for worms if the child has not been treated during the previous
may decrease food 6 months
intake 4. Give Vitamin A if the child has not been treated during the past 6
✔ Diarrhoea
months
Oral or oesophageal ✔ Potential pain with 1. Make sure child receives treatment for thrush
thrush swallowing may result 2. Offer foods that have been mashed up or pureed
in decreased oral intake 3. Avoid spicy foods
primarily for solids, but 4. Paracetamol half an hour before feeds may be helpful in extreme
also for liquids cases
Persistent ✔ Impaired absorption of 1. Follow the feeding recommendations for the child with recurrent or
diarrhoea caused by nutrients chronic infection (above); the child with intestinal infections (above)
cryptosporidia or other and the child with persistent diarrhoea (in the chart booklet)
parasites
Nausea and vomiting 1. These are infrequent but may occur.
as a result of ARV drugs 2. For ritonavir containing medication coat tongue with peanut butter
before dose is given.
3. Encourage small frequent sips of fluids and give food that the child
likes
4. Let the child eat before medication
55
CHILD HAS A POOR APPETITE

This is especially common with HIV infection, and may be made worse if the child
has mouth lesions such as ulcers or oral thrush.
✔✔ Treat the oral lesions urgently and appropriately. Paracetamol may be used in
addition for pain relief before each meal.
✔✔ Use soft, varied favourite foods to encourage the child to eat as much as possible
✔✔ Keep up fluid intake
✔✔ Give foods that are not too thick or dry
✔✔ Offer small, frequent feeds. Feed the child when he is alert and happy. Give more
food if he shows interest.
✔✔ If the child has mouth lesions, offer foods that do not burn the mouth – such
as eggs, mashed potatoes, sweet potato, pumpkin or avocado. Do not give spicy
or salty foods.
✔✔ Ensure that the spoon is the right size, that food is within the reach of the child
and that he is actively fed. For example, he sits on the mother’s lap while eating.
WHAT ARE THE RECOMMENDATIONS FOR SAFELY STOPPING

BREASTFEEDING?
Mothers known to be HIV-infected who decide to stop breastfeeding at any time
should stop gradually within one month. The mother’s reason for stopping should
be discussed and the health worker should assess if there are specific difficulties
that can be overcome. Health workers should discuss with the mother what food
she will give to her infant after stopping breastfeeding and if these will be sufficient
for the child’s growth and development.
HOW SHOULD A MOTHER BE COUNSELLED ABOUT STOPPING

BREASTFEEDING?
It is advised to stop breastfeeding gradually over one month. Below are important
counselling notes.
n Planning ahead: Mothers should think and plan ahead about how she will
provide supplementary foods and alternative sources of milk.
n Comfort is an important part of breastfeeding: babies want to breastfeed
not only because it gives them nutrition but also because they want the comfort
and security of being with their mothers. Stopping breastfeeding means that
mothers need to plan how they will feed their infant and also how they will
comfort them when crying when they are tired or upset. Babies cry when they are
hungry. However, they can also cry when they are tired or want their mother’s
attention. Babies also have growth spurt when they want more milk and therefore
they will want to breastfeed for longer. Mothers sometime interpret crying as
meaning that their baby is always hungry and that they do not have enough
milk. This is not true and the mother should not decide to stop breastfeeding
based on this thinking.
56
n Preparing the baby before breastfeeding is stopped: if a mother plans to

stop breastfeeding then she can help to prepare her baby.
— While breastfeeding, mothers can teach their babies to drink expressed breast
milk from a cup
— If the mother or baby are not receiving ARVs to prevent HIV transmission,
then this milk may be boiled to destroy HIV
— Once the baby is drinking comfortably from a cup, replace one breastfeed
with one cup-feed using expressed breast milk
— Increase the frequency of cup-feeding every few days and reduce the frequency
of breastfeeding. Ask an adult member of the family to help with cup feeding
— Stop putting your baby to your breast completely as soon as your baby is
accustomed to frequent cupfeeding
— If a baby needs to suck, give the child one of your clean fingers instead of the
breast
n Once a mother begins to stop breastfeeding:
— To avoid breast engorgement (swelling) mothers should express a little milk
whenever her breasts feel full. This will help mothers feel more comfortable.
Use cold compresses to reduce inflammation.
— Mothers should not begin breastfeeding again once they have stopped. If
a mother does start again, this may increase the risk of passing HIV to her
baby. If a mother’s breasts become engorged then it is better for her to express
breast milk by hand.
— Mothers should begin using a family planning method of her choice even
before the end of breastfeeding and certainly as soon as she starts reducing
breastfeeds.
— Check with the mother that she has had a blood sample taken for a CD4 count
in the past 6 months and that she knows this result. Remind her that this
should be done every 6 months to assess if she needs lifelong ART for herself.
WHEN SHOULD ARV PROPHYLAXIS BE STOPPED AFTER

BREASTFEEDING STOPS?
Mothers or infants who have been receiving ARV prophylaxis should continue
prophylaxis for one week after breastfeeding is fully stopped. Mothers should also
know to continue the ARV prophylaxis for the child for one week following the complete
cessation of breastfeeding: this means from the date that the child has absolutely
no breastmilk. Health workers must ensure she has enough supplies of ARVs.
WHAT IF A MOTHER IS TOO SICK TO BREASTFEED?

If the HIV-infected mother who has chosen to breastfeed develops symptomatic AIDS,
she may no longer be able to manage the physical requirements of breastfeeding.
Help the mother to make a safe and complete transition to replacement feeds. For
women without adequate financial resources or any family support, you may have
to arrange for a secure supply of formula milk (under six months) or plain milk
(older children).
The mother should be assessed and referred for ART and she should be placed on
cotrimoxazole.
57
WHAT ARE THE FEEDING RECOMMENDATIONS FOR ORPHANS?

Abandoned children or maternal orphans require special consideration. Their
feeding options are as follows:
0 TO 6 MONTHS
Three options for feeding orphans are discussed below:
1. Receive a safe and appropriate breast milk substitute
If the child receives formula milk, make sure that the milk given is appropriate.
Follow the feeding recommendations for a child on formula milk in the Counsel
the mother section of the chart booklet.
2. Receive breast milk from confirmed HIV negative women
If the child receives breast milk from a wet nurse it will be crucial to determine
that this wet nurse is confirmed HIV negative, is not in the window period where
she might still become HIV-infected, and is not at risk of becoming HIV-infected.
3. Receive breast milk from a breast milk bank
If the child receives breast milk from a milk bank, the milk bank should pasteurize
the milk according to standard procedures.
6 to 24 MONTHS
Infants from six months to 2 years who are not breastfed should be given safe family
foods and milk or some other animal-source food every day.
HOW DO YOU COUNSEL A MOTHER ABOUT HER OWN HEALTH?

During a sick child visit, listen for any problems that the mother (or caregiver)
herself may have. The mother may need treatment or referral for her own health
problems. Do not force mothers to queue twice or attend different places for simple
problems. Write down her health concerns at the bottom of the recording form. This
will remind you to help the mother after attending to her child.
WHAT COUNSELLING IS GIVEN TO MOTHERS WHO ARE

HIV-INFECTED?
Mothers known to be HIV-infected should be provided with lifelong antiretroviral
therapy (ART) or antiretroviral prophylaxis interventions to reduce HIV
transmission through breastfeeding according to WHO recommendations. Mothers
should also have blood samples tested every 6 months to measure her CD4 count
and assess if she needs ART.
WHAT ARE IMPORTANT COUNSELLING TOPICS?

✔✔ FAMILY PLANNING – Ask her about family planning and if she is happy with
the method she has chosen. Discuss the alternatives with her and prescribe
contraception as you have been taught in family planning. Offer barrier
contraception as well, and ensure that the mother has enough contraception
for at least 3 months.
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✔✔ SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STI) – Assess

and treat these according to the National STI protocols.
✔✔ SOCIAL PROBLEMS – Encourage the mother to discuss any social problems.
These can include her partner, family, support networks, housing, childcare,
workload, and other issues. Provide ongoing counselling and care if she is HIV-
infected. If necessary, refer her.
n Counsel the mother about her own health

✔✔ IF SICK: If the mother is sick provide care for her, or refer her for ART.
✔✔ BREAST PROBLEMS: If she has a breast problem (such as engorgement, sore
nipples, breast infection), provide care or refer her for help.
✔✔ NUTRITION: Advise her to eat well to keep up her own strength and health.
✔✔ TT SHOTS: Check her immunization status and give tetanus toxoid if needed.
✔✔ ACCESS TO HEALTHCARE: Make sure she has access to:
✔✔ Regular testing for CD4 count
✔✔ Contraception and sexual health services
✔✔ Counselling on STI and AIDS prevention
✔✔ STIs: Counsel about safe sex and early treatment of STIs
n Give additional counselling if the mother is HIV-infected

•• FOLLOW UP: Reassure her that with regular follow-up, much can be done to
prevent serious illness, and maintain her and the child’s health
•• HYGIENE & CARE: Emphasize good hygiene, and early treatment of illnesses
•• PAIN: See guidelines for palliative care in chart booklet
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SELF-ASSESSMENT EXERCISE G – INFANT FEEDING

In this exercise you will answer questions about the feeding recommendations
that you have read about in this module.
1. Are the following statements true or false? These questions are about a country
that recommends breastfeeding and ARV interventions for HIV-infected
mothers.
a. It is advisable to give children fewer feeds during
illness. TRUE FALSE
b. It is best for a 3-month-old HIV-infected child to be
exclusively breastfed. TRUE FALSE
c. It is recommended that a 2-week-old child of
unknown HIV status born to an HIV negative mother
is never breastfed. TRUE FALSE
d. It is advisable that a breastfeeding child born to an
HIV-infected woman continues breastfeeding for as
long as the mother wants to breastfeed up to
12 months of age. TRUE FALSE
e. It is recommended that a 5-month-old child whose
mother is HIV negative breastfeeds as often as he
wants, day and night. TRUE FALSE
f. A 9-month-old child who is HIV-infected on
virological (PCR) tests can continue breastfeeding. TRUE FALSE
g. All breastfeeding HIV-infected women transmit HIV
to their infants. TRUE FALSE
h. It is advisable that a child born to a mother with
unknown HIV status is given formula TRUE FALSE
i. ARVs to an HIV-infected mother or to her exposed
infant very significantly reduces the risk of
transmission through breastfeeding TRUE FALSE
2. Traci is born to an HIV-positive mother. When should she begin receiving family
foods? What foods should be added, and in what quantity?
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n How will you advise Lungile about infant feeding?

Lungile is HIV-infected and you have classified Peter as HIV EXPOSED. You must advise Lungile about feeding
options for Peter.
From your IMCI assessment, you know that Peter’s weight is not low for age. You know that Peter is
breastfeeding.
n Peter is 6 months old – what will you recommend his mother?

You will advise Lungile according to the feeding recommendations in your feeding chart:
✔✔ BREASTFEED as often as the infant wants
✔✔ COMPLEMENTARY FOODS. Give 3 adequate servings of nutritious complementary foods, plus one
snack, per day. Each meal should be ¾ cup. 1 cup = 250 ml. This should include protein, and mashed fruits
and vegetables. If possible, give an additional animal-source food, such as liver or meat.
You emphasize that:
•• She should provide safe family foods like porridge and mashed vegetables or fruit. She should give
him 3 meals a day, plus one snack. You ask Lungile about what foods she has available in the home
and what she can afford to give Peter. She tells you that she sometimes has eggs, potatoes, squash,
and some chicken. You tell her how to prepare porridge, and show her how to feed Peter with a
spoon. You ask her checking questions to make sure she understands what you have explained.
•• She should not give Peter sugary drinks or unhealthy snacks.
You will re-evaluate this feeding advice during follow-up visits. You will also discuss breastfeeding
transitions with Lungile at the appropriate time. Remember that once Peter has stopped
breastfeeding for at least 6 weeks, you will test again to confirm his HIV status.
n How will you counsel Lungile about her own health?

You ask more about Lungile’s situation. She tells you that she just found out that she is HIV-infected. Lungile
lives in a tin shack in the centre of the city. She gets water from the tap in the street 200 metres from her
home. She lives alone. Her partner works in another city and comes home at weekends. Her mother lives on
the farm. Lungile visits her mother during Christmas.
Previously she was working temporary jobs. Since Peter was born, she has struggled trying to find work
during the days. She thinks that she might take Peter to the farm for some time. When she returns to the
city her mother will look after her baby. Neither her mother nor her partner knows that she is HIV infected.
She wants to tell her partner but she is scared. Maybe he will get angry with her and he will not give her any
money for Peter’s care.
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n What are important topics to discuss with Lungile?

Lungile has a complicated social situation. Today you want to discuss the most important care topics, and
encourage Lungile to continue seeking counseling and HIV care.
Lungile might already be receiving counseling on these topics at her clinic. Today you can ask her more
about the care she is receiving. If you notice areas that should be discussed more, you can address these with
her.
Lungile will need to be counseled on:
✔✔ HEALTH: is she ill?
✔✔ ACCESS TO CARE and FOLLOW UP: how frequently is she going for visits at the clinic where she was
tested for HIV and is receiving care?
✔✔ FEEDING PROBLEMS: including breast problems?
✔✔ IMMUNIZATIONS: does she have her TT shots?
✔✔ NUTRITION: what advise has she been given about eating well? She must keep up her own health and
strength, this is critical.
✔✔ SEXUALLY TRANSMITTED INFECTIONS: does she have any signs?
✔✔ FAMILY PLANNING: what method is she using, and is she happy with it?
✔✔ HYGIENE: discuss handwashing and other important hygiene practices, especially keeping Peter in mind
Lungile does not feel ill today, but has many questions for you about her own nutrition. She is also worried
that she is not making enough milk for Peter, so you discuss this issue. Her other clinic has provided her
immunizations, screening for sexually transmitted infections, and a family planning method (condoms), so
you only briefly discuss these topics.
Now you will return to Peter’s care. This counseling with Lungile has given you a better sense for Peter’s
environment and how the two of them will seek care. This information will be useful for approaching
treatment. You will now learn about treatment for Peter.
62
8.8 ANTIRETROVIRAL TREATMENT

•• Describe the common antiretroviral drugs
•• Decide which children are eligible to receive ART
•• Stage children using the clinical staging criteria in the IMCI chart booklet
•• Understand which children should be started on ART by nurses at primary
level
•• Refer certain children to a doctor for initiation of ART
•• Undertake a baseline assessment, including sending of laboratory results
•• Counsel the mother/care giver for adherence to ART
•• Describe the recommended ARV regimens for children
•• Prescribe ARVs in the correct dosages
•• Explain the possible side effects of ARV drugs and know how to manage them
SECTION OUTLINE
This section is separated into three parts. These are described below:
1. WHAT IS ANTIRETROVIRAL TREATMENT?
2. THE FIVE STEPS OF INITIATING ART IN CHILDREN
1st . Decide if child has confirmed HIV infection
2nd. Decide if caretaker is able to give ART
3rd. Decide if ART can be initiated in your first level facility
4th. Record baseline information on the child’s HIV treatment card
5th. Start on ART and cotrimoxazole prophylaxis
3. SIDE EFFECTS OF ARVS
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PART 1: What is antiretroviral treatment?

HIV is a special kind of virus called a retrovirus. So the drugs against HIV are called
antiretroviral drugs:
Anti
Retro shortened to ARV drugs, or simply ARVs
Viral drugs
In the first part of this module, you learned about how the HIV virus replicates by
turning CD4 cells into HIV ‘factories’. Antiretroviral drugs interfere with the life
cycle of the HIV virus, thus preventing it from replicating.
Giving ARVs in the correct way, with adherence support, is called ARV Therapy. This
is shortened to ART. ART does NOT cure HIV, but through preventing replication
of the virus it prevents immune system damage and can improve the quality of life
and life expectancy of the patient.
HOW IS ART DIFFERENT FOR CHILDREN AND ADULTS?

Antiretroviral (ARV) drugs are handled differently in children’s bodies, affecting
the doses that are needed. Dosages in children need to be adjusted to weight as the
child grows.
WHICH CHILDREN ARE GIVEN ANTIRETROVIRAL DRUGS?

All children under five who are CONFIRMED HIV INFECTION are eligible to receive
ART.
WHY ARE SEVERAL ARVS GIVEN AS ONE TREATMENT?

For ART to be effective it is important that a combination of three drugs is used,
rather than using one or two drugs. Combination therapy for HIV is like combination
therapy for TB, and makes sense for lots of reasons. Here are the most important
ones:
n IT TAKES A LOT OF FORCE TO STOP HIV

HIV makes new copies of itself very rapidly. Every day, many new copies of HIV
are made. Every day, many infected cells die. One drug, by itself, can slow down
this fast rate of infection of cells. Two drugs can slow it down more, and
three drugs together have a very powerful effect.
n ARVs from different drug groups attack the virus in different ways
Different ARV drugs attack HIV at different steps of the process of making copies
of itself: first when entering the cell, second when making new copies and third
when the new copies want to leave the cell. Targeting at least two of these
steps increases the chance of stopping HIV from making new copies of
itself and preventing new immune cells from infection.
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n Combinations of anti-HIV drugs may overcome or delay resistance

Resistance is the ability of HIV to change its structure in ways that make drugs
less effective. HIV has to make only a single, small change to resist the effects
of some drugs such as nevirapine.
For other drugs, such as zidovudine, HIV has to make several changes. When
one drug is given by itself, sooner or later HIV makes the necessary changes to
resist that drug. But if two drugs are given together, it takes longer for
HIV to make the changes necessary for resistance. When three drugs
are given together, it takes even longer.
WHAT ARE COMMONLY USED ANTIRETROVIRAL DRUGS?

ARV classes and examples of ARVs are shown in the table below. You will learn much
more about these ARVs later in this module. Recommended first-line regimens
usually include 2 NsRTI with 1 NNRTI.
STAVUDINE: You should note that stavudine was previously used as a first-line
agent, and many children are still on this drug. However it is no longer a preferred
first-line treatment.
Nucleoside reverse Nucleotide reverse Non-nucleoside Protease inhibitors
transcriptase transcriptase reverse (PI)
inhibitors (NsRTI) inhibitors (NtRTI) transcriptase
inhibitors (NNRTI)
lamivudine (3TC) tenofovir disoproxil nevirapine (NVP) lopinavir (LPV)
stavudine (d4T) fumarate (TDF) efavirenz (EFV) indinavir (IDV)
zidovudine (AZT) retonavir (RTV)*
didanosine (ddI) atazanavir (ATV)
abacavir (ABC) darunavir
* ritonavir is used as a ‘helper’ for one PI to make the effect of a second PI stronger
WHEN IS IT POSSIBLE TO INITIATE ART?

Before starting antiretroviral therapy, a child must first be stabilised. This means
any acute common illnesses and opportunistic infections must be treated and the
general condition of the child improved. The following pages discuss the 6 steps for
initiating ART in children.
65
PART 2: HOW DO YOU INITIATE ART IN CHILDREN?1

There are 5 steps to initiating ART in children. These are also in your chart booklet.
You will read more about each step in the following pages. Remember that if a
child has any general danger sign or a severe classification, they need URGENT
REFERRAL. ART initiation is not urgent, but should be initiated as soon as the
5 steps are completed.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FIRST
INFECTION LEVEL FACILITY
Child is under 18 months: ➜ If child weighs less than 3 kg or has TB, refer for ART
n HIV infection is confirmed if virological (PCR) is positive initiation.
n Check that child has not breastfed for at least 6 weeks ➜ If child weighs 3 kg or more and does not have TB,
move to STEP 4
Child is over 18 months:
n Two different serological tests are positive
n Send any further confirmatory tests required
n If results are discordant, refer
➜ If HIV infection confirmed, and child is stable, move to
STEP 2
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE
CHILD’S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
caregiver should ideally have disclosed the child’s HIV status n Weight and height
to another adult who can assist with providing ART, or be n If pallor is present
part of a support group. n If child has feeding problem
➜ If caregiver able to give ART: move to STEP 3 n Laboratory results (if available): Hb, viral load, CD4 count
➜ If caregiver not able: classify as CONFIRMED HIV and percentage
INFECTION not on ART. Follow-up regularly. Support ➜ Send any laboratory tests that are required. If the child is
caregiver and move forward once she is willing and able confirmed HIV infection, do not wait for results.
to give ART. ➜ Move to STEP 5
STEP 5: START ON ART TREATMENT AND COTRIMOXAZOLE PROPHYLAXIS

n Child is up to 3 years old: initiate preferred ART treatment: ABC or AZT +3TC+ LPV/R or other recommended first-line
regimen
n Child is 3 years or older but less than 35 kg: initiate preferred ART treatment: ABC + 3TC + EFV, or other recommended
first-line regimen
n Give cotrimoxazole prophylaxis
n Give other routine treatments, including Vitamin A and immunizations
n Follow-up regularly as per national guidelines
1
These steps were modified from South Africa’s IMCI Chart Booklet (2011).
66
RECORDING THE FIVE STEPS:
In addition to the IMCI recording form, you will use a supplementary form to record the five steps and your assessments. It includes critical instructions
for each step, and is a very useful job tool when determining HIV/AIDS care using IMCI. Review the form below:
STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. Age: ...................... Weight: ............ kg Temperature: ............... °C Date: ....................
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test RECORD ACTIONS AND TREATMENTS HERE:
• Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in stable ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
Ensure child has not breastfed for condition, GO TO STEP 2 PROVIDE ROUTINE CARE
at least 6 weeks
• Child 18 months and over:  Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
 YES: caregiver available and willing to give medication • If none present: GO TO STEP 3
 YES: caregiver has disclosed to another adult, or is part of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR  YES  NO • If any present: REFER NON-URGENTLY
FIRST LEVEL FACILITY • If none present: GO TO STEP 4
67
• Weight under 3 kg  YES  NO
• Child has TB  YES  NO
STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Send tests that are required
• Record weight and height,  SEVERE ACUTE MALNUTRITION
assess & classify malnutrition  MODERATE ACUTE MALNUTRITION • REFER IF:
 NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION
• Pallor is present  YES  NO — SEVERE OR SOME ANAEMIA
• Child has feeding problem  YES  NO
• Hb: ............................. g/dl Viral load: .................................................... • If none present: GO TO STEP 5

• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS RECORD ARVS & DOSAGES HERE:
• Child is under 3 years old: Initiate preferred first-line regimen 1. .............................................................................................................
• Child is 3 years or older: Initiate preferred first-line regimen 2. .............................................................................................................
• Cotrimoxazole 3. .............................................................................................................
• Give other routine treatments, including Vitamin A and immunizations
RECORD OTHER TREATMENTS HERE:
• Follow-up after one week

PROVIDE FOLLOW-UP CARE NEXT FOLLOW-UP DATE: ..................................................
• If child is stable, follow-up regularly
STEP 1. CONFIRM HIV INFECTION

The first step in initiating ART is to confirm the diagnosis of HIV infection. In
many cases, all the necessary tests will have been done, and you must correctly
document the results. In other cases it may be necessary to do some of the tests,
and to record the results.
HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN LESS

THAN 18 MONTHS?
A positive virological (PCR) test is required to confirm HIV infection in children
less than 18 months of age.
HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN 18 MONTHS

OR OLDER?
HIV infection in children older than 18 months of age is diagnosed using a serological
test. If the first serological test is positive, it requires a confirmatory test. If the
child is 18 months or older, repeat a serological test.
WHAT ARE YOUR NEXT STEPS AFTER A CHILD IS CONFIRMED

INFECTED?
Before starting antiretroviral therapy, a child must first be stabilised. This means
any acute common illnesses and opportunistic infections must be treated and the
general condition of the child improved. If the child is stable, you will then move
on to STEP 2.
REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR

STEP 1?
Review this section of the recording form to become familiar with the information
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
recorded: Age: ...................... Weight: ............ kg Temperature: ..
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test RECORD ACTIO
• Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in stable ALWAYS REMEM
Ensure child has not breastfed for condition, GO TO STEP 2 PROVIDE ROUTI
at least 6 weeks
at least 6 weeks
• Hb: ............................. g/dl
68
Viral load: .................................................... • If none present: GO TO STEP 5
SELF-ASSESSMENT EXERCISE H – CONFIRMING HIV INFECTION

1. Why is it important to use 3 drugs in ART for children?
2. Decide whether or not these children have confirmed HIV infection. The answer
may be: YES, NO, or TO BE CONFIRMED. If the answer is TO BE CONFIRMED,
write down in the final column what needs to done to confirm whether or not
the child has HIV infection.
Does the child have What should be done to

HIV infection? confirm the diagnosis?
a. 2 month old child has a positive

PCR test.

b. 12 month old child with positive
PCR test.
c. A 2 month old breastfeeding

child has a positive HIV
serological test.
d. An 18 month old breastfeeding
child has a positive HIV serological
test. A second test is also positive.
e. 9 month old breastfeeding child
has a negative PCR test. Mother
is HIV infected.
f. An 19 month old has a positive
serological test. The second test
is negative.
g. 9 month old child has a negative
PCR test. The child last breastfeed
3 months ago.
h. An 18 months old child has a
negative serological test. The child
last breastfed one week ago.
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SELF-ASSESSMENT EXERCISE I – ART ELIGIBILITY

Decide whether or not the following children are eligible to receive ART.
AGE DETAILS ANSWER
Child is CONFIRMED HIV INFECTION but
a. 4 years
appears healthy
b. 6 months Child is HIV exposed, and mother is very sick
c. 9 months Child had a positive serological test
d. 3 years Child had a positive serological test
e. 9 years Child is CONFIRMED HIV INFECTION

STEP 2. MAKE SURE THAT THE CARETAKER IS READY

TO GIVE ART
Adherence is the cornerstone of successful ART. For a good response at least
95% of the ARVs need to be taken.
WHAT MAKES ADHERENCE COMPLICATED FOR CHILDREN?

Adherence is therefore the key to successful therapy, but may be difficult to achieve
in children due to a number of reasons:
■■ Young children are heavily reliant on their parents/caregivers to
ensure adherence. There may be a poor understanding of the need to take the
medication both for parent and the child.
■■ Many parents may not wish to disclose the HIV status to the child or to
others involved in care.
■■ Lack of suitable easy to use paediatric fixed dose combinations means
complicated mixtures of pills/syrups need to be taken.
■■ Often the medicines are often not palatable to children, resulting in
difficulty in their administration.
WHAT SOCIAL ENVIRONMENTS ARE IMPORTANT FOR ADHERENCE?

The social criteria attempt to ensure good adherence. They aim to ensure that
adherence is at least probable. They are:
■■ Availability of at least one identifiable caregiver who is able to supervise
the child for administering medication (all efforts should be made to ensure that
the social circumstances of vulnerable children, e.g. orphans, are addressed so
that they too can receive treatment)
■■ Disclosure to another adult living in the same house is encouraged so that
there is someone else who can assist with the child’s ART
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WHY SHOULD THESE CRITERIA BE MET BEFORE INITIATING ART?

The social criteria highlight the fact that starting ART is not just a medical
issue, but has implications for the child and his/her caregiver. These criteria
should not be used as a barrier to giving a child ART, but should rather be thought
of as part of the process for preparing a child to start ART.
Some caregivers may be ready to commit themselves to giving their child ART
immediately, while others may need more time to get used to the idea. In some
instances there may be practical problems or issues that need to be addressed.
HOW CAN HEALTH WORKERS PREPARE CARETAKERS AND

CHILDREN FOR ADHERENCE?
Health care providers should use the ‘5 As’ to prepare children and their caregivers
for ART adherence. These are helpful to use during each clinic or follow-up visit.
‘5 As’ for adherence counselling

1. ASSESS 2. ADVISE 3. AGREE 4. ASSIST 5. ARRANGE

1. ASSESS
Try to ensure that a treatment supporter is identified. Make sure that the
caregiver understands that ART is lifelong therapy, and that she understands the
side effects of the medication. Though one cannot force another to disclose, the
primary caregiver should be supported to identify an additional person who can
assist treatment supervision. This will also provide insight into potential family
supports and challenges to successful chronic care adherence.
2. ADVISE
As you have learned in the previous counselling lessons in IMCI, it is very important
when advising caretakers to approach them in an open, non-judgmental, and patient
way. You might introduce the topic like this: “I have some information about HIV and
AIDS and ART. Would you like to hear it?”
Do not overwhelm the caregiver with too much information at once. She
will need time to think about and digest some information before being able to
concentrate on further information. That is why it is good to split the advice over
several visits, and indicate on the education side of the child’s treatment card the
information that has been given already.
WHAT TOPICS SHOULD HEALTH WORKERS ADVISE

CARETAKERS ON?
HIV ILLNESS AND EXPECTED PROGRESSION: Explain that in children the
progression of disease is often rapid. Children may be asymptomatic, but will
become vulnerable to opportunistic infections that gradually become more serious.
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ARV THERAPY (ART): Advise the caregiver that ARVs are life-saving drugs. Her
child’s life depends on taking the correct dose twice daily and at the right time.
ADVISE ON WHAT ADDITIONAL STEPS SHOULD BE TAKEN TO IMPROVE
ADHERENCE
•• Involve all caregivers, both parents, and child (depending on age and
maturity) in counselling sessions. Careful disclosure to the child can help
them understand why adherence is important. In many cases the child will be
too young to understand. It is important to gradually disclose to the child. This
is the caregiver’s responsibility, but the health worker or counsellor needs to
support and facilitate the process of disclosure.
•• Involve school nurses or orphanage staff, if and where applicable
•• Consider referral to support groups if available
3. AGREE
It is important to establish that the caregiver (and the child in older children) is
willing and motivated, and agrees to treatment, before initiating ART. The caregiver
must be willing to take responsibility for regular supervision of treatment and make
any life adjustments this may require. As children get older it is important they
know about ART and understand the importance of 100% adherence.
Start by asking: “After hearing all the explanation and advice, how do you think your
child will be able to take this kind of treatment?”
HOW CAN YOU CHECK THE MOTIVATION OF THE CAREGIVER?

In addition to considering the response to this question, use some other measures
to check the motivation of the caregiver (since in practice the health care provider’s
impression does not always correspond with the real situation).
You can check, for example:
•• Has the caregiver demonstrated ability to keep appointments for her child and
to adhere to other medications?
•• Does the caregiver want treat-
ment for her child and under-
stand what treatment is for?
•• Is the caregiver willing to bring
the child to the clinic for the
required follow-up?
•• Is the caregiver taking her treat-
ment or does she need it?
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4. ASSIST
Explore what is needed to assist the caregiver with ART for her child:
“What problems might arise when you follow this plan?”
“What questions do you have about this treatment or how to follow this plan?”
WHAT KINDS OF ASSISTANCE WILL A CAREGIVER NEED FOR

PROVIDING ART?
Help the caregiver develop the resources/support/arrangements needed for
adherence. These include:
•• Ability to bring the child for required schedule of follow-up – plans for time off
work and transport need to be in place.
•• Home and work situation of caregiver that permits her giving medications
regularly to the child without stigma
•• Supportive family or friends
•• Disclosure to child and or family
•• ART adherence support group
5. ASSIST
Note that it is often not be possible to prepare the caregiver and child for adherence
on the same visit that you decide the child is medically eligible for ART. It usually
takes at least 2 to 3 visits and the involvement of others on the clinical team and
a treatment supporter.
The adoption of ART requires long-term commitment on the side of both
the clinical team and the caregiver (and child, depending on his/her age).
Both will need support and help from treatment supporters and others in
the community.
If the caregiver needs another adherence preparation session, arrange a follow-up
to reinforce key messages. Arrange an appointment with the ART support group if
the caregiver wishes so. Remember that it is important to provide ongoing support
and counselling to an HIV-infected caregiver. Refer to a support group with other
caregivers
It often takes 2 to 3 visits to prepare a caregiver and child for adherence,

involve others on the clinical team, and arrange treatment supporters.
73
STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. Age: ...................... Weight: ..
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation
REVIEW: WHAT PART OF THE ART INITIATION FORM
• Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in st
Ensure child has not breastfed for condition, GO TO STEP 2
IS USED FOR STEP 2? at least 6 weeks
Review this section ofmonths
• Child 18 the recording
and over: form to
 become
Serological familiar
test positivewith the information
being recorded.
at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO • If NO: classify as CONFIRMED HIV INFECTION N
STEP 3. DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST-LEVEL FACILITY
•
Record weight and height,  SEVERE ACUTE MALNUTRITION
Once a decisionassess & classify
to start ART malnutrition
has been  MODERATE
taken, it needs ACUTE to MALNUTRITION
be decided WHERE • REFER IF:
and
 NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRIT
WHO will initiate the ART. This can be a nurse
• Pallor is present
or a doctor. Your national guidelines
 YES  NO — SEVERE OR SOME ANAEMIA
will specify WHERE and WHO
• Child has feeding problem can initiate ART.
 YES  NO
WHEN CAN ART BE INITIATED IN A FIRST-LEVEL FACILITY?
In the past, only
STEP doctors initiated
5: START ART TREAT AND ART, but it is anticipated
COTRIMOXAZOLE that nurses will
PROPHYLAXIS play ARVS
RECORD an & DOSAGES HERE:
• Child is under 3 years old: Initiate preferred first-line regimen 1. ......................................................................................
increasing role. In general, nurses should initiate ART in children who are stable.
• Child is 3 years or older: Initiate preferred first-line regimen 2. ......................................................................................
This means they are not ill and do not have signs of advanced HIV infection.
• Cotrimoxazole 3. ......................................................................................
WHEN DO CHILDREN REQUIRE REFERRAL FOR ART?
In general, the following children should be referred to a doctor for initiation of
PROVIDE FOLLOW-UP CARE
ART, or a nurse should start ART in consultation with a doctor. • If child is stable, follow-up regularly
1. Children who weigh less than 3 kg

Initiating ART is difficult in very small children due to the small doses that are
required. These children should be referred to the next level of care for initiation
of ART.
2. Children with TB or children in whom TB is suspected
It can be difficult to diagnose TB in children with HIV infection, and investigations
such as Chest X-rays and sputum microscopy, are required. ART doses also need
to be adjusted. These children require referral.
WHAT DOES NON-URGENT REFERRAL MEAN IN THIS CONTEXT?

Non-urgent referral will mean different things in different settings. Children
should be referred as soon as possible, but it does not need to be the same day. The
children should be referred to an on-site doctor if available, or to the local hospital
or community health centre. Many children who should be started on treatment
by doctors, can be referred to nurses for follow-up and ongoing care.
Remember that if the child has a general danger sign or a severe
classification, they must be referred urgently.
74
STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. Age: ...................... Weight: ............ kg Tempe
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test RECOR
• Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in stable ALWAY
Ensure child has not breastfed for condition, GO TO STEP 2 PROVID
at least 6 weeks
IS USED FOR STEP 3? Ensure child has not breastfed for
at least 6 weeks
Review this section of the recording form to become familiar with the information
being recorded.
STEP 4. RECORD BASELINE INFORMATION  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION
WHY IS BASELINE INFORMATION IMPORTANT?
• CD4 Children who arecells/mm
count: ......................... started 3 onCD4ART percentageshould begin to%thrive. It is important that baseline
.........................
• WHO information
clinical stage today: is recorded before they begin ART. This same baseline information will
................................................................................................
beSTART
STEP 5: monitored
ART TREATduring the course of
AND COTRIMOXAZOLE their ART. This
PROPHYLAXIS way, RECORD
their response to ART
ARVS & DOSAGES can
HERE:
be monitored.
• Cotrimoxazole 3. .............................................................................................................
WHAT BASELINE INFORMATION IS DOCUMENTED?
The following information should be clearly documented:
IMCI
PROVIDE NUTRITIONAL
FOLLOW-UP CARE CLASSIFICATION • If child is stable, follow-up regularly
NEXT F
Assess and classify the child’s nutritional status using the relevant chart in the
IMCI chart booklet. If the child has a severe classification they must be referred.
All other children should be managed according to IMCI TREAT charts. ART should
not be delayed.
FEEDING ASSESSMENT
Use the guidance in your chart booklet to assess the feeding of:
•• All children under 2 years of age
•• Children classified with acute malnutrition
•• Check for feeding problems of all young infants
Counsel the mother regarding feeding recommendations and any feeding problems.
CLINICAL STAGING
If the child has not already been staged, do this now as described above. Make
sure that you record the child’s stage from 1 to 4. Information about staging is
located in Annex 1.
CD4 COUNT AND PERCENTAGE

CD4 should be measured at the time of diagnosing HIV infection, prior to starting
ART (as possible, and preferably with increasing frequency as the CD4 count
approaches the threshold for starting ART), and every 6 months once the child
has initiated ART. Send these tests if they have been done or were done more than
three months ago. Record them accurately.
75
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test RECORD AC
IMCI DISTANCE • If HIV infection confirmed, and child is in stable

• Child under 18 months: Virological test positive ALWAYS REM
LEARNING COURSE | MODULE 8. HIV/AIDS
Ensure child has not breastfed for condition, GO TO STEP 2 PROVIDE RO
at least 6 weeks
VIRAL LOAD MONITORING Ensure child has not breastfed for
Viral load testing is desirable, but not essential.
at least 6 weeks It is not always available.
IS USED
STEP 3: DECIDE FOR
IF ART CAN STEP 4?
BE INITIATED AT YOUR  YES  NO • If any present: REFER NON-URGENTLY
FIRST LEVEL FACILITYthis section of the recording form to become •familiar
Review If none present:
with theGO information.
TO STEP 4
• Cotrimoxazole STEP 5. START ART AND COTRIMOXAZOLE PROPHYLAXIS 3. .............................................................................................................
WHEN SHOULD CHILD CONFIRMED WITH HIV INFECTION
BEGIN ART?
PROVIDE FOLLOW-UP CARE
All children under 5 years of age with confirmed NEXT FOLLO
• HIV infection
If child should
is stable, follow-up begin
regularly
ART. This is a new and important recommendation for paediatric HIV.
If children are 5 years and older, there are two criteria used to determine
eligibility for ART:
✔✔ CD4 count less than 500 cells/mm3 (give priority to those with CD4 less than
350), or
✔✔ Clinical stage 3 or 4
All HIV-infected children under 5 should begin ART
WHAT FORMS ARE ARVS AVAILABLE IN?

Most ARVs are currently available separately. However it is anticipated that fixed
dose combinations and co-packaged formulations will become available. This will
facilitate dispensing of ARVs, and promote adherence by reducing the number of
medicines that patients have to take.
HOW WILL YOU DETERMINE ARV DOSING?

Doses are based on the child’s weight. It is important to regularly check that
children receive the correct dose based on their weight as they grow. Switch
to tablets or capsules from syrups or solutions as soon as possible. Ensure the
caregiver demonstrates ability to properly use a dosing syringe when prescribing
liquid preparations. In older children or adolescents ensure that maximum doses
are not exceeded.
76
WHAT ARE FIRST-LINE ARV RECOMMENDATIONS

FOR AGE BELOW 3 YEARS?
The following regimens are recommended by WHO as first line ART for children
age below 3 years. The choice of ART regimen at country level will be determined
by national guidelines.
AGE PREFERRED ALTERNATIVE CHILDREN WITH TB/HIV INFECTION

Birth up to ABC or AZT + 3TC + NVP
ABCa or AZT + 3TC + LPV/rb ABC or AZT + 3TC + NVP
3 years AZT + 3TC + ABC
Special notes:
a
Based on the general principle of using non-thymidine analogues in first-line and thymidine analogues in second-line regimens, ABC should
be considered as the preferred NRTI whenever possible. This recommendation was developed by the CHAIN working group. Availability and
cost should be carefully considered.
b
As recommended by the Food and Drug Administration (FDA), the use of LPV/r oral liquid should be avoided in premature babies (born one
month or more before expected date of delivery) until 14 days after their due date, or in full-term babies younger than 14 days of age. Dosing
in children younger than 6 weeks should be calculated based on body surface area (see Annex 3).
WHAT ARE FIRST-LINE ARV RECOMMENDATIONS FOR AGE 3 YEARS

AND ABOVE?
The following regimens are recommended by WHO as first line ART for children
3 years and above. The choice of ART regimen at country level will be determined
by national guidelines. After the age of 3 years the child could be switched to an
EFV-based regimen.
AGE PREFERRED ALTERNATIVE CHILDREN WITH TB/HIV INFECTION

ABC or AZT + 3TC + EFV
3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP
AZT + 3TC + ABC
WHAT ARE THE ARV DRUG PREPARATIONS FOR CHILDREN?

The range of commercially available paediatric ARV formulations is narrow and
most drugs do not have solid formulations in doses appropriate for paediatric use.
Lopinavir/ritonavir needs to be kept cool (<25 °C), and should be refrigerated prior
to dispensing. It can be kept out of the fridge for up to 42 days. If the caregiver has
a fridge at home, encourage them to store the lopinavir/ritonavir in the fridge. Do
not dispense more than one month’s supply if there is no fridge at home.
WHAT IS THE DOSING FOR ART?

Refer now to Annex 2. This explains the appropriate doses for antiretroviral
therapies.
ART DOSING IS LOCATED IN ANNEX 2
77
at least 6 weeks
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
IMCI DISTANCE
YES  NO
LEARNING COURSE | MODULE 8. HIV/AIDS
• If any present: REFER NON-URGENTLY
• Record weight and height,
assess & classify malnutrition
 SEVERE ACUTE MALNUTRITION
 MODERATE ACUTE MALNUTRITION
• REFER IF:
IS USED FOR STEP 5? NO ACUTE MALNUTRITION
— COMPLICATED SEVERE ACUTE MALNUTRITION
• Child has feeding problem Review this section of the recording form to become familiar with the information.
 YES  NO
• Cotrimoxazole 3. .............................................................................................................

78
SELF-ASSESSMENT EXERCISE J – DOSING

Practice writing the drugs and the dosages for all first-line ARVs for the following
children. Refer to Annex 2 for dosing information.
Since accurate calculation of dosage based upon weight is the preferred method, use
the following example to practice calculating the dosage needed to treat children
of different weights. Refer to the ART drug dosage tables in your chart booklet, or
in the ANNEX of this module.
In this clinic the preferred regimen are the following:
•• Birth up to 3: ABC (20 mg/ml liquid) + 3TC (10 mg/ml liquid) + LPV/r
(80/20 mg liquid)
•• 3 years and older: ABC (20 mg or 300 mg tablet) + 3TC (30 mg tablet) +
EFV (200 mg tablet)
1. 12 month old 10 kg child
2. 4 year old 20 kg child
79
SELF-ASSESSMENT EXERCISE K – ART INITIATION

Bhengu works in a small clinic in a rural area. A doctor visits once a week. She sees
the following children. Decide whether each child requires: URGENT REFERRAL,
non-urgent referral to the doctor or whether Bhengu should initiate ART at the
clinic. Tick your answer.
URGENT NON-URGENT ART AT

REFERRAL REFERRAL FOR ART CLINIC
1. LEATILE: Leatile is four years old. He shows signs of severe   

acute malnutrition, and has CHRONIC EAR INFECTION,
but has no other problems. His CD4 count is 200 cells/mm3.
2. OFENTSE: Ofentse is three years old. She has been diagnosed   
with TB and on routine testing was found to be HIV-infected.
3. LUKE: Luke is two months old. When he was six weeks old he   
was admitted to hospital with severe pneumonia. In the
hospital he was confirmed HIV infected. He is well now and is
gaining weight – his weight today is 4.5 kg. His CD4 count and
percentage have been sent, but the result is not back yet.
4. LENTSWE: Lentswe is four years old. He was seen a week ago   
and you classified PNEUMONIA. Despite receiving an
antibiotic for five days he still has fast breathing (50 breaths
per minute). At the previous visit he was found to be HIV-
infected, and his CD4 count is 150 mm3.
5. LEAH: Leah is 18 months old. Her CD4 count is not yet   
available. Her Z-score is -3 but she has no other health
concerns.
6. OWETHU: Owethu is eleven months old. She was recently   
confirmed HIV infection. Her mother wanted some time to
discuss starting Owethu on ART with her family, but had
agreed to come today to start treatment. Owethu’s mother says
that Owethu has been feverish since the previous day. When
you examine Owethu she finds that she is lethargic and does
not respond when her mother or Sister Bhengu speaks to her
or claps their hands.
80
PART 3: SIDE EFFECTS OF ARVs

WHAT ARE THE SIDE EFFECTS OF ARVS?
Most drugs have side effects of some sorts, although in the majority of cases they are
mild, and not all people taking drugs will experience the same effects and to the same
extent. Less than 5% of patients taking ART will have serious clinical side effects.
Many more will have non-serious, self-limiting side effects, especially at the
beginning of their therapy. If children and their caregivers know about possible
side effects it is easier to deal with them.
Caregivers and children must be aware of side effects, so that they do not
stop the drug in reaction to the side effect. This is important for adherence.
WHY IS IT IMPORTANT TO UNDERSTAND AND EXPLAIN

THESE SIDE EFFECTS?
Many mothers and children are worried about possible side effects when they start
ART for the first time. It is important that you warn mothers about the very common
side effects, and suggest ways in which the mother can manage these side effects.
If mothers or children do complain about side effects, you should take their
complaints seriously. Mothers of children with side effects may be concerned and
may stop giving the child the drug correctly because of this. Similarly children who
have side effects may refuse to take the medication. We have already discussed the
need to take all the doses to make sure the therapy works properly, and this should
be emphasized at each visit.
WHAT KINDS OF ARV SIDE EFFECTS ARE REPORTED?

ARV side effects can be divided into three categories.
1. Very common side effects

Warn patients and suggest ways patients can manage; also be prepared to manage when patients seek care.
2. Potentially serious side effects

Warn patients and tell them to seek care if they experience these side effects. These side effects are the ART
Danger Signs which you will learn about in the next section. If these signs are present, stop ART and REFER
URGENTLY.
3. Side effects occurring later during treatment

You will need to look out for these during follow-up visits. The table below describes commonly experienced
side effects of ARV drugs.
81
WHAT ARE IMPORTANT SIDE EFFECTS FOR ARVS?

VERY COMMON: POTENTIALLY SERIOUS: OCCURRING LATER DURING TREATMENT:
Inform patients and suggest Warn patients
ways to manage; manage when and tell them to Discuss with patients
patients seek care seek care
Stavudine •• Nausea •• Seek care urgently: •• Changes in fat distribution:
(d4T) •• Diarrhoea Severe abdominal •• Arms, legs, buttocks, cheeks become
pain AND difficulty THIN
breathing •• Breasts, tummy, back of neck become
•• Seek advice soon: FAT
Tingling, numb or painful
feet or legs or hands.
Abacavir •• Seek care urgently: fever,
(ABC) vomiting, rash – this may
indicate hypersensitivity to
abacavir
Lamivudine •• Nausea
(3TC) •• Diarrhoea
Lopinavir/ •• Nausea •• Elevated blood cholesterol and glucose
ritonavir •• Vomiting •• Changes in fat distribution:
•• Diarrhoea —— Arms, legs, buttocks, cheeks become
THIN
—— Breasts, tummy, back of neck become
FAT
Nevirapine •• Nausea Seek care urgently:
(NVP) •• Diarrhoea •• Yellow eyes
•• Severe skin rash
•• Fatigue AND shortness of
breath
•• Fever
Zidovudine •• Nausea Seek care urgently:
(ZDV or •• Diarrhoea •• Pallor (anaemia)
AZT) •• Headache
•• Fatigue
•• Muscle pain
Efavirenz •• Nausea Seek care urgently:
(EFV) •• Diarrhoea •• Yellow eyes
•• Strange dreams •• Psychosis or confusion
•• Difficulty sleeping •• Severe skin rash
•• Memory problems
•• Headache
•• Dizziness
82
WHY IS IT IMPORTANT TO EXPLAIN SIDE EFFECTS FOR ALL DRUGS

IN A COMBINATION?
For all combination treatments, it is important to advise the mother about the
regimen as a whole and not on each specific drug.
The mother should never stop giving the child just one drug or giving him a
lower dose.
If the mother thinks that the child has a side effect from one drug, which is so bad
that she wants to stop or change the treatment, she should go with the child as
soon as possible to the clinic. Consult with the clinician or, if not available, STOP
ALL THREE DRUGS. Never just stop one or two drugs.
HOW DO YOU MANAGE SIDE EFFECTS?

Good management of side effects should include the following:
INTRODUCE: Discuss common possible side effects before the

child starts the medication
MANAGEMENT ADVICE: Give advice on how to manage these

side effects.
NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and

children about potentially serious side effects and tell them to
seek care urgently if they occur.
PROVIDE IMMEDIATE ATTENTION: Give immediate attention

to side effects, including access to the clinic or by phone
QUESTION DURING FOLLOW-UP: Initiate a discussion about

side effects, even if the mother or child does not mention them
spontaneously
REFER FOR SUPPORT: Refer the patient to peer-educators.
83
WHAT ARE APPROPRIATE CARE RESPONSES TO ART SIDE EFFECTS?

The table below outlines side effects experienced in patients on ART and appropriate
responses or advice for the caregiver. Only gastrointestinal upsets and fatigue are
fairly common in the small child treatment. Sleep disturbances, headaches and
memory problems are fairly common in Efavirenz containing regimens.
SIGNS or SYMPTOMS RESPONSE

Yellow eyes (jaundice) or
Stop drugs and REFER URGENTLY
abdominal pain
Rash If on abacavir, assess carefully. Is it a dry or wet lesion? Call for
advice. If the rash is severe, generalized, or peeling, involves
the mucosa or is associated with fever or vomiting: stop
drugs and REFER URGENTLY.
Nausea Advise that the drug should be given with food. If persists for
more than 2 weeks or worsens, call for advice or refer.
Vomiting Children may commonly vomit medication. Repeat the dose if
the medication is seen in the vomitus, or if vomiting occurred
30 minutes of the dose being given.
If vomiting persists, the caregiver should bring the child to
clinic for evaluation.
If vomiting everything, or vomiting associated with
severe abdominal pain or difficult breathing, REFER
URGENTLY.
Diarrhoea Assess, classify, and treat using diarrhoea charts. Reassure
mother that if due to ARV, it will improve in a few weeks.
Follow-up as per chart booklet. If not improved after two
weeks, call for advice or refer.
Fever Assess, classify, and treat using fever charts.
Headache Give paracetamol. If on efavirenz, reassure that this is
common and usually self-limiting. If persists for more than 2
weeks or worsens, call for advice or refer.
Sleep disturbances, This may be due to efavirenz. Give at night and take on an
nightmares, anxiety empty stomach with low-fat foods. If persists for more than 2
weeks or worsens, call for advice or refer.
Tingling, numb or painful
If new or worse on treatment, call for advice or refer.
feet or legs
Changes in fat distribution Consider switching from Stavudine to Abacavir. Refer if
needed.
84
SELF-ASSESSMENT EXERCISE L – SIDE EFFECTS

The table below lists common or potentially serious side effects to common ARV
drugs. For each side effect listed, fill in the name of the drug (or drugs – there
may be more than one) that cause the described side effect:
Side effect Drug/s which causes the side effect

* requires urgent care
Severe abdominal pain
* potentially serious, because could be pancreatitis
Tingling or numbness in feet or hands

* this is neuropathy, should seek advice soon
Yellow eyes
* needs urgent referral as it may indicate liver toxicity
Skin rash
* It could be a severe reaction to the drug and may require
urgent referral.
Nausea, vomiting, diarrhoea Common -patients will need to

be prepared to cope with these side effects
Changes in fat distribution

Important side effect occurring with long term treatment
Fever, vomiting, skin rash

* may indicate hypersensitivity
Difficulty sleeping and nightmares
85
n How will you initiate ART for Peter?

Peter does not require any stabilization today for acute illness or opportunistic infections. As he is stable, you
will walk through the six steps for ART initiation today.
STEP 1: CONFIRM HIV INFECTION

Peter’s HIV infection has been confirmed through a positive virological test.
STEP 2: MAKE SURE LUNGILE IS READY TO GIVE ART

You will use the ‘5As’ to determine if Lungile is ready to give Peter ART:
1. ASSESS: Ask Lungile more about her social situation, as you have previously discussed. Ask her about
her understanding of HIV/AIDS. Ask what questions she has about HIV/AIDS and treatment. Ask her how
she feels about starting Peter on treatment now – can she handle this responsibility? Use small, specific
questions.
2. ADVISE: You will want to discuss key topics with Lungile. As she has already tested positive for HIV and is
receiving care, she might know this information already. Ask her questions about topics so that you can
try to understand what topics she might need more information about. These include: how HIV affects
the body, ART, and adherence. Ask Lungile checking questions to see if she understands.
3. AGREE: After you explain this information, ask Lungile how she feels about the treatment, and how Peter
will handle it. Ask her if she will be willing and able to come to appointments and give the medications
everyday at home.
4. ASSIST: Discuss what support Lungile has, and will need, for providing ART. This includes her ability
to bring Peter, for example transportation and time off work. It also includes stigma about giving
medications in the home, support from friends and family, and her choice to disclose to her partner,
mother, or friends.
5. ARRANGE: arrange another session with Lungile to continue discussing adherence.
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FACILITY

Peter does not require referral for ART. This is because he does not have TB or fast breathing, and he weighs
more than 3 kg. You will be able to initiate ART in your clinic.
86
How will
n STARTING you complete Peter’s recording form thus far?
ART: FOLLOW THE FIVE STEPS Name: ............................................................................. Age: ...................... Weight: ............ kg Temperature: ..............
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test RECORD ACTIONS AN
• Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in stable ALWAYS REMEMBER TO
Ensure child has not breastfed for condition, GO TO STEP 2 PROVIDE ROUTINE CAR
at least 6 weeks
at least 6 weeks
 MODERATE ACUTE MALNUTRITION
STEPassess & classify malnutrition
4: ASSESS AND RECORD BASELINE INFORMATION
 NO ACUTE MALNUTRITION
• REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
Peter is not
• Pallor low weight for age and
is present  YES he  isNO not anaemic. You review — theSEVEREclinical staging.
OR SOME ANAEMIA You know that Peter
has had pneumonia, persistent diarrhoea, and ear infections within the past couple of months. When you
assess him today you see that herpes zoster is beginning to develop. You will send for the CD4 and viral load
STARTING
tests today, ART:
and FOLLOW
will fillTHE
in FIVE STEPS
results once Name:they.............................................................................
return. Age: ...................... Weight: ............ kg Temperature: ...............
ASSESS
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS TREAT ARVS & DOSAGES HERE:
RECORD
STEP 5: START
• Child ARTold:
is under 3 years AND COTRIMOXAZOLE
Initiate preferred first-line regimen 1. .............................................................................................................
STEP 1: CONFIRM HIV INFECTION  YES  NO •2. Send any test required, including confirmation test RECORD ACTIONS AN
• Child is 3 years or older: Initiate preferred first-line regimen .............................................................................................................
You
• will
Childdetermine
under 18 months: the first-line regimen
 VirologicalfortestPeter.
positive •3. If HIV infection confirmed, and child is in stable ALWAYS REMEMBER TO
•
Cotrimoxazole .............................................................................................................
• Ensure
Give other routine treatments, including childAhas
Vitamin andnot breastfed for
immunizations condition, GO TO STEP 2 PROVIDE ROUTINE CAR
n What ART doses will Peter require? at least 6 weeks RECORD OTHER TREATMENTS HERE:
Remember that Peter is 7.2 kg and 6.5 months
 Second serologicalold.
test positive
Ensure child has not breastfed for • Follow-up after one week
PROVIDE FOLLOW-UP CARE NEXT FOLLOW-UP DAT
•• ABC (20 mg/ml): 4 ml AM, 4 ml PM6 weeks
at least • If child is stable, follow-up regularly
 YES  NO
•• STEP
3TC:2: CAREGIVER ABLE TO GIVE ART
(10 mg/ml): 4 ml AM, 4 ml PM • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
•• LPV/r: (80/20hasmg):
YES: caregiver 1.5 to
disclosed mlanother
AM, 1.5 ml
adult, or PM
is part of a support group
n How will you finish Peter’s ART initiation form?
• Cotrimoxazole 3. .............................................................................................................

PROVIDE FOLLOW-UP CARE NEXT FOLLOW-UP DAT
87
n How will you counsel Lungile on side effects?

Today you will inform Lungile about the possibility of side effects:
INTRODUCE: Discuss common possible side effects before the

child starts the medication
MANAGEMENT ADVICE: Give advice on how to manage these

side effects.
NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and

children about potentially serious side effects and tell them to
seek care urgently if they occur.
PROVIDE IMMEDIATE ATTENTION: Give immediate attention

to side effects, including access to the clinic or by phone
QUESTION DURING FOLLOW-UP: Initiate a discussion about

side effects, even if the mother or child does not mention them
spontaneously
REFER FOR SUPPORT: Refer the patient to peer-educators.
When Peter visits your clinic for follow-up, you will need to: (a) question Lungile to see if any side effects have
been occuring, (b) address any side effects, and (c) refer if necessary.
88
SELF-ASSESSMENT EXERCISE M – STEPS OF INITIATING ART
CASE 1: AKSHAY
Akshay is a boy aged 30 months. He has been classified as HIV EXPOSED. He has severe oral thrush. His temperature is 36.7 °C and his weight now
is 10 kg. His height is 75 cm. For the past 3 months his weight has remained the same. He has not received any treatment for poor weight gain.
He has SOME ANAEMIA and his Hb is 8g/dL. A serological test was done which shows that he is HIV-infected. The diagnosis is confirmed with a
second test which is also positive. His blood was sent to the laboratory for a CD4 count. The absolute count was 250 cells/mm3, which was 12%.
Akshay’s mother has been on ART for the past year. She has been taking her medication every day and is very motivated to take care of herself
and of Akshay. She is supported by her mother who know that she is HIV-infected and on treatment. She now asks that Akshay should also receive
ART. Akshay lives with his mother. She runs a shop from home and looks after Akshay as well. Is Akshay is eligible for ART? If you decide that he is
eligible complete the ART initiation form.
ASSESS TREAT
at least 6 weeks
89
at least 6 weeks

• Cotrimoxazole 3. .............................................................................................................

CASE 2: NANCY
Nancy is 6 months old and weighs 3.3 kg. Her mother was found to be HIV-infected during pregnancy. Nancy was tested at six weeks and was
found to be PCR positive. Nancy’s CD4 count was 800 cells/ mm3 (30%). A full blood count done at the same time, showed that her Hb is 11g/dL.
She is breastfeeding and is generally well. Her length is 60 cm. Her temperature was recorded as 36.5 °C. She lifts her head when her mother
carries her with support, responds to sounds and follows close objects with both eyes. Her mother has not disclosed her own or Nancy’s HIV
status to anyone at home, but is a regular member of the clinic support group. She has been counselled regarding adherence, and is available
and committed to ensuring that Nancy receives her ARVs twice a day.
1. Is Nancy eligible for ART?
2. If you decide that she is eligible for ART complete the ART initiation form. You might need to know that Nancy is well, and there is no close
TB contact.
ASSESS TREAT
at least 6 weeks
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at least 6 weeks

• Cotrimoxazole 3. .............................................................................................................

8.9 PROVIDING FOLLOW-UP CARE

•• Provide follow-up care to children and young infants exposed to HIV
•• Explain the principles of good chronic care and how they can be used in your
clinic
•• Use the six steps for follow-up with children on ART
•• Know when to refer children on ART, both for urgent and non-urgent reasons
WHY IS FOLLOW-UP SO IMPORTANT FOR HIV EXPOSED INFANTS?

All children born to an HIV-infected mother are at risk of HIV infection. Effective
prevention of mother-to-child transmission (PMTCT) can reduce the risk of infection.
ARV prophylaxis is an important intervention to prevent HIV transmission from
mother to child. Please turn back to Section 8.6 to re-read this information.
It is also important that all children born to HIV-infected mothers are provided
follow-up care to ensure safe feeding, optimal growth and development, HIV testing,
and other care.
In high HIV settings, an important part of follow-up care for exposed infants
is an HIV test. Children classified as HIV EXPOSED will be reclassified once
you can confirm their HIV test results. You will provide care according to
their new classification.
WHAT ARE WAYS TO ENSURE THAT HIV-EXPOSED INFANTS

ARE TESTED?
All infants born to HIV-infected mothers should be offered PCR virological testing
at 4–6 weeks of age. This can be done when the child comes for immunizations. It
is very important that there is a system in every clinic for identifying infants and
offering testing. The infant should also initiate cotrimoxazole. The caregiver should
be counselled to return for HIV test results.
How can you work with your facility to better identify HIV-exposed infants?
Sometimes a clinic needs to be structured in a certain way to help identify more infants. For example,
integrated RCH clinics in health facilities and hospitals provide pregnant women and their children care
together. This helps a health worker respond to both the mothers’ and children’s needs. Another example is a
family-based care model. Here, all members of a family are linked for care. For example, if a mother or father
comes to the clinic, you ask about the health and HIV status of their children or partner, and keep their health
records together.
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AFTER CHILD HAS CONFIRMED HIV INFECTION, WHAT FOLLOW-UP

IS PROVIDED?
When managing children with HIV, it is important to be able to provide both good
acute care and good chronic care at health facilities. There should be continuity
between services.
WHAT IS ACUTE CARE FOR CHILDREN INFECTED WITH HIV?

You learned about acute care in the IMCI case management course. Acute care
includes the management of common childhood illnesses, such as bacterial
infections, malaria, pneumonia, ear infections and skin conditions. In countries
with a high prevalence of HIV infection, more and more of these acute problems are
due to opportunistic infections that occur because of immunodeficiency caused
by HIV infection.
WHAT IS CHRONIC CARE FOR CHILDREN INFECTED WITH HIV?

HIV infection causes a chronic disease and this requires special health care. If
we only care for the patient during episodes of acute illness, then we are not yet
providing good chronic care. Good chronic care for children under the age of 5 years
recognises that the mother (or other primary caregiver) must understand and learn
to help with managing the child’s condition. The mother of an HIV-infected child
has a double burden: she must firstly cope with her own illness, and second learn
to manage and cope with her child’s illness.
HOW IS PROVIDING CHRONIC CARE DIFFERENT THAN ACUTE CARE?

Providing chronic care is different from providing acute care. When we provide
chronic care for an infant or child we have to take note of and follow several
principles. These principles are important and are listed below:
General Principles of Good Chronic Care for HIV-infected children

1. Develop a treatment partnership with the mother and child
2. Focus on the mother or child’s concerns and priorities
3. Use the IMCI counselling skills as well as the ‘5 As’ that you learned in this module
4. Support the mother and child’s self-management
5. Organize proactive follow-up
6. Involve “expert patients”, peer educators and support staff in your health facility
7. Link the mother and child to community-based resources and support
8. Use written information to document, monitor and remind.
9. Work as a clinical multidisciplinary team (i.e. nurses, social workers, counsellors, rehab therapists, doctors,
pharmacists and health promoters)
10. Assure continuity of care
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Research has shown that when patients receive this kind of health care, they do
better. Five of these principles are explained in detail below:
1 HOW DO YOU DEVELOP A TREATMENT PARTNERSHIP?

What is a partnership? A partnership is an agreement between two or more people
to work together in an agreed way toward an agreed goal. For good chronic care, the
partnership is between the health worker (or clinical team) and the mother and child.
In a partnership both parties share responsibility for the agreement. Each
partner knows what role he or she plays in the partnership. Partners treat each
other with respect. One partner does not have all the power.
2 HOW DO YOU FOCUS ON THE MOTHER’S OR CHILD’S

CONCERNS AND PRIORITIES?
Often we focus only on the obvious signs or symptoms of illness and may miss the
real reason that the mother came to the clinic.
It is important to find out why the mother has come: Is the child sick? Does
he have a cough or diarrhoea or mouth sores or all three? Is the mother afraid or is
she having some difficulty or a psychosocial need? If the child is sick you will need
to Assess, Classify, Treat, Counsel and Follow-up this child for all the common
childhood illnesses. In addition, ask about or observe any psychosocial needs and
make sure that these are addressed.
3 HOW DO YOU USE COUNSELLING SKILLS YOU LEARNED IN

PREVIOUS MODULES?
The counselling skills that you learned in the INTRODUCTION (PART 2) and
previous modules will help you develop a good relationship with the mother and will
ensure that good long-term care is provided. For long-term care, the mother and the
child (depending on age and maturity) will need to agree to the treatment plan. The
health worker should assist the caretaker to overcome barriers to ensure long term
care. There need to be arrangements for definite follow-up dates and scheduling and
arranging for the mother to pick up medication such as cotrimoxazole prophylaxis
or ART.
4 HOW WILL YOU SUPPORT THE MOTHER AND CHILD SELF-

MANAGEMENT?
Whenever you think and speak about how an HIV-infected mother and her HIV-
infected child should be managed, you need to realize that the mother should be left
as much in charge of her and her child’s care as is practically possible and feasible.
This self-help approach will give the mother a better sense of control and
make her feel better about her situation. It has been shown that this approach
makes people more successful in caring for themselves. Self-management recognizes
that the mother takes responsibility for the daily treatment of the child’s condition.
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9 HOW WILL YOU WORK AS A CLINICAL TEAM?

Providing good chronic care (and also good acute care) requires teamwork. To be
able to deliver ART, this requires long-term commitment from a clinical
team that includes a nurse, clinical officer, an ART aid (for education, psychosocial
support and adherence counselling) and a medical officer or doctor. The team may
work together differently depending on where they are located.
SELF-ASSESSMENT EXERCISE N – FOLLOW-UP CARE

Complete this exercise about follow-up care for exposed and infected infants
or children
1. Children are classified during their first visit with you,
and you will continue to provide follow-up care according
to this classification TRUE FALSE
2. Children under 24 months are started on ART. TRUE FALSE
3. All children born to HIV-positive women should be
identified and provided HIV testing by PCR at 4–6 weeks
of age. TRUE FALSE
4. Sami is 8 months old, and had a negative PCR test while
he was still breastfeeding. He needs to be re-tested after
breastfeeding has been stopped for 4 weeks. TRUE FALSE
5. Cotrimoxazole is an important element of follow-up care
for HIV-exposed and infected children. TRUE FALSE
6. Jyothi was classified as HIV EXPOSED. You will provide
follow-up and test for HIV as soon as possible. TRUE FALSE
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WHAT ARE THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN

ON ART?
Follow the steps outlined below whenever you follow-up a child on ART. This follow-
up lets you assess if ART drugs are working (child will be well and growing well with
few intercurrent infections), or causing any harm like side effects. You will read
details in the following pages.
STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART AND

COTRIMOXAZOLE
➞ ASK: Does the child have any problems?
Has the child received care at another health ➞ Assess and classify IF ANY OF
facility since the last visit? for malnutrition and FOLLOWING
anaemia PRESENT, REFER
➞ CHECK: for general danger signs
Record child’s height NON-URGENTLY:
➞ ASSESS, CLASSIFY, TREAT: for main and weight n Not gaining weight
symptoms using IMCI for 3 months
➞ Assess adherence n Poor adherence
➞ CHECK: for ART severe side effects Ask about adherence: n Stage worse than
how often, if ever, before
• Severe skin rash
does the child miss n CD4 count lower
• Difficulty breathing and than before
severe abdominal pain If present, a dose? Record your
n LDL higher than
• Yellow eyes REFER assessment. 3.5 mmol/L
• Severe anaemia URGENTLY ➞ Assess clinical stage n TG higher than
5.6 mmol/L
• Fever, vomiting, rash Assess clinical stage. n Manage side
(only if on Abacavir) Compare with the effects
child’s stage at n Send tests that are
previous visits. due
➞ Monitor laboratory
results
Record results of tests that have been sent.
STEP 3: CONTINUE ART AND STEP 4: COUNSEL THE MOTHER OR CAREGIVER

OTHER MEDICATIONS
Use every visit to educate and provide support to the mother
➞ If child is stable: continue with ART or caregiver
and cotrimoxazole doses. Remember
➞ Key issues to discuss include:
these will need to increase as the
How the child is progressing, feeding, adherence, side
child grows
effects and correct management, disclosure (to others
➞ If the child has developed and the child), support for the caregiver
lipodystrophya on Stavudine,
➞ Remember to check that the mother and other
substitute with Abacavir or
family members are receiving the care that they
Zidovudine.
need
➞ Set a follow-up visit: if well, follow-up in one month.
If problems, follow-up as indicated.
Lipodystrophy will be explained later in this section.

a
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RECORDING THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN ON ART
This follow-up form is in addition to the IMCI recording form. It provides critical instructions for the four steps of ART follow-up. The ART Follow-up
Recording Form provides an easy tool to remind you of the steps. Record the information on the form. All HIV-infected children should have a clinic
file where these forms, growth charts and laboratory results are filed.
ART FOLLOW UP Name: .......................................................................................................... Age: ...................... Weight: ............ kg Height: ............ cm Temperature: ............... °C Date: ....................
STEP 1: ASSESS AND CLASSIFY

ASK: does the child have any problems? If yes, record here: ...............................................................................................................................................................................................................................................................................................................
ASK: has the child received care at another health facility since the last visit?  YES  NO
Check for general danger signs: Provide pre-referral treatment and REFER RECORD ACTIONS TAKEN:
 NOT ABLE TO DRINK OR BREASTFEED  CONVULSIONS DURING THIS ILLNESS URGENTLY.
 VOMITS EVERYTHING  LETHARGIC OR UNCONSCIOUS
Check for ART danger signs:
 Severe skin rash  Difficulty breathing and severe abdominal pain
 Yellow eyes  Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms: Assess, classify, treat, and follow-up according to IMCI
 Cough or difficult breathing  Diarrhoea guidelines. Refer if necessary.
 Fever  Ear problem  Other problems
STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE 1. REFER NON-URGENTLY IF ANY OF THE RECORD ACTIONS TAKEN:
Assess and classify for malnutrition: FOLLOWING ARE PRESENT:
Weight: ............................... kg Height: ............................... cm ✔ Not gaining weight for 3 months
✔ Loss of milestones
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 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION ✔ Poor adherence despite adherence counselling
 MODERATE ACUTE MALNUTRITION  NO MALNUTRITION ✔ Significant side effects despite appropriate
Assess development: management
 Developing well  Some delay  Losing milestones ✔ Higher clinical stage than before
Assess adherence: ✔ CD4 count significantly lower than before
 Takes all doses  Frequently misses doses ✔ LDL higher than 3.5 mmol/L
 Occasionally misses a dose  Not taking medication ✔ TGs higher than 5.6 mmol/L
Assess clinical condition: 2. MANAGE MILD SIDE EFFECTS
 Progressed to higher stage Stage when ART initiated:  1  2  3  4  unknown 3. SEND TESTS THAT ARE DUE
Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:  CD4 count
 LDL cholesterol and Triglycerides
DATE: ...............................  CD4 COUNT: ............................... cells/mm3 OTHERWISE, GO TO STEP 3

If on LPV/r:  LDL Cholesterol: ...............................
STEP 3: CONTINUE 1 2 3 RECORD ART DOSAGE:

ART AND OTHER  Abacavir (ABC), or  Lamivudine (3TC)  Lopinavir/Ritonavir (LPV/r) 1. ......................................................................................................................................................................................
MEDICATIONS  zidovudine (AZT)  Nevirapine (NVP)
 Abacavir (ABC) 2. ......................................................................................................................................................................................
OVER 3 YEARS:  Abacavir (ABC), or  Lamivudine (3TC)  Efavirenz (EFV) 3. ......................................................................................................................................................................................

 zidovudine (AZT)  Nevirapine (NVP) OTHER:
 Abacavir (ABC)
OTHER MEDICATIONS:  Cotrimoxazole  Mebendazole  Other medications
STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include: RECORD ISSUES DISCUSSED: DATE OF NEXT VISIT:
 How is child progressing  Adherence  Support to caregiver
.......................................................................
 Disclosure (to others & child)  Side effects and correct management
Step 1. ASSESS AND CLASSIFY

The first step when providing follow-up for a child on ART is to identify and manage
any serious problems or intercurrent illnesses.
HOW DO YOU IDENTIFY PROBLEMS FOR THE CHILD ON ART?

In order to identify problems so you can address them in follow-up care, you need to:
✔✔ Ask if the child has experienced any problems since the last visit
It is important to know how the child has been since the last visit, and whether
the mother has any concerns. Make sure that you address any concerns at some
point during the visit.
✔✔ Find out if the child has received care at another health facility since
the last visit
It is also important to know whether the child has received care at another
facility –intercurrent illnesses may suggest that ART is not working adequately,
or that the child is experiencing side effects. You will need to find out details
of any admissions to hospital including what treatment the child received, and
whether any changes were made to the child’s ARV medication.
✔✔ Check for general danger signs (IMCI charts)
✔✔ Check for ART Danger Signs
✔✔ Check for main symptoms (IMCI charts)
WHAT ARE ART SEVERE SIGNS?

As you learned about in the previous section, children on ART can develop side
effects. A very small number of children can develop serious life-threatening
side effects. Although these are very rare, they require immediate action, so it is
important to always ask about them.
ART SEVERE Signs are:

■■ Severe skin rash
■■ Difficulty breathing and severe abdominal pain
■■ Yellow eyes
■■ Two of the following:
•• Fever
•• Vomiting
•• Rash in a child on abacavir
If any of these danger signs are present, the child requires URGENT
REFERRAL. It is not necessary to complete the ART follow-up assessment, but
remember to provide relevant pre-referral treatment.
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Step 2. MONITOR ARV TREATMENT

Most children who are put on ART will start to thrive. Their weight will increase,
and they will experience fewer infections and other HIV-related problems. Many
children will not experience any side effects. Where side effects are present, these
are usually mild and will respond to simple measures.
Each follow-up visit provides the opportunity to assess whether the child is adhering
to ART and whether ART is working well. It is also important to find out whether
the child is experiencing any side effects. The steps can be outlined as follows:
1. Assess growth and nutritional status 4. Assess side effects
2. Assess development 5. Assess stage
3. Assess adherence 6. Monitor laboratory results
1. ASSESS THE CHILD’S GROWTH AND NUTRITIONAL STATUS

Children on ART should grow well and gain weight. It is important to monitor the
child’s height and weight on a regular basis. Follow the guidelines in the well child
module.
2. ASSESS DEVELOPMENT
It is important to assess the child’s development. Children on ART should develop
normally. Any child who is stalling in milestones should be referred. Review your
well child module.
3. ASSESS ADHERENCE
Adherence is key to successful ART. In order to be fully effective at least 95% of
doses should be taken. Decide which of the four adherence categories the
child fits into:
1. Takes all doses
2. Occasionally misses a dose (one or two doses missed per week)
3. Frequently misses doses (more than two doses missed per week)
4. Not taking medication
TIPS TO ASSESS: It is not always easy to assess, as caregivers may not want to tell
the health care worker that doses have been missed. Use a welcoming approach that
acknowledges that chronic medications can be difficult to take. Ask about the last
time the child missed a dose of ART and how often that occurs. This opens the
door to explore possible reasons for missed doses, such as multiple caregivers, travel
or simply forgetting. You may also be able to do a pill count to monitor adherence.
Once you categorize the child by one of the above 4 categories, document this on
your recording form. If poor adherence persists despite adherence counselling,
consider referral. Remember to praise and encourage good adherence at all visits.
Poor adherence = missing more than two doses per week
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4. ASSESS SIDE EFFECTS

Ask about any side effects, and manage as described in previous section. You
must refer if the child has any ART severe signs, or if side effects persist despite
appropriate management.
5. ASSESS CLINICAL STAGE

Assess the child’s stage at each visit. You can learn more about clinical staging
in Annex 1. Any new clinical stage 3 or 4 illness may be an indication that the ART
is no longer working well and the child must be referred.
6. MONITOR BLOOD RESULTS

Several clinical and laboratory assessments should be performed to help health
workers track a child’s progress on ART. These are in three stages:
■■ BASELINE: when children are identified as HIV-infected and enter into HIV
care, but are not yet eligible for ART
■■ ART INITIATION: when children initiate ART
■■ WHILE ON ART: ongoing to monitor response to ART
In resource-limited settings, the WHO recommends that clinical presentations
should also be used to monitor children on ART, in addition to laboratory results.
If laboratory monitoring is not available, for example CD4 counts or viral loads, it
should not prevent children from receiving ART. Other regular blood tests might
be included as per availability in the country. These may include viral load, and if a
child is on lopinavir/ritonavir, LDL cholesterol and triglyceride tests.
How will you monitor CD4 results?

CD4 counts and percentage should be monitored routinely. These tests should be
repeated after six months, after one year and thereafter annually. Normal CD4
counts are higher in young children than in adults and decrease with age to reach
adult levels around the age of 6 years. The absolute CD4 count depends on age and
so cannot be used in the same way as for adults to determine progression of HIV
infection.
What do the viral load (VL) test results mean?

✔✔ VL of less than 400 copies/mL: Suggests that ART is working well. The child
should receive routine follow-up and support, and the VL should be repeated
after a year.
✔✔ VL of between 400 and 1000 copies/mL: suggests that improvements are
required. Step-up adherence counselling, and repeat the test after six months.
✔✔ VL of above 1000 copies/mL: suggests that the ARVs are not working
adequately. This may be because of poor adherence, but may also be because
resistance is developing. Adherence counselling should be stepped-up, and the
VL should be checked after three months. If the VL is still above 1000 copies/
mL the child should be referred to the next level of care.
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HOW WILL YOU DETERMINE IF THERE IS TREATMENT FAILURE?

The detection of new or recurrent clinical events classified within the WHO clinical
staging (Annex 1) may also reflect progression of disease when a child is on ART.
Treatment failure should be considered when either new or recurrent clinical stage
3 or 4 events develop in a child adherent to therapy.
Using WHO paediatric clinical staging of events to guide decision-making on switching to second-line
therapy for treatment failure:
New or recurrent event develops
Management optionsc,d
after at least 24 weeks on ARTa,b
No new events or Stage 1 events Do not switch to new regimen
Maintain regular follow-up
Stage 2 events Treat and manage staging event
Do not switch to new regimen
Assess and offer adherence support
Assess nutritional status and offer support
Schedule earlier visit for clinical review and CD4 or viral load measurement where
available
Stage 3 events Treat and manage staging event and monitor patient
Check if on treatment 24 weeks or more
Check CD4f or viral load where available
Institute early follow-up
Stage 4 events Treat and manage staging event
Check if on treatment 24 weeks or more
Check CD4f or viral load where available
Consider switching regimen or refer to higher levels
a
A clinical event refers to a new or recurrent condition as classified in the WHO clinical staging at the time of evaluating the infant or child on
ART. Annexes C and D provides more details about clinical events.
b
It needs to be ensured that the child has had at least 24 weeks of treatment and that adherence to therapy has been assessed and
considered adequate before considering switching to a second-line regimen.
c
Differentiating OIs from IRIS is important.
d
In considering change of treatment because of growth failure, it should be ensured that the child has adequate nutrition and that any
intercurrent infections have been treated and resolved.
e
Pulmonary or lymph node TB, which are clinical stage 3 conditions, may not be an indication of treatment failure, and thus may not require
consideration of second-line therapy. The response to TB therapy should be used to evaluate the need for switching therapy.
f
CD4 measurement is best performed once the acute phase of the presenting illness has resolved.
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WHEN SHOULD A CHILD BE REFERRED?

However, some children will not thrive. This may be due to a number of reasons,
including:
•• Poor adherence – if the child is not taking the ARVs they cannot be expected
to have any effect. It may be helpful to enlist help from a treatment supporter.
If the problem persists, then refer the child to the doctor.
•• Untreated opportunistic infections e.g. TB.
•• Immune reconstitution – as the child’s immune function improves, symptoms
and signs can develop or worsen as the body begins to fight pre-existing
unrecognized or partially treated infections.
•• Inadequate nutrition
•• Resistance – the HI virus may have developed resistance to the ARVs that the
child is taking. The only option is to change the child to another (second-line)
regimen but this can only be done under expert supervision for which the child
should be referred – and only once adherence problems are excluded or attended
to.
WHEN SHOULD A CHILD BE REFERRED?

The following criteria can be used in deciding whether to refer a child.
•• Not gaining weight for 3 months
•• Loss of development milestones
•• Poor adherence despite adherence counselling
•• Significant side effects despite appropriate management
•• Higher clinical stage than before
•• CD4 count significantly lower than before
•• Viral load > 400 copies despite adherence counselling
Step 3. CONTINUE ART AND OTHER MEDICATIONS

If the child is stable, then ARVs should be prescribed and dispensed. Remember to
check that the child is receiving the correct dose at each visit.
IF THE CHILD IS STABLE, WHAT ACTIONS SHOULD BE TAKEN

ON ART?
Continue the child on the same regimen that they are currently on. This means that
most children will be on a first-line regimen. In general, children should only
receive first-line regimens at primary level. Decisions to change the regime
should only be taken by experienced clinicians who are usually based at treatment
centres or hospitals. Some children on second-line regimens may be referred back
to primary level for ongoing care. However, caring for children on these regimens
is not covered in IMCI.
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n Substituting Abacavir for Stavudine:

Nurses working at primary level should only prescribe first-line regimens, and should not substitute or
change any ARVs without consultation with an expert.
The one exception is as follows. Stavudine is being phased out as it has a number of side effects,
including peripheral neuropathy and lipodystrophy.
•• Peripheral neuropathy causes tingling sensations in the hands and feet.
•• Lipodystrophy is used to describe the development of an abnormal distribution of fat. It usually only
develops when the child has been on Stavudine for some time. The child’s arms, legs, buttocks and
cheeks become THIN, while the breasts, tummy, and back of neck become FAT. Lipodystrophy can be very
unsightly and may not resolve when treatment is stopped. It is therefore important to identify it early and
to switch to Abacavir in these children.
However children who were previously started on Stavudine, and are doing well on Stavudine should
remain on it.
Step 4. COUNSEL
Counselling is an ongoing process. Key issues that need to be discussed include:
✔✔ How the child is progressing
✔✔ Adherence
✔✔ Side effects and correct management
✔✔ Disclosure (to others and to the child)
✔✔ Support for the caregiver
✔✔ Access to local or government child and family support programmes
Counselling children for disclosure of their HIV status, to discuss antiretroviral
therapy (ART), and to support adherence to ART requires special effort and skills
in communication.
WHO IS RESPONSIBLE FOR DISCLOSING HIV STATUS TO A CHILD?

It remains the role of the caregiver to disclose HIV status to a child. Caregivers
should be counselled by a knowledgeable health care worker regarding disclosure.
Health care workers play an important role in helping to meet multiple client needs,
including gaining access to social support pre- and post-disclosure and improving
mental health.
Many health care workers express anxiety around disclosing HIV-status to
children. Several key principles and recommendations can help guide health care
workers. HIV disclosure should be viewed in a process-oriented approach.
Disclosure is not an “event”, instead it is an ongoing conversation with the child
that gradually involves more and more detail about his or her status and need for
medical treatments.
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WHY DISCLOSE TO A CHILD?

Increased knowledge and understanding about HIV helps to:
•• Facilitate children’s adjustment within the family and broader society
•• Boost self-esteem
•• Increase adherence to treatment
•• Decrease risky behaviours such as unprotected sex and multiple partners
•• Build stronger family ties to tackle more challenging issues in the future.
HOW DO YOU DISCLOSE HIV STATUS TO A CHILD?

Disclosure should be individualized to include the child’s level of understanding,
developmental stage, clinical status and social circumstances. As mentioned, it is
a process which can begin with partial disclosure where the child is presented with
information that avoids specific mention of HIV and AIDS. This is then followed
over time with full disclosure where detailed HIV and AIDS terminology is used.
The “Soldier Story” is one of many strategies commonly used to discuss concepts
about HIV, the body’s defences and the role of medication in a developmentally
appropriate way.
WHEN SHOULD HIV STATUS BE DISCLOSED TO A CHILD?

Several studies and developmental specialists advocate the need to consider each
child individually, and as such, a definite age for disclosure should not be outlined.
A general rule is that if a child is asking questions about their need to go to clinic,
take treatments or demonstrates oppositional behaviour related to treatment, this
is a sign they want more information and disclosure should be furthered.
Caregivers may oppose disclosure out of a natural response to “protect” the child
from negative information. This is an opportunity to explore further some of the
negative outcomes that have been observed should one fail timely disclosure:
✔✔ Impaired understanding of HIV increases ignorance of HIV
✔✔ Less participation in treatment
✔✔ Increased psychological and behavioural problems
✔✔ Decreased desire to access support services
✔✔ More complicated bereavement, difficulty dealing emotionally with illness,
dying and death
✔✔ Continuation of risky behaviours associated with adolescents
✔✔ Children can think about inaccurate and hurtful fantasies about their illness if
not properly informed
✔✔ Silence about their illness isolates the child
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✔✔ Increases the risk of accidental disclosure, where children find out by overhearing
conversations with other individuals. Self-discovery can undermine the child’s
sense of trust in adults
Adolescents, however, should know their HIV status. They should be fully
informed to appreciate consequences for many aspects of their health, including
sexual behaviour. They also require the information to make appropriate decisions
about their treatment plan.
SELF-ASSESSMENT EXERCISE O – FOLLOW-UP

The following children have come in for follow-up visits. They are all on ART.
Using the 4 steps, describe what you will do for each child.
1. Mandla is a 4 year old boy who has been on ART for 3 years. He is currently on
Stavudine, Lamivudine and Liponavir/ritonavir. His mother has noticed that
his face and arms are looking very thin, but that his body is looking fatter than
before.
2. Ross is a 9 month old boy has been on ART for two weeks. His mother complains
that he has not wanted to eat and has had diarrhoea. On examination he has
sunken eyes, but no other signs of dehydration.
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n What follow-up care will you provide to Peter?

You have classified Peter as HIV EXPOSED. He has been instructed to follow up monthly for care. When he
returns to the clinic, what follow-up care will you provide during visits?
✔✔ Provide routine child health care: Vitamin A, immunization, growth monitoring, and feeding assessment
and counselling
✔✔ Continue cotrimoxazole prophylaxis
✔✔ Assess, classify, and treat any new problems
✔✔ Ask about the mother’s health. Provide HIV counselling and testing and referral if necessary
n When will you retest Peter to confirm his HIV status?

Lungile decides to stop breastfeeding after Peter is 9 months old. She is out of the house working during the
days and is not able to breastfeed any more. Peter and Lungile return to the clinic 7 weeks after he stopped
breastfeeding. You will now re-test and classify Peter because he has not breastfed for at least 6 weeks.
n How will you retest Peter?

Peter is now almost 11 months old. He will require a virological test to confirm his status. First, it is important
than you provide counselling to Lungile about re-testing Peter and confirming his status. You also discuss
disclosure with her. Then, you draw specimen for a PCR test. Lungile needs to return for the results in 2
weeks. You schedule Peter for a follow-up visit to return for his test results.
n What happens when Peter and Lungile return for the results?
Lungile returns about two and a half weeks later for Peter’s PCR results. Peter’s results are positive. You
counsel Lungile on this news. She is very upset and says she feels very guilty that she made Peter sick. You
counsel her about this reaction, emphasizing that treatment will be very important for Peter and can keep
him healthy. You also discuss how Lungile will disclose Peter’s status.
n How will you re-classify Peter with these test results?

You first classified Peter as HIV EXPOSED because you didn’t have a test result. Now that a virological test is
positive, and Peter has not breastfed in over 6 weeks, you will reclassify as CONFIRMED HIV INFECTION.
n With Peter’s new classification, how will you provide follow-up care?
You have learned that all children under 5 years who are classified as CONFIRMED HIV INFECTION should
receive ART.
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n How will you provide follow-up care for Peter?

Peter has come for his first monthly follow-up visit. You will complete the following seven steps.
n STEP 1: ASSESS AND CLASSIFY

1. Conduct a full IMCI assessment: check for general danger signs and main symptoms
2. Ask Lungile if Peter has had any new problems since the last visit. Ask if he has received care from
anywhere else since the last visit.
3. Check for ART danger signs
4. Screen for TB
Lungile says there are no new problems. Peter does not have any general danger signs. You check for main
symptoms, and Peter has none. You check him for severe skin rash, difficult breathing, yellow eyes, fever, and
vomiting. He has none.
n STEP 2: MONITOR ART

Peter has gained a little weight to 7.4 kg. You talk to Lungile about adherence, and she says that she has given
all of the pills. She has brought the containers to show you. You praise her and encourage and she continue
such good adherence. You check for side effects and clinical staging, and there is no difference. You will
monitor the CD4 count and viral load tests that have come back. His CD4 count is 600 cells/mm3.
n STEP 3: PROVIDE ART

So far, Peter is stable. He will remain on this ART. You will continue to monitor him.
n STEP 4: COUNSEL PETER’S MOTHER

Counselling is an ongoing process. Key issues that need to be discussed include:
✔✔ How the child is progressing
✔✔ Adherence – especially in light of his detected viral load even though it is not very high.
✔✔ Side effects and correct management
✔✔ Disclosure (to others and to the child)
✔✔ Support for the caregiver, including local support services, government schemes, etc.
n FINALLY, ARRANGE NEXT VISIT

You are relieved to see Peter responding well to treatment. You praise his mother for good drug adherence.
You counsel when to come for the next visit.
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SELF-ASSESSMENT EXERCISE P – FOLLOW-UP

You will return to the cases of Akshay and Nancy. Read the cases below and
complete the ART follow-up recording forms on the following two pages.
CASE 1: NANCY
Nancy is now 12 months old. She has been doing very well. After six months of
treatment her CD4 count had risen to 1,200 cells/mm3, and her VL was 340 copies/
mm3. She has come for a routine follow-up visit. She was well until the previous
day, when she started vomiting. She has been able to drink fluids, but vomits after
every meal. Her mother noticed that her eyes are yellow. How will you provide
follow-up care today?
CASE 2: AKSHAY
Akshay has come for a follow-up visit. He has been on ART for three months and has
been doing well – he has been completely well in the last month and is developing
well. His weight is 12.5 kg, his height is 86 cm. He has no General Danger Signs,
ART Danger Signs or main symptoms. He is screened for TB, but does not require
further assessment for TB. His mother is proud that he never misses a dose of
ARVs. She tells the nurse that she has recently discovered that she is pregnant
again. Akshay has no symptoms or signs of HIV infection. He does not require any
routine treatments.
Complete the ART follow-up form.
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ART FOLLOW UP Name: .......................................................................................................... Age: ...................... Weight: ............ kg Height: ............ cm Temperature: ............... °C Date: ....................
STEP 1: ASSESS AND CLASSIFY

ASK: does the child have any problems? If yes, record here: ...............................................................................................................................................................................................................................................................................................................
ASK: has the child received care at another health facility since the last visit?  YES  NO
Check for general danger signs: Provide pre-referral treatment and REFER RECORD ACTIONS TAKEN:
 NOT ABLE TO DRINK OR BREASTFEED  CONVULSIONS DURING THIS ILLNESS URGENTLY.
 VOMITS EVERYTHING  LETHARGIC OR UNCONSCIOUS
Check for ART danger signs:
 Severe skin rash  Difficulty breathing and severe abdominal pain
 Yellow eyes  Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms: Assess, classify, treat, and follow-up according to IMCI
 Cough or difficult breathing  Diarrhoea guidelines. Refer if necessary.
 Fever  Ear problem  Other problems
STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE 1. REFER NON-URGENTLY IF ANY OF THE RECORD ACTIONS TAKEN:
Assess and classify for malnutrition: FOLLOWING ARE PRESENT:
Weight: ............................... kg Height: ............................... cm ✔ Not gaining weight for 3 months
✔ Loss of milestones
 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION ✔ Poor adherence despite adherence counselling
 MODERATE ACUTE MALNUTRITION  NO MALNUTRITION ✔ Significant side effects despite appropriate
Assess development: management
 Developing well  Some delay  Losing milestones
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✔ Higher clinical stage than before
Assess adherence: ✔ CD4 count significantly lower than before
 Takes all doses  Frequently misses doses ✔ LDL higher than 3.5 mmol/L
 Occasionally misses a dose  Not taking medication ✔ TGs higher than 5.6 mmol/L
Assess clinical condition: 2. MANAGE MILD SIDE EFFECTS
 Progressed to higher stage Stage when ART initiated:  1  2  3  4  unknown 3. SEND TESTS THAT ARE DUE
Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:  CD4 count
 LDL cholesterol and Triglycerides
DATE: ...............................  CD4 COUNT: ............................... cells/mm3 OTHERWISE, GO TO STEP 3
If on LPV/r:  LDL Cholesterol: ...............................
STEP 3: CONTINUE 1 2 3 RECORD ART DOSAGE:

ART AND OTHER  Abacavir (ABC), or  Lamivudine (3TC)  Lopinavir/Ritonavir (LPV/r) 1. ......................................................................................................................................................................................
MEDICATIONS  zidovudine (AZT)  Nevirapine (NVP)
 Abacavir (ABC) 2. ......................................................................................................................................................................................
OVER 3 YEARS:  Abacavir (ABC), or  Lamivudine (3TC)  Efavirenz (EFV) 3. ......................................................................................................................................................................................

 zidovudine (AZT)  Nevirapine (NVP) OTHER:
 Abacavir (ABC)
OTHER MEDICATIONS:  Cotrimoxazole  Mebendazole  Other medications
STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include: RECORD ISSUES DISCUSSED: DATE OF NEXT VISIT:
 How is child progressing  Adherence  Support to caregiver
.......................................................................
 Disclosure (to others & child)  Side effects and correct management

1. Follow-up for young infants exposed to HIV is critical for preventing
mother-to-child transmission.
Mothers should be told about the important need for follow-up during antenatal
care. Exposed infants should be offered PCR virological testing at 4-6 weeks of
age.
2. Regular follow-up care for exposed and infected children (who are not
receiving ART) includes:
•• Testing and counselling for HIV, both for the child and mother
•• Routine care like immunizations, feeding assessments and counselling,
Vitamin A
•• Cotrimoxazole prophylaxis, to reduce the risk of illness by bacterial infections
3. Infants and children need to be reclassified based on new test results.
Follow-up care should change according to the new classifications.
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MANAGING HIV CARE FOR SICK CHILDREN AND INFANTS?
Now that you have finished the module, answer the same questions you tested before
you started studying. This will help demonstrate what you have learned!
1. A child is under 16 months old. What HIV test should be used for this child,
and why?
a. Serological tests, because it can detect if virus antibodies are present
b. Virological (PCR) tests, because it can actually detect the virus
c. Serological tests now, but after the child is 18 months, confirm with a PCR
2. What follow-up treatments are critical for HIV-exposed and infected infants
and children?
a. Cotrimoxazole prophylaxis
b. Paracetamol
c. Amoxicillin
3. What is the overall risk of a mother transmitting HIV to her child during
pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used in
prevention of mother-to-child transmission?
a. 70%
b. 10%
c. 35%
4. A 2 month breastfeeding baby has a positive virological (PCR) test. Is the child
HIV infected?
a. Yes, HIV-infected
b. No, HIV negative
c. Possibly, he is HIV exposed
5. When is an HIV-positive child or infant eligible for ART?
a. If a child has stage 2 HIV infection
b. Any child under five with confirmed HIV infection
c. Children over 5 years old with a count less than 350 cells per mm3
6. If a mother is HIV-positive, but the child is not confirmed with HIV infection,
what is the recommended feeding practice?
a. Exclusive breastfeeding as long as the child wants
b. Breastfeeding and also formula, in order to provide additional nutrition
c. Exclusive breastfeeding until 12 months
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8.11 ANSWER KEY
REVIEW QUESTIONS
Did you miss the question?
QUESTION ANSWER
Return to this section to read and practice:
1 B HIV TESTING
2 A PROPHYLAXIS & OTHER PREVENTIVE MEASURES
3 C BASIC INFORMATION ABOUT HIV
4 A HIV TESTING
5 B ANTIRETROVIRAL TREATMENT
6 C COUNSEL HIV-POSITIVE MOTHERS ABOUT FEEDING
EXERCISE A – HIV TERMS

a. Immune system: The immune system protects the body against infections.
b. CD4: Lymphocytes are one of the types of white blood cell in the body and some of these
have a marker on their surface called CD4, and so are called CD4 lymphocytes. These
CD4 lymphocytes are responsible for warning your immune system that there are germs
trying to invade the body.
c. Opportunistic infection: An opportunistic infection is an infection which is not able to
attack a healthy body. When the body’s immune system is weak, the infection is able to
infect the body. Examples of opportunistic infections include thrush and herpes zoster.
EXERCISE B – HIV TESTING

11. An HIV virological (PCR) test detects the actual HIV virus or virus products in the
blood. An HIV serological test detects the presence of antibodies made in response
to the presence of HIV – however these antibodies can be from the mother and do
not disappear until the child is 18 months.
12. Virological (PCR)
13. Confirmed HIV infection
14. EXPOSED, not confirmed infection, as antibodies present can be from mother and
from breastfeeding. To confirm, child needs positive virological test at least 6 weeks
after stopping breastfeeding.
15. Confirmed HIV infection
16. Confirmed HIV negative
17. EXPOSED, breastfeeding should be done for 6 weeks and serological test completed
again
18. EXPOSED, because the child can still be infected through breastfeeding. Virological
(PCR) tests should be done 6 weeks after breastfeeding has stopped to confirm that
the child is HIV-negative.
19. YES, confirmed HIV negative
20. Yes, confirmed HIV negative
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EXERCISE C – ASSESS & CLASSIFY SICK CHILD

a. TRUE: virological test is positive
b. FALSE: he should be classified HIV EXPOSED. Status must be confirmed after
breastfeeding has stopped for 6 weeks.
c. FALSE: she should be classified HIV EXPOSED. The status must be confirmed with
a virological test because the child is under 18 months old. The result can only be
confirmed 6 weeks after stopping breastfeeding.
d. TRUE: positive virological test in a child, and has not been breastfeeding for 4 months,
so is out of 6 week ‘window’.
e. TRUE: status must be confirmed after breastfeeding has stopped for 6 weeks.
f. FALSE: she should be classified as HIV EXPOSED. The result can only be confirmed
6 weeks after stopping breastfeeding.
g. TRUE
EXERCISE D – CLASSIFY YOUNG INFANT

1. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped,
and with virological test
5. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped,
and with virological test
EXERCISE E – COTRIMOXAZOLE
The following children should receive cotrimoxazole prophylaxis:
1. All young infants classified as CONFIRMED HIV INFECTION. Should start immediately.
• Children (under 12 months of age) classified as CONFIRMED HIV INFECTION
• Children (between 12 months and under 5 years of age) classified as CONFIRMED
HIV INFECTION when they are clinically staged at 2, 3, or 4. Their CD4% does not
matter. Should start immediately.
• Children (between 12 months and under 5 years of age) classified as CONFIRMED
HIV INFECTION who have a CD4% less than 25%. Their clinical stage does not
matter. Should start immediately.
• All children classified as HIV EXPOSED. Should start immediately.
• All young infants who are HIV EXPOSED. Should start from 4-6 weeks of age
2. All HIV-infected or -exposed infants should begin from 4-6 weeks of age. Otherwise,
children and young infants classified as HIV EXPOSED should start as soon as possible.
All HIV-infected children under 12 months should start immediately. All HIV-infected
children aged 12 months up to 5 years with WHO stage 2-3-4 or CD4% under 25%.
If children are HIV-infected and over 5 years of age, they follow adult guidelines for
cotrimoxazole.
3. Severe toxicity can include Steven Johnson syndrome or severe pallor
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4. Answers are below:

a. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength
b. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
single strength
c. NO
d. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength
e. NO
f. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
g. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
h. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength; requires referral
today for SEVERE PNEUMONIA
i. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
j. NO
5. Cotrimoxazole prophylaxis should be stopped if: (a) children classified as EXPOSED
are confirmed HIV negative, and the child is not breastfeeding and has not for at
least 6 weeks, or (b) child develops severe drug reactions.
EXERCISE F – INTEGRATED TREATMENT

1. How would you treat a child with the classifications: HIV EXPOSED and PNEUMONIA?
• Oral antibiotic for 5 days
• Provide HIV test appropriate for age and breastfeeding status
• If mother is HIV-positive, give nevirapine if indicated
• Initiate cotrimoxazole
• Provide Vitamin A and immunizations as required
• Follow-up in 3 days for PNEUMONIA
2. When should you follow-up a child with the classifications: PERSISTENT DIARRHOEA
and HIV EXPOSED?
• Follow-up in 5 days on persistent diarrhoea, see if zinc and multivitamin treatment
is lessening diarrhoea and no other issues have developed
• Repeat HIV testing after breastfeeding has stopped for 6 weeks
3. How would you treat a child with the classifications: PNEUMONIA (wheeze present)
and HIV EXPOSED?
• Oral antibiotic for 5 days
• Give inhaled bronchodilator for 5 days
• Advise on throat remedy
• Provide HIV test appropriate for age and breastfeeding status
• If mother is HIV-positive, give nevirapine if indicated
• Initiate cotrimoxazole
• Follow-up in 3 days for PNEUMONIA
4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA,
CONFIRMED HIV INFECTION, and exposure to TB?
• Zinc and multivitamins for 2 weeks
• Initiate cotrimoxazole prophylaxis
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• Initiate ART if fulfills 5 steps for initiating in your clinic

• Initiate izoniazid preventive therapy (IPT) for 6 months
• Follow-up in 5 days for PERSISTENT DIARRHOEA
5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC EAR
INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and CONFIRMED HIV
INFECTION?
• Test for low blood sugar, then treat and prevent
• Give first dose of antibiotic
• Give ciprofloxacin
• REFER URGENTLY (COMPLICATED SEVERE ACUTE MALNUTRITION is a severe
classification)
EXERCISE G – INFANT FEEDING

1. TRUE/FALSE
a. F – children need more feeds and fluids during illness
b. T
c. F – the child should be exclusively breastfed, especially as there is no risk of HIV
infection from the mother
d. T – the mother should breastfeed exclusively until 6 months of age, and then
begin adding safe complementary foods at 6 months in addition
e. T
f. T
g. F – according to studies, the risk of infection during breastfeeding is 15%
h. F – it is recommended for all women, regardless of HIV status, to breastfeed
exclusively at least for the first 6 months
i. T
2. Traci’s mother should begin adding family foods at 6 months of age. Foods should
include porridge and a mix of locally available foods, like eggs, mashed vegetables,
beans, and meat livers. If the child is not growing well, oil, margarine, or peanut
paste should be mixed with porridge. Traci should receive 2 meals a day from 6-8
months, and then increase to 5 meals a day.
EXERCISE H – CONFIRMING HIV INFECTION

1. Antiretrovirals are best used in combination to act against HIV and prevent rapid
drug resistance
2. Answers are below:
a. Yes
b. Yes
c. Possibly; Send a PCR test
d. Yes
e. Possibly; Repeat the child’s HIV test 6 weeks after breastfeeding stops. The test
will depend on the child’s age when the test is done.
f. Possibly; Send a confirmatory test as per national procedures
g. No
h. Possibly; Repeat the child’s HIV test after 5 weeks i.e. 6 weeks after breastfeeding
stopped. Use a serological test because the child is older than 18 months.
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EXERCISE I – ART ELIGIBILITY

AGE DETAILS ANSWER
Child is CONFIRMED HIV INFECTION
f. 4 years YES
but appears healthy
Child is HIV exposed, and mother is
g. 6 months NO; need to confirm infection
very sick
h. 9 months Child had a positive serological test NO; need to confirm infection
i. 3 years Child had a positive serological test YES
j. 9 years Child is CONFIRMED HIV INFECTION HANDLED BY ADULT GUIDELINES
EXERCISE J – DOSING
a. ABC: 2 tablets (20 mg), twice a day
b. 3TC: 2 tablets (30 mg), twice a day
c. EFV: 1 tablet (200 mg) in evening
2. 4 year old 20 kg child
c. EFV: 1.5 tablet (200 mg) in evening
a. ABC: 3ml, twice a day
b. 3TC: 1 tablet (30 mg), twice a day
c. LPV/r: 1ml, twice a day
c. EFV: 1 tablet (200 mg) in evening
EXERCISE K – ART INITIATION

1. LEATILE: Start ART at clinic
2. OFENTSE: Non-urgent referral for ART because of her TB
3. LUKE: Start ART
4. LENTSWE: Urgent referral; his PNEUMONIA is not improving
5. LEAH: Non-urgent referral for ART because of SEVERE UNCOMPLICATED ACUTE
MALNUTRITION
6. OWETHU: URGENT REFERRAL
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EXERCISE L – SIDE EFFECTS

Severe abdominal pain
Stavudine
*potentially serious, because could be pancreatitis
Tingling or numbness in feet or hands
Stavudine
* this is neuropathy, should seek advice soon
Yellow eyes
Efavirenz
* needs urgent referral as it may indicate liver toxicity
Skin rash
* It could be a severe reaction to the drug and may require urgent Abacavir
referral.
Nausea, vomiting, diarrhoea Common -patients will need to be Stavudine, Efavirenz
prepared to cope with these side effects Lopinavir/ritonavir
Lamivudine
Changes in fat distribution Stavudine
Important side effect occurring with long term treatment Lopinavir/ritonavir
Fever, vomiting, skin rash
Abacavir
* may indicate hypersensitivity
Difficulty sleeping and nightmares Efavirenz
EXERCISE M – BASELINE ASSESSMENT

CASE 1: AKSHAY
1. Akshay is eligible to receive ART. Criteria considered:
• He has confirmed HIV infection and is under 5 years of age.
• His mother has disclosed her HIV status to her mother and is willing to give ART
to Akshay.
2. Recording form follows.
CASE 2: NANCY
1. Nancy is eligible to receive ART. Criteria considered:
• She has confirmed HIV infection and is under 5 years of age.
• Her mother is willing to give her treatment. She has not disclosed to anyone at
home, but is a regular member of a support group.
2. Recording form follows.
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Akshay Age: ......................
30 mo Weight: ............
9.1 kg Temperature: ...............
36.7 °C Date: ....................
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION 

✔YES  NO • Send any test required, including confirmation test RECORD ACTIONS AND TREATMENTS HERE:
at least 6 weeks
• Child 18 months and over: ✔Serological test positive
 − TST negative
✔Second serological test positive
 − Viral load sent
Ensure child has not breastfed for − ARVs given
at least 6 weeks − Cotrimoxazole given
STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART − Vitamin A 200 00IU
✔ YES: caregiver available and willing to give medication
 • If none present: GO TO STEP 3 − Mebendazole 500 mg stat
✔ YES: caregiver has disclosed to another adult, or is part of a support group
 − Mother counselled re: adherence
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR ✔YES
  NO • If any present: REFER NON-URGENTLY and side effects
FIRST LEVEL FACILITY • If none present: GO TO STEP 4 − Follow-up in one week to check
• Weight under 3 kg  YES ✘ NO progress
• Child has TB  YES ✘ NO
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250 kg, 145 cm  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION
• Hb: ............................. g/dl
8 Viral load: .................................................... • If none present: GO TO STEP 5
250 12
3
ABC (20 mg/ml) 6ml AM, 6ml PM
3TC (10mg/ml) 6ml AM, 6ml PM
• Cotrimoxazole 3. .............................................................................................................
EFV (200mg tablet) 1 in PM
Treat thrush, ferrous gluconate 2.5ml tds
Nancy Age: ......................
6 mo Weight: ............
3.3 kg Temperature: ...............
36.5 °C Date: ....................
ASSESS TREAT
STEP 1: CONFIRM HIV INFECTION 

✔YES  NO • Send any test required, including confirmation test RECORD ACTIONS AND TREATMENTS HERE:
• Child under 18 months: ✔Virological test positive
 • If HIV infection confirmed, and child is in stable ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
at least 6 weeks
• Child 18 months and over:  Serological test positive − ARVs given
 Second serological test positive − Cotrimoxazole given
Ensure child has not breastfed for − 10 week immunization given
at least 6 weeks − Mother counselled re: adherence
STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART and side effects
✔ YES: caregiver available and willing to give medication
 • If none present: GO TO STEP 3 − Follow-up in one week to check
✔ YES: caregiver has disclosed to another adult, or is part of a support group
 progress
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR ✔YES
  NO • If any present: REFER NON-URGENTLY
• Weight under 3 kg  YES ✘ NO
• Child has TB  YES ✘ NO
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6 kg, 61 cm  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION
• Hb: ............................. g/dl
11 550 copies/mm
Viral load: .................................................... • If none present: GO TO STEP 5
30
800
31
ABC (20mg/ml): 3ml AM, 3 ml PM
3TC: (10mg/ml): 3ml AM, 3 ml PM
• Cotrimoxazole 3. .............................................................................................................
LPV/r: (80/20mg): 1 ml AM, 1 ml PM
Cotrimoxazole 5ml daily
EXERCISE N – FOLLOW-UP CARE

1. False – children are reclassified according to test results, and follow-up care must
follow these new classifications
2. False – all children under 5 years should begin ART.
3. True
4. False – he should be re-tested after breastfeeding has been stopped for 6 weeks
5. True
6. True
EXERCISE O – ART AND DOSING

1. Mandla
a. Check his VL.
b. If VL is less than 400 copies/mL, stop Stavudine and replace it with Abacavir.
c. If VL is greater than 400 copies/mL, refer non-urgently.
1. Ross
a. Explain to his mother that the diarrhoea may be due to the ARVs, but that it is
likely to get better in a few weeks.
b. Stress the importance of adherence.
c. Advise mother to continue feeding and give SSS after each loose stool.
d. Follow-up in 5 days.
EXERCISE P – FOLLOW-UP
1. NANCY: Nancy’s ARVs must be stopped immediately. She must be referred urgently.
2. AKSHAY: see form below
FORM DATA:
• Akshay
• 33 months
• 86 cm
• 12.5 kg
• FOLLOW-UP VISIT
• STEP 1: NO problems, NO other visits. Nothing further to check.
• STEP 2: Check NO MALNUTRITION, DEVELOPING WELL, TAKES ALL DOSES
• BLOOD
• STEP 3:
1. ABC (20 mg/ml) 6 ml AM, 6 ml PM
2. 3TC (10 mg/ml) 6 ml AM, 6 ml PM
3. EFV (200 mg tablet) 1 in PM
• STEP 4: Discuss upcoming pregnancy, PMTCT, nutrition, family planning, ART
adherence…
119
ANNEXES
CONTENTS
Annex 1 Clinical staging 121
Annex 2 Treatment dosing tables 123
120
ANNEX 1 – CLINICAL STAGING

WHAT IS CLINICAL STAGING?
Once a child is confirmed to be HIV infected it is important to perform a task called
CLINICAL STAGING when you ASSESS the infant or child. If the child does not have
confirmed HIV infection but you suspect they have severe HIV disease, they will
need referral to assess whether ART is indicated. Please turn to the WHO Clinical
Staging chart on the next page to read more about severe HIV disease.
Clinical staging will help you estimate the degree of immune deficiency
the infant or child has. Staging uses a combination of signs and symptoms to
determine the degree of immune deficiency. When you STAGE an HIV-infected
infant or child you will need to LOOK, LISTEN, FEEL, and also conduct laboratory
tests if possible.
You should be aware of some of the staging criteria so that you can identify when a
child is in need of referral. According to the WHO REVISED PAEDIATRIC CLINICAL
STAGING developed in 2005, a child with confirmed HIV infection can fall into
one of four stages:
■■ STAGES 1 and 2 clinical statuses indicate that the immune system is not yet
seriously affected. Most conditions can be managed at first level facility.
■■ STAGES 3 and 4 indicate advanced immune deficiency. Most conditions need
URGENT REFERRAL.
HOW IS CLINICAL STAGING USED TO INDICATE ART?

Review the clinical stages on the following page. Carefully review the final row,
which discusses when ART is indicated for a child
■■ All children under 24 months of age with HIV INFECTION should be started
on ART irrespective of staging. However these children still need to be staged,
as changes in stage are used to monitor response to ART.
■■ In children 24 months and older, staging is used to decide whether or not
the child should receive ART. Once the child is on ART it is used to monitor the
child’s response.
SELF-ASSESSMENT EXERCISE – CLINICAL STAGING

Using the WHO paediatric clinical staging, where will you stage these HIV-infected
children?
STAGE
a. 4 years old with many lymph nodes more than 0.5 cm in diameter in the
axilla, groin and neck without underlying cause.
b. 6 months old and severe wasting which has not responded to treatment.
c. 9 months old with PERSISTENT DIARRHOEA (no response to treatment) and
herpes zoster.
d. 3 years old with persistent lymphadenopathy and recurrent SEVERE
PNEUMONIA
e. 9 years old with Kaposi’s sarcoma, otherwise well.

121
WHO PAEDIATRIC CLINICAL STAGING FOR HIV
This is only used for confirmed HIV infected children. Determine the clinical stage by assessing the child’s signs and symptoms. Look at the classification for each
stage. Decide what is the highest stage applicable to the child where one or more of the child’s symptoms are represented.
STAGE 1 STAGE 2 Stage 3 Stage 4

Asymptomatic Mild Disease Moderate Disease Severe Disease (AIDS)
Growth — — Moderate unexplained malnutrition not Severe unexplained wasting/
responding to standard therapy stunting/Severe malnutrition not
responding to standard therapy
Symptoms No symptoms, or ➞ Enlarged liver and/or ➞ Oral thrush (outside neonatal period) ➞ Oesophageal thrush
& signs only: spleen ➞ Oral hairy leukoplakia ➞ More than one month of herpes
Persistent ➞ Enlarged parotid ➞ Unexplained and unresponsive to simplex ulcerations
generalized ➞ Skin conditions (prurigo, standard therapy: ➞ Severe multiple or recurrent
lymphadenopathy seborrhoeic dermatitis, • Diarrhoea for over 14 days bacterial infections ≥ 2 episodes
extensive molluscum • Fever for over 1 month in a year (not including
contagiosum or warts, • Thrombocytopeniaa (under pneumonia)
fungal nail infections, 50,000/mm3 for more than 1 ➞ Pneumocystis pneumonia (PCP)a
herpes zoster)
122
month) ➞ Kaposi’s sarcoma
➞ Mouth conditions • Neutropeniaa (under 500/mm3
➞ Extrapulmonary tuberculosis
(recurrent mouth for 1 month)
ulcerations, angular • Anaemia for over 1 month ➞ Toxoplasma brain abscessa
cheilitis, lineal gingival (haemoglobin under 8 gm)a ➞ Cryptococcal meningitisa
Erythema) ➞ Recurrent severe bacterial pneumonia ➞ Acquired HIV-associated rectal
➞ Recurrent or chronic RTI ➞ Pulmonary TB fistula
(sinusitis, ear infections, ➞ HIV encephalopathya

➞ Lymph node TB
otorrhoea) b
➞ Symptomatic LIPa for presumptive diagnosis of
➞ Acute necrotizing ulcerative gingivitis/ severe HIV disease, see definition
periodontitis below.
➞ Chronic HIV associated lung disease

including bronchiectasisa
a
Conditions requiring diagnosis by a doctor or medical officer – should be referred for appropriate diagnosis and treatment.
b
In a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated.
ANNEX 2 – TREATMENT DOSING TABLES

WEIGHT AZT/3TC AZT/3TC/NVP ABC/AZT/3TC ABC/3TC
(Kg) 60/30 mg 300/150 mg 60/30/50 mg 300/150/200 mg 60/60/30 mg 300/300/150 mg 60/30 mg 600/300 mg
tablet tablet tablet tablet tablet tablet tablet tablet
a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m.
3–5.9 1 1 1 1 1 1 1 1
6–9.9 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5
10–13.9 2 2 2 2 2 2 2 2
14–19.9 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5
20–24.9 3 3 3 3 3 3 3 3
25–34.9 1 1 1 1 1 1 0.5 0.5

LOPINAVIR / RITONAVIR (LPV/R), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)

EFAVIRENZ
LOPINAVIR / RITONAVIR (LPV/r) NEVIRAPINE (NVP)
(EFV)
WEIGHT
Target dose 15 mg/kg
(KG) Target dose 230–350 mg/m² twice daily
once daily
80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet 200 mg tablet
a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. pm.
3–5.9 1 ml 1 ml 5 ml 5 ml 1 1
6–9.9 1.5 ml 1.5 ml 8 ml 8 ml 1.5 1.5
10–13.9 2 ml 2 ml 2 1 10 ml 10 ml 2 2 1
14–19.9 2.5 ml 2.5 ml 2 2 2.5 2.5 1.5
20–24.9 3 ml 3 ml 2 2 3 3 1.5
25–34.9 3 3 1 1 2
ABACAVIR (ABC), ZIDOVUDINE (AZT OR ZDV) & LAMIVUDINE (3TC)

WEIGHT ABACAVIR (ABC) ZIDOVUDINE (AZT or ZDV) LAMIVUDINE (3TC)
(KG) Target dose: 8mg/kg/dose twice daily Target dose 180–240mg/m² twice daily
60 mg
20 mg/ml 300 mg 10 mg/ml 60 mg 300 mg 10 mg/ml 30 mg 150 mg
dispersible
liquid tablet liquid tablet tablet liquid tablet tablet
tablet
a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m.
3–5.9 3 ml 3 ml 1 1 6 ml 6 ml 1 1 3 ml 3 ml 1 1
6–9.9 4 ml 4 ml 1.5 1.5 9 ml 9 ml 1.5 1.5 4 ml 4 ml 1.5 1.5
10–13.9 6 ml 6 ml 2 2 12 ml 12 ml 2 2 6 ml 6 ml 2 2
14–19.9 2.5 2.5 2.5 2.5 2.5 2.5
20–24.9 3 3 3 3 3 3
25–34.9 1 1 1 1 1 1
123
SIMPLIFIED HARMONIZED DOSING FOR CURRENTLY AVAILABLE TDF FORMULATIONS

FOR CHILDREN
Size of powder Strength of Number of
scoop (mg) or Number of scoops or tablets by weight band once daily adult tablet tablets by
Drug (mg) weight band
strength of tablet
(mg) 3–5.9 kg 6–9.9 kg 10– 13.9 kg 14–19.9 kg 20–24.9 kg 25–34.9 kg
Oral powder
scoops – – 3 – –
40 mg/scoop 1 (200 mg)b or
TDFa 300 mg
1 (300 mg)
Tablets 150 mg
– – – 1 (150 mg) 1 (200 mg)
or 200 mg

a
Target dose: 8 mg/kg or 200 mg/m2 (maximum 300 mg). The Paediatric Antiretroviral Working Group developed this guidance to harmonize TDF dosing with
WHO weight bands and to reduce the numbers of strengths to be made available. The WHO generic tool was used based on the target dose provided by the
manufacturer’s package insert. In accordance with the standard Paediatric Antiretroviral Working Group approach, dosing was developed ensuring that a child
would not receive more than 25% above the maximum target dose or more than 5% below the minimum target dose.
b
200-mg tablets should be used for weight 25–29.9 kg and 300-mg tablets for 30–34.9 kg.
SIMPLIFIED DOSING OF ISONIAZID (INH) AND COTRIMOXAZOLE (CTX,

SULFAMETHOXAZOLE (SMX) + TRIMETHOPRIM (TMP)) PROPHYLAXIS
Number
Strength of tablet or Strength
of tablets
Drug oral liquid Number of tablets or ml by weight band once daily of adult
by weight
(mg or mg/5 ml) tab (mg)
band
3–5.9 kg 6–9.9 kg 10– 13.9 kg 14–19.9 kg 20–24.9 kg 25–34.9 kg
INH 100 mg 0.5 1 1.5 2 2.5 300 mg 1
Suspension 200/40
CTX (SMX + TMP) 2.5 ml 5 ml 5 ml 10 ml 10 ml – –
per 5 ml
Tablets (dispersible)
1 2 2 4 4 – –
100 + 20 mg
Tablets (scored) 400 +
– one half one half 1 1 2
400 + 80 mg 80 mg
Tablets (scored) 800 +
– – – one half one half 1
800 + 160 mg 160 mg
Tablets (scored) 960 mg +
INH + CTX + B6a 960 mg + 300 mg + – – – one half one half 300 mg + 1
25 mg 25 mg
This formulation is currently awaiting regulatory approval, and a scored junior tablet (480 mg + 150 mg + 12.5 mg ) is also under development.
a
124
PRACTICE USING THE DOSING TABLES!

List the ARVs with doses that the following children should receive based on drug
recommendations for their age and weight.
1. 3 year old boy. Weighs 14.5 kg.
2. 5 year old girl. Weighs 18.5 kg.
3. 2 month old boy. Weighs 6 kg.
4. 4 year old boy. Weighs 17 kg.
125
ISBN 978 92 4 150682 3
IMCI
Module 9
CARE OF THE
WELL CHILD
15 booklets
IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD
n CONTENTS
This module includes the following sections of information. It follows
a different flow compared to the other IMCI modules and process.
Acknowledgements 4
9.2 Introducing growth and care for child development 8
9.3 Growth monitoring 10
9.4 Caregiver–child interaction: bonding and attachment 19
9.5 Interventions for child development 23
9.6 Monitoring a child’s development 29
9.7 Counselling about feeding problems 37
9.8 Feeding recommendations 41
9.9 Water, sanitation & hygiene 50
9.10 Immunization 53
9.11 Routine vitamin A and deworming 60
9.12 Prevention of childhood accidents 64
9.14 Answer key 70
3
Acknowledgements
Region of WHO.
of Tanzania
modules.
4
9.1 MODULE OVERVIEW

In this course, you have learned how to assess, classify, and treat the sick child.
You have learned about giving treatments, and counselling on treatment at home.
You have learned about follow-up visits, and how to teach a caregiver about signs
of illness.
This module is a little different from your previous study of the sick child.
In this module, you are going to learn how to care for a well child.
WHAT IS A WELL CHILD?

This is a child coming to the health facility seeking preventive health services such
as immunizations, feeding advice, growth and developmental monitoring.
HOW DOES IMCI FOR THE SICK CHILD RELATE TO WELL CHILD CARE?
Throughout this course, you have learned how to care for a sick child coming to your
health facility. You will use some of the same skills that you have already practiced
when assessing and treating a sick child. Despite the fact that you may feel you
have a lot of children to attend to, and that these are well children, it is important
to take time to assess a well child properly.
For example, when caring for a well child, you will use the IMCI counselling
and communication skills you have learned. You will ask the mother questions
to determine how she is caring for her child. You will then listen carefully to the
mother’s answers so that you can make your advice relevant to her. You will praise
the mother for appropriate practices such as bringing her child for important
interventions such as immunizations, and advise her about any practices that need
to be changed. You will use simple language that the mother understands. Finally,
you will ask checking questions to ensure that the mother knows how to care for
her well child.
WHAT IS CARE FOR CHILD DEVELOPMENT AND WHY IS IT SO

IMPORTANT?
There are over 200 million children under age 5 who are not developing to their full
potential because they did not get simple and essential interventions to promote
their development. Care that children receive has powerful effects on their survival,
growth, and development. The key risk factors for development include issues
like stunting, iron deficiency, iodine deficiency, frequent illness and difficulty
learning new skills, understanding the world around them, solving problems and
communicating with others.
This module is a small introduction to care for child development.

The WHO has a full course called Care for Child Development: improving the care for
young children (2012) if you would like further information.
5
CHECK FOR GENERAL DANGER SIGN General danger sign
IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD Danger sign when
selecting
classifications
For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing?
WHAT TYPES OF CARE ARE DESCRIBED IN THIS MODULE?
You are going to learn about several
Look and new topics,
listen for wheezingincluding infant and young child
DOES THE CHILD HAVE care
feeding, DIARRHOEA?
for the child’s healthy growth and development, and prevention Yes __ No __
Is there blood inmeasures.In caring a well child,
the stool? it isorimportant
Lethargic unconscious? for youand
Restless toirritable?
learn on different
preventive measures. These include preventing accidents,
Offer the child fluid. Is the child: poisoning, abuse, and
Not able to drink or drinking poorly? Drinking eagerly, thirsty?
neglect of children, in an effortPinch
to resolve this universal problem.
the skin of the abdomen. Does it go back:
Very slowly (longer then 2 seconds)? Slowly?
Why these topics? As you have already learned, immunizations, good nutrition, and Yes __ No __
Decide malaria risk:healthy growth
High ___ Low and development
___ No___ Look are
or feelessential
for stiff neck for a child’s wellness and to realize
his or
If more than 7 days, hasher
feverfull
been potential. In addition,
present every day? youofwill
Look for signs learn about injuries and abuse. This is
MEASLES:
Has child had measles within the last 3 months? Generalized rash and
because injuries in children haveOne
Do a malaria test, if NO general danger sign in all cases in
become
of these:acough,
major problem
runny worldwide,
nose, or red eyes including in
high malaria risk ordeveloping
NO obvious cause countries. There is also
of fever in low clear evidence that child abuse is a global problem,
malaria risk:
Test POSITIVE? P.but that the
falciparum patterns
P. vivax of child abuse are not very clear, so the issue requires individual
NEGATIVE?
attention
If the child has within theThis module
withorfamilies.
measles now has
Look for mouth a special
ulcers. If yes,focus on prevention.
are they deep and extensive?
last 3 months: Look for pus draining from the eye.
Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear
THEN CHECKThis
FORmodule
ACUTE will describe and allow
MALNUTRITION Lookyou to practice
for oedema the following tasks:
of both feet.
AND ANAEMIA Determine WFH/L z-score:____
✔✔ Optimal infant and young child
Lessfeeding
than -3? Between -3 and -2? -2 or more ?
✔✔ Care for child’s healthy growth and development
If child has MUAC less than 115 mm or Is there any medical complication: General danger sign?
✔✔ Immunization and related interventions
WFH/L less than -3 Z scores or oedema of Any severe classification? Pneumonia with chest indrawing?
both feet: Child 6 months or older: Offer RUTF to eat. Is the child:
✔✔ Prevention of childhood accidentsNot able to finish? Able to finish?
Child less than 6 months: Is there a breastfeeding problem?
YOUR RECORDING FORM
Look at your IMCI
Child's serological test: NEGATIVE POSITIVE
recording form for the
NOT DONE
sick child. This section deals with this
module:
________________
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole
(Date)
RTV-1 RTV-2 RTV-3
ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, FEEDING
ANAEMIA, or is HIV exposed or infected PROBLEMS
Do you breastfeed your child? Yes ___ No ___
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___
Does the child take any other foods or fluids? Yes ___ No ___
If Yes, what food or fluids?
How many times per day? ___ times. What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child's feeding changed? Yes ___ No ___
If Yes, how?
Page 60 of 75
6
BEFORE YOU BEGIN

What do you know about caring for a well child?
Before you begin this module, quickly practice your knowledge with these questions.
Circle the most correct answer for each question:
1. Sami is 8 months old, and his mother is not infected with HIV. What would
you recommend for his feeding?
a. Exclusive breastfeeding
b. Four meals a day of porridge and vegetables, and no breastfeeding
c. Breastfeeding as often as he will have, and three meals a day of cereals,
mashed fruits and vegetables, and sources of protein
2. What is child development?
a. Is an increase in physical size, composition and distribution of tissues
b. Is the increase in the complexity of structures and of their functions (what
a child can do)
c. Is the same as child growth
3. Interaction of mother and child involve
a. Bonding only
b. Attachment only
c. Bonding and attachment
4. What is the interval for administering Pneumococcal vaccine in children?
a. 4 weeks
b. 6 weeks
c. 8 weeks
5. At what age do we begin giving Vitamin A to children?
a. 12 months
b. 9 months
c. 6 months
6. Why is it important to deworm (giving antihelminths medicines) children?
a. Soil-transmitted helminthes (intestinal worms) is a serious worldwide health
problem
b. Worm infestations are associated with a significant loss of micronutrients
and contribute to anemia, growth failure and malnutrition
c. Worm infestation is common in young infants
7. Regarding childhood injuries:
a. Burns and falls are rare
b. Are not a significant problem in developing countries
c. Can be prevented through family and community sensitization and
awareness raising
After finishing the module, you will answer the same questions. This will
7
9.2 INTRODUCING GROWTH AND CARE FOR CHILD

DEVELOPMENT
In this section, you are going to learn about growth and development of a child.
This will enable you to monitor children’s progress, to identify abnormalities in
development, and to counsel parents.
WHAT IS CHILD GROWTH?

Child growth is defined as an increase in physical size, composition, and distribution
of tissues. It is associated with changes in a child’s proportions, shape, and function
– and includes among other things like a child’s weight, height, and length. You
will learn more about child growth later in this module. For now, we will focus on
child development.
WHAT IS CHILD DEVELOPMENT?

Child development is the gradual unfolding of capacities. Children become more
and more capable, and learn to talk, walk, run, solve problems, receive affection
and express emotions. Healthy child development is an interaction between
biology and genes, a child’s experiences of the world around him/her and their
environment. In other words, children need good physical and mental health and
nutrition, opportunities to explore the world, and a safe and nurturing caregiving
environment.
WHAT ARE THE SKILLS THAT A CHILD IS DEVELOPING?

You have read that child development is defined as, in simple terms, what a child
can do. Child development especially focuses on four areas of skills development.
These areas are motor, cognitive, social, and affective skills.
1. MOTOR SKILLS
Motor skills are particularly physical, like reaching and grabbing. The goal of
motor skills is to organize planned eye and hand movement, and control and
strengthen muscles.
2. COGNITIVE SKILLS
Cognitive skills focus on the ability to explore and learn, like seeing, hearing,
moving, and touching. Cognitive skills help a child to recognize people, things,
and sounds. They help to compare sizes and shapes. They also stimulate
exploring and learning.
3. SOCIAL SKILLS
Social skills help a child communicate interests and needs. Social skills develop
to help someone express self through verbal and non-verbal skills.
4. AFFECTIVE/EMOTIONAL SKILLS
Affective skills help a child to receive and express appropriate emotions and
affection. Good affective skills help a person have appropriate emotional
reactions to his or her own efforts, and to other people.
8
WHY SHOULD CHILD GROWTH AND DEVELOPMENT BE A FOCUS

FOR HEALTH WORKERS?
Health care workers need to understand growth and development in order to monitor
children’s progress, to identify delays or abnormalities in development, to counsel
caregivers, and to prescribe treatment.
There are evidence-based strategies to help health workers focus on
improving growth and development. One strategy is growth promotion and
monitoring (GPM), which you will learn about below. This strategy helps health
workers identify and target risk factors for poor growth and development.
It also requires health workers to think about the caregiver-child relationship and
interactions within the family. A child’s growth and development may also reflect
larger social or economic issues, like the issues of inequity that you discussed during
the first face-to-face meeting. Some examples of these issues were poverty, poor
education in the family, and access to nutritious diets, safe water, and health services.
In the next section, you will learn about important interactions between a child
and caregiver, and how this impacts a child’s development.
Practice child development skills that you read about on the previous page: motor,
cognitive, social, and affective skills. Which skill type is the activity describing?
Which skill type?
Tick the best answer for the skill type it is demonstrating.
M C S A
1. Child sees ball rolling and tries to take and hold it
2. Child cries and reaches for the ball when it rolls away
3. Child examines ball’s shape and size
4. Child smiles at mother when she begins speaking to him about the ball

9
9.3 GROWTH MONITORING

You will remember that we started this module by defining child growth and
development. Until this point you have been focusing on child development. You
also learned how to monitor a child’s development. Similarly, now you will read
more about growth and growth monitoring.
REFRESH: WHAT IS CHILD GROWTH?

Let us begin by refreshing on the definition of child growth: Child growth is
defined as an increase in physical size, composition, and distribution of tissues.
It is associated with changes in a child’s proportions, shape, and function – and
includes among other things both weight and height.
WHAT CAUSES POOR GROWTH?

There are many reasons a child’s growth is poor. It is important to examine a child’s
history and current living and nutrition situations to better understand how to
address poor growth. Caretakers will need to be counselled on these issues as well.
1. ACUTE OR CHRONIC ILLNESS: you learned about these in the previous IMCI
modules
2. ACUTE MALNUTRITION: you learned about this in MODULE 6
3. FEEDING PROBLEMS: which you will learn about in a later section
WHY IS IT IMPORTANT TO CONDUCT GROWTH MONITORING

AND PROMOTION?
As you read above, one strategy for children is growth and development monitoring
and promotion (GMP). GMP is a strategy that helps health workers detect growth
delays in a child early and in a timely way, in order to prevent further growth delays.
GMP does not only focus on measuring a child’s physical growth, like weight
and height. It also emphasizes using that information to counsel caregivers on how
to take actions in the home that could improve growth and health status.
Here are some important benefits of growth monitoring and promotion:
✔✔ It helps health workers to analyze the causes of a child’s poor growth.
✔✔ It uses a growth chart that helps demonstrate the child’s condition to the
caregiver.
✔✔ It involves caregivers in thinking through what actions can be done in the home
to address causes of poor growth.
✔✔ It involves caregivers in taking preventative or early corrective actions with a
child.
✔✔ It can help a health worker connect families to important community and
nutrition interventions.
✔✔ It can help keep a child or family in regular contact with your clinic, or with
other community interventions.
The actions that can be taken to improve a child’s status are broadly called ‘child
care development’.
10
HOW DO YOU MEASURE CHILD GROWTH?

Measuring and monitoring child growth means comparing certain indicators of
the child across the averages of many other children. There are three recommended
indicators for growth monitoring children below the age of 5 years.
1. WEIGHT-FOR-AGE
2. LENGTH/HEIGHT-FOR-AGE
3. WEIGHT-FOR-LENGTH/HEIGHT
Now let us explore each of these indicators a bit more.
WEIGHT FOR AGE (WFH)

LOW WFH = UNDERWEIGHT
The relative change of weight for age is more rapid than height and is much more
sensitive to any deterioration or improvement in the health of the child. Significant
changes can be observed over period of few days making the measurements easy,
so a high level of accuracy is possible. It is for these reasons that weight for age
is the measurement employed in growth monitoring, particularly in infants and
young children.
HEIGHT FOR AGE

LOW HFA = STUNTING
Stunting refers to a child that is short for his/her age and is also known as chronic
malnutrition. The levels are very high in many developing countries and it is a
result of long-term poor nutrition. You will learn more about infant and young child
feeding practices that have a great impact of stunting levels.
WEIGHT FOR LENGTH/HEIGHT

LOW WFH/L = WASTING
By relating the weight of the child to its height or length, the child’s degree of
thinness can be obtained. Wasting is a measurement of acute malnutrition.
You have learned about this in module 6.
WHAT IS THE DIFFERENCE BETWEEN LENGTH AND HEIGHT?

There is an important difference between height and length for you to remember.
They are measured differently for certain age groups.
■■ LENGTH is measured when the child is lying down. Length is measured for
children below 2 years of age.
■■ HEIGHT is measured when the child is standing upright. Children 2 years and
older are measured in height.
11
What happens if you do not use the recommend method for the child’s age?
If you measure a child other than with the method recommended, you must make corrections to the
measurement. The height of a child is 0.7 cm shorter than length.
•• If you measure a child below 2 years in standing position (height), instead of the recommended length,
you must add 0.7 cm to give you his/her correct length.
•• If you measure a child 2 years and above while they are laying down (length), instead of height, you must
subtract 0.7 cm to give you his/her correct height.
HOW FREQUENTLY SHOULD CHILDREN UNDER 5 BE MONITORED

FOR GROWTH?
The current international recommendations are the following for growth monitoring:
BIRTH TO 2 YEARS 2 TO 5 YEARS

MONTHLY MONITORING MONITORING EVERY 3 MONTHS
• Weight: measured monthly Weight, length, height on every
• Length/height: every 3 months attendance

WHERE CAN GROWTH MONITORING OCCUR?

Growth monitoring can occur both in the health facility and in the community
during outreach services. There are different requirements for both settings.
HEALTH FACILITY: The clinic should be spacious.
✔✔ There should be chairs or benches for caregivers and children to sit while
waiting.
✔✔ There should be a strong table and a wall to hold the measuring board.
COMMUNITY: Community leaders should be informed to prepare a strong table
for growth monitoring.
No matter the location, it is important for you to use the opportunity of growth
monitoring to provide other services and interventions to a child. These can include
child assessment, treatment, vaccination, Vitamin A supplementation, deworming
and psychosocial support.
WHAT ARE TOOLS USED TO MONITOR GROWTH?

These are several tools you require to effectively do growth monitoring. We will
review these tools now.
1. CHILD GROWTH AND MONITORING BOOKLET

✔✔ Why is this tool useful? It provides growth charts to record child’s indicators at
each visit. At the time of the visit, it helps you determine if the child is growing
poorly. In the long-term, it also helps you chart the child’s growth. It also includes
various service schedules, for example vaccinations, vitamin A, and deworming.
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✔✔ Important tips: this booklet is different for male

child and female child. It should NOT be used
interchangeably.
•• Male child book is blue in colour, with picture of
male child
•• Female child book is pink in colour, with picture
of a female child
You will learn more about the importance of these books
in the following pages.
2. WEIGHING SCALE
✔✔ What scale is best? There are two important qualities for the acceptable scale:
•• It should be a solar scale.
•• It should be a taring scale, which means the standing type with
the ability to erase the mother/care taker’s weight.
✔✔ What if these scales are not immediately available? Salter scales
can be used temporarily while a recommended scale is being procured.
3. LENGTH AND HEIGHT BOARD

✔✔ What kind of board should be used? A wooden length board is preferred. The
board should have two or three pieces. If the child is tall, the pieces can be joined.
HOW WILL YOU MEASURE A CHILD’S LENGTH?

Remember that length is used for children under 2 years, or those too weak to stand.
One assistant should hold the child’s head over the ears and with straight arms.
The measurer hold one hand on the child’s knees keeping the legs straight and the
other on the foot-place to read the length. The child should lie flat on the board.
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Once you have measured the child’s length, you will use the weight and length
HOW WILL YOU MEASURE A CHILD’S HEIGHT?

Remember that height is used
for children 2 years and older.
The assistant should hold the
child’s knees to keep the legs
straight with one hand, and
the other hand on the shins
to keep the heels against the
back and base of the board. The
measurer should hold one hand
the child’s chin and the other
on the head-piece to read the
height. The child’s eyes should
the in horizontal level and the
body flat against the board.
Once you have measured the child’s height, you will use the weight and height
14
HOW DO YOU CALCULATE A CHILD’S Z-SCORE?

You should remember this calculation from the MALNUTRITION module. Let us
quickly review how to plot weight and height on the chart, and find the Z-score.
Once you have the child’s weight and height/length, you will calculate their Z-score.
This is basically a score comparing the weight-for-height/length of children across
the world. Children with low Z-scores have low weight-for-height/length. The Z-score
does not require any math. You will use an easy chart, which you can refer to
your IMCI Chart Booklet.
1. THERE ARE SEPARATE CHARTS FOR HEIGHT (2 to 5 years) and LENGTH

(birth to 2 years)
2 DETERMINE WHICH CHART TO USE BASED ON THE CHILD’S SEX

It is important to note that there are two separate charts for females and males.
They cannot be used interchangeably.
3. MARK THE INTERSECTION OF THE CHILD’S WEIGHT AND HEIGHT

Next you will find the intersection of the weight and height. The numbers for
weight (kg) run up the chart, and guiding lines run across the chart. The
numbers for height (cm) are along the bottom of the chart, and the guiding
lines run up the chart.
Let us review an example. Ben is 10.5 kg and 82 cm. See how we find the
intersection:
15
4. USE THE INTERSECTION POINT TO FIND THE Z-SCORE

Think about the Z-scores like zones between two lines. Look at the figure below.
You should be most worried about any
weight-for-height intersection points that
fall:
✔✔ Between the -2Z and -3Z lines, like
the circle below. This is moderate
malnutrition.
✔✔ Below the -3Z line, like the star
below. This is severe malnutrition.
n CASE STUDY – SAMSON

Practice measuring length and height
Samson is 6 months old boy. His mother has brought him to the clinic today for growth and development
monitoring, and for vitamin A supplementation. His weight is 8 kg and his length is 64 cm.
Review your chart – what is Samson’s Z score? Once you have your answer, read on.
The growth-monitoring chart from the CHILD HEALTH BOOK for boys shows that he is between median and
-2, Z-score. This indicates that Samson child is doing well.
Practice measuring length and height
1. How often should children under 2 years be monitored for growth?
2. How often should children between 2 and 5 years be monitored?
3. What equipment is important for growth monitoring?
WHERE WILL YOU RECORD INFORMATION ABOUT THE

CHILD’S GROWTH?
You have just read about three important tools for growth monitoring: the growth
monitoring chart in the child health book, a weighing scale, and a length board.
Once you have measured a child’s growth, where you will record and track this
information? You will use the child health book available in your country.
16
Every child should receive a growth and monitoring book as soon as possible after birth.
You should explain the book to the caregivers.
Caregivers should be encouraged to bring the book with the child whenever coming
to the health facility. It has important child records, including services given.
HOW SHOULD YOU INVOLVE CAREGIVERS IN GROWTH

MONITORING?
You have an important job in explaining to caregivers why regular growth monitoring
is critical for their child’s health. Even if they think their child is healthy and growing
(for example, as compared to other children in the house) it is important to track.
Here are some helpful tips about what to explain to caregivers:
✔✔ Explain why child growth is important
✔✔ Explain what the child health book is used for monitoring growth
✔✔ Use the growth monitoring chart to show caregivers how the child is growing
✔✔ Use the chart to help caregivers understand the child’s growth pattern
✔✔ Show feeding recommendations (if available) from the book
✔✔ Show other schedules (if available) from the book, including vaccinations
✔✔ Remind caregivers about the different interventions expected during the visit
✔✔ Remind caregivers to always carry the child health book to the facility, because
it has important child records
Remember!
Health of the mother is an important factor in the health of the child.
Assess the mother about pregnancy through post delivery history and record.
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This is practice for what you have learned about monitoring growth and
development.
1. Review the children below. Tick if their growth or development is normal, or
not. If you decide that the growth or development is not normal, make a note
with your reasons.
Growth/development is:
If the child:
Normal Not normal
a. Edward is 6 months. He does not have neck control
b. Maria, girl, 24 months. She weighs 13 kg, height is 85 cm
c. Asha is 30 months old. She says few words with meaning.
She can hop on one foot and can walk backwards.
d. Hamisi, 17 months, is only able to walk with support.
e. Amiri is 4 years old. He is not able to say a single word
f. Alice can dress herself and is toilet trained. She is 4½
years.
g. Kemilembe is 3 years old. She is not able to tell a short
story. She does not know her sex.
h. Alex is 4 years, 10 months. He weighs 22 kg, and his height
is 113 cm. He has started kindergarten/nursery school.

2. Jandika is 19 months old boy. His mother brought him to the clinic for growth
monitoring. He weighs 8 kg and his length is 71 cm. What are you going to do
for Jandika during this visit? What advice do you need to give Jandika’s mother?
Write reasons for your answers.
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9.4 CAREGIVER-CHILD INTERACTION: BONDING

AND ATTACHMENT
This section describes an important piece of child development, the bonding and
attachment between a caregiver and child. We will begin by defining these concepts.
WHAT IS ‘BONDING’?
Bonding is the process of a mother forming a relationship with her new infant.
It begins during the first few hours after birth. The connection is mother-to-child.
WHAT IMPACTS BONDING?

It is important to remember that bonding occurs early in the child’s life, and
can have a lasting impact on his or her development. Bonding is a process that
happens very quickly after birth. Therefore, some actions might affect the bonding
between a mother and child. For example:
✔✔ Mother is separated from infant for a long period after birth, like many days
or even weeks
✔✔ Mother has poor health
✔✔ Mother is depressed after delivery, which happens to many women. This
depression often goes undetected and many mothers do not seek help.
✔✔ The mother or someone else is abusing or neglecting the child
✔✔ The infant is a low weight baby and therefore need even more attention and care
✔✔ The infant is ill
WHAT IS ‘ATTACHMENT’?
Attaching is primarily a process of the infant forming a relationship with his or
her mother or the primary caregiver, and reinforced by the responses. It occurs
during the first two years of life, but especially between 2 and 7 months of age.
During attachment, the child develops a personal communication system with
the primary caregiver. The connection is child-to-caregiver.
WHAT ARE CONSEQUENCES OF POOR ATTACHMENT?

Poor attachment between a child and caregiver can have very serious impact on
development. Some of the known complications of poor attachment include:
✔✔ Child might have difficulty trusting others in their life.
✔✔ Child can experience increasing depression or rage.
✔✔ Child fails to thrive as a child that is physically and emotionally healthy, curious
about the world around him/her, active, and happy.
✔✔ Child can have difficulty adapting to change.
✔✔ As child grows older, he or she will have more behavioral problems and worse
peer relations compared to their peers.
✔✔ Older children may also have poor problem-solving abilities, and low self-esteem.
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WHAT IS IMPORTANT FOR STRONG INTERACTIONS BETWEEN A

CAREGIVER AND CHILD?
There are two important concepts to understand about strong interactions between
a caregiver and a child. These concepts are sensitivity and responsiveness.
SENSITIVITY
Is the ability of the caregiver to be aware of the infant. This includes the infant’s acts and vocalizations that
communicate the infant’s needs and wants. If the caregiver is sensitive, this means the caregiver:
✔✔ Is aware of the infant’s signals, and interprets them accurately
✔✔ Accepts the child’s interests
✔✔ Regards the child as an individual, separate person
✔✔ Sees things from the child’s point of view
What are some examples of sensitivity?
RESPONSIVENESS
Is the ability of the caregiver to respond appropriately to the infant’s signals. The response is triggered by
the child’s signal. It happens quickly after the signal, and is the appropriate level of response.
A caregiver must be sensitive in order to be responsive. That means that the caregiver must be aware of the
infant’s signals in order to appropriately respond to them. A caregiver would for example be able to see the
child’s signs of discomfort, recognize that the child is hungry, and feed the child.
What are some examples of responsiveness?
WHY IS IT IMPORTANT THAT A CAREGIVER BE SENSITIVE

AND RESPONSIVE?
There are two primary reasons why it is critical for a caregiver to be sensitive and
responsive. First, it helps a caregiver be more effective in giving care to a young
child. Second, it creates attachment with the child, which helps development. Let
us review these two in more detail:
1. To be effective in caring for a young child:
—— Providing feeds on demand
—— Protect a child from any potential harm
—— Recognize when the child is sick, and seek care
—— See cause and effect in the environment and in social relationships
—— Learn to talk to the child to resolve problem
2. To develop a secure attachment with a young child. This is the basis for
health growth, and a child’s intellectual, social, and emotional development.
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LET US REVIEW THE CONNECTIONS BETWEEN WHAT YOU HAVE

LEARNED SO FAR
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Practice concepts of bonding and attachment.
1. How would you describe bonding to a mother?
2. How would you describe attachment to a caregiver?
3. Are the following actions examples of a caregiver’s sensitivity or responsiveness?

Tick your answer.
A mother, Sara, takes the following actions with her son John: S R
a. Sara hears John crying
b. Sara picks up John to soothe his crying
c. Sara is giving John a bath and notices a rash on his leg
d. Sara sees John watching the tree’s branches blowing in the wind
e. Sara asks John, “Do you see the wind blowing? The leaves are blowing!”
f. Sara notices that John is not feeding as much as usual
g. Sara offers John a food he likes to see if he will eat

4. Sara’s grandmother told her that it’s important John be left alone so he’ll become
a strong and independent man, instead of emotional and weak. How would you
address this concern of Sara’s? How should she discuss with her grandmother?
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9.5 INTERVENTIONS FOR CHILD DEVELOPMENT

WHAT ARE THE INTERVENTIONS THAT HELP CHILD CARE
DEVELOPMENT?
Care for child care development begins with improving the skills of health workers
and others who work with families. Many people are not very trained in this area.
This is why you are studying this module on well child care.
Next, there are tools for health workers to use while counselling families on play
and communication activities with their child. One such tool is the child care
development chart on the next page. This chart includes recommended activities
for children and caregivers for specific age groups.
WHAT DO THESE ACTIVITIES DO?

These activities help to:
✔✔ Stimulate the child’s learning
✔✔ Improve routine care practices, including newborn and child feeding
✔✔ Improve a caregiver’s care-giving skills, especially to prevent and solve any
problems in care
✔✔ Improve the interaction between caregivers and their children
Review the chart on the next page to see examples of these activities.
Watch “Care for Child Development” (on Care for Child

Development CD)
This video clip reviews all steps child development through case
stories
23
24
WHY ARE TOYS IMPORTANT?

When you review the important play activities on the Care for Development chart,
you see many involve toys. It is very important that caregivers understand that
play materials can be made using simple, available materials at home. It is not
necessary to buy toys from the store. Mothers might be discouraged by the price of
toys. As a health worker, it is important to explain that homemade toy items help
a child develop.
WHAT ARE GOOD TOYS TO MAKE AT HOME?

Here is a list of great toys for children. It is recommended that you make these toys
and have them at your clinic to show caregivers. You can demonstrate how easy it
was to make, and also show how the child can play with it.
SAMPLE TOY ITEMS MATERIALS NEEDED

Newborn
Sponge (rough and smooth) Sponges
1 week up to 6 months
Shaker rattle Small plastic jars with lids and small stones, strips of plastic, or
other items to make noise inside
Rings on a string Rings (e.g. rubber bands or spools) on a piece of colourful
yarn
6 to 9 months
Containers with lids Plastic containers with lids small enough for child to take on
and off
Metal objects to bang and drop Metal pots, lids, bowls, plates, cups, and wooden spoons
9 to 12 months
Peek-a-boo cloths Clean cotton cloth to hide things and face
Homemade doll with face Cloth, thread, needle, scissors
12 months up to 2 years
Stacking cups, plastic or metal with handles Stacking cups, plastic or metal with handles (different sizes
and shapes, at least three to a set)
Empty boxes, bowls, other containers with small, safe objects Boxes, bowls, or other containers to put things in and take
like clothes clips them out, clothes clips, stones
Nesting objects (bowls, cups, boxes) Plastic or metal bowls and cups and other nesting objects to
stack
2 years and older
Pictures Magazine pictures or marker to draw on paper
Face puzzles Magazine picture or drawn face, on cardboard, cut in 3-5
pieces
Coloured circles, squares, triangles to sort by colour and Cardboard or magazine covers, glue, scissors, bowls or other
shape containers for sorting shapes
Ball Small, soft ball
Chalk and flat stone for writing Chalk and flat stone
Book Pages with pictures and words, punched and tied together
25
Other helpful supplies for making toys:

■■ Scissors
■■ Coloured paper or cardboard
■■ Box cardboard
■■ Marking pens
■■ Punch
■■ Glue
■■ Dish soap for cleaning toys
■■ Plastic boxes and bags to hold supplies and toys
Check that a caregiver understands after you explain.
The following questions are not good checking questions, because they can be
answered “yes” or “no”. Rewrite the questions as good checking questions.
1. Do you understand how to improve skills of other people at home who take care
of the child?
2. Did the nurse explain to you how to stimulate play and communication to your
child?
Practice using the care for child development chart.
The following children are in your clinic for a well child visit. What activities would
you recommend to their caregivers for play and communication? Take quick notes
on the activities below.
PLAY? COMMUNICATION?
1. Jyothi, 2 months
2. Linus, 11 months
3. Julie, 7 months
4. Nathan, 4 days
5. Frank, 17 months

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HOW WILL YOU USE THIS CHART IN YOUR CLINICAL CARE?

The figure below shows the important steps you will take when using the care
development chart in your clinic. First, you will determine the child’s age and the
age-appropriate activities. You will show these to the caregiver and explain how
the chart works.
You will use your 3 basic teaching steps to teach the caregiver how to use these
activities. First, you will explain how to play and communicate with the child.
Second, you will demonstrate. Third, you will watch as the caregiver practices and
give feedback. Once the caregiver is practicing well, you will explain how to use
the chart activities regularly at home. As you explain, remember to use checking
questions to check her understanding.
Next, you will complete a self-assessment exercise.
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Practice concepts of child development.
1. Rakim and his mother Beta have come for their immunizations, and you would
like to do a well child assessment. How would you explain ‘child development’
to Beta?
2. Beta does not seem very interested. What would you explain to her about child
development is important for Rakim’s health?
3. Describe to Beta how she can play and communicate with Rakim. He is 4 months
old.
4. Beta insists that he is too little to understand how to communicate or play. How
will you address this concern?
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9.6 MONITORING A CHILD’S DEVELOPMENT

In the previous sections, you have learned important information about child
development. You have read about the importance of bonding and attachment
between a child and a caregiver. You have also learned about counselling a caregiver
on age-appropriate activities and interactions with a child.
In this section, you will learn about how to assess a child’s development.
WHY SHOULD YOU MONITOR CHILD DEVELOPMENT?

You should monitor growth and development of all children. A growing child passes
through several stages of development. Each of these development stages has
milestones. These milestones are important actions or skills that the child should
develop at a particular stage.
REMINDER: what are the types of skills that children

are developing?
Quickly refresh yourself on the skill sets you have read about:
✔ Motor (physical) ✔ Adaptive (emotional)
✔ Social (communication) ✔ Cognitive (exploratory)
You will use these milestones to monitor a child’s development. Health workers
should also educate caregivers on these simple milestones so that they can help you
identify children early who might have developmental delays.
WHAT TOOLS ARE AVAILABLE TO MONITOR CHILD DEVELOPMENT?

There are many different charts that explain milestone development for certain
age groups. These milestones are usually described for particular skills, like motor
or speech.
Review the milestone chart on the next page.
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REVIEW THE MILESTONE DEVELOPMENT CHART FOR CHILDREN

AGED 6 WEEKS TO 5 YEARS
This chart can be used to identify children who are delayed in reaching their milestones. Children with
delayed developmental milestones should be referred for further management. As a health worker, you can
also use this chart to counsel the mother on ways to stimulate the child’s mental and motor development.
SPEECH AND ADAPTIVE AND SOCIAL
AGE GROSS MOTOR FINE MOTOR
LANGUAGE SKILLS
Prone-lifts chin
6 weeks
intermittently
Prone-arms extended
2 months Pulls at clothes Coos
forward
Prone-raises head and
Reach and grasp, objects
4 months chest, rolls rolls over front Responds to voice
to mouth
to back, no head lag
Prone-weight on hands, Begins to babble,
6 months Ulnar grasp Stranger anxiety
tripod sit responds to name
Mama, dada, imitates one Plays games, separation
9 months Pulls to stand Finger-thumb grasp
word anxiety
Walks with support, 2 words with meaning Plays peek-a-boo, drinks
12 months Pincer grasp, throws
“cruises” besides mama or dada with cup
15 months Walks without support Draws a line Jargon Points to needs
Tower of 3 cubes, 10 words, follows simple Uses spoon, points to
18 months Up steps with help
scribbling commands body parts
Up 2 feet per step, runs, Tower of 6 cubes, 2–3 word phrases, uses I, Parallel play, helps to
24 months
kicks ball undresses me, you, 25% intelligible undress
Tricycle, up 1 foot per
Prepositions, plurals, 75% Dress and undress fully
step, down 2 feet per Copies a circle and a
3 years intelligible, knows sex, except buttons, counts
step, stands on one foot, cross, puts on shoes
age to 10
jumps
Tells tory, normal
Hops on 1 foot, down 1 Copies a square, uses Cooperative play, toilet
4 years dysfluency, speech
foot per step scissors trained, buttons clothes
intelligible
Copies a triangle, prints Fluent speech, future
5 years Skips, rides bicycle Knows four colours
name, ties shoelaces tense, alphabet
Practice using the milestone development chart.
1. What type of fine motor skills should a child aged 2 years have?
2. Which sounds or words should a child at 9 months be able to speak?
3. What social and adaptive skills should a child aged 3 years have?
30
HOW ARE YOU GOING TO ASSESS DEVELOPMENTAL MILESTONES IN CHILDREN?

Using the development milestone chart on the previous page as a starting point, you will now learn how to
assess milestones in children.
2 TO 4 MONTHS
What the child should be able How you will conduct your Is the child meeting these What actions will you take?
to do at this age: assessment: development milestone If a child is not meeting these
criteria? milestones, how will you advise
the caregiver? Record your
notes here:
A child holds the head erect 1. Lay the child down face up The child must be able to do
and lifts his head. Turns head (supine position). these things:
from side to front.
2. Hold both her hands and ✔✔ Hold her head in erect
A child is able to recognize pull to a sitting position.
✔✔ Turn her head sideways
faces and follows objects
3. Play with an object like
through a visual field. ✔✔ Become responsive to
keys to make a noise.
voice
Becomes alert in response
4. Ask the caregiver to play
to voice, and can smile ✔✔ Smile at the mother/
with the child by making a
spontaneously. caregiver
joyful sound.
5 TO 7 MONTHS
to do at this age: assessment: development milestone How will you advise the
criteria? caregiver if child is not
meeting? Record notes:
A child can sit without using 1. Look and smile at the The child must be able to do
hands or being supported. child. these things:
The head is straight up for at
2. Make the child sit on a safe ✔✔ The child must have a
least 10 seconds.
and flat surface. neck control.
Usually the lower limb is
3. Offer the child a toy to ✔✔ The child does not use
flexed at the knee joint. A
hold so as not to support hands to support the
child reaches for and brings
the body with hands. body while sitting.
objects to mouth.
4. Place a clean safe object ✔✔ The child is able to
within a child’s reach. maintain that posture for
at least 10 seconds.
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8 TO 11 MONTHS
At this age group, a child 1. Look at the child. Let the ✔✔ The child must be able to
starts standing up with mother or caregiver stand do these things:
support before being able to the child upright.
✔✔ A child is able to stand
stand up alone by 11 months
2. Observe closely if the up.
of age.
lower limbs are able to
✔✔ A child holds on to a
This is an important stage for support the child’s weight.
table or any other object
a child to be able to stand up Make sure the child’s body
without leaning to it.
before beginning to move is not in contact with the
forward. A child is able to supporting object. ✔✔ The child’s body is not in
withstand his/her weight by contact with the object
3. Ensure that child’s weight
either being supported or he is holding on.
is supported by his/
supporting himself.
her lower limbs. The ✔✔ The lower limbs are able
In this stage a child also height of the table or the to support the weight of
crawls by being able to supporting object should the child.
moves to and fro using be parallel to the child’s
✔✔ The child is able to stand
upper and lower limbs. The abdomen.
with support for at least
abdomen may or may not
4. Put the child upright then 10 seconds.
be in contact with the floor.
leave him standing slowly
Then, a child is able to stand ✔✔ Hands and knees move to
and carefully. Observe if
still for a period of time. and fro in exchange
the child is able to stand
The lower limbs are straight ✔✔ A child moves to and
on his own for at least 10
without flexion at the knees. fro at least three times
seconds.
A child imitates “bye bye”, consecutively.
5. Place a child in a prone
passes object from hand to
position on a flat and safe ✔✔ A child is able to stand
hand in midline, and obeys on his two feet and not
surface. Stand in front of
simple command like “no, on his toes with his back
the child at a distance of
stop, shh”. A child also rolls upright.
at least 120 to 150cm. If
from back to stomach.
the child does not crawl, ✔✔ The lower limbs are able
encourage him/her by to support the child’s
showing a toy or an weight.
attractive object. Ask the
mother or caregiver to ✔✔ A child is able to stand
help you to encourage the still without being
child to crawl. supported for at least 10
seconds.
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12 TO 18 MONTHS
At this age group, a child is 1. Place the child upright. ✔✔ The child must be able to
able to stand up with the do these things:
2. The child should be at a
back upright. A child is able
distance but able to reach ✔✔ A child is able to stand up
to move sideways or forwards
for a supporting object with the back upright.
with support of one or both
with either one or both
hands. ✔✔ A child is able to move
hands.
forwards or sideways with
In this stage a child is able to
3. Encourage the child to support of one or both
walk on his own at least five
move by showing him hands.
steps with confidence. The
a toy or an attractive
child is able to stand up on ✔✔ One lower limb moves
object. Ask the mother
his own and moves forward while the other supports
or caregiver to help
without being supported. the weight of the child.
you to encourage the
One leg moves forwards
child. Ensure that the ✔✔ A child is able to walk
while the other supports the
supporting object is at the at least five steps
weight of the child without
same height as the child’s consecutively.
being held or supported by
abdomen.
an object. This stage is more ✔✔ The child is able to stand
than the early stages when a 4. Let the child stand in a with a straight back.
child is learning how to walk by safe place. Stand in front
✔✔ The child is able to move
moving one to two steps alone of the child at a distance
one limb forward while
then waits for support. of around 120 to 150 cm.
the other being supports
A child is able to climb stairs 5. Encourage the child to the child’s weight.
with help and throws a walk towards you by
✔✔ While walking a child
ball. Says 4-20 words with showing him a toy or an
is not in contact with
meaning. Drinks with cup. attractive object. Ask the
a person or being
mother or caregiver to
supported by an object.
help you encourage the
child to walk towards you. ✔✔ A child is able to move at
least five steps.
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19 TO 24 MONTHS
A child speak short phrases, 1. Ask or ask the mother/ ✔✔ The child must be able to
2 words or more, kicks ball caregiver to ask the do these things:
on request, dresses and child simple question(s)
✔✔ A child is able to speak
undresses with help, and requiring short answer.
short sentences with
verbalizes toilet needs.
2. Ask the child to stand and meaning (in baby
A child is also able to jump offer a ball to kick. tongue/language)
off floor with both feet, and
3. Give pictures or objects ✔✔ While standing, a child
turns pages of book singly.
such as common toys kicks a ball upon request
Points to named objects or
and ask the child to name
pictures. ✔✔ The child names objects
them.
or pictures correctly
✔✔ A child indicates when
wants to go toilet
30 TO 36 MONTHS
The child is able to walk 1. Ask or ask the mother ✔✔ The child must be able to
backwards, and hop on one to ask the child to walk do these things:
foot. backwards, or to hop on
✔✔ From standing position, a
one foot from a standing
Refers to self as I, and gives child can walk backwards
position.
first and last name. Child while facing front
knows sex (gender). 2. Speak or ask the mother
✔✔ From standing position a
to speak to the child to get
A child is able to put on child can hop on one foot
the name of the child.
shoes, and can dress/undress at least 3 steps
with supervision full except 3. Ask the child to remove
✔✔ While speaking, a child
buttons. then put on shoes and
refers himself as I, and
remove a shirt if the child
can give first and last
is wearing one.
name accurately when
asked
✔✔ A child is able to put on
clothes or remove them
with supervision
34
3 TO 4 YEARS
At this age group children 1. Ask child to button or ✔✔ The child must be able to
can climb stairs with unbutton his/her shirt. do these things:
alternating feet.
2. Ask the child if s/he is a ✔✔ From standing position,
Begins to button and girl or a boy, or to tell a a child climbs stairs alone
unbutton. Is able to feed short story. with alternating feet
himself/herself.
✔✔ A child puts on or takes
Knows own sex and gives full off shirt or jacket and
name. A child can tell a short is able to button and
story, engage in cooperative unbutton
play, and is toilet trained.
✔✔ When asked, a child is
able to tell if is a boy or
a girl
✔✔ A child can tell a short
story
4 TO 5 YEARS
At this age, child runs and 1. Ask the child to run and ✔✔ The child must be able to
turns while maintaining then make a turn while do these things:
balance. run.
✔✔ While running, a child
A child also can do self-care 2. Show 3 different types of is able to turn without
at toilet (although may need primary colours for a child losing balance
care with wiping). to identify.
✔✔ A child goes to toilet
Child has fluent speech, when wants to relieve
knows future tense, and him/herself
knows at least 3 colors. Child
✔✔ A child is fluent in speech
of this age also copies and in
and use future tense
imitation.
✔✔ Child recognizes at least 3
different types of primary
colours
35
Practice using child development charts
1. Mariamu has brought her daughter Manka to your health facility. She says Manka
was born 5 months ago at term with birth weight of 3.1 kg. Manka attained neck
control at 5 months. Mariamu is worried that Manka is not able to sit without
support. How are you going to advice Mariamu?
2. Ikupa is 36 months old. She has been brought to the clinic by her grandmother
for growth and development monitoring. When you assess Ikupa, she can stand,
move sideways or forwards with support of one or both hands of which she
moves at least five steps in that state. Ikupa says about 10 words with meaning
and drinks with cup. So far this is what Ikupa can do. What advice would you
give to Ikupa’s grandmother and why?
36
9.7 COUNSELLING ABOUT FEEDING PROBLEMS

What are good practices in counselling about feeding?
When you have identified the feeding problems, you will be able to give advice that
is most relevant to the mother.
✔✔ BEFORE GIVING ADVICE, BUILD CONFIDENCE
If the feeding recommendations are being followed, praise the mother for her
good feeding practices. Encourage her to keep feeding the child the same way
during illness and health. Avoid using words that are judgmental.
✔✔ COUNSEL ACCORDING TO THE CHILD’S AGE
If the child is entering a new age group with different feeding recommendations,
explain these new recommendations to the mother. For example, if the child is
almost 6 months old, explain the value of good complementary foods and when
to start them.
✔✔ EXPLAIN RECOMMENDATIONS IF THEY ARE NOT BEING FOLLOWED
If the feeding recommendations for the child’s age are not being followed, explain
those recommendations and make suggestions.
WHAT ARE COMMON FEEDING PROBLEMS THAT YOU MAY HAVE

TO COUNSEL?
There are many reasons that a child might have a feeding problem. You should refer
to the counselling tools you have available in your country about counselling on
feeding recommendations and issues. Below are some common problems that you
might hear from caretakers about feeding.
Mother reports difficulty with breastfeeding

Refer to MODULE 2 – SICK YOUNG INFANT. You learned to check and improve
positioning and attachment.
If the mother has a breast problem, such as engorgement, sore nipples, or a
breast infection, she may need referral to a specially trained breastfeeding counselor.
This could be a health worker who has taken Breastfeeding Counseling: A Training
Course or someone experienced in managing breastfeeding problems.
Child under 6 months old is taking other milk or foods

All children should be exclusively breastfed until the age of 6 months. If a child
under 6 months old is receiving food or fluids other than breastmilk, the goal is
to gradually change back to more or exclusive breastfeeding.
Suggest giving more frequent, longer breastfeeds, day and night. As
breastfeeding increases, the mother should gradually reduce other milk or food.
Since this is an important change in the child’s feeding, be sure to ask the mother
to return for follow-up in 5 days.
37
If the mother has started to give complementary feeds under the age of 6 months,
encourage her to try and reduce these feeds and give breastmilk (or other milk if
she is not breastfeeding) 8 times a day before complementary feeds.
All mothers should be strongly encouraged to breastfeed their children for 6 months.
In some cases this might not be impossible. For example, if the mother passed away,
if she must be away from her child for long periods, or if she will not breastfeed for
personal reasons. Explain to her how to correctly prepare breastmilk substitutes
and use the feed within one hour to avoid spoilage.
Mother is using a bottle to feed the child

Recommend the use of a cup rather than a bottle, and show the mother how to
use a cup to feed her child. A cup is easier to keep clean and does not interfere with
breastfeeding.
If the child is not being actively fed (when older)

The mother should sit with the child and encourage him to eat. He should have his
own serving and not have to compete with siblings for food. If all the children are
eating from the same plate, the younger children will often not eat enough.
If the child has a poor appetite or is not feeding well during illness
Even though children may lose their appetite during illness, they should be
encouraged to eat the types of food recommended for their age, as often as
recommended.
If possible, children should be breastfed more frequently and for longer. Soft,
nutritious foods which the child likes should be offered. Offer small feeds
frequently. After illness, good feeding helps make up for any weight loss and prevent
malnutrition.
Sometimes the poor appetite is due to snacks or juices that satisfy the appetite for a
short time, but are not sufficiently nutritious. This practice needs to be discouraged.
Also look at the recommendations for the child with a poor appetite in the Chart
Booklet.
How can families encourage a young child to eat?
✔✔ Offer small amounts at times when the child is alert and happy;
✔✔ Offer more food if the child shows interest;
✔✔ Give foods of a suitable consistency, not too thick or dry;
✔✔ Give physical assistance – a spoon of a suitable size, food within reach of the
child, young child sitting on caregiver’s lap while eating;
✔✔ Offer verbal encouragement (e.g. “open for tasty beans”), smiles, songs, and other
positive facial gestures. If a child receives more attention for refusing food than
for eating it, the child may eat less in order to get the attention.
38
Special feeding problems for HIV-infected children

Careful attention needs to be given to the feeding of the HIV-infected child.
Belonging to an HIV-affected family may affect a young child’s nutrition in a
number of ways:
•• As time goes on, the child’s mother may become sicker with HIV-related illnesses.
•• Her illness may result in the child getting less care, increasing risk of malnutrition.
•• The mother may soon be pregnant again, or have another young baby. This can
also affect the feeding of the young child.
•• Illness and death in a household can reduce the availability of food, through lack
of money or inability to work the land fully, to go to the shop, or to prepare food.
•• An older child may be responsible for caring for young children.
•• The child may be at increased risk of illness, if not breastfeeding, or if infected
with HIV, and need extra care.
•• Active feeding is needed to help with catch-up growth after an illness – but less
care may be available.
These need to be addressed carefully as disease progression can be slowed down
considerably if the nutritional state is optimal. You will learn more about feeding
recommendations for HIV-exposed or infected children and infants in the
HIV MODULE.
HOW WILL YOU PROVIDE FOLLOW-UP CARE FOR A FEEDING

PROBLEM?
Caregiver should be instructed to return with the child for follow-up in 5 days.
When a caregiver and child return for a feeding problem:
✔✔ Reassess the child’s feeding by asking the questions in the top box on the
COUNSEL THE MOTHER chart. Refer to the child’s chart or follow-up note for
a description of any feeding problems found at the initial visit and previous
recommendations.
✔✔ Ask the mother how she has been carrying out the recommendations.
For example, if on the last visit more active feeding was recommended, ask the
mother to describe how and by whom the child is fed at each meal.
✔✔ Counsel the mother about any new or continuing feeding problems. If she
encountered problems when trying to feed the child, discuss ways to solve them.
For example, if the mother is having difficulty changing to more active feeding
because it requires more time with the child, discuss some ways to reorganize
the meal time.
✔✔ If the child is very low weight for age, ask the mother to return 30 days after
the initial visit. At that visit a health worker will measure the child’s weight gain
to determine if the changes in feeding are helping the child.
39
CONSIDER AN EXAMPLE SITUATION FOR FOLLOW-UP:

On the initial visit the mother of a 3-month-old infant said that she was giving the infant 2 or 3 bottles of
milk and breastfeeding several times each day. The health worker advised the mother to give more frequent,
longer breastfeeds and gradually reduce other milk or foods.
At the follow-up visit, the health worker asks the mother questions to find out how often she is giving the
other feeds and how often and for how long she is breastfeeding. The mother says that she now gives the
infant only 1 bottle of milk each day and breastfeeds 6 or more times in 24 hours. The health worker tells the
mother that she is doing well.
The health worker then asks the mother to completely stop the other milk and breastfeed 8 or more times in
24 hours. Since this is a significant change in feeding, the health worker also asks the mother to come back
again. At that visit the health worker will check that the infant is feeding frequently enough and encourage
the mother.
40
9.8 FEEDING RECOMMENDATIONS

This section of the module will explain the feeding recommendations on the
COUNSEL chart. The recommendations are listed in columns for different age
groups.
HOW WILL YOU DETERMINE WHAT RECOMMENDATIONS

ARE REQUIRED?
You need to understand all of the feeding recommendations. However when you
are counselling a caregiver, you will only need to explain the recommendations
specific to the child’s age group.
✔✔ FIRST, ASK QUESTIONS to find out how her child is already being fed.
✔✔ SECOND, GIVE SPECIFIC ADVICE that is needed for the child’s age and
situation. You may need to give different feeding advice if the mother is HIV
positive.
WHEN WILL YOU USE THESE FEEDING RECOMMENDATIONS?

These feeding recommendations are appropriate both when the child is sick and
when the child is healthy. Sick children visits are a good opportunity to counsel
the mother (or other caregiver) on how to feed the child both during illness and
when the child is well.
During illness, children may not want to eat much. However, they should be
offered the types of food recommended for their age, as often as recommended,
even though they may not take much at each feed.
After a child has been ill, good nutrition helps make up for weight loss and helps
to build up the resistance. In this way good feeding helps prevent future illness.
Children up to 6 months
The best way to feed a child from birth to 6 months of age is to
breastfeed exclusively. Breastfeeding advantages are described
in the SICK YOUNG INFANT module.
Exclusive breastfeeding means that the child takes only
breastmilk and no additional food, water, or other fluids. The
only exception is medicines and vitamins, if needed.
How often should children breastfeed? Children at this age
should be breastfed as often as they want, day and night. This
will be at least 8 times in 24 hours.
REVIEW IMPORTANT RECOMMENDATIONS FOR THIS AGE GROUP

•• Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours
•• Do not give other foods or fluids
41
Children 6 months up to 12 months

MILK IS STILL THE MOST IMPORTANT SOURCE OF FOOD. The mother should
continue to breastfeed the baby during the day and night. However after 6 months
of age, breastmilk cannot meet all of the baby’s energy needs, so you will read below
about beginning complementary foods. If the baby is not breastfed, give formula
or three cups of full cream cow’s milk (only from 9 months of age). If the baby gets
no milk, give five nutritionally adequate complementary feeds per day.
BEGIN GIVING NUTRITIOUS COMPLEMENTARY FOODS. If the child is breastfed,
she should also take 3 meals a day plus snacks. If the child is not breastfeeding, she
should take 5 meals a day. Always give breastmilk first before giving other foods.
Start giving 2–3 teaspoons of soft porridge or mashed food, and begin to introduce
vegetables and fruit. Gradually increase the amount and frequency of feeds. Children
between 6 and 8 months of age should have two meals a day, by 12 months this
should have increased to 5 meals per day. Give a variety of locally available food.
IMPORTANT TO INCLUDE ALL FOOD GROUPS

•• Cereals, roots, and tubers: rice, wheat, maize, millet, sorghum, cassava, yams, potatoes
•• Foods of animal original and legumes: meats, chicken, fishes, eggs, milk products (milk, cheese and
yoghurt), chickpeas, lentils, beans, cowpeas
•• Green leafy and orange-fleshed vegetables: carrots, pumpkins, avocados, leafy greens
•• Fruits: mangoes, oranges, bananas, all locally available fruits, given mashed
•• Oils, fats, sugar, and honey: Diets need adequate fat content, including oils (preferably seed oils like
groundnuts, cashew, pumpkin, and sunflower), margarine, butter, or lard
Do not recommend pre-cooked, bottled complementary foods. Some mothers

may be using them. These have the advantage of being quick and easy to prepare, and
clean when first opened. They are not recommended because they are expensive, cost
much more than other healthy foods, supply can be unreliable, and many products
also lack important nutrients. Many mothers give them before 6 months, because
of advertising and confusing instructions on the labels. Fruit juices, tea, and sugary
drinks should be avoided.
VEGETABLES AND FRUIT PROVIDE ESSENTIAL VITAMINS AND MICRO
NUTRIENTS. The child should have 2 servings a day. For example, squeeze the
juice of an orange and give it between meals. Mashed or grated can be given with
meals. Use fortified complementary foods or vitamin-mineral supplements for the
infant, as needed.
CLEAN, SAFE PREPARATION AND FEEDING OF COMPLEMENTARY FOODS IS
ESSENTIAL to reduce the risk of contamination. It is important to observe that
hands, utensils, water and food are clean. Drinking water and milk should be boiled
and kept in clean covered containers. Food should be well-cooked and kept in clean
covered containers as well.
42

✔✔ Breastfeed as often as the child wants
✔✔ Give adequate servings of complementary foods
a. If the child is breastfeeding, give 3 meals plus healthy snacks every day
b. If the child is not breastfeeding, give 5 meals a day
Children 12 months up to 2 years

During this period the mother should continue to breastfeed as often as
the child wants and also give nutritious complementary foods.
THE VARIETY AND QUANTITY OF FOOD SHOULD BE INCREASED. Give nutritious
complementary foods or family foods five times a day. Give locally available protein
at least once a day. Give food from all the food groups mentioned above. Give fresh
fruit or vegetables twice every day. Family foods should become an important part
of the child’s diet. Family foods should be chopped or mashed, so that they are easy
for the child to eat. If the child is not getting breastmilk, she should receive full
cream milk every day.
THE CHILD SHOULD BE RECEIVING FOODS RICH IN VITAMINS. Important
vitamins include iron, zinc, Vitamin A, and Vitamin C. As you have read in previously
modules, iron and zinc are important to prevent anaemia and strengthen the
immune system.
IMPORTANT VITAMINS AND RECOMMENDED FOODS

IRON Green leafy vegetables, fish, meat, chicken, liver or kidney, eggs
ZINC Fish, meat, chicken, liver or kidney, eggs
VITAMIN A Dark coloured fruits and vegetables, red palm oil
VITAMIN C Many fruits, vegetables, and potatoes
B VITAMINS: RIBOFLAVIN Liver, egg, dairy products, green leafy vegetables, soybeans
B VITAMINS: VITAMIN B6 Meat, poultry, fish, banana, green leafy vegetables, potato and other tubers,
peanuts
B VITAMINS: FOLATE Legumes, green leafy vegetables, orange juice
IT IS IMPORTANT TO ACTIVELY FEED THE CHILD. Active feeding means

encouraging the child to eat. The child should not have to compete with older
brothers and sisters for food from a common plate. He should have his own serving.
Feed infants directly and assist older children when they feed themselves, being
sensitive to their hunger and satiety cues.
Feed slowly and patiently, and encourage children to eat, but do not force them. If
children refuse many foods, experiment with different food combinations, tastes,
textures and methods of encouragement. Minimize distractions during meals if
the child loses interest easily.
43
Remember that feeding times are periods of learning and love. They are times to
talk to children, with eye-to-eye contact. An “adequate serving” means that the
child does not want any more after active feeding.

✔✔ Breastfeed as often as the child wants
✔✔ Give adequate servings of complementary foods, 3 to 4 times a day plus snacks
✔✔ Encourage active feeding
Children above 2 years

GIVE A VARIETY OF FAMILY FOODS AS 3 MEALS PER DAY. The child should also
be given 2 extra feedings per day. These may be family foods or other nutritious
foods, which are convenient to give between meals. Examples are bread with peanut
butter, fresh fruit or full cream milk.
CONTINUE ACTIVE FEEDING. If a new food is refused, offer ‘tastes’ several times.
Show that you like the food. Continue to ensure that the child receives foods rich
in iron and vitamins.

✔✔ Give 3 meals a day of family foods
✔✔ Give 2 snacks a day in between meals
Recommendations for children of HIV-positive mothers

(above 2 years)
Children whose mothers are known to be HIV positive may need special
feeding. HIV can be passed from the mother to the baby through breastmilk. At the
same time, breastmilk is very important for these infants to prevent other infections.
The importance of breastmilk is discussed in the SICK YOUNG INFANT module.
Feeding recommendations for HIV-exposed or infected children are in the
HIV/AIDS module.
44
If the child has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
MANAGEMENT
Is there ear pain? OF THE SICK
IMCI CHILD
DISTANCE AGEDLook
LEARNING 2forMONTHS
COURSE pus draining
| MODULE UP9.
from TO
the ear 5 OF
CARE YEARS
THE WELL CHILD
Name: Age: for oedema of bothWeight feet.(kg): Height/Length (cm): Temperature (°C):
Ask: What are the child's problems?
Look
Initial Visit? Follow-up Visit?
Less than -3? Between -3 and -2? -2 or more ?
ASSESS (Circle all signs present) Look for palmar pallor. CLASSIFY
If child has MUAC Answer less the
thanquestions
NOT ABLE TO DRINK OR BREASTFEED
115 mm or for each feeding
Is there assessment
any medical complication: in
LETHARGIC OR UNCONSCIOUS
thedanger
General following
sign? case studies.
present?
both feet:
CONVULSIONS In the cases below, identify correct and incorrect feeding practices. Write the feedingRemember to use
Child 6 months or older: Offer RUTF to eat. Is the child:
Not able to finish? Able to finish?
Danger sign when
problem in the classification box. Child Identify possible
less than 6 months: reasons
Is there for the
a breastfeeding feeding problem.
problem?
selecting
Then write down your feeding advice. classifications
DOESMother's
THE CHILD
HIV test:HAVE COUGH OR
NEGATIVE DIFFICULT
POSITIVE BREATHING?
NOT DONE/KNOWN Yes __ No __
For Child's
how long? 1. THULI
___ Days
virological test: is 3 months
NEGATIVE POSITIVE old NOT and weighs
Count
DONE 5.5in one
the breaths kg minute:
today.___She is classified
breaths asbreathing?
per minute. Fast cough or
Child's serological test: NEGATIVE POSITIVE NOT Look
DONEfor chest indrawing
cold and not underweight. Her mother
Look and
If mother is HIV-positive and NO positive virological test in child: listen forstopped
stridor breastfeeding at 6 weeks because
Is the child breastfeeding now? Look and listen for wheezing
she had to go back to work. The grandmother looks after her during the day
DOESWas
THEtheCHILD HAVE DIARRHOEA?
child breastfeeding at the time of test or 6 weeks before it? Yes __ No __
For Ifhow
breastfeeding: Isand
long? ___ Days the and
the mother mother
child on comes homeLook at
ARV prophylaxis? night.
at the Her condition.
childs general motherIs makes
the child: up three bottles of
Is thereTHE
CHECK bloodCHILD'S
in the stool?IMMUNIZATION STATUS (Circle Lethargic or unconscious?
immunizations Restless
needed and irritable?
today) Return for next
125 ml formula a day. ThuliLook drinks 2 bottles
for sunken eyes. during the day, and 1 at night. Sheimmunization on:
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A
Offer the child fluid. Is the child: ________________
OPV-0 OPV-1 also gets 1OPV-2
bottle of thin porridge
OPV-3 a day. Mebendazole
Not able to drink or drinking poorly? Drinking eagerly, thirsty? (Date)
RTV-1a. Use theRTV-2 chart to note feeding
RTV-3 problems:
ASSESS
Decide FEEDING
malaria risk: High if___ theLowchild is less then 2 years
___ No___ Look or has
old, feel for stiff neck
MODERATE ACUTE MALNUTRITION, FEEDING
Look for runny nose PROBLEMS
ANAEMIA,
For how long?or is___HIV Daysexposed or infected
If more Look for signs of MEASLES:
Do you than 7 days,your
breastfeed haschild?
fever been present
Yes ___ every day?
No ___
HasIfchild Generalized rash and
yes, had
how measles
many times within thehours?
in 24 last 3 months?
___ times. Do you breastfeed during the night? Yes ___ No ___
Do aDoes the child
malaria test, iftake
NOany otherdanger
general foods or fluids?
sign in all Yes ___
cases in No ___
high malaria
If Yes,risk or food
what NO obvious
or fluids?cause of fever in low
malariaHowrisk:many times per day? ___ times. What do you use to feed the child?
If MODERATE
Test POSITIVE? ACUTE MALNUTRITION:
P. falciparum P. vivax How large are servings?
NEGATIVE?
Does the child receive his own serving? ___ Who feeds the child
for and how?
If the child has measles now or within the
During this illness, has the child's feeding changed? Yes ___Look
Look
No ___
mouth ulcers. If yes, are they deep and extensive?
last 3Ifmonths: for pus draining from the eye.
Yes, how? Look for clouding of the cornea.
Is there ear discharge? If Yes, for how long? ___ Days
b. Possible reasons
THEN CHECK FOR ACUTE MALNUTRITION for feeding
Look for problems:
oedema of both feet.
Less than -3? Between -3 and -2? -2 or morePage 60 of 75
?
WFH/L less than -3c. Feeding
Z scores advice, of
or oedema including praise
Any severe for what is Pneumonia
classification? being done correctly:
with chest indrawing?
2. BONGI is 5 months old.
Child's virological test: NEGATIVE POSITIVE
She weighs 6.8kg. She is classified as ACUTE EAR
NOT DONE
Child's serologicalINFECTION. She is GROWING
test: NEGATIVE POSITIVE NOT DONE WELL. She is breastfed on demand during the
day and
Is the child breastfeeding now? night. She started formula and porridge with milk twice a day at 3
If breastfeeding: Is the mother of
months andage, because
child on the mother felt she did not have enough milk. Sometimes
ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION
Bongi STATUS
also gets water (Circle
or tea withimmunizations needed
a cup and spoon today)
on hot days. Due to her illness Return for next
OPV-0 during
OPV-1 theOPV-2
last few daysOPV-3
she has only wanted to breastfeed. Mebendazole
________________
(Date)
a. Use
RTV-1 theRTV-2
chart to note feeding problems:
RTV-3
If Yes, how?
45
Page 60 of 75
If more than 7 days, has fever been present every day? Look for signs of MEASLES:
Has child had measles within the last 3 months? Generalized rash and
Do a malaria test, if NO general danger sign in all cases in
high malaria risk or NO obvious cause of fever in low
malaria risk:
Test POSITIVE? P. falciparum P. vivax NEGATIVE?
If the child has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
b. Possible reasons for feeding problems:
c. Feeding advice, including praise for what
is being done correctly:
3. PIET is 10 months old and weighs
Child less than7 kg. HeIs is
6 months: classified
there as problem?
a breastfeeding COUGH OR COLD,
Note mother's and/or LOW WEIGHT
child's HIV status FOR AGE (UNDERWEIGHT), and has been exposed to HIV. He
lives with his grandmother,
as his mother went to the city to look for work. He
Child's serologicaldoes not get milk
test: NEGATIVE every
POSITIVE NOT day.
DONE He has porridge three times a day, occasionally
with now?
Is the child breastfeeding yogurt for breakfast, usually plain porridge for lunch and porridge with
gravy
If breastfeeding: Is the motherforand
diner.
child onOccasionally
ARV prophylaxis? the grandmother adds meat and vegetables to the
CHECK THE CHILD'S IMMUNIZATION
soup or stew at night. STATUS His(Circle immunizations
feeding needed with
has not changed today)this illness. The only Return for next
OPV-0 OPV-1
source of family OPV-2
incomeOPV-3is the grandmother’s pension. Mebendazole
________________
(Date)
a. Use
RTV-1 theRTV-2
chart to note feeding problems:
RTV-3
If Yes, how?

Page 60 of 75
c. Feeding advice, including praise for what is being done correctly:
4. DUMISANI is 20 months old. He weighs 8 kg. He is classified as PNEUMONIA

and LOW WEIGHT FOR AGE (UNDERWEIGHT). He is exposed to HIV. He is
still breastfed a few times a day. He gets family foods three times a day. This
is usually plain porridge for breakfast and lunch, and porridge with relish or
vegetables once a day. The family has avocado, banana, and orange trees in the
garden. The family sells the fruit on the road. If they cannot sell fruit the family
consumes it. Dumisani does not have his own serving and is not actively fed.
There are 6 older siblings at home. They have a few chickens and sometimes
have eggs and meat.
46
DOESChild's
THEvirological
CHILD HAVE COUGH OR
test: NEGATIVE DIFFICULT
POSITIVE BREATHING?
NOT DONE Yes __ No __
For Child's
how long? ___ Days
serological test: NEGATIVE POSITIVE NOT Count
DONEthe breaths in one minute: ___ breaths per minute. Fast breathing?
Is the child breastfeeding now? Look and listen for stridor
Was the child breastfeeding at the time of test or 6 weeksLook and
before it?listen for wheezing
DOESIf THE
breastfeeding:
CHILDIsHAVE the mother and child on ARV prophylaxis?
DIARRHOEA?
IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD Yes __ No __
CHECK
For howTHE
long?CHILD'S
___ Days IMMUNIZATION STATUS (Circle
Look at immunizations needed
the childs general condition. today)
Is the child: Return for next
Is there blood in the
BCG stool?
DPT+HIB-1 DPT+HIB-2 Lethargic orMeasles1
DPT+HIB-3 unconscious? Restless
Measlesand
2 irritable?
Vitamin A immunization on:
Look for sunken eyes. ________________
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole
Offer the child fluid. Is the child: (Date)
RTV-1a. Use theRTV-2
chart to note feeding
RTV-3 problems:
ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, Yes __ No __
FEEDING
ANAEMIA,
Decide malariaor isHigh
risk: HIV___exposed
Low ___ or infected
No___ Look or feel for stiff neck PROBLEMS
Do you
For howbreastfeed
long? ___ your
Dayschild? Yes ___ No ___ Look for runny nose
If yes,
If more thanhow manyhas
7 days, times in 24
fever hours?
been ___ every
present times.day? Look for signs
Do you breastfeed duringofthe
MEASLES:
night? Yes ___ No ___
Doeschild
Has the child take any within
had measles other foods or3fluids?
the last months? Yes ___ No ___ Generalized rash and
If Yes,test,
whatiffood or fluids? One of these: cough, runny nose, or red eyes
Do a malaria NO general danger sign in all cases in
How many
high malaria risk ortimes per day?
NO obvious ___ times.
cause of feverWhat do you use toLook
in low feed for
theany other cause of fever.
child?
malariaIfrisk:
MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child
Test POSITIVE? receive his
P. falciparum P.own serving?
vivax ___ Who feeds the child and how?
NEGATIVE?
If the Ifchild has measles now or within the
Yes, how? Look for mouth ulcers. If yes, are they deep and extensive?
Is there ear pain? b. Possible reasons for feeding
Look for problems:
pus draining from the ear
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. Page 60 of 75
c. Feeding advice, includingSevere
praise palmar
forpallor?
whatSome palmar pallor?
is being done correctly:
5. LEFUNO
Note mother's and/or is 3 years old and weighs 12 kg. She has had diarrhoea for 3 days. She
child's HIV status
is classified
Child's virological test: NEGATIVE as NO VISIBLE
POSITIVE NOT DONE DEHYDRATION, NOT GROWING WELL and HIV
Child's serologicalINFECTION
test: NEGATIVE POSITIVE
UNLIKELY. NOTSheDONEis not breast-fed. She has milk with sugar and
porridge
Is the child breastfeeding now? for breakfast and eats some family food, but often leaves her bowl
If breastfeeding: Isuntouched. Her
the mother and child on mother says Lefuno has a poor appetite and will not eat. This
ARV prophylaxis?
CHECK THE CHILD'S
hasIMMUNIZATION STATUS
become worse (Circle
with this immunizations
illness. needed
The mother buystoday)
her chips Return for next
and sweets, asimmunization
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A on:
OPV-0 this is often
OPV-1 all she willOPV-3
OPV-2 eat. Lefuno does not like fruit or vegetables.
Mebendazole
________________
(Date)
a. Use theRTV-2
RTV-1 chart to note feeding problems:
RTV-3
If Yes, how?

Page 60 of 75
c. Feeding advice, including praise for what is being done correctly:
47
SELF-ASSESSMENT EXERCISE K
Answer questions about counselling on feeding recommendations.
1. How could you restate the following advice in simpler words? Give foods that
are high in energy and nutrient content in relation to volume.
2. The mother of an 8-month-old girl says that her child usually takes infant
formula by cup about 5 times a day and plain cereal 3 times per day. The mother
stopped breastfeeding about 1 month ago when she had to return to work, which
requires that she be away from the child for 10 hours each work day. The child
has taken the same amount of food during the illness. Which of the following
comments are appropriate when counselling this mother? (Tick appropriate
comments.)
 a. You should still be breastfeeding this child.
 b. It is good that your child is still eating as usual during the illness.
 c. It is good that you are using a cup instead of a feeding bottle.
 d. Your child needs food more often. Try to increase the number of times
you give the cereal gruel to 5 times a day.
 e. The cereal is good for your child. Add a little oil and some mashed
vegetables or peas, or bits of meat to the cereal gruel. Then it will be
even better for your child.
3. A health worker has just counselled the mother of a 5-month-old about starting
complementary foods. The first and second columns below show the health
worker’s first checking questions and the mother’s responses. In the third
column, write another checking question to make sure that the mother knows
how to feed the child correctly.
First Checking Question Mother’s Response Second Checking Question
What are some good foods to Thick foods with
give when your baby is ready? nutrition
When will you begin giving
When he is ready
these foods?
4. Greg is 10 months old and is still breastfed. He gets porridge once a day and
mashed fruit or vegetables twice a day. Greg’s mother often uses baby food jars
of fruit and vegetables for convenience. Greg eats a jar at each meal.
a. Comment on his diet.
b. How would you increase the energy density of Greg’s diet?
48
c. List alternate ways the mother could spend this money to feed the baby and
the family.
5. Fatima is 14 months old. You have classified her as having PNEUMONIA and
ANAEMIA. The mother says that he often gets chest infections.
a. Which micronutrients are important for Fatima?
b. Which foods contain these micronutrients?
6. The mother of three month old Joyce is still exclusively breastfeeding her baby,
but her mother-in-law says she does not have enough milk and must start giving
the baby porridge.
a. Why is it important to continue exclusive breastfeeding until 6 months?
b. The mother also gives Joyce water. What do you think of this?
7. Xoli is 15 months old. He still breastfeeds but also takes a variety of other foods
including rice, bits of meat, vegetables, fruit and yoghurt.
a. How many times should Xoli be given these foods?
b. How can the mother judge whether she is giving an adequate serving to
Xoli?
49
9.9 WATER, SANITATION, & HYGIENE

WHY IS WATER, SANITATION, AND HYGIENE IMPORTANT
FOR CHILD HEALTH?
Over 1.6 million children die every year from diarrhoeal diseases. About 9 out of
10 diarrhoeal disease cases is caused by unsafe water supply or poor sanitation and
hygiene. Unsafe drinking water and poor sanitation and hygiene also lead to other
infections like pneumonia or intestinal parasites that contribute to anaemia. These
diseases are very serious risks to a child’s health and development.
At the same time, there are important and inexpensive interventions that health
workers can advise families on in order to prevent childhood illness from poor
water, sanitation, and hygiene.
WHAT ARE IMPORTANT INTERVENTIONS TO PREVENT ILLNESS?

Some of the most important interventions to discuss with families include:
•• Access to safe drinking water
•• Washing hands
•• Improving sanitation in the home and community, including use of toilets
WHY IS HAND WASHING IMPORTANT?

Hand washing is a simple practice that can make a significant difference in reducing
diarrhoeal disease. Washing hands at important times can reduce the number of
diarrhoeal cases by more than one-third.
As a health worker, you have an opportunity to talk to caregivers about their own
hand washing, which is important for their own health but also the contact they
have with their children. You can also support families to teach their children how
to wash their hands and prevent illness.
WHEN IS HAND WASHING IMPORTANT?

There are important times for hand washing:
✔✔ Before preparing food
✔✔ Before eating
✔✔ Before feeding a child
✔✔ After using the toilet
✔✔ After cleaning up a child who has used the toilet
✔✔ After coughing, sneezing, or blowing your nose
✔✔ Before and after cleaning a child’s face, mouth, or nose
✔✔ After handling animals, animal waste, or garbage
WHAT ARE GOOD PRACTICES IN HAND WASHING?

There are some important messages about good practice in hand washing. They are
also demonstrated in the picture.
50
✔✔ Use soap
✔✔ Rub hands together – including between fingers and under
fingernails – for 20 seconds
✔✔ Pour water over the hands (instead of dipping hands into water,
which then contaminates that water)
WHAT ARE THE STEPS FOR HAND WASHING?

Washing your hands properly takes about as long as singing “Happy
Birthday” twice, using these steps.
51
HOW CAN YOU SUPPORT A FAMILY IN HAND WASHING?

During a well child visit with a caregiver, ASK:
✔✔ Where do you wash your hands?
✔✔ Is there soap?
✔✔ When do you wash your hands?
If necessary, help the caregiver identify how they can prepare a convenient place to
wash their hands. This should include access to water and soap.
Review when to wash hands.
Demonstrate how to wash hands, using the steps above.
Let the caregiver practice.
WHY SHOULD A FAMILY KEEP THE ENVIRONMENT CLEAN AND

SAFE?
Young babies explore their environment by taking objects to their mouth. Therefore,
we have to make sure the environment is clean and safe with no harmful objects.
It is important to discuss this with a caregiver. You can start by asking:
•• Where does the child rest and play?
•• How does your child explore the environment?
Here are some key messages for the caregiver:
•• Keep the environment clean and safe, with no harmful objects. This includes:
—— Small objects that the child might put into his/her mouth
—— Items that might be sharp, like glass or stones
—— Sources of heat, like cooking/warming fires, outlets for electricity, heaters,
or lamps
•• One idea might be to lay a blanket or mat on the floor for the child to play on.
Shake or clean this regularly to remove any harmful objects.
52
9.10 IMMUNIZATION
In this section, you will learn about the types of vaccines routinely given, and the
schedule for each. You will also learn how to check a child’s vaccination status, and
when it is necessary to provide a child with a vaccine on the same day of the visit.
You should be aware that the terms ‘immunization’ and ‘vaccination’ could be
used interchangeably. You will see both terms used in this study session.
WHY IS IMMUNIZING CHILDREN IMPORTANT?

Several diseases that affect children are vaccine-preventable. Given this,
immunization is the single most cost-effective strategy to decrease childhood
morbidity and mortality. The objective of immunization programmes is to reduce
and control the illness, death, and disability caused by vaccine-preventable diseases.
As you will remember from studying the IMCI process, ‘check immunizations’ is an
important step after you have assessed and classified main symptoms, malnutrition,
and anaemia.
WHY SHOULD YOU CHECK CHILDREN FOR IMMUNIZATIONS?

Ideally, every child must complete vaccination before celebrating his/her first
birthday. Therefore, you must assess every child at the health facility. You need to
check whether they have been vaccinated up to the appropriate schedule, and if not,
you should give any missed vaccinations on the day of the visit.
The recommended vaccine should be given when the child reaches the
appropriate age for each dose. If vaccination is administered too early,
protection may not be adequate. If there is any delay in giving the appropriate
vaccine, this will increase the risk of the child developing the disease.
WHAT DISEASES DO IMMUNIZATIONS PROTECT CHILDREN FROM?

Currently, immunization programmes deliver twelve vaccine antigens to protect
children against the following serious illnesses: tuberculosis, poliomyelitis,
diphtheria, pertussis, tetanus, Hemophilus influenzae-B (Hib) infections,
hepatitis-B, and measles. There are additional vaccinations to protect against
pneumococcal infections, rotavirus diarrhea, and Human papilloma virus (HPV)
infections.
WHAT IS THE RECOMMENDED SCHEDULE FOR IMMUNIZATIONS?

Review the table below. This shows the recommended vaccination schedule, and how
you will give the doses of each childhood vaccine. The immunization schedule
is also available in your IMCI chart booklet, at the very end of the ASSESS
and CLASSIFY charts.
Most vaccines (except BCG and measles) require administration of repeated
doses for about 3 times. For these vaccines: after the first dose, give the remaining
doses at least 4 weeks apart.
53
If you see a child who has not been immunized at the recommended age, you should
give the necessary immunizations as soon as possible.
AGE VACCINATION DOSE HOW TO GIVE
BCG 0.1 ml Upper arm of right intradermal
At birth
OPV-0 2 drops Oral
DPT1-HepB1-Hib1 0.5 ml Front outer side of the left thigh muscle
Pneumococcal 1 Deep IM to the right thigh
6 weeks
Rota 1 Oral
OPV-1 2 drops Oral
OPV-2 2 drops Oral
10 weeks
Rota 2 Oral
OPV-3 2 drops Oral
14 weeks
Rota 3 Oral
9 month MEASLES 0.5 ml Outer side of the right thigh
SPECIAL CASES FOR OPV

You should not give OPV-0 (Oral Polio Vaccine-0) to an infant who is more
than 14 days old. Therefore, if an infant has not received OPV-0 by the time s/he is
15 days old, you should wait until he is 6 weeks old to give him his first OPV (OPV-1),
therefore the child should receive OPV-1 and DPT1-HepB1-Hib1 at this encounter.
If child has diarrhoea: Children with diarrhoea who are due for OPV should still
receive a dose of OPV during this visit. However, you should not count this dose as
it may be passed through the body. You should tell the mother to return with the
child in 4 weeks’ time so that you can give the child an extra dose of OPV.
HOW WILL YOU CHECK FOR VACCINATION STATUS AND DETERMINE

WHAT NEEDS TO BE GIVEN?
You must check the vaccination status of all the children who visit your health
facility. You can use your IMCI Chart Booklet or a child health book, if available,
to locate the recommended immunization schedule.
ASK: the caregiver if she has the child health book, and if she brought it
with her today:
If the mother answers YES, ask her if she has brought the book with her today.
YES If she has brought the book with her, ask to see it.
1. Compare the child’s vaccination record (and the dates) with the recommended
schedule.
2. Decide if the child has had all vaccinations recommended for his/her age.
54
3. Identify any vaccination the child needs today. These will be any vaccines the
child should have already received but has not or if the child is due for vaccine
today.
4. Unless the child is being referred, the mother needs to be advised that the child
should receive vaccination(s) today.
5. Give the required immunizations and record the immunization and date on the
child’s book.
EXAMPLE: a 9 week old infant has not yet been vaccinated with DPT-HB-Hib1 and
OPV-1, which she should have received at 6 weeks old. You should give the child these
vaccines while she is at the clinic. On the immunization page of the child’s health book,
record the date of vaccination.
If the mother says that she does NOT have a CHILD HEALTH BOOK with her
NO
1. Ask her to tell you what vaccinations the child has received.
2. Use your judgment to decide if the mother has given a reliable report. If you have
any doubt, vaccinate the child.
3. Give the child vaccines according to the child’s age.
4. Give MOTHER the CHILD HEALTH BOOK and ask her to bring it with her each
time she brings the child to the health facility.
WHERE WILL YOU RECORD THE CHILD’S IMMUNIZATION STATUS?

To review what you read just above, after giving the correct dose of vaccines for
the child’s age, you should record the date for when each specific vaccine was
administered. This is recorded in the appropriate place in the child health book.
If the child needs to return for vaccination, write the date when they should return.
There is usually space for this on the immunization page of the health book.
SELF-ASSESSMENT EXERCISE L
Practice what you have learned about immunizations.
1. Why is it important to check the vaccination status of all children under 12
months old?
2. How would you decide if a child needs vaccination today?
55
3. What dose of OVP would you give to a 6 week old baby who did not receive OVP
at birth? What are the reasons for your answer?
So far, you have gone through the twelve recommended vaccines and their
schedule of administration. You also learned how to check immunization status
of children. Now you will learn about adverse events following immunization and
contraindications for vaccination.
WHAT IS AN ‘ADVERSE EVENT’ FOLLOWING IMMUNIZATION?

After receiving immunization a child may develop an adverse event. Adverse event
following immunization (AEFI) is an unwanted or unexpected event occurring
following administration of vaccine(s). Such an event may be caused by the vaccine(s),
or it might have occurred by chance (it would have occurred despite vaccination).
The majority of vaccines cause minor adverse events, and therefore these
should be explained to the caregivers. These minor events include low-grade
fever, or pain or redness at the injection site.
These common adverse events do not require any case from health providers.
However, if the adverse events are significant, they should be reported to the health
providers. Common adverse events also not contraindicate subsequent vaccination
(you will read more about contraindication below).
WHAT ARE COMMON ADVERSE EVENTS?

Please review some of the common adverse events below.
Vaccine(s) Common event, should not last long Uncommon, return to facility
DTP-HepB-Hib ✔✔ Swelling at injection site Extensive swelling of limb, not just
✔✔ Redness, soreness at injection site injection site
✔✔ Low-grade fever
✔✔ Crying and irritability (in infants)
✔✔ Injection site nodules are not
as common, but do not require
treatment
Oral rotavirus ✔✔ Mild fever
✔✔ Diarrhoea

HOW DO YOU MANAGE FEVER FOLLOWING VACCINATION?

If a child develops fever of over 38.5 °C following vaccination, give oral
paracetamol at a dose of 15 mg/kg/dose in 6 divided doses. This can be given for
up to 2 days if child is still with high fever.
DO NOT GIVE PARACETAMOL AT THE TIME OF VACCINATION, THIS IS NO
LONGER RECOMMENDED.
56
WHY COUNSEL CAREGIVERS ON COMMON ADVERSE EVENTS?

During the consent process, advise caregivers on what common adverse events
are to be expected, and what should be done. Common adverse events should be
expected after vaccination. If parents/caregivers are not well counseled, the events
can be upsetting.
It is important to understand these events, because they may cause a mother not
to bring the child for subsequent immunizations, or they may create fear in other
mothers and might not to bring their children for immunization.
WHAT IS A CONTRAINDICATION TO VACCINE?

A contraindication is a condition when the vaccine is not advised due to some
potential and serious adverse effects.
First, it is important to note that common illnesses are not a contraindication
to vaccination. Therefore no sick child, including the malnourished child, should
miss vaccination. A child should only miss the vaccination if there is a clear
contraindication.
There are only three situations that are contraindications to vaccination.
These are important to remember:
✔✔ Do not give BCG to a child known to have AIDS.
✔✔ Do not give DTP-HepB-Hib2 and DTP-HepB-Hib3 to a child who has had
convulsions or shock within 3 days of the last dose of the vaccine.
✔✔ Do not give DTP-HepB-Hib to a child with recurrent convulsions or another
active neurological disease of the central nervous system.
HOW WILL YOU HANDLE IMMUNIZATIONS IN A SICK CHILD?

There are two good rules to remember:
1. If a sick child is well enough to go home, there are no contraindications
to vaccination.
2. If you are referring a child, you do not need to give him a vaccine before
referral. The health care worker at the referral site should make the decision
about vaccinating the child when the child is admitted. This will avoid delaying
referral.
Remember what you learned about managing a child with diarrhoea who is due
for OPV. They receive their dose of OPV during this visit, but the dose should not
be counted. You should tell the mother to return with the child in 4 weeks for an
extra dose of OPV.
IMPORTANT TIP: Also advise the mother to get other children in family vaccinated.
57
SELF-ASSESSMENT EXERCISE M
Complete the questions about this case study of Salma.
CASE STUDY: Salma is a 4 month year old girl. She has come for immunization,
growth and development monitoring today on 20/4/2012. Her vaccination record
on the CHILD HEALTH BOOK shows that she has received BCG and OPV0 on
02/1/2012 when she was 1 day old; OPV1, DTP-HepB-Hib1, Pneumococcal 1 and
Rota 1 on 17/2/2012 and OPV2, DTP-HepB-Hib2, Pneumococcal 2 and Rota 2 on
18/3/2012. You can see this below on her immunization schedule.
Age Type of Vaccine Date Site of administration

At birth BCG 02/1/2012 Right shoulder
OPV0 02/1/2012 Oral Drops
6 weeks OPV1 17/2/2012 Oral Drops
DTP-HepB-Hib1 17/2/2012 Left Thigh
Pneumococcal 1 17/2/2012 Right Thigh
Rota 1 17/2/2012 Oral Drops
10 weeks OPV2 18/3/2012 Oral Drops
DTP-HepB-Hib2 18/3/2012 Left Thigh
Pneumococcal 2 18/3/2012 Right Thigh
Rota 2 18/3/2012 Oral Drops
14 weeks OPV3 Oral Drops
DTP-HepB-Hib3 Left Thigh
Pneumococcal 3 Right Thigh
Rota 3 Oral Drops
At 9 months Measles Vaccine Right Thigh
1. Will you give any immunizations today? Which ones?
2. What date should Salma return to the clinic next? Which immunizations will
be given?
3. What advice would you give Salma’s mother about Salma’s vaccinations?
58
SELF-ASSESSMENT EXERCISE N
Complete the questions about immunizations.
1. In the scenarios below, decide if a contraindication is present, and if you will
vaccinate today or not. If you decide that the child should not be vaccinated,
make a note giving your reasons.
IF THE CHILD: Vaccinate Do not Reasons:

today (if due) vaccinate today
a. Will be treated at home
with antibiotics
b. Has a local skin infection
c. Had convulsion
immediately after
DPT1-HepB1-Hib1,
Pneumococcal 1, Rota 1
and needs DPT2-HepB2-
Hib2, Pneumococcal 2
OPV 2 and Rota 2 today
d. Has diarrhoea
e. Older brother had
convulsion last year
f. Is VERY LOW WEIGHT
g. Is known to have AIDS
and has not received any
immunizations at all
h. Has NO PNEUMONIA:
COUGH OR COLD

2. Samuel is 6 months old boy. He has NO GENERAL DANGER SIGNS. He is

classified as having NO PNEUMONIA: COUGH OR COLD and NO ANAEMIA
AND NOT VERY LOW WEIGHT FOR his AGE. Vaccination history of Samuel: BCG,
OPV 0 received at birth; OPV 1, OPV 2, DPT-HepB-Hib1, Pneumococcal 1 and
Rota 1 given at 8 weeks. OPV 2, DPT-HepB-Hib2, Pneumococcal 2 and Rota 2
were given 6 weeks ago.
What vaccinations, if any, does Samuel need today? Give reasons for your answer.
59
9.11 ROUTINE VITAMIN A AND DEWORMING

This section focuses on two other important routine interventions: vitamin A and
deworming. Vitamin A deficiency (VAD) and worm infestation are common in
developing countries. Both have serious health effects for a growing child. Therefore,
preventive therapy should be given routinely for both.
WHAT IS VITAMIN A AND VITAMIN A DEFICIENCY?

Vitamin A helps maintain surface tissue of the eyes and respiratory, intestinal,
and urinary tracts. It also helps the immune system to resist severe infections.
Vitamin A deficiency (VAD) is a public health problem in many countries. It is
the leading cause of preventable blindness in children. It also increases the risk
of disease and death from severe infections particularly measles, diarrhea, and
pneumonia. Improving vitamin A status of children aged 6–59 months can reduce
measles mortality rates by 50%, and diarrhoea mortality rates by 33%. It can
decrease overall under-five mortality by 23%. As you can see, vitamin A is a very
important regular intervention for child health.
WHAT IS ROUTINE VITAMIN A DOSAGE?

Routine supplementation of vitamin A every 6 months is recommended for all
children aged 6–59 months. The first dose is usually given at 6 months of age and
it should be given every 6 months up to 5 years. If a child in your clinic has not
received a dose in the last 6 months, you should give one dose.
These dosages are also included in your IMCI Chart Booklet in the TREAT
charts.
VITAMIN A CAPSULES
AGE
200 000 IU 100 000 IU 50 000 IU
6 months up to 12 months 1 capsule 2 capsules
12 months up to 5 years 1 capsule 2 capsules 4 capsules
HOW WILL YOU GIVE VITAMIN A TO A CHILD?

As you see in the dosage chart, Vitamin A is given in various capsule strengths.
To give vitamin A, first cut across the nipple of the Vitamin A capsule with a clean
instrument. This could be a surgical blade, razor blade, scissors or sharp knife). If
the Vitamin A capsule does not have a nipple, pierce the capsule with a clean unused
needle. Then pour contents into the child’s mouth.
HOW WILL YOU RECORD VITAMIN A?

In the child’s health book, remember to record the date each time you give Vitamin
A to a child. This is important.
If you give repeated doses of Vitamin A in a period of less than 6 months,

there is danger of an overdose and toxicity.
60
WHY IS DEWORMING IMPORTANT?

Intestinal worms (helminthes) that are transmitted through soil are a serious
public health problem wherever the climate is tropical, and there are conditions of
inadequate sanitation and hygiene.
Worm infestations are associated with a significant loss of micronutrients in a child.
Infestations negatively affect a child’s physical fitness and appetite. This contributes
to anemia, poor growth, and malnutrition.
Three types of worms are most prevalent and have the most damaging effect on
the health of children. These are roundworms (Ascaris lumbricoides), hookworms
(Ancylostoma duodenale and Necator americanus), and whipworms (Trichuris trichiura).
WHAT DOSAGES ARE PROVIDED FOR ROUTINE DEWORMING?

All children aged 12 months or older need to be given Mebendazole or Albendazole
every 6 months to treat intestinal parasites, especially hookworm and whipworm
infections. These dosages are also included in your IMCI Chart Booklet in
the TREAT charts.
Give as a single dose every 6 months
Medicine
0–1 year 1–2 years 2–5 years
Albendazole (400 mg tablets) None ½ tablet (200 mg) 1 tablet (400 mg)
Mebendazole (500 mg tablet) None ½ tablet (250 mg) 1 tablet (500 mg)
For children under 5 years of age, it is preferable to give deworming tablets that
are chewable and taste good. For children under 3 years of age, tablet(s) should be
broken and crushed between two spoons, then water added to help give the tablet(s).
WHEN WILL YOU GIVE CHILDREN DOSES FOR DEWORMING?

Every time you attend a child aged 12 months or older, you should check whether
the child has been given a dose of Mebendazole or Albendazole in the previous 6
months. If not, give the child Mebendazole or Albendazole as indicated above.
A QUICK REVIEW OF IMMUNIZATIONS, VITAMIN A,

AND DEWORMING
These three interventions are important, time-sensitive measures that help reduce
illness and mortality in children. Let us review what you have learned.
✔✔ You will provide 12 vaccines to protect children against: tuberculosis, poliomy-
elitis, diphtheria, pertussis, tetanus, Hemophilus influenzae-B (Hib) infections,
hepatitis-B, measles, pneumococcal infections and rotavirus diarrhoea
✔✔ Most vaccines (except BCG and Measles) require repeated doses, usually 3 times.
✔✔ Ideally, every child must complete full vaccination before celebrating a first
birthday.
✔✔ You must check the vaccination status of all the children who visit your health
facility. ASK, does the child have a vaccination card? If the mother answers
NO, ask her to tell you what vaccination has the child received, and use your
61
judgment to decide if the mother has given a reliable report. If you have any
doubt, immunize the child.
✔✔ Common illnesses are not contraindications for immunization. If the sick child
is well enough to go home s/he should be vaccinated.
✔✔ Vitamin A deficiency and worm infections are common and both have serious
health effects for a growing child and therefore preventive therapy should be
given routinely for both conditions.
✔✔ Supplementation every 6 months is recommended for vitamin A (all children
aged 6–59 months) and deworming (all children 12–59 months of age). The
following tables demonstrates a schedule for both vitamin A supplementation
and deworming:
SCHEDULE FOR VITAMIN A SUPPLEMENTATION AND DEWORMING
AGE VITAMIN A DATE DEWORMING DATE
Birth
6 months Begins at 6 months of age.
1 year Begins at 1 year of age.
1 ½ years
2 years
2 ½ years
3 years
3 ½ years
4 years
4 ½ years
5 years

SELF-ASSESSMENT EXERCISE O
Answer the questions about immunizations, vitamin A, and deworming for a
well child.
1. Khadija is 3 months old. She has been brought to the clinic by her grandmother
for vaccination. Her grandmother says Khadija is well and you see that the
child looks healthy. Vaccination history: BCG, OPV 0, OPV 1, DPT-HepB-Hib1,
Pneumococcal 1 and Rota 1 were given 5 weeks ago.
a. What immunizations, if any, would you give Khadija today?
b. What advice would you give to Khadija’s grandmother and why?
62
2. Thabit is 15 months old boy. He has completed his full immunization, and had
received a dose of vitamin A at 6 months and mebendazole at 1 year of age.
a. What are you going to do for Thabit during this visit?
b. What advice will you give to Thabit’s mother? Write reasons for your answers.
3. Sabrina, 8 months, has not received vitamin A or deworming. Circle your

answers.
CIRCLE: IF FALSE, WHY?
a. She requires Vitamin A today. TRUE FALSE
b. She requires a Vitamin A dose
TRUE FALSE
(100 000 IU) of 2 capsules.
c. She requires mebendazole today. TRUE FALSE

4. Angie, 12 months, received Vitamin A six months ago. Circle your answers.
a. She requires mebendazole today. TRUE FALSE
b. She requires mebendazole dose
TRUE FALSE
(200 mg).
c. She requires Vitamin A in
TRUE FALSE
6 months.

5. Jot, 26 months, received Vitamin A four months ago. He received mebendazole

8 months ago during an outreach programme. Circle your answers.
a. He requires Vitamin A (1 capsule)
TRUE FALSE
today.
b. He does not require
TRUE FALSE
mebendazole today.
c. He requires 500 mg of
TRUE FALSE
mebendazole today.

63
9.12 PREVENTION OF CHILDHOOD ACCIDENTS

In this section, you will learn about the problems of childhood accidents. The
major causes include road accidents, burns, falls, poisoning, and drowning. Most
importantly, you will learn about how you can help prevent them as a health worker.
HOW BIG IS THE PROBLEM OF CHILDHOOD INJURIES?

Childhood injuries are a global concern. They are becoming a major health problem
in developing countries.
In 2002 WHO reported 14% of fatal injuries occur in children less than 15 years
old. The report showed 712,000 children die every year due to injury worldwide.
This accounts for 10% of the burden of disease in children.
Nearly all of these injuries (93%) are unintentional injuries (accidents).
Accidents are the leading cause of fatal injuries. Accidents include road traffic
collisions, burns, falls, drowning, and poisoning. The morbidity due to unintentional
injuries is also very high. For each death that occurs from an accident, there are
several thousand children that survive but are left with permanent disabilities.
Nearly all of the childhood unintentional injuries around the world (98%) occur
in low and middle-income countries. The hardest hit areas are Africa, South East
Asia, and Western Pacific. Together these areas account for 77% of all unintentional
injuries.
Now you will learn about some of the specific types of unintentional injuries.
HOW BIG IS THE PROBLEM OF ROAD TRAFFIC ACCIDENTS?

The leading cause of death by injury is road traffic accidents. It is
also the 10th leading cause of all deaths globally. An estimated
1.2 million people are killed in road crashes each year, and as
many as 50 million are injured.
Everyday 720 children die from road traffic injuries
worldwide. Road traffic injuries are one of the primary causes of disability in
children.
AS HEALTH WORKERS, HOW CAN WE PREVENT ROAD TRAFFIC

INJURIES?
You can counsel caregivers on several important prevention measures. You might
begin by discussing where the house is located (like if it is near a busy road), and
where the child frequently plays. You can also discuss how the child travels locally.
The caregiver’s answers will help you give the appropriate counselling.
Here are some actions to discuss with caregivers:
✔✔ Child should not play near the road; caregiver should watch where child plays
to monitor this.
✔✔ If child rides on a motorcycle or on a bicycle, they should wear helmets all the
time.
64
✔✔ If child rides in a vehicle, child must always wear a seatbelt or sit in a child safety
seat.
✔✔ Child should be under supervision; child-child caretaking should be discouraged
for children that are preschool aged.
Besides your interactions with caregivers, there are other measures that the larger
community can take in preventing accidents. You and others can be involved in
these efforts.
✔✔ Developing sidewalks away from the main traffic so people can walk safely.
✔✔ Establishing safe play grounds for children away from traffic.
✔✔ Establishing speed reduction zones particularly around residential areas, schools,
and children playgrounds.
WHAT IS THE RISK OF CHILDREN DROWNING?

In 2002 the WHO reported 40% of all drowning occur in children.
Children less than 5 years of age have the highest risk of drowning.
480 children drown everyday worldwide.
Most of the child drownings (98%) occurs in low and middle income
countries. In these countries, drowning mostly occurs in open bodies
of water. These include toilet pits, wells, ponds, streams, rivers, lakes, and oceans.
However children even have a risk for drowning in small amounts of water, like
buckets or drums used to store water.
AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION

OF DROWNING?
You can counsel caregivers on several important prevention measures. You might
begin by speaking to caregivers about any open bodies of water in their living area,
or some nearby that the child might visit. You might also speak to them about how
they store water in the home, or how activities like baths are done in the home.
Some topics to discuss with the caregivers can include:
✔✔ All hazardous water bodies in the residential areas should be removed or covered
properly. This includes toilet pits, wells, and ponds.
✔✔ Everyone in the home should follow the safety instructions on water vessels like
buckets or water drums.
✔✔ When children are around bodies of water, adults must supervise them closely.
This includes even small amounts, like the bathtub.
✔✔ If children are in water, like for swimming, they should wear personal flotation
devices at all times.
65
WHY ARE BURNS SUCH A SERIOUS PROBLEM FOR CHILDREN?

The WHO reports 260 fatal child burns occur every day
worldwide. Infants have the greatest risk of fatal child burns.
Low and middle-income countries have a death rate from burns
11 times higher than developed countries. Most non-fatal burns
(75%) are scalds from hot liquids. Burns leave many children with
disability or disfigurement for life.

OF BURNS?
Burn morbidity and mortality can be reduced if families and community are
sensitized on preventive measures. It is very important to speak with the caregiver
about these measures to be taken in the home. You can also make your counseling
more specific if you ask about practices in the house like cooking, heating, and
lighting.
Prevention measures to discuss in the community include:
✔✔ Children should never be allowed to play with fire or around fireplaces.
✔✔ Cooking areas should be raised and protected. Children should not be allowed
cooking areas. They might try to reach and grab onto surfaces or items like hot
pots. Ensure that pot handles are out of reach.
✔✔ When cooking, do not hold the infant as you are near a fire source.
✔✔ Children sitting by the fire (during cold weather or in cold areas) must be
supervised.
✔✔ Never leave children alone at home, especially at night. Never lock children
inside the house.
✔✔ Never leave candles or kerosene lamps lit while sleeping.
WHAT IS THE RISK OF INJURY BY FALLING?

Worldwide 130 children fall to their death every day. Falls
commonly occur from trees, windows, beds, or rooftops. They
can also occur during sport and play. Injury due to falls is among
the leading cause of emergency attendance at outpatient clinics.
Many children are left with permanent disability due to falls.

OF FALLS?
Several measures can be taken at the community level to reduce mortality and
morbidity due to falls.
These measures, among others, include:
✔✔ Building safety guards where children might flight and fall, like beds, stairs,
windows, and rooftops.
✔✔ Community sensitization on closely supervising children at their playgrounds.
66
WHAT IS THE RISK OF INJURY BY POISONING?

Globally, poisoning is a significant public health concern.
Children less than one year are at greatest risk of dying from
poisoning than older children. Worldwide 125 children die
from poisoning everyday.
The rate of fatal poisoning is 4 times higher in low and
middle-income countries than in high-income countries. In low and middle-income
countries, most poisoning is the result of kerosene/paraffin or household products.
Children consume these accidentally, or think they are something safe to eat or
drink.
AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION OF

POISONING?
The first point is that poisonous agents should not be kept in the home. This
advocacy should be done with caregivers and also the larger community.
In case there are products in the home that could cause poisoning, the following
measures can be used at home and at the community to reduce morbidity and
mortality:
✔✔ Never leave a poisonous agent/material unattended, even for a second!
✔✔ All medicines or poisons in the home should be packaged in child-resistant
packs/bottles.
✔✔ All medicines should be kept out of reach of children. Children should not be
asked to fetch medicines for someone else’s use. Children should not be given
medicines with instructions to give to another person in the household.
✔✔ All medicines should be packaged in small quantities so they are not lethal.
✔✔ If poisonous agents or petroleum distillates (such as kerosene) are in the house,
they should never be stored in containers, tins, or bottles that were previously
used to keep drinks or food. They should never be kept in soda or mineral water
bottles.
✔✔ Keep products in their original labeled containers.
✔✔ Use poison stickers and teach your children to recognize them.
✔✔ Be careful of what you store in your bedside table and other cupboards that are
lower than your shoulder height.
67

WHAT DO YOU KNOW NOW ABOUT WELL CHILD CARE?
Now that you have finished the module, answer the same questions you tested before
you started studying. This will help demonstrate what you have learned!
Circle the most correct answer for each question:
1. Sami is 8 months old, and his mother is not infected with HIV. What would you
recommend for his feeding?
a. Exclusive breastfeeding
b. Four meals a day of porridge and vegetables, and no breastfeeding
c. Breastfeeding as often as he will have, and three meals a day of cereals, mashed
fruits and vegetables, and sources of protein
2. What is child development?
a. Is an increase in physical size, composition and distribution of tissues
b. Is the increase in the complexity of structures and of their functions (what
a child can do)
c. Is the same as child growth
3. Interaction of mother and child involve
a. Bonding only
b. Attachment only
c. Bonding and attachment
4. What is the interval for administering Pneumococcal vaccine in children?
a. 4 weeks
b. 6 weeks
c. 8 weeks
5. At what age do we begin giving Vitamin A to children?
a. 12 months
b. 9 months
c. 6 months
6. Why is it important to deworm (giving antihelminths medicines) children?
a. Soil-transmitted helminthes (intestinal worms) is a serious worldwide health
problem
b. Worm infestations are associated with a significant loss of micronutrients
and contribute to anemia, growth failure and malnutrition
c. Worm infestation is common in young infants
7. Regarding childhood injuries:
a. Burns and falls are rare
b. Are not a significant problem in developing countries
c. Can be prevented through family and community sensitization and awareness
raising
68
69
9.14 ANSWER KEY

REVIEW QUESTIONS
Did you miss the question? Return to this section to read and
QUESTION ANSWER
practice:
1 C
2 B GROWTH AND DEVELOPMENT
3 C CAREGIVER-CHILD INTERACTION
4 A IMMUNIZATION
5 C VITAMIN A SUPPLEMENTATION
6 B DEWORMING
7 C CHILDHOOD ACCIDENTS
EXERCISE A (DESCRIBING ACTIVITY)

Which skill type?
M C S A
1. Child sees ball rolling and tries to take and hold it X
2. Child cries and reaches for the ball when it rolls away X
3. Child examines ball’s shape and size X
4. Child smiles at mother when she begins speaking to him about the ball X
EXERCISE B (MEASURING LENGTH AND HEIGHT)

✔✔ 1. Every month
✔✔ 2. Every 3 months
✔✔ 3. Weight, length and heightboards
EXERCISE C (GROWTH AND DEVELOPMENT)

1. Answers below:
Growth/development is:
If the child:
Normal Not normal
a. Edward is 6 months. He does not have neck control ✔
b. Maria, girl, 24 months. She weighs 13 kg, height is 85 cm ✔
c. Asha is 30 months old. She says few words with meaning.
✔
She can hop on one foot and can walk backwards.
d. Hamisi, 17 months, is only able to walk with support. ✔
e. Amiri is 4 years old. He is not able to say a single word ✔
f. Alice can dress herself and is toilet trained. She is 4½ years. ✔
g. Kemilembe is 3 years old. She is not able to tell a short
✔
story. She does not know her sex.
h. Alex is 4 years, 10 months. He weighs 22 kg, and his height
✔
is 113 cm. He has started kindergarten/nursery school.
70
2. In Jandika’s case, you should go back to your growth monitoring charts on boy’s CHILD HEALTH.
First you assess Jandika on weight for length, which lies between 0 and -1 Z score, this is
normal. However, when you assess Jandika on length for age, he falls below -3 Z score which is
severe stunting. You should refer Jandika to hospital for further assessment regarding stunting.
This is a non-urgent referral but advice Jandika’s mother not to delay going to hospital. This is
important so as to identify risk factors and reasons for stunting inorder to treat and prevent it.
EXERCISE D (BONDING AND ATTACHMENT)

1. Bonding is a mother-to-child connection. Bonding is the process of a mother forming a
relationship with her new infant. It begins during the first few hours after birth. Bonding is a
process that happens very quickly after birth. It is important to remember that bonding occurs
early in the child’s life, and can have a lasting impact on his or her development. Therefore,
some actions might affect the bonding between a mother and child. These situations can
include, for example:
✔✔ Mother is separated from infant for a long period after birth, sometimes many days or
even weeks
✔✔ Mother has poor health
✔✔ Mother is depressed after delivery, which happens to many women. This depression often
goes undetected and many mothers do not seek help.
✔✔ The mother or someone else is abusing or neglecting the child
✔✔ The infant is a low weight baby and therefore need even more attention and care
✔✔ The infant is ill
2. Attaching is primarily a process of the infant forming a relationship with his or her mother or
the primary caregiver, and reinforced by the responses. It occurs during the first two years of
life, but especially between 2 and 7 months of age. During attachment, the child develops
a personal communication system with the primary caregiver. The connection is child-to-
caregiver. Poor attachment between a child and caregiver can have very serious impact on a
child’s development. Some of the known complications of poor attachment include:
✔✔ Child might have difficulty trusting others in their life
✔✔ Child can experience increasing depression or rage
✔✔ Child fails to thrive: Physically and emotionally healthy, curious about the world around
them, active and happy.
✔✔ In situations of neglect, e.g. no primary caregiver or if there is poor institutional care
a child attaches to things, environment, routines, etc. As a result, child has difficulty
adapting to change.
✔✔ As child grows older, he or she will have more behavioral problems and worse peer
relations compared to their peers. They may also have poor problem-solving abilities, and
low self-esteem.
3. Answers below:
A mother, Sara, takes the following actions with her son John: S R
a. Sara hears John crying X
b. Sara picks up John to soothe his crying X
c. Sara is giving John a bath and notices a rash on his leg X
d. Sara sees John watching the tree’s branches blowing in the wind X
e. Sara asks John, “Do you see the wind blowing? The leaves are blowing!” X
f. Sara notices that John is not feeding as much as usual X
g. Sara offers John a food he likes to see if he will eat X
71
4. You need to explain to Sara (and give her tips for speaking to her grandmother) the benefits
of bonding and attachment during childhood, and the positive impacts this has on the child’s
growth and development of skills. It is helpful to provide very clear examples of each concept
that she can share with her grandmother.
EXERCISE E (CAREGIVER UNDERSTANDING)

1. Answers could vary, some examples:
•• How will you work with your husband at home to improve his skills with the child?
•• What skills can your husband improve upon? How will you suggest that he improve the
way he interacts with the child to improve the child’s development?
2. Answers could vary:
•• What activities can you do with your child to play?
•• What are important things to keep in mind when communicating with your child?
EXERCISE F (CHILD DEVELOPMENT CONCEPTS)

PLAY? COMMUNICATION?
1. Jyothi, 2 months • Allow child to see, hear, feel, move • Smile and laugh with child
freely, and touch you • Talk to child
• Move colourful things for your child • Copy child’s gestures or
to see and reach for. sounds, like mimicking a
• Make toys like a shaker rattle or a conversation
big ring on a string.
2. Linus, 11 months • Hide a child’s toy and see if they can • Tell child the names of things
find it and people
• Play peek-a-boo • Teach gestures like waving
• Make toys like a doll with a face ‘bye bye’
3. Julie, 7 months • Give child household items to • Respond to child’s sounds
handle and bang, make sure they and interests (e.g. if they look
are clean and safe at something or repond)
• Give toys like containers with lids, • Call name and see if child
metal pot and spoon responds
4. Nathan, 4 days • Allow child to see, hear, feel, move • Look into baby’s eyes
arms and legs freely, and touch you • Talk to baby
• Skin to skin contact is very good These activities are good during
• Gently soothe and stroke child breastfeeding.
• Hold your child
5. Frank, 17 months • Give child things to stack up or put • Ask child simple questions
into containers • Respond to child’s attempts
• Give household objects like to talk
containers and small items • Show child things around
them (nature, pictures,
people) and talk to them
72
EXERCISE G (CHILD DEVELOPMENT CONCEPTS)

1. Answers will vary, but should be in simple terms with clear Child development is the skills
that a child gains as they grow, like the abilities to move, communicate, solve problems, and
interact socially and with emotion. To develop well, children need good physical and mental
health, nutrition, opportunities to explore and learn about the world, and be supported in a
safe and nurturing environment.
2. Answers will vary, but should stress how development has strong impacts on a child’s
long-term health and abilities. Child development has strong effects on a child’s physical
development, interactions and connections to caregivers, and abilities to develop skills for
solving problems, learning, interacting with others, communicating, etc.
3. Answers will vary, but should outline the play and communication activities for his age group.
It should tailor the discussion to toys and products they have in their home.
4. Answers will vary, but should emphasize that child development begins at birth, and even
in the earliest hours of a child’s life he is making connections with others around him, and
his environment. Play and communication with a child is absolutely critical for development.
You can demonstrate with Beta how Rakim is communicating and playing now (e.g. following
voices, pointing, reaching).
EXERCISE H (MILESTONES)
1. Undresses him/herself, can tower 6 cubes
2. Basic (one or two syllable) words like ‘mama’ or ‘dada’, begins to mimic other words
3. Dress/undress fully except buttons, can count to 10
EXERCISE I (USING CHARTS)

1. This question was asking you to decide how you going to advice Mariamu regarding Manka.
You should remember the normal developmental milestone for an infant. An infant aged 5–7
months is able to sit without support. Since Manka is only 5 months old which is the lower age
limit of the normal for sitting without support, you should advice Mariamu that this is normal,
and that Manka will be able to sit without support in a few months’ time. You should tell
Mariamu that she needs to continue attending clinic for growth and development monitoring
of her child, and for other interventions.
2. This question was asking on the advice you would give Ikupa’s grandmother, and to give
reasons for your answers. You should remember normal developmental milestone for children.
Ikupa can only walk with support and say 4–20 words with meaning even though she is 3
years old. This milestone is for children between 8–11 months old. Therefore Ikupa has delayed
milestone development. At her age, Ikupa was supposed to be able to run backwards and
forwards with confidence and hop on one foot. You should refer Ikupa for further assessment
on why she has delayed milestone development. This is a non-urgent referral but advice
the grandmother that it is important to go to hospital within few days so as to manage the
problem inorder to optimizing growth and development.
73
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULTChild BREATHING?
less than 6 months: Is there a breastfeeding problem? Yes __ No __
For howFOR
CHECK long?HIV___ Days
INFECTION Count the breaths in one minute: ___ breaths per minute. Fast breathing?
Note mother's and/or child's HIV status Look for chest indrawing
Mother's HIV test: NEGATIVE Look and listen for stridor
POSITIVELEARNING
NOT DONE/KNOWN
IMCI DISTANCE COURSE | MODULE 9. CARE OF THE WELL CHILD
DOESChild's
THE serological
CHILD HAVE DIARRHOEA?
test: NEGATIVE POSITIVE NOT DONE Yes __ No __
For how long?
If mother ___ Daysand NO positive virological test in child:
is HIV-positive Look at the childs general condition. Is the child:
Is there
Is theblood
childinbreastfeeding
the stool? now? Lethargic or unconscious? Restless and irritable?
Was the child breastfeeding at the time of test or 6 weeksLook beforeforit?
sunken eyes.
EXERCISE J (FEEDING ASSESSMENT)
If breastfeeding: Is the mother and child on ARV prophylaxis? Offer the child fluid. Is the child:
CHECK THE CHILD'S IMMUNIZATION STATUS Not able
(Circle to drink or drinking
immunizations poorly?today)
needed Drinking eagerly, thirsty? Return for next
1. THULI Pinch the skin of the abdomen. Does it go back:
Very slowly (longer then 2 seconds)? Slowly? ________________
OPV-0 a.
OPV-1 Possibly correct
OPV-2preparation of
OPV-3
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)the feeds Mebendazole
Yes(Date)
__ No __
b. Feeding Problems:
RTV-1 RTV-2 RTV-3
Look for runny nose
If more than 7 days, has fever been present every day?
ASSESS
Has childFEEDING
had measlesifwithinthe child
the lastis3 months?
less then 2 years old, Generalized rash and
has MODERATE ACUTE MALNUTRITION, FEEDING
One of these: cough, runny nose, or red eyes PROBLEMS
ANAEMIA,
Do or is
a malaria test, if NOHIV exposed
general dangeror signinfected
in all cases in
highDomalaria risk or NOyour
you breastfeed obvious cause
child? Yes of
___ X
fever in low
No ___ Not breastfed
malariaIfrisk:
yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___
TestDoes
POSITIVE?
the childP.takefalciparum
any otherP.foods
vivaxor fluids? X
NEGATIVE?
Yes ___ No ___ Not enough feeds
Yes, what food or fluids? Formula feeding per day
If the Ifchild has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
How many times per day? ___ 3 times. What do you use toLook feed for
thepuschild? A bottle
draining from the eye.
last 3Ifmonths:
MODERATE ACUTE MALNUTRITION: How large are servings? Fed by bottle, not cup
DOES THE CHILD HAVE AN EAR PROBLEM?
Early
Yesintroduction
__ No __
Is there earhow?
If Yes, pain? Look for pus draining from the ear of semi-solids
AND ANAEMIA c. Possible reasons for feeding problems: Determine WFH/L z-score:____
•• Lack of appropriate information For children 6 months or older measure MUAC ____ mm.
•• Common belief that early introduction Look for palmarof semisolids is essential
pallor.
Severe palmar pallor? Some palmar pallor? Page 60 of 75
•• Mother returned to work Is there any medical complication: General danger sign?
If child has MUAC less than 115 mm or
WFH/L less than d. -3 Feeding
Z scoresadvice:
or oedema of Any severe classification? Pneumonia with chest indrawing?
•• Try to reintroduce exclusive breastfeedingNot able to finish? andAble
findtosolutions
finish? for this
•• Increase the number of feeds Child less than 6 months: Is there a breastfeeding problem?
•• Replace porridge feed with formula
Mother's HIV test: •• Ensure that POSITIVE
NEGATIVE the preparation of formula is correct
NOT DONE/KNOWN
Child's virological test: NEGATIVE
•• Change from POSITIVE NOT DONE
bottle to cup
If mother is HIV-positive••andFollow-up
NO positivein 5 days test in child:
virological
Was the child BONGI at the time of test or 6 weeks before it?
2. breastfeeding
a. Possibly
CHECK THE CHILD'S correct preparation
IMMUNIZATION STATUS of the feeds
(Circle immunizations needed today) Return for next
BCG •• Bongi is DPT+HIB-2
DPT+HIB-1 breastfed as often as she wants,Measles1
DPT+HIB-3 day and night Measles
as recommended.
2 Vitamin A immunization on:
________________
OPV-0 OPV-1•• Bongi is OPV-2
given other fluids or foods with a spoon and cup which.
OPV-3 Mebendazole
(Date)
RTV-1 RTV-2 RTV-3
X
Do you breastfeed your child? Yes ___ No ___ Not only breastfed
X
Does the child take any other foods or fluids? Yes ___ No ___ Early introduction
If Yes, what food or fluids? Formula and porridge with milk of semi-solids and
How many times per day? ___ 2 times. What do you use to feed the child? other fluids
X
If Yes, how? Only breastfeeding
c. Possible reasons for feeding problems:

•• Lack of appropriate information
•• Common belief that early introduction of semisolids and other fluids are essential
Page 60 of 75
d. Feeding advice:
•• Congratulate mother for using a cup and spoon and not a bottle
•• Breastfeed more frequently and for longer at each feed, day and night
•• Ensure that Bongi is fed at least 8 times in 24 hours
•• Possibly suggest to reduce other milk and fluids gradually until 6 months old
•• Tea is not recommended for smaller children
74
VOMITS EVERYTHING CONVULSING
Child less than 6 NOW
months: Is there a breastfeeding problem? Yes ___ No ___
CONVULSIONS
CHECK FOR HIV INFECTION Remember to use
Note mother's and/or child's HIV status Danger sign when
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN selecting
Child's virological test: NEGATIVE POSITIVE NOT DONE classifications
DOESChild's
THEserological
CHILD HAVE test: NEGATIVE
COUGH POSITIVE
IMCI DISTANCE
OR NOT DONE
LEARNING
DIFFICULT COURSE | MODULE 9. CARE OF THE WELL CHILD
BREATHING? Yes __ No __
CHECK THECHILD
DOES THE CHILD'S
3. PIET IMMUNIZATION
HAVE DIARRHOEA?STATUS (Circle immunizations needed today) Return for next
Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child: ________________
OPV-0 a. stool?
OPV-1
Is there blood in the Giving milk,OPV-2
yogurt, meat and vegetables
OPV-3 Lethargic orare good practice
unconscious? Mebendazole
Restless and irritable? (Date)
Hep B0 Hep B1 Hep B2 Look for sunken eyes.
Hep B3
RTV-1 RTV-2 Offer the child fluid. Is the child:
RTV-3
Pneumo-1 Pneumo-2 Not able to drink or drinking poorly? Drinking eagerly, thirsty?
Pneumo-3
ASSESS FEEDING if the child is less then 2 years old, Veryhas
slowlyMODERATE ACUTE MALNUTRITION,
(longer then 2 seconds)? Slowly? FEEDING
Do you
Decide breastfeed
malaria your___
risk: High child?
LowYes
______ XNo ___
No___ Look or feel for stiff neck Not breastfed
If yes, how many times in 24 hours? ___ times. Do you breastfeed duringnose
Look for runny the night? Yes ___ No ___ Not getting milk
X
If more than 7 days, has fever been present every day? Look for signs of MEASLES: Not getting 6
If Yes, what food or fluids? Porridge Generalized rash and nutritious meals
Has child had measles within the 3 last 3 months?
How many times per day? ___ times. What do you use to feed theof
One child?
these: cough, runny nose, or red eyes
Do a malaria test, if NO general danger sign in all cases
If MODERATE ACUTE MALNUTRITION: How large are servings? in per day
Look for any other cause of fever. Not enough food
high malaria risk or NO obvious cause of fever in low
malaria risk: available in the
During
Test POSITIVE? P. falciparum P. vivax NEGATIVE?
X
this illness, has the child's feeding changed? Yes ___ No ___
house
If Yes, how?
If the child
ASSESS has measles
OTHER now or within the
PROBLEMS: AskLook
aboutfor mouth ulcers.
mother's own health If yes, are they deep and extensive?
last 3 months: c. Possible reasons for feeding problems:
•• There
DOES THE CHILD HAVE AN is inadequate
EAR PROBLEM?food available in the house Yes __ No __
Is there ear pain? •• Lack of appropriate information Look for
re:pus draining
Piet’s from the
dietary ear how to meet these needs and
needs,
Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear Page 60 of 75
how to obtain local supportLook for oedema of both feet.
AND ANAEMIA d. Feeding advice: Determine WFH/L z-score:____
•• Piet needs 3 servings of nutritious For children 6 months or olderfoods
complementary measure MUAC
per day.____ mm.
(6 servings if he does
not get 3 cups of full cream milk per day)
If child has MUAC less •• Piet
than needs
115 mmfoodor
from all 6 food
Is theregroups.
any medical complication: General danger sign?
WFH/L less than -3 •Z• scores Give the oedema of local Any
orgrandmother severefor
recipes classification?
enriched (energy Pneumonia
dense)with chest indrawing?
porridge e.g. always mix
fat, oil, peanut butter etc with porridge
•• Each day he must have some Childprotein
less thane.g. eggs, Is
6 months: beans,
there alocally available
breastfeeding protein etc
problem?
•• Each day he must have mashed fruit and vegetables
Mother's HIV test:
•• Advise the grandmother
NEGATIVE POSITIVE
on how to go about obtaining local food support, including
NOT DONE/KNOWN
Child's virological test: government schemes or
NEGATIVE POSITIVE local
NOT organizations
DONE
•• If the clinic has a vegetable garden, give her vegetables from it. Teach her how to plant
Is the child breastfeedinghernow?
own Food Garden or put her in contact with someone who can
Was the child breastfeeding at the time
•• Follow-up in 5ofdays
test or 6 weeks before it?
4. DUMISANI Return for next
________________
OPV-0 a. Still breastfed
OPV-1 and receivesOPV-3
OPV-2 family foods Mebendazole
(Date)
RTV-1 RTV-2 RTV-3
Do you breastfeed your child? Yes ___ No ___ X Breastfeeds
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ infrequently
X
If Yes, what food or fluids? Porridge Only three meals per
How many times per day? ___ 3 times. What do you use to feed the child? day – inadequate
Does the child receive his own serving? ___ Who feeds the child and how? Not actively fed with
During this illness, has the child's feeding changed? Yes ___ No ___ X own serving
If Yes, how?
c. Possible reasons for feeding problems:

•• Family is struggling financially
•• Mother too busy to feed and breastfeed Dumisani more frequently as there are at least 7
Page 60 of 75
children at home
d. Feeding advice:
•• Breastfeed as often as Dumisani wants
•• Give at least 5 adequate nutritious meals per day of increased variety and quantity
•• Mix fat, oil, peanut butter etc. with porridge
•• Give fruit (from garden) and vegetables at least twice every day
75
IMCI DISTANCE LEARNING COURSE | MODULE
Severe palmar 9. CARE
pallor? Some OFpallor?
palmar THE WELL CHILD
•• Give some protein to Dumisani every
Child less thanday: e.g. eggs
6 months: from
Is there their chickens,
a breastfeeding locally available
problem?
protein etc
Mother's HIV test:
•• Feed actively with ownNOT
NEGATIVE POSITIVE
serving
DONE/KNOWN
•• Encourage
Child's virological test: NEGATIVE feeding
POSITIVEduringNOTillness.
DONE Suggest an extra meal a day for a week after getting
better
•• Follow-up
Is the child breastfeeding now? in 5 days
Was the child breastfeeding at the time
•• Encourage of testplanning
family or 6 weeks before it?
5. LEFUNO Return for next
________________
OPV-0 Given family food,
OPV-1 given milk
OPV-2 OPV-3 Mebendazole
(Date)
a. Feeding Problems:
RTV-1 RTV-2 RTV-3
X
Do you breastfeed your child? Yes ___ No ___ Given non-nutritious
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ foods
X
If Yes, what food or fluids? Milk with sugar and porridge Poor appetite
If MODERATE ACUTE MALNUTRITION: How large are servings? Dislikes fruit and
Does the child receive his own serving? ___ Who feeds the child and how? vegetables
X
If Yes, how? Reduced appetite

•• Lack of appropriate information regarding the nutritional needs of a 3 year old child
•• Poor appetite (and possibly diarrhoea) due to eating too many sweet things and non-
Page 60 of 75
nutritious foods
•• Bad eating habits
•• Manipulation by Lefuno as she knows that she will get sweet things etc. if she does not
eat her food
•• Not fed actively
c. Feeding advice:
•• Avoid sweet foods and drinks (this will help to stop the diarrhoea)
•• Stop giving Lefuno sweets and chips as well as adding sugar to her milk etc. Only put 1
teaspoon of sugar (if you must) on her porridge and in her tea etc
•• Educate the rest of the family and friends that they are NOT to give Lefuno sweets etc.
as this is making her ill and causing her not to grow well. They must rather give her fresh
fruit or vegetables, but first consult with her caregiver in this regard
•• Educate that Lefuno is not to get “samples” of food or a drink (even water) before a meal
as it will decrease her appetite
•• Give Lefuno her own servings of family foods three times a day and feed her actively at
the time when the family eats (if feasible). Educate the family regarding correct eating
habits so that they are good examples for Lefuno to follow as children learn by imitating
what the family does
•• In addition, Lefuno is to be given 2 nutritious snacks such as bread with peanut butter,
full cream milk or fresh fruit between meals
•• Continue to feed Lefuno actively
•• Follow-up in 5 days
76
EXERCISE K (FEEDING RECOMMENDATIONS)

1. ANSWERS WILL VARY: Give foods that are filled with energy and nutrients, some examples
are….
2. The mother of an 8-month-old girl
X b. It is good that your child is still eating as usual during the illness.
X c. It is good that you are using a cup instead of a feeding bottle.
X e. The cereal is good for your child. Add a little oil and some mashed vegetables or peas,
or bits of meat to the cereal gruel. Then it will be even better for your child.
3. ANSWERS WILL VARY:
First Checking Question Mother’s Response Second Checking Question

What are some good foods to Thick foods with Which of these foods are in your
give when your baby is ready? nutrition home?
When will you begin giving When will you know that he is
When he is ready
these foods? ready?
4. Greg
•• Greg should receive 4–5 servings of nutritious food per day.
•• Add margarine, fat, oil, peanut butter or groundnuts to the porridge.
•• She could buy eggs, fresh fruit and vegetables, peanut butter, etc.
5. Fatima
•• Iron and Vitamin A.
•• Iron: Liver, kidney, meat chicken, fish, legumes. Dark green leafy vegetables if eaten
together with food rich in vitamin C (e.g. pumpkin, if not overcooked). Vitamin A:
Vegetable oil, liver, mangoes, pawpaw, sweet potato, dark green leafy vegetables and
legumes.
6. Joyce
•• Breastmilk is the perfect food for infants: nutrients and micronutrients are well absorbed.
Breastmilk prevents infections.
•• There is no need to give water as the breastmilk provides all the fluids that the infant
needs.
7. Xoli
•• Xoli should be given these feeds 5 times a day.
•• An ‘adequate serving’ means that Xoli does not want any more food after active feeding.
EXERCISE L (IMMUNIZATIONS)
1. Vaccination is the most effective strategy to decreasing childhood morbidity and mortality; it
can reduce and control illness, disability or death caused by vaccine preventable diseases.
2. You are now going to look in more detail what you should do step by step. To decide if the
child needs vaccination today, look at the child’s age on the clinical record. If you do not have
the child’s age on the clinical record, ask about the child’s age.
3. You would give OVP1. OVP-0 should not be given to an infant who is more than 14 days old.
You would also give the 6 weeks old infant her DPT1-HepB1-Hib1 vaccination.
77
EXERCISE M (IMMUNIZATIONS)
1. Yes, 4 are required: OPV3, DTP-HepB-Hib3, Pneumococcal 3, and Rota 3.
2. At 9 months for measles, or before if the child has any issues with health or feeding.
3. There are several things you could talk to the mother about, for example the correct age to
bring Salma for vaccination (i.e. at 9 months), and that she should bring the child’s health book
with her each time she comes to the health facility. You would also need to tell the mother that
she must return for her child to receive Measles vaccine when Salma reaches 9 months old,
which will be on 01/9/2012. You should also tell her that it is important that all children in the
family are vaccinated. Lastly, explain the potential side effects of the vaccines.
EXERCISE N (CONTRAINDICATIONS)
1. Answers in the table below:
IF THE CHILD: Immunize this child today Do not immunize today

a. Will be treated at home
X
with antibiotics
b. Has a local skin infection X
c. Had convulsion Give OPV 2 but----> Do not give DPT2-HepB2-
immediately after Hib2
DPT1-HepB1-Hib1,
Pneumococcal 1, Rota 1
and needs DPT2-HepB2-
Hib2, Pneumococcal 2
OPV 2 and Rota 2 today
d. Has diarrhoea Give dose of OPV during,
but the dose should not be
counted. You should tell the
mother to return with the child
in 4 weeks for an extra dose of
OPV
e. Older brother had
X
convulsion last year
f. Is VERY LOW WEIGHT X
g. Is known to have AIDS Give OPV, DPT-HepB- Do not give BCG
and has not received any Hib,Pneumococcal, Rota &
immunizations at all measles but --->
h. Has NO PNEUMONIA:
X
COUGH OR COLD
3. This question was asking you to decide whether Samuel needed any immediate
immunizations or not, and to give reasons for your answers. From the information on the
recording form you can see that Samuel’s vaccinations are not up-to-date. This means that he
needs DPT-HepB-Hib3, Pneumococcal 3, Rota 3 and OPV 3 today. You should advise the mother
that it is important that she ensures Samuel is brought for his future vaccinations at the right
age. You should tell her that he needs to return to the health facility at 9 months of age for his
measles vaccination.
78
EXERCISE O (VITAMIN A AND DEWORMING)

1. Khadija case:
a. What immunizations, if any, would you give Khadija today? This question was asking you
to decide whether Khadija needed any immediate immunizations or not, and to give
reasons for your answers. You should also have identified that her vaccinations are not
up-to-date. This means that she needs OPV 2, DPT-HepB-Hib2, Pneumococcal 2 and Rota 2
today. However, do not record OPV 2 since today she has diarrhea, but the OPV 2 needs to be
repeated during the next vaccination visit.
b. What advice would you give to Khadija’s grandmother and why? You should advise
the grandmother that it is important that she ensures Khadija is brought for her future
vaccinations at the right age. You should tell her that she needs to return to the health
facility after 4 weeks (at 4 months of age) to receive DPT-HepB-Hib3, Pneumococcal 3, Rota 3
and repeat OPV 2 immunizations.
2. Thabit case:
a. What are you going to do for Thabit during this visit? In Thabit’s case, you should have
identified that he has completed his vaccination schedule and does not need additional
vaccines. However, he received a dose of vitamin A at 6 months and Mebendazole 1 year
of age. You should give appropriate dose of Vitamin A because Thabit was supposed to
receive the dose at 1 year together with mebendazole. Thabit does not need a dose of
mebendazole today because he received the dose at 1 year (i.e. at 12 months of age). The
interval for mebendazole is 6 months apart, of which Thabit has not fullfilled today because
he got mebendazole only 3 months ago.
b. What advice will you give to Thabit’s mother? You should advise the mother that it is
important that she ensures Thabit is brought for his next doses of Vitamin A after 6 months
and Mebendazole after 3 months. You should tell her that she needs to return to the health
facility for Thabit to get these treatments till he is 5 years old. Remind the mother that the
interval between specific doses is 6 months.
3. Sabrina, 8 months, has not received vitamin A or deworming. Circle your answers.
a. TRUE
b. FALSE: that is dose for child 12 months to 5 years. She needs 1 capsule of 100 000 IU.
c. FALSE: deworming starts only after the child is 12 months
4. Angie, 12 months, received Vitamin A six months ago. Circle your answers.
a. TRUE
b. TRUE
c. FALSE: it has been 6 months, so she requires another supplementation today
5. Jot, 26 months, received Vitamin A four months ago. He received mebendazole 8 months ago
during an outreach programme. Circle your answers.
a. FALSE: received last supplementation less than 6 months ago. Providing another dose
within 6 months is dangerous.
b. FALSE: it has been more than 6 months, so he requires today
c. TRUE
79
ISBN 978 92 4 150682 3
Integrated Management of Childhood Illness
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD
CHECK FOR GENERAL DANGER SIGNS 1 Does the child have an ear problem? 5 THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A, 9
THEN CHECK FOR ACUTE MALNUTRITION 6 DEWORMING STATUS, and ORAL HEALTH
THEN ASK ABOUT MAIN SYMPTOMS: 2
THEN CHECK FOR ANEMIA 7 ASSESS OTHER PROBLEMS: 9
Does the child have diarrhea? 3
THEN CHECK FOR HIV INFECTION 8 HIV TESTING AND INTERPRETING RESULTS 10
Does the child have fever? 4
WHO PEDIATRIC STAGING FOR HIV INFECTION 11
TREAT THE CHILD
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME 12 Clear the Ear by Dry Wicking and Give Eardrops* 15 PLAN B: TREAT SOME DEHYDRATION WITH ORS 19
Give an Appropriate Oral Antibiotic 12 Treat for Mouth Ulcers with Gentian Violet ﴾GV﴿ 15 PLAN C: TREAT SEVERE DEHYDRATION QUICKLY 20
Give Inhaled Salbutamol for Wheezing 13 Treat Thrush with Nystatin Oral Suspension 15 GIVE READYTOUSE THERAPEUTIC FOOD 21
Give Oral Antimalarial for P. falciparum MALARIA 13 GIVE VITAMIN A AND MEBENDAZOLE or ALBENDAZOLE IN THE 16 Give ReadytoUse Therapeutic Food for SEVERE ACUTE 21
HEALTH CENTER MALNUTRITION
Treatment Schedule for confirmed P. vivax or P. OVALE Cases 13
Give Vitamin A Supplementation and Treatment 16 TREAT THE HIV INFECTED CHILD 22
Treatment Schedule for Plasmodium malariae Malaria 14
Give Mebendazole or Albendazole 16 Steps when Initiating ART in Children 22
Treatment Schedule for mixed P. falciparum and P. vivax infection 14
GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY 17 Preferred and Alternative ARV Regimens 23
Give Paracetamol for High Fever ﴾> 38.5°C﴿ or Ear Pain 14
Give Intramuscular Antibiotics 17 Give Antiretroviral Drugs ﴾Fixed Dose Combinations﴿ 23
Give Iron* 14
Give Diazepam to Stop Convulsions 17 Give Antiretroviral Drugs 24
Give Micronutrient Powder 14
Give Artesunate Suppositories or Oral Quinine for Severe Malaria 18 Side Effects ARV Drugs 25
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME 15
Treat the Child to Prevent Low Blood Sugar 18 Manage Side Effects of ARV Drugs 26
Soothe the Throat, Relieve the Cough with a Safe Remedy 15
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING 19 Give Pain Relief to HIV Infected Child 27
Treat Eye Infection with Tetracycline Eye Ointment 15
PLAN A: TREAT DIARRHEA AT HOME 19 IMMUNIZE EVERY SICK CHILD AS NEEDED 27
FOLLOWUP
GIVE FOLLOWUP CARE FOR ACUTE CONDITIONS 28 FEVER: NO MALARIA 29 MODERATE ACUTE MALNUTRITION 30
PNEUMONIA 28 MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR 29 GIVE FOLLOWUP CARE FOR HIV EXPOSED AND INFECTED 31
MOUTH ULCERS, OR THRUSH CHILD
PERSISTENT DIARRHEA 28
EAR INFECTION 29 HIV EXPOSED 31
DYSENTERY 28
FEEDING PROBLEM 29 CONFIRMED HIV INFECTION NOT ON ART 31
MALARIA 29
ANEMIA 29 CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF 32
UNCOMPLICATED SEVERE ACUTE MALNUTRITION 30 FOLLOWUP CARE
COUNSEL THE MOTHER
FEEDING COUNSELLING 33 Recommendation for Feeding and Care for Development 36 EXTRA FLUIDS AND MOTHER'S HEALTH 39
Assess Child's Appetite 33 Feeding Recommendations for HIV EXPOSED Child on Infant Formula 37 Advise the Mother to Increase Fluid During Illness 39
Only Counsel the Mother about her Own Health 39
Assess Child's Feeding 34
Stopping Breastfeeding 38 WHEN TO RETURN 40
Feeding Recommendations During Sickness and Health 35
Feeding Recommendations For a Child Who Has PERSISTENT 38
DIARRHEA
Recording Form: Recording form 61
Recording Form: ART initiation steps 63
Recording Form: HIV on ART followup steps 65
PH Version, January 2015
↺
SICK YOUNG INFANT AGE UP TO 2 MONTHS
ASSESS AND CLASSIFY THE SICK
THEN CHECK FOR HIV INFECTION 44 THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND 47
YOUNG INFANT THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR 45 VITAMIN A STATUS:
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL 42 AGE ASSESS OTHER PROBLEMS 47
INFECTION THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR 46 ASSESS THE MOTHER’S HEALTH NEEDS 47
CHECK FOR JAUNDICE 43 AGE IN NONBREASTFED INFANTS
THEN ASK: Does the young infant have diarrhea*? 43
TREAT AND COUNSEL
TREAT THE YOUNG INFANT 48 TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME 49 TEACH CORRECT POSITIONING AND ATTACHMENT FOR 51
To Treat Diarrhea, See TREAT THE CHILD Chart. 49 BREASTFEEDING
GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS 48
Immunize Every Sick Young Infant, as Needed 50 TEACH THE MOTHER HOW TO EXPRESS BREAST MILK 51
TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR 48
GIVE ARV FOR PMTCT PROPHYLAXIS 50 TEACH THE MOTHER HOW TO FEED BY A CUP 51
TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM 49
ON THE WAY TO THE HOSPITAL COUNSEL THE MOTHER 51 TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT 51
WARM AT HOME
GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL 49
BACTERIAL INFECTION ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG 52
INFANT
FOLLOWUP
GIVE FOLLOWUP CARE FOR THE YOUNG INFANT 53 DIARRHEA 53 LOW WEIGHT FOR AGE 54
ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" 53 JAUNDICE 54 THRUSH 55
DURING FOLLOWUP VISIT FEEDING PROBLEM 54 CONFIRMED HIV INFECTION OR HIV EXPOSED 55
LOCAL BACTERIAL INFECTION 53
Recording Form: Young infant recording form 67
Annex:
Skin Problems
IDENTIFY SKIN PROBLEM 56
IF SKIN IS ITCHING 57
IF SKIN HAS BLISTERS/SORES/PUSTULES 58
NONITCHY 59
CLINICAL REACTION TO DRUGS 60
DRUG AND ALLERGIC REACTIONS 60
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD

ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE
Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS
on TREAT THE CHILD chart.
if initial visit, assess the child as follows:
CHECK FOR GENERAL DANGER SIGNS
Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referral treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
Page 1 of 77
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
If yes, ask: Look, listen, feel: Any general danger sign Pink: Give first dose of an appropriate antibiotic
For how long? Count the or SEVERE Refer URGENTLY to hospital*
Classify
breaths in COUGH or Stridor in calm child. PNEUMONIA OR
one minute. DIFFICULT VERY SEVERE
Look for BREATHING DISEASE
chest
CHILD Chest indrawing or Yellow: Give oral Amoxicillin for 5 days**
indrawing.
MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
Look and
CALM acting bronchodilator) give an inhaled
listen for
bronchodilator for 5 days***
stridor.
If chest indrawing in HIV exposed/infected child,
Look and
give first dose of amoxicillin and refer.
listen for
wheezing.
safe remedy
If wheezing with either If coughing for more than 14 days or recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for up Follow-up in 3 days
to three times 15-20 minutes
No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting
apart. Count the breaths and
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
look for chest indrawing
5 days***
again, and then classify.
If the child is: Fast breathing is: safe remedy
2 months up to 12 months 50 breaths per minute or more If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
12 Months up to 5 years 40 breaths per minute or more assessment
* If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
**Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
*** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatment of severe acute wheeze.
Page 2 of 77
Does the child have diarrhea?
If yes, ask: Look and feel:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
For how long? Look at the child's general
Is there blood in the stool? condition. Is the child:
Not able to drink or drinking If child also has another severe
Lethargic or
poorly classification:
unconscious? Classify DIARRHEA
Skin pinch goes back very Refer URGENTLY to hospital with mother
Restless and irritable? giving frequent sips of ORS on the way
slowly.
Look for sunken eyes. Advise the mother to continue
Offer the child fluid. Is the breastfeeding
child: If child is 2 years or older and there is
Not able to drink or cholera in your area, give antibiotic for
drinking poorly? cholera
Drinking eagerly,
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some
thirsty?
Restless, irritable SOME dehydration (Plan B)
Pinch the skin of the
Drinks eagerly, thirsty Refer URGENTLY to hospital with mother
Very slowly (longer
Skin pinch goes back giving frequent sips of ORS on the way
than 2 seconds)?
slowly. Advise the mother to continue
Slowly? breastfeeding
Not enough signs to classify as Green: Give fluid, zinc supplements, and food to treat
some or severe dehydration. NO DEHYDRATION diarrhea at home (Plan A)
Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhea 14 SEVERE has another severe classification
DIARRHEA
PERSISTENT PERSISTENT DIARRHEA
DIARRHEA Give multivitamins and minerals (including zinc) for
14 days
Give Vitamin A.
Follow-up in 5 days

and if blood in
stool
Page 3 of 77
Does the child have fever?
(by history or feels hot or temperature 37.5°C* or above)
If yes: Any general danger sign or Pink: Give first dose of artesunate or oral quinine for severe
Stiff neck. VERY SEVERE FEBRILE malaria (under medical supervision)
Decide Malaria Risk:
Malaria Risk DISEASE Give first dose of an appropriate antibiotic
Ask: Treat the child to prevent low blood sugar
Does the child live in a malaria area? Give one dose of paracetamol in clinic for high fever (38.5°C
Classify FEVER
Has the child travelled during the past 3 weeks and, if so, where? or above)
Then ask: Look and feel: Refer URGENTLY to hospital
For how long? Look or feel for stiff neck. Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
If more than 7 days, has fever been Look for runny nose. MALARIA Give one dose of paracetamol in clinic for high fever (38.5°C
present every day? Look for any bacterial cause of or above)
Has the child had measles within the fever**. Give appropriate antibiotic treatment for an identified bacterial cause
last 3 months? Look for signs of MEASLES. of fever
Generalized rash and Advise mother when to return immediately
One of these: cough, runny nose, Follow-up in 3 days if fever persists
or red eyes. If fever is present every day for more than 7 days, refer for
Do a malaria test***: If NO severe classification assessment
In all fever cases with malaria risk. Malaria test NEGATIVE Green: Give one dose of paracetamol in clinic for high fever (38.5°C
If no obvious cause of fever present. Other cause of fever PRESENT. FEVER: or above)
NO MALARIA Give appropriate antibiotic treatment for an identified bacterial
cause of fever
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign or Pink: Give first dose of an appropriate antibiotic.
No Malaria Risk and No
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
Travel to Malaria Risk
DISEASE Give one dose of paracetamol in clinic for high fever (38.5°C
Area
or above).
Refer URGENTLY to hospital.
No general danger signs Green: Give one dose of paracetamol in clinic for high fever (38.5°C
No stiff neck. FEVER or above)
Give appropriate antibiotic treatment for any identified bacterial
cause of fever
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign or Pink: Give Vitamin A

If the child has measles now or Look for mouth ulcers. Clouding of cornea or SEVERE COMPLICATED Give first dose of an appropriate antibiotic
within the last 3 months: Are they deep and extensive? If MEASLES now or within last 3 Deep or extensive mouth ulcers. MEASLES**** If clouding of the cornea or pus draining from the eye, apply
Look for pus draining from the eye. months, Classify tetracycline eye ointment
Look for clouding of the cornea. Refer URGENTLY to hospital
Pus draining from the eye or Yellow: Give Vitamin A.
Mouth ulcers MEASLES WITH EYE OR If pus draining from the eye, apply tetracycline eye ointment.
MOUTH COMPLICATIONS If mouth ulcers, teach the mother to treat with gentian violet.
Follow-up in 3 days.
Advise mother when to return immediately.
Measles now or within the last 3 Green: Give Vitamin A
months. MEASLES
Assess Dengue Hemorrhagic Fever Bleeding from nose or gums or Pink: If persistent vomiting or persistent abdominal pain or skin petechiae or
ASK: LOOK AND FEEL: Bleeding in stools or vomitus or SEVERE positive torniquet test are the only positive signs, give ORS(Plan B)
Has the child had any bleeding from Look for bleeding from nose or gums. Black stools or vomitus or DENGUE If any other signs of bleeding are present, give fluids rapidly(Plan C).
Classify Dengue Treat the child to prevent low blood sugar.
the nose or gums or in the vomitus or Look for skin petechiae. Skin petechiae or HEMORRHAGIC
stools? Hemorrhagic Fever Cold and clammy extremities or Refer all children URGENTLY to hospital.
Feel for cold and clammy extremities. FEVER
Has the child had black vomitus? Check for slow capillary refill. Capillary refill more than 3 seconds or DO NOT GIVE ASPIRIN.
Has the child had black stools? if none of above ASK or LOOK and FEEL persistent abdominal pain
Has the child had persistent signs are present and the child is 6 Persistent vomiting or
abdominal pain? months or older and fever is present for Touriquet test positive
Has the child had persistent vomiting more than 3 days. No signs of severe dengue hemorrhagic Green: Give ORS
Perform the tourniquet test. fever FEVER:DENGUE Advise mother when to return immediately.
HEMORRHAGIC FEVER Follow-up in 3 days if fever persists or child shows signs of
UNLIKELY bleeding.
DO NOT GIVE ASPIRIN.
* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C higher.
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
*** If no malaria test available: If in malaria risk area - classify as MALARIA; If NO obvious cause of fever - classify as MALARIA.
**** Other important complications of measles - pneumonia, stridor, diarrhea, ear infection, and acute malnutrition - are classified in other tables.
Page 4 of 77
Does the child have an ear problem?
If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain
Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital
If yes, for how long? Feel for tender swelling
behind the ear.
the ear and discharge is ACUTE EAR Give paracetamol for pain
days, or Follow-up in 5 days
Ear pain.
reported for 14 days or INFECTION Follow-up in 5 days
more.
No pus seen draining from NO EAR INFECTION
the ear.
Page 5 of 77
CHECK FOR ACUTE MALNUTRITION Edema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar
STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Look for edema of both feet.
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
complication present
If WFH/L less than -3 z-scores or MUAC less than 115 or
mm, then: Not able to finish RUTF
Check for any medical complication present: or
Any general danger sign Breastfeeding
Any severe classification problem.
Pneumonia with chest indrawing WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
If no medical complications present: scores UNCOMPLICATED Continue breastfeeding
Child is 6 months or older, offer RUTF*** to eat. OR SEVERE ACUTE Give ready-to-use therapeutic food if available
Is the child: MUAC less than 115 mm MALNUTRITION for a child aged 6 months or more
Not able to finish RUTF portion? Counsel the mother on how to feed the child.
AND
Able to finish RUTF portion? Assess for possible TB infection
Able to finish RUTF.
Child is less than 6 months, assess Advise mother when to return immediately
breastfeeding: (see page 45 of 77) Follow up in 5 days
Does the child have a breastfeeding WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
problem? 2 z-scores MODERATE ACUTE mother on the feeding recommendations
OR MALNUTRITION If feeding problem, follow up in 5 days
MUAC 115 up to 125 mm. Assess for possible TB infection.
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
more NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
recommendations
MUAC 125 mm or more.
Give micronutrient powder supplement.
*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.
Page 6 of 77
THEN CHECK FOR ANEMIA
.....................................................................................................................................................................................................................................................................................................................................................................................................
Check for anemia Severe palmar pallor Pink: Refer URGENTLY to hopsital
Look for palmar pallor. Is it: SEVERE ANEMIA
Severe palmar pallor? Classify
Some pallor Yellow: Give iron*
Some palmar pallor? ANEMIA Classification
arrow ANEMIA Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
NO ANEMIA child's feeding and counsel the mother according
to the feeding recommendations
Give micronutrient powder (MNP)
*If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.
Page 7 of 77
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care.
Positive virological test in Yellow: Initiate ART treatment and HIV care
ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis*
Classify OR INFECTION Assess the child’s feeding and provide appropriate
Has the mother or child had an HIV test? HIV counselling to the mother
status Positive serological test in a
IF YES: child 18 months or older Advise the mother on home care
Decide HIV status: Assess or refer for TB assessment and INH
Mother: POSITIVE or NEGATIVE preventive therapy
Child: Follow-up regularly as per national guidelines
Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status**
unknown, ASK: ago Assess the child’s feeding and provide appropriate
Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother
the test? Mother HIV-positive, child Advise the mother on home care
Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines
If breastfeeding ASK: Is the mother and child on ARV OR
prophylaxis?
Positive serological test in a
IF NO, THEN TEST: child less than 18 months
Mother and child status unknown: TEST mother. old
Mother HIV positive and child status unknown: TEST child.
or child HIV INFECTION
UNLIKELY
* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children until confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breastfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
Page 8 of 77
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A, DEWORMING STATUS, and
ORAL HEALTH
IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE VITAMIN A SUPPLEMENTATION
Give every child a dose of Vitamin A every six
months from the age of 6 months. Record the
dose on the child's chart.
Birth BCG* Hep B0 ROUTINE DEWORMING

Give every child Mebendazole or Albendazole
6 weeks Pentavalent 1** OPV1 RTV1**** PCV1***** every 6 months from the age of one year.
Record the dose on the child's card.
10 weeks Pentavalent 2 OPV2 RTV2 PCV2
14 weeks Pentavalent 3 OPV3 RTV3 PCV3 ORAL HEALTH

Advise mother to bring the child to a dentist
9 months Measles ***
every 6 months for dental check-up from the
age of 6 months
12 months - MMR
15 months
*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated with BCG. Infant born to mother with TB disease, do not give BCG first, instead
give Isoniazid Preventive therapy {IPT} for 3 months. If TST negative after 3 months, give BCG.
**DPT+HIB+HepB is available as pentavalent vaccine
***Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.
****Rotavirus Vaccine is given to children in selected areas due to limited supplies; Rotavirus Vaccine is available as 2 dose or 3 dose schedule
*****Pneumococcal Conjugate Vaccine ( PCV ) is given to children in selected areas only due to limited supplies.
ASSESS OTHER PROBLEMS:
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
blood sugar.
Page 9 of 77
HIV TESTING AND INTERPRETING RESULTS
HIV testing is RECOMMENDED for:
All children with unknown HIV status especially those born to HIVpositive mothers. (If you do not know the mother’s status, test the mother first, if possible)
Types of HIV Tests

What does the test detect? How to interpret the test?
SEROLOGICAL These tests detect antibodies made by HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not
TESTS immune cells in response to HIV. disappear until the child is 18 months of age.
(Including rapid They do not detect the HIV virus itself. This means that a positive serological test in children less than 18 months in NOT a reliable way to check for infection of the child.
tests)
VIROLOGICAL These tests directly detect the presence of Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old.
TESTS the HIV virus or products of the virus in the If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected.
(Including DNA blood. Tests should be done six weeks or more after breastfeeding has completely stopped—only then do the tests reliably rule out infection.
or RNA PCR)
For HIV exposed children 18 months or older, a positive HIV antibody test result means the child is infected.
For HIV exposed children less than 18 months of age:
If PCR or other virological test is available, test from 4 - 6 weeks of age.
A positive result means the child is infected.
A negative result means the child is not infected, but could become infected if they are still breast feeding.
If PCR or other virological test is not available, use HIV antibody test. A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected.
Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age
Breastfeeding status POSITIVE (+) test NEGATIVE (-) test
NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected
last 6 weeks Repeat test at 18 months.
BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been
could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks.
breastfeeding has been discontinued for more than 6 weeks.
Page 10 of 77
WHO PEDIATRIC STAGING FOR HIV INFECTION
This is used for monitoring children during follow up to determine clinical response to ARV treatment. Determine the clinical stage by assessing the child’s signs and symptoms. Look at the classification for each
stage. Decide what is the highest stage applicable to the child where one or more of the child’s symptoms are represented.
Stage 1 Stage 2 Stage 3 Stage 4

Asymptomatic Mild Disease Moderate Disease Severe Disease (AIDS)
- - Unexplained severe Severe unexplained wasting/stunting/severe acute

acute malnutrition not responding malnutrition not responding to standard therapy
to standard therapy
Symptoms/Signs No symptoms, or only: Enlarged liver and/or spleen Oral thrush (outside neonatal Esophageal thrush
Persistent generalized Enlarged parotid period). More than one month of herpes simplex ulcerations.
lymphadenopathy (PGL) Skin conditions (prurigo, seborrheic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacterial infections > 2
molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis
herpes zoster) to standard pneumonia (PCP)*
Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma.
gingival Erythema) Diarrhea for over 14 days Extrapulmonary tuberculosis.
Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess*
(sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis*
otorrhea) 50,000/mm3 for 1month Acquired HIV-associated rectal
Neutropenia* (under fistula
500/mm3 for 1 month) HIV encephalopathy*
Anemia for over 1 month
(hemoglobin under 8 gm)*
Recurrent severe bacterial
pneumonia
Pulmonary TB
Lymph node TB
Symptomatic lymphoid
interstitial pneumonitis (LIP)*
Acute necrotising ulcerative
gingivitis/periodontitis
Chronic HIV associated lung
diseases including
bronchiectasis*
*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.
Page 11 of 77
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Give an Appropriate Oral Antibiotic
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table. FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
AMOXICILLIN*
Determine the appropriate drugs and dosage for the child's age or weight.
Tell the mother the reason for giving the drug to the child. AGE or WEIGHT
DROPS SUSPENSION
Demonstrate how to measure a dose. 100mg/ml 250mg/5 ml
Watch the mother practise measuring a dose by herself. 2 months up to 12 months (4 - <10 kg) 2.5 ml 5 ml
Ask the mother to give the first dose to her child. 12 months up to 3 years (10 - <14 kg) 10 ml
Explain carefully how to give the drug, then label and package the drug. 3 years up to 5 years (14-19 kg) 15 ml
If more than one drug will be given, collect, count and package each drug * Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy and increasing high
resistance to cotrimoxazole.
separately.
FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:
Explain that all the oral drug tablets or syrups must be used to finish the course of ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
treatment, even if the child gets better. COTRIMOXAZOLE
Check the mother's understanding before she leaves the clinic. (trimethoprim + sulfamethoxazole)
Give once a day starting at 4-6 weeks of age
AGE
Suspension Adult tablet
(40mg Trimethoprim/200 mg (Single strength 80mg Trimethoprim/400 mg
Sulfamethoxazole/5ml) Sulfamethoxazole)
Less than 6 months 2.5 ml ---
6 months up to 5
5 ml 1/2 tablet
years
FOR DYSENTERY give Ciprofloxacin
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacin
CIPROFLOXACIN
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet 500 mg tablet
Less than 6 months 1/2 1/4
6 months up to 5 years 1 1/2
FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: COTRIMOXAZOLE
ALtERNATE DRUG FOR CHOLERA: FURAZOLIDONE
FURAZOLIDONE
COTRIMOXAZOLE Give 1.25 mg/kg 4
Give 5 mg / kg / day in 2 divided doses for 3 days times a day for 3
days
AGE or WEIGHT
SUSPENSION SUSPENSION
Adult tablet 80 mg Solution
40mg Trimethoprim 80 mg trimethoprim / Trimethoprim / 400
/200 mg 400 mg mg Sulfamethoxazole 16.7mg/5ml solution
Sulfamethoxazole sulfamethoxazole
2 years up to 5
5 ml 2 times a day for 3 2.5 ml 2 times a day for 1/2 tablet 2 times a day for 3 5 - 7.5 ml 4 times a
years (10 -
days 3 days days day for 3 days
19 kg)
Page 12 of 77
Follow the instructions below for every oral drug to be given at home.
Give Oral Antimalarial for P. falciparum MALARIA
Also follow the instructions listed with each drug's dosage table.
If Artemether-Lumefantrine (AL)
Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child
vomits within an hour repeat the dose.
Give Inhaled Salbutamol for Wheezing Give second dose at home after 8 hours.
Then twice daily for further two days as shown below.
USE OF A SPACER* Artemether-lumefantrine should be taken with food.
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years Advice patient to take AL with milk or fat containing food ("gata"or coconut milk, buko, or suman
should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. sa latik and cookies)particularly on the 2nd and 3rd days of treatment.
From salbutamol metered dose inhaler (100 µg/puff) give 2 puffs. Since lumefantrine is highly lipophilic, its absorption is enhanced by co-administration of fat.
Repeat up to 3 times every 15 minutes before classifying pneumonia. low blood levels would resultant treatment failure could potentially result from inadequate fat
intake.
Spacers can be made in the following way:
Use a 500ml drink bottle or similar. WEIGHT (age)
ARTEMETHER-LUMEFANTRINE TABLETS PRIMAQUINE
(20mg artemether and 120 mg lemefantrine) (1 tablet contains 15mg base of primaquine)
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. (1) use body weight in kgs as basis
(2) If weight cannot be taken, use age as basis
This can be done using a sharp knife. 0H 8H Day 2 Day 3 Day 4
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the 5 - <15 kg (6months up to 3years old) 1 1 1 tab BID 1 tab BID Give PRiMAQUINE only to > 1 yr old, 1/2 tab single dose (contraindicated in <1 year old)
bottle. 15 - <25 kg (4 - 8 years old) 2 2 2 tabs BID 2 tabs BID 1 tab single dose
Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as
a mask.
Flame the edge of the cut bottle with a candle or a lighter to soften it. Treatment Schedule for confirmed P. vivax or P. OVALE Cases
In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup.
Alternatively commercial spacers can be used if available.
PRIMAQUINE
No. of CHLOROQUINE Tablet (15 mg/tablet)
To use an inhaler with a spacer:
(150 mg base/tablet) No. of Tablet
Remove the inhaler cap. Shake the inhaler well. Age(years)
Day 1 - 10 mg base/kg BW Day 4-17
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. (1) Use weight in kgs as basis
The child should put the opening of the bottle into his mouth and breath in and out through the mouth. Day 2 - 10 mg base/kg BW treatment
(2) If weight cannot be taken, use age
A carer then presses down the inhaler and sprays into the bottle while the child continues to breath Day 3 - 5 mg base/kg BW use 0.5 mg base per kg
as basis
normally. per day
Wait for three to four breaths and repeat. Day
For younger children place the cup over the child's mouth and use as a spacer in the same way. Day 2 Day 3 Day 4 -17
1
0-11 mos. 1/2 1/2 1/2 contraindicated
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
1-3 years 1 1 1/2 1/2 daily
1
4-6 years 1 1/2 1 1/2 daily
1/2
1. Chloroquine remains highly effective against vivax malaria. Hence, it remains the recommended drug of
choice for P. ovale. However, in the absence of CQ and in case of treatment failure, AL can be used.
2. Primaquine must not be given to infants <1 year old
3. Primaquine should be taken with meals {causes abdominal discomfort taken on an empty stomach}
4. Primaquine can induce hemolysis in people with glucose-6-phosphate dehydrogenase {G6PD}
deficiency. Consider G6PD test if available. If G6PD test is not available, observe a change in urine
color.
Stop Primaquine intake if urine turns dark {tea-colored}
↺
Page 13 of 77
Follow the instructions below for every oral drug to be given at home. Give Paracetamol for High Fever (> 38.5°C) or Ear Pain
Also follow the instructions listed with each drug's dosage table. Give paracetamol every 6 hours until high fever or ear pain is gone.
PARACETAMOL Paracetamol
AGE or WEIGHT SYRUP(120 mg / SYRUP [250 DROPS [100 Tablet (500
Treatment Schedule for Plasmodium malariae Malaria 5 ml) mg/5ml] mg/ml] mg)
2 months up to 3 years 1/2 teaspoon

PRIMAQUINE 1 teaspoon [5ml] 1.2 ml 1/4 tablet
(4 - <14 kg) [2.5 ml]
No. of CHLOROQUINE Tablet (15 mg/tablet)
(150 mg base/tablet) 3 years up to 5 years 2 teaspoon [10 1 teaspoon [5
No. of Tablet ----- 1/2 tablet
Age(years) (14 - <19 kg) ml] ml]
Day 1 - 10 mg base/kg BW Day 4
(1) Use weight in kgs as basis
Day 2 - 10 mg base/kg BW treatment
(2) If weight cannot be taken, use
Day 3 - 5 mg base/kg BW use 0.75 mg base per kg
age as basis
per day
Give Iron*
Day
Day 2 Day 3 Day 4
1 Give one dose daily for 14 days.
0-11 mos. 1/2 1/2 1/2 contraindicated IRON/FOLATE
IRON SYRUP
TABLET
1-3 years 1 1 1/2 1/2 tablet single dose
AGE or WEIGHT Ferrous sulfate
1
4-6 years 1 1/2 1 1 tablet single dose 200 mg + 250 µg Ferrous fumarate 100 mg per 5 ml (20 mg
1/2
Folate (60 mg elemental iron per ml)
Perform thick and thin blood film including parasite count (for RHU, hospital and laboratory facilities elemental iron)
only) after completing treatment on Day 3 then on Day 7, 14, 21 and 28. Refer to the next level of
2 months up to 4 months (4 -
health care if parasitemia is still present. 1.00 ml (< 1/4 tsp.)
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp.)
(6 - <10 kg)
Treatment Schedule for mixed P. falciparum and P. vivax 12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp.)
infection (10 - <14 kg)
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
ARTEMETHER - PRIMAQUINE 19 kg)
LUMEFANTRINE tablets (15 mg/tablet) * Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
AGE
(20mg artemether and 120 mg No. of Tablet not be given Iron.
(years) lumefantrine) for 14 days
1 8H1 Day 2 Day 3 Day 4
5 - <15 kg Give PRIMAQUINE only to > 1 yr old, 1/2 Give Micronutrient Powder
(6months up to 3 1 1 1 tab BID 1 tab BID tablet single dose
years old) (contraindicated in <1 yr. old) Give Micronutrient Powder Supplement or (MNP) daily to children 6 - 23 months old
Use this at 6 months of age during the introduction of complementary feeding
15 - <25 kg
2 2 2 tab BID 2 tab BID 1 tablet single dose Mix MNP into complementary food preferably soft or semi-solid before feeding it to the child
(4 - 8 years old) Do not add MNP to food before or during cooking
* Treatment should be given after meals for 6 - 11 months infant, give a total of 60 sachets over a period of 6 months
* First day of treatment should be under the supervision of the health worker for 12 - 23 months children, give 60 sachets every 6 months for a total of 120 sachets in a
year
Page 14 of 77
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
Treat for Mouth Ulcers with Gentian Violet (GV)
Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box. Treat for mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except for remedy for Wash hands.
cough or sore throat). Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
Tell her how often to do the treatment at home. Paint the mouth with half-strength gentian violet (0.25% dilution).
If needed for treatment at home, give mother the tube of tetracycline ointment or a Wash hands again.
small bottle of gentian violet. Continue using GV for 48 hours after the ulcers have been cured.
Give paracetamol for pain relief.
Check the mothers understanding before she leaves the clinic.
Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin Oral Suspension
Safe remedies to recommend: Treat thrush four times daily for 7 days
Breast milk for a breastfed infant. Wash hands
Increase fluid intake. Wet a clean soft cloth with salt water and use it to wash the child’s mouth
Give calamansi juice. Give nystatin 1ml four times a day
Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
If breastfed check mother’s breasts for thrush. If present treat with nystatin
Don't give cough syrups or mucolytics. Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
Don't give nasal decongestant like phenylpropanolamine. Give paracetamol if needed for pain
Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 4 times daily.
Wash hands.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.
Clear the Ear by Dry Wicking and Give Eardrops*

Dry the ear at least 3 times daily.
Roll clean absorbent cloth or soft, strong tissue paper into a wick.
Place the wick in the child's ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps until the ear is dry.
Instill quinolone eardrops after dry wicking three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.
Page 15 of 77
GIVE VITAMIN A AND MEBENDAZOLE or ALBENDAZOLE IN THE HEALTH CENTER
Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately
Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHILDREN
Thereafter vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has MEASLES or PERSISTENT DIARRHEA. If the child has had a dose of vitamin A within the past month
or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
Always record the dose of Vitamin A given on the child's card.
AGE VITAMIN A DOSE
6 up to 12 months 100 000 IU
One year and older 200 000 IU
Give Mebendazole or Albendazole

Give 500 mg Mebendazole as a single dose in the health center if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.
OR
Give 400 mg Albendazole as single dose in the health center if:
12 to 23 months - 200 mg single dose every 6 months
24 months and above - 400 mg single dose every 6 months
Page 16 of 77
GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY
Give Diazepam to Stop Convulsions
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Turn the child to his/her side and clear the airway. Avoid putting things in the mouth.
Use a sterile needle and sterile syringe when giving an injection. Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a
Measure the dose accurately. tuberculin syringe) or using a catheter.
Give the drug as an intramuscular injection. Check for low blood sugar, then treat or prevent.
Give oxygen and REFER
If child cannot be referred, follow the instructions provided.
If convulsions have not stopped after 10 minutes repeat diazepam dose
DIAZEPAM
AGE or WEIGHT
10mg/2mls
Give Intramuscular Antibiotics 2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
GIVE TO CHILDREN BEING REFERRED URGENTLY
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). 12 months up to 3 years (10 - <14 kg) 1.5 ml
Alternate drug for Ampicillin is Benzyl Penicillin 500,000 units/ml 3 years up to 5 years (14-19 kg) 2.0 ml
BENZYL PENICILLIN
Add 8 ml sterile water to vial of 5 million units
AMPICILLIN
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times.
GENTAMICIN
7.5 mg/kg/day once daily
Benzyl
Penicillin
AMPICILLIN GENTAMICIN
AGE or WEIGHT 5 million
500 mg vial 40 mg/ml vial
units
vial
2 up to 4 months (4 - <6 kg) 1 ml 0.5-1.0 ml 0.3 ml
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml 0.6 ml
12 months up to 3 years (10 -
3 ml 1.9-2.7 ml 1.0 ml
<14 kg)
3 years up to 5 years (14 -
5 ml 2.8-3.5 ml 1.5 ml
19 kg)
Page 17 of 77
GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY
Treat the Child to Prevent Low Blood Sugar
If the child is able to breastfeed:
Give Artesunate Suppositories or Oral Quinine for Severe Ask the mother to breastfeed the child.
Malaria If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
If neither of these is available, give sugar water*.
Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
artesunate injection or quinine). Give 30 - 50 ml of milk or sugar water* before departure.
Artesunate suppository: Insert first dose of the suppository and refer child urgently If the child is not able to swallow:
Oral quinine: Give first dose and refer child urgently to hospital. Give 50 ml of milk or sugar water* by nasogastric tube.
IF REFERRAL IS NOT POSSIBLE: If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
.For artesunate suppository:
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
Give first dose of suppository water.
Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
Give full dose of oral antimalarial as soon as the child is able to take orally
For Quinine:
Give first dose of oral Quinine.
Pulverize tablet and give through NGT
RECTAL ARTESUNATE
ORAL QUININE SULFATE*
SUPPOSITORY
AGE or 50 mg 200 mg
WEIGHT suppositories suppositories 300 mg /tablet
Dosage 10 Dosage 10 Dosage: 10 mg/kg body weight
mg/kg mg/kg
0 months up
to 12
1 ------- 1/4 tablet
months (5 -
8.9 kg)
13 months
up to 42
2 ------- 1/4 -3/4 tablet
months (9 -
19 kg)
43 months
up to 60
4 1 3/4 - 1 tablet
months
(20 - 29 kg)
* quinine salt
Page 18 of 77
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart)
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
PLAN A: TREAT DIARRHEA AT HOME WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
Counsel the mother on the 4 Rules of Home Treatment: AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5
months months years years
1. Give Extra Fluid In ml 200 - 450 450 - 800 800 - 960 960 - 1600
2. Give Zinc Supplements (age 2 months up to 5 years) * Use the child's age only when you do not know the weight. The approximate amount of ORS
3. Continue Feeding required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
4. When to Return. If the child wants more ORS than shown, give more.
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
1. GIVE EXTRA FLUID (as much as the child will take)
period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
TELL THE MOTHER:
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Breastfeed frequently and for longer at each feed.
Give frequent small sips from a cup.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.
If the child vomits, wait 10 minutes. Then continue, but more slowly.
If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean Continue breastfeeding whenever the child wants.
water. AFTER 4 HOURS:
It is especially important to give ORS at home when: Reassess the child and classify the child for dehydration.
the child has been treated with Plan B or Plan C during this visit. Select the appropriate plan to continue treatment.
the child cannot return to a clinic if the diarrhea gets worse. Begin feeding the child in clinic.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
ORS TO USE AT HOME. Show her how to prepare ORS solution at home.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID Show her how much ORS to give to finish 4-hour treatment at home.
INTAKE: Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
Up to 2 years 50 to 100 ml after each loose stool in Plan A.
2 years or more 100 to 200 ml after each loose stool
Explain the 4 Rules of Home Treatment:
Tell the mother to:
1. GIVE EXTRA FLUID
Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more slowly. 2. GIVE ZINC (age 2 months up to 5 years)
Continue giving extra fluid until the diarrhea stops. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
2. GIVE ZINC (age 2 months up to 5 years)
4. WHEN TO RETURN
TELL THE MOTHER HOW MUCH ZINC TO GIVE :
ZINC
ZINC ZINC
TABLET
AGE SYRUP 20 DROPS 10
20 mg
mg / 5 ml mg / ml
tablet
1/2 tsp
2 months 1.0 ml daily 1/2 tablet
{2.5 ml}
up to 6 for 14 daily for 14
daily for 14
months days days
days
1 tsp {5 ml} 2.0 ml daily 1 tablet
6 months
daily for 14 for 14 daily for 14
or more
days days days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
↺
Page 19 of 77
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
START HERE Start IV fluid immediately. If the child can drink, give ORS by
Can you give mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid YES→ Solution (or, if not available, normal saline), divided as follows
immediately? AGE First give Then give
NO 30 ml/kg in: 70 ml/kg in:
↓ Infants (under 12 1 hour* 5 hours
months)
Children (12 months up 30 minutes* 2 1/2 hours
to 5 years)
* Repeat once if radial pulse is still very weak or not
detectable.
Reassess the child every 1-2 hours. If hydration status is
not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can
drink: usually after 3-4 hours (infants) or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B,
or C) to continue treatment.
Is IV treatment Refer URGENTLY to hospital for IV treatment.

available nearby (within YES→ If the child can drink, provide the mother with ORS solution and
30 minutes)? show her how to give frequent sips during the trip or give ORS
NO by naso-gastric tube.
↓
Are you trained to use Start rehydration by tube (or mouth) with ORS solution:
a naso-gastric (NG) YES→ give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
tube for rehydration? Reassess the child every 1-2 hours while waiting for
NO transfer:
↓ If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
Can the child drink? YES→
If hydration status is not improving after 3 hours, send the
NO child for IV therapy.
↓ After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.
Refer URGENTLY to NOTE:

hospital for IV or NG If the child is not referred to hospital, observe the child at least
treatment 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
Page 20 of 77
GIVE READY-TO-USE THERAPEUTIC FOOD
Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Wash hands before giving the ready-to-use therapeutic food (RUTF).
Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
Encourage the child to eat the RUTF without forced feeding.
Give small, regular meals of RUTF and encourage the child to eat often 5–6 meals per day.
If still breastfeeding, continue by offering breast milk first before every RUTF feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breastfeed and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE
MOTHER chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.
Recommended Amounts of Ready-to-Use Therapeutic Food

Packets per day
CHILD'S WEIGHT (kg) Packets per Week Supply
(92 g Packets Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
Page 21 of 77
TREAT THE HIV INFECTED CHILD
Steps when Initiating ART in Children

All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage.
Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
Child is under 18 months: If child is less than 3 kg or has TB, Refer for ART initiation.
HIV infection is confirmed if virological test (PCR) is positive If child weighs 3 kg or more and does not have TB, GO TO STEP 4
Child is over 18 months:
Two different serological tests are positive
Send any further confirmatory tests required
If results are discordant, refer
If HIV infection is confirmed, and child is in stable condition,
GO TO STEP 2
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
caregiver should ideally have disclosed the child’s HIV status Weight and height
to another adult who can assist with providing ART, or be part Pallor if present
of a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests
Caregiver not able: classify as CONFIRMED HIV INFECTION that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.
STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatement:
Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
Give co-trimoxazole prophylaxis
Give other routine treatments, including Vitamin A and immunizations
Page 22 of 77
Preferred and Alternative ARV Regimens

AGE Preferred Alternative Children with TB/HIV Infection
Birth up to 3 YEARS ABC or AZT + 3TC + LPV/r ABC or AZT + 3TC + NVP ABC or AZT + 3TC + NVP
AZT + 3TC + ABC
3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP ABC or AZT + 3TC + EFV
AZT + 3TC + ABC
Give Antiretroviral Drugs (Fixed Dose Combinations)

AZT/3TC AZT/3TC/NVP ABC/AZT/3TC ABC/3TC
WEIGHT (Kg) Twice daily Twice daily Twice daily Twice daily
60/30 mg tablet 300/150 mg tablet 60/30/50 mg tablet 300/150/200 mg tablet 60/60/30 mg tablet 300/300/150 mg tablet 60/30 mg tablet 600/300 mg tablet
3 - 5.9 1 - 1 - 1 - 1 -
6 - 9.9 1.5 - 1.5 - 1.5 - 1.5 -
10 - 13.9 2 - 2 - 2 - 2 -
14 - 19.9 2.5 - 2.5 - 2.5 - 2.5 -
20 - 24.9 3 - 3 - 3 - 3 -
25 - 34.9 - 1 1 1 - 0.5
Page 23 of 77
Give Antiretroviral Drugs

LOPINAVIR / RITONAVIR (LPV/r), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)
LOPINAVIR / RITONAVIR (LPV/r) NEVIRAPINE (NVP) EFAVIRENZ (EFV)

WEIGHT (KG) Target dose 230‐350mg/m² twice daily T arget dose 15 mg/Kg
onc e d a ily
80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet 200 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Once daily
3 - 5.9 1 ml - 5 ml 1 - -
6 - 9.9 1.5 ml - 8 ml 1.5 - -
10 - 13.9 2 ml 2 10 ml 2 - 1
14 - 19.9 2.5 ml 2 - 2.5 - 1.5
20 - 24.9 3 ml 2 - 3 - 1.5
25 - 34.9 - 3 - - 1 2
ABACAVIR (ABC), ZIDOVUDINE (AZT or ZDV) & LAMIVUDINE (3TC)
ABACAVIR (ABC)
ZIDOVUDINE (AZT or ZDV)
Target dose 180‐240mg/m² twice daily LAMIVUDINE (3TC)
WEIGHT (KG) T arget dose: 8mg/Kg/dose twice daily
20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml liquid 30 mg tablet 150 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
Page 24 of 77
Side Effects ARV Drugs

Very common side-effects: Potentially serious side effects: Side effects occurring later during
treatment:
warn patients and suggest ways patients can warn patients and tell them to seek care discuss with patients
manage;
manage when patients seek care
Abacavir (ABC) Seek care urgently:
Fever, vomiting, rash - this may indicate hypersensitivity to
abacavir
Lamivudine (3TC) Nausea
Diarrhea
Lopinavir/ritonavir Nausea Changes in fat distribution:
Vomiting Arms, legs, buttocks, cheeks become THIN
Breasts, tummy, back of neck become FAT
Diarrhea
Elevated blood cholesterol and glucose
Nevirapine (NVP) Nausea Seek care urgently:
Diarrhea Yellow eyes
Severe skin rash
Fatigue AND shortness of breath
Fever
Zidovudine Nausea Seek care urgently:
(ZDV or AZT) Diarrhea Pallor (anemia)
Headache
Fatigue
Muscle pain
Efavirenz (EFV) Nausea Seek care urgently:
Diarrhea Yellow eyes
Strange dreams Psychosis or confusion
Difficulty sleeping Severe skin rash
Memory problems
Headache
Dizziness
Page 25 of 77
Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS APPROPRIATE CARE RESPONSE
Yellow eyes (jaundice) or Stop drugs and REFER URGENTLY
abdominal pain
Rash If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is associated with
fever or vomiting: stop drugs and REFER URGENTLY
Nausea Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer.
Vomiting Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being given.
If vomiting persists, the caregiver should bring the child to clinic for evaluation.
If vomiting everything, or vomiting associated with severe abdominal pain or difficulty breathing, REFER URGENTLY.
Diarrhea Assess, classify, and treat using diarrhea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If not
improved after two weeks, call for advice or refer.
Fever Assess, classify, and treat using fever chart.
Headache Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or refer.
Sleep disturbances, This may be due to efavirenz. Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for advice or
nightmares, anxiety refer.
Tingling, numb or painful feet If new or worse on treatment, call for advice or refer.
or legs
Changes in fat distribution Consider switching from stavudine to abacavir, consider to viral load. Refer if needed.
Page 26 of 77
Give Pain Relief to HIV Infected Child

Give paracetamol or ibuprofen every 6 hours if pain persists.
For severe pain, morphine syrup can be given.
PARACETAMOL ORAL MORPHINE
AGE or WEIGHT
TABLET (100 mg) SYRUP (120 mg/5ml) (0.5 mg/5 ml)
2 up to 4 months (4 - <6 kg) - 2 ml 0.5 ml

4 up to 12 months (6 - <10 kg) 1 2.5 ml 2 ml
12 months up to 2 years (10 - <12 kg) 1 1/2 5 ml 3 ml
2 up to 3 years (12 - <14 kg) 2 7.5 ml 4 ml
3 up to 5 years (14 -<19 kg) 2 10 ml 5 ml
Recommended dosages for ibuprofen: 510 mg/kg orally, every 68h to a maximum of 500 mg per day i.e. ¼ of a 200 mg tablet below 15 kg , ½ tablet for 15 up to 20 kg of body weight. Avoid
ibuprofen in children under the age of 3 months.
IMMUNIZE EVERY SICK CHILD AS NEEDED
Page 27 of 77
FOLLOW-UP
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

DYSENTERY
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications. After 3 days:
If the child has any new problem, assess, classify and treat the new problem as on Assess the child for diarrhea. > See ASSESS & CLASSIFY chart.
the ASSESS AND CLASSIFY chart.
Ask:
Are there fewer stools?
Is there less blood in the stool?
PNEUMONIA Is there less fever?
Is there less abdominal pain?
After 3 days: Is the child eating better?
Check the child for general danger signs.
Treatment:
Assess the child for cough or difficult breathing.
Ask: If the child is dehydrated, treat dehydration.
If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or
Is the child breathing slower? See ASSESS & CLASSIFY chart.
the same:
Is there a chest indrawing? Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days.
Is there less fever? Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to
Is the child eating better? hospital.
Exceptions - if the child: is less than 12 months old, or
Treatment: was dehydrated on the first visit, or REFER to hospital.
If any general danger sign or stridor, refer URGENTLY to hospital. if he had measles within the last 3 months
If chest indrawing and/or breathing rate, fever and eating are the same or worse, refer
URGENTLY to hospital. If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better,
If breathing slower, no chest indrawing, less fever, and eating better, complete the 5 days of continue giving ciprofloxacin until finished.
antibiotic.
Ensure that mother understands the oral rehydration method fully and that she also understands
the need for an extra meal each day for a week.
PERSISTENT DIARRHEA
After 5 days: MALARIA
Ask:
Has the diarrhea stopped? If fever persists after 3 days:
How many loose stools is the child having per day? Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Treatment:
If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full Treatment:
reassessment of the child. Treat for dehydration if present. Then refer to hospital.
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the diarrhea has stopped (child having less than 3 loose stools per day), tell the mother to follow
If the child has any othercause of fever other than malaria, provide appropriate treatment.
the usual feeding recommendations for the child's age.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the
child to a hospital.
If there is no other apparent cause of fever and you do not have a microscopy to check for
parasites, refer the child to a hospital.
↺
Page 28 of 77
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is tender swelling behind the ear or high fever (38.5°C or above), refer URGENTLY to
hospital.
Treatment: Acute ear infection:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking
to dry the ear. Follow-up in 5 days.
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
days if the fever persists.
finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the child has any other cause of fever other than malaria, provide treatment. Chronic ear infection:
If there is no other apparent cause of fever: Check that the mother is wicking the ear correctly and giving quinolone drops three times a day.
If the fever has been present for 7 days, refer for assessment. Encourage her to continue.
MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR FEEDING PROBLEM

MOUTH ULCERS, OR THRUSH After 5 days:
Reassess feeding. > See questions in the COUNSEL THE MOTHER chart.
After 3 days: Ask about any feeding problems found on the initial visit.
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers or white patches in the mouth (thrush). Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make
Smell the mouth. significant changes in feeding, ask her to bring the child back again.
If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to return 30 days
Treatment for eye infection:
after the initial visit to measure the child's WFH/L, MUAC.
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.
If the pus is gone but redness remains, continue the treatment.
If no pus or redness, stop the treatment. ANEMIA
After 14 days:
Treatment for mouth ulcers:
Give iron. Advise mother to return in 14 days for more iron.
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Continue giving iron every 14 days for 2 months.
If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5
If the child has palmar pallor after 2 months, refer for assessment.
days.
Treatment for thrush:

If thrush is worse check that treatment is being given correctly.
If the child has problems with swallowing, refer to hospital.
If thrush is the same or better, and the child is feeding well, continue nystatine for a total of 7 days.
↺
Page 29 of 77
UNCOMPLICATED SEVERE ACUTE MALNUTRITION

After 14 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for edema of both feet.
Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older.
Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or edema of both feet AND has developed a medical complication
or edema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or edema of both feet but NO medical complication and passes appetite
test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask mother
to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell
her to return again in 14 days. Continue to see the child every 14 days until the child’s WFH/L is 2 z
scores or more, and/or MUAC is 125 mm or more.
If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).
MODERATE ACUTE MALNUTRITION

After 30 days:
Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit:
If WFH/L, weigh the child, measure height or length and determine if WFH/L.
If MUAC, measure using MUAC tape.
Check the child for edema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Treatment:
If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and
encourage her to continue.
If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any
feeding problem found. Ask the mother to return again in one month. Continue to see the child monthly
until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or
MUAC is 125 mm. or more.
Exception:
If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has
diminished, refer the child.
Page 30 of 77
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
CONFIRMED HIV INFECTION NOT ON ART
Follow up regularly as per national guidelines.
HIV EXPOSED At each follow-up visit follow these instructions:
Follow up regularly as per national guidelines. Ask the mother: Does the child have any problems?
At each follow-up visit follow these instructions: Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
new problem
Ask the mother: Does the child have any problems?
Counsel and check if mother able or willing now to initiate ART for the child.
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
new problem
counselling
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
Continue cotrimoxazole prophylaxis if indicated.
counselling
Initiate or continue isoniazid preventive therapy if indicated.
Continue cotrimoxazole prophylaxis
If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children)
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How
Monitor CD4 count and percentage.
often, if ever, does the child/mother miss a dose?
Ask about the mother’s health, provide HIV counselling and testing.
Ask about the mother’s health. Provide HIV counselling and testing and referral if necessary
Home care:
Plan for the next follow-up visit
Counsel the mother about any new or continuing problems
HIV testing:
If appropriate, put the family in touch with organizations or people who could provide support
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Advise the mother about hygiene in the home, in particular when preparing food
test result. Plan for the next follow-up visit
Recheck child’s HIV status six weeks after cessation of breastfeeding. Reclassify the child according
to the test result.
If child is confirmed HIV infected
Start on ART and enrol in chronic HIV care.
Continue follow-up as for CONFIRMED HIV INFECTION ON ART
If child is confirmed uninfected
Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks
of cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about her own health
↺
Page 31 of 77
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF

FOLLOW-UP CARE
Follow up regularly as per national guidelines.
STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART
ASK: Does the child have any IF ANY OF FOLLOWING PRESENT, REFER
problems? NON-URGENTLY:
Has the child received care at another If any of these
health facility since the last visit? present, refer
CHECK: for general danger signs - If NON-
present, complete assessment, give URGENTLY:
pre-referral treatment, REFER Record the Child's weight Not gaining
URGENTLY. and height weight for 3
ASSESS, CLASSIFY, TREAT and Assess adherence months
COUNSEL any sick child as Ask about adherence: how Loss of
appropriate. often, if ever, does the milestones
CHECK for ART severe side effects child miss a dose? Record Poor
your assessment. adherence
Severe Assess and record clinical Stage
skin rash stage worse than
Assess clinical stage. before
Difficulty
breathing Compare with the child’s CD4 count
and stage at previous visits. lower than
If present, give before
severe Monitor laboratory results
any pre- LDL higher
abdominal Record results of tests
referral than 3.5
pain that have been sent.
treatment, mmol/L
Yellow
REFER TG higher
eyes
URGENTLY than 5.6
Fever,
vomiting, mmol/L
rash (only Manage side effects
if on Send tests that are due
Abacavir)
Check for other ART side effects
STEP 3: PROVIDE ART, STEP 4: COUNSEL THE MOTHER OR CAREGIVER
COTRIMOXAZOLE AND ROUTINE
TREATMENTS Use every visit to educate and provide support to
If child is stable: continue with the the mother or caregiver
ART regimen and cotrimoxazole doses.
Key issues to discuss include:
Check for appropriate doses:
remember these will need to increase How the child is progressing, feeding, adherence,
as the child grows side-effects and correct management, disclosure
Give routine care: Vitamin A (to others and the child), support for the caregiver
supplementation, deworming, and
immunization as needed Remember to check that the mother and other
family members are receiving the care that
they need
Set a follow-up visit: if well, follow-up as per
nastional guidelines. If problems, follow-up as
indicated.
Page 32 of 77
COUNSEL THE MOTHER
FEEDING COUNSELLING
Assess Child's Appetite

All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (edema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical
complication should be assessed for appetite.
Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed to eating the
RUTF. Usually the child eats the RUTF portion in 30 minutes.
Explain to the mother:
The purpose of assessing the child's appetite.
What is ready-to-use-therapeutic food (RUTF).
How to give RUTF:
Wash hands before giving the RUTF.
Sit with the child on the lap and gently offer the child RUTF to eat.
Encourage the child to eat the RUTF without feeding by force.
Offer plenty of clean water to drink from a cup when the child is eating the RUTF.
Offer appropriate amount of RUTF to the child to eat:
After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide:
Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Page 33 of 77
FEEDING COUNSELLING
Assess Child's Feeding

Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED. 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.
ASK - How are you feeding your child?
If the child is receiving any breast milk, ASK:
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?
If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What foods are available in the home?
During this illness, has the child's feeding changed?
If yes, how?
In addition, for HIV EXPOSED child:

If mother and child are on ARV treatment or prophylaxis and child breastfeeding, ASK:
Do you take ARV drugs? Do you take all doses, miss doses, do not take medication?
Does the child take ARV drugs (If the policy is to take ARV prophylaxis until 1 week after breastfeeding has stopped)? Does he or she take all doses, missed doses,
does not take medication?
If child not breastfeeding, ASK:
What milk are you giving?
How many times during the day and night?
How much is given at each feed?
How are you preparing the milk?
Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant.
Are you giving any breast milk at all?
Are you able to get new supplies of milk before you run out?
How is the milk being given? Cup or bottle?
How are you cleaning the feeding utensils?
Page 34 of 77
FEEDING COUNSELLING
Feeding Recommendations During Sickness and Health

Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis
Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months
Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child —but do not force— "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
Page 35 of 77
FEEDING COUNSELLING
Recommendation for Feeding and Care for Development

Birth up to 6 months 6 up to 12 monts 12 months up to 2 years 2 years and older
Exclusively breastfeed as often as the Breastfeed as often as the child wants. Breastfeed as often as the child wants. Give adequate amount of family food at 3
child wants, day and night, at least 8 times Add any of the following Give adequate amount of family foods meals a day.
in 24 hours. Lugaw with added oil, mashed vegetables such as: rice, camote, potato, fish, Give twice daily nutritious food between
Do not give other foods or fluids or beans, steamed tokwa, flaked fish, chicken, meat, mongo, steamed tokwa, meals such as:
pulverized roasted dilis, finely ground pulverized roasted dilis, milk and eggs, Boiled yellow camote, boiled yellow corn,
meat, eggyolk, bite-sized fruits dark green leafy and yellow peanuts, boiled saba, banana, taho, fruits
3 times per day if breastfeed vegetables(malunggay, squash), fruits and fruits juices.
5 times per day if not breastfeed (papaya, banana)
Add oil or margarine
5 times per day
Feed the baby nutritious snacks like fruits
Birth up to 4 months of age 6 months to 12 months 12 months and 2 years 2 years and older
Play: Provide ways for your child to see, Play: Play: Play:
hear, feel and move Give your child clean, safe house hold Give your child things to stack up, and to Help your child count, name and compare
things to handle, bang and drop. put into container and take out. things. Make simple toys for your child.
4 months to 6 months
Play: Have large colourful things for your child
to reach for, and new things to see.
Communicate: Communicate: Communicate:

Respond to your child's sounds and Ask your child simple questions. Respond Encourage your child to talk and answer
interest. Tell your child the names of things to your child's attempts to talk, play games your child's questions. Teach your child
Communicate: Talk to your child and get a and people. like "bye". stories, song and games.
coversation going with sounds or gestures.
Feeding Recommendation for a child who has PERSISTENT DIARRHEA

If still breastfeeding, give more frequent, longer breastfeeding, day and night
If taking other milk such as milk supplements:
Replace with increase breastfeeding.
Replace half the milk with nutrient-rich semi-solid food.
Do not use condensed or evaporated filled milk.
For other food, follow feeding recommendations for the child's age.
Page 36 of 77
FEEDING COUNSELLING
Feeding Recommendations for HIV EXPOSED Child on Infant Formula Only

These feeding recommendations are for HIV EXPOSED children in setting where the national authorities recommend to avoid all breastfeeding or when the mother has chosen
formula feeding.
PMTCT: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.
Up to 6 months 6 up to 12 monts 12 months up to 2 years Safe preparation of replacement feeding
Infant formula
Always use a marked cup or glass and
spoon to measure water and the
scoop to measure the formula
powder.
Wash your hands before preparing a
feed.
Bring the water to boil and then let it
cool. Keep it covered while it cools.
FORMULA FEED exclusively. Do not give Give 1-2 cups (250 - 500 ml) of infant Give 1-2 cups (250 - 500 ml) of boiled,
Measure the formula powder into a
any breast milk. Other foods or fluids formula or boiled, then cooled, full then cooled, full cream milk or infant
marked cup or glass. Make the scoops
are not necessary. cream milk. Give milk with a cup, not a formula.
level. Put in one scoop for every 25 ml
Prepare correct strength and amount bottle. Give milk with a cup, not a bottle.
of water.
just before use. Use milk within two Give: Give: Add a small amount of the cooled
hours. Discard any left over—a fridge
boiled water and stir. Fill the cup or
can store formula for 24 hours.
glass to the mark with the water. Stir
Cup feeding is safer than bottle
well.
feeding. Clean the cup and utensils * * Feed the infant using a cup.
with hot soapy water.
Start by giving 2-3 tablespoons of food 2 or family foods 3 or 4 times per day. Give Wash the utensils.
Give the following amounts of formula 8 - 3 times a day. Gradually increase to 1/2 3/4 cup (1 cup = 250 ml) at each meal.
to 6 times per day: cup (1 cup = 250 ml) at each meal and to
Offer 1-2 snacks between meals. Cow’s milk
Age in months Approx. amount and times giving meals 3-4 times a day.
Continue to feed your child slowly, Cow' s or other animal milks are not
per day Offer 1-2 snacks each day when the
patiently. suitable for infants below 6 months of
0 up to 1 60 ml x 8 child seems hungry.
Encourage - but do not force - your child age (even modified).
1 up to 2 90 ml x 7 For snacks give small chewable items
to eat. For a child between 6 and 12 month of
2 up to 4 120 ml x 6 that the child can hold. Let your child try to
4 up to 6 150 ml x 6 age: boil the milk and let it cool (even if
eat the snack, but provide help if needed.
pasteurized).
Feed the baby using a cup.
* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
Page 37 of 77
FEEDING COUNSELLING
Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup
Find a regular supply or formula or other milk (e.g. full cream cow’s milk)
Learn how to prepare a store milk safely at home
2. HELP MOTHER MAKE TRANSITION:

Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2 months)
Clean all utensils with soap and water
Start giving only formula or cow’s milk once baby takes all feeds by cup
3. STOP BREASTFEEDING COMPLETELY:
Express and discard enough breast milk to keep comfortable until lactation stops
Feeding Recommendations For a Child Who Has PERSISTENT DIARRHEA

If still breastfeeding, give more frequent, longer breastfeeds, day and night.
If taking other milk:
replace with increased breastfeeding OR
replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food.
For other foods, follow feeding recommendations for the child's age.
Page 38 of 77
EXTRA FLUIDS AND MOTHER'S HEALTH
Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given.
Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.
FOR CHILD WITH DIARRHEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.
Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.
If mother or anyone in the family is smoking, provide advise or refer for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counselling on STD and AIDS prevention.
Give additional counselling if the mother is HIV-positive

Reassure her that with regular followup, much can be done to prevent serious illness, and maintain her and the child’s health
Emphasize good hygiene, and early treatment of illnesses
Page 39 of 77
WHEN TO RETURN
Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the child's
problems.
If the child has: Return for
follow-up in:
PNEUMONIA 3 days
DYSENTERY
MALARIA, if fever persists
FEVER: NO MALARIA, if fever persists
WHEN TO RETURN IMMEDIATELY
MEASLES WITH EYE OR MOUTH
COMPLICATIONS Advise mother to return immediately if the child has any of these signs:
MOUTH OR GUM ULCERS OR THRUSH Any sick child Not able to drink or breastfeed
FEVER: DENGUE HEMORRHAGIC FEVER Becomes sicker
UNLIKELY Develops a fever
PERSISTENT DIARRHEA 5 days If child has COUGH OR COLD, also return if: Fast breathing
ACUTE EAR INFECTION Difficult breathing
CHRONIC EAR INFECTION If child has diarrhea, also return if: Blood in stool
COUGH OR COLD, if not improving Drinking poorly
UNCOMPLICATED SEVERE ACUTE 14 days
MALNUTRITION
FEEDING PROBLEM 5 days
ANEMIA 14 days
MODERATE ACUTE MALNUTRITION 30 days
CONFIRMED HIV INFECTION According to national
HIV EXPOSED recommendations
NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
Page 40 of 77
SICK YOUNG INFANT AGE UP TO 2 MONTHS
ASSESS AND CLASSIFY THE SICK YOUNG INFANT

ASSESS CLASSIFY IDENTIFY TREATMENT
DO A RAPID APPRAISAL OF ALL WAITING INFANTS
ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE
USE ALL BOXES THAT MATCH THE
Determine if this is an initial or follow-up visit for this problem. INFANT'S SYMPTOMS AND PROBLEMS TO
if follow-up visit, use the follow-up instructions.
CLASSIFY THE ILLNESS
if initial visit, assess the young infant as
follows:
Page 41 of 77
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
ASK: LOOK, LISTEN, FEEL: Any one of the following Pink: Give first dose of intramuscular antibiotics
Is the infant having Count the signs VERY SEVERE Treat to prevent low blood sugar
Classify ALL YOUNG
difficulty in feeding? breaths in one DISEASE Refer URGENTLY to hospital **
YOUNG INFANTS Not feeding well or
Has the infant had minute. Repeat Advise mother how to keep the infant warm
INFANT Convulsions or
convulsions (fits)? the count if more on the way to the hospital
MUST Fast breathing (60 breaths
than 60 breaths
BE per minute or more) or
per minute.
CALM Severe chest indrawing or
Look for severe
Fever (37.5°C* or above) or
chest indrawing.
Low body temperature (less
Measure axillary than 35.5°C*) or
temperature. Movement only when
Look at the umbilicus. Is it stimulated or no movement
red or draining pus? at all.
Look for skin pustules.
Umbilicus red or draining pus Yellow: Give an appropriate oral antibiotic
Look at the young infant's
or LOCAL Teach the mother to treat local infections at home
movements.
If infant is sleeping, ask
the mother to wake
INFECTION infant
him/her. Follow up in 2 days
Does the infant move None of the signs of very Green: Advise mother to give home care.
on his/her own? severe disease or local SEVERE DISEASE
If the young infant is not bacterial infection OR LOCAL
moving, gently stimulate INFECTION
him/her. UNLIKELY
Does the infant not
move at all?
* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5°C higher.
** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
Page 42 of 77
CHECK FOR JAUNDICE
If jaundice present, ASK: LOOK AND FEEL: Any jaundice if age less Pink: Treat to prevent low blood sugar
When did the jaundice Look for jaundice (yellow than 24 hours or SEVERE JAUNDICE Refer URGENTLY to hospital
appear first? eyes or skin) CLASSIFY Yellow palms and soles at Advise mother how to keep the infant warm
Look at the young infant's JAUNDICE any age on the way to the hospital
palms and soles. Are they
Jaundice appearing after 24 Yellow: Advise the mother to give home care for the
yellow?
hours of age and JAUNDICE young infant
Palms and soles not yellow Advise mother to return immediately if palms and
soles appear yellow.
If the young infant is older than 14 days, refer to a
hospital for assessment
Follow-up in 1 day
THEN ASK: Does the young infant have diarrhea*?
IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification:
Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C)
Infant's movements Classify stimulated or no movement DEHYDRATION OR
Does the infant move on his/her own? DIARRHEA for at all If infant also has another severe
Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification:
then stops? Skin pinch goes back very Refer URGENTLY to hospital with mother
Does the infant not move at all? slowly. giving frequent sips of ORS on the way
Is the infant restless and irritable? Advise the mother to continue
breastfeeding
Pinch the skin of the abdomen. Does it go back: Two of the following signs: Yellow: Give fluid and breast milk for some dehydration
Very slowly (longer than 2 seconds)? Restless and irritable SOME (Plan B)
or slowly? Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with mother
slowly. giving frequent sips of ORS on the way
breastfeeding
Not enough signs to classify Green: Give fluids to treat diarrhea at home and continue
as some or severe NO DEHYDRATION breastfeeding (Plan A)
dehydration. Advise mother when to return immediately
* What is diarrhea in a young infant?

A young infant has diarrhea if the stools have changed from usual pattern and are many and watery (more water than fecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not diarrhea.
Page 43 of 77
THEN CHECK FOR HIV INFECTION
Positive virological test in Yellow: Give cotrimoxazole prophylaxis from age 4-6
ASK young infant CONFIRMED HIV weeks
Classify INFECTION Give HIV ART and care
Has the mother and/or young infant had an HIV test? HIV Advise the mother on home care
status
IF YES: Mother HIV positive AND Yellow: Give cotrimoxazole prophylaxis from age 4-6
What is the mother's HIV status?: negative virological test HIV EXPOSED weeks
Serological test POSITIVE or NEGATIVE in young Start or continue PMTCT ARV prophylaxis as per
What is the young infant's HIV status?: infant breastfeeding or if national recommendations**
Virological test POSITIVE or NEGATIVE only stopped less than 6 Do virological test at age 4-6 weeks or repeat 6
Serological test POSITIVE or NEGATIVE weeks ago. weeks after the child stops breastfeeding
OR Advise the mother on home care
If mother is HIV positive and NO positive virological test Mother HIV positive, young Follow-up regularly as per national guidelines
in child ASK: infant not yet tested
Is the young infant breastfeeding now? OR
Was the young infant breastfeeding at the time of test Positive serological test in
or before it? young infant
Is the mother and young infant on PMTCT ARV
prophylaxis?*
or young infant HIV INFECTION
UNLIKELY
IF NO test: Mother and young infant status unknown

Perform HIV test for the mother; if positive, perform
virological test for the young infant
* Prevention of Maternal-To-Child-Transmission (PMTCT) ART prophylaxis.

**Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis from birth for 6 weeks if breastfeeding or 4-6 weeks if on replacement
feeding.
Page 44 of 77
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING
PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS"
If an infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL: Not well attached to breast Yellow: If not well attached or not suckling effectively,
Is the infant breastfed? If Determine weight for age. or FEEDING PROBLEM teach correct positioning and attachment
yes, how many times in 24 Look for ulcers or white Classify FEEDING Not suckling effectively or OR If not able to attach well immediately, teach the
hours? patches in the mouth Less than 8 breastfeeds in LOW WEIGHT mother to express breast milk and feed by a cup
Does the infant usually (thrush). 24 hours or If breastfeeding less than 8 times in 24 hours,
receive any other foods or Receives other foods or advise to increase frequency of feeding. Advise
drinks? If yes, how often? drinks or the mother to breastfeed as often and as long as
If yes, what do you use to Low weight for age or the infant wants, day and night
feed the infant? Thrush (ulcers or white If receiving other foods or drinks, counsel the
patches in mouth). mother about breastfeeding more, reducing other
foods or drinks, and using a cup
If not breastfeeding at all*:
Refer for breastfeeding counselling and
possible relactation*
Advise about correctly preparing breast-milk
substitutes and using a cup
infant
Follow-up any feeding problem or thrush in 2 days
Follow-up low weight for age in 14 days
no other signs of inadequate NO FEEDING infant
feeding. PROBLEM Praise the mother for feeding the infant well
ASSESS BREASTFEEDING:
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)
Mouth wide open
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
* Unless not breastfeeding because the mother is HIV positive.
Page 45 of 77
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS
Use this chart for HIV EXPOSED infants not breastfeeding AND the infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL: Milk incorrectly or Yellow: Counsel about feeding
What milk are you giving? Determine weight for age. unhygienically prepared or FEEDING PROBLEM Explain the guidelines for safe replacement feeding
How many times during the Look for ulcers or white Classify FEEDING
Giving inappropriate OR Identify concerns of mother and family about
day and night? patches in the mouth replacement feeds or LOW WEIGHT feeding.
How much is given at each (thrush). If mother is using a bottle, teach cup feeding
Giving insufficient
feed? Advise the mother how to feed and keep the low
replacement feeds or
How are you preparing the weight infant warm at home
milk? An HIV positive mother
mixing breast and other
Let mother demonstrate or Advise mother to give home care for the young
feeds before 6 months or
explain how a feed is infant
prepared, and how it is Using a feeding bottle or
Follow-up any feeding problem or thrush in 2 days
given to the infant. Low weight for age or Follow-up low weight for age in 14 days
Are you giving any breast Thrush (ulcers or white
milk at all? patches in mouth).
What foods and fluids in Not low weight for age and Green: Advise mother to give home care for the young
addition to replacement no other signs of inadequate NO FEEDING infant
feeds is given? feeding. PROBLEM Praise the mother for feeding the infant well
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
Page 46 of 77
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:
IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN A
Birth BCG HEP B0 Give 200,000 IU to the MOTHER within 6

weeks of delivery
6 weeks Pentavalent 1* OPV1 RTV1 PCV1
Give all missed doses on this visit.

Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.
*Note: DPT-HIB-HEP B is available as Pentavalent vaccine
ASSESS OTHER PROBLEMS
ASSESS THE MOTHER’S HEALTH NEEDS
Nutritional status and anemia, contraception. Check hygienic practices. Smoking cessation in the family.
Page 47 of 77
TREAT AND COUNSEL
TREAT THE YOUNG INFANT
GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

Give first dose of both ampicillin and gentamicin intramuscularly.
AMPICILLIN
Dose: 50 mg per kg GENTAMICIN
To a vial of 250 mg
WEIGHT Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 ml sterile water to 2 ml vial containing 80
mg* = 8 ml at 10 mg/ml
Add 1.3 ml sterile water = 250 mg/1.5ml
AGE <7 days AGE >= 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
1.5-<2 kg 0.5 ml 0.9 ml* 1.3 ml*
2-<2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
2.5-<3 kg 0.8 ml 1.4 ml* 2.0 ml*
3-<3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
3.5-<4 kg 1.1 ml 1.9 ml* 2.8 ml*
4-<4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
* Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times
daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.
TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10 ml/kg) sugar water (To make sugar water: Dissolve 4 level
teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.
Page 48 of 77
TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM ON THE WAY TO THE HOSPITAL
Provide skin to skin contact
OR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with
a blanket.
GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL BACTERIAL INFECTION

First-line antibiotic: Amoxicillin drops or suspension
Second-line antibiotic:_________________________________________________________________________________________
AMOXICILLIN
Give 2 times daily for 5 days
AGE or WEIGHT
Drops Suspension
100 mg/ml 125 mg in 5 ml
Birth up to 1 month (<4 kg) 0.6 2.5 ml
1 month up to 2 months (4-<6 kg) 1.25 5 ml
.
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain how the treatment is given.
Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.
To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment twice daily for 5 days: The mother should do the treatment four times daily for 7 days:
Wash hands Wash hands
Gently wash off pus and crusts with soap and water Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger
Dry the area An alternative treatment to gentian violet is Nystatin oral suspension 100,000 units/ml. Give 1-2 ml into
Paint the skin or umbilicus/cord with full strength gentian violet (0.5%) OR the mouth for 7 days
Mupirocin cream 2x a day until dry (usually in 3 days) Wash hands
Wash hands
To Treat Diarrhea, See TREAT THE CHILD Chart.
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Page 49 of 77
Immunize Every Sick Young Infant, as Needed
GIVE ARV FOR PMTCT PROPHYLAXIS

Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis*:
Nevirapine or zidovudine are provided to young infant classified as HIV EXPOSED to minimize the risk of mother-to-child HIV transmission (PMTCT).
If breast feeding: Give NVP for 6 weeks beginning at birth or when HIV exposure is recognized.
If not breast feeding: Give NVP or ZDV for 4-6 weeks beginning at birth or when HIV exposure is recognized.
NEVIRAPINE ZIDOVUDINE (AZT)
AGE
Give once daily. Give once daily
Birth up to 6 weeks:
Birth weight 2000 - 2499 g 10 mg 10 mg
Birth weight > 2500 g 15 mg 15 mg
Over 6 weeks: 20 mg -
* PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART PROPHYLAXIS:

OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR AZT FOR 4-6 WEEKS IF ON
REPLACEMENT FEEDING.
OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NVP OR
AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.
Page 50 of 77
COUNSEL THE MOTHER
TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT
WARM AT HOME
TEACH CORRECT POSITIONING AND ATTACHMENT FOR
Keep the young infant in the same bed with the mother.
BREASTFEEDING Keep the room warm (at least 25°C) with home heating device and make sure that there is no draught
of cold air.
Show the mother how to hold her infant.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm
with the infant's head and body in line. water, dry immediately and thoroughly after bathing and clothe the young infant immediately.
with the infant approaching breast with nose opposite to the nipple. Change clothes (e.g. nappies) whenever they are wet.
with the infant held close to the mother's body. Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
with the infant's whole body supported, not just neck and shoulders. Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's
Show her how to help the infant to attach. She should: head turned to one side.
touch her infant's lips with her nipple Cover the infant with mother's clothes (and an additional warm blanket in cold weather).
wait until her infant's mouth is opening wide When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all
move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple. times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young
infant in a soft dry cloth and cover with a blanket.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
again. Breastfeed the infant frequently (or give expressed breast milk by cup).
TEACH THE MOTHER HOW TO EXPRESS BREAST MILK

Ask the mother to:
Wash her hands thoroughly.
Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they
are opposite each other (at least 4 cm from the tip of the nipple).
Compress and release the breast tissue between her finger and thumb a few times.
If the milk does not appear she should re-position her thumb and finger closer to the nipple and
compress and release the breast as before.
Compress and release all the way around the breast, keeping her fingers the same distance from
the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on
the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.
TEACH THE MOTHER HOW TO FEED BY A CUP

Put a cloth on the infant's front to protect his clothes as some milk can spill.
Hold the infant semi-upright on the lap.
Put a measured amount of milk in the cup.
Hold the cup so that it rests lightly on the infant's lower lip.
Tip the cup so that the milk just reaches the infant's lips.
Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
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COUNSEL THE MOTHER
ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG

INFANT
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT
Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the
infant wants.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
Follow up visit
If the infant has: Return for first follow-up in:
JAUNDICE 1 day
LOCAL BACTERIAL INFECTION 2 days
FEEDING PROBLEM
THRUSH
DIARRHEA
LOW WEIGHT FOR AGE 14 days
CONFIRMED HIV INFECTION According to national recommendations
HIV EXPOSED
WHEN TO RETURN IMMEDIATELY:

Advise the mother to return immediately if the young infant has any of these
signs:
Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow
Page 52 of 77
FOLLOW-UP
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT
LOCAL BACTERIAL INFECTION

After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.
Treatment:
If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.
DIARRHEA
After 2 days:
Ask: Has the diarrhea stopped?
Treatment
If the diarrhea has not stopped, assess and treat the young infant for diarrhea. >SEE "Does the Young Infant Have Diarrhea?"
If the diarrhea has stopped, tell the mother to continue exclusive breastfeeding.
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JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?
Treatment:
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.
FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
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 the mother to return 14 days of this follow up visit. Continue follow-up until the infant is gaining weight well.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.
LOW WEIGHT FOR AGE

After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within 14 days or when she returns for immunization, whichever is the
earlier.
If the 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 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly and is no longer low weight for age.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
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THRUSH
After 2 days:
If thrush is worse check that treatment is being given correctly.
If the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.
CONFIRMED HIV INFECTION OR HIV EXPOSED

A young infant classified as CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits regularly as per national guidelines.
Follow the instructions for follow-up care for child aged 2 months up to 5 years.
Page 55 of 77
Annex:
Skin Problems
IDENTIFY SKIN PROBLEM

↺
Page 56 of 77
IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Itching rash with small papules PAPULAR Treat itching: Is a clinical stage 2 defining case
and scratch marks. Dark spots ITCHING Calamine lotion
with pale centers RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV
An itchy circular lesion with a RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
raised edge and fine scaly area WORM patches existing nail infection which has to be treated
in the center with loss of hair. (TINEA) adequately to prevent recurrence of tinea
If extensive refer, if not give:
May also be found on body or infections of skin.
web on feet Ketoconazole
Fungal nail infection is a clinical stage 2
for 2 up to 12 months(6-10 kg) 40mg per day
defining disease
for 12 months up to 5 years give 60 mg per
day or give griseofulvin 10mg/kg/day
if in the hair, shave hair treat itching as above
Rash and excoriations on torso; SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals, scabies may
burrows in web space and 25% topical Benzyl Benzoate at night, repeat for 3 manifest as crust scabies.
wrists. face spared days after washing and/ or 1% lindane cream or
Crusted scabies presents as extensive areas
lotion once, wash off after 12 hours
of crusting mainly on the scalp, face back and
feet. Patients may not complain of itching. The
scales will be teeming with mites
Page 57 of 77
IF SKIN HAS BLISTERS/SORES/PUSTULES

SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV
Vesicles over body. CHICKEN POX Treat itching as above Presentation atypical only if
Vesicles appear Refer URGENTLY if pneumonia or child is immunocompromised
progressively over jaundice appear Duration of disease longer
days and Complications more frequent
form scabs after they Chronic infection with
rupture continued
appearance of new lesions
for >1 month; typical vesicles
evolve into nonhealing ulcers
that become necrotic, crusted,
and hyperkeratotic.
Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease longer
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Hemorrhagic vesicles, necrotic
body with intense pain Give pain relief ulceration
or scars Follow-up in 7 days Rarely recurrent, disseminated
plus shooting pain. or multi-dermatomal
Herpes zoster is
uncommon in
Is a Clinical stage 2 defining
children except where
disease
they are
immuno-compromised,
for example
if infected with HIV
Red, tender, warm IMPETIGO OR Clean sores with antiseptic

crusts or small lesions FOLLICULITIS Drain pus if fluctuant
Start cloxacillin if size >4cm or red streaks or tender nodes or multiple
abscesses for 5 days ( 25-50 mg/kg every 6 hours)
Refer URGENTLY if child has fever and /
or if infection extends to the muscle.
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NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules with MOLLUSCUM Can be treated by various Incidence is higher
a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm in
commonly seen on the face and trunk in Leave them alone unless size), or coalescent
children. superinfected Double or triple lesions
Use of phenol: Pricking each lesion may be seen
with a needle or sharpened More than 100 lesions
orange stick and dabbing the lesion may be seen.
with phenol Lesions often chronic and
Electrodesiccation difficult to eradicate
Liquid nitrogen application (using Extensive molluscum
orange stick) contagiosum is a Clinical
stage 2 defining disease
Curettage
The common wart appears as papules WARTS Treatment: Lesions more numerous
or nodules with a rough (verrucous) Topical salicylic acid preparations ( and recalcitrant to
surface eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is a
Electrocautery Clinical stage 2 defining
disease
Greasy scales and redness on central SEBORRHEA Ketoconazole shampoo Seborrheic dermatitis may
face, body folds If severe, refer or provide tropical be severe in HIV
steroids infection.
For seborrheic dermatitis: 1%
Secondary infection may
hydrocortisone cream X 2 daily
be common
If severe, refer
Page 59 of 77
CLINICAL REACTION TO DRUGS
DRUG AND ALLERGIC REACTIONS

SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Generalized red, wide spread with small bumps or blisters; or FIXED DRUG Stop medications give oral Could be a sign of reactions to
REACTIONS antihistamines, if pealing ARVs
one or more dark skin areas (fixed drug reactions)
rash refer
Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching
Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
Page 60 of 77
Name: Age: Sex: Weight (kg): Height/Length (cm): Temperature (°C):
Ask: What are the child's problems? Initial Visit? Follow-up Visit? Date:

Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES______NO ______
DOES THE CHILD HAVE DIARRHEA? YES ______ NO______
For how long? ___ Days Look at the child's general condition. Is the child:
Is there blood in the stool? Lethargic or unconscious? Restless and irritable?
DOES THE CHILD HAVE FEVER?(by history/feels hot/temperature 37.5°C or above) YES _____ NO______
Decide malaria risk LOOK AND FEEL:
Does the child live in malaria area? Look or feel for stiff neck
Has the child visited/travelled or stayed overnight in a Look for runny nose
malaria area in the past 3 weeks?
If malaria risk, obtain a blood smear. Look for signs of MEASLES
(+) (Pf) (Pv) (-) (Not done) Generalized rash and
For how long has the child had fever?_____days One of these, cough, runny nose, or red eyes
If more than 7 days, has fever been present every day? Look for any other cause of fever
Has the child had measles within the past 3 months?
If the child has measles now or within the last Look for mouth ulcers. If yes, are they deep and extensive?
3 months: Look for pus draining from the eye.
ASSESS DENGUE HEMORRHAGIC FEVER YES______ NO______
THEN ASK: LOOK AND FEEL:
Has the child had any bleeding from the nose or gums or in Look for bleeding from nose or gums
the vomitus or stool? Look for skin petechiae
Has the chid had black vomitus or stool? Feel for cold and clammy extremities
Has the child had persistent abdominal pain? Check capillary refill_____seconds.
Has the child had persistent vomiting? Perform tourniquet test if child is 6 months or older AND has no other signs
AND has fever for more than 3 days.
DOES THE CHILD HAVE AN EAR PROBLEM? YES_____ NO ______
THEN CHECK FOR ACUTE MALNUTRITION Look for edema of both feet.
AND ANEMIA Determine WFH/L z-score:
Child 6 months or older measure MUAC ____ mm.
If child has MUAC less than 115 mm or WFH/L Is there any medical complication: General danger sign?
less than -3 Z scores: Any severe classification? Pneumonia with chest indrawing?
Child 6 months or older: Offer RUTF to eat. Is the child:
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today), Vitamin A Return for next
status,deworming status, Dental Check-up { Circle if needed today} immunization on:
________________
BCG Pentavalent 1 Pentavalent 2 Pentavalent 3 Measles1 MMR Vitamin A (Date)
Hep B0 OPV-1 OPV-2 OPV-3 Mebendazole/Albendazole
RTV-1 RTV-2 RTV-3 Dental check-up
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, ANEMIA, or is FEEDING
HIV exposed or infected PROBLEMS
If Yes, how?
ASSESS OTHER PROBLEMS: ASK ABOUT MOTHER'S OWN HEALTH
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TREAT
Remember to refer any child who has a danger sign and no other severe classification
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
Page 62 of 77
ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): Temperature (°C): Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positive Send tests that are required ____
Check that child has not breastfed for at least 6 weeks Send confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____ NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5
Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS
Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other
2. ____________________________________________________________
recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
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RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
Page 64 of 77
FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): Temperature (°C): Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ___________________________________________________ ACTIONS
ASK: has the child received care at another health YES ____ NO ____ TAKEN:
facility since the last visit?
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING If general danger signs or ART severe side effects, provide pre-referral treatment
CONVULSIONS and REFER URGENTLY
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Difficulty breathing and severe abdominal pain Refer if necessary.
Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms:
Cough or difficulty breathing
Diarrhea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
TAKEN:
Takes all doses - Frequently misses doses - Not gaining weight for 3 months
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER MEDICATION
ABC+3TC+LPV/r RECORD ART DOSAGES:
ABC+3TC+EFV 1. ____________________________________________________________
Cotrimoxazole 2. ____________________________________________________________
Vitamin A 3. ____________________________________________________________
Other Medication COTRIMOXAZOLE DOSAGE:_______________________________________
VITAMIN A DOSAGE: _____________________________________________
OTHER MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Side-
effects and correct management
Page 65 of 77
RECORD ACTIONS TAKEN:
Page 66 of 77
Name: Age: Sex: Weight (kg): Temperature (°C):
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit? Date:

Look for severe chest indrawing.
Fever (temperature 37.5°C or above, feels hot ) or
low body temperature (below 35.5°C, feels cool)
Look for skin pustules.
Movement only when stimulated or no movement even when stimulated?
DOES THE YOUNG INFANT HAVE DIARRHEA? Yes Look at the young infant's general condition. Does the infant:
____ No ____ move only when stimulated?
Very slowly?
Slowly?
Does the infant usually receive any other foods or drinks? Yes ___ No
___
If yes, how often?
CHECK FOR HIV INFECTION (OPTIONAL)
Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast.
Observe the breastfeed for 4 minutes.
Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)?
not sucking effectively sucking effectively
CHECK THE INFANT'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG Pentavalent 1 RTV 1 PCV1 Vitamin A, 200,000 immunization on:
Hep B 0 OPV-1 I.U to mother ________________
(Date)
ASSESS OTHER PROBLEMS: ASK ABOUT MOTHER'S OWN HEALTH
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TREAT
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
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IMCI

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IMCI

DISTANCE LEARNING COURSE

© World Health Organization 2014

1.1 MODULE OVERVIEW

A sick child is 2 months up to 5 years of age.

MODULE LEARNING OBJECTIVES

WHERE DOES THIS MODULE FIT IN THE IMCI PROCESS?

IMCI FOR THE SICK CHILD (2 months up to 5 years of age)

GREET THE CAREGIVER

CHECK FOR GENERAL DANGER SIGNS ASSESS MAIN SYMPTOMS

URGENT TREAT IN TREAT AT

URGENT REFERRAL REQUIRED REFERRAL NOT REQUIRED REFERRAL NOT REQUIRED

WHAT SECTION OF THE IMCI RECORDING FORM IS USED

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

BEFORE YOU BEGIN

1.2 CHECKING ALL SICK CHILDREN FOR

n OPENING CASE STUDY – LEBO

WHAT IS THE FIRST THING YOU DO WHEN NTHABELENG

WHY IS GOOD COMMUNICATION WITH A CAREGIVER IMPORTANT?

WHAT ARE GOOD COMMUNICATION SKILLS?

WHAT IS THE IMPORTANT INFORMATION YOU GATHER

Weight and temperature

Initial or follow up visit

ASK: first time coming to the clinic for this problem?

INITIAL VISIT FOLLOW-UP VISIT

Watch “Introduction” on the IMCI DVD (disc 1)

Sick child Sick young infant

2. List the important pieces of information you gather during a greeting:

n LET US RETURN TO THE CASE OF LEBO

What is Lebo’s problem? Use the charts:

Is Lebo coming for an initial or follow-up visit?

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

If child has MUAC less than 115 mm or

WHAT IS A GENERAL DANGER SIGN?

✔✔ Child is not able to drink or breastfeed

CHECK FOR GENERAL DANGER SIGNS

Ask: Look: Any general danger sign P

ASK – IS YOUR CHILD ABLE TO DRINK OR BREASTFEED?

ASK – DOES YOUR CHILD VOMIT EVERYTHING?

ASK – HAS YOUR CHILD HAD CONVULSIONS?

LOOK – IS THE CHILD LETHARGIC OR UNCONSCIOUS?

Watch “Demonstration: danger signs” (disc 1)

WHAT DO YOU DO IF A CHILD SHOWS ONE OR MORE

If a child has a general danger sign, you must take

DVD EXERCISE – GENERAL DANGER SIGNS

SELF-ASSESSMENT EXERCISE B (GENERAL DANGER SIGNS)

SELF-ASSESSMENT EXERCISE C (SALINA)

Here is the top part of a Recording Form:

n What will you do for Lebo and Nthabeleng?

HOW DOES THE ASSESSMENT CONTINUE AFTER CHECKING FOR

NO signs present YES, one or more signs present

Child requires urgent referral.

CONTINUE ASSESSMENT: assess for main symptoms (cough or difficult breathing,

First, assess for main symptoms

Second, assess the child’s nutritional status

Then check immunizations, HIV status, and other problems

Blood in the stool. Yellow: Give ciprofloxacin for 3 days

FLIP THROUGH YOUR CHART BOOKLET TO SEE THE

CLASSIFICATION PRE-REFERRAL TREATMENT IDENTIFIED

HOW DO YOU URGENTLY REFER THE CHILD?

3. WRITE A REFERRAL NOTE for the caregiver to carry.

REMEMBER: any child with a general danger sign or

WHAT IF REFERRAL IS NOT POSSIBLE?

When you can refer, remember to:

What is FEVER = 37.5 °C or above