INTEGRATED

MANGEMENT OF
CHILDHOOD
ILLNESSES
(IMCI)

Prepared by: Araceli Flores Surat

Clinical Instructor

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BACKGROUND

 Each year more than 10 million children

in low-and middle-income countries die
before they reach their fifth birthday.
 Seven in ten of these deaths are due to
just five preventable and treatable
conditions: pneumonia, diarrhoea,
malaria, measles, and malnutrition, and
often to a combination of these
conditions

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 Factors
Every day, millions of parents seek
health care for their sick children,
taking them to hospitals, health
centers, pharmacists, doctors and
traditional healers.

Surveys reveal that many sick

children are not properly assessed
and treated by these health care
providers, and that their parents
are poorly advised.
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Factors

At first-level health facilities in low-

income countries, diagnostic supports
such as radiology and laboratory
services are minimal or non-existent,
and drugs and equipment are often
scarce.
 Limited supplies and equipment,
combined with an irregular flow of
patients

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Factors

doctors leave at this level with

few opportunities to practice
complicated clinical procedures.
 they often rely on history and
signs and symptoms to determine
a course of management that
makes the best use of the
available resources.

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These factors make providing
quality care to sick children a
serious challenge.
WHO and UNICEF have
addressed this challenge by
developing a strategy called
Integrated Management of
Childhood Illness (IMCI).

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What is IMCI?

IMCI is an integrated
approach to child health that
focuses on the well-being of
the whole child.
 IMCI includes both preventive
and curative elements that
are implemented by families
and communities as well as by
health facilities.
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 Objectives of IMCI

Major objectives:
To reduce under five
mortality and morbidity.
To improve growth and
development of children.

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In health facilities:
the IMCI strategy promotes
the accurate identification of
childhood illnesses in
outpatient settings
 ensures appropriate
combined treatment of all
major illnesses
 strengthens the counselling
of caretakers
 speeds up the referral of
severely ill children.
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In the home setting:
it promotes appropriate
care seeking behaviors
 improved nutrition and
preventative care, and the
correct implementation of
prescribed care

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How does IMCI accomplish
these goals?

Introducing and
implementing the IMCI
strategy in a country is
a phased process that
requires a great deal of
coordination among
existing health
programs and services.

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 The main steps involve

Adopting an integrated approach

to child health and development in
the national health policy.
Adapting the standard IMCI clinical
guidelines to the country’s needs,
available drugs, policies, and to
the local foods and language used
by the population.
Upgrading care in local clinics by
training health workers in new
methods to examine and treat
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children, and to effectively counsel

 The main steps involve
Making upgraded care possible by
ensuring that enough of the right
low-cost medicines and simple
equipment are available.
Strengthening care in hospitals for
those children too sick to be
treated in an outpatient clinic.
Developing support mechanisms
within communities for preventing
disease, for helping families to care
for sick children, and for getting
children to clinics or hospitals when
needed
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3 Main Components of
Strategy

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1. Improving case management skills of
the health-care staff
 Provision of case management
guidelines and standards.
 Training of public and private health
care providers ( pre- and in-service)
 Follow-up and support supervision of
trained health workers.
 Train health workers in problem
solving in the community
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2. Improving the overall health
system
Sound district planning and
management based on
burden of disease.
Facilitating essential drug
supply and management.
Improving support supervision
at health facilities.
.
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2. Improving the overall health
system
. Strengthen the service quality
and organization at health
facilities.
Reinforce referral services
Ensure equity of access to
health care

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3. Improving family and
community health care
practices
Appropriate and timely care
seeking behavior
Appropriate feeding practices
Appropriate home case
management and adherence
to recommended treatment
prescriptions.
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3. Improving family and community
health care practices
Community involvement I health
service planning and monitoring
Develop interventions to strengthen
community participation.
Promote appropriate family
response to childhood illness
Promote child nutrition
Create safe environment for
children
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 How is IMCI implemented?

IMCI is implemented by
working with local
governments and ministries
of health to plan and
adapt the principles of this
approach to local
circumstances.
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 Case Management Process
- presented on a series of charts
which show the sequence of
steps and provide information for
performing them.
Relies on case detection using
simple clinical signs and
empirical treatment.
The treatments are developed
accdg to action-oriented
classification rather than exact
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diagnosis.
STEPS

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 Step #1: ASSESS the
child or young infant
means taking a history
and doing a physical
examination

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Step #2: CLASSIFY the Illness

 means taking a decision on

the severity of the illness.
 Making use of the 3 color
coded triage system:

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Step #2: CLASSIFY the
Illness
A. classification in a
pink row needs
Urgent attention and
referral or admission.
A severe
classification

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 Step #2: CLASSIFY the
Illness
B. classification in yellow row
means that the child needs an
appropriate antibiotic.
The treatment includes
teaching the mother how to
give the oral drugs or treat
local infections at home.
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Step #2: CLASSIFY the
Illness
Continiation B.
The health worker
advises her about
caring for the child at
home and when she
return .
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Step #2: CLASSIFY the
Illness
C. A classification in
green row means that
the child does not
need specific medical
treatment such as
antibiotics. The health
worker teaches the
mother how to care
for her child at home.

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Step # 3: IDENTIFY treatment

 based from the selected

classification of the disease.

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 Step # 4 : TREAT the child

 means giving treatment in health

center
 prescribing drugs or other
treatments to be given at home
 teaching the mother how to carry out
the treatments.

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 Step # 5: COUNSEL the
mother
Includes assessing how the
child is fed
about the foods and fluids to
give the child
when to bring the child back to
the health center.
 Health of the mother

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Step# 6: Give FOLLOW-UP care :

includes when to bring back the

child to the center

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HOW TO SELECT THE APPROPRIATE
CASE MANAGEMENT CHARTS?

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Decide which age group is in:

1. Age 1 week up to 2 months

 Use the Chart ASSESS CLASSIFY

AND TREAT THE SICK YOUNG
INFANT.

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2. Age 2 months up to 5 years
 Use ASSESS AND CLASSIFY THE SICK
CHILD AGE 2 MONTHS UP TO 5 YEARS
means the child has not yet had his 5th
birthday. This age group includes a child
who is 4 years and 11 moths but not a
child who is 5 year old.
If the child who is 2 months old would be
in the group 2 months up to 5 years, not
in the group 1 week up to 2 months

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

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WHAT TO DO:

1. When you see the mother and the sick child:

Greet the mother appropriately and ask
her to sit with the child.
Know the child’s age so you can
choose the right management chart.
Look at the child’s record to find the
child’s age .

If the child’s age is 2 months up to 5

years, assess and classify the child
according to the steps on the ASSESS &
CLASSIFY chart.
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If the child is 1 week up to 2
months, assess and classify the
young infant according to the
steps on the YOUNG IFANT chart
Look also if the child’s weight
and temperature have been
measured and recorded. 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.
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2. Ask the mother what are child’s problem
are and record in the recording form
using good communication skills.
 Listen carefully to what the mother tells
you. This will show her that you are taking
her concerns seriously.
 Use words the mother will understand. If
she does not understand the questions
you ask, she cannot give information you
need to assess the child and to classify
his or her illness correctly.
 Give the mother time to answer the
questions. She may need time to decide
whether the sign you’ve asked about is
present.
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Ask additional questions
when the mother is not sure
about her answer. When you
ask about a main symptom or
related sign, the mother may
not be sure if t is present. Ask
he additional questions to
help her give clearer answer.

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Communicating well with the
mother helps reassure her that her
child will receive good care.
Determine if this is an initial visit or
follow – up visit for this problem.
If follow-up visit: If the child was
seen a few days ago for the
same illness, use the follow-up
visit for this problem
If initial visit: If this is the child’s
first visit for this episode of an
illness, assess the child from the
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1st step.
 A. Check for General Danger
Signs
A child with a general danger sign has
a serious problem.
Needs URGENT referral to the hospital
Complete the rest of the assessment
immediately.

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 General Danger Signs:
1. Unable to drink or breastfeed

2. Convulsion

3. Vomits everything

4. Lethargic/abnormally
sleepy/unconscious
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 1. Is the child able to drink or breastfeed?

A child has the sign “not able to drink or

breastfeed” If the child is too weak to drink
and is not able to suck or swallow when
offered a drink or breast milk
When you ask the mother if the child is able
to drink, make sure that she understand your
question.
If she says that the child is not able to drink
or breastfeed, ask her to describe her child
what happens when she offers the child
something to drink.
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NOTE:
If you are not sure about the mother’s
answer, ask her to offer the child drink of
clean water or breast milk. Look to see if
the child is swallowing the water or
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 breastfed after
his nose is cleared, the child does not
have the danger sign, “not able to drink
or breastfed”.

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 2. Does the child vomit everything
he or she takes in?
• A child who is not able to hold anything
down at all has the sign “vomits everything”.
A child who vomits everything he or she takes
in will not be able to hold down food, fluids,
or oral drugs.
• What goes down goes up. A child who vomits
several times but can hold down some fluids
does not have this general danger sign.
• Ask the mother how often the child vomits.
Also ask, if the child vomits each time he or
she swallow foods or fluids.
• If you are no sure of the answer, ask the
mother to offer the child drink and see if the
child will vomit.
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 3. Has the child had
convulsions?

 During a convulsion, the child’s arms and legs

stiffen because the muscles are contracting.
 The child may lose consciousness or may not
be able to respond to spoken directions and
handling, even his eyes are open.
 Ask the mother if the child has had convulsion
during this current illness.

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 3. Has the child had
convulsions?
Use words the mother
understands like “ fits or spasms”
or “jerky movements”
Children may shiver when the
fever is rising rapidly. A child that
shivers does not lose
consciousness, he is always
awake and responds to directions
and handling.
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 4. Look : See if the child is
abnormally sleepy or difficult
to awaken
An abnormal sleepy child is
not awake and alert when he
or she should be.
He or she is drowsy
 does not show interest in what
is happening around him or
her.
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4. Look : See if the child is
abnormally sleepy or difficult to
awaken
The child does not look at his
or her mother or watch your
face when you talk
 The child may stare blankly
and appear not to notice
what is going on around him
or her
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 4. Look : See if the child is
abnormally sleepy or difficult to
awaken
 A child who is abnormally sleepy or is difficult
to awake does not respond when he or she
touched, shaken or spoken to.
 Ask the mother if the child seems unusually
sleepy or if she cannot wake the child.
 Look to see if the child wakens when the
mother talks or shakes the child or when you
clap your hands.
If the child is sleeping and has cough or
difficult breathing, count the number of
breaths first before you try to wake the
child.
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 B. ASK ABOUT THE MAIN
SYMPTOMS
1. Cough or difficult breathing

2. Diarrhea

3. Fever

4. Ear Problem

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 B1. Assess Cough or Difficult
Breathing

A child with cough or difficult

breathing is assesses for:
How long the child has had
cough or difficult breathing
Fast breathing
Chest indrawing
Stridor in calm child.
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 B1. Assess Cough or Difficult Breathing

Ask: Does the child have cough or

difficult breathing?
If the mother says NO, look to see if
you think the child has cough or
difficult breathing.
If the child does not have cough or
difficult breathing, ask about the main
symptom diarrhea. Do not assess the
child further for signs related to cough
or difficult breathing.
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 B1. Assess Cough or Difficult
Breathing
If the mother says YES, ask the next
question
Ask: for how long?
A child who has cough or
difficult breathing for more than 30
days has chronic cough. This may
be a sign of tuberculosis, asthma,
whooping cough or another
problem

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 B1. Assess Cough or Difficult
Breathing
Look and listen:
Count the child’s breaths in one minute to
decide if the child has fast breathing. The
child must be quiet an calm when you
look and listen to his breathing
Tell the mother you are going to count
her child’s breathing. Remind her to keep
her child calm.
 If the child is sleeping, do not wake the
child.
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 B1. Assess Cough or Difficult
Breathing

Cut –off for Fast breathing:

The cut-off for fast breathing
depends on the child’s age.
Normal breathing rates are
higher in children age 2 month
up to 12 months than in
children age 12 months up to
5 years.
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 B1. Assess Cough or Difficult
Breathing
Cut –off for Fast breathing:
The cut-off for fast breathing depends
on the child’s age.
Fast breathing IF:
1 week – 2 months - 60 or more breaths
per minute
2 months – 12 months – 50 breaths or
more
12 months – 5 years - 40 breaths or
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more
 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when
the child breaths IN
The child has chest indrawing if
the lower chest wall goes IN
when the child breath IN.
In normal breathing: The whole
chest wall ( upper and lower)
and the abdomen move OUT
when the child breaths IN.
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 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when
the child breaths IN
If can’t hardly visualize the chest
indrawing
ask the mother to change the
position of the child lying flat in her
lap. If still you do not see the lower
chest wall go IN when the child
breaths IN, the child does not
have chest indrawing
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 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when
the child breaths IN
Chest indrawing should be
present , must be clearly visible
at all time. If you any see chest
indrawing when the child is
crying or feeding, the child does
not have chest indrawing.
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 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when
the child breaths IN
If the child has abdominal
distention and malnutrition,
what appears to be chest
indrawing may not be the “real
chest indrawing”.

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 B1. Assess Cough or Difficult
Breathing
Look and listen for stridor

 Stridor is a harsh noise made when the

child breaths IN.
Stridor happens when there is a swelling
of the larynx, trachea or epiglottis,. This
swelling interferes with air entering the
lungs.
It can be life threatening when the
swelling causes the child’s airway to be
blocked.
A child who has stridor is a dangerous
condition.
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 B1. Assess Cough or Difficult
Breathing
Look and listen for stridor
 To look and listen for stridor,, look to
see when the child breaths IN.
Listen for the stridor. Put your ear
near the child’s mouth because
stridor can be difficult to hear.
The child should be calm.
You may hear a wheezing noise
when the child breaths OUT. This is
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not stridor it is WHEEZES.

B2. Classify cough or difficulty in
breathing

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 B2. Classify cough or difficulty in
breathing
Classification of cough 0r
difficult breathing:
• Severe Pneumonia or Very Severe
Disease

• Pneumonia

• No Pneumonia: Cough or Cold

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 2. Assess Diarrhea

A child with diarrhea is

assessed for:
How long the child has had
diarrhea
Blood in the stool to
determine if the child has
dysentery
Signs of dehydration
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 2. Assess Diarrhea

ASK: Does the child have diarrhea?

 If he mother says NO, ask about the
next main symptom, fever. You do
not need to assess the child further
signs related to diarrhea.
 If the mother says YES, if the mother
said earlier that diarrhea was the
reason for coming to the health
center, record her answer. Then
assess the child for signs of
dehydration, persistent diarrhea
and dysentery.
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 2. Assess Diarrhea

a. ASK : For how long?

Diarrhea which last 14 days or
more is persistent diarrhea.
Give the mother time to
answer the question. She may
need time to recall the exact
number of days.

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 2. Assess Diarrhea

b. ASK : Is there blood in the stool?

Ask the mother if she has seen
blood in the stools at any time
during the episode of diarrhea.

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2. Assess Diarrhea

c. CHECK for signs of Dehydration

 at first restless and irritable.
 If dehydration continues, the child
becomes abnormally sleepy or difficult
to awaken
 As child’s body loses fluids,, eyes may
look sunken
 When pinched, skin goes back slowly or
very slowly

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2. Assess Diarrhea
d. LOOK for the condition of the
child
• abnormally sleepy or difficult to
awaken?
•Restless and irritable?
A child has the sign restless and
irritable if the child is restless and
irritable
•Has sunken eyes?

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 2. Assess Diarrhea
d. LOOK for the condition of the child
Ask the mother if she thinks her child’s eyes
look unusual. Her opinion helps you
confirm that the child’s eyes are sunken.
In a severely malnourished child who is
visibly wasted ( that is, who has
marasmus), the eyes may always look
sunken, even if the child is not dehydrated.
Even though sunken eyes is less reliable in
a visibly wasted child, still use the sign to
classify the child’s dehydration.
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 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able
to dink or drinking poorly? Drinking
eagerly, thirsty?
Ask the mother to offer the child some
water in a cup or a spoon. Watch the
child drink. If the child is exclusively
breastfeed, offer expressed breast milk.
A child is not able to drink if he is not
able to take fluid in his mouth and
swallow it. or not able to suck and
swallow.
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 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able
to dink or drinking poorly? Drinking
eagerly, thirsty?
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.

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 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to
dink or drinking poorly? Drinking eagerly,
thirsty?
A child is drinking eagerly, thirsty if it
is clear that the child wants to drink.
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
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 2. Assess Diarrhea

f. FEEL for the following . Pinch

the skin of the abdomen,
assess skin turgor
 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 in her lap.

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 2. Assess Diarrhea

f. FEEL for the following . Pinch

the skin of the abdomen,
assess skin turgor
 Locate the area on the child’s
abdomen halfway between the
umbilicus and the side of he
abdomen.
 Use you thumb and first finger, do
not use your fingertips because this
will cause pain.

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 2. Assess Diarrhea

f. FEEL for the following . Pinch

the skin of the abdomen,
assess skin turgor
Place your hand in line up and down
the child’s body and not across the
child’s body.
Firmly pick up all the layers of the ski
and the tissue under them.
Pinch the skin for one second and
then release it.

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 2. Assess Diarrhea

f. FEEL for the following . Pinch

the skin of the abdomen,
assess skin turgor
Look if the skin goes goes
back
• Very slowly (longer than 2
seconds)
• Slowly?
• Immediately
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 2. Assess Diarrhea

f. FEEL for the following . Pinch the skin of

the abdomen, assess skin turgor
 In a child with marasmus, the skin may
go back slowly even if the child is not
dehydrated.
 In an overweight child or a child with
edema, the skin may go back
immediately even if the child is
dehydrated.
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 2. Assess Diarrhea

f. FEEL for the following . Pinch the skin of

the abdomen, assess skin turgor
 Even though skin pinch is less reliable in
these children, still use it to classify the
child’s dehydration.

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 B2. Classify Diarrhea
There are three classification tables
for classifying diarrhea:
All children with diarrhea are
classified for dehydration
If the child had diarrhea for 14
days or more, classify the child
for persistent diarrhea
If the child has blood in the
stool, classify the child with
dysentery.
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 B3. Classify Dehydration
To classify the child’s dehydration ,
begin with the pink row.

If two or more of The signs in

the pink row are present,
classify the child as having
SEVERE DEHYDRATION

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 B3. Classify Dehydration

If two or more of the signs are

not present, look at the yellow
row. If two or more of the signs
are present, classify the child
as having SOME
DEHYDRATION

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 B3. Classify Dehydration

If two or more of the sign

from the yellow row are not
present, classify the child
having NO DEHYDRATION.

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 B4. Classify Persistent
Diarrhea
Severe Persistent Diarrhea - If
a child has had diarrhea for 14
days or more and also has
some or severe dehydration.
Persistent Diarrhea – A child
who has had diarrhea for 14
days or more and who has no
signs of dehydration.
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Classify Dysentery

Dysentery – blood in the

stool

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SELECTING THE APPROPRIATE TREATMENT PLAN
ACCORDING THE DEGREE OF DEHYDRATION

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TREATMENT PLAN A: TREAT
DIARRHEA AT HOME

ARACELI F. SURAT
A. Counsel the mother regarding the 3
Rules of Home Treatment:

1. . Give Extra Fluid ( as much as the child

will take)
a. Tell the mother:
Breastfeed frequently and for a longer
time at each feeding
If the child is exclusively breastfed,
give ORS or clean water in addition to
breast milk
If the child is not exclusively breastfed,
give one or more of the following:
ARACELI F. SURAT
A. Counsel the mother regarding the 3
Rules of Home Treatment:

1. . Give Extra Fluid ( as much as the child

will take)
a. Tell the mother:
If the child is not exclusively breastfed,
give one or more of the following:
ORS solution, food-based fluids ( such s
soup, rice water, or buko juice) or clean
water.
Give the child frequent sips from a cup
If the child vomits, wait for 10 minutes.
Then continue, but more slowly
ARACELI F. SURAT
A. Counsel the mother regarding the 3
Rules of Home Treatment:
1. . Give Extra Fluid ( as much as the child
will take)
a. Tell the mother:
If the child is not exclusively breastfed,
give one or more of the following:
Continue giving the extra fluid until the
diarrhea stops
It is especially important to give ORS at
home when:
The child has been treated with Plan B
or Plan C during the visit
The child cannot return to a health
center if the diarrhea gets worse
ARACELI F. SURAT
A. Counsel the mother regarding the 3
Rules of Home Treatment:
1. . Give Extra Fluid ( as much as the child
will take)
B. Teach the mother how to mix and give
ORS
Give the mother 2 packets of ORS to use
at home
Show the mother how much fluid to give
the child in addition to he
 child’s usual fluid intake:
Up to 2 years 50 to 100 ml after
each loose stool evacuation
2 years or more 100 to 200 ml after each
loose evacuation
ARACELI F. SURAT
B. Continue Feeding
 Assess the child’s feeding pattern
 Ask questions about the child’s
usual feeding and his or her
feeding during illness. Compare
the mother’s answers with the
Feeding Recommendations for
the child’s age n the Box below.

ARACELI F. SURAT
B. Continue Feeding
 Assess the child’s feeding pattern
 ASK:
 Do you breastfeed your child?
How many times do you do so
during the day?
Do you also breastfeed during
the night?
Does the child take in any other
food or fluid?
ARACELI F. SURAT
B. Continue Feeding
What food or fluid does the
child take in?
How many times per day does
the child take in this food or
fluid?
What do you use to feed the
child?
If he child has very low weight
for age: How large are his or
her servings? Is the child given hi or her own
serving? Who feeds the chills and how?

ARACELI F. SURAT
B. Continue Feeding
During this illness, has the child’s
feeding changed? If yes,, in what way
has it changed?
Advise the mother to increase the
child’s Fluid Intake during Illness
For any sick child:
Breastfeed the child more
frequently an for a longer time
each feed
Increase the child’s fluid
intake. For example, give the
child soup, rice water, buko
juice or clean water
ARACELI F. SURAT
B. Continue Feeding
During this illness, has the child’s
feeding changed? If yes,, in what way
has it changed?
Advise the mother to increase the
child’s Fluid Intake during Illness
For a Child with diarrhea:
Giving the child extra fluid can
save his or life. Give the child fluid
according to Plan A or Plan B on
the TREAT the CHILD chart.
Instruct the mother what are the
recommended food to be given to
the child depending on the child’s
age
ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
If the child is not being fed as
described in the above
recommendations, counsel the
mother accordingly.
If the mother reports difficulty with
breastfeeding, assess the child’s
breast feeding. If needed show
the mother the correct positioning
and attachment for
breastfeeding.
ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
If the child is less than 4 months old and is
taking other kinds of milk of foods:
Build the mother’s confidence by telling
her that she can produce all the breast
milk that her child needs.
Suggests giving the child more frequent,
longer breastfeed, day and night, and
gradually reducing the child’s intake of
other kinds of milk or foods.

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
If the child’s intake of other kinds of milk
needs to be continue, counsel the mother
to:
Breastfeed the child often as possible,
including at night.
Make sure that the other kind of milk to
be given to h child is a locally appropriate
breast milk substitute, and give it to the
child only when necessary,
Make sure that the other kind of milk to be
given Is correctly and hygienically prepared,
and that it is given in adequate amounts
ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
Prepare only an amount of milk that
the child can consume within an hour.
Discard leftover milk, If any.
If the mother is using a bottle to feed
the child:
Recommend substituting a cup for a
bottle
Show the mother how to feed the
child using a cup
ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
IF the child is not being fed actively,
counsel the mother to:
Sit with the child while the latter is
eating, and encourage him or her
to eat
Give he child an adequate
serving in a separate late or bowl.
Observe what the child likes and
consider these in the preparation
of hjs or her food.
ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 If the child I not feeding well during
illness, counsel the mother to:
 Breastfeed the child more frequently and
for a longer time at each feed, if possible.
 Give the child soft, varied and appetizing
foods, as well as the child’s favorite foods,
to encourage him or her to eat as much
as possible and offer the child frequent
small feedings.

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 Clear the child’s blocked nostril if
they interfere with his o her feeding.

 Expect the child’s appetite to

improve as he or she gets better.

ARACELI F. SURAT
Feeding Recommendations
for a child who has Persistent
Diarrhea:
.

ARACELI F. SURAT
If the child is still breastfeeding,
give him or her more frequent,
longer breastfeeds, day and night

ARACELI F. SURAT
If the child is taking other kinds of
milk, such as milk supplements:
Replace these with increased
beast feeding or
Replace half the child’s milk
intake with nutrient rich, semi-solid
foods
Do not give the child condensed
milk or evaporated milk.
For other foods, follow the
feeding recommendations for
the child’s age.
ARACELI F. SURAT
 Know when to Return
Advise the mother regarding when to
return to the Health Center if the
child has any of these signs:
Persistent diarrhea
Return after 5 days
Ask: Has the diarrhea stopped?
 How many times does the child
evacuate loose stool per day?

ARACELI F. SURAT
 Treatment:
If the diarrhea has not stopped ( the child still
evacuates loose stool 3 or more times per
day), conduct a full assessment of the child.
Give him or her any treatment he or she
needs. Then, refer the child to a hospital.
If the diarrhea has stopped ( the child
evacuates loose stool less than 3 times per
day), tell the mother to follow he usual
recommendations for the child’s age.

ARACELI F. SURAT
Feeding problem

return after 5 days

Reassess the child’s feeding
ASK about any feeding problem
found in the initial visit
Counsel the mother about any
new or continuing feeding
problem of the child. If you will
counsel the mother to implement
significant changes in feeding, ask
her to brig the child back to the
health center for follow-up
ARACELI F. SURAT
TREATMENT PLAN B : TREAT SOME
DEHYDRATION WITH ORS

ARACELI F. SURAT
Determine the amount of ORS to give to
the child during the first 4 hours.
Use the child’s age only when
you do not know the weight.
The approximate amount of
ORS required ( in ml ) can also
be calculated by multiplying the
child’s weight ( in kg ) by 75.
If the child wants more ORS
than shown, give him or her
more.
ARACELI F. SURAT
For infants under 6 months of age
who are not being breastfeed,
give 100 -200 ml clean water as
well during this period.
Show the mother how to give ORS
solution to her child:
Give the child frequent sips from a
cup.
If the child vomits, wait for 10
minutes. Then continue, but more
slowly.
Continue breastfeeding
whenever the child wants o be
breastfeed.
ARACELI F. SURAT
After 4 hours:
Reassess the child and
classify him or her for
dehydration
Select the appropriate
plan to use in
continuing the
treatment
Begin feeding the child
in the health center
ARACELI F. SURAT
If the mother must leave before completing
the treatment:

Show her how to prepare ORS solution at home

Show her how much ORS to give her child to
finish the 4 hour treatment at home.
Give her enough ORS packets to complete her
child’s rehydration. Also, give her 2 packs as
recommended in Plan A.
Explain to her the 4 rules of home treatment:
Give Extra fluid
Continue feeding
Know when to return
Zinc supplement
ARACELI F. SURAT
TREATMENT PLAN C : TREAT SEVERE
DEHYDRATION QUICKLY

ARACELI F. SURAT
Assess the following:

can you give intravenous fluid

immediately
Is IV treatment available nearby (
within 30 minutes)
Are you trained to use a NGT for
rehydration?
Can the child drink?

Refer urgently to a hospital for IV or

NG treatment.
ARACELI F. SURAT
IF YOU CAN GIVE INTRAVENOUS FLUID TO
THE PATIENT :

Start IV fluid immediately. If he child

can drink, give ORS by mouth while the
drip is being set up. Give 100 ml/kg
Ringer’s Lactate Solution ( if not
available, use normal saline), divided as
follows:
Repeat once the radial pulse is still
very weak or is not detectable.
Reassess the child every 1 -2 hours. If the
child’s hydration status does not improve,
give the IV drip more rapidly.

ARACELI F. SURAT
Also give ORS (about 5
ml/kg/hr) as soon as the child
can drink: usually after 3 – 4
hours ( infants) or 1- 2 hour (
children)

Reassess an infant after 6 hours

and a child after 3 hours.
Classify the dehydration. Then
choose the appropriate plan (
A,B,C) to continue the
treatment.
ARACELI F. SURAT
IF THERE IS IV TREATMET
AVAILABLE EARBY WITHIN 30
MINUTES:

Refer the child urgently o a

hospital for IV treatment
If he child can drink, provide
the mother with ORS solution
and show how to give the
child frequent sips of it during
the trip.
ARACELI F. SURAT
IF YOU ARE TRAINED TO PLACE NGT
FOR REHYDRATION AND IF THE
CHILD ABLE TO DRINK:

Start the rehydration by tube (

mouth) with ORS solution: Give 20
ml/kg/hr for 6 hours ( total of 120
,l/kg)
Reassess the child every 1 – 2 hours
If there is repeated vomiting or
increasing abdominal distention,
give the fluid more slowly.
ARACELI F. SURAT
If the child’s hydration status has
not improved after 3 hours, send
the child for IV therapy.

After 6 hours, reassess the child.

Classify the dehydration. Then
choose the appropriate plan ( A,
B, C ) to continue the treatment.
If possible, observe the child
at least 6 hours after
rehydration to be sure that the
mother can maintain the
hydration, giving the child ORS
solution by mouth.
ARACELI F. SURAT
REVIEW FROM IMCI
PART 1
 IMCI
- Background
- Definition
- Objective
- How IMCI implemented
- Case management process
 STEPS
1. ASSESS – history and PE
2. CLASSIFY THE ILLNESS
a. PINK ROW
b. YELLOW ROW
c. GREEN ROW
3. IDENTIFY TREATMENT
 STEPS
4. TREAT THE CHILD

5. COUNSEL THE MOTHER

6. GIVE FOLLOW UP CARE

 DANGER SIGN
1. UNABLE TO DRINK AND
BREASTFEEDING
2. CONVULSION
3. VOMITS EVERYTHING
4. LETHARGIC / ABNORMALLY /
SLEEPY / UNCONCIOUS
ASK ABOUT THE MAIN
SYMPTOMS
1. COUGH OR DOB
2. DIARRHEA
3. FEVER
4. EAR PROBLEM
IMCI PART 2
 3RD MAIN SYMPTOM:
FEVER

• A child with fever may have Malaria,

Measles or another severe disease.
• Or a child with fever may have simple
cough or cold or other viral infection.
 MALARIA
• Caused by parasites in The blood
called plasmodia.
• Transmitted through the bite of
anopheles mosquitoes.
• Plasmodium Falciparum is the most
dangerous specie of plasmodia.
• Fever is the main symptom of
malaria.
• Other signs: shivering
sweating
vomiting
• A child with malaria may have chronic
anemia ( with no fever) as the only
sign of illness.
• Signs of malaria can overlap with
signs of other illnesses.
 DECIDING MALARIA
RISK
• Palawan • Agusan del Sur
• Davao Oriental • Mindoro
• Davao del Norte Occidental
• Compostela Valley • Kalinga Apayao
• Tawi-tawi • Agusan del Norte
• Sulu • Isabela
• Cagayan • Misamis Oriental
• Quezon • Quirino
• Ifugao • Mt.
• Zambo. Sur Province
• Davao • Basilan
• Bukidnon
 Malaria Risk areas in
Region VI
• 1. Caluya Island,
Antique
• 2. CHICKS area in
Negros
C – Candone • K – Kabankalan
H- Hinoba-an • S – Sipalay
I – Ilog
C - Calatrava
• Note:You may see children with fever in a no
malaria area who have been in a malaria risk
area in the past 4 weeks. These children
should be considered to be at risk of
malaria. Therefore, you should ask all
children with ever in no malaria risk areas
whether they have been in areas where
there is a risk of malaria in the past 4
weeks, and take blood smear from them.
 Measles
• Fever and generalized rash The main
signs of measles.
• Measles is highly infectious
• Caused by a virus, infecting the skin
and the layer of cells that line the
lungs, gut, eye, mouth and throat.
Complications of measles
• Occur in about 30% of all cases
• Diarrhea
• Pneumonia
• Stridor
• Mouth ulcers
• Ear infection
• Severe eye infection ( which may lead to
corneal ulceration and blindness)
• Encephalitis ( brain infection) occurs
in about one in one thousand cases.
- may have general danger sign such
as convulsions or abnormally sleepy or
difficult to awaken.
• Measles contributes to malnutrition
because it causes diarrheas high fever and
mouth ulcers that interfere feeding.
• Malnourished children are more likely to
have sever complications due to measles
especially those who lacks vitamin A.
• 1 in 10 severely malnourished children with
measles may die.
 Dengue Hemorrhagic
Fever
• Caused by a virus that is spread by
Aedes Mosquitoes.
• Have fever which may last for
several days.
• Causes damage to the blood and
blood vessels which may lead to
bleeding.
• Petechiae are seen in the skin.
• May bleed from the mouth or nose or my
vomit black fluid or pass black stools
showing that they are bleeding from the
stomach or intestines.
• The most severe signs of DHF often occur
in the 2 days after the fever has
disappeared.
• The management of DHF depends on
looking for signs that a child is
bleeding and that he is or may
become shocked. Shock must be
treated with IVF and all cases of
DHF MUST be referred.
 Deciding Dengue Risk
• All regions of the country are
endemic for dengue.
• The National Capital Region is highly
endemic all year round with a peak
two months after the rainfall.
ASSESS FOR FEVER
• A child has the main symptom fever
if:
The child has a history of fever
The child feels hot
The child has an axillary temperature
of 37.c or above
ASK: Does the child have
fever?
• Check to see If the child has a
history of fever, feels hot has a
temperature of 37.5 or above.
• Feel the child’s stomach or axilla and
determine if the child feels hot.
• If the child does not have fever ( by
history, feels hot or Temperature
37.5 or above) ASK about the next
main symptoms EAR problem.
• If the child has fever, assess for
additional signs related to fever.
• Note: Assess the child’s fever even
if the child does not have a
temperature of 37.5 or above or does
but feel hot.
• History is enough to assess the child
for fever.
 Decide if it is Malaria
Risk
• ASK whether the child lives in a
malaria area or whether the child has
visited malaria area in the last 4
weeks.
 ASK: For how long?
• If more than 7 days
• has fever been present everyday?
 A fever which has been present
everyday for more than 7 days can mean
that the child has a more severe disease
such as TYPHOID FEVER.
 Refer the child or further assessment.
 ASK: Has the child had measles
within the last 3 months?

Note:
 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 due to
complications of measles such as
eye infection.
 Look or Feel for Stiff
Neck
• A child with fever and stick neck may
have MENINGITIS.
• A child with meningitis needs urgent
treatment with injectable antibiotics
and referral to a hospital
• While you talk with the mother
during the assessment, LOOK to see
if the child moves and bends his neck
easily as he looks around. If the child
is moving and bending his neck, he
does not have a stiff neck.
• If you do not see any movement, or if
you are not sure, draw the child’s
attention to his umbilicus or toes.
 Look for runny nose
• A runny nose in a child with fever may
mean that the child has common cold.
• Ask the mother if the child has had runny
nose only with this illness.
• When there is malaria, a child with fever
an a runny nose does not need an
antimalarial. The child’s fever is probably
due to the common cold.
Look for signs suggesting
MEASLES
• Look for a generalized rash and one
of the following: cough, runny nose,
red eyes.
1. Generalized rash
A measles rash does not have a
vesicles (blisters) or pustules. It
does not itch.
 Chicken Pox a generalized rash with
vesicles.
 Scabies occurs on the hands, feet, ankles,
elbows, buttocks and axilla. It also itches.
 Heat rash can be a generalized rash with
small bumps and vesicles which itch. A
child with heat rash is not sick.
• Generalized rash
found in measles
• Koplick spots
• Scabies rash
• Chicken pox rash
• 2. Cough, runny nose or red eyes
To classify a child as having
measles, the child with fever must
have a generalized rash AND one of
the following signs: cough, runny nose
or red eyes.
• The child has red eyes if there is
redness in the white part f the eye.
• In a healthy eye, the white part of
the eye is clearly white and not
discolored.
 Look for mouth ulcers
• Are they deep and
extensive?
• Mouth ulcers are
different than the
small spots called
Koplik spots.
• Koplik spots in he
mouth insid the cheek
during early stages of
he measles infection.
They are small,
irregular, bright red
spots with a white
spot in the center.
They don’t interfere
with drinking or
eating. Don’t need
treatment.
 Look for Pus draining
from the eye
• Pus draining fro the eye is a sign of
conjunctivitis.
- an infection o the conjunctiva,
the inside surface of the eyelid and
the white part of the eye.
• Often PUS forms a crust when the
child is sleeping and seals the eye
shut.
 Look for clouding of the
cornea
• The normal cornea is clear.
• Look carefully at the cornea for
clouding. The cornea may appear
clouded or hazy.
• Clouding may occur in one or both
eyes.
• Corneal clouding is a dangerous
condition.
• Due to: Vit A Deficiency which has
been worsen by measles.
• If not treated: Cornea can ulcerate
an can cause blindness
• A child with corneal clouding needs
vitamin A.
• A child wit corneal clouding may keep
his eyes shut when exposed to light.
Light cause irritation and pain to the
child’s eye.
• To check for the child’s eye, WAIT
for the child to open hi eye OR
gently pull down the lower eyelid to
look or clouding.
• If there is clouding of the cornea
ASK the mother for how long the
clouding has been present.
• If the mother is certain that the
corneal clouding has been there for
some time, ASK if the clouding has
already been assessed and treated t
the hospital. If it has, you don't need
to refer again the child for corneal
clouding.
 Dengue Hemorrhagic
Fever
• Assess all children 2 months of age
or older with fever in areas where
there is a risk of DHF.
 Decide Dengue Risk
• Has the child has any bleeding from
the nose or gums, in the vomitus or in
the stools since the present illness
started?
• Has the child had black vomitus in
this illness?
• Has the child had black stools?

• Has the child had abdominal pain?

• Has the child been vomiting?

 Look and Feel for signs
of Bleeding and Shock
• Bleeding manifestations:
 Look for bleeding from the nose and gums
 Skin Patechiae- are small hemorrhages in
the skin. They look like small dark red
spots or patches in the skin. They re not
raised and they are not tender. If you
stretch the skin they do no lose their
color. Mostly seen on the abdomen, chest
and extremities.
 Look and feel for signs
suggesting Shock
• Shock is a condition where the blood
circulation is failing.
• Children who have shock need urgent
attention including referral.
• A child with shock looks pale and
abnormally restless and abnormally
sleepy or difficult to awaken.
• In a child at risk for dengue hemorrhagic fever,
they feel clammy extremities and slow capillary
refill.

• Cold Clammy Extremities

- Take the child’ hands in yours. If the child's hand
feels warm the child has no problem on circulation
and no need to check capillary refill but if the
child’s hands are cold or clammy, the child is in
shock and assess the capillary refill.
• Slow Capillary Refill
Hold the child's hand or foot. Look at the
pink nailbed of the thumb or big toe.
For 2 seconds apply minimum pressure
needed to make the nailbed lose its pink
color.
Release the pressure and watch to see how
quickly the pink color returns to the
nailbed
• Interpretation:
• <3 seconds – the circulation is
adequate
• >3 seconds- circulatory failure which
may progress to profound shock.
 Tourniquet test
• If the child is not in shock, has no
signs of bleeding or petechiae, has no
abdominal pain or vomiting and is 6
months or older and fever present
for more than 3 days do the
tourniquet test
 How:
• 1. Take a systolic BP and diastolic BP using a
pediatric cuff.
• 2. Inflate the cuff to a pressure halfway between
the sytolic and diastolic pressure and keep that
pressure for 5 minutes.
• 3. Release the pressure and a draw a one-inch
square below the cuff on the front surface of the
forearm ( 1 inch is about the size of the last joint
of the index). Count the number of petechiae
inside the square. If there are 20 or more the
test is positive.
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 measles.
• If there is a risk of dengue, classify
the child first for malaria and for
measles and then for DHF.
 Classification of Fever
• Note: To classify fever, you must know if there
is a malaria risk or not.

1. Malaria risk
 Very Sever Febrile disease/Malaria
 Malaria
 Fever: Malaria Unlikely
2. No Malaria Risk
 Very Severe Febrile Disease
 Fever: No Malaria
 CLASSIFICATION OF FEVER
1. MALARIAL RISK
 Classification of FEVER
2. No malarial risk
 Classify Measles
• First classify the child's fever then
measles.
• If the child has no signs suggesting
measles or has not had measles
within the last 3 months DO NOT
CLASSIFY MEASLES.
Classification of Measles
• 1. Severe Complicated Measles

• 2. Measles with eye or mouth

complications.

• 3. Measles
CLASSIFICATION OF
MEASLES
 Classify DHF
• A child with fever when there is a
risk of DHF should first be classified
or malaria an measles then DHF.
• If there is no risk don’t classify
 Classifications for DHF
• 1. Severe Dengue Hemorrhagic Fever

• 2. Fever: Dengue Hemorrhagic Fever

Unlikely
CLASSIFICATION FOR
DHF
• CASE 1: Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 °C. The
health worker asked, “What are the child’s problems?” The mother said “Fatima has been
coughing for 6 days, and she is having trouble breathing.” This is the initial visit for this
illness.
• The health worker checked Fatima for general danger signs. The mother said that Fatima
is able to drink. She has not been vomiting. She has not had convulsions during this illness.
The health worker asked, “Does Fatima seem unusually sleepy?” The mother said, “Yes.”
The health worker clapped his hands. He asked the mother to shake the child. Fatima
opened her eyes, but did not look around. The health worker talked to Fatima, but she did
not watch his face. She stared blankly and appeared not to notice what was going on
around her.
• The health worker asked the mother to lift Fatima’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker
did not see any chest indrawing. He did not hear stridor.
• The health worker asked, “Does the child have diarrhoea?” The mother said, “Yes, for 3
days.” There was no blood in the stool. Fatima’s eyes looked sunken. The health worker
asked, “Do you notice anything different about Fatima’s eyes?” The mother said, “Yes.” He
gave the mother some clean water in a cup and asked her to offer it to Fatima. When
offered the cup, Fatima would not drink. When pinched, the skin of Fatima’s abdomen went
back slowly.
• Because Fatima’s temperature is 37.5 °C and she feels hot, the health worker assessed
Fatima further for signs related to fever. The mother said Fatima’s fever began 2 days
ago. It is the dry season, and the risk of malaria is low. The mother said that Fatima did
not travel away from home in the last two weeks. Fatima has not had measles within the
last 3 months, and there are no sign suggesting measles. She does not have stiff neck. The
health worker noticed that Fatima has a runny nose.
EXAMPLE: CASE RECORDING FORM WITH THE MAIN
SYMPTOM FEVER
 ASSESS AND
CLASSIFY EAR
PROBLEM
• A Child with ear problem may have
ear infection.
• When a child has an ear infection,
PUS collects behind the ear drum and
causes pain and often fever.
• If the infection is not treated, the
eardrum may burst.
• Sometimes the infection can spread
from the ear to the bone behind the
ear (mastoid) causing mastoiditis.
• Infection can also spread from the
ear to the brain causing meningitis.
• They are severe diseases that needs
urgent attention.
ASSESS EAR
PROBLEM
• A Child with ear problem is assessed for:
 Ear pain
 Ear discharges
 If with ear discharges, how long the child
has had discharges
 Tender, swelling behind the ear, a sign of
mastoiditis.
ASK: Does the child have
an ear problem?
• If the mother says NO, record her
answer. Do not assess the child for
ear problem. Go the next question
and heck for malnutrition and anemia.
• If the mother says YES, ask the
next question
ASK: Does the child have
ear pain?
• Ear pain mean that the child has an
ear infection. If the mother is not
sure that the child ha ear pain, Ask if
the child has been irritable and
rubbing his ear.
 ASK: Is there ear
discharges? If yes, how
long?
• Ear discharges is also a sign of
infection.
• Ask for how long
• Note: You will classify and treat the
ear problem depending on how long
the ear discharge has been present.
• An ear discharge that has been
present for 2 weeks or more is
treated as a chronic ear infection.
• An ear discharge that has been
present for less than 2 weeks is
treated as acute ear infection.
 Look for Pus draining
from the ear
• Pus draining from the ear is a sign of
infection, even if the child no longer
has any pain. Look inside the child’s
ear to see if pus is draining from the
ear.
 Feel for tender swelling
behind the ear
• 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.
• Both tenderness and swelling must be
present to classify mastoiditis, a deep
infection in the mastoid bone.
• Do not confuse this swelling of the
bone with swollen lymph nodes.
CLASSIFY EAR
PROBLEM
 4 CLASSIFICATIONS
FOR EAR PROBLEM
• Mastoiditis
• Acute Ear Infection
• Chronic Ear infection
• No Ear Infection
• CASE 2: Mbira is 3 years old. She weighs 13 kg.
Her temperature is 37.5 °C. Her mother came to
the clinic because Mbira has felt hot for 2 days.
She was crying last night and complained that her
ear was hurting. The health worker checked and
found no general danger signs. Mbira does not
have cough or difficult breathing. She does not
have diarrhoea. Her malaria risk is high. Her fever
was classified as MALARIA.
• Next the health worker asked about Mbira’s ear
problem. The mother said she is sure Mbira has
ear pain. The child cried most of the night
because her ear hurt. There has not been ear
discharge. The health worker did not see any pus
draining from the child’s ear. She felt behind the
child’s ears and found no tender swelling.
EXAMPLE : EAR PROBLEM SECTION OF THE
CASE RECORDING FORM
 CHECK for Malnutrition
and Anemia
• A child with malnutrition has a higher
risk of many types of diseases and
death.
• Even children with mild and moderate
malnutrition have an increased risk of
death.
 Type of Malnutrition
• Protein-energy malnutrition
- Develops when the child is not getting
enough energy or protein from his food to
meet his nutritional needs.
• A child who has had frequent illnesses can
also develop protein-energy malnutrition in
which he has decrease appetite and the
food that the child eats is not used
efficiently.
 Manifestations of a child
with Protein –energy
malnutrition
• The child may become severely
wasted, a sign of marasmus.
• The child may develop edema, a sign
of kwashiorkor.
• The child may not grow well and
become stunted ( too short)
• Marasmus
• Kwashiorkor
• A child whose diet lacks
recommended amounts of essential
vitamins and minerals can develop
malnutrition.
• The child may not be eating enough
of the recommended amounts of
specific vitamins or minerals.
• Not eating foods that contain
Vitamin A can result in Vitamin A
deficiency.
• A child with Vitamin A deficiency is
at risk of death from measles and
diarrhea.
• The child is also at risk of blindness.
• Not eating foods rich in iron can
lead to iron deficiency and anemia.
• Anemia is a reduced number of red
blood cells or a reduced amount of
hemoglobin in each red cell.
• A child can also develop anemia as a
result:
Infections
Parasites such as hookworms or
whipworms.
Malaria
 ASSESS FOR
MALNUTRITION AND
ANEMIA
 Look for visible severe
wasting
• A child with visible severe wasting
has MARASMUS, a form of severe
malnutrition.
• Signs of Marasmus
Very thin
Has no fat
Looks like skin and bones
• To look for severe wasting, remove
the child’s clothes.
• Look for severe wasting in the
muscles and shoulders, arms,
buttocks and legs.
• Look to see if the outline of the
child’s ribs is easily seen.
• Look at the child’s hips.
They may look small
when you compare them
with the chest and
abdomen.
• Look at the child from
the side to see if the
fat of the buttocks is
missing.
• When wasting is
extreme, there are
many folds of the skin
on the buttocks and
thigh. It looks as if the
child is wearing baggy
pants.
• The face of the child with visible
wasting may still look normal.
• The child’s abdomen may be large or
distended.
 Look for Palmar pallor
• Pallor is unusual paleness of the skin. It is
a sign of anemia.
• Look at the skin of the child’s palm. Hold
the child’s palm open by grasping from the
side. Do not stretch the fingers
backwards. This may cause pallor by
blocking the blood supply.
• Compare the color of the child’s palm
with your own palm and with the
palms of other children.

• If the color of the child’s palm is

pale, the child has some palmar
pallor.
• If the skin of the palm is very pale or
so pale that it looks white, the chils
has severe palmar pallor.
Look and Feel for edema
of both feet
• A child with edema of both feet may
have KWASHIORKOR- another form
of severe malnutrition.
• Signs of Kwashiorkor:
Thin
Sparse and pale hair which easily
falls out
 Dry scaly skin especially on the arms and
legs
 Puffy or “moon face”

• Edema is when an usually large of fluids

gathers in the child’s tissues. The tissues
becomes filled with the fluid and look
swollen or puffed up.
• Look and feel to determine if the child has
edema of both feet.
- use your thumb to press gently for a few
seconds on the top side of each foot.
- the child has edema if a dent remains in
the child’s foot when you lift your thumb.
 Determine weight for
age
• Weight for age compares the child’s
weight with the weight of other children
who are the same age.
• Weight below the bottom curve of the
weight chart means that the child has a
very low weight for age and needs sspecial
attention to how they are fed.
Look at the WHO weight
for age chart
• To determine weight for age:
 Calculate the child’s age in months.
 Weigh the child if he has not already been
weighed today.Use a scale which you know
gives accurate weights. The child should
wear light clothing when he is weighed. Ask
mother to help remove any coat, sweater
or shoes.
Use the weight for age chart to
determine weight for age.
 left-hand axis = child’s weight
 Bottom axis= child’s age in months
 Find the point on the chart where
the line for the child’s weight meets
the line for the child’s age.
 Decide if the point is above on or below
the bottom curve.
 If the point is below the bottom curve,
the child is very low weight for age.
 If the point is above or on the bottom
curve, the child is not very low weight for
age.
 CLASSIFY
NUTRITIONAL
STATUS
 3 Classifications for
nutritional status
• 1. Severe Malnutrition or Severe
Anemia
• 2. Anemia or Very low weight
• 3. No anemia and Not Very Low
Weight
• CASE 3: Alulu is 9 months old. He weighs 7 kg. His
temperature is 36.8 °C. He is at the clinic today because
his mother and father are concerned about his diarrhoea.
He does not have any general danger signs. He does not
have cough or difficult breathing. He has had diarrhoea
for 5 days, and is classified as diarrhoea with SOME
DEHYDRATION. He does not have fever. He does not
have an ear problem.

• Next, the health worker checked for signs of malnutrition

and anaemia. The child does not have visible severe
wasting. There is some palmar pallor. He does not have
oedema of both feet. The health worker uses the Weight
for Age chart to determine Alulu’s weight (7 kg.) for his
age (9 months).
EXAMPLE: MALNUTRITION AND ANAEMIA
SECTION OF THE CASE RECORDING FORM
 Check the child’s
Immunization Status
• Use a recommended Immunization
Schedule
• All children should receive all the
recommended immunization below
their first birthday.
• Age Vaccine
• Birth BCG, Hep B1
• 6 weeks DPT1, OPV1
• 10 weeks DPT2, OPV2, Hep B2
• 14 wks DPT3, OPV3, Hep B3
• 9 months measles
 Contraindications to
immunization
• Do not BCG to a child known to have AIDS
• Do not give DPT2 or DPT3 to a child who
has had convulsions or shock within 3 days
of the most recent dose.
• Do not give DPT to a child with recurrent
convulsions or another active neurological
disease of the central nervous system.
 Other Points to
Remember
• If a child is going to be referred, do not
immunize the child before referral. This
will avoid delaying referral.
• Children with diarrhea who are due to OPV
should receive a dose of OPV during this
visit. Do not count the dose
Look at the child’s age on
the clinical record
• If you don’t know the child’s age, ask
about the child’s age.
Ask the mother if the child
has an immunization card
• If the mother says yes, Ask her if she has
brought the card to the health center today:
• If she has brought the card with her, ask to see
the card
• Compare the child’s immunization, record with the
recommended immunization schedule. Decide
whether the child has had all the immunizations
recommended for the child’s age.
• On the Recording Form, check all immunizations
the child has already received. Circle any
immunizations the child needs today.
• If the child is not being referred,
explain to the mother that the child
needs to receive an immunization
today.
• If the mother says that she does
NOT have an immunization card with
her:
• Ask the mother to tell you what
immunizations the child has received.
• Use your judgment to decide if the mother
has given a reliable report. If you have any
doubt, immunize the child. Give the child
BCG, OPV, DPT, Hepatitis and Measles
vaccine according to the child's age.
• Give an immunization card to the mother
and ask her to bring it with her each time
she brings the child to the health center.
• CASE 4: Salim is 4 months old. He
has no general danger signs. He is
classified as diarrhoea with NO
DHYDRATION. His immunization
record shows that he has received
BCG, OPV0, OPV1, OPV2, DPT1, and
DPT2.
 EXAMPLE: IMMUNIZATION STATUS
SECTION OF THE CASE RECORDING FORM
Check the child’s Vitamin
Status
• Vitamin A plays a vital role in the
growth and development of children.
It helps prevent invasion by
infectious organisms and it maintains
tissues in the skin, the respiratory
tract, the intestinal tract and the
cornea of the eye.
 When to give Vitamin A
• The child’s age is 6 mos or older
• Doesn’t receive Vitamin A in the past
6 months
• The child is sick
 Side effects of Vitamin
A
• Vomiting
• Headaches
• Nausea

• The symptoms will disappear within

24 hrs.
 Assess other Problems
• Identify and treat any other
problems according to your trainings,
experience and the health center
policy.
• Refer the child for any problem you
can’t manage in the health center.
THANK YOU VERY
MUCH FOR
LISTENING
GOOD LUCK TO YOUR RHU
DUTY!!
Resuscitation in Neonates
Prepared By:
Mrs. Anna Dianne R. Altuhaini
Clinical Instructor
Neonatal Resuscitation is a set of interventions used to
assist the airway, breathing and circulation of a newborn
following birth, also known as ABCs

Neonatal Resuscitation is intervention after a baby is

born to help it breathe and to help its heart beat.
 • A neonate refers to a baby from birth to
4 weeks. Another word for "neonate" is
"newborn."
Resuscitation is the process of correcting physiological
disorders (such as lack of breathing or heartbeat) in an
acutely ill patient. Well known examples are
cardiopulmonary resuscitation and mouth-to-
mouth resuscitation.
The adaptation from intrauterine to extrauterine life involves a
complex and rapid orchestration of physiologic changes. Within
minutes of life, the newly born infant is subjected to multiple
unfamiliar stimuli such as cold, light, and noise compared with the
warm, dark environment of intrauterine life. In addition, the infant
must make the transition from dependence on placental gas exchange
to spontaneous air breathing and pulmonary gas exchange. Most
often, this transition occurs without difficulty.

However, multiple maternal, placental, mechanical, and fetal

conditions exist that can jeopardize a smooth transition and signal
the need for intervention.
 uropartum (Maternal) Intrapartum Postpartum

Diabetes mellitus Multiple gestation Apnea

Hypertension Nonvertex presentation Bradycardia

Risk Factors
Substance abuse Postdates Respiratory distress

Vascular disease Macrosomia/microsomia Hypoperfusion

Associated Vasoactive medications

Smoking
Maternal hypotension

Placental abruptio or previa

Anemia

Congenital anomaly

With the Need Poor maternal weight gain Cord accidents Infection

for Neonatal
Myasthenia gravis Maternal infection Prematurity

Ssexually transmitted disease Operative delivery Birth trauma

Resuscitation Prior fetal or neonatal demise

No prenatal care
General anesthesia

Poly/oligohydramnios

Chronic disease states Fetal anomaly

Anemia Isoimmunization

Hemorrhage Prematurity

Maternal age > 35 yr Prolonged labor

Maternal age < 15 yr Meconium stained amniotic fluid

Abnormal fetal heart rate pattern

Maternal sedation
Pre-term birth

✔ birth that takes place more than three weeks before the baby's estimated due date.

∙ Late preterm, born between 34 and 36 completed weeks of pregnancy

∙ Moderately preterm, born between 32 and 34 weeks of pregnancy
∙ Very preterm, born at less than 32 weeks of pregnancy
∙ Extremely preterm, born at or before 25 weeks of
pregnancy
 Complications:
∙ Breathing problems. A premature baby may have trouble breathing due to an
immature respiratory system. If the baby's lungs lack surfactant — a substance that allows
the lungs to expand — he or she may develop respiratory distress syndrome because the
lungs can't expand and contract normally.
• Temperature control problems. Premature babies can lose
body heat rapidly. They don't have the stored body fat of a full-
term infant, and they can't generate enough heat to counteract
what's lost through the surface of their bodies. If body
temperature dips too low, an abnormally low core body
temperature (hypothermia) can result.
• Hypothermia in a premature baby can lead to breathing problems
and low blood sugar levels. In addition, a premature infant may
use up all of the energy gained from feedings just to stay warm.
That's why smaller premature infants require additional heat from
a warmer or an incubator until they're larger and able to maintain
body temperature without assistance.
Neonatal respiratory distress syndrome
is a problem often seen in premature babies. The condition makes it hard for
the baby to breathe.
Causes:
occurs in infants whose lungs have not yet fully developed.

Neonatal prematurity higher the chance of RDS after birth. RDS can also be
due to genetic problems with lung development.

Most cases of RDS occur in babies born before 37 to 39 weeks. The more
premature the baby is, the higher the risk.
 Meconium aspiration syndrome
•Sometimes, if the gastrointestinal system
has matured to a certain point, the unborn
baby might pass some meconium into the
amniotic fluid while they are still in the
womb.

Risk factors that may cause stress on the baby before birth
include:
∙ "Aging" of the placenta if the pregnancy goes far
past the due date
∙ Decreased oxygen to the infant while in the
uterus
∙ Diabetes in the pregnant mother
∙ Difficult delivery or long labor
∙ High blood pressure in the pregnant mother
If meconium gets into the amniotic fluid, there is a chance that
the unborn baby will inhale it. This is called meconium
aspiration.

When this happens, the newborn baby’s air passages can become
blocked, and their lungs can become inflamed. Meconium
aspiration is a frequent problem in newborn babies, and affects
10% to 15% of deliveries. About 5% to 10% of babies who are
born with meconium aspiration develop respiratory distress,
which is a condition where the baby has difficulty breathing.

Some of these newborn babies require extra oxygen and

ventilation.
 The inhaled meconium adversely affects the lung in
several ways:
•Mechanical obstruction of the airways leading to
ventilation/perfusion mismatch
•Chemical pneumonitis
•Infection
Symptoms

∙ Bluish skin color (cyanosis) in the infant

∙ Working hard to breathe (noisy breathing, grunting,
using extra muscles to breathe, breathing rapidly)
∙ No breathing (lack of respiratory effort, or apnea)
∙ Limpness at birth
A baby’s cry at birth signifies to the medical team that their lungs are
healthy.
❖Neonatal respiratory conditions can arise for several
reasons: delayed adaptation or maladaptation to extra-uterine
life, existing conditions such as surgical or congenital
anomalies or from acquired conditions such as pulmonary
infections occurring either pre- or post-delivery.

❖Respiratory conditions are the most common reason for

admission to a neonatal unit in both term and preterm
infants
Those newly born infants who do not require resuscitation can
generally be identified by a rapid assessment of the following
3 characteristics:
•Term gestation?
•Crying or breathing?
•Good muscle tone?
If the answer to all 3 of these questions is “yes,” the baby does
not need resuscitation and should not be separated from the
mother. The baby should be dried, placed skin-to-skin with the
mother, and covered with dry linen to maintain temperature.
Observation of breathing, activity, and color should be
ongoing.
If the answer to any of these assessment questions is
“no,” the infant should receive one or more of the following
4 categories of action in sequence:

A.Initial steps in stabilization (provide warmth, clear

airway if necessary, dry, stimulate
B.Ventilation
C.Chest compressions
D.Administration of medication and/or volume expansion
Materials/ Equipment
Prior to delivery, risk factors should be identified, neonatal
problems anticipated, equipment checked, qualified personal should
be available, and a care plan formulated.

A known perinatal risk factor, such as preterm birth, requires

preparation of supplies specific to thermoregulation and respiratory
support, and the delivery room should be equipped with all the tools
necessary for successful resuscitation. A standardized checklist may
be helpful to ensure that all necessary supplies and equipment are
present and functioning.
Suction Equipment
Bulb syringe
Mechanical suction
No. 5, 8, 10 French suction
catheters
8 French feeding tube and 20-mL
syringes
Meconium aspirator
Wall suction
Bag and Mask Equipment
Infant resuscitation bag
with pressure-release valve or
pressure manometer; the bag
must deliver 100% oxygen
Face masks in premature and
term infant sizes (No. 1, 2, 3)
with cushioned rims
Oral airways
Oxygen source with intact flow
meter and tubing
∙ Intubation Equipment
Stylet
Laryngoscopes with straight blades
Scissors
∙ No. 0—premature
No. 1—term Gloves

∙ Medications
Epinephrine 1:10,000, 3- or 10-mL ampules
Naloxone hydrochloride 0.4 mg/mL in 1-mL ampules or 1 mg/mL in 2-mL ampules
Volume expanders
∙ Whole blood
Fresh frozen plasma
Albumen (5%)/saline solution
∙ Other Equipment and Supplies
Radiant warmer
Stethoscope
Blood pressure monitor with appropriate cuffs
Adhesive tape
Syringes
Needles
Alcohol sponges
Umbilical catheterization tray
Umbilical tape
Umbilical catheters—3.5, 5 French
3-way stopcocks
5 French feeding tube
Cardiotachometer with electrocardiogram oscilloscope
Pressure transducer and monitor
Pulse oximeter
Steps to Resuscitation
A.Preparation

1. Prepare the area for delivery.

2. Do handwashing and don gloves.
3. Prepare an area for ventilation and check equipment.
B. Initial Assessment:

4. Assess the neonate:

Assess the Color, Tone, Breathing, and Heart Rate
a. If neonate is term, with good cry and good tone, do routine newborn
care.
b. If neonate has abnormal breathing or poor cry, cyanotic or with low HR (less than 100 beats/minute);
Thoroughly dry and keep the baby warm.
Clear the airway.
Stimulate.

C. Re-assess: Color, Tone, Breathing, and Heart Rate

1. If neonate is pink in color, with good tone, with good cry or breathing, and has HR >100 :
Return the baby to the mother for skin-to-skin contact to keep the baby warm.
Initiate breastfeeding.
1. If neonate is still pale or cyanotic, floppy, no breathing and has HR <100: (see considerations)

Give 5 inflation breaths:

Position the baby’s head in neutral position.

Place a mask of appropriate size over the baby’s mouth and nose, connecting it with an Ambu bag.
Provide five inflation breaths by slowly squeezing the bag.
Provide a two- to three-second long breath by counting out loud to allow accurate rhythm.
Inspect the baby’s chest movement.
Reassess the inflation and listen to the heart rate (normal is greater than 100 beats/minute) and check whether the baby is
breathing.
Repeat the maneuver if the baby is still not responding or use jaw thrust alone or with the help of another responder to open the
airway.
CONSIDERATIONS:

❖ Warm the neonate

Rationale: Preventing heat loss in the newly born is vital

because cold stress can increase oxygen consumption
and impede effective resuscitation

∙ The ultimate goal is a neutral thermal environment. In this

state, the infant maintains a normal core temperature, yet
oxygen consumption is minimal.
Ways to keep babies warm
There are several ways to keep babies warm, including the following:
•Immediate drying and warming after delivery. A baby's wet skin loses heat
quickly by evaporation and can lose 2° to 3°F. Immediate drying and warming can
be done with warm blankets and skin-to-skin contact with the mother, or another
source of warmth such as a heat lamp or over-bed warmer.
•Open bed with radiant warmer. An open bed with radiant warmer is open to
the room air and has a radiant warmer above. A temperature probe on the baby
connects to the warmer to regulate the amount of warming. When the baby is cool,
the heat increases. Open beds are often used in the delivery room for rapid
warming. They are also used in the NICU for initial treatment and for sick babies
who need constant attention and care. Babies on radiant warmer beds are usually
dressed only in a diaper.
•Incubator/isolette. Incubators are walled plastic boxes with a heating system to
circulate warmth. Babies are often dressed in a T-shirt and diaper.
❖Clearing the Airway
To prevent further aspiration, removal of secretion (if needed)

❖Stimulate breathing

If respirations are ineffective, tactile stimuli such as gentle

rubbing of the back or flicking of the heels may be added.
3. Ensure proper positioning
The newly born infant should be placed supine or lying on its side,
with the head in a neutral position.

If respiratory efforts are present but not producing effective tidal

ventilation, often the airway is obstructed; immediate efforts must be
made to correct overextension or flexion or to remove secretions.
D. Re-assess: Color, Tone, Breathing, and Heart Rate
If neonate is pink in color, with good tone, with good cry or breathing,
and has HR >100 :
Return the baby to the mother for breastfeeding and skin-to-skin contact.
If neonate is still pale or cyanotic, floppy, no breathing and
has HR <100:
Give 30 seconds of ventilation breaths:
With the infant in neutral position, place the bag-valve mask onto the
baby’s face.
Provide ventilation breaths by squeezing the bag about 1-2 seconds for about
30 seconds.
E. Re-assess: Color, Tone, Breathing, and Heart Rate
If neonate is now breathing:
Provide post-resuscitation care.

If neonate still has no progress:

Start chest compression.

Hold the baby’s chest with two hands while placing the thumbs on the lower third of the sternum just
below the nipple line.
Compress straight down at least 1/3 the depth of the chest, about 1 ½ inches.
Provide three chest compressions to one breath with the help of another attendant.
Make sure there is time for the chest to recoil.
Check for responses by listening to the baby's heart rate every 30 seconds and see chest movements
with each breath, after each intervention.

*Another method in smaller babies is using the index and middle fingers to gentle
press over the breastbone
A. After about 30 seconds, evaluation is done again.
If the heart rate is still < 60 bpm then epinephrine is administered
along with continued PPV and chest compression.
If the heart rate remains < 60 bpm, epinephrine can be repeated
every three to five minutes.

A. After 10 minutes of continuous and adequate resuscitative efforts,

discontinuation of resuscitation may be justified.
• Oxygen is indicated when cyanosis is present. Blow by oxygen at a flow of 5 L/min can be
administered via a face mask and flow-inflating bag, an oxygen mask, or a hand cupped around
oxygen tubing. The maximal inhaled concentration of oxygen is delivered by holding the oxygen
source as close to the face as possible. Although there is some evidence to suggest that 100% oxygen
may not be necessary, current guidelines recommend starting at that level and weaning as the infant
responds (see controversies section). Thus, the goal of supplemental oxygen should be normoxia. This
entire process of drying, suctioning, and stimulation should take less than 30 seconds. If an adequate
response is not established, the subsequent steps of active resuscitation should be performed.
 Cessation of Resuscitation
It is appropriate to consider discontinuing effective resuscitation efforts if:
∙ Infant is not breathing and heartbeat is not detectable beyond 10
min. Stop resuscitation.
∙ There is no spontaneous breathing and the heart rate remains below
60/min after 20 min of effective resuscitation, discontinue active
resuscitation.
Record the event and explain to the mother or parents that the infant has
died. Give them the infant to hold if they so wish.
 Post resuscitation care
Infants who require resuscitation are at risk for
deterioration after their vital signs have returned to
normal. Once adequate ventilation and circulation has
been established:
∙ Stop ventilation.
∙ Return to mother for skin-to-skin contact as soon as
possible.
∙ Closely monitor breathing difficulties, signs of asphyxia
and anticipate need for further care.
THANK YOU FOR
LISTENING
NASOGASTRI
C FEEDING
FOR
NEONATES
(GAVAGE
FEEDING)
Feeding and
Nutrition
Nutritional requirements may increase
while infant or child is ill but the ability
to feed naturally may be impaired by
illness or the child’s response to illness.
If existing feeding patterns cannot be
maintained alternate methods may be
necessary.
 NGT/GAVAGE FEEDING
1. NGT/Gavage feeding is a means of
providing food by way of a catheter passed
through the nares or mouth, past the pharynx,
down the esophagus and into the stomach
slightly beyond the cardiac sphincter.
Feedings may be continuous or intermittent.
2. Gavage feeding can provide a method of
feeding or administering medications that
require minimal patient effort when the
child is unable to suck or swallow
adequately (e.g. premature neonates under
32 weeks gestation or under 1, 560 g;
children with neurologic deficits or
respiratory compromise
 3. Gavage feedings provide a
route that allows adequate
calorie or fluid intake; they can
also provide supplemental or
additional calories.
 4. Gavage feedings can prevent
fatigue or cyanosis that is apt to
occur from bottle-feeding.
They can provide supplements
for an infant who is a poor
bottle-feeder.
 5. Gavage feedings can provide a safe
method of feeding hypotonic patients,
patients experiencing respiratory distress
(respiratory rate greater than 60/min),
patients with uncoordinated suck &
swallow, intubated patients, debilitated
patients & patients with anomalies in the
digestive tract
Gavage (guh-vahj) feeding is a way to
provide breastmilk or formula directly
to a baby’s stomach. A tube placed
through the baby’s nose (called a
Nasogastric or NG tube) carries breast
milk/formula to the stomach.
 Why does my baby need gavage
feeding?

Babies who are premature and too

small or weak to suck enough from
the breast or bottle.
 • Babies who have a problem
coordinating their suck and
swallow.

• Babies who have a problem

with their throat, esophagus, or
bowel.
• Babies, who may have
lung and heart
problems, are breathing
too hard or too fast to
be able to suck and
swallow.
NGT INSERTION
What equipment is needed?
• Appropriate size feeding tube
• Small syringe (3cc) for checking
stomach contents and injecting air
• Large syringe for breast milk or
formula (60cc)
 • Stethoscope
• Tape
• A cup of water or water soluble
lubricating jelly (do not use
petroleum jelly because this will
clog
the tube)
• A blanket for swaddling your baby
NGT FEEDING
MATERIALS
 You Have To Prepare All The Materials,
Formula, Medicines, Fluid/Water At The
Preparation Area Of The Nurses’ Station
Before Going To The Patient
- Wash hands before preparing all the
materials, formula, medicines, water
- Wash hands after preparing everything
CHECKLIST
1. Explain procedure
to parents and gain
informed consent.
2. Begin by washing your
hands
3. Put protective towel or
napkin over the neonate's
chest.
4. The feeding position should be right
side lying, with head and chest slightly
elevated.
 Right-side Lying Position
Rationale: This position allows the
flow of fluids aided by gravity.
5. Aspirate the tube before
feeding.
This begins to assess for
residual contents and to
remove any air.
 Aspirating
Rationale: This is done to monitor for
appropriate fluid intake, digestion time
or overfeeding that can cause
distention,
a. If over one-half of the previous
feeding is obtained by aspiration,
withhold the next feeding. Do not
return aspirate to the stomach.
Notify the health care provider of
the large residual volume.
b. If a small residual of formula is
obtained, return it to the stomach
and subtract that amount from the
total amount of formula to be
given. Document any residual
contents.
6. Attach the reservoir to catheter and fill
with feeding.
Encourage the infant to suck on a pacifier
during the feeding. Hold the infant when
possible.
Rationale: The use of the pacifier will relax
the infant, allowing for easier flow of fluids
as well as provide for normal sucking
needs.
 7. The flow of the feeding should
be slow. Do not apply pressure.
Elevate the reservoir 6-8 inches (15-
20 cm) above the patient's head.
 The rate of flow
Rationale: The rate of flow is controlled by
the size of the catheter; the smaller the
size, the slower the flow. If the reservoir is
too high, the pressure of the fluid itself
increases the rate of flow
 a. Feedings given too rapidly may
interfere with peristalsis, causing
abdominal distention, regurgitation
and possibly, emesis.
b. Feeding time should last
approximately as long as 5
ml/5-10 minutes or 15-20
minutes total time.
 8. When the feeding is completed, the
catheter may be irrigated with clear water.
Before the fluid reaches the end of the
catheter, clamp it off and withdraw it
quickly or keep in place for the next
feeding.
 Rationale:
Clamping the catheter before air enters the
stomach prevents abdominal distention.
Clamping also prevents dripping of fluids
from the catheter to the pharynx
causing the patient to gag and aspirate.
9. Discard the feeding tube and
any leftover solution.
10. Burp the patient. (The patient
may not burp if air was aspirated
from the tube following the
feeding.)
 Rationale:
Adequate expulsion of air swallowed or
ingested during the feeding will decrease
abdominal distention and allow for better
tolerance of the feeding.
 11. Place the patient on his
right side for at least 1 hour.
 Rationale:
To facilitate gastric emptying and
minimize regurgitation and aspiration.
12. Observe the patient's condition
after feeding; bradycardia and
apnea may still occur.
 Rationale:
Because of vagal stimulation
13. Note vomiting or abdominal
distention.
 Rationale:
Due to overfeeding or too rapid feeding.
Regurgitation of 1-2 ml may occur in the
premature infant as the musculature of the
sphincter of the GI tract is relaxed and
allows for easy reflex.
 14. Accurately describe and record
procedure, including time of
feeding, type of gavage tube
feeding, type and amount of
feeding fluid given, amount
retained or vomited, how the patient
tolerated feeding and activity
before, during and after feeding.
 Rationale:
Observe for the readiness of the infant to
feed by nipple- note sucking activity and
sleep wake cycle in relation to feeding