MINISTRY OF HEALTH

Federal Republic of Somalia

SOMALI GUIDELINES ON
INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES

CHART BOOKLET
2022 EDITION
 INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESS IMNCI
Assess and Classify the sick child aged 2 months up to 5 years
ASSESS AND CLASSIFY
CHECK FOR GENERAL DANGER SIGNS 1 Does the child have an ear problem? 5 ASSESS MOUTH AND GUM CONDITIONS 10
THEN ASK ABOUT MAIN SYMPTOMS 2 THEN CHECK FOR ACUTE MALNUTRITION 6 THEN CHECK THE CHILD’S IMMUNIZATION, VITAMIN A 11
Does the child have diarrhoea? 3 THEN CHECK FOR ANEMIA 7 ASSESS OTHER PROBLEMS 11
THEN CHECK FOR TUBERCULOSIS 8 ASSESS MOTHERS OWN HEALTH 11
Does the child have fever? 4
THEN CHECK FOR HIV INFECTION 9

TREAT THE CHILD 14

Give Vitamin A Give Artesunate Suppositories or Intramuscular Artesunate or 17
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME 12
Give Iron 14 Quinine for Severe malaria
Give Appropriate Oral Antibiotic for HIV INFECTION and HIV 12
Give Mebendazole or Albendazole 14 Treat convulsing Child With Diazeam Rectally 17
EXPOSED: POSSIBLE HIV INFECTION
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME 15 Treat Convulsing Child With (IM) phernobarbitone 17
Give Appropriate Oral Antibiotic for PNEUMONIA or ACUTE EAR 12 Treat Eye Infection wht Tetracycline Eye Ointment 15 Treat the Child to Prevent low Blood Sugar 18
Give an Appropriate Oral Antibiotic DYSENTERY 13 Clear the Ear by Dry Wicking and Give Eardorps GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
15 19
Give an Appropriate Oral Antibiotic for Cholera 13 Treat for Mouth/Gum Ulcers (See FEEDING advice on COUNSEL THE MOTHER chat)
15 19
Give an Oral Antimalarial 13 Soothe the Throat, Relieve the Cough with a Safe Remedy Plan A: Treat Diarrhoea at Home
15 19
Give Quine Tablets 13 Plan B: Treat Some Dehydration with ORS and Zinc
GIVE THESE TREATMENTS IN THE CLINIC ONLY 16 19
GIVE ZINC FOR CHILDREN HAVING DIARRHOEA 14 Plan C: Treat Severe Dehydration Quickly
Give an Intramuscular Anribiatic 16 20
Give Multivitamin for SYMPTOMATIC or POSSIBLE/EXPOSED HIV 14 Immunize Every Sich Child, Give Vatamin A and Deworm 20
INFECTION and for PERSISTENT DIARRHOEA 14 as Described in the Assess and classify part 20

Feeding Recommendations For Stunted Child 25

SPECIAL FEEDING ASSESSMENT AND AFVICE 26
COUNSEL
COUNSEL MOTHER FEEDING 21 Assess Feeding if Child Has ANAEMIA, MODERATE ACUTE 26 "AFASS" Criteria for Formula Milk Feeding to Eligible Infants 28
Assess Child’s Appetite 21 MALNUTRITION, HIV Infection, HIV Exposed or is Less Than 2 years Counsel the Mother About Feeding Problems 29
Assess Child’s Feeding 22 Old Practice Good Hygiene and Proper Food Handling 26 COUNSEL ON FLUID 30
Feeding Recommendations During Sickness and Health 23 Safe Preparation of Formula Milk 27 Advise the Mother to Increase Fluid During Illness 30
Teach the Mother How to Feed by a Cup COUNSEL FOR WHEN TO RETURN 31
Feeding Recommendations for Children Who are Not breastfed 24 27
Feeding Advice for the Mother of a Child with HIV Infection Counsel the Mother about Her Own Health 32
Feeding Recommendations For a Child Who Has PERSISTENT 25 27
DIARRHOEA

FEVER: NO MALARIA 34 MODERATE ACUTE MALNUTRITION 35

FOLLOW-UP MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR 34 GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED 36
GIVE FOLLOW-UP CARE FOR ACUTE CONDITION 33 MOUTH ULCERS, OR THRUSH CHILD
PNEUMONIA 33 EAR INFECTION 34 HIV EXPOSED 36
PERSISTENT DIARRHOEA 33 FEEDING PROBLEM 34 CONFIRMED HIV INFECTION NOT ON ART 36
DYSENTERY 33 ANAEMIA 34 CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF 37
MALARIA 33 UNCOMPLICATED SEVERE ACUTE MALNUTRITION 35 FOLLOW-UP CARE 38

Recording Form: Recording form child 60

II
Assess, classify and treat the sick young infant aged up to 2 months
ASSESS AND CLASSIFY THEN CHECK YOUNG INFANT FOR HIV INFECTION? 42 THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND 46
CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION, VERY
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR 43 VITAMIN A STATUS:
SEVERE DISEASE, PNEUMONIA AND LOCAL BACTERIAL AGE OR WASTING IN BREASTFEEDING INFANTS
INFECTION 39 THEN CHECK AND IMMUNIZE MOTHER FOR TETANUS 46
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT OR 44
THEN ASK: Does the young infant have diarrhoea"? 40 ASSESS OTHER PROBLEMS 46
WASTING IN INFANTS NOT RECEIVING BREAST MILK
ASSESS MOTHER'S OWN HEALTH 46
CHECK FOR JAUNDICE 41 ASSESS AND CLASSIFY FOR BIRTH WEIGHT AND GESTATIONAL 45
CHECK FOR EYE PROBLEM 41 AGE IF YOUNG INFANT <7 days old

TREAT THE SICK YOUNG INFANT AND IF REFERRAL IS REFUSED OR NOT POSSIBLE, further assess and
Teach Correct Positioning and Attachment for Breastfeeding 52
classify the sick young infant with POSSIBLE SERIOUS BACTERIAL
COUNSEL THE MOTHER INFECTION or VERY SEVERE DISEASE 50 Advise the Mother to Give Home Care for the Young Infant 52
TREAT THE SICK YOUNG INFANT TREAT THE SICK YOUNG INFANT 51 CARE OF PRE-TERM OR LOW BIRTH WEIGHT YOUNG INFANT 53
47
Give an Appropriate Oral Antibiotic for PNEUMONIA and LOCAL 51 Kangaroo Mother Care (KMC) 53
Give First Dose of Intramuscular Gentamicin and Ampicilin or 47
BACTERIAL INFECTION Tips to Help the Mother Breastfeed Her Low Birth Weight Baby 53
Benzyl-penicillin.
Give Appropriate Oral Antibiotic for Infants with HIV INFECTION and 51 How to Express Breastmilk 53
Treata Convulsing Young Infant Less Than 1 Month with
48 HIV EXPOSED SAFE PREPARATION OF INFANT FORMULA 53
Phenobarbitone Intramusculary
48 To Treat Diarrhoea, See TREAT THE CHILD Chart: Page 26. 51 Counsel the Mother on Infection Prevention Actions 54
To Treat to Prevent Low Blood Sugar
48 Teach the Mother to Treat Local Infections, Eye Infection and Thrush 51
Treat Young Infant for Low Body Temperature( temperature less than
35.5°C)
at Home
Treat Young Infant for Fever( temperature 38.5°C or above) 49 Immunize Every Sick Young Infant and 51
Teach the Mother How to Keep the Young Infant Warm on the Way to
Give Vitamin A as Described in the ASSESS AND CLASSIFY part: 51
the Hospital 49 Page 10.
Give Vitamin K for PRE-TERM AND/OR LOW BIRTH WEIGHT Babies 49 COUNSEL THE MOTHER 52

FOLLOW-UP LOCAL BACTERIAL INFECTION 55 PRE-TERM or LOW BIRTH WEIGHT 56

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT 54 DIARRHOEA 55 LOW WEIGHT FOR AGE 56
ASSESS EVERY YOUNG INFANT FOR "POSSIBLE SERIOUS 54 JAUNDICE 56 ORAL THRUSH 56
BACTERIAL INFECTION or VERY SEVERE DISEASE DURING EYE INFECTION 56 CONFIRMED HIV INFECTION or HIV
FOLLOW-UP VISIT FEEDING PROBLEM 56 EXPOSED: POSSIBLE HIV INFECTION as in Older Child 56
CRITICAL ILLNESS WHEN REFERRAL WAS REFUSED OR NOT 55
FEASIBLE
CLINICAL SEVERE INFECTION WHEN REFERRAL WAS REFUSED 55
OR NOT FEASIBLE
PNEUMONIA or SEVERE PNEUMONIA 55

Annex 1: Tables of Other Causes of Fever 57 Recording Form: Young infant recording form 63
OTHER CAUSES OF FEVER IN CHILDREN WHO HAVE NEGATIVE 57
MALARIA TEST
Annex 2: Dosages For RUFT in Children with acute malnutrition. 58
DOSAGE FOR RUTF FOR CHILDREN WITH ACUTE
MALNUTRITION 58
Annex 3: HOW TO MEASURE MID UPPER ARM CIRCUMFERENCE
(MUAC) 59
Annex 4: REFERRAL NOTE FOR THE SICK YOUNG INFANT 59
REFERRAL NOTE FOR THE SICK YOUNG INFANT

III
 ASSESS AND CLASSIFY THE SICK CHILD
AGE 2 MONTHS UP TO 5 YEARS MINISTRY OF HEALTH
Federal Republic of Somalia

ASSESS CLASSIFY IDENTIFY TREATMENT

ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE USE ALL BOXES THAT MATCH THE (URGENT PRE-REFERRAL TREATMENTS ARE
CHILD’S SYMPTOMS AND PROBLEMS IN BOLD PRINT.)
• Determine if this is an initial or follow-up visit for this problem. TO CLASSIFY THE ILLNESS.
- If follow-up visit, use the follow-up instructions on TREAT THE CHILD chart.
- If initial visit, assess the child as follows:

SIGNS CLASSIFY TREATMENT

CHECK FOR GENERAL DANGER
Any general VERY SEVERE ►Treat convulsing child
If the child is convulsing now, manage the airway and treat the child with
diazepam. Then rapidly assess, classify and provide other danger sign DISEASE with diazepam rectally

ASK AND CHECK : LOOK: ► Quickly complete the

Is the child able to drink or See if the child is lethargic or assessment
breastfeed? unconscious. URGENT
► Give any pre-referral
Does the child vomit everything? Is the child convulsing now? ATTENTION
Has the child had convulsions? treatment immediately

A child with any general danger sign needs URGENT attention; complete ► Treat to prevent low
the assessment and any pre-referral treatment immediately so referral blood sugar
is not delayed
► Keep the child warm

► Refer URGENTLY.

1
 ASSESS AND CLASSIFY THE SICK CHILD AGE
2 MONTHS UP TO 5 YEARS
ASSESS CLASSIFY IDENTIFY TREATMENT

THEN ASK ABOUT THE MAIN SYMPTOMS:

DOES THE CHILD HAVE COUGH OR DIFFICULT SIGNS CLASSIFY TREATMENT
BREATHING? Any general danger sign ► Give first dose of an appropriate
or SEVERE PNEUMONIA
antibiotic.
IF YES, ASK: LOOK, LISTEN, FEEL*: Stridor in a calm child. OR VERY SEVERE ► Treat to prevent low blood sugar
Chest indrawing DISEASE ► Refer URGENTLY to hospital.**
Count the breaths in
one minute ►Give oral Amoxicillin for 5 days ***
For how long? CHILD
Look for chest indrawing. ►Treat wheezing if present
MUST BE ►If chest indrawing in HIV infected /
Listen for stridor exposed give the first dose Amoxicillin
CALM and refer the child to the hospital.
Listen for wheeze
CLASSIFY Fast breathing ►Sooth the throat and relief the cough
PNEUMONIA with a safe remedy
COUGH OR ►If coughing more than 14 days refer to
IF WHEEZING WITH EITHER FAST BREATHING OR CHEST INDRAWING : the hospital.
DIFFICULT
Give trial of inhaled rapid acting bronchodilator for up to 3 times 15-20 min ►Advice the mother when to retain
BREATHING immediately
a part. ►Follow up in 2 days
- Reassess the child for cough or difficult breathing (Count the child
►If coughing more than 15 days, refer
breathing and look for chest indrawing) then classify accordingly.
for assessment.
►Sooth the throat and relieve cough
IF THE CHILD IS: FAST BREATHING IS: No signs of pneumonia NO PNEUMONIA: with a safe remedy.
2 months up to 12 months 50 breaths per minute or more or very severe COUGH OR COLD ►Treat wheezing if present.
disease. ►Advise mother when to return
12 months up to 5 years 40 breaths per minute or more immediately.
► Follow up in 5 days if not improving

* If pulse oximiter is available, determine O2 saturation if <90 refer

** If refer is not possible see instructions in TREAT THE CHILD CHART
*** Oral Amoxicillin for 3 days is recommended to children with fast breathing but not chest indrawing in low HIV settings
*** In settings where inhaled bronchodilator is not available, use oral bronchodilator, but not recommended for treatment of acute severe wheeze

2
 ASSESS AND CLASSIFY FOR DIARRHOEA
ASSESS CLASSIFY IDENTIFY TREATMENT

DOES THE CHILD HAS DIARRRHOEA? SIGNS CLASSIFY TREATMENT

Two of the following signs: ► If child has another severe classification:
IF YES, ASK: LOOK, LISTEN, FEEL*: for - Refer URGENTLY to hospital with mother giving
Lethargic or unconscious frequent sips of ORS on the way.
DEHYDRATION
Look at the child’s general condition. Sunken eyes - Advise the mother to continue breastfeeding.
SEVERE
► If child is 2 years or older and there is cholera in
Is the child: Not able to drink or drinking DEHYDRATION your area, give antibiotic for cholera.
Lethargic or unconscious? poorly ► If child has no other severe classification:
Skin pinch goes back very - Give fluid for severe dehydration (Plan C).
For how long? Restless and irritable?
- Give Zinc supplement
Look for sunken eyes. slowly.

Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Is there blood Drinking eagerly, thirsty?
in the stool? Pinch the skin of the abdomen.
Does it go back:
Very slowly (longer than 2 seconds)?
Slowly? Immediately?
CLASSIFY Two of the following signs: ► If child has a severe classification:
DIARRHOEA Restless, irritable - Refer URGENTLY to hospital with mother giving
SOME frequent sips of ORS on the way.
Sunken eyes
- Advise the mother to continue breastfeeding.
Drinks eagerly, thirsty DEHYDRATION ► If child has no severe classification:
Skin pinch goes back - Give fluid and food for some dehydration
(Plan B).
slowly.
- Give Zinc.
- Advise mother when to return immediately.
- Follow-up in 5 days if not improving.

No enough signs to
classify as severe or
some dehydration.
► Give fluid, ZInc Tab. and food to treat diarrhoea
at home (Plan A).
NO
►Advise mother when to return immediately.
DEHYDRATION ►Follow-up in 5 days if not improving.

SEVERE ►Treat dehydration before referral unless the child

PERSISTENT has another severe classification.
Dehydration present. ► Give Zinc
DIARRHOEA
and if diarrhoea ►Refer to hospital.
14 days or more
►Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA.
No dehydration. ► Give multivitamin, minerals and Zinc supplement
DIARRHOEA
►Follow-up in 5 days.

and if blood ►Treat for 5 days with an oral antibiotic

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

3
 ASSESS AND CLASSIFY FOR FEVER
ASSESS CLASSIFY IDENTIFY TREATMENT

Does the child have fever? SIGNS CLASSIFY TREATMENT

(By history, feel hot or temperature 37.5o C* or above ► Give first dose of artesunate or quinine for severe
malaria
Decide malaria risk High, Low or No malaria risk VERY SEVERE ► Give first dose of an appropriate antibiotic.
Any general danger sign
FEBRILE ►Treat the child to prevent low blood sugar.
Stiff neck. ► Give one dose of paracetamol in clinic for high fever
IF YES, ASK: CHECK: LOOK, FEEL DISEASE (38.5° or above)
► Refer URGENTLY to hospital.

For how long?
If more than 7 days,
has fever been present
every day?
Has the child has
measles within the last
Look or feel for stiff neck. ► Give oral first line antimalarial.
► Give one dose of paracetamol in clinic for high fever
Look for runny nose. (≥38.5°C ).
Positive malaria test. MALARIA ►Advise the mother when to return immediately.
Look for any other cause of fever ►Follow-up in 3 days if fever persists.
HIGH OR LOW
Look of signs of measles MALARIA RISK ► If fever is present every day for more than 7 days,
refer for assessment
Generalized rash and ► Assess for other cause of fever and treat accordingly
One of these: cough, runny nose, ►Give one dose of paracetamol for high fever (≥ 38.5°)

Classify for fever

FEVER ►If fever for 7 days or more refer for assessment
three months or red eyes. Negative malaria test ►Advice the mother when to return immediately
NO MALARIA
► Advice the mother to use insecticide treated bed net
► Follow up in 3 days if fever persist

NO MALARIA
Do malaria test if: NO general danger signs or other sever Any general danger sign ► Give first dose of an appropriate antibiotic.
RISK AND NO VERY SEVERE ►Treat the child to prevent low blood sugar.
classifications : TRAVEL TO or FEBRILE ► Give one dose of paracetamol in clinic for high
In all fever cases in high malaria risk MALARIA Stiff neck. fever(≥38.5°)
DISEASE ► Refer URGENTLY to hospital.
In low and No malaria risk if no obvious cause of fever present RISK AREA
► Assess for other cause of fever and treat accordingly
No general danger sign ►Give one dose of paracetamol for high fever ( ≥ 38.5°)
No stiff neck FEVER ►Advice the mother when to return immediately
► Follow up in 3 days if fever persist

If the child has measles
now or within the last
three months :
Look for mouth ulcers are they deep or
Any general danger sign ► Give Vitamin A.
extensive SEVERE ► Give first dose of an appropriate antibiotic IM
CLASSIFY FOR MEASLES IF Clouding of the cornea COMPLICATED ► If clouding of the cornea or pus draining from the eye,
Look for pus draining from the eye apply tetracycline eye ointment.
MEASLES NOW OR WITHIN Deep or extensive mouth MEASLES***
Look for clouding of the cornea THE LAST 3 MONTHS ► Activate measles surveillance system in the area.
ulcers. ► Refer URGENTLY to hospital.

► Give Vitamin A.
These Temperatures are based on axillary temperature. Rectal temperature readings are approximately Pus draining from the MEASLES WITH ► If pus draining from the eye, treat eye infection
0.5°C higher EYE OR MOUTH with tetracycline eye ointment.
Look for local tenderness. Oral sores; Refusal to use the limb, hot tender swelling, red tender skin or eye or ► If mouth ulcers, treat with gentian violet.
COMPLICA-
boils; lower abdominal pain or pain when passing urine in older children Mouth ulcers. ►Advise the mother when to return immediately
***If no malaria test available : High malaria risk - classify as MALARIA; Low malaria risk AND NO TIONS* ► Activate measles surveillance system in the area.
obvious cause of fever – classify as MALARIA.
****Other important complications of measles - pneumonia, stridor, diarrhea, ear infection, and Measles now or within the
malnutrition - are classified in other tables. last 3 months. MEASLES ► Give Vitamin A.

4
 ASSESS AND CLASSIFY FOR EAR PROBLEM
ASSESS CLASSIFY IDENTIFY TREATMENT

DOES THE CHILD HAVE AN EAR PROBLEM? SIGNS CLASSIFY TREATMENT

►Give first dose of an appropriate antibiotic.
Tender swelling behind ►Give first dose of paracetamol for pain
MASTOIDS
the ear. ► Refer URGENTLY to hospital.

IF YES, ASK: LOOK AND FEEL: Pus is seen draining from ►Give an appropriate oral antibiotics for 5 days
the ear and discharge is ► Give paracitamol for pain
ACUTE EAR
CLASSIFY reported for less than 14 ►Dry the ear by wicking
Is there ear pain? Look for pus draining INFECTION
EAR PROBLEM days, or ►Advice the mother when to return immediately
Is there ear discharge? from the ear. Ear pain. ►Follow up in 5 days

If yes, for how long? Feel for tender swelling ►Dry the ear by wicking.
Pus is seen draining from
►Treat with appropriate topical antibiotics for 14
the ear and discharge is CHRONIC EAR
behind the ear. days
reported for 14 days or INFECTION
►Advice the mother when to return immediately
more.
►Follow-up in 5 days

No ear pain and

No pus seen draining from NO EAR ►Assess other ear problem, if present, refer to
the ear. INFECTION ENT

5
 THEN CHECK FOR ACUTE MALNUTRITION
ASSESS CLASSIFY
SIGNS
LOOK AND FEEL:
Oedema of both feet OR
CHECK FOR ACUTE MALNUTRITION: WFH/L less than -3 z scores
Look for signs of acute malnutrition OR
MUAC less than 115 mm
Look for oedema of both feet. AND any of the following:
Medical complication present
Determine WFH/L* ___ z-score. And/ Or
Not able to finish RUTF.
Measure MUAC**____ mm in a child 6 months or older.
CLASSIFY
If WFH/L less than -3 z-scores or MUAC less than WFH/L less than -3 z- Scores
115 mm OR
MUAC less than 115 mm
AND
Then Check for any medical complication present:
Able to finish RUTF.
* Any general danger signs
* Any severe classification
* Pneumonia with chest indrawing
If no medical complications present; do appetite test
WFH/L between -3 and -2
Child is 6 months or older, offer RUTF*** to eat. Is the child: z-scores
* Not able to finish RUTF portion OR
MUAC 115 up to 125 mm
* Able to finish RUTF portion?
Child is less than 6 months assess breast feeding
WFH/L - 2 z-scores or more
OR
MUAC 125 mm or more.
*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 malnutrition.
6
IDENTIFY TREATMENT
CLASSIFY TREATMENT
►Give first dose appropriate antibiotic.
COMPLICATED ►Treat the child to prevent low blood sugar.
SEVERE ACUTE ►Keep the child warm.
MALNUTRITION
►Refer URGENTLY to hospital (stabilization center
SC)
►Give oral antibiotics for 5 days.
►Refer for Outpatient management for SAM
nearby or
UNCOMPLICATED Give ready-to-use therapeutic food for a child aged
6 months or more.
SEVERE ACUTE
►Counsel the mother on how to feed the child.
MALNUTRITION
►Assess for possible TB infection.
►Advise mother when to return immediately.
►Follow up in 7 days
►Refer for the child for Supplementary feeding
program if available.
►if not available; Assess the child's feeding and
MODERATE counsel the mother on the feeding recommenda-
tions and refer for growth monitoring and health
ACUTE
promotion.
MALNUTRITION ► If feeding problem, follow up in 7days
►Assess for possible TB infection.
►Advise mother when to return immediately
►Follow-up in 30 days
►If child is less than 2 years old, assess the child's
NO ACUTE feeding and counsel the mother on feeding
MALNUTRITION according to the feeding recommendations
► If feeding problem, follow-up in 7 days
 THEN CHECK FOR ANAEMIA

ASSESS CLASSIFY IDENTIFY TREATMENT

CHECK FOR ANEMIA SIGNS CLASSIFY TREATMENT

Look for palmar pallor. Is it: Severe palmar pallor SEVERE ►Treat the child to prevent low blood sugar
ANAEMIA ►Refer URGENTLY to hospital
CLASSIFY
Severe palmar pallor*? ►Give iron**

Some palmar pallor? ►Give Albendazole if child is 1 year or older

Some palmar pallor ANAEMIA and has not had a dose in the last 6 months
No palmar pallor?
► Advise mother when to return immediately
►Follow-up in 14 days

No palmar pallor NO ANAEMIA ►No additional treatment

*Assess for sickle cell anaemia if common in your area, DO NOT give Iron.

**If child has severe acute malnutrition and receiving RUTF, DO NOT give iron because here is already adequate amount of iron in RUTF.

7

ASSESS
Check for TB
ASK LOOK AND FEEL
If child has house-
hold//other contact with a
known case of TB.
Determine if child has
cough for more than 14
days.
Determine if the child
has unexplained or
prolonged fever for more
than 7 days.
Unexplained fatigue,
reduced playfulness, less
active.
THEN CHECK FOR TUBERCLOSIS INFECTION
Look for generalized
lymphadenopathy.
Are there any enlarged
lymph glands in two or
more of the following sites:
neck, armpit, or groin?
Does the child have
Growth faltering or
UNCOMPLICATED
SEVERE ACUTE MALNU-
TRITION or MODERATE
ACUTE MALNUTRITION?
CLASSIFY IDENTIFY TREATMENT
SIGNS CLASSIFY TREATMENT
Two or more Criteria present POSSIBLE ►Trace contact
TUBERCULOSIS ► Check for HIV infection
►Refer for TB center for management as
per national TB guidelines
► Activate TB surveillance system in the
area
► Advice the mother when to return
CLASSIFY immediately
► Follow up monthly
The child has household//other TUBERCULOSIS
► Refer for TB assessment
contact with a known case of TB. CONTACT
►Advice on growth monitoring and breast
NO
Non of the above criteria feeding, immunization,deworming and
TUBERCULOSIS general nutrition
8
 THEN CHECK FOR HIV INFECTION
ASSESS
Check for HIV infection:
ASK
Has the mother and /or If YES: Then note the mother
the child had an HIV test and/or the child HIV stats
Mother's HIV test: NEGATIVE
POSITIVE
Child's HIV test
* Virological test: NEGATIVE
POSITIVE
* Serological test: NEGATIVE
POSITIVE
If mother is HIV-positive and
child is negative or unknown
* Is the child breastfeeding
now?
* Was the child breastfeeding
at the time of test 6 weeks
Advice
before it?
* If breastfeeding: Is the
mother and child on ARV
prophylaxis?
* Give Cotrimoxazole prophylaxis for all children less than 1 year who are exposed to HIV infection and to children 1-4 years who are confirmed HIV positive
** If virological test is negative, repeat test 6 weeks after the breast feeding stopped of serological test is positive do a virological test as soon as possible.
CLASSIFY
SIGNS
Positive virological test for the
child, or
Positive serological test in 18
months child or older
CLASSIFY
HIV
Mother HIV positive and the
child has negative virology test
and is breast feeding or
stopped less than 6 weeks OR
Mother HIV positive and child
not tested
Positive serological test in a
child less than 18 months
Non of the above criteria
9
IDENTIFY TREATMENT
CLASSIFY TREATMENT
► Give prophylaxis Cotrimoxazole *
CONFIRMED
► Refer to HIV to initiate ART
HIV INFECTION
►Assess the child feeding and counsel
the mother on feeding
► Refer for TB assessment
► Advice the mother when to return
immediately
► Follow up regularly as per national
guidelines
► Give prophylaxis Cotrimoxazole
► Refer to HIV center for confirmatory
test and to initiate ART as needed.
►Assess the child feeding and counsel
the mother on feeding
► Refer for TB assessment
HIV EXPOSED ► Advice the mother when to return
immediately
► Follow up regularly as per national
guidelines
HIV INFECTION
► No treatment needed
UNLIKELY
 THEN CHECK FOR MOUTH AND GUM CONDITION

ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY TREATMENT

SEVERE GUM ►Refer URGENTLY to hospital

Deep or extensive gum or
FOR CHILDREN ON ART OR HIV mouth ulcer OR
CONFIRMED OR EXPOSED Not able to eat due to mouth
ulcer
OR MOUTH ►If possible give first dose of acyclovir
pre- referral.
INFECTION
►Start metronidazole if referral is not
possible (see treat)
If the child in ART refer for assessment
(this may be drug reaction)

►Teach the mother to treat mouth ulcer

in HIV art home
ASK: LOOK: CLASSIFY ►If lips or anterior gum are affected give
acyclovir ; if not possible refer (see treat
Does the child has gum Look for gum or mouth ulcer the child)
or mouth ulcer? ►If the child received drugs (ART,
Cotrimoxazole , Isoniazid INH) in the last
Are they deep or extensive? month refer for assessment (drug
Mouth or gum ulcer GUM OR
reaction specially if the child has a skin
Is the child not able to MOUTH ULCER
reaction)
eat due to mouth ulcer? ►If the child has thrush; teach the
mother to treat oral thrush at home
►give paracetamol for pain
►Teach the mother when to return
immediately
Follow up in 7 days

No mouth or gum ulcers NO GUM OR ►Advice the mother about feeding and
MOUTH ULCER her own health

10
THEN CHECK THE CHILD’S IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND DEWORMING STATUS

VACCINATION VITAMI A SUPPLEMENTATION

AGE VACCINE ROUT/SITE DOSE
Give every child age 6 months and above a dose of vitamin A then
BIRTH BCG* INTRADERMAL, 0.05 ML
LT SHOULDER every 6 months .

OPV 0** 2 DROPS Record the dose in the child card

ORAL DROPS
For vitamin A dose see (TREAT THE CHILD CHART)
6 WEEKS OPV 1 ORAL DROPS 2 DROPS

PENTAVALENT 1 RT THIGH 0.5 ML ROUTIENE WORM TREATMENT

OPV 2 2 DROPS Give every child aged one year and above a dose of mebendazole
10 WEEKS ORAL DROPS
every 6 months
PENTAVALENT 2 RT THIGH 0.5 ML Give every child above 2 years either mebandazol or albendazol
every 6 months
14 WEEKS OPV 3 ORAL DROPS 2 DROPS
Record the dose in the child card

PENTAVALENT 3 RT THIGH 0.5 ML

IPV LT THIGH 0.5 ML IMPORTANT

MEASLES 1 SUBCUTANEOUS RT Vitamin A and deworming medicine that given during mass
9 MONTHS SHOULDER LT THIGH 0.5 ML
IPV2 immunization campaigns should be recorded in the child card ;
SUBCUTANEOUS
15 MONTHS MEASLES 2 RT SHOULDER 0.5 ML look at it before giving the child a new dose

* GIVE BCG untill 12 months of age if not received before

** Don’t give OPV 0 to an infant above 14 days
IMPORTANT: GIVE PENTA 1, OPV1 at age of 6 weeks, keep the interval of 4 weeks for the subsequent vaccine.
*** in case of measles outbreak the vaccine should be given between 6 months-59 months.
**** children above one year who were previously unvaccinated should receive OPV,IPV,PENTA, MCV, until…..

ASSESS OTHER PROBLEMS

ASSESS MOTHER OWN HEALTH

11
 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. FOR PNEUMONIA, ACUTE EAR INFECTION
Also follow the instructions listed with each drug’s dosage table.

Determine the appropriate drugs and dosage for the child’s age or weight. FIRST-LINE ANTIBIOTIC: AMOXICILLIN, Cotrimoxazole
SECOND LINE ANTIBIOTIC : ERYTHROMYCIN
Tell the mother the reason for giving the drug to the child.

Demonstrate how to measure a dose.

Watch the mother practice measuring a dose by herself. AMOXYCILLIN ERYTHROMYCIN

Ask the mother to give the first dose to her child. GIVE TWO TIMES DAILY GIVE 4 TIMES DAILY
FOR 5 DAYS FOR 5 DAYS
Explain carefully how to give the drug, then label and package the drug.
50 MG/KG 50 MG/KG/ DAY
If more than one drug will be given, collect, count and package each drug

separately.

Explain that all the oral drug tablets or syrups must be used to finish the
AGE or WEIGHT TABLET SYRUP TABLET SYRUP
course of treatment, even if the child gets better. 250 mg 125 mg/ 5 ml 250 mg 125 mg/ 5 ml
Check the mother’s understanding before she leaves the clinic.

2 - >4 months
GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR HIV 1/2 5 ml 1/4 2.5 ml
INFECTION AND HIV EXPOSED, POSSIBLE HIV INFECTION (4 - < 6kg)

Give Cotrimoxazole prophylaxis for PCC from 6 weeks: once a day

4 - > 12 months
AGE ADULT TABLE PEDIATRICS SYRUP
OR WEIGHT (80/400 MG) TABLET (20/100 MG) (40/200 MG/5 ML) 1 10 ml 1/2 5 ml
(6 > 10 kg)

6 weeks to 12
months 1/4 1 2.5 ml
12 months up to 5
4- .>10 kg
years 1 1/2 15 1 10
12 months—5
years 1/2 2 10 ml (10 - 19 kg)
10->19 kg

Avoid giving Cotrimoxazole to young infant who is premature or jaundice Use Cotrimoxazole if amoxicillin is not available

12
 TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug’s dosage table.

FOR DYSENTERY: GIVE AN ORAL ANTIMALARIAL

Give antibiotic recommended for Shigella in your area for 5 days. FIRST-LINE ANTIMALARIAL: ARTEMETHER 20mg + LUMEFANTRINE 120mg (coartem) .
The recommended dose is 5- 24mg/kg body weight Artemether and 29-144 mg /kg body weight lumfantrine
FIRST-LINE ANTIBIOTIC FOR CHOLERA : CiPROFLOXACIN
SECOND-LINE ANTIBIOTIC FOR CHOLERA CEFTRIXONE Artemether 20 MG Lumefantrine 120 mg (Coartem)
Give with fatty meals to enhance the absorption
CIPROFLOCACIN 15 MG/KG/ DOSE
AGE OR WEIGHT Age/ Weight DAY 1 DAY 2 DAY 3
GIVE 2 TIMES DAILY FOR 5 DAYS
Adult tablet Syrup Initially 8 hours Morning Evening Morning Evening
250 mg 250 mg/5 ml
2 - >4 months 1/4 1.25 ml 3 months up-to 3 yrs (5 up to 15 kg) 1 1 1 1 1 1
(4 - < 6kg)
3—up-to 8 yrs (15 up to 25 kg) 2 2 2 2 2 2
4— > 12 months 1/2 2.5 ml
(6 > 10 kg)
12 mon up to 5 years SECOND-LINE ANTIMALARIAL : DIHYDROARTEMISININ+P IPRAQUENE(DHAP)
(10 - 19 kg)
1 5 ml The recommended dose is 4mg/kg body weight of dihydroartemisinine+18mg/kg body weight of piperaquine per day

Combined formulation Combined formulation

Give ceftriaxone for each child with sever classification (see give the WEIGHT DIHYDROARTEMISNIN PIPRAQUENE
160 PIPRAQUENE + 20 320PIPRAQUENE + 40
treatment in the clinic only) Daily dose (mg) Daily dose (mg)
DIHYDROARTEMISNIN DIHYDROARTEMISNIN

5-7 kg 10 80 1/2

GIVE PARACETAMOL FOR HIGH FEVER 7 -13 kg 20 160 1 1/2

(≥38.5°C) OR EAR PAIN
13 - 24 kg 40 320 2 1
Give paracetamol every 6 hours until high fever or ear pain is gone.

GIVE QUININE
AGE PARACETAMOL
OR WEIGHT THIRD LINE OF ANTIMALARIA : QUININE
TABLET TABLET Syrup The recommended dose is 10 mg/kg/does; three times daily for 7 days.
(100 mg) (500 mg) 120 mg/5ml QUININE TABET 300 mg
AGE/WEIGHT
2 months up to 3 years Given 3 times daily for 7 to 10 days
1 1/4 5 ml
(4 - <14 kg)
2 up to 12 months (up to 11 KG) 1/4
3 years up to 5 years
2 1/2 1/2 5 ml
(14 - <19 kg) 12 months up to 5 years 1/2

13
 TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug’s dosage table.

FOR CHOLERA GIVE IRON

Give one dose daily for 14 days
FIRST-LINE ANTIBIOTIC FOR CHOLERA : ERYTHROMYCINE
IRON/FOLATE TABLET IRON SYRUP
SECOND-LINE ANTIBIOTIC FOR CHOLERA CORTIMOXAZOL IRON SYRUP
Ferrous sulfate 200 mg Ferrous fumarate100
Age/ Weight Ferrous sulfate
+ 250 mcg Folate mg /5 ml (20 mg
ERYTHROMYCIN COTRIMOXAZOL COTRIMOXAZOL COTRIMOXAZOL 100 mg/5ml
(60 mg elemental iron/ml) elemental iron/ ml)
AGE OR WEIGHT GIVE 4 TIMES GIVE 2 TIMES GIVE 2 TIMES DAILY GIVE 2 TIMES
2 months up to 4 months
DAILY FOR 3 DAYS DAILY FOR 3 DAYS FOR 3 DAYS DAILY FOR 3 DAYS 1.0 ml (< 1/4 tsp.) 1.00 ml (< 1/4 tsp.)
(4 - <6 kg)

2 - >4 months Adult tablet 250 mg Adult tablet 80/400 Pediatric tablet 20/100 Syrup 40/200 mg/5ml 4 months up to 12 months
1.25 ml (1/4 tsp.) 1.25 ml (1/4 tsp.)
(6 - <10 kg)
(4 - < 6kg) 1/4 1/4 2 5 ml
12 months up to 3 years
1/2 tablet 2.0 ml (<1/2 tsp.) 2.00 ml (<1/2 tsp.)
4- > 12 months (10 - <14 kg)

(6 > 10 kg) 1/2 1/2 2 5 ml 3 years up to 5 years

1/2 tablet 2.5 ml (1/2 tsp.) 2.5 ml (1/2 tsp.)
(14 - 19 kg)
1 up to 5 years
(10 - 19 kg) 1 1 4 8.5 ml GIVE MEBANDAZOL OR ALBEMDAZOL
Give 500 mg of Mebandazol as a single dose in the clinic: If the child is one year or
older, and has not had a dose in the previous 6 months OR
GIVE VITAMIN A Give 400 mg of Albendazol as a single dose in the clinic; if the child is two years or
For measles, give three doses.
older and has not had a dose in the last 6 months
Give first dose in clinic.
Give mother a dose to give at home, the next day. Don’t give Albendazol for child less than 1 year
Give the third dose at the clinic after one month
For SEVER COMPLICATED MEASLES give one dose before referral to hospital.
GIVE ZINC
For vitamin A supplementation of child age 6 months or older who has not received vitamin A in previous 6
months: Give one dose daily for 10-14 days
Give one dose in clinic.

AGE VITAMIN A CAPSULES Age Zinc TABLET 20 mg\tablet)

OR WEIGHT 200 000 IU 100 000 IU 50 000 IU

Up to 6 months 1/2 capsule 1 capsule

<6 Month 1/2 tab
6 months up to 12
1/2 capsule 1 capsule 2 capsule
months
12 months up to 5 > 1 tabs
1 capsule 2 capsule 4 capsule - 6 Month
years

14
 TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given.
TREAT MOUTH ULCERS / GUM ULCER
Describe the treatment steps listed in the appropriate box. For child with measles treat the mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except remedy Wash hands.
for cough or sore throat). Wash the child’s mouth with clean soft cloth wrapped around the finger and wet
Tell her how often to do the treatment at home. with salt water.

If needed for treatment at home, give mother the tube of tetracycline ointment Paint the mouth with half-strength gentian violet
Wash hands again.
or a small bottle of gentian violet.
For children on ART or HIV infection, or HIV EXPOSED or HIV INFECTION
Check the mother’s understanding before she leaves the clinic.
Wash hands.
Wash the child’s mouth with clean soft cloth wrapped around a stick and wet with
TREAT EYE INFECTION WITH TETRACYCLINE
EYE OINTMENT saline peroxide or sodium bicarbonate

Clean both eyes 3 times daily. Give acyclovir 20 mg/kg 4 times daily for 5 days if lips or anterior gum is involved .

Wash hands. Provide Pain relief

Ask child to close the eye. Wash hands again.

Use clean cloth and water to gently wipe away pus.

Then apply tetracycline eye ointment in both eyes 3 times daily.
Ask the child to look up. SOOTHE THE THROAT, RELIEVE COUGH WITH A SAFE
Squirt a small amount of ointment on the inside of the lower lid.
REMEDY
Wash hands again. Safe remedies to recommend:
Treat until redness is gone. Breastmilk for exclusively breastfed infant.
Tea with honey
DRY THE EAR BY WICKING
Tea with lemon
Dry the ear at least 3 times daily.
Harmful remedies and practices to discourage:
Roll clean absorbent cloth or soft, strong tissue paper into a wick.
All cough medicines
Place the wick in the child’s ear.
Removal of the uvula
Remove the wick when wet.
The use of oil as nasal drops
Replace the wick with a clean one and repeat these steps until the ear is dry.
For CHRONIC EAR INFECTION use QUINOLONE (Ciprofloxacin, oflofloxacin ear
drop after dry wicking 3 times daily for 14 days.

15
 GIVE THESE TREATMENTS IN CLINIC ONLY

Explain to the mother why the drug is given.

GIVE AN INTRAMUSCULAR ANTIBIOTIC
Determine the dose appropriate for the child’s
FOR CHILDREN BEING REFERRED URGENTLY
weight (or age). Give first dose of intramuscular ampicillin and gentamycin and refer child urgently to hospital.
Use a sterile needle and sterile syringe. Measure Give ampicillin (50mg/kg) or benzyl penicillin (50000IU/kg) and gentamycin (3 to 5 mg/kg)
the dose accurately. If ampicillin is not available give benzyl penicillin
Give the drug as an intramuscular injection. For children with COMPLICATED ACUTE MALNUTRITION give Benzyl penicillin and gentamycin then refer urgently.
For children with DYSENTRY and other sever classification or GEBNERAL DANGER SIGN
If child cannot be referred, follow the instructions
give first dose of ceftriaxone injection and refer urgently to the hospital
provided.
IF REFERRAL IS NOT POSSIBLE:
Continue giving both antibiotics (Ampicillin and gentamycin) as follow:

* Repeat ampicillin or benzyl injection every 6 hours for 5 days

* Give gentamycin once daily for 5 days
Then change to appropriate e oral antibiotics to complete 10 days
When there is strong suspicions of meningitis increase the dose of ampicillin up to 4 times
For children with DYSENTRY repeat the dose of ceftriaxone ever 12 hours for 3 days

AMPICILLIN BENZYL PENICILLIN BENZYL PENICILLIN GENTAMYCIN CEFTRIXON 1g

AGE or WEIGHT
Dose: 50 mg/kg/day Dose 50 000 units per kg Dose 50 000 units per kg Ampule 2ml/40 mg/ml Dose: 50-80mg/kg/day
Add 2.5 sterile water Add 2.1 ml sterile water to vial Add 8 ml sterile water to vial Dose: 7.5 mg/kg Add 10 ml of sterile water to
to vial of 500 mg containing 600 mg (1 000 000 containing 3 g (5 000 000 1 g vial = 100 mg/ml
units) = 2.5 ml at 400000 IU units) = 10 ml at 500000 IU

2->4 kg 0.5 0.5 1.5 ml

2 months up to 4 months
1.0 ml 0.8 ml 0.6 ml 1.0 ml 3.0 ml
(4 - < 6 kg)
4 months up to 9 months
1.5 ml 1.0 ml 0.8 ml 1.3 ml 6.0 ml
(6 - < 8 kg)

9 months up to 12 months
2.0 ml 1.2 ml 1.0 ml 1.5-1.8 ml 7.0 ml
(8 - < 10 kg)
12 months up to 3 years
(10 - < 14 kg) 3.0 ml 1.5 ml 1.2 ml 1.9-2.7 ml 10.0 ml

3 years up to 5 years
(14 - 19 kg) 5.0 ml 2.5 ml 1.5 ml 2.8-3.5 ml 13.0 ml

16
Give Artesunate suppositories or Intramuscular or Artemether I.M Quinine for Severe Malaria

TREAT A CONVULSING CHILD WITH DIAZEPAM RECTALLY

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Manage the Airway
Check which pre-referral treatment was available in your clinic (rectal artesunate suppository, artesunate injection, or
Artemether injection quinine). Turn the child on his or her side to avoid aspiration.
Do not insert anything in the mouth
If Artesunate rectal capsule/suppositories is available insert the first dose and refer the child urgently to the hospital.
If the child is blue (cyanosed), open the mouth and make sure the airway is clear.
Recommended dose of artesunate is 10 mg/kg body weight (in form of 50 mg or 200mg per recto_cap) If necessary, remove secretions from the throat
Injectable artesunate or quinine; give the first intramuscular injection and refer the child urgently to the hospital If High Fever, Lower the Fever
Recommended dose of Artemether injection is loading dose: 3.2mg/kg. Maintenance dose: 1.6mg/kg. Sponge the child with room-temperature water.
Check quinine formulation available in your clinic. if ARTESUNATE CAPSULE OR SUPPOSITORIES not available. For children aged more than one month Give Diazepam Rectally
Be sure the child is well hydrated. Draw up the dose from an ampule of diazepam into a small syringe, then remove
IF REFERRAL IS NOT POSSIBLE: the needle.
For artesunate suppository: Insert approximately 5 cm of nasogastric tube or the tip of the syringe into the
Give the first dose of artesunate suppository at the clinic rectum.
Inject the diazepam solution into the nasogastric tube and flush it with 2 mls
Repeat the dose every 24 hours until the child van take orally
room-temperature water.
Give a full dose of oral antimalarial when the child can take orally
Hold buttocks together for a few minutes.
For artesunate injection: Don’t give diazepam to children below one month; give Phenobarbitone instead
Give the first dose of artesunate intramuscular injection at the clinic
Repeat the dose after 12 hours then after 24 hours then very 24 hours until the child van take orally AGE or WEIGHT DIAZEPAM RECTALLY(10mg/2mls)
Give a full dose oral antimalarial when the child can take orally Dose: 0.2-0.4 mg/kg
Steps to dilute artesunate injection 1 -2 months (3->4 kg) 0.125 ml
Dilute the powder with 1 ml of 5% sodium bicarbonate and shake for 2-3 minutes tell the solution becomes clear
For intramuscular injection add 2 ml of normal saline or 5% dextrose and mix again; to obtain a concentration of 2 up to 4 months (4 - < 6 kg) 0.25 ml
20mg/ml artesunate 4 up to 12 months (6 - < 10 kg) 0.50 ml
For Artemether injection
Loading dose: 3.2mg/kg Maintanance dose: 1.6mg/kg daily until the patient can take oral medication 1 up to 3 years (10 - < 12 kg) 0.75 ml
For quinine injection
3 up to 5years (12 - < 14 kg ) 1.0 ml
Give the first dose of intramuscular quinine in the clinic The child should remain lying down for 1 hour
Repeat the dose every 8 hours until the child van take orally Give a full dose of oral quinine when the child can take
orally TREAT A CONVULSING CHILD WITH INTRAMUSCULAR PHENOBARBITONE
Manage the Airway
RECTAL ARTESUNATE INTRAMUSCULAR
INTRAMUSCULAR Turn the child on his or her side to avoid aspiration.
AGE or WEIGHT SUPPOSITORIES ARTESUNATE Do not insert anything in the mouth
QUININE
Dose 10 mg/kg 60 mg vial 20mg/ml If the child is blue (cyanosed), open the mouth and make sure the airway is clear.
Dose 2.4 mg/kg 150 mg/ml 300 mg/ml If necessary, remove secretions from the throat
50 mg 200 mg 2ml ampule 2ml ampule
2 up to 4 months If High Fever, Lower the Fever
(4 - < 6 kg) 1 1.5 ml 0.4 0.2
Sponge the child with room-temperature water.
4 up to 12 months 2 1 ml 0.6 0.3 For children aged lass than one month Give Phenobarbitone intramuscularly
(6 - < 10 kg)
1 up to 2 years Weight Phenobarbitone 200mg/ml Dose is 15 mg/kg
(10 - < 12 kg) 2 1.5 ml 0.8 0.4
1.5 -< 2.5 kg 0.2 ml
2 up to 3years 3 1 1.5 ml 1.0 0.5
(12 - < 14 kg ) 2.5 - < 4 kg 0.3 ml
3 up to 5 years 3 2 ml 1.2 0.6 4 - < 6 kg 0.4 ml
(14 - < 19 kg) 1
6 - < 10 kg 0.6 ml

17
 GIVE THESE TREATMENTS IN THE CLINIC ONLY

GIVE INHALED SALBUTAMOL FOR WHEEZING

Give oral salbutamol for wheezing if inhaler
USE OF A SPACER
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years should be not available:
given an
inhaler without a spacer. A spacer works as well as a nebulizer if correctly used.
Oral salbutamol 3 times daily for 5 day
From salbutamol metered dose inhaler (100 μg/puff) give 2 puffs.
Repeat up to 3 times every 20 minutes before classifying pneumonia.

To use an inhaler with a spacer: Age or Weight Syrup 2mg/5ml Tablet 2mg Tablet 4mg
Remove the inhaler cap. Shake the inhaler well.
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
2month<12 2 ½ ml
The child should put the opening of the bottle into his mouth and breath in and out through the mouth. A carer then
month (<10kg)
½ ¼
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 12m<5yr
(10kg-19kg)
5 ml 1 ½
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.

TREAT THE CHILD TO PREVENT LOW BLOOD SUGAR

If the child is able to breastfeed:
Ask the mother to breastfeed the child.
If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or another milk.
If neither of these is available, give sugar water.
Give 30 - 50 ml of milk or sugar water before departure.
To make sugar water: Dissolve 4 level teaspoons of sugar (20grams) in a 200-ml cup of clear water.
If the child is not able to swallow:
Give 50 ml of milk or sugar water by nasogastric tube.

18
 GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
(See Feeding advice on COUNSEL THE MOTHER chart)

PLAN A: TREAT DIARRHOEA AT HOME PLAN B: TREAT SOME DEHYDRATION WITH ORS
Counsel the mother on the 4 Rules of Home Treatment: Give in clinic recommended amount of ORS over 4-hour period
1. Give Extra Fluid, DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.
2. Give zinc supplement
3. Continue Feeding, 4 months up to 12 months up to 2 years up to
AGE* Up to 4 months
4. When to Return 12 months 2 years 5 years

1. GIVE EXTRA FLUID (as much as the child will take) WEIGHT < 6 kg 6 -< 10 kg 10 -< 12 kg 12 - 19 kg
TELL THE MOTHER: In ml 200 - 400 400 - 700 700 - 900 900 - 1400
Breastfeed frequently and for longer time each feed.
If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk.
Use the child’s age only when you do not know the weight. The approximate amount of ORS
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 water. required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75.
If the child wants more ORS than shown, give more.
It is especially important to give ORS at home when:
The child has been treated with Plan B or Plan C during this visit. For infants under 6 months who are not breastfed, also give 100-200 ml clean water during this
The child cannot return to a clinic if the diarrhoea gets worse. period.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
PACKETS OF ORS TO USE AT HOME. Give frequent small sips from a cup.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL If the child vomits, wait 10 minutes. Then continue, but more slowly.
FLUID INTAKE: Continue breastfeeding whenever the child wants.
Up to 2 years 50 to 100 ml after each loose stool
AFTER 4 HOURS:
2 years or more 100 to 200 ml after each loose stool
Reassess the child and classify the child for dehydration.
Select the appropriate plan to continue treatment.
Tell the mother to:
Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Begin feeding the child in clinic.
Continue giving extra fluid until the diarrhoea stops.
IF THE MOTHER MUST LEAVE BEFORE COMPLETING
2. Give Zinc 20 mg tabs TREATMENT:
Tell the mother how much zinc to give
Show her how to prepare ORS solution at home.
2-6 months 1/2 tabs daily for 10 days Show her how much ORS to give to finish 4-hour treatment at home.
6 month or more 1 tabs daily for 10 days Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
in Plan A.
SHOW THE MOTHER HOW TO Explain the 4 Rules of Home Treatment:
GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup.
1. GIVE EXTRA FLUID
Older children - tablets can be chewed or dissolved in a small amount of water. 2. GIVE ZINC (For children more than 2 months)
3. CONTINUE FEEDING (exclusive breast feeding if less than 6 months)
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
4. WHEN TO RETURN

19
 GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
See Feeding advice on COUNSEL THE MOTHER chart)
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
FOLLOW THE ARROWS. IF ANSWER IS “YES”, GO ACROSS. IF “NO”, GO DOWN.

START HERE
Can you give intravenous
(IV) fluid immediately?
NO
Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give
100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows: Immunize every sick child,
YES
FIRST GIVE THEN GIVE give vitamin A and deworm
AGE
30 ML/KG IN: 70 ML/ KG IN:
as describe in Assess and
Infant (under 12 months) 1 hour 5 hours
Children (12 months up to 5 years) 30 minutes* 2 1/2 hours
Classify part
* 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 available Refer URGENTLY to hospital for IV treatment.

YES
nearby (within 30 minutes)? If the child can drink, provide the mother with ORS solution and show her how to give frequent
sips during the trip.
NO

Are you trained to use a
naso-gastric (NG) tube for
Rehydration?
NO
Can the child drink?
Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total
of 120 ml/kg).
Reassess the child every 1-2 hours:
If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly.
YES f hydration status is not improving after 3 hours, send the child for IV therapy.
After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A,
B, or C) to continue treatment.

NO
NOTE:
If the child is not referred to the hospital possible, observe the child at least 6 hours after
Refer URGENTLY to hospital rehydration to be sure the mother can maintain hydration by giving the child ORS solution by
for IV or NG treatment mouth.

20
 COUNSEL THE MOTHER

COUNSEL THE MOTHER ON FEEDING

Assess Child's Appetite
All children aged 6 months or more with SEVERE ACUTE MALNUTRITION, oedema 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.

21
 COUNSEL THE MOTHER

COUNSEL THE MOTHER ON FEEDING

Assess Child's Feeding
Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA. 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

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?
What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION or if the child with CONFERMID HIV INFECTION failed to gain weight or loses weight
between monthly measurement ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What food are available at home
During this illness, has the child's feeding changed?
If yes, how?

22

COUNSEL THE MOTHER ON FEEDING
NOTES: These feeding recommendation should be followed in infants with HIV negative mothers, unknown HIV status mothers should be encouraged to breastfeed
but also be tested for HIV in order to make an informed choice
Up to 6 months
Immediately after birth, put
your baby in skin to skin
contact with you
Allow the baby to take the
breast milk within the first
hour, because of much
colostrum in the early milk
which protects the baby
from many illnesses
Breastfeed as often as the
child wants, day and night
at least & times in 24 hours
wake the baby to
breastfeed every 3 hours
Do not give other foods or
fluids not even water.
Monitor the child's growth at
the nearest health facility.
AVOID
Never give the baby a honey
COUNSEL THE MOTHER
6 up to 9 months 9 months up 12 months 12 months up to 2 years 2 years up to 5 years
Breast milk is not enough in this stage Breastfed as often as the child wants. Breastfed as often as the child wants. Give family foods 3 meals each day.
so the child needs complementary
feeding for his growth. Give small frequency meals 5-6 times Nutritious foods twice daily such
Rice with mashed fruit and minced
One kind of porridge mixed with milk every day
meat Milk and milk product
for breakfast OR
Mashed vegetable with milk and milk
Bread OR enjera
product Fruits and vegetables
Give small frequency meals 5-6 times
Veg. soup
every day Eggs
One teaspoonful of olive oil to
Legumes
prevent constipation Minced meat
Mashed Carrot Bread
Rice
Mashed potatoes
Legumes for iron Normal family foods with no spices.
Lemon drink
Banana with milk
Monitor the child's growth at the
nearest health facility.
AVOID
Never give these foods to prevent choking
Monitor the child's growth at the Monitor the child's growth at the Monitor the child's growth at the
a. Carrot b. Chips c. Peanuts nearest health facility. nearest health facility. nearest health facility.
d. Chewing gum e. Popcorn
23
 COUNSEL THE MOTHER

Feeding Recommendations for children who are not breastfed

NOTE: These feeding recommendation should be followed for infant who is not been breastfed due to acceptable reasons such as: orphan or mother too sick to
breastfed her infant
NOTE : HIV infection is not a contraindication of not to breastfeed an infant; HIV positive should be encouraged to breastfeed as usual.

Up to 6 months 6 up to 9 months 9 months up 12 months 12 months up to 2 years

Give formula feed as often as the child If the child was exclusive replacement feeding Give 3 adequate servings of nutritious comple- Give 3 adequate servings of nutritious comple-
wants advice the mother to continue feeding mentary foods plus one snack per day between mentary foods plus 2 snack per day between
meals meals
Preparation Give whole milk
Give foods example Fruit and veg. Twice a day
0-1 month- 60mlx8hrs
In 9 months give animal source like liver and
1-2 months-90mlx7 hrs. Potatoes Potato
2-3 moths-120mlx6 hrs. minced meat
Banana Porridge
3-4 months 120mlx6 hrs
One kind porridge mixed with milk for
4-5 months 150mlx6 hrs Fish Fish
5-6 months 150mlx6 hrs breakfast OR
Beans Eggs
Bread OR enjera
Note: one hour after preparation, Minced meat Legumes
discard the left. Veg. soup
Rice Minced meat
One teaspoonful of olive oil to prevent
Porridge Bread
Cup feeding is better constipation
Ground nuts Rice
Other feeds are not necessary Mashed Carrot
Mashed potatoes
Make sure the cup is clean Legumes for iron
Lemon drink
Banana with milk

24
 COUNSEL THE MOTHER ON FEEDING

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

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

Feeding Recommendations For Stunted Child

Continue feeding as per feeding recommendation according to age.
Give extra meals rich in animal protein like milk, egg, fish, beef ,chicken meat

25
 SPECIAL FEEDING ASSESSMENT AND ADVISE

Assess feeding if the child has ANAEMIA, MODERATE ACUTE MALNUTRITION, HIV INFECTION,
HIV EXPOSED or less than 2 years

Ask questions about the child usual feedings and feeding during this illness; compare the mothers answers with feeding recommendations for the child’s age.. ASK:
Do you breastfed your child?
How many times during the day ?
Do you also breastfeed at night?
Does the child takes any other food or drinks?
What food or fluids?
How many times per day?
What did you use to feed you child?
If very low for weight ASK:
How large are serving?
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 changes? If yes how?
If HIV positive mother who opted not to breastfeed ASK:
What milk are you giving?
How many times during the day and night?
How much is giving at each feed?
How are you preparing the milk?
Let mother demonstrate or explain how a feed is prepared and how its given to the infant
Are you giving any breast milk at all?
What foods and fluid in addition to replacement feeds is given?
How is the milk been given? Cup or bottle?
How are you cleaning the feeding utensils ?

PRACTICE Good hygiene and proper food handling

Wash hands before food preparation, before and after eating
Serve food immediately after preparation
Use clean utensils to prepare and serve foods
Make sure fruits are properly washed

26
 SPECIAL FEEDING ASSESSMENT AND ADVISE

SAFE PREPARATION OF FORMULA MILK

Always use a marked cup or glass and spoon, to measure water and the scoop to measure the formula powder IF AVAILABLE
Wash you hands before preparing a feed
Bring the water to boil then let it cool, keep it covered while cooled.
Measure the formula powder into a marked cup or glass, make the scoops level. Put in one scoop for every 25 ml of water
Add a small amount of the cooled boiled water and stir, fill the cup or the glass to the mark with the water. Stir well.
Feed the infant using a cup
Wash the utensils
IMPORTANT; Cows milk is not safe for children and is not recommended for infant below 6 months

TEACH THE MOTHER HOW TO FEED HER CHILD BY A CUP

Hold the infant sitting upright or semi upright in your lap
Hold a small cup of milk to the infant’s lips
Tip the cup so the milk just touches the infant’s lips
The cups rest gently on the infant’s lower lip and the edges of the cup touch the outer part of the infants upper lip
The infant becomes alert and open his mouth and eyes
Do not pour the milk into the infant mouth, just hold the cup to his lops and let her/ him take it himself
When the infant has had enough he closes his mouth and will not take any more.
When the infant takes enough and refuses put him or her to the shoulder and burp him / her rubbing the back

FEEDING ADVISE FOR THE MOTHER OF A CHILD WITH HIV INFECTION

The child with CONFIRMED HIV INFECTION should be encouraged to breastfeeding as s/he is already infected and needs the benefit of breastfeeding.
The child should be fed according the feeding recommendations for his age
These children often suffering from poor appetite and mouth sores– give appropriate advice.
If the child is being fed with a bottle, encourage a mother to use a cup; as this is more hygienic and will reduce episodes of diarrhoea
Inform the mother about importance of hygiene when preparing food because her child can easily get sick. She should wash her hand after going to toilet and before preparing food
If the child is not gaining weight well, the child can be given extra meal each day and the mother can encourage him to eat more by offering him snakes that he like if these are available
Advice her about her own nutrition and the importance of well balanced diet to keep herself healthy.

27
 SPECIAL FEEDING ASSESSMENT AND ADVISE

AFASS criteria for formula milk feeding to eligible infant

Acceptable : Mothers perceives no problem in replacement feeding
Feasible: mother has adequate time, knowledge, skills, recourses and support to correctly mix formula or milk and feed the infant up to 12 times per 24 hours.
Affordable: Mother and family with community can pay the cost of purchasing, producing, preparing and using replacement feeding without harming the health and nutrition of the family.
Sustainable: Availability of a continuous supply of all ingredients needed for safe replacement feed as long as the infants needs it for up to one year of age or longer.
Safe: replacement food are correctly and hygienically replaced, stored and fed in nutritionally adequate quantities

28
 SPECIAL FEEDING ASSESSMENT AND ADVISE

Counsel the mother about feeding problems

If the child is not being fed as described in the above mentioned recommendation , counsel the mother accordingly in addition

If the mother report difficulty in breastfeeding , assess breastfeeding (See YOUNG INFANT CHART). Show the mother correct
positioning and attachment.
If the child is less tan 6 months old and is taking other milk or food :
Build mother’s confidence that she can produce all the breast milk that the child need
Suggest giving more, longer breastfeeds day or night, and gradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother to:
Breastfeed as much as possible, including at night.
Make sure that other milk is a locally appropriate breastmilk substitute.
Make sure other milk is correctly and hygienically prepared and give an adequate amounts.
Finish prepared milk within an hour
If the mother is HIV positive and is mix feeding:
Counsel the mother on appropriate feeding (Avoid mixing feeding as it increase the risk of HIV transmission)
If the mother is using a bottle to feed the child:
Recommend substituting a bottle with a cup.
Show the mother how to feed the child with a cup.
If the child is not feeding well during illnesses, counsel the mother to:
Breastfeed more frequently and for longer period if possible
Use soft, varied, appetizing favorite foods to encourage the child to eat as much as possible, and offer frequent small feedings
Clear a blocked nose if it interfere with feeding.
Avoid spicy, salty, or acid food if the child has oral thrush or mouth ulcers
Expect that appetite will improve as the child get better .
If the infant is 6 months or older and the mother is decided to stop breastfeeding, counsel the mother to:
Continue breastfeeding until the infant is at least one year.
Breastfeeding the child early in the morning and in the evening if the mother has to work outside the home.
If the complementary food is not adequate, counsel t he mother to:
Give the child adequate serving of notorious complementary food such as thick enriched porridge, mixed foods, continuing
milk and mashed food (According to feeding recommendation during sickness and health)
Add a spoonful of extra oil to the child food.
Add greens and fruits
Follow up any feeding problems in 5 days

29
 COUNSEL THE MOTHER

COUNSEL THE MOTHER ON FLUID

GIVE EXTRA FLUIDS

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:

Breastfeed more frequently and for longer at each feed. increase the amount of milk given.

For children more than 6 months increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

30
 COUNSEL ON WHEN TO RETURN

Return for
If the child has follow up in

PNEUMONIA
2 days
DYSENTERY

MALARIA, if fever persists

FEVER: NO MALARIA, if fever persists 3 days
MEASLES WITH EYE OR MOUTH COMPLICATIONS

PERSISTENT DIARRHOEA
ACUTE EAR INFECTION
5 days
CHRONIC EAR INFECTION
COUGH OR COLD, if not improving
FEEDING PROBLEM

WHEN TO RETURN IMMEDIATELY

GUM OR MOUTH ULCER 7 days
Advise mother to return immediately if the child has any of these signs
UNCOMPLICATED SEVERE ACUTE
Not able to drink or breastfeed
MALNUTRITION Any sick child Becomes sicker
14 days
ANAEMIA Develops a fever
HIV EXPOSED, BOSSIBLE HIV INFECTION
If child has COUGH OR COLD Fast breathing
Difficult breathing

MODERATE ACUTE MALNUTRITION

30 days Blood in stool
MEASLES If child has diarrhoea Drinking poorly

31
 COUNSEL THE MOTHER

Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.

If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.

Advise her to eat well to keep up her own strength and health. If the mother is breastfeeding advice her to take two extra meal daily.

Ask the mother to show her Tetanus Toxoid card; check the mother's immunization status and give her tetanus toxoid if needed.

Make sure she has access to:

CHILD SPACING Counselling on Sexual Transmitted Disease (STD), and Reproductive Transmission Infection (RTI); AIDS prevention.

Encourage the mother to know her HIV status and to seek HIV testing if she doesn't know her status, or is concerned about the possibility of HIV infection in herself and her family.

Hygiene promotion

32
 FOLLOW UP
Care for the child who returns for follow-up using all the boxes that match the child’s previous classifications.
If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

DYSENTERY
PNEUMONIA After 2 days:
After 2 days: Assess the child for diarrhoea. See ASSESS & CLASSIFY chart.
Check the child for general danger signs. Ask:
See ASSESS & Are there fewer stools?
Assess the child for cough or difficult breathing. CLASSIFY chart. Is there less blood in the stool?
Ask: Is there less fever?
Is the child breathing slower? Is there less abdominal pain?
Is there less fever? Is the child eating better?
Is the child eating better? Treatment:
If the child is dehydrated, treat dehydration.
is there a chest Indrawing?
If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same or worse:
Treatment: Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days.
If any general danger sign or stridor: refer URGENTLY to the hospital. Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to hospital.
If chest indrawing, breathing rate, fever and eating are the same or worse, refer URGENTLY Exceptions - if the child:
- Is less than 12 months old, or
to the hospital. If referral is not possible follow the treatment instructions of where Refer to hospital.
- was dehydrated on the first visit, or
referral is not possible at the charts GIVE THESE TREATMENTS IN THE CLINIC ONLY for - had measles within the last 3 months
Severe pneumonia or very severe disease If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue
If breathing slower, no chest indrawing, less fever, or eating better, complete the 5 days of giving ciprofloxacin and Zinc until finished.
antibiotic. Ensure that mother understand the oral rehydration methods fully and that she also understands the need for
extra meal each day for a week .

PERSISTENT DIARRHOEA MALARIA

If fever persists after 3 days:
After 5 days: Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Ask: DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Has the diarrhoea stopped? Treatment:
How many loose stools is the child having per day? If the child has any general danger sign or stiff neck, treat as VERY SEVERE
Ask if the caretaker is still giving multivitamins and zinc sulphate FEBRILE DISEASE.
If the child has any other cause of fever other than malaria, provide appropriate
Treatment: treatment.
If the diarrhoea has not stopped (child is still having 3 or more loose stools per If there is no other apparent cause of fever:
day), do a full reassessment of the child. Treat for dehydration if present Then refer If fever has been present for 7 days, refer for assessment.
URGENTLY to hospital. Do microscopy to look for malaria parasites. If parasites are present and the child
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell has finished a full course of the first line antimalarial, give the second line
the mother to follow the usual feeding recommendations for the child’s age and to antimalarial, if available, or refer the child to a hospital.
continue giving Zinc to complete 10 days. If there is no other apparent cause of fever and you do not have a microscopy to check
for

33
 GIVE FOLLOW-UP CARE FOR ACUTE CONDITION

FEVER: NO MALARIA EAR INFECTION

After 5 days:
If fever persists after 3 days:
Reassess for ear problem. See ASSESS & CLASSIFY chart.
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Measure the child's temperature
Repeat the malaria test.
Treatment:
Treatment:
If there is tender swelling behind the ear or high fever (38.5°C or above), refer URGENTLY to
If the child has any general danger sign or stiff neck, treat as VERY SEVERE
hospital.
FEBRILE DISEASE.
Acute ear infection:
If a child has a positive malaria test, give first-line oral antimalarial., Advise the
If ear pain or discharge persists, treat with 5 more days of the same antibiotic.
mother to return in 3 days if the fever persists.
Continue wicking to dry the ear. Follow-up in 5 days.
If the child has any other cause of fever other than malaria, provide treatment.
If no ear pain or discharge, praise the mother for her careful treatment. if she has not
If there is no other apparent cause of fever:
yet finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the fever has been present for 7 days, refer for assessment.
Chronic ear infection:
Check if the mother is wicking the ear correctly, and giving quinolone ear drops 3 times daily.
MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR
MOUTH ULCERS, OR THRUSH
After 3 days:
FEEDING PROBLEM
After 7 days:
Look for red eyes and pus draining from the eyes.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Look at mouth ulcers or white patches in the mouth .
Ask about any feeding problems found on the initial visit.
Smell the mouth.
Counsel the mother about any new or continuing feeding problems. If you counsel the
Treatment for eye infection:
mother to make significant changes in feeding, ask her to bring the child back again.
If pus is draining from the eye, ask the mother to describe how she has treated the
If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to
eye
return 30 days after the initial visit to measure the child's WFH/L, MUAC.
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. ANAEMIA
Treatment for mouth ulcers: After 14 days:
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Give iron. Advise mother to return in 14 days for more iron.
If mouth ulcers are the same or better, continue using half-strength gentian violet for a
total of 5 days. Continue giving iron every 14 days for 2 months.
Treatment for oral thrush:
If the child has palmar pallor after 2 months, refer for assessment.
If thrush is getting worse, check that treatment is being giving correctly.
If the child has problem with swallowing, refer to the hospital
If thrush is same or better, continue using and the child is feeding well, continue
nystatine for total of 7 days.

34
 GIVE FOLLOW-UP CARE FOR ACUTE CONDITION

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 oedema 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 oedema of both feet AND has developed a medical
complication 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 oedema 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 RUSF. 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 oedema 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 to the hospital.

35
 GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD

HIV EXPOSED CONFIRMED HIV INFECTION NOT ON ART

Follow up regularly as per national guidelines.
At each follow-up visit follow these instructions:
Ask the mother: Does the child have any problems?
Do a full assessment including checking for mouth or gum problems, treat,
counsel and follow up any new problem
Provide routine child health care: Vitamin A, deworming, immunization, and
Follow up regularly as per national guidelines.
At each follow-up visit follow these instructions:
Ask the mother: Does the child have any problems?
Do a full assessment including checking for mouth or gum problems, treat,
counsel and follow up any new problem

feeding assessment and counseling Counsel and check if mother able or willing now to initiate ART for the child.
Continue Cotrimoxazole prophylaxis Provide routine child health care: Vitamin A, deworming, immunization, and
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended;
feeding assessment and counseling
check adherence: How often, if ever, does the child/mother miss a dose?
Continue Cotrimoxazole prophylaxis if indicated.
Ask about the mother’s health. Provide HIV counseling and testing and
Initiate or continue isoniazid preventive therapy if indicated.
referral if necessary
Plan for the next follow-up visit If no acute illness and mother is willing, initiate ART (See Box Steps when
HIV testing: Initiating ART in children)
If new HIV test result became available since the last visit, reclassify the child Monitor CD4 count and percentage.
for HIV according to the test result.
Ask about the mother’s health, provide HIV counseling and testing.
Recheck child’s HIV status six weeks after cessation of breastfeeding.
Home care:
Reclassify the child according to the test result.
If child is confirmed HIV infected Counsel the mother about any new or continuing problems

Start on ART and enroll in chronic HIV care. If appropriate, put the family in touch with organizations or people who
Continue follow-up as for CONFIRMED HIV INFECTION ON ART could provide support
If child is confirmed uninfected
Advise the mother about hygiene in the home, in particular when preparing
Continue with Cotrimoxazole prophylaxis if breastfeeding or stop if the test
food
results are after 6 weeks of cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about Plan for the next follow-up visit

her own health

36
 GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD

CONFIRMED HIV INFECTION ON ART THE FOUR STEPS OF FOLLOW UP CARE

STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART STEP 3: PROVIDE ART, STEP 4: COUNSEL THE MOTHER OR

ASK: Does the child have any IF ANY OF FOLLOWING PRESENT, REFER COTRIMOXAZOLE AND ROUTINE CAREGIVER
problems NON-URGENTLY: TREATMENTS Use every visit to educate and provide support to
Has the child received care at another If any of these the mother or caregiver
health facility since the last visit? present, refer If child is stable: continue with the
CHECK: for general danger signs - If NON- ART regimen and cotrimoxazole doses. Key issues to discuss include:
present, complete assessment, give
URGENTLY:
pre-referral treatment, REFER Check for appropriate doses: How the child is progressing, feeding, adherence,
Record the Child's weight Not gaining side-effects and correct management, disclosure
URGENTLY. remember these will need to increase (to others and the child), support for the caregiver
and height weight for 3
ASSESS, CLASSIFY, TREAT and
Assess adherence months as the child grows Remember to check that the mother and other
COUNSEL any sick child as
Give routine care: Vitamin A family members are receiving the care that
appropriate. Ask about adherence: how Loss of
they need
CHECK for ART severe side effects often, if ever, does the milestones supplementation, deworming, and Set a follow-up visit: if well, follow-up as per
child miss a dose? Record Poor nastional guidelines. If problems, follow-up as
immunization as needed indicated.
• Severe your assessment. adherence
skin rash Asess and record clinical Stage
• Difficulty stage worse than
breathing Assess clinical stage. before
and
If present, give Compare with the child's CD4 count
severe
any pre- stage at previous visits. lower than
abdominal
pain
referral before
Monitor laboratory results
• Yellow treatment, LDL higher
REFER Record results of tests
eyes than 3.5
URGENTLY that have been sent.
• Fever, mmol/L
vomiting,
TG higher
rash (only
than 5.6
if on
Abacavir) mmol/L

Check for other ART side effects Manage side effects

Send tests that are due

37
 ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
AGE UP TO 2 MONTHS Ministry of Health
Federal Republic of Somalia

ASSESS CLASSIFY IDENTIFY TREATMENT

DO A RAPID APRAISAL OF ALL WAITING INFANTS USE ALL BOXES THAT MATCH URGENT PRE-REFERRAL
THE INFANT'S SYMPTOMS AND TREATMENTS ARE
ASK THE MOTHER WHAT THE YOUNG
INFANT'S PROBLEMS ARE PROBLEMS TO CLASSIFY IN BOLD PRINT
THE ILLNESS

Determine if this is an initial or follow-up visit for this problem.

If follow-up visit, use the follow-up instructions.

If initial visit, assess the child as follows:

38
 CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION, VERY SEVERE DISEASE,
PNEUMONIA AND LOCAL BACTERIAL INFECTION
ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY TREATMENT

ASK:
Has the young infant had
Convulsion?
Is the infant having difficulty
in feeding?
Is the infant not feeding
at all? Or not feeding well?
Has the mother had TB
infection two weeks before
delivery (smear +ve)?
IF THE YOUNG INFANT IS
From birth up to 2 months
LOOK, LISTEN, FEEL:
Look if the young infant is: Convulsing
now,
YOUNG
Count the breaths in one
minute
INFANT
Repeat the count if 60 breaths
MUST BE
per Minute or more
Look for severe chest
indrawing.
Look at the umbilicus. Is it red or
draining pus?
Look for skin pustules.
Look for pus draining from the eyes
Measure axillary temperature. Or feel
for fever or low body temperature
Look at the young infant's movements.
Does the infant move on his/her
own?
Does the infant move only when
stimulated?
Does the infant not move at all
FAST BREATHING IS
60 breaths per minute or more
Any of the following signs
Not feeding well or
Convulsions or
Fast breathing (60 breaths per
minute or more) or
Severe chest indrawing or
INFECTION OR
Fever (37.5°C* or above) or
CLASSIFY Low body temperature less than VERY SEVERE
CALM
ALL YOUNG 35.5°C*) or
Movement only when stimulated
INFANTS or
No Movement at all.
Fast breathing (60 breath per
minute or more) if the infant is
7 – 59 days
Umbilicus red or
draining pus Or
Skin pustules or
Pus draining from eye
None of the signs of
very severe disease or
local bacterial infection
Give first dose of intramuscular
POSSIBLE antibiotics
Treat to prevent low blood sugar
SERIOUS
Refer URGENTLY to hospital
BACTERIAL Advise mother how to keep the infant warm on the way
to the hospital
If the young infant is convulsing now
If less than 1 month treat with phenoparbitone
DISEASE intramuscularly
If more than 1 months treat with rectal diazepam
Give oral antibiotics for 7 days
If the mother has TB refer the infant for TB assessment
PNEUMONIA
Advice the mother for home care for the young infant
Follow up in 3 days
Give an appropriate oral antibiotic for 5 days
Teach the mother to treat local infections at
home.
LOCAL
If the mother has TB, refer the infant for TB
BACTERIAL
assessment and INH prevention therapy
INFECTION
Advise mother to give home care for the young
Infant
Follow up in 2 days
INFECTION
Advice the mother to give home care for the
UNLIKELY
young infant

These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5°C higher.
If referral is not possible see treat the young infant chart.
If the infant has any sever classification necessitating referral; and referral is not possible give full course of antibiotics and follow up regularly.

39
 THEN ASK: Does the young infant have diarrhoea?

ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY TREATMENT

IF YES, ASK: LOOK AND FEEL:
For how long? Look at the young infant’s general
Is there blood in the stool? condition. Is the infant:
- Movement only when stimulated or
no movement at all?
- Restless or irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it
go back:
- Very slowly (longer than 2 seconds)?
- Slowly?
Two of the following signs:
Movement only when stimulated or
no movement at all.
Sunken eyes
CLASSIFY Skin pinch goes back very slowly.
DIARRHOEA
FOR
DEHYDRATION
Two of the following signs:
Restless, irritable
Sunken eyes
Skin pinch goes back slowly.
No enough signs to classify as
some or severe dehydration.
If infant has no other severe classification:
- Give fluid for severe dehydration (Plan C) OR
If infant also has another severe classification:
- Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way
SEVERE - Advise the mother to continue breastfeeding
DEHYDRATION If the infant has diarrhoea lasting more than 7 days
refer for assessment
If the infant has blood in the stool refer URGENTLY
to the hospital
If the infant has any severe classification :
-Refer urgently to hospital with mother giving
frequent sips of ORS on the way
- Advise mother to continue breastfeeding
Advise mother to keep the young infant warm
If infant has no severe classification: Give fluid for some
SOME dehydration (plan B)
DEHYDRATION If the infant has diarrhoea lasting more than 7 days
refer for assessment
If the infant has blood in the stool refer for assessment
Advice the mother when to return immediately
Follow up in 2 days if not improved
Give fluids to treat diarrhea at home (Plan A).
If the infant has diarrhea lasting more than 7 days refer for
NO assessment
If the infant has blood in the stool refer for assessment
DEHYDRATION Advice the mother to contineu breastfeeding
Advise mother when to return immediately
Follow-up in 2 days if not improving.

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 water than fecal matter).
The normally frequent or semi solid stool for breastfed baby are not diarrhoea.

40
 THEN CHECK FOR JAUNDICE

ASSESS CLASSIFY IDENTIFY TREATMENT

ASK: LOOK AND FEEL: SIGNS CLASSIFY TREATMENT

Dosed the infant had Look at infant’s eyes and face Any jaundice if age less than 24 Treat to prevent low blood sugar
SEVERE Refer URGENTLY to hospital
yellow discoloration of does the infant has jaundice ? hours or Advise mother how to keep the infant warm
CLASSIFY JAUNDICE on the way to the hospital and continue
skin or eyes? Yellow palms and soles at any age
Look at the palms and soles are JAUNDICE breastfeeding
If yes; When did the
they yellow? Advise the mother to breastfed as much as often
jaundice appears? and as much as infant want day and night.
Look for jaundice in any other part
- Before 24 hours Advise mother to when to return immediately, and
of the body? Jaundice appearing after 24 hours of to return if palms and soles appear yellow.
from birth?
age or Advice the mother to expose the infant to sunlight
JAUNDICE
- After 24 hours from before 10 am and after 4pm for a maximum of 1
Palms and soles not yellow
birth hour
If jaundice present more than 14 days refer for
If No; check for assessment.
Jaundice Follow-up in 1 day

None of the signs suggestive NO Advise the mother to give home care for the
jaundice young infant
JAUNDICE
THEN CHECK FOR EYE PROBLEM

LOOK Give first dose of intramuscular antibiotics

Eye profusely discharging pus with Apply first dose of eye ointment
SEVER
Look for pus draining or without swelling. Treat to prevent low blood sugar
EYE INFECTION
from the eye? CLASSIFY Advice the mother to keep the infant warm
on the way to the hospital and continue
EYE PROBLEM breastfeeding
Is the draining
Refer URGENTLY to the hospital
profuse?
Teach the mother to treat eye infection at home
Are the eyes swollen? Advice the mother to give home care to the infant
Eye draining pus EYE INFECTION
Advice the mother when to return immediately
Follow up in 2 days

NO EYE
No pus draining from the eyes Advice the mother to give home care to the infant
INFECTION

41
 THEN CHECK FOR HIV INFECTION
ASSESS CLASSIFY
SIGNS
ASK AND NOTE
Infant has positive virological
Has the mother tested for HIV? test
Has the infant tested for HIV by PCR or Antibody test?
Is the HIV status of the mother or the infant unknown?
INFANT HIV STATUS MOTHER HIV STATUS CLASSIFY
HIV
Infant has positive serological
Virological test: positive HIV positive test or
Mother has positive serological
test and infant not yet tested or
Serological test: positive HIV negative
Mother has positive serological
test and infant is breastfeeding
or stopped less than 6 weeks
Serological test: negative and has a negative virological
test.
If the mother HIV positive and the infant does NOT have a
positive virological test (PCR), ASK: HIV test not one for mother
- Is the infant breastfed now? and infant
- Was the infant breastfeeding at the time of the test or
before it?
- Is the mother and or infant on antiretroviral prophy- Negative HIV test in mother
laxis? and infant
Unknown includes those who don't have test result for confirmation, Do PITC for HIV before classifying the illness, if PICT is
not possible decide HIV status unknown
42
IDENTIFY TREATMENT
CLASSIFY TREATMENT
Give Cotrimoxazole prophylaxis at age of 6 weeks.
Refer for HIV care and treatment center (CTC) to start ART
Refer the infant for TB assessment and preventive therapy
CONFIRMED HIV Assess feeding and counsel the mother according to feeding
recommendation in COUNSEL THE MOTHER CHARTS
INFECTION
Advice the mother on home care
Advise the mother when to return immediately
Follow up in 14 days.
Give Cotrimoxazole prophylaxis at age of 6 weeks.
Confirmed HIV status with virological testing as soon as
possible
Refer for HIV care according to test result.
HIV EXPOSED;
Assess feeding and counsel the mother according to feeding
POSSIBLE HIV recommendation in COUNSEL THE MOTHER CHARTS
INFECTION Advice the mother on home care
Advise the mother when to return immediately
Follow up in 14 days.
UNKNOWN Offer PICT to mother and infant and refer for HIV test.
HIV STATUS Advice the mother on home care
Advise the mother when to return immediately
HIV INFECTION
Advice the mother on feeding and home care for infant
UNLIKELY
 THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFEEDING INFANT

ASSESS CLASSIFY IDENTIFY TREATMENT

If the young infant has no indication to be referred to the hospital

If the infant has an indication to be referred to the hospital do not assess feeding or low weight

ASK: LOOK AND FEEL:

SIGNS CLASSIFY TREATMENT
Is the infant breastfed? If yes, how Determine weight for age.
many times in 24 hours? Weight less than 2 kg
Weight less than 2 kg in an Refer to the hospital for Kangaroo
Does the infant usually receive any Low weight ( < -2SD)
infant less than 7 days mother care (KMC)
other foods or drinks? If yes, Not low weight (> - 2SD)
VERY LOW Treat to prevent low blood sugar
how often? Look for ulcers or white patches in
WEIGHT FOR AGE Advice the mother to keep the infant
what do you use to feed the infant the mouth (thrush).
warm on the way to the hospital
IF AN INFANT IS :
CLASSIFY Less than 8 breastfeeds in Advice the mother to breastfed the infant
Less than 7 days age as often and for as long as the infant
Is breastfeeding less than 8 times in 24 hours FEEDING 24 hours or want day and night
Is taking any other food or drinks Receives other foods or If not well attached or not suckling
Is low weight for age drinks or effectively, teach correct positioning and
attachment
ASSESS BREASTFEEDING: Low weight for age or
If receiving other foods or drinks, counsel
Has the infant breastfeed in the previous hour? Poor positioning or the mother about breastfeeding more,
If the infant has not fed in the previous hour, ask the mother to put her Not well attached to breast reducing stop other foods or drinks, and
infant to the breast. Observe the breastfeeding for 4 minutes. (If the infant FEEDING using a cup.
or
was fed during the last hour, ask the mother if she can wait and tell you If not breastfeeding at all*: Refer for
when the infant is willing to feed again.) Not suckling effectively or PROBLEM OR
breastfeeding counseling and possible
Thrush ( ulcers or white LOW WEIGHT relactation*
IS THE INFANT ABLE TO ATTACH? Well attached
Not well attached patches in mouth) If thrush, teach the mother to treat thrush
TO CHECK ATTACHMENT LOOK FOR at home
Chin touching breast Advise mother to give home care for the
Mouth wide open young infant
Lower lip turned outwards Follow-up any feeding problem or thrush
More areola visible above than below the mouth in 2 days
All of these signs should be present if the attachment is good Follow-up low weight for age in 14 days

IS THE INFANT SUCKLING EFFECTIVELY

Advise mother to give home care for the
(That is, slow deep sucks, sometimes pausing)? suckling effectively Not low weight for age and
NO FEEDING young infant
not suckling effectively no other signs of
PROBLEM Praise the mother for feeding the infant
inadequate feeding
CLEAR A BLOCKED NOSE IF IT INTERFERES WITH BREASTFEEDING well

43
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE FOR AN INFANT NOT RECEIVING BREAST MILK
ASSESS
ASK:
What milk are you giving?
How many times during the day
and night?
How much is giving each fed?
How are you preparing the milk?
Let the mother demonstrate or
explain how a feed is prepared
Are you giving any breast milk at
all?
What other food and fluids in
addition to replacement foods are
given?
What do you use to feed the
infant? Cup or bottle?
How do you clean the feeding
utilities?
LOOK AND FEEL:
Determine weight for age.
Weight less than 2 kg
Low weight ( < -2SD)
Not low weight (> - 2SD)
Look for ulcers or white
patches in the mouth (thrush).
CLASSIFY
SIGNS
Weight less than 2 kg in an
infant less than 7 days
WEIGHT FOR AGE
CLASSIFY Milk incorrectly or
in-hygienically prepared.
FEEDING
Giving inappropriate
replacement milk or other
food or fluids
An HIV positive mother
mixing breast milk and other
feeds or
Bottle feeding or
Low weight for age
Thrush ( ulcers or white
patches in mouth)
Not low weight for age and
no other signs of
inadequate feeding
44
IDENTIFY TREATMENT
CLASSIFY TREATMENT
Refer to the hospital for Kangaroo
mother care (KMC)
VERY LOW Treat to prevent low blood sugar
Advice the mother to keep the infant
warm on the way to the hospital
Counsel the mother on feeding
according to feeding recommendation in
COUNSEL THE MOTHER CHART. If
the mother is HIV positive:
Explain the guideline for safe replace-
ment feeding.
Identify concerns of mother and family
about feeding
FEEDING Help the mother to withdraw other food
PROBLEM OR and drinks
LOW WEIGHT If the mother is using bottle teach for cup
feeding
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
Advise mother to give home care for the
NO FEEDING young infant
PROBLEM Praise the mother for feeding the infant
well
ASSESS AND CLASSIFY FOR BIRTH WEIGHT AND GESTATIONAL AGE IF YOUNG INFANT LESS THAN 7 DAYS OLD

ASSESS CLASSIFY IDENTIFY TREATMENT

SIGNS CLASSIFY TREATMENT

ASK OR NOTE:
For the gestational age at delivery
____Weeks?
For the birth weight ___gm?
LOOK
Weight less than 1500 gm or Treat to prevent low blood sugar
Look for the birth weight on VERY PRE-TERM Advise mother how to keep the infant
gestational age less than 32
the child health passport book weeks AND/OR VERY warm on the way to the hospital
LOW Refer URGENTLY with mother to
or weight the baby* hospital.^*
BIRTH WEIGHT

CLASSIFY
Weight 1500 gm up to 2500 Advise mother on home care for the
gm or gestational age 32-36 young infant
Counsel the mother on care of pre-term
weeks
PRE-TERM or low birth weight young infant
Follow-up in 14 days
AND/OR
Give vitamin K
LOW BIRTH
WEIGHT

Weight 2500 gm or more or Advise mother on home care of the

young infant
Gestational age 37 weeks or
more TERM AND
NORMAL BIRTH
WEIGHT

For those young infants whose birth weight is not known, the measured weight of that day should be regarded as representing birth weight.
** If referral is not possible , Please remember: Always all young infants with birth weight of less than 1.500gm MUST be referred to hospital.

45
 THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS

IMMUNIZATION SCHEDULE
AGE VACCINE ROUTE OR SITE OF INJECTION DOSE
BCG* Intradermal (Lt) shoulder 0.05 ml
BIRTH
OPV-0 ** Oral 2 drops
OPV-1 Oral 2 drops
6 WEEKS
PENTAVALANT -1 Intramuscular Outer (Rt) thigh 0.5 ml

* If an infant is less than 12 months old and did not receive BCG, the vaccine can be given at any time the child come to the health facility; young infant
who are HIV positive or of unknown HIV status with symptoms consistent with HIV should not be given BCG vaccine.
** Do not give OPV-0 to an infant more than 14 days .
IMPORTANT: Give Penta-1 and OPV-1 at the age of 6 weeks, keep an interval of 4 weeks between the subsequent vaccine; immunize the sick infants
unless they are being referred . Advice the caretaker when to return for next immunization.

VITAMIN A SUPPLEMENTATION IF THE MOTHER IS BREASTFEEDING GIVE 200.000 IU to the mother within 6 weeks of delivery

ASSESS OTHER PROBLEMS

THEN CHECK AND IMMUNIZE THE MOTHER FOR TETANUS

Immunize all women of child bearing age against TETANUS VACCINE AGE
Tetanus toxoid 1 15 – 45 at any contact
Give intramuscular injection of 0.5 ml on the shoulder . Tetanus toxoid 2 4 months from the 1st dose
Tetanus toxoid 3 6 months from the 2nd dose
Tetanus toxoid 4 1 year from the 3rd dose
Tetanus toxoid 5 1 year from the 4th dose

ASSESS MOTHER’S OWN HEALTH

46
 TREAT THE SICK YOUNG INFANT AND COUNSEL THE MOTHER

TREAT THE YOUNG INFANT : GIVE THESE TREATMENT IN THE CLINIC ONLY
GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS
Give first dose of intramuscularly Gentamicin and Ampicillin or Benzyl penicillin
FOR YOUNG INFANT BEING REFERRED URGENTLY FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVER DISEASE:
Give the first dose of Benzyl Penicillin (50.000 IU/ Kg / day) or Ampicillin ( 50 mg/Kg / day) and Gentamycin ( 5 mg / kg / day) intramuscularly and refer the child urgently
to the hospital.
IF REFERAL IS NOT POSSIBLE: Re-classify for POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVER DISEASE and treat as follow:
All young infant of birth weight less than 1500 g (low birth weight) MUST be referred to hospital, should not be treated as outpatient
Newborn aged 0-6 days: If has only fast breathing has Sever pneumonia* needs referral, but if not possible give oral Amoxicillin twice daily for 7 days.
Young infant age 0-59 days: if have signs of clinical sever infection** give oral Amoxicillin twice daily for 7 days PLUS injectable Gentamycin once daily for 7 days.
Young infant age 0-59 days and has signs of critical sever infection*** treat with twice daily injectable Ampicillin and once daily injectable Gentamycin for 7 days.

Gentamycin 3 to 5 mg/kg Benzyl Penicillin 50.000 IU/Kg Ampicillin 50 mg/kg

Undiluted 2 ml vial containing 20 mg= 2 ml at 10 Add 2.1 ml water for injection Add 3.6 ml of water to a vial of Add 1.3 ml of sterile water to 250
Weight mg/ml to vial of 600 mg (1000.000 IU) mg vial to make 1.5 ml of 250 mg
Or add 6 ml sterile water to 2 ml vial containing 600 (1000.000 IU) to make 4.0
to make 2.5 ml
80 mg
Of 40.000 IU/ml ml of 250.000 IU/ml
8 ml at 10 mg/ml

1.0-- < 1.5 kg 0.5 ml 0.1 ml 0.2 ml 0.3 ml

1.5 – < 2.5 kg 1.0 ml 0.2 ml 0.4 ml 0.6 ml

2.5 -- < 3.5 Kg 1.5 ml 0.4 ml 0.6 ml 0.9 ml

3.5 -- < 4.5 Kg 2.0 ml 0.5 ml 0.8 ml 1.2 ml

4.5 -- < 5.5 Kg 2.5 ml 0.6 ml 1.0 ml 1.5 ml

*Sever pneumonia signs: fast breathing in infant age less than 7 days
** Clinical sever infection signs are : not feeding well on observation, fever or low body temperature, sever chest indrawing and moving only when stimulated.
*** Critical sever infection signs are: not able to fed at all, no movement on stimulation
**** Avoid using undiluted 40mg/ml gentamycin the dose is 1/4 that listed

47
 TREAT THE SICK YOUNG INFANT AND COUNSEL THE MOTHER

TREAT THE YOUNG INFANT : GIVE THESE TREATMENT IN THE CLINIC ONLY

Treat a Convulsing Young Infant Less Than 1 Month with Phenobarbitone Intramuscularly
Manage the Airway
Turn the child to his/her side to avoid aspiration.
PHERNOBARBITONE 200 mg/ml
Do not insert anything in the mouth. WEIGHT
dose of 15mg/kg
If the child is blue (cyanosis), open the mouth and make sure the airway is clear
If necessary, remove secretions from the throat. 1.5 - <2.5 kg 0.2 ml
If high fever
2.5 - <4.0 kg 0.3 ml
Undress the infant to lower the fever.
GIVE INTRAMUSCULLAR PHERNOBARBITONE 4.0 - <6.0 kg 0.4 ml
Select an appropriate vial of phernobarbitone concentration before giving the medicine.

To Treat 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 body weight) of expressed breastmilk before departure. If expressed breastmilk cannot be given, give 20 - 50 ml of sugar water. (To make sugar
water: Dissolve 4 level teaspoons of sugar (20 gm) in a 200 ml cup of clean water.)
If the young infant is not able to swallow:
Give 20 - 50 ml (10 ml/kg body weight) of expressed breastmilk or sugar water by nasogastric tube.

Treat Young Infant for Low Body Temperature( temperature less than 35.5°C)
Dry the young infant if wet, and remove any soiled or wet clothing.

Wrap the young infant with dry clean and warm cloth and cover with a blanket.

Keep the young infant close to mother.

If pre-term or low birth weight use Kangaroo Mother Care (KMC) to provide skin to skin contact with and infant.

48
 TREAT THE SICK YOUNG INFANT AND COUNSEL THE MOTHER

TREAT THE YOUNG INFANT

Treat Young Infant for Fever( temperature 38.5°C or above)

If necessary to lower temperature undress the child and the temperature will be lowered.
Note : Young infant should not be given antipyretic for the risk of permanent liver damage.

Teach the Mother How to Keep the Young Infant Warm on the Way to the Hospital
Hold the infant in 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 Vitamin K for PRE-TERM AND/OR LOW BIRTH WEIGHT Babies

Give single dose Vitamin K to the young infant who is Pre-term or low birth weight

WEIGHT DOSE

< 1.5 kg 0.5 ml

1.5 - 2.5 kg 1.0 ml

49

ASSESS
IF REFERRAL IS NOT POSSIBLE : further assess and classify the sick young infant with
POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVER DISEASE
SIGN
The sick infant has any of the following
Convulsions
Not able to feed at all
Not moving at all
Weight less than 2 kg
The sick infant has any of the following
Not feeding well on observation
Temperature 38 °C or more
Temperature 35.5 °C or less
Sever chest indrawing
Movement only when stimulated
The sick infant has
Fast breathing 60 breath or more in two
occasions in less than 7 days
TREAT THE SICK YOUNG INFANT
CLASSIFY IDENTIFY TREATMENT
CLASSIFY IDENTIFY TREATMENT
Reinforce URGENT referral, explain to the caregiver that the infant is very sick and MUST be URGENTLY
referred for hospital care.
If referral is not feasible, give once daily intramuscular gentamycin and twice daily intramuscular
CRITICAL ampicillin until referral is feasible or for 7 days( for doses refer to treat the young infant chart)
Treat to prevent low blood sugar
ILLNESSES Treat any other classifications for the young infant
Reassess the young infant at each visit
Teach the mother to keep the young infant warm at home
Advice the mother to come daily for injections
Give daily intramuscular gentamycin and oral amoxicillin twice daily for 7 days (for doses treat the sick
CLINICAL young infant chart)
Treat to prevent low blood sugar
SEVER Teach the mother to keep the young infant warm at home
Advice the mother to come daily for injection
INFECTION
Treat any other classifications for the young infant
Reassess the young infant at each visit
Give oral amoxicillin twice daily for 7 days (for doses treat the sick young infant chart)
SEVER Treat any other classifications for the young infant
PNEUMONIA Follow up in 3 days
50
 TREAT THE SICK YOUNG INFANT

FOLLOW THE INSTRUCTIONS BELOW FOR EVERY ORAL DRUG TO BE TO TREAT DIARRHOEA, SEE TREAT THE CHILD CHART PAGE 26
GIVEN AT HOME. ALSO FOLLOW THE INSTRUCTIONS LISTED WITH EACH
DRUG’S DOSAGE TABLE.
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS, EYE INFECTION
Determine the appropriate drugs and dosage for the infant age or weight.
AND THRUSH AT HOME
Tell the mother the reason for giving the drug to the young infant
Explain to the mother what the treatment is and why it should be given.
Demonstrate how to measure a dose.
Watch the mother as she does the first treatment in the clinic
Watch the mother practice measuring a dose by herself.
Ask the mother to give the first dose to her child. Tell her how often to do the treatment at home, and to come to the clinic if infection get
Explain carefully how to give the drug, then label and package the drug. worsens
If more than one drug will be given, collect, count and package each drug separately. Check the mothers understanding before she leaves the clinic.
Explain that all the oral drug tablets or syrups must be used to finish the course of
TO TREAT SKIN TO TREAT THRUSH (ULCER
treatment, even if the child gets better. PUSTULES AND UMBILI- OR WHITE PATCHES IN THE TREAT EYE
Check the mother’s understanding before she leaves the clinic. CAL INFECTION BY MOUTH) WITH NYSTATIN OR INFECTION
GENTIAN VIOLET (GV) GENTIAN VIOLET

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR PNEUMONIA AND LOCAL Treat the infection twice daily Treat the thrush four times daily Clean both eyes 6-8 times
BACTERIAL INFECTION for 7 days. daily.
for 5 days.
First line antibiotics: Amoxicillin Wash hands Wash hands.
Wash hands. Use clean cloth and water
Second line antibiotics: Ampicillin+ Cloxacillin Wash mouth with clean soft
Gently wash off pus and to gently wipe away pus.
clothes wrapped around the
AMPICILLIN + CLOXACILLIN Then apply tetracycline eye
AMOXICILLIN crust with soap and water. finger and wet with salt water
GIVE 50MG/KG TWICE ointment in both eyes 4
WEIGHT / GIVES TWO TIMES DAILY FOR 5 DAYS Dry the area Give Nystatin 1ml 4 times daily or
DAILY FOR 5 DAYS times daily.
AGE Dispersible Dispersible Syrup Paint the mouth with half-strength Squirt a small amount of
Syrup 125 mg / 5 ml Paint the skin or umbilicus
tablet (250 mg) tablet (125 mg) 125mg/5 ml gentian violet (0.25%) using a ointment on the inside of
with full-strength gentian
soft cloth wrapped around the the lower lid.
< 3.0 kg ½ 1 2.25 ml 2.5 ml violet (0.5% dilution). finger Wash hands again.
3-4 kg ½ 1 5.0 ml 5.0 ml Wash hands again. Wash hands Treat until there is no pus
4-5 kg 1 2 10.0 ml discharge..

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR HIV INFECTION AND HIV IMMUNIZE EVERY SICK YOUNG INFANT
EXPOSED, POSSIBLE HIV INFECTION AGE VACCINE
Give Cotrimoxazole prophylaxis for PCC from 6 weeks BCG*
BIRTH
OPV-0 **
ADULT TABLE PEDIATRICS TABLET SYRUP 6 WEEKS OPV-1
AGE OR WEIGHT
(80/400 MG) (20/100 MG) (40/200 MG/5 ML) PENTAVALANT -1
6 weeks to 12 months
1/4 1 2.5 ml
4-<10kg
GIVE VITAMIN A AS DESCRIPED IN ASSESS AND CLASSIFY PAGE 10

51
 COUNSEL THE MOTHER

TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING ADVICE THE MOTHER FOR GIVE HOME CARE TO THE YOUNG INFANT
Show the mother how to hold her infant.
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT (for breastfeeding mother)
With the infant's head and body in line.
Give only breastmilk to the young infant
Facing the breast, with the infant nose opposite to the nipple.
With the infant held close to the mother's body. Breastfeed frequently as often and as for long as the infant want day and night,
With the infant's whole body supported, not just neck and shoulders. in sickness and health.
Show her how to help the infant to attach. She should: 2. MAKE SURE THAT THE YOUNG INFANT KEPT WARM ALL THE TIME
Touch her infant's lips with her nipple In cool weather cover the infant’s head and feet and add extra clothing
Wait until her infant's mouth is opening wide 3. KNOW WHEN TO RETURN
Move her infant quickly on to her breast
Look for signs of good attachment and effective suckling. If the attachment or suckling WHEN TO RETURN FOR FOLLOW UP VISIT WHEN TO RETURN IMMEDIATELY
is not good, try again.
Advice the mother when to return
Return for immediately if the young infant
If the young infant has
follow up in develop any of the followings:

ESSENTIAL NEWBORN CARE PACKAGE JAUNDICE 1 day Breastfeeding or drinking poorly

LOCAL BACTERIAL Infant moves only when stimulated

COUNSEL THE MOTHER ON INFECTION or not moving at all

ANY FEEDING PROBLEM 2 days
Convulsions
THRUSH
INSURANCE WORMTH OF THE YOUNG INFANT: In cool weather cover the EYE INFECTION Become sicker
Develops a fever
infant’s head and feet and add extra clothing PNEUMONIA
SEVERE PNEUMONIA 2 days Feels unusually cold
BERASTFEEDING: Ensure optimal breastfeeding emphasize on proper
(when referral is not possible) Fast breathing
positioning and attachment
Difficult breathing
PRE-TERM OR LOW
CORD CARE: Keep cord clean and dry, do not put anything in the cord
WEIGHT Blood in stool
7 days
EYE CARE: clean baby’s eye immediately after birth and instill eye ointment LOW WEIGHT FOR AGE Yellowish discoloration of Palm and
(IN NON BREASTFED INFANT)
prophylaxis sole
ROUTINE IMMUNIZATION: Get the baby immunized with all the recommended LOW WEIGHT FOR AGE

EPI vaccine on time (IN BREASTFED INFANT)

14 days
CONFIRMED HIV INFECTION
HIV EXPOSED; POSSIBLE
HIV INFECTION

52
 COUNSEL THE MOTHER CARE OF PRE-TERM OR LOW BIRTH WEIGHT YOUNG INFANT

KANGAROO MOTHER CARE (KMC) HOW TO EXPRESS BREASTMILK

Expressing breastmilk can take 20-30 minute or longer in the beginning
There are three components of Kangaroo mother care (KMC): Wash hand with soap and water
1. Continuous skin to skin contact between the infant’s front and mother chest Prepared a clean and boiled cup
2. Continuous exclusive breastfeeding: the clothes that wraps around the mother and Sit comfortably and lean slightly toward the container.
the baby is loosened to breastfeed. Hold the breast in a “C- hold”
3. Support to the mother from the health worker and family: to continue to do what she 1. Place the finger and the thumb on the areola and press inward toward the chest wall.
normally does while providing kangaroo mother care. 2. Press the areola behind the nipple between the finger and thumb
How to wrap the baby and mother: mother and baby should be chest to chest with baby’s 3. Press from the side to express milk from other segment of the breast.
head turn to one side TIPS for storing and using stored breastmilk
Fresh breastmilk has the best quality, if the breastmilk must be saved advice the mother and
Place the center of a long cloth over the baby’s head turned to one side.
family to :
Wrap both ends of the cloths firmly around the mother, under her arm to her back. Use either a clean glass or hard plastic container with a large opening and a tight lid to
The wrap should not be so tight that it constrict the baby. Leave room to the baby to store a breastmilk
breath normally . Explore with mothers how to distinguish the time the milk is expressed
Cross the cloth ends behind the mother and tie the end of the cloth in a secure knot. Empty the breast and store the milk the coolest place possible
If the cloth is long bringing both end of the cloth to front and tie the end of the cloth in Milk can be stored 8-10 hours at room temperature in a cool place and for 72 in
a knot under the baby. refrigerator
The wrap should be tight enough so that the baby does not slip out when the mother Mother or caregiver dives an infant expressed breastmilk from a cup, bottles are
stands. unsafe to use because they are difficult to wash and can be easily contaminated
Support the baby’s head by pulling the wrap up just under the baby’s ear, the wrap Quantity to feed by cup (in ml) every 2-3 hours from birth
(Use calibrated vessel to measure the required quantity each time you want to feed the young
can be loosened for breastfeeding .
infant
Have the mother put on her blouse or dress. Be sure to use clothing that is loose
and that has an adequate opening in the front so as not to cover the baby’s face and Weight Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
so that the breastfeeding will be easy (KG)

1.5-1.9 15 17 19 21 23 25 27 27
TIPS TO HELP THE MOTHER BREASTFED HER LOW BIRTH WEIGHT BABY 2.0-2.4 20 22 25 27 30 32 35 35
Express few drops of milk on the baby’s lips to help the baby start sucking
Give the baby short rest during breastfeeding. Feeding is hard work for LBWB SAFE PREPARATION OF INFANT FORMULA
If the baby coughs, gasps or spills up when he/ she starts to breastfeed the milk may be Always use a marked cup or glass and spoon, to measure water and the scoop to
getting down too fast for the little baby. Tell the mother to take the baby off the breast if measure the formula powder
Wash your hand before preparing a feed
this happens. Bring the water to boil then let it cool, keep it covered while cooled.
Hold the baby against her chest until the baby can breath well again, then put it back to Measure the formula powder into a marked cup or glass, make the scoops level. Put in
one scoop according to manufacture’s advice or recommendations
the breast.
Add a small amount of the cooled boiled water and stir, fill the cup or the glass to the
If the LBWB does not have enough energy to suck for long or strong enough sucking mark with the water. Stir well.
reflex; teach the mother to express breastmilk and fed it by a cup. Feed the infant using a cup
Wash the utensils

53
 GIVE FOLLOW UP CARE FOR THE YOUNG INFANT

ASSESS EVERY YOUNG INFANT FOR "POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE
DISEASE" DURING FOLLOW-UP VISIT

CRITICAL ILLNESS WHEN REFERRAL WAS REFUSED OR NOT FEASIBLE LOCAL BACTERIAL INFECTION
At each contact for injection of antibiotics (every day):
After 2 days:
Explain again to the caregiver that the infant is very sick and should urgently
Look at the umbilicus. Is it red or draining pus?
be referred for hospital care.
Look at the skin pustules.
Reassess the young infant as described in the chart IF REFERRAL WAS

NOT FEASIBLE page 49. Treatment:

Treat any new problem. If umbilical pus or redness remains same or is worse, refer to hospital. If pus
If referral is still not feasible, continue giving once daily intramuscular and redness are improved, tell the mother to continue giving
gentamicin and twice daily intramuscular Ampicillin until referral is feasible or The 5 days of antibiotic and continue treating the local infection at home.
for 7 days. 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.

54
 GIVE FOLLOW UP CARE FOR THE YOUNG INFANT

CLINICAL SEVERE INFECTION WHEN REFERRAL WAS NOT FEASIBLE
At each contact for injection ( every day ):
Reassess the young infant as described in the chart IF REFERRAL IS
REFUSED OR NOT FEASIBLE in page 49.
If the young infant is improving, complete the 7 days of treatment with
intramuscular gentamicin. Ask the mother to continue giving the oral
amoxicillin twice daily until all tablets are finished.
Refer the young infant urgently to hospital if:
The infant shows any sign of CRITICAL ILLNESS or
Any new sign of CLINICAL SEVERE INFECTION appear while on treatment
or
There is no improvement on day 4 after 3 full days of treatment or
Any sign of CLINICAL SEVERE INFECTION is still present at the 7 intrath
muscular injection of gentamicin.
PNEUMONIA OR SEVERE PNEUMONIA
After 2 days
Reassess the young infant for POSSIBLE SERIOUS BACTERIAL INFECTION
or PNEUMONIA or LOCAL BACTERIAL INFECTION as described in the
assess and classify sick young infants charts.
Treatment
Refer urgently to hospital if:
The infant becomes worse or
Any new sign of POSSIBLE SERIOUS BACTERIAL INFECTION or
VERY SEVERE DISEASE appears while on treatment.
If the young infant is improving, ask the mother to continue giving the oral
amoxicillin twice daily until all the tablets are finished.
Ask the mother to bring the young infant back in more days.

DIARRHOEA
After 2 days:

ASK: Has the diarrhoea stopped?

If the diarrhoea has not stopped , assess, classify and treat the young

infant for diarrhoea (see page 18 and 39)

if diarrhoea has stopped, tell the mother to continue exclusive breast

feeding.

55
 GIVE FOLLOW UP CARE FOR THE YOUNG INFANT

JAUNDICE PRE-TERM OR LOW BIRTH WEIGHT

After 1 day: After 14 days:
Reassess infant for jaundice Check weight and determine if the young infant gaining weight
Look for jaundice. Are palms and soles yellow? Reassess feeding and KMC
If the infant has yellow palms and soles , classify as SEVER JAUNDICE and refer If the infant is gaining weight praise the mother and encourage her to continue with optimal
URGENTLY to the hospital. feeding , ask the mother to come back after 1 month or according to immunization schedule.
If the infant does not have yellow palms and soles, but jaundice has not decreased, If infant weight is the same and is feeding well, encourage the mother to continue with
advise the mother on home care and continue to follow up in 1 day until jaundice optimal breastfeeding; Ask the mother to return in 7 days.
start to decrease . If the infant is loosing weight, refer to the hospital.
If jaundice has started decreasing, reassure the mother and ask her to continue If the mother have difficulty with KMC, review KMC steps.
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 LOW WEIGHT FOR AGE
for further assessment After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. See "Then Check for Feeding Problem or Low Weight".
EYE INFECTION If the infant is no longer low weight for age, praise the mother and encourage her to continue.
After 1 day: If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have
Look for pus draining from the eye her infant weighed again within 14 days or when she returns for immunization, whichever is
If eye discharge worsen, refer the earlier.
If eye discharge the same or bitter, If the infant is still low weight for age and still has a feeding problem, counsel the mother
Continue with 1 % tetracycline ointment for a total of 5 days; about the feeding problem. Ask the mother to return again in 14 days (or when she returns for
Reassess after 2 days immunization, if this is within 14 days). Continue to see the young infant every few weeks until
Remind the mother when to return immediately the infant is feeding well and gaining weight regularly and is no longer low weight for age.

Exception:
FEEDING PROBLEM If you do not think that feeding will improve, or if the young infant has lost weight, refer to
After 2 days: hospital.
Reassess feeding. - See "Then Check for Feeding Problem or Low Weight".
Ask about any feeding problems found on the initial visit. THRUSH
Counsel the mother about any new or continuing feeding problems. If you counsel the After 2 day:
mother to make significant changes in feeding, ask her to bring the young infant back again. Look for ulcers or white patches in the mouth (thrush).
If the young infant is low weight for age, ask the mother to return 14 days of this follow up Reassess feeding. - See "Then Check for Feeding Problem or Low Weight".
visit. Continue follow-up until the infant is gaining weight well. If thrush is worse check that treatment is being given correctly. If the infant has problems with
attachment or suckling, refer to hospital.
Exception: If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian
violet for a total of 5 days.
If you do not think that feeding will improve, or if the young infant has lost weight, refer the
child
CONFERMID HIV INFECTION, HIV EXPOSED; POSSIBLE HIV INFECTION
Give follow up care as older children

56
 ANNEX1: TABLE OF OTHER CAUSES OF FEVER WHEN MALARIA TEST IS NEGATIVE

OTHER CAUSES OF FEVER WHEN MALARIA TEST IS NEGATIVE IN CHILDREN UNDER FIVE YEARS

SIGNS CLASSIFICATIONS TREATMENT MORE INFORMATION

Give paracetamol for high fever Cold is caused by viral infection which there is
Runny nose COLD
Give extra fluid no need for antibiotics

Sore throat for older children

TONSILITIS Use a torch and spatula to look for a child
Pain or difficulty swallowing Give amoxicillin for 5 days
PHARYNGITIS throat to see if there is redness, pus or swelling
Give paracetamol for high fever (38.5 0C or
Painful swollen neck gland
more)

Pain in passing urine

Growth faltering
Give amoxicillin for 5 days Do urinalysis if feasible
Lower abdominal pain URINARY TRACT Give paracetamol for high fever (38.5 0C or If WBC count > 5HPF that indicate urinary tract
Increase frequency of micturition INFECTION more) infection
Bed wetting to the child who does
not have the habit

Skin pustules Give amoxicillin for 5 days

Boils LOCAL BACTERIAL Give paracetamol for high fever (38.5 0C or more
INFECTION Do incision and drain the abscess
Cellulitis
Clean wound using antiseptics

Fever Give first dose of intramuscular antibiotics

Vomiting Treat to prevent low blood sugar At hospital cerebral spine fluid will be taken for
MENINGITIS
Neck stiffness Give paracetamol for high fever (38.5 0C or more diagnosis
Meningitides spots (rose spots) Refer URGENTLY to the hospital

57
 ANNEX 2: TABLE OF DOSE OF RUTF FOR CHILDREN WITH ACUTE MALNUTRITION

DOSAGE OF RUTF FOR CHILDREN WITH ACUTE MALNUTRITION

Table bellow show how to give Ready to Use Therapeutic Food (RUTF) per day/week according to child weight

PLUMPY NUT SACHETS

(1 BACK OF PLUMPY NUT WEIGHT 92 GRAMS)
WEIGHT
(KG)
SACHETS PER DAY SACHETS PER WEEK

3.0—3.4 1¼ 8

3.5—3.9 1½ 11

4.0 –5.4 2 14

5.5 –6.9 2½ 18

7.0 – 8.4 3 21

8.5 – 9.4 3½ 25

9.5 -10.4 4 28

10.5 – 14.9 4½ 32

15.0 – 19.9 5 35

58
 ANNEX3: HOW TO MEASURE MID UPPER ARM CIRCUMFERENCE (MUAC)

To measure Mid upper arm circumference (MUAC)
MUAC: MUAC is the circumference of the left upper arm, measured at the mid-point
between the tip of the shoulder and the tip of the elbow (olecranon process and the
acromion). In children, MUAC is useful for the assessment of nutritional status.
This measurement is not significant for children aged less than 6 months.
How to measure Mid Upper Arm Circumference for children
There is a special tool called Arm circumference insertion tape, however a normal tape
measure can function similarly.
Make sure the child has undressed the whole of left arm.
Flex the child’s arm to lie on his or her abdomen to make an angle of 90º.
Locate the tip of the shoulder and the elbow.
Measure the length from the tip of the shoulder to the tip of the elbow.
Look for place on the upper arm where way half of the distance of the measured length
and put a mark. Then remove the tape.
Let the child extend the arm straight before using the tape for measurement.
Encircle the tape around the arm at the part where you put the mark.
Make sure the tape is not very tight or not very loose on the child’s.
Read the measurement on the tape at the corresponding point.
Record the measurement in millimeters (mms) in single decimal places.
Look at the following pictures in the steps for easy understanding.

1. Locat e t ip of 2. Tip of shoulder 4. Pl ace tape at tip of shoulder

shoulder 5. P ull tape past tip of bent 6. Mark the mid point
3. Tip of Elbow
elbow

0 Correct t ape posit ion for

10.
7. Correct t ape t ension 8. Tape too tight 9. Tape too loose upper arm circumference

59
 ANNEX 4: REFERRAL NOTE FOR THE SICK YOUNG INFANT

Infant's name: Mother name

Caregiver's name: Age of infants: Temperature:
Address or village:
Tick the signs present that are reason for referral of the young infant.

POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE REASONS FOR REFERRAL
Unable to feed at all or not feeding well
Convulsions..
Severe chest indwing
Temperature 38°C or above
Temperature 35.5°C or less
No movement at all
Fast breathing (60 breaths per minute or more) in infants less than 7 days old

SEVERE DEHYDRATION
Sunken eyes
Skin pinch goes back very slowly
SEVERE JAUNDICE
Any Jaundice in infant aged less than 24 hours
Yellow palms or soles at any age
SEVERE EYE INFECTION
Eyes profusely discharging pus with or without swelling
VERY LOW WEIGHT FOR AGE
Weight less than 2.0 kg
VERY PRE-TERM AND/OR VERY LOW BIRTH WEIGHT
Weight less than 1500 gm or gestational age less than 32 weeks
Prerferral treatments given:

Comments:

Date of referral: Time of referral:

Name of Referring Health Worker: Name of Facility

60
 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMNCI)
CASE MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Child's Name Age: (Months) Weight Kg.Height/L: cm. MUAC: mm. Temperature: °C
ASK What are the child's problem? Initial visit?_____ Follow-up Visit?___

ASSESS Circle all signs present CLASSIFY

CHECK FOR GENERAL DANGER SIGNS General danger sign present
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS Yes___ No__
CONVULSIONS NOW
VOMITS EVERYTHING
Remember to use danger sign
when selectiong classifications
HAS THE CHILD HAD CONVULSIONS?
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 (if wheezing and fast breathing or chest in drawing,
Give trial of rapid acting bronchodilator 3 doses and reassess again)
DOES THE CHILD HAVE DIARRHOEA? Yes____ No____

For how long? ______Days Look at the child's general condition is the child
Is there blood in the stool? o Lethargic or unconscious?
o Restless and irritable
Look for sunken eyes.
o Offer the child fluid. Is the child:
o Not able to drink or drinking poorly?
Pinch the skin of the abdomen. Does it go back
o Very slowly (Longer than 2 seconds)? Slowly?
DOES THE CHILD HAVE FEVER? (by history, feels hot, temperature 37.5°C or above) Yes____ No____
For how long?______ Days Look feel for stiff neck
If more than/ days, has fever been present every day? Look for runny nose
Has child had measles within the last 3 months? Look for any other cause of over
Do Malaria test if No Severe classifications in all cases. Look for signs of MEASLES
Test Positive? NEGATIVE? P Falciparum P. vivax o Generalized rash and
o One of these: cough, runny nose or red eyes

If the child has measles now or within the last 3 months: Look for mouth ulcers
o If Yes are they deep and extensive?
Look for pus draining for the eye
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes____ No____
Is there ear pain? Look for pus draining from the ear
Is there war discharge? Feel for tender swelling behind the ear
If yes, for how long?______ Days

61
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feel
Determine WFHI/L Z-score Less than -3? between-3 and -2? -2 or more?
For children 6 months and older measure MUAC____cm
Is MUAC <115 mm or 115-125 mm or
>125 mm
Is there any medical complication:
o General severe classifications?
o Any severe classification?
o Pneumonia with chest in drawing?
Child 6 months or older. offer RUTF to eat. Is the child:
o Not able to finish? Able to finish?
THEN CHECK FOR ANEMIA
Look for palmar pallor.
o Severe palmar pallor? Some palmar pallor? No palmar pallor?
THEN CHECK FOR TUBERCULOSIS
If child has household/other contact with a known case of TB. Look for generalized lymphadenopathy.
Determine child has cough for more than 14 days Are there any enlarged lymph glands in two or more of the following sites:
Determine the chis has unexplained or prolonged fever for more than 7 days neck, armpit, or groin?
Unexplained fatigue, reduced play fullness, loss active
Does the child have Growth faltering or UNCOMPLICATED SEVERE ACUTE
MALNUTRITION or MODERATE ACUTE MALNUTRITION?
THEN CHECK FOR HIV
Note mother's and/or child's HIV status
o Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
o Child’s virological test: NEGATIVE POSITIVE NOT DONE/KNOWN
o Child’s serological test: NEGATIVE POSITIVE NOT DONE/KNOWN
if mother is HIV-positive and child is negative or unknown:
o Is the child breastfeeding now?
o Was the child breastfeeding at time of test 6 weeks before it?
o If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION AND VITAMIN A SUPPLEMENTATION STATUS Circle immunications needed today. Retun for next immunization on

BCG PENTA-1 PENTA-2 PENTA-3 Measles 1 Vitamin A

_________________________
OPV 0 OPV 1 OPV 2 OPV 3 Measles 2 Mebendazole (Date)
IPV
ASSESS CHILD'S FEEDING if child is less than 2 years old, or has MODERATE ACUTE MALNUTRITION or ANAEMIA, CONFIRMED HIV INFECTION or HIV EXPOSED Feeding problem:
Do you breastfeed your child? Yes_____ No________
If Yes, how many times in 24 hours?_______time.. Do you breastfeed during the night? Yes____ No___
Does the child take any other foods or fluids? Yes____ No____
If Yes, What foods or fluids?________________________________________________________________
How many time per day?_______times. What do you use to feed the child?__________________________
If MODERATE ACUTE MALNUTRITION How large are serving?________________________________
Does the child receive his own serving?____ Who fees the child and how?___________________________
During this illness, has the child’s feeding changed? Yes_____ No_______
If Yes, how?
ASSES OTHER PROBLEM
ASSES MOTHER’S OWN HEALTH:
 TREAT
Remember to refer any child who has a danger sign and no other severe classification

62
Return for follow-up in: .........................................................................................................................................................

Advise mother when to return immediately. .........................................................................................................................................................

Give any immunizations needed today: .........................................................................................................................................................

Feeding advice: .........................................................................................................................................................

 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMNCI)
CASE MANAGEMENT OF THE SICK YOUNG INFANT AGE FROM BIRTH UP TO 2 MONTHS
Name: Age. (Day/weeks) Weight: Kg. Temperature: °C
ASK: What are the infant's problems? Initial visit Follow-up Visit
ASSESS (Circle all signs present) CLASSIFY:...........................
CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION or VERY SEVERE DISEASE or PNEUMONIA or LOCAL BACTERIAL INFECTION
ASK LOOK AND FEEL

Is the infant having difficulty in feeding? • Is the infant convulsing now?

Has the infant had convulsions? • Count the breaths____________in one minute
Has the mother had tuberculosis infection two weeks before delivery?(smear+ve) • Repeat if elevated_____________ Fast breathing
• Look if infant is not able to feed or breastfeed?
• Look for severe chest indrawing.
• Look at umbilicus. Is it red or draining pus?
• High body temperature (138°C or above or feels hot) or low body temperature
(below 35.5°C or feels cold)
• Look for skin pustules
• Look for pus draining from the eyes.
• Look at young infants movements.
• Movement only when stimulated or no movements even when stimulated?
DOES THE YOUNG INFANT HAVE DIARRHOEA?
For how long?________Days Look at the infants general condition
Is there blood in stool? • Look at the young infant's movement
o does not move our moves only when simulated
o Is the infant restless and imitable
• Look for sunken eyes.
• Pinch the skin of the abdomen.
Very slowly (>2 seconds)? Slowly
THEN CHECK FOR JAUNDICE
• Look for jaundice
Does the baby have yellow colouration of skin or eyes? yes____No____ • Yellow palms and soles.
If yes, ask when did it start? (If no, check for jaundice). • Yellow eyes and skin of the face.
Before 24 hours for birth. • Yellow at any part of the body.
After 24 hours from birth

THEN CHECK FOR EYES PROBLEM Look at the infant's eyes

Are they profusely discharging pus?.
Are they draining pus?
Are they swollen?

THEN CHECK FOR HIV INFECTION Check the mother and infant HIV status
Has the mother tested for HIV? Yes... No. • Infant PCR test positive
Has the infant tested for HIV by PCR Or Antibody test? • Infant seropositive
Is the HIV status of mother or infant Unknown? • Mother HIV positive
• Both mother HIV negative and baby is HIV negative

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT OR WASTING IN BREASTFEEDING INFANTS

63
If the infant has no indication to refer urgently to hospital
Is there any difficulty feeding? Yes___No____ • Determine the weight for age.
Is the infant breastfed? Yes____No_______ o Low weight (<-2SD) Not low (>-2SD)
If Yes, how many times in 24 hours?_____time • Look for ulcers or patches in the mouth (thrush).
Does the infant usually receive any? Yes____No_____
If yes, how often?________time/day
What do you use to feed the child?
ASSESS BREASTFEEDING • Is the infant wall positioned? To check for positioning, look for,
Has infant breastfed in the previous hour? o Infant's head and body in line. Yes__NO_
If the infant has not fed in the previous hour, ask the mother to put her infant to the o Infant approaching breast with nose opposite to the nipple. Yes_No__
breast. Observe the breastfeed for 4 minutes. o Infant held close to the mother's body. Yes___No___
o Infant's whole body supported, not just neck and shoulder. Yes_No___
not well positioned well positioned
• Is the infant able to attach? To check attachment, look for
o Chin touching breast: Yes____ No____
o Mouth wide open: Yes____No____
o Lower lip tumed outward: Yes_____No_____
o 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 effectively sucking effectively
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT OR WASTING IN NON
BREATFEEDING INFANTS Is the replacement milk: Correctly prepared? Yes No
How milk are you giving?...........................How many times in 24hrs_____ Hygienically prepared? Yes____ No____
How much is given at each feed________ Appropriate? Yes____ No____
how are you prepraing the milk?
Are you giving any breast milk? Yes___ N0___
Sufficient? Yes____No____
What the other food/fluids are giving? Look for ulcers or white patches in the mouth (thrush)
How the child fed by cup or bottle? Determine the weight for age. Low weight (<-25D) Not low (>-2SD)
How is cleaning the utensils done? Appropriate / Not appropriate
How much is given at each feed?
Measure weight?
CHECK FOR BIRTH WEIGHT AND GESTATIONAL AGE (In Infants < 7 days old). o Weight <1500 gm or gestational age <32 weeks
What was the gestational age at birth? ________________weeks o Weight 1500 am to 2500 am or gestational age 32 to 36 week
What was the birth weight? kg
o Weight _> 2600 gm for gestational age _> 37 weeks

CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS Circle immunizations needed today. Retun for next immunization on
:_________________________
BCG OPV-0 Penta-1 OPV-1 200,000 I.U vitamin A to mother
(Date)

ASSES OTHER PROBLEM

ASSES MOTHER’S OWN HEALTH:

 TREAT

64

Return for follow-up in: .........................................................................................................................................................

Give any immunization needed today:..................................................................................................................................
................................................................................................................................................................................................
Advice
Given: ....................................................................................................................................................................................
65
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70
 PRINCIPLES OF THE INTEGRATED CLINICAL CASE MANAGEMENT
IMNCI clinical guidelines are based on the following
principles:
1. Examining all sick children aged up to five
years of age for general danger signs and all
young infants for signs of very severe disease.
These signs indicate severe illness and the need
for immediate referral or admission to hospital.
2. The children and infants are then assessed for
main symptoms:
In older children the main symptoms include:
• Cough or difficulty breathing,
• Diarrhoea,
• Fever, and
Ear infection.
In young infants, the main symptoms include:
• Local bacterial infection,
Diarrhoea,
Jaundice, and
• Eye problem
3. Then in addition, all sick children are routinely
checked for:
Nutritional and immunization status,
• HIV status in high HIV settings, and
• Other potential problems.
71
4. Only a limited number of clinical signs are
used, selected on the basis of their sensitivity and
specificity to detect disease through
classification.
A combination of individual signs leads to a child's
classification within one or more symptom groups
rather than a diagnosis. The classification of illness
is based on a colour-coded triage system:
"PINK" indicates urgent hospital referral or
admission.
"YELLOW” indicates initiation of specific
outpatient treatment,
"GREEN" indicates supportive home care.
5. IMNCI nanagement procedures use a limited
number of essential drugs and encourage
active participation of caregivers in the
treatment of their children.
6. An essential component of IMNCI is the
counselling of caregivers regarding home care:
Appropriate feeding and fluids,
When to return to the clinic immediately, and
When to return for follow-up
IMNCI Chart Booklet
This IMNCI chart booklet is for use by nurses, clinicians and other health professionals who see young infants
and children less than five years old. It facilitates the use of the IMNCI case management process and the charts
describe the sequence of all the case management steps. The chart booklet should be used by all health
professionals providing care to sick children to help them apply the IMNCI case management guidelines. Health
professionals should always use the chart booklet for easy reference during the process of clinical care.

The chart booklet is divided into two main parts because clinic al signs in sick young infants and older children
are somewhat different and the case management procedures also differ between these age groups:
SICK CHILD AGED 2 MONTHS TO 5 YEARS. This part contains all the necessary clinical algorithms,
information and instructions on how to provide care to sick children aged 2 months to 5 years.

and

SICK YOUNG INFANT AGED UP TO 2 MONTHS. This part includes case management clinical algorithms for
the care of a young infant aged up to 2 months

Each of these parts contains IMNCI charts corresponding to the main steps of the
IMNCI case management process.

72