Session 4

Main Symptoms
- cough or difficult breathing
- diarrhea
- fever
- ear problems
1
 Learning Objectives
By the end of this session, the students will be
able to:
(1) recall the anatomy and pathophysiology;
(2) recognize the symptoms and signs;
(3) assess and classify symptoms and signs;
(4) identify the correct treatment and when to refer;
(5) provide counseling; and
(6) specify necessary follow-up care

2
 Session 4-a

Cough or Difficult Breathing

3
 Parts of the Respiratory System

•Nasal
passages
•Windpipe
or trachea
•Lungs

4
 Inside the alveolus

5
 Cough or Difficult Breathing
ASK: Does the child have cough or difficult breathing?

If NO If YES

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

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

If the child is: Fast breathing is:

Ask about 2 mos – 12 mos. 50 breaths/min or more
next main 12 mos – 5 yrs 40 breaths/min or more
symptoms:
diarrhea,
fever, ear Classify child’s illness using the color-coded
problems classification table for cough or difficult breathing
6
 Video of child with chest indrawing

7
 Video of child with stridor

8
 Cough or Difficult Breathing
SIG N CLASSIF Y A S ID EN TIF Y
S danger
•Any general Give TR
firstEA TM
dose ofENT
an
sign or SEVERE PNEUMONIA appropriate antibiotic
•Chest indrawing or OR VERY SEVERE Refer URGENTLY to hospital
•Stridor in a calm child DISEASE

Give an appropriate oral

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

If coughing > 30 days, refer for

No signs of pneumonia
or very severe disease
9
assessment
NO PNEUMONIA: Soothe the throat and relieve the
COUGH OR COLD cough with a safe remedy
Advise mother when to return
immediately
Follow-up in 5 days if not improving
 Treatment
Soothe the Throat, Relieve the Cough with
a Safe Remedy
Safe remedies to recommend:
Breastmilk for exclusively breastfed
infant
tamarind, calamansi, ginger

Harmful remedies to discourage:

Codeine cough syrup
Other cough syrups
10 Oral and nasal decongestants
 Treatment for Pneumonia or Very
Severe Disease
Age or Cotrimoxazole Amoxycillin
Weight Give 2 times daily Give 3 times daily
for 5 days for 5 days
Adult Syrup Tablet Syrup
tab. 40 mg
80mg TMP 250 mg 125
TMP 200 mg mg/ 5 ml
400 mg SMX
SMX

2 -12 mos 1/2 5.0 ml. 1/2 5.0 ml

11 12mos-5yrs 1 7.5 ml 1 10 ml.

 Vitamin A Supplementation
for Severe Pneumonia or Very Severe
Disease

Age Vitamin A Capsule

100,000 I U 200,000 I U

6 to 12 mos. 1 capsule ½ capsule

12 mos-5 yrs 2 capsules 1 capsule

12
 Session 4-b

DIARRHEA

13
 Anatomy of the Gastrointestinal
System

14
 Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs,
ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHOEA?

If NO If YES

Does the child have diarrhoea?

IF YES, ASK: LOOK, LISTEN, FEEL:
For how long? Look at the child’s general condition.
Is the child:
Is there blood in the
stool Lethargic or unconscious?
Restless or irritable?

Look for sunken eyes.

Classify
DIARRHOEA
Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

Pinch the skin of the abdomen.

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

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

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and

15 anaemia, immunization status and for other problems.

 DIARRHEA
Does the child have diarrhea?
IF YES, ASK:
For how long?
Is there blood in the stool?
LOOK, LISTEN, FEEL:
 Look at the child’s general
condition, is the child:
 Lethargic or unconscious?
 Restless or irritable?
 Look for sunken eyes
 Offer the child fluid. Is the Pinch the skin of the
child: abdomen
 Not able to drink or drinking Does it go back:
poorly? Very slowly (> than 2 secs)?
16  Drinking eagerly, thirsty? Slowly?
 Video of a child with sunken eyes

17
 Video of Skin Pinching

18
 CLASSIFICATION TABLE FOR DEHYDRATION
SIGNS
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking
poorly
Skin pinch goes back very
slowly
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back
slowly
Not enough signs to
classify as some or
severe dehydration.
19
IDENTIFY TREATMENT
CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
If child has no other severe classification:
— Give fluid for severe dehydration (Plan C).
SEVERE OR
DEHYDRATION If child also has another severe classification:
— Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
If child is 2 years or older and there is cholera
in your area, give antibiotic for cholera.
Give fluid and food for some dehydration (Plan
B).
If child also has a severe classification:
SOME
DEHYDRATION — Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
Give fluid 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.
 No Dehydration

20
 Some Dehydration

21
 Severe Dehydration

22
 No Dehydration

Tell the Mother:

(a) Breastfeed frequently and longer for each feed.
(b) If the child is exclusively breastfed, give ORS or
clean water in addition to breastmilk.
(c) If the child is NOT exclusively breastfed, give 1 or
more of the following:
ORS
Food-based fluids
Clean Water

23
 No Dehydration

Treatment Plan A
Age Amount of Fluid Type
< 2 yrs
of Fluid
50-100 ml (¼-½ cup) after each loose stool ORS, rice water,
2-10 yrs 100-200 ml (½-1 cup) after each loose yogurt,
stool soup with
salt

• Give frequent small sips from a cup.

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

more slowly.
24 • Continue giving extra fluids until the diarrhea stops.
 Some Dehydration

 Give frequent small sips from a cup.

 If the child vomits, wait 10 minutes. Then
continue, but more slowly.
 Continue giving extra fluids until the
diarrhea stops.
 Reassess after 4 hours and classify the
child for dehydration.

25
 Some Dehydration

If the mother must leave before completing

treatment:
show her how to prepare the ORS solution at
home.
show her how much to give to finish the 4
hour treatment at home
give her enough ORS packets to complete
rehydration.
26
 Some Dehydration

Treatment Plan B
(Determine amount of ORS to be given in 4 hours)

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

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

WEIGHT
In ml 200-400 400-700 700-900 900-1400

• The approximate amount of ORS can also be

calculated by multiplying the child’s weight (in kg)
by 75.
27
 Severe Dehydration

Can you give Intravenous

fluids (IV) immediately?

28
 Severe Dehydration

Treatment Plan C
To treat severe dehydration (IV fluid: pLRS)
Age Initial Phase Subsequent Phase
(30 ml/kg) (70 ml/kg)

Infants (<12 mos) 1 hour *

5 hours
Older children 30 minutes* 2½
hours
*Repeat once if radial pulse is still very
weak or imperceptible.
29
 Severe Dehydration

 Reassess the child every 1-2 hours. If hydration

status is not improving, give the IV drip more
rapidly.

 Alsogive ORS (5ml/kg/hr) as soon as the child

can drink.

 Reassess the infant after 6 hours & a child after

30 3 hours. Classify dehydration.
 Severe Dehydration

If trained to use a
nasogastric tube for
rehydration?

31
 Severe Dehydration

 Starthydration by tube (or mouth) with

ORS solution. Give (20ml/kg/hr) for 6 hours.
(Total of 120ml/kg)
 Reassess the child every 2 hours.
– If there is repeated vomiting or increasing abdominal
distention, give the fluid more slowly.
– If hydration status is not improving after 3 hours, send
the child for IV therapy.
 After
6 hours, reassess the child. Classify
dehydration.
32
 CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

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

Treat dehydration before referral unless

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

Advise the mother on feeding a child who has

No dehydration PERSISTENT PERSISTENT DIARRHOEA.
Follow-up in 5 days.
DIARRHOEA

33
 Persistent Diarrhea

 After 5 days:
Ask:
 Ifthe diarrhoea has NOT stopped (3 or more
stools) do a full reassessment, give the
treatment, then refer to hospital.

 Ifthe diarrhoea has stopped (< 3 stools per

day) Tell the mother to follow the usual
feeding recommendations for the child’s age.

34
 CLASSIFICATION TABLE FOR DYSENTERY

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

Treat for 5 days with an oral

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

35
 Dysentery

 After 2 days:
Ask:
 if the child is dehydrated, treat hydration.

 ifthe number of stools, amount of stools,

fever, abdominal pain or eating is same or
worse: Change to 2nd line antibiotics & give
for 5 days. Advise to return in 2 days.

36
 Dysentery

 EXCEPTIONS:

If the child is less than 12 months old or was

dehydrated on the 1st visit or had measles
within the last 3 months. REFER TO
HOSPITAL.
If fewer stools, less blood in stools, less
fever, less abdominal pain & eating better,
continue antibiotics.
37
 Session 4-c

Fever

38
 Assess FEVER

A child has the main symptom of fever if:

– the child has history of fever

– the child feels hot
– the child has an axillary temperature of
37.5 or above

39
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk

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

 Has the child visited malaria area in the past 4 weeks?

 If yes to either, obtain a blood smear.

Then Ask: Look and Feel:

 For how long does the child has fever?
 If >7 days, has the fever been present
everyday?
 Has the child had measles within the
last 3 months?
40
 Look and feel for stiff neck.
 Look for runny nose
Look for signs of Measles:
• Generalized rash.
• One of these: cough, runny nose or
red eyes
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

If the child has measles now or within the last

three months:

 Look for mouth ulcers.

– Are they deep and extensive?

 Look for pus draining from the eye.

 Look for clouding of the cornea.

41
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Dengue Risk: Yes or No

If Dengue Risk:

Then Ask: Look and Feel:

 Has the child had any bleeding
from the nose or gums or in the
vomitus or stools?
 Has the child had black vomitus
or stools?
 Has the child had abdominal
pain?
 Look for bleeding from nose or
gums.
 Look for skin petechiae
 Feel for cold clammy extremities.
If none of the above ASK or LOOK
and FEEL signs are present and the
child is 6 months or older and fever
present for more than 3 days.

42  Has the child been vomiting? Perform Torniquet Test.

 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Classify Malaria Risk

Decide Malaria Risk: (including travel to
FEVER malaria area)

If the child has measles

now or within the last
three months:

Decide Dengue Risk: Yes

or No No Malaria
Risk

43 If Dengue Risk:
 Deciding Malaria Risk

 Malaria is caused by parasites in the blood

called “plasmodia”
– “Plasmodium falciparum”

 Transmitted by Anopheles mosquito

 Know the malaria risk in your areas.

44
 Malaria Risk Areas
1. Palawan 1. Isabela
2. Davao Oriental 2. Cagayan
3. Davao del Norte 3. Quezon
4. Compostela Valley 4. Ifugao
5. Tawi-tawi 5. Zamboanga del Sur
6. Sulu 6. Bukidnon
7. Agusan del Sur 7. Misamis Oriental
8. Mindoro Occidental 8. Quirino
9. Kalinga Apayao 9. Mountain Province
10. Agusan del Norte 10. Basilan

45
 Classify FEVER
Malaria Risk
 Any general danger sign or VERY SEVERE FEBRILE
Malaria Risk  Stiff Neck DISEASE/MALARIA
(including travel to
Blood smear (+)
malaria area)
If blood smear not done:
NO runny nose and, MALARIA
NO measles, and NO other

Classify causes of fever

Blood smear (-), or
FEVER
Runny nose, or FEVER:
Measles or MALARIA UNLIKELY
Other causes of fever.
No Malaria Risk
No Malaria  Any general danger sign or VERY SEVERE
 Stiff Neck FEBRILE DISEASE
Risk
 No sign of very severe FEVER:
46 febrile disease NO MALARIA
 Malaria Risk
 Any general danger Give first dose of Quinine (under medical
sign or VERY SEVERE supervision or if a hospital is not accessible withing 4
 Stiff Neck FEBRILE hours)
DISEASE Give first dose of appropriate antibiotics.

/MALARIA Treat the child to prevent low blood sugar.

Give one dose of Paracetamol in health center for

high fever (38.5C or above.)

Send a blood smear with the patient.

Refer URGENTLY to a hospital.

Blood smear (+) Treat the child with an oral antimalarial.
If blood smear not Give one dose of Paracetamol in health center for

done: MALARIA high fever (38.5C or above.)

NO runny nose and, Advise mother when to return immediately.
NO measles, and Follow up in 2 days if fever persists.
NO other causes of If the fever is present every day for more than 7

47 fever days, refer for assessment.

 Malaria Risk
 Blood smear  Give one dose of Paracetamol in
(-), or FEVER: health center for high fever (38.5C
 Runny nose, MALARIA or above.)
or UNLIKELY  Advise mother when to return
 Measles or immediately.
 Other  Follow up in 2 days if fever persists.
causes  If the fever is present every day for
of fever. more than 7 days, refer for
assessment.
Treat other causes of fever.

48
 TREAT THE CHILD:
Antimalarial Agents
 Give an Oral Antimalarial
1st line Antibiotics: Chloroquine and Primaquine
2nd line Antibiotics: Sulfadoxine and Pyrimethamine

 If Chloroquine:
The child should be watched closely for 30 minutes. If the child
vomits, give another dose.

Itching is a possible side effect of the drug.

 If Sulfadoxine and Pyrimethamine:

Give single dose in health center.
49
 Antimalarial Agents
CHLOROQUINE PRIMAQUINE PRIMAQUINE SULFADOXINE +
Give for 3 days Single dose for Daily for 14 PYRIMETHAMINE
P. days for P. Single dose
falciparum vivax

AGE Tablet
(150mg base)
Tablet
Tablet Tablet
(500mg Sulfadoxine 25mg
(15mg base) (15mg base)
Pyrimethamine)
Day 1 Day 2 Day 3

2 months up to
5 months (4 -
<7kg) ½ ½ ½ 1/4

5 months up to
12 months (7 -
<10kg) ½ ½ ½ 1/2

12 months up
to 3 years (10 -
<14kg) 1 1 ½ 1/2 1/4 3/4

3 years up to 5
years (14 –

50 19kg) 1½ 1½ 1 3/4 1/2 1

 TREAT THE CHILD:
Antimalarial Agents

 Chloroquine is given for 3 days.

 Explain to the mother that itching is a possible

side effect. It is NOT dangerous. The mother
should continue to give the drug.

51
 TREAT THE CHILD:
Antimalarial Agents
 If the species of malaria is identified through
blood smear, give the following:

– P. falciparum – single dose Primaquine with the

first dose of Chloroquine

– P. vivax – first dose of Primaquine with

Chloroquine and give mother enough for one dose
each day for the next 13 days.

52
 TREAT THE CHILD:
Antimalarial Agents

 Ifyou do not have the blood smear or you do

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

 Donot give Primaquine to children under 12

months of age.

53
 TECHNICAL UPDATES:
Antimalarial Agents
TECHNICAL BASIS: Artemisinin Based Combination
Therapies
Based on available safety and efficacy data, the following
therapeutic options are available and have potential for
deployment (in prioritized order) if costs are not an issue:
 Arthemether – lumefantrine (Coarthem TM)
 Artesunate (3 days) + amodiaquine
 Artesunate (3 days) + SP in areas where SP remains high
 SP + Amodiaquine in areas where both SP and

Amodiaquine remain high. This mainly limited to West

54 Africa.
 TECHNICAL UPDATES:
Antimalarial Agents

 Administer intramuscular antibiotic if the child

cannot take an oral antibiotic

 Quinine for severe malaria

 Breastmilk or sugar to prevent low blood sugar.

55
 Give an Intramuscular Antibiotic

A child may need an antibiotic before he

leaves for the hospital, if he/she:
– is not able to drink or breastfeed
– vomits everything
– has convulsions
– is abnormally sleepy or difficult to awaken

56
 Give an Intramuscular Antibiotic

Age or Weight CHLORAMPHENICOL

Dose: 40 mg/kg
Add 5 ml sterile water to vial containing 1000mg =
5.6 ml at 180mg/ml

2 – 4 months (4 - <6kg) 1 ml = 180 mg

4 – 9 months (6 - <8kg) 1.5 ml = 270 mg
9 – 12 months (8 -10 kg) 2 ml = 360 mg
1 – 3 years (10 - <14kg) 2.5 ml = 450 mg
3 – 5 years (14 – 19 kg) 3.5 ml = 630 mg
57
 Give Quinine for Severe Malaria

 Quinine is the preferred because it is rapidly

effective.
 Quinine is more safe and effective than
intramuscular Chloroquine.
 Possible side effects of Quinine injections
are: sudden drop in blood pressure,
dizziness, ringing in the ears and a sterile
abscess.
58
 Give Quinine for Severe Malaria
 For children being referred with very severe
febrile disease/Malaria:
– Give the 1st dose of IM Quinine and refer the child urgently
to the hospital
 If referral is not possible:
– Give the 1st dose of IM Quinine
– The child should remain lying down for 1 hour
– Repeat the Quinine injection 4 to 8 hours later, and then
every 12 hours until the child is able to take an oral
antimalarial.
– Do not continue Quinine injection for more than 1 week.
– DO NOT GIVE QUININE TO A CHILD LESS THAN 4
59 MONTHS OF AGE.
 Give Quinine for Severe Malaria

INTRAMUSCULAR QUININE
Age or Weight
300 mg/ml (In 2 ml ampules)
4 months – 12 months 0.3 ml
(6 - <10kg)
12 months – 2 years 0.4 ml
(10 - <12kg)
2 – 3 years 0.5 ml
(12 - <14kg)
3 – 5 years (14 – 19kg) 0.6 ml
60
 TREAT THE CHILD:
To Prevent Low Blood Sugar

 If the child is able to breastfeed:

– Ask the mother to breastfeed the child.
 If the child is not able to breastfeed but is
able to swallow:
– Give expressed breastmilk or breastmilk
substitute. If neither is available, give
sugar water. Give 30 – 50 ml of milk or
sugar water before departure.
61
 TREAT THE CHILD:
To Prevent Low Blood Sugar

To make Sugar Water:

Dissolve 4 level teaspoons of sugar (20 grams)

in a 200 ml cup of clean water.

If the child is not able to swallow:

– Give 50 ml of sugar water by nasogastric tube.

62
 TREAT THE CHILD:
Paracetamol for High Fever

PARACETAMOL

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

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

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

63
 No Malaria Risk
 Any general VERY SEVERE Give first dose of appropriate antibiotics.
danger sign or FEBRILE Treat the child to prevent low blood sugar.
 Stiff Neck DISEASE Give one dose of Paracetamol in health center
for high fever (38.5C or above.)
Refer URGENTLY to a hospital.

 No sign of FEVER: Give one dose of Paracetamol in health center

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

64
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Severe

Risk: Complicated
Measles
If the child has
measles now or
within the last Classify Measles with
three Eye or Mouth
FEVER
months: Complications

Decide Dengue
Risk: Yes or No
Measles

If Dengue Risk:
65 If dengue Risk, classify page 77 of the module Assess
and Classify the Sick Child Age 2 months up to 5 years
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

If the child has Look for mouth

measles now ulcers: are they
or within the last deep and
three months: extensive
Look for pus If
draining from the measles
eye now
Look for clouding or within
of the cornea last
three
months,
classify
66
 Measles
 Fever and generalized rash are the main
signs of measles.
 Highly infectious.
 Over crowding and poor housing increases
the risk of developing measles.
 Caused by a virus that infects the layers of
cells that line the lung, gut, eye, mouth and
throat.

67
 Measles
 Complications of measles occur in about 30% of all
cases
– diarrhea (including dysentery and persistent
diarrhea)
– pneumonia and stridor
– mouth ulcers
– ear infection
– severe eye infection (which may lead to corneal
ulceration and blindness)
 Encephalitis occurs in about 1/1000 cases. (look for
danger signs such as convulsions, abnormally sleepy
68 or difficult to awaken)
 Classify MEASLES
Clouding of the SEVERE Give Vitamin A
cornea COMPLICATED Give first dose of an appropriate
Deep extensive MEASLES antibiotics
mouth ulcers If clouding of the cornea or pus draining

from the eye, apply Tetracycline eye

ointment
Refer URGENTLY to the hospital

Pus draining from the MEASLES WITH EYE Give Vitamin A

eye OR MOUTH Give first dose of an appropriate
Mouth ulcers COMPLICATIONS antibiotics
If pus draining from the eye, apply

Tetracycline eye ointment

If mouth ulcers, teach the mother to treat

with gentian violet

Follow up in two days

Measles now or MEASLES Give Vitamin A

within the last 3
months
69
 Children with Measles

70
71 Koplik’s spots
 TREAT THE CHILD:
Give Vitamin A

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

Vitamin A Capsule
AGE
100,000 IU 200,000 IU

2 – 6 months 50,000 IU

6 – 12 months 1 cap 1/2 cap

1 – 5 years 2 caps 1 cap

 200,000 IU = 6 drops
 100,000 IU = 3 drops
73
 Does the child have fever?
(by history, or feels hot or temperature 37.5C and above)

Decide Malaria Risk:

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

Decide Dengue Risk:

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

Torniquet Test 1.3gp

74 Torniquet Test 2.3gp

 Tourniquet Test

 Inflate blood pressure

cuff to a point midway
between systolic and
diastolic pressure for 5
minutes

 Positive test: 20 or
more petechiae per 1
inch² (6.25 cm²)

75
 Classify DENGUE HEMORRHAGIC
FEVER

bleeding from the nose SEVERE DENGUE If skin petechiae or abdominal pain or
or gums HEMORRHAGIC vomiting or positive torniquet test are
Bleeding in the vomitus FEVER the only positive signs, give ORS
or stools If any other signs of bleeding are
Skin petechiae present, give fluids rapidly as in Plan C
Cold clammy extremities Treat the child to prevent low blood

Capillary refill more than sugar

Refer all chioldren URGENTLY to the
3 seconds
abdominal pain or hospital
DO NOT GIVE ASPIRIN
Vomiting or
Positive torniquet test

No signs of severe FEVER; DENGUE Advise mother when to return

dengue hemorrhagic fever HEMORRHAIC FEVER immediately
UNLIKELY Follow up in 2 days if fever persists or
child shows signs of bleeding.
76 DO NOT GIVE ASPIRIN
 Dengue Hemorrhagic Fever

A child with dengue hemorrhagic fever or

dengue shock syndrome may present
severely hypotensive with disseminated
intravascular coagulation (DIC), as this
severely ill PICU patient did. Crystalloid
fluid resuscitation and standard DIC
treatment are critical to the child's survival.
77
 Delayed capillary refill may be the first sign of intravascular volume
depletion. Hypotension usually is a late sign in children. This child's
capillary refill at 6 seconds was delayed well beyond a normal duration of
2 seconds.

78
 Session 4-d

Ear Problem

79
 Assess EAR PROBLEM
A child with ear problem is assessed for:

– Ear pain
– Ear discharge
If present, how long has the child has
had ear discharge
– Tender swelling behind the ear, a sign of
mastoiditis

80
 Assess EAR PROBLEM

Then Ask: Does the child have an ear problem?

If YES, ASK:
 Is there ear pain?
 Is there ear discharge? If yes, for how long?

LOOK and FEEL:

 Look for pus draining from the ear.
 Feel for tender swelling behind the ear.

Ask about ear problem in ALL sick children.

81
 Classify EAR PROBLEM
Tender swelling behind MASTOIDITIS Give the first dose of an appropriate
the ear antibiotics
Give first dose of Paracetamol for pain
Refer URGENTLY to hospital

Pus is seen draining ACUTE EAR Give an antibiotic for 5 days.

from the ear and INFECTION (Amoxicillin)*
discharge is reported for Give Paracetamol for pain.
less than 14 days, or Dry the ear by wicking.
Ear pain
Follow up in 5 days.

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

No ear pain and no pus NO EAR INFECTION No additional treatment.
is seen draining from the
82 ear.
*Oral amoxicillin is a better choice for the management of suppurative otitis media in countries where antimicrobial resistance to cotrimoxazole is high.
 TECHNICAL UPDATES:
Chronic Suppurative Otitis Media
TECHNICAL BASIS:
 aural toilet combined with antimicrobial
treatment is more effective than aural toilet
alone
 topical antibiotics were found to be better than
systemic antibiotics in resolving otorrhea and
eradicating middle ear bacteria
 topical quinolones were found to be better than
topical non-quinolones
– topical ofloxacin or ciprofloxacin vs

83
intramuscular gentamicin, topical gentamicin,
tobramycin or neomycin-polymyxin
 TECHNICAL UPDATES:
Acute Otitis Media

TECHNICAL BASIS:
 oral amoxicillin as the better choice for the
management of acute ear infection in
countries where antimicrobial resistance to
cotrimoxazole is high.

 reduces the risk of mastoiditis in

populations where it is more common
84
 TREAT THE CHILD:
Dry the Ear by Wicking

 Dry the ear at least 3 times daily.

– Roll a clean absorbent cotton or soft tissue
paper into a wick.
– Place the wick in the child’s ear.
– Remove the wick when wet.
– Replace the wick with a clean one and
repeat these steps until the ear is dry.
 Do not use a cotton-tipped applicator, a stick
85 or a flimsy paper that will fall apart in the ear.
 TREAT THE CHILD:
Dry the Ear by Wicking

 Wick the ear 3 times daily.

 Use this treatment for as many days as it
takes until the wick no longer gets wet when
put in the ear and no pus drains from the ear.
 Do not place anything (oil, foil or other
substances) in the ear between wicking
treatments.
 Do not allow the child to go into swimming.

86