INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

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

TREAT THE CHILD, continued

Assess, Classify and Identify Treatment

Check for General Danger Signs..................................... 2
Then Ask About Main Symptoms:

Give Extra Fluid for Diarrhoea

and Continue Feeding

Does the child have cough or difficult breathing? ................. 2

Does the child have diarrhoea? ............................................ 3
Does the child have sore throat? .......................................... 4
Does the child have an ear problem? ................................... 4
Does the child have fever? ................................................... 5
Classify malaria ............................................................. 5
Classify measles ............................................................ 5

Then Check for Malnutrition............................................. 6

Then Check for Anaemia ................................................ 6
Then Check the Child's Immunization Status ................. 6
Then Check the Child's Vitamin A Supplementation Status6
Then Check the Child's Deworming Status .................... 6
Assess Other Problems .................................................. 6

TREAT THE CHILD

Teach the Mother to Give Oral Drugs at Home
Oral Antibiotic ............................................................ 7
Oral Antimalarial ....................................................... 8
Paracetamol............................................................... 8
Multi Vitamin / Mineral Supplement ........................... 8
Vitamin A ................................................................... 8
Iron ............................................................................ 8
Medendazole ............................................................ 8
Teach the Mother to Treat
Local Infections at Home
Treat Eye Infection with
Chloramphenicol Eye Ointment................... 9
Dry the Ear by Wicking.............................................. 9
Treat Mouth Ulcers with Gentian Violet .................... 9
Soothe the Throat, Relieve the Cough with
a Safe Remedy............................................ 9
Give These Treatments in Clinic Only
Treat Convulsions with Diazepam .......................... 10
Intramuscular Antibiotic .......................................... 10
Quinine for Severe Malaria ..................................... 10
Treat Wheezing ...................................................... 11
Prevent Low Blood Sugar ...................................... 11
antibiotic for Streptococcal Sore Throat ................. 11

Plan A: Treat Diarrhoea at Home......................................... 12

Plan B: Treat Some Dehydration with ORS......................... 12
Plan C: Treat Severe Dehydration Quickly........................... 13

Immunize Every Sick Child, As Needed..........................13

Give Follow-up-Care
Pneumonia............................................................................14
No Pneumonia - Wheeze......................................................14
Dysentery..............................................................................14
Persistent Diarrhoea.............................................................15
Ear Infection..........................................................................15
Malaria (Low or High Malaria Endemic Area)........................15
Fever-Malaria Unlikely (Malaria non Endemic Area).............15
Fever No Malaria (No Malaria Risk)......................................15
Measles with Eye or Mouth Complications............................16
Measles.................................................................................16
Feeding Problems.................................................................16
Anaemia................................................................................16
Very Low Weight...................................................................16

COUNCEL THE MOTHER

Food
Assess the Child's Feeding...................................................17
Feeding Recommendations..................................................18
Counsel About Feeding Problems.........................................19

Fluid
Increase Fluid During Illness.................................................20

Ministry of Health
Pakistan

World Health
Ogranization

UNICEF

SICK YOUNG INFANT

AGE LESS THEN 2 MONTHS
ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
Assess, Classify and Identify Treatment
Check for Possible Infection ............................................................22
Check for Possible Neonatal Tetanus ..............................................22
Then Check for Jaundice .................................................................22
Then ask: Does the young infant have diarrhoea?...........................23
Then Check for Feeding Problem,Low Birth Weight,Low Weight.....24
Then Check the Young Infant's Immunization Status ......................25
Assess Other Problems....................................................................25

Treat the Young Infant and Counsel the Mother

Intramuscular Antibiotics .................................................................26
To Treat Diarrhoea, See TREAT THE CHILD Chart................... 12-13
Immunize Every Sick Young Infant ..................................................27
Traat Local Infections at Home ........................................................27
To Treat Eye Infection, See TREAT THE CHILD Chart .....................9
Correct Positioning and Attachment for Breastfeeding....................28
Home Care for Young Infant ............................................................28

Give Follow-up Care for the Sick Young Infant

Local Bacterial Infection...................................................................29
Diarrhoea.........................................................................................29
Feeding Problem..............................................................................30
Low Weight, Low Birth Weight.........................................................30
Thrush..............................................................................................30

Advise the Mother When to Return to

Health Worker ...............................................................20

RECORDING FORMS
SICK YOUNG INFANT ..........................................................31
SICK CHILD ...............................................................................33

Counsel the Mother About

Her Own Health.......................................................................21

WEIGHT FOR AGE CHART ...................................................... on back cover

When to Return

February 2010

ASSESS AND CLASSIFY THE SICK CHILD

AGE 2 MONTHS UP TO 5 YEARS
ASSESS

CLASSIFY

ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE

Determineif thisis an initiao
l r follow-up
visitforthisproblem.
- if follow-up
visit,use thefollow-up
instructiono
sn FOLLOW-UP chart.
- if initialvisit,assess the childas follows:

CHECK FOR GENERAL DANGER SIGNS

ASK:

See if the childis lethargicor

unconscious.
See if thechildis convulsingnow

THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?
IF YES, ASK:
For howlong?

If the child is:

USE ALL BOXES THAT MATCH THE

CHILD'S SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS.

SIGNS

CLASSIFY AS

LOOK, LISTEN:
Countthe breathsin one
minute.
Look forchestindrawing.
Look and listenforstridor
Look and listenforwheeze.

Fast breathing is:

2 monthsup
to 12 months

50 breathsper
minuteor more

12 monthsup
to 5 years

40 breathsper
minuteor more

CHILD
MUST BE
CALM

If wheezing and either fast

breathing or chest indrawing:
Give a trialof rapidactinginhaled
bronchodilatofrorup to threetimes15-20
minutesapart.Countthebreathsand
lookforchestindrawing
again,and
thenclassify
.

Classify
COUGH or
DIFFICULT
BREATHING

TREATMENT
(Urgent pre-referral treatments are in bold and italic print.)

LOOK:

Is thechildnotable to drinkor breastfeed?

Does the childvomiteverything?
Has the childhad convulsions?

IDENTIFY
TREATMENT

Any generaldangersign

Any general danger sign

or
Stridor in calm child

VERY
SEVERE DISEASE

Treat convulsions if present now.

Complete assessment immediately
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
Refer URGENTLY to hospital.

VERY SEVERE
DISEASE

Give first dose of an appropriate antibiotic.

Treat wheezing if present
Treat the child to prevent low blood sugar.
Refer URGENTLY to hospital.*
Give an appropriate Oral antibiotic for 5 days
Ifwheezing(evenif it disappearedafterrapidlyacting
bronchodilator)give oral bronchodilatorfor5 days

FastBreathingand/or
LowerChestIndrawing

PNEUMONIA

No signsofpneumonia
orveryseveredisease.
NO PNEUMONIA:
(if wheeze go directlyto treat COUGH OR COLD
wheezing)

Soothe thethroatand relievethecough witha safe remedy

Ifcoughingformore than 3 weeks or if havingrecurrent

wheezing,refer for assessment forTB or Asthma
Advise mother when to return immediately.
Follow-upin 3 days.
Ifwheezing(evenif it disappearedafterrapidly
actingbronchodilator)give a oralbronchodilato
r
for5 days.
Ifcoughingmorethan3 weeks or if having recurrent
wheezing refer for assessment forTB or Asthma.
Soothe thethroatand relievethecoughwith
a safe remedy.
Advise mother when to return immediately.
Followup in 3 days if not improving.

Does the child have diarrhoea?

IF YES, ASK:
For how long?
Is there bloodin the
stool?

LOOK AND FEEL:

Look at the child'sgeneral condition.
Is the child:

Two of the followingsigns:

for
DEHYDRATION

Lethargicor unconscious?
Restlessand irritable?

Lethargicor unconscious
Sunken eyes
Not able to drinkor drinkingpoorly
Skin pinchgoes back very slowly.

SEVERE
DEHYDRATION

Look for sunkeneyes.

Not able to drinkor drinkingpoorly?

Drinkingeagerly, thirsty?

Classify
DIARRHOEA

Pinch the skin of the abdomen.

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

Restless,irritable
Sunken eyes
Drinkseagerly, thirsty
Skin pinchgoes back slowly.

Not enoughsignsto classifyas some

or severe dehydration.

and if blood
in stool

NO
DEHYDRATION

No dehydration.

PERSISTENT
DIARRHOEA

Bloodin the stool.

If child also has any other severe classification:

- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding.
Advisemotherwhen to returnimmediatel.y
Follow-upin 2 days if not improving.

SEVERE
PERSISTENT
DIARRHOEA

* I f refer ral is n ot p ossib le, m an ag e t h e ch ild as d escr ib ed in In te g ra te d M a n a g e m e n t o f C h ild h o o d Illn e ss, Treat t h e Ch ild ,
An n ex: W h ere Refer ral I s Not Possib le, an d W HO g u id elin es for in p at ien t care.

ASSESS AND CLASSIFY

SOME
DEHYDRATION

Dehydrationpresent.

if diarrhoea is for
14 days or more

DANGERSIGNS, COUGH
DIARRHOEA

Give fluidand food for some dehydration(Plan B).

Give appropriatedose of Zinc Suspensionfor 10 days.

Two of the followingsigns:

Offer the childfluid.Is the child:

If childhas no other severe classification:

- Give fluidfor severe dehydration(Plan C).
- Give appropriatedose of Zinc Suspensionfor 10 days.
OR
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.

DYSENTERY

Give fluidand food to treat diarrhoeaat home (Plan A).

Give appropriatedose of Zinc Suspensionfor 10 days.
Advisemotherwhen to returnimmediatel.y
Follow-upin 2 days if not improving.

Treat dehydrationbefore referralunlessthe childhas any other

severe classification.
Give appropriatedose of Zinc Suspensionfor 10 days.
Refer to hospital.
Advisethe motheron feedinga childwho has
PERSISTENT DIARRHOEA.
Give appropriatedose of Zinc Suspensionfor 10 days.
Give multivitaminm
, ineralsupplementfor two weeks
Advisemotherwhen to returnimmediately
Follow-upin 5 days.
Treat for 3 days with an oral antibiotic recommended for
Shigella.
Give appropriatedose of Zinc Suspensionfor 10 days.
Advisemotherwhen to returnimmediately
Follow-upin 2 days.

Does the child have throat problem:

IF YES, ASK:
Does the child have sore
throat?
Is the child not able to drink?
Does the child have fever?

LOOK AND FEEL:

Fever (temperature 37.5o C or above)
Feel the front of the neck for tender
enlarged lymph nodes.
Look for red, enlarged tonsils
Look for exudate on the throat.

Classify
SORE THROAT

Sore throat AND not able to drink

THROAT ABSCESS

Give first does of an appropriate antibiotic.

Treat the child to prevent low blood sugar.
Give first dose of paracetamol for high fever or pain.
Refer URGENTLY to hospital.

STREPTOCOCCAL
SORE THROAT

Give benzathine penicillin or Amoxycillin.

Give paracetamol for high fever or pain.
Give safe, soothing remedy for sore throat.
Advice mother when to return immediately
Follow-up in 5 days if not improving

Fever and/ or sore throat AND

at least two of the following signs.
Tender, enlarged lymph nodes on
neck.
Red, enlarged tonsils.
White exudate on throat.
Not enough signs to classify as
throat abscess or streptococcal
sore throat.

VIRAL SORE
THROAT

Give safe, soothing remedy for sore throat.

Give paracetamol for high fever or pain.
Advice mother when to return immediately
Follow-up in 5 days, if not improving.

No signs present (with or without

fever)

NO THROAT
PROBLESM

No additional treatment.

Does the child have an ear problem?

IF YES, ASK:
Is there severe 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.

Classify
EAR PROBLEM

Tender swelling behind the ear.

Pus is seen draining from the ear

and/or discharge is reported for
less than 14 days, OR
Severe ear pain.

Discharge is reported for 14 or

more days (pus is seen or not seen
draining from the ear).
No ear pain and
No pus draining from the ear.

MASTOIDITIS

ACUTE EAR
INFECTION

CHRONIC EAR
INFECTION
NO EAR
INFECTION

Give first dose of an appropriate antibiotic.

Treat the child to prevent low blood sugar.
Give first dose of paracetamol for high fever or pain.
Refer URGENTLY to hospital.
Give an appropriate oral antibiotic for 5 days.
Give paracetamol for high fever or pain.
Dry the ear by wicking.
Advise mother when to return immediately.
Follow-up in 5 days.
Dry the ear by wicking if pus seen draining from the ear
Give appropriate topical quinolone ear drops for 2 weeks
Give paracetamol for high fever or pain
Refer to Ear Nose & Throat specialist.
Follow-up in 5 days.
If any other ear problem present give appropriate treatment or
refer to Ear Nose & Throat specialist.

Does the child have fever?

(by historyor feels hot or temperature37.5OC *** or above)

VERY SEVERE
FEBRILE
DISEASE

Take the slide (thick and thin) immediately before giving IM artimether or
quinine and send it with the patient.
Give first dose of IM artimether or quinine for suspected severe or
complicated malaria.
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Refer URGENTLY to hospital.

SUSPECTED
(CLINICAL)
MALARIA****

Confirm through RDTs or Microscopy if available.

Treat the child with appropriate antimalarial.
o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Advisemotherwhen to returnimmediatel.y
Follow-upin 3 days if fever persists.
If fever is presentevery day for more than 7 days, refer for assessment.

VERY SEVERE
FEBRILE
DISEASE

Take the slide (thick and thin) immediately before giving IM artimether or
quinine and send it with the patient.
Give first dose of IM artimether or quinine for suspected severe or
complicated malaria.
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
Refer URGENTLY to hospital.

IF YES:
A patient presenting with fever
(continuous or intermittent)
o
(temp=or >more then 37.5 C)
or history of fever with in the
last 3 days associated with
rigors, with no features of
other diseases and have one
or more of the following:
headache, nausea vomiting.

Malaria transmissionin the area = Yes

Transmissionseason = Yes
In non or low endemicareas travel
historywithinthe last 15-days to an area
where malaria transmissionoccurs= Yes
Yes_____ No_____
(if yes, use the treatmentinstructions
for the relevantmalaria risk area)

IF YES

CLASSIFY
FEVER
THEN ASK:

Look or feel for stiff neck.

If more than 7 days, has fever

been presentevery day?

Look for runnynose.

If the child has measles now

or within the last 3 months:

IF NO

Any general danger sign or

Stiff neck.

Look for signsof MEASLES

Generalizedrash of measles AND
One of these: cough,runnynose,
or red eyes.

Fever for more than two days.

AND
- Runny nose PRESENT or
- Measles PRESENT or
- Other cause of fever PRESENT

FEVER MALARIA
UNLIKELY

Look for mouthulcers.

Are they deep and extensive?
Look for pus drainingfrom the eye.
Look for cloudingof the cornea.

*
***
*****

Fever (by history or feels hot or

O
temperature 37.5 C*** or above).

LOOK AND FEEL

Fever For how long?

Has the childhad measles within

the last 3 months?

Any general danger sign or

Stiff neck.

ACT Artemesinine based Combination Therapy.

These temperatures are based on axillary temperature.
Other important complications of measles - pneumonia, stridor, diarrhoea,
ear infection, and malnutrition - are classified in other tables.

MEASLES NOW
OR WITH IN THE
LAST 3 MONTHS

Any general danger sign or

Clouding of cornea or
Deep or extensive mouth
ulcers.

SEVERE
COMPLICATED
MEASLES*****

Pus draining from the eye

or
Mouth ulcers.

MEASLES WITH
EYE AND / OR
MOUTH
COMPLICATIONS
****

Measles now or within the

last 3 months.

MEASLES

Give one dose of paracetamol in clinic for high fever (38.5o C or above).
Treat other cause of fever accordingly.
Advise mother when to return immediately.
Follow-up in 3 days if fever persists.
If fever is present every day for more than 7 days, refer for assessment.

Give first dose of an appropriate antibiotic.

o
Give one dose of paracetamol in clinic for high fever (38.5 C or above).
If clouding of the cornea or pus draining from the eye, apply
chloramphenicol eye ointment.
Treat the child to prevent low blood sugar.
Give Vitamin A.
Refer URGENTLY to hospital.
Give one dose of paracetamol in clinic for high fever (38.5o C or above).
If pus draining from the eye, treat eye infection with chloramphenicol eye
ointment. If mouth ulcers, treat with gentain violet
Give Vitamin A.
Advice mother when to return immediately.
Follow-up in 2 days.
Give one dose of paracetamol in clinic for high fever (38.5o C or above).
Give Vitamin A.
Advice mother when to return immediately.
Follow-up in 2 days if not improving or if measles now follow-up in 2 days

** RDT is Rapid Diagnostic Test.

**** All Suspected (Clinical) Malaria cases may be confirmed through RDTs or Microscopy for determining wether it is a Vivax or Falciparum Malaria and then treat appropriately
(Give Chloroquine for Vivax Malaria and ACT for Falciparum Malaria).

SORE THROAT EAR PROBLEM FEVER, MALARIA, MEASLES,

5

THEN CHECK FOR MALNUTRITION

Classify
NUTRITIONAL
STATUS

LOOK AND FEEL:

Visiblesevere wastingor
Oedema of both feet.

SEVERE
MALNUTRITION

VERY
LOW WEIGHT

Assessthe child'sfeedingand counselthe motheron feeding

accordingto the FOOD box on the COUNSEL THE MOTHER
chart.
Advisemotherwhen to returnimmediatel.y
If feedingproblem,follow-upin 5 days.
Follow-upin 30 days.

NOT VERY
LOW WEIGHT

If child is less than 2 years old, assess the child'sfeeding and

counselthe motheron feedingaccordingto the FOOD box on the
COUNSEL THE MOTHER chart.
Advisemotherwhento returnimmediatel.y
If feedingproblem,follow-upin 5 days.

Look for visiblesevere wasting.

Look and feel for oedema of both feet.

Very low weightfor age.

Determineweightfor age.

Not very low weightfor age AND

no other signsof malnutrition/.

THEN CHECK FOR ANAEMIA

LOOK

Classify
ANAEMIA

Look for palmar pallor. Is it:

Severe palmar pallor

SEVERE ANAEMIA

No palmar pallor

Treat the child to prevent low blood sugar

Refer URGENTLY to hospital.
Assess the child's feeding and counsel the mother on feeding
according to the FOOD box on the COUNSEL THE MOTHER
chart.
Give iron.
Give oral antimalarial if high malaria risk.
Deworm if child is two years or older & has not had a dose in
previoussixmonths,or has evidenceor worminfestation
Advisemotherwhento returnimmediatel.y

Severe palmar pallor?

Some palmar pallor?
Some palmar pallor

Give Vitamin A.
Treat the child to prevent low blood sugar
Refer URGENTLY to hospital.

ANAEMIA

NO ANAEMIA

No additionaltreatment.

THEN CHECK CHILD'S IMMUNIZATION, VITAMIN A SUPPLEMENTATION, AND DEWORMING STATUS

AGE

IMMUNIZA
TION
SCHEDULE:

Birth
6 weeks
10 weeks
14 weeks
9 months
15 months
of age

VACCINE
BCG
PENTAVLENT-1
PENTAVLENT-2
PENTAVLENT-3
MEASLES-1
MEASLES-2

OPV-0
OPV-1
OPV-2
OPV-3

VITAMINA
SUPPLEMENTATION
STATUS:

if childis 6 monthsor older and has

not receiveda dose in the last 6
months,give a dose of vitaminA in
the clinic

DEWORMING
STATUS:

ASSESS OTHER PROBLEMS

MAKE SURE CHILD WITHANY GENERAL DANGER SIGN IS REFERRED after firstdose of an appropriateantibioticand other urgenttreatments.
Exception: Rehydrationof the childaccordingto Plan C may resolvedanger signsso that referralis no longerneeded.

if childis 1 year or older and has

not receiveddewormingdose in
the last 6 months,give a dose of
Mebendazole500mg (singledose)

TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIEDON
THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE

ORAL DRUGS AT HOME

Give an Appropriate Oral Antibiotic

FOR PNEUMONIAAND ACUTE EAR INFECTION:

Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.

A MOXYCILLIN
C EPHRADINE

FIRST-LINE ANTIBIOTIC:
SECOND-LINE ANTIBIOTIC:

AMOXYCILLIN
Give two times
daily for 5 days

Determine the appropriate drugs and dosage for the child's age
or weight.

CEPHRADINE
Give three times daily for 5 days

SYRUP

SYRUP

SYRUP

SYRUP

125 mg
per 5 ml

250 mg
per 5 ml

125 mg
per 5 ml

250 mg
per 5 ml

2 months up to 12 months
(4 - <10 kg)

5 ml

2.5 ml

5 ml

2.5 ml

12 months up to 5 years
(10 - 19 kg)

10 ml

5 ml

10 ml

5 ml

AGE or WEIGHT

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.
FOR DYSENTERY AND CHOLERA:
Give recommendedantibioticfor 5 days.
C IPROFLOXCIN
FIRTS-LINE ANTIBIOTIC
SECOND-LINE DRUG
METRONIDAZOLE (REFE R TO FOLLOW UP B OX)
C IPROFLOXCIN
METRONIDAZOLE

Ask the mother to give the first dose to her child.

Explain carefully how to give the drug, then label and package
the drug.

AGE or WEIGHT

2 months up to 4 months
(4 - <6 kg)
4 months up to 12 months
(6 - <10 kg)
12 months up to 3 years
(10 -< 14 kg)
3 years up to 5 years
(14 - 19 kg)

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 course of treatment, even if the child gets better.
Check the mother's understanding before she leaves the clinic.

ANTIBIOTICS

MALNUTRITION and ANAEMIA

IMMUNIZATION STATUS

TREAT

Give two times daily for 3 days

TABLET
SYRUP
500 mg
250 mg per 5 ml

Give three times daily for 5 days

TABLET
SYRUP
200 mg
200 mg per 5 ml

1/5

1.5ml

1/3

3.5 ml

1/2

2.5 ml

1/2

5 ml

5 ml

TEACH THE MOTHER TO GIVE

ORAL DRUGS AT HOME

Give Zinc Suspension

Along with increased fluids and continued feeding, all children with diarrhoea should be given
Zinc Suspension for 10 days

Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.

Give an Oral Antimalarial

Up to 6 months

IF Artemesinine based Combination Therapy (ACT), which is Artesunate + SULFADOXINE - PYRIMETHAMINE:

Give the first dose as directly observed therapy in the clinic.
If the child vomits the drug with in 30 minutes of intake, repeat the dose.
IF CHLOROQUINE:
Explain to the mother that she should watch her child carefully for 30 minutes after giving a dose of
chloroquine. If the child vomits within 30 minutes, she should repeat the dose and return to the clinic for
additional tablets.
Explain that itching is a possible side effect of the drug, but is not dangerous.

Dose in mg (No. of tablets)

Artesunate (50 mg)

Sulfadoxine-Pyrimethamine (500/25mg)

AGE
DAY 1

DAY 2

DAY 3

5 months up to 12 months

25 ()

25 ()

25 ()

250 / 12.5 ()

1 year to 5 years

50 (1)

50 (1)

50 (1)

500/25 (1)

DAY 1

DAY 3

DAY 2

2.5ml

6 months up to 5 years

ACT (Artemesinine based Combination Therapy) ,

CHLOROQUINE

ANTIMALARIAL FOR FALCIPARUM MALARIA :

ANTIMALARIAL FOR VIVAX MALARIA:

Zinc Sulphate (20mg /5ml)

AGE

5ml

Give Multivitamin / Mineral Supplement

For persistent diarrhoea, give 5 ml (one tea spoon) once daily of multivitamin minerals for 2 weeks
each 5 ml contains
Vitamin-A:
8000 IU (800 micrograms)
Folate:
100 micrograms
Magnesium:
150 mg
Iron:
20 mg
Zinc:
20 mg
Copper:
2 mg

Give Vitamin A
Give two doses.
Give first dose in clinic.
Give mother one dose to give at home the next day.
VITAMINA CAPSULE S

AGE
200 000 IU

AGE or WEIGHT

TAB LE T
(150 mg base)
DAY 1 DAY 2

2 months up to 12 months
1/2
(4 - <10 kg)
12 months up to 3 years
1
(10 - <14 kg)
3 years up to 5 years
1 1/2
(14 - 19 kg)

6 months up to 12 months

TAB LE T
(100 mg base)

SYRUP
(50 mg base per 5 ml)

DAY 3

DAY 1

DAY 1

DAY 2

DAY 3

1/2

1/2

DAY 2 DAY 3
1

1/2

7.5 ml

7.5 ml

5.0 ml

1/2

1 1/2

1 1/2

1/2

15.0 ml 15.0 ml

1 1/2

1 1/2

5.0 ml

12 months up to 5 years

1/2 capsule

1 capsule

1 capsule

2 capsules

Give Iron
Give one dose daily for 14 days.
IRON/FOLATE TAB LE T
Ferrous sulfate 200 mg +
250 mcg Folate
(60 mg elemental iron)

AGE or WEIGHT

2 months up to 4 months (4 - <6 kg)

Give Paracetamol for High Fever (> 38.5 C) or

Sore Throat or Ear Pain

100 000 IU
50 000 IU

Up to 6 months

CHLOROQUINE
Give for 3 days

IRON SYRUP
Ferrous Fumarate 100 mg
per 5 ml
(20 mg elemental iron per ml)

1.00 ml

4 months up to 12 months (6 - <10 kg)

1.25 ml

12 months up to 3 years (10 - <14 kg)

1/2

2.00 ml

3 years up to 5 years (14 - 19 kg)

1/2

2.5 ml

Give paracetamol every 6 hours until high fever or sore throat or ear pain is relieved.

Give Mebendazole

PARAC ETAMOL
AGE or WEIGHT

TAB LE T (500 mg)

SYRUP (120 mg per 5 ml)

2.5 ml

2 months up to 6 months (4- <7 kg)

6 months up to 3 years (7- <14 kg)

1/4

5 ml

3 years up to 5 years (14 - 19 kg)

1/2

10 ml

F OR TREATMENT OF A NEMIA A ND IF S TOOLS POSITIVE FOR WORMS OR:

If the child is 1 year or older and has not had a dose in the previous 6 months or
If child is less then 12 months of age and has evidence of worm infestation, such cases should be referred
and managed on case by case basis.
G IVE MEB ENDAZOLE AS A SINGLE DOSE IN CL INIC.
AGE or WEIGHT

Above 12 months (10 - <19 kg)

MEBE NDAZOLE (500 mg)

AL BE NDAZOLE (200 mg)

TEACH THE MOTHER TO TREAT LOCAL INFECTIONSAT HOME

Explain to the motherwhatthe treatmentis and why it should be given.

Dry the Ear by Wicking

Describe the treatmentsteps listed in the appropriatebox.

Dry the ear at least 3 times daily.

Watch the motheras she doses the first treatmentin the clinic (exceptremedy
for cough or sore throat).

Roll clean absorbentclothor soft, strongtissuepaper into a wick.

Place the wick in the child'sear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps untilthe ear is dry.

Tell her how often to do the treatmentat home.

If needed for treatment at home, give mother the tube of chloramphenicol
ointmentor a small bottleof gentianviolet.

Treat Mouth Ulcers with Gentian Violet

Check the mother'sunderstandingbefore she leaves the clinic.

Treat the mouthulcerstwice daily.

Wash hands.
Wash the child'smouthwith clean soft clothwrappedaroundthe fingerand wet with salt water.
Paint the mouthwith half-strengthgentianviolet(0.25 %).
Wash hands again.

Treat Eye Infection with Chloramphenicol

Eye Ointment
Clean both eyes 3 times daily.

Soothe the Throat, Relieve the Cough

with a Safe Remedy

Wash hands
Ask childto close the eye.
Use clean clothand water to gentlywipe away pus.

Safe remediesto recommend:

Breast milk for exclusivelybreastfedinfant.
Honey with water : one tea spoonhoney in half cup of luke warm water.
Green tea, Soup etc.

Then apply Chloramphenicoelye ointmentin both eyes 3 times daily.

Ask the childto look up.
Squirta small amountof ointmenton the insideof the lower lid.
Wash hands again.

Harmfulremediesto discourage:
Cough syrupcontainingcodeine,antihistaminesa
, lcohol,atropineand expectorants.
Oral and nasal decongestants
Do not massage or bind the chest
Do not give opium,alcoholetc.

Treat untilrednessis gone.

Do not use other eye ointmentsor drops,or put anythingelse in the eye.
Return to clinicimmediatel,yif infectionbecomesworse.

ORAL DRUGS
LOCAL INFECTIONS

10

GIVE THESE TREATMENTS IN

CLINIC ONLY
Explain to the motherwhy the drug is given.
Determinethe dose appropriatefor the child's weight(or age).
Use a sterile needle and sterile syringe. Measure the dose accurately.
Give the drug as an Intramuscularinjection.

Give Intramuscular Antibiotics

FOR CHILDREN BEING REFERRED URGENTLY:

Give firstdose of IntramuscularAmpicillinand Gentamicinand refer childurgentlyto hospital.

IF REFERRAL IS NOT POSSIBLE:
Repeat the Ampicillinand Gentamicinor Chloramphenicoilnjectionin divideddoses every
12 hoursfor 7 and 5 days respectivel.y
Then change to an appropriateoral antibioticto complete10 days of treatment.
AMPICILLIN
Dose: 50 mg per kg
Add 3 ml sterilewater to vial containing
500 mg = 3.5ml at 143 mg/ml

GENTAMICIN
Dose: 7.5 mg per kg
1 vial = 40mg/2ml

CHLORAMPHENICOL
Dose: 40 mg per kg
Add 5.0 ml sterilewater to vial containing
1000 mg = 5.6 ml at 180 mg/ml

2 monthsup to 4 months (4 - < 6 kg)

1.5 ml = 214 mg

1.5 ml = 30 mg

1.0 ml = 180 mg

4 monthsup to 9 months (6 - < 8 kg)

2 ml = 286 mg

2.5 ml = 50 mg

1.5 ml = 270 mg

9 monthsup to 12 months (8 - < 10 kg)

3 ml = 429 mg

3 ml = 60 mg

2.0 ml = 360 mg

12 monthsup to 3 years (10 - < 14 kg)

3.5 ml = 500 mg

4 ml = 80 mg

2.5 ml = 450 mg

5 ml = 715 mg

5 ml = 100 mg

3.5 ml = 630 mg

AGE or WEIGHT

Ifchild cannot be referred,follow the instructions provided.

Treat the convulsing Child with

Diazepam
Manage the Airway:
Turn the childon the side to avoid aspiration
Do not insertany thingin the mouth
If lips and tongueare blue, open the mouthand make sure the airway is
clear.
If necessaryremove secretionsfrom the throatthrougha catheterinserted
throughthe nose
Give DiazepamRectally:
Draw up the dose of diazepam into a small syringe
Add 2-3 ml water Then remove the needle
Attacha piece of nasogastrictube to the syringeif possible.
Insert 4 to 5 cm of the tube or tip of the syringeinto the rectumand inject
the diazepam solution.
Hold buttockstogetherfor a few minutes
AGE or WEIGHT

Diazepam Given Rectally (10 mg=2ml)

Dose 0.5mg/kg

Less then 7 days

(If weight< 2.5 kg)

0.25 ml

Less then 7 days

(If weight> 2.5 kg)

0.5 ml

7 days up to 4 months(3 - < 6 kg)

3 years up to 5 years (14 - 19 kg)

Give Quinine HCL/ARTEMETHER INJ. for Severe Malaria

FOR CHILDREN BEING REFERRED WITHVERY SEVERE FEBRILE DISEASE:

Check whichquinine*/artemethefrormulationis availablein your clinic.

Give firstdose of intramuscularquinine/artemethea
r nd refer childurgentlyto hospital.
If low risk of malaria, do not give quinine/artemethetro a childless than 4 monthsof age.
IF REFERRAL IS NOT POSSIBLE:

Give firstdose of intramuscularquinine/artemether.

The childshouldremain lyingdown for one hour.
Repeat the quinineinjectionat 4 and 8 hourslater, and then every 12 hoursuntilthe childis able to take an oral
antimalarial.Do not continuequinineinjectionsfor more than 1 week.
In case of intramuscularartemetherinjectiongive 1.6mg/kg body weightevery day for 7 days.
If low risk of malaria, do not give quinineto a childless than 4 monthsof age.

AGE or WEIGHT

0.5 ml

INTRAMUSCULAR QUININE HCL (in 2 ml ampoules)

INTRAMUSCULAR ARTEMETHER
(1ml ampoules)

AMPOULES (300 mg/ml)

AMPOULES (40 & 80 mg/ml)

Draw up this dose of

undiluted quinine
in syringe

Add this
amount of
normal saline

Total diluted
solution to
administer (60 mg/ml)

40 mg/ml

80 mg/ml

0.2 ml

0.8 ml

1.0 ml

0.2 ml

0.1 ml

4 monthsup to 12 months (6- < 10 kg)

1 ml

12 monthsup to 3 years (10- < 14 kg)

1.25 ml

4 monthsup to 12 months (6 - < 10 kg)

0.3 ml

1.2 ml

1.5 ml

0.4 ml

0.2 ml

3 years up to 5 years (14 - 19 kg)

1.5 ml

12 monthsup to 2 years (10 - < 12 kg)

0.4 ml

1.6 ml

2.0 ml

0.5 ml

0.25 ml

2 years up to 3 years (12 - < 14 kg)

0.5 ml

2.0 ml

2.5 ml

0.5 ml

0.25 ml

3 years up to 5 years (14 - 19 kg)

0.6 ml

2.4 ml

3.0 ml

0.5 ml

0.3 ml

IfHigh Fever, Lower the Fever:

Sponge the childwith tap water
Give antipyretic
Treat the child to preventlow blood suger.

2 monthsup to 4 months (4 - < 6 kg)

* In Pakistan Quinine HCL is available in ampoules of 300mg / ml.

Treat the Child

to Prevent Low Blood Sugar

Treat Wheezing:
CHILDREN WITH WHEEZING AND GENERAL DANGER SIGN OR STRIDOR

If the child is able to breastfeed:

Give one dose of rapid acting bronchodilator and REFER immediately

Ask the mother to breastfeed the child.

CHILDREN WITH WHEEZING AND CHEST INDRAWING AND/OR FAST BREATHING

Give a rapid acting bronchodilator and reassess the child 30 minutes later

If the child is not able to breastfeed but is able to swallow:

IF:

THEN:

CHEST INDRAWING OR
FAST BREATHING PERSISTS

Treat for PNEUMONIA

Give oral salbutamol for 5 days.

Give expressed breast milk or a breast milk substitute.

If neither of these is available, give sugar water.
Give 30-50 ml of milk or sugar water before departure.

NO FAST BREATHING

Treat for NO PNEUMONIA COUGH OR COLD

Give oral salbutamol for 5 dats,

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 milk or sugar water by nasogastric tube.

CHILDREN WITH WHEEZING AND NO DANGER SIGNS, NO STRIDOR,NO CHEST

INDRAWING NO FAST BREATHING
Treat for no pneumonia: cough or cold
Give oral salbutamol for 5 days

RAPID ACTING BRONCHODILATOR

ORAL SALBUTAMOL
Three times daily for five days

AGE or WEIGHT

Nebulized Salbutamol
(5mg/ml)

0.25 ml

2 months up to 6 months
(4- <7 kg)

(plus 2.0 ml sterile water)

6 months up to 12 months
(7- <10 kg)

(plus 2.0 ml sterile water)

12 months up to 5 years
(10- 19 kg)

(plus 2.0 ml sterile water)

0.5 ml

0.5 ml

Metered dose inhaler

with spacer device
(100mcg/dose)

AGE or WEIGHT

TABLETS
(2 mg)

SYRUP
(2 mg/5ml)

Give An Antibiotic for Streptococcal

Sore Throat
Give a single dose of Intramuscular Benzathine Penicillin

1 puff

2 months up to 6 months
(4- <7 kg)

1/4

1.25 ml

Age

Benzathine Penicillin
(600,000 units add 5 ml sterile water)

1 to 2 puffs

6 months up to 12 months
(7- <10 kg)

1/2

2.5 ml

< 5 years

600,000 unit

2 to 3 puffs

12 months up to 5 years
(10- 19 kg)

5 ml

OR
Give Amoxycillin for 10 days (see "Appropriate Oral Antibiotic" box
for dose of Amoxycillin)

11
CONVULSIONS
INTRAMUSCULARANTIBIOTIC
INTRAMUSCULAR QUININE
WHEEZING, LOW BLOOD SUGAR
STREPTOCOSCAL SORE THROAT

12

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan A: Treat Diarrhoea at Home

Counsel the mother on the 3 Rules of Home Treatment:
Give Extra Fluid, Continue Feeding, When to Return

Plan B: Treat Some Dehydration with ORS

Give in clinic recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.

1. GIVE EXTRA FLUID (as much as the child will take)

TELL THE MOTHER:
- Breastfeed frequently and for longer time at each feed.
- If the child is exclusively breastfed, give ORS or clean water in addition to breast milk
- If the child is not exclusively breastfed, give one or more of the following: ORS solution,
food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water.
It is especially important to give ORS at home when:
- the child has been treated with Plan B or Plan C during this visit.
- the child cannot return to a clinic if the diarrhoea gets worse.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS, GIVE THE MOTHER 2 PACKETS
OF ORS (1000 ml) TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL
FLUID INTAKE:
Up to 2 years
50 to 100 ml after each loose stool
2 years or more
100 to 200 ml after each loose stool
Tell the mother to:
- Give frequent small sips from a cup.
- If the child vomits, wait 10 minutes. Then continue, but more slowly.
- Continue giving extra fluid until the diarrhoea stops.
GIVE ZINC SUSPENSION
- Along with increased fluids and continued feeding, all children with diarrhoea should
be given Zinc Suspension for 10 days
AGE
Up to 6 months
6 months up to 5 years

Zinc Suspension (20mg / 5ml)

2.5ml
5ml

AGE*

Up to 4 months

4 months up to
12 months

12 months up to
2 years

2 yearsup to
5 years

WEIGHT

< 6 kg

6 - < 10 kg

10 - < 12 kg

12 - 19 kg

In ml

200 - 400

400 - 700

700 - 900

900 - 1400

* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can
also be caluclated by multiplying the child's weight (in kg) times 75.

If the child wants more ORS than shown, give more.

For infants under 6 months who are not breastfed, also give
100-200 ml clean water during this period.
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more slowly.
Continue breastfeeding whenever the child wants.
AFTER 4 HOURS:
Reassess the child and classify the child for dehydration.
Select the appropriate plan to continue treatment.
Begin feeding the child in clinic.
IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
Show her how to prepare ORS solution at home.
Show her how much ORS to give to finish 4-hour treatment at home.
Give her enough ORS packets to complete rehydration. Also give her 2 packets
as recommended in Plan A.
Explain the 3 Rules of Home Treatment:
GIVE ZINC SUSPENSION
- Along with increased fluids and continued feeding, all children with diarrhoea should
be given Zinc Suspension for 10 days
AGE
Up to 6 months
6 months up to 5 years

2. CONTINUE FEEDING
3. WHEN TO RETURN

See COUNSEL THE MOTHER chart

1. GIVE EXTRA FLUID

2. CONTINUE FEEDING
3. WHEN TO RETURN

Zinc Suspension (20mg / 5ml)

2.5ml
5ml

See Plan A for recommended fluids

and
See COUNSEL THE MOTHER chart

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD 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?

Start IV fluidimmediatel.yIf the childcan drink,give ORS by mouthwhile the drip is

set up. Give 100 ml/kg Ringer'sLactate Solution(or, if not available,normalsaline),
dividedas follows:
YES

Is IV treatment
availablenearby
(within30 minutes)?

AGE

NO

Are you trainedto

use a naso-gastric
(NG) tube for
rehydration?
NO

Can the childdrink?

First give
30 ml/kg in:

Then give
70 ml/kg in:

1 hour*

5 hours

30 minutes*

2 1/2 hours

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the child every 1- 2 hours. If hydrationstatusis 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 hoursand a child after 3 hours.Classifydehydration. Then
choosethe appropriateplan (A, B, or C) to continue treatment.

YES

YES

Refer URGENTLY to hospital for IV treatment.

If the child can drink, provide the motherwith ORS solution and show her how to give
frequentsips during the trip.

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 vomitingor increasing abdominal distension,give the fluid move
slowly.
- If hydrationstatus is not improving after 3 hours, send the childfor IV therapy.
After 6 hours,reassess the child. Classify dehydration.Then choose the appropriate
plan (A, B, or C) to continue treatment.

NO

Refer URGENTLY to
hospitalfor IV or NG
treatment

AGE
Up to 6 months

Infants
(under 12 months)
Children
(12 monthsup to 5 years)

NO

GIVE ZINC SUSPENSION

- Along with increased fluids and continued feeding, all children with diarrhoea should
be given Zinc Suspension for 10 days

NOTE:
If possible, observe the childat least 6 hours after rehydrationto be sure the mother
can maintain hydrationgivingthe childORS solution by mouth.

13

PLAN A, PLAN B
PLAN C

6 monthsup to 5 years

Zinc Suspension (20mg / 5ml)

2.5ml
5ml

GIVE VITAMIN-A SUPPLEMENTATION, AS

NEEDED

GIVE MEBENDAZOLE, AS NEEDED

IMMUNIZE EVERY SICK CHILD, AS NEEDED

14

NO PNEUMONIA: COUGH OR COLD- WHEEZE

GIVE FOLLOW-UP CARE

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.

Check the childfor general danger signs.

Assessthe childfor coughor difficultbreathing.

See ASSESS & CLASSIFY chart.

Treatment:
If any general danger sign or stridor -, treat as VERY SEVERE DISEASE, give a dose of
pre-referralintramuscularantibioticsI.f wheezingnow, give one dose of rapid acting
bronchodilatoa
r nd refer URGENTLY to hospital.

If fast breathing or chest indrawing, with wheeze also give a dose of rapid actingbronchodilator
and reassessaccordingto "treatwheezing"box.
If child is wheezing but has no general danger signs, no stridor, no chest indrawing or no
fast breathing
- if this is the firstepisodeof wheezingor if the childhad previousepisodesbut has not been
referred,give salbutamoland refer for assessment.
- If the childhas already been referredfor a previousepisodeof wheezingadvise the motherto
continuewith treatmentprescribedby the referralhospital.Advisethe motherto returnif the
child'sbreathingbecomesmore difficult.If this childreturnsbecause conditionhas worsened,
refer URGENTLY to hospitalfor furthertreatment.
If had wheeze and now no wheezing- complete5 days of oral salbutamol.

PNEUMONIA
After 3 days:
Check the childfor general danger signs.
Assessthe childfor coughor difficultbreathing.
Ask:
- Is the childbreathingslower?
- Is there less fever?
- Is the childeating better?
- Is the childwheezing?

After 3 days:

See ASSESS & CLASSIFY chart.

Treatment:

If child has chest indrawing or has fast breathing

and with or without wheeze, give a dose of intramusculaA
r mpicillinand Gentamicin.
If wheezingalso give three cyclesof rapidlyactingbronchodilato.r
If breathing rate, fever and eating are the same, with or without wheeze, change to the secondline antibioticand advise the motherto returnin 3 days. If wheezingnow or had wheezingon first
visitgive/continueoral salbutamol.(If this childhad measles withinthe last 3 months,refer).
If breathing rate slower, less fever, or eating better, with or without wheezing, completethe 5
days of antibiotic.If wheezingnow or had wheezingon firstvisitgive/continueoral salbutamolfor
five days.
If child had no wheeze on the first visit but has wheeze now and had no general danger signs
or stridor, or chest indrawing or fast breathing, treat as in "No Pneumonia:Cough or Cold Wheeze" box.

DYSENTERY
After 2 days:
Assessthe childfor diarrhoea. > See ASSESS & CLASSIFY chart.
Ask:
- Are there fewer stools?
- Is there less bloodin the stool?
- Is there less fever?
- Is there less abdominalpain?
- Is the childeating better?
Treatment:
If the childis dehydrated, treat dehydration.
If numberof stools,amountof bloodin stools,fever, abdominalpain, or eating is worse-referto
hospital.
If number of stools, amount of blood in stools, fever, abdominal pain, or eating is the same:
Add metronidazole.Give for 5 days.Advisethe motherto returnin 2 days.
Exceptions - if the child:
- is less than 12 monthsold, or
- was dehydratedon the firstvisit,or
Refer to hospital.
- had measles withinthe last 3 months

If fewer stools, less blood in the stools, less fever, less abdominal pain, and
eating better, continuegivingthe same antibioticuntilfinished.

GIVE FOLLOW-UP CARE

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.

PERSISTENT DIARRHOEA
After 5 days:
Ask:
-

MALARIA (Low or High Malaria Endemic Area)

If fever persistsafter 3 days, or returnsimmediatelyif the same symptomsreappear within28 days:
Do a full reassessmentof the child. Assessfor other causes of fever. > See ASSESS & CLASSIFY chart.

Has the diarrhoeastopped?

How many loose stoolsis the childhavingper day?

Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per
day), do a full reassessmentof the child.Give any treatmentneeded. Then refer to
hospital.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the
motherto followthe usual feedingrecommendationsfor the child'sage.
Tell the motherto continuegivingmultivitaminmineralssupplementfor two weeks.

Treatment:
If the childhas any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.

EAR INFEC TION

FEVER-MALARIA UNLIKELY (Malaria non endemic Area)

After 5 days:
Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child'stemperature.

If fever persistsafter 2 days:

Do a full reassessmentof the child. Assessfor other causes of fever. > See ASSESS & CLASSIFY chart.

Treatment:
If there is tender swelling behind the ear or high fever (38.5oC or above), refer
URGENTLY to hospital.
Acute ear infection: if ear pain or discharge persists,treat for 5 more days with the
same antibiotic.Continuewickingto dry the ear. Follow-upin 5 days.
Chronic ear infection: Check that the motheris wickingthe ear correctl,yencourageher
to continue.Check for complianceof treatmentprescribedby the Ear Nose & Throat
specialist
If no ear pain or discharge, praise the motherfor her carefultreatment.If she has not
yet finishedthe 5 days of antibiotic,tell her to use all of it before stopping.

If the childhas any cause of fever other than malaria, providetreatment.

If malaria is the only apparent cause of fever:

- Treat with the second-lineoral antimalarial.(If no second-lineantimalarialis available,refer to

hospital.)Advisethe motherto returnagain in 2 days if the fever persists
- If fever has been presentfor 7 days, refer for assessment.

Treatment:
If the childhas any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.

If the childhas any cause of fever other than malaria, providetreatment.

If malaria is the only apparent cause of fever:

- Treat with the first-lineoral antimalarial.Advisethe motherto returnagain in 2 days if the fever persists.
- If fever has been presentfor 7 days, refer for assessment.

15

PNEUMONIA, NO PNEUMONA, WHEEZE DYSENTERY, PERSISTENT

DIARRHOEA, EAR INFECTION, MALARIA, FEVER,

FOLLOW-UP

16

GIVE FOLLOW-UP CARE

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.

FEEDING PROBLEM
After 5 days:
Reassess feeding. > See questions at the top of the COUNSEL Chart
Ask about any feedingproblemsfoundon the initialvisit.
Counselthe motherabout any new or continuingfeedingproblems.If you counselthe
motherto make significantchangesin feeding,ask her to bringthe childback again.

MEASLES WITHEYE OR MOUTH COMPLICATIONS

If the childis very low weightfor age, ask the motherto return30 days after the initial
visitto measure the child'sweightgain.

After 2 days:
Look for red eyes and pus drainingfrom the eyes.
Look at mouthulcers.
Smell the mouth.
Treatmentfor Eye Infection:

If pus is draining from the eye, ask the motherto describehow she has treated the eye infection.
If treatmenthas been correct,refer to hospital.If treatmenthas not been correct,teach mothercorrect
treatment.
If the pus is gone but redness remains, continuethe treatment.
If no pus or redness, stop the treatment.
Treatmentfor Mouth Ulcers:

If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
If mouth ulcers are the same or better, continueusinghalf-strengthgentianviolet(0.25 %) for a
total of 5 days.

MEASLES

ANAEMIA
After 14 days:
Give iron.Advisemotherto returnin 14 days for more iron.

Continuegivingiron every 14 days for 2 months.

If the childhas palmar pallorafter 2 months,refer for assessment.

VERY LOW WEIGHT

After 30 days:
Weigh the childand determineif the childis stillvery low weightfor age.
Reassess feeding. > See questions at the top of the COUNSEL chart
Treatment:
If the childis no longer very low weight for age, praise the motherand encourageher
to continue.
If the childis stillvery low weight for age, counselthe motherabout any feeding
problemfound.Ask the motherto returnagain in one month.Continueto see the child
monthlyuntilthe childis feedingwell and gainingweightregularlyor is no longervery
low weightfor age.

After 2 days:
Do a full reassessmentof the child.> See ASSESS & CLASSIFY Chart.

Exception:
If you do not thinkthat feedingwill improve,or if the childhas lost weight, refer the
child.

Treatment:

If general danger sign or clouding of the corrnea or deep extensive mouth ulcers or pneumonia,
treat as SEVERE COMPLICATED MEASLES.
If pus draining from the eye or mouth ulcers, treat as MEASLES WITH EYE OR MOUTH
COMPLICATIONS.

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE

INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER FOR THE
NEXT FOLLOW-UP VISIT

If none of the above signs, advise the motherwhen to returnimmediatel.y

Followup in two days if not improving.
If the childreceivedalready the dose of vitaminA in the previousvisit,do not repeat.

ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.

(SEE COUNSEL CHART.)

COUNSEL THE MOTHER

FOOD
Assess the Child's Feeding
Ask questionsaboutthe child'susualfeedingand feedingduringthisillness,Comparethe mother'sanswersto the Feeding Recommendations
forthechild'sage in thebox below.

ASK
Do you breastfeedyourchild?
- Howmanytimesduringtheday?
- Do you also breastfeedduringthenight?
Does thechildtakeany otherfoodor fluids?
- Whatfoodor fluids?
- Howmanytimesper day?
- Whatdo you use to feedthechild?
- Ifverylowweightforage: Howlargeare servings?
Duringthisillness,has thechild'sfeedingchanged?Ifyes, how?

17

MEASELS
FEEDING PROBLEM
PALLOR, VERY LOW WEIGHT

ASSESS FEEDING
COUNSEL

18

Feeding Recommendations During Sickness and Health

Up to 6 Months
of Age

Breast feed as often as the child

wants, day and night,at least 8 times
in 24 hours.
Breast feed at least for 10 minuteson
each breast every time
Do not give other foods
water.
Do not use bottlesor pacifiers

6 Months
up to
12 Months

Breastfeedas often as the childwants.

Give adequate servingsof:
Khichri*,Rice (Bhatt)* with seasonal
vegetables(Carrot, Spinach,Potatoes
etc.), or Minced Meat. Rice Kheer, Suji
ka Halwa or Kheer*, Dalia*,
Vermicellis*, Choori*,Mashed Potato
or vegetables*,Egg, Banana and
othersSeasonal fruits.
(upto 9 monthsfood shouldbe
mashed)
- 3 times per day if breastfed;
- 5 times per day if not breastfed.
- Each servingshouldbe equivalentto
1/2-3/4 or a cup.

12 Months
up to
2 Years

Breastfeedas often as the child

wants.
Give adequate servingsof:
Roti, Parattha, Khichrior Rice, Curry,
Minced Meat, Chicken,Egg,
Seasonal Vegetables,Choori,
Vermicellis, and/or any foodslisted
for 6-12 monthschild
Give food at least 3 times per day
AND
Give also snacks2 times per day
between meals such as seasonalfruit
(Banana,Apple, Mango, Orange etc.)
Biscuit,home made Pakora or
Samosa, Lassi,Yoghurt,Bread with
Egg, Halwa etc.
OR
Family foods5 times per day.

2 Years
and Older

Give familyfoodsat 3 meals each

day. Also, twice daily, give nutritious
food between meals, such as:
Seasonal fruit(Banana,Apple,
Mango, Orange etc.) Biscuit,Rusk,
Chips, Pakora, Samosa, Lassi,
Yoghurt,Bread with Eggs, Halwa etc.

Wash your hands before preparing the child's food and use clean cooking utensils.
* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil / Ghee / Butter); meat, fish, eggs, or pulses; and fruits and vegetables.
Feeding RecommendationsFor a Child Who Has PERSISTENT DIARRHOEA
If stillbreastfeeding,give more frequent,longerbreastfeeds,day and night.
If takingother milk:
- replace with increasedbreastfeedingOR
- replace with fermentedmilk products,such as yoghurtOR
- replace half the milk with nutrient-richsemisolidfood.
For other foods,followfeedingrecommendationsfor the child'sage.

Counsel the MotherAbout Feeding Problems

If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:

If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.)
As needed, show the mother correct positioning and attachment for breastfeeding.
If the child is less than 6 months old and is taking other milk or foods OR:

If the mother thinks she does not have enough milk:

- Buildmother'sconfidencethat she can produceall the breast milk that the childneeds.
- Suggestgivingmore frequent,longerbreastfeedsday or night,and graduallyreducingother milk or foods.
If other milk needs to be continued,counselthe motherto:
-

Breastfeedas much as possible,includingat night.

Make sure that other milk is a locallyappropriatebreast milk substitute.
Make sure other milk is correctlyand hygienicallypreparedand given in adequate amounts.
Prepare only an amountof milk whichchildcan consumewithinone hour. If their is some left over milk, discard.

If the mother is using a bottle to feed the child:

- Recommendsubstitutinga cup for bottle.
- Show the motherhow to feed the childwith a cup.
If the child is being fed too small amounts
- Recommendincreasingthe frequencyand portionsize for each meal day by day. untilrecommendedportionsize achieved.
- Recommendthat the motherencouragesthe childto eat more.
If the child is not being fed actively, counsel the mother to:
-

Sit with the childand encourageeating.

Give the childan adequate servingin a separate plate or bowl.
Observe what the childlikes and considerthese for preparingthe food.(considerenergy rich, high densityfood).

If the child is not feeding well during illness, counsel the mother to:
- Breastfeedmore frequentlyand for longerif possible.
- Use soft, varied, appetizing,favoritefoodsto encouragethe childto eat as much as possible,and offer frequentsmall feedings.
- Add oil/ghee/butterto prepare foods.Also give green leafy and yellowvegetablesand fruitsto the child.
- Clear a blockednose if it interfereswith feeding.
- Expect that appetitewill improveas childgets better.
- Give expressedbreast milk if necessary.
Follow-up any feeding problem in 5 days.
Advise mother not to give her child, harmful, contaminated and unhygienicaly prepared junk foods from vendors e.g. kulfi, ice cream, sodas/
sherbet/drinks etc., paparrs, pakoras, samosas, nimkos etc.

19

FEEDING RECOMMENDATION
FEEDING PROBLEMS

20

FLUID AND FOOD

Advise the Mother to Increase Fluid and Continue Feeding During Illness
FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed.
Increase fluid. For example, give soup, rice water, yoghurt drinks or clean water.
Give small frequent meals of energy rich food.

FOR CHILD WITH DIARRHOEA:

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

WHEN TO RETURN
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT
Advise the mother to come for follow-up at the earliest time listed for
thechild's
childs problems.
problems.
he
If the child has:

Return for
follow-up in:

PNEUMONIA
NO PNEUMONIA WITH WHEEZE if no improvement
MALARIA, if fever persists
FEVER-MALARIA UNLIKELY, if fever persists

3 days

DYSENTERY
MEASLES WITH EYE OR MOUTH COMPLICATIONS
MEASLES (if measles now)

3 days
2 days

WHEN TO RETURN IMMEDIATELY

PERSISTENT DIARRHOEA
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving

5 days

ANAEMIA

14 days

VERY LOW WEIGHT FOR AGE

30 days

NEXT WELL-CHILD VISIT

Advise mother when to return for next immunization according to
immunization schedule.

Advise mother to return immediately if the child has any of these signs:
Any sick child

Not able to drink or breastfeed

Becomes sicker
Develops a fever

If child has NO PNEUMONIA:

COUGH OR COLD, also return if:

Chest indrawing
Fast breathing
Difficult breathing

If child has Diarrhoea, also return if:

Blood in stool
Drinking poorly

Counsel the MotherAbout 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 for help.
Advise her to eat well to keep up her own strength and health.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
- Family planning
- Counseling on STD and AIDS prevention

21

FLUID
WHEN TO RETURN
MOTHER'S HEALTH

22

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

AGE LESS THEN 2 MONTHS
ASSESS

CLASSIFY

IDENTIFYTREATMENT

ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE

Determineif this is an initialor follow-upvisitfor this problem.
- if follow-upvisit,use the follow-upinstructionson the FOLLOW-UP chart.
- if initialvisit,assess the younginfantas follows:

USE ALL BOXES THAT MATCH INFANT'S SYMPTOMS

AND PROBLEMS TO CLASSIFY THE ILLNESS.

CHECK FOR POSSIBLE INFECTION

SIGNS

ASK:
Has the infanthad
convulsions(fits)?
Is the infanthaving
difficultyin feeding?

TREATMENT
(Urgentpre-referraltreatmentsare in bold

Any one of the following signs

LOOK, LISTEN, FEEL:

Count the breaths in one minute.
Repeat the count if elevated.
Look for severe chest indrawing.
Look and listen for grunting.

CLASSIFY AS

YOUNG
INFANT
MUST BE
CALM

Classify
ALL
YOUNG
INFANTS

Measure axillary temperature.

Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.

ConvulsionsOR
Not feedingwell OR
Fast breathing(60 breathsper minuteor more) OR
Severe chest indrawingOR
GruntingOR
Fever (37.5oC* or above) OR
low body temperature(less than 35.5oC*) OR
Movementsonly when stimulatedor
no movementseven when stimulated

Umbilicusred or drainingpus
Skin pustules

Look at the young infants movements.

Does the infant move only when stimulated?
Does the infant not move even when stimulated?

VERY
SEVERE
DISEASE

LOCAL
BACTERIAL
INFECTION

Give first dose of Intramuscular

antibiotics.
Treat to prevent low blood sugar.
Advise mother how to keep the infant
warm on the way to the hospital.
Refer URGENTLY to hospital.**

Give an appropriateoral antibiotic.

Teach the motherto treat local infections
at home.
Advisemotherto give home care for the
younginfant.
Follow-upin 2 days.

None of the signsof very severe disease

or bacterialinfection
local

BACTERIAL
INFECTION
UNLIKELY

Advisemotherto give home care for

younginfant.

THEN CHECK FOR JAUNDICE

ASK

LOOK, LISTEN, FEEL:

Look for jaundice
Look at the younginfantsplams and soles.
Are they yellow?

Classify
JAUNDICE

Any jaundiceif age less than 24 hoursor

Yellow palms and soles at any age

SEVERE
JAUNDICE

Jaundiceappearingafter 24 hoursof age and

Palms and soles not yellow
No jaundice

JAUNDICE

NO JAUNDICE

Treat to prevent low blood sugar.

Refer URGENTLY to hospital.
Advise the mother how to keep the
young infant warm on the way to the
hospital.
Advisethe motherto give home care
for the younginfant
Advisemotherto returnimmediatelyif
palms and soles appear yellow.
Follow-upin 1 day.
Advisethe motherto give home care for
the younginfant.

THEN ASK:
Does the young infanthave diarrhoea?

IF YES, ASK

LOOK AND FEEL:

For how long ?

Look at the younginfants general condition.

Is there blood
in the stool?

Does the infantmove only when stimulated?

Does the infantnot move even when stimulated?

Movement only when

stimulaetd or no movement
even when stimulated
Sunken eyes
Skin pinch goes back very
slowly.

SEVERE
DEHYDRATION

for
DEHYDRATION

Two of the following signs:

Is the infantrestlessand irritable?

Restless, irritable
Sunken eyes
Skin pinch goes back slowly.

Look for sunkeneyes.

Pinch the skin of the abdomen.
Does it go back:

If infantdoes not have VERY SEVERE

DISEASE:
- Give fluidfor severe dehydration
(Plan C).
OR

Two of the followingsigns:

Classify
DIARRHOEA

SOME
DEHYDRATION

Very slowly(longerthan 2 seconds)?

Slowly?

Not enough signs to

classify as some or
severe dehydration.

Diarrhoea lasting 14
days or more.

and if diarrhoea
14 days or more

and if blood in
stool

If infant also has VERY SEVERE

DISEASE:
- Refer URGENTLY to hospital with
mother giving frequent sips of ORS
on the way.
Advise the mother to continue
breastfeeding.

Give fluid and food for some dehydration

(Plan B).
If infant also has VERY SEVERE
DISEASE:
- Refer URGENTLY to hospital
with mother giving frequent sips of
ORS on the way.
- Advise mother to continue
breastfeeding.
Advisemotherwhen to return
immediately.
Follow-up in 2 days if not improving.

Give fluids to treat diarrhoea at home

(Plan A).
NO DEHYDRATION Advisemotherwhen to return
immediately.
Follow-up in 2 days if not improving.

SEVERE
PERSISTENT
DIARRHOEA

Bloodin the stool.

BLOOD INSTOOL

* These thresholds are based on axillary temperature.

** If referral is not possible, see Integrated Management of Childhood Illness, Treat the Child, Annex: "Where Referral is Not Possible."

23

BACTERIALINFECTION
DIARRHOEA
ASSESS AND CLASSIFY

If the young infant is dehydrated, treat

dehydration before referral unless the
infanthas also VERY SEVERE
DISEASE OR SEVERE JAUNDICE
Refer to hospital.

Treat to prevent low blood sugar

Advise mother how to keep the infant
warm on the way to hospital
Refer URGENTLY to hospital

24

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT:

ASK:

LOOK, LISTEN, FEEL:

Is the infant breastfeed? If yes,

how many times in 24 hours?

Determine weight for age.

Not well attached to breast or

not suckling effectively,
OR

If not well attached or not suckling effectively,

teach correct positioning and attachment.
If not able to attach well immediately, teach the
mother to express breast milk and feed by a cup.

Less than 8 breastfeeds

in 24 hours,
OR

Does the infant usually receive

any other foods or drinks?
If yes, how often?

If an infant has no indications to refer urgently to hospital:

ASSESS BREASTFEEDING:
Has the infant
breastfeeding
previous hour?

Classify
FEEDING

If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the
mother if she can wait and tell you when the infant is
willing to feed again).

If breastfeeding less than 8 times in 24 hours,

advise to increase frequency of feeding. Advise
her to breastfeed as often and for as long as the
infant wants, day and night.

Receive other foods or drinks,

OR
Low weight for age,
OR
Thrush (Ulcers or white patches
in month)

FEEDING
PROBLEM
OR
LOW
WEIGHT

Advise the mother how to feed and keep the low

weight young infant warm at home.

Is the infant able to attache well?

not well attached
good attachment

If thrush, teach the mother to treat thrush at home.

TO CHECK ATTACHMENT, LOOK FOR:

- More areola visible above than below the mouth
- Mouth wide open
- Lower lip turned outward
- Chin touching breast
(All of these signs should be present if the attachment is good.)
Is the infant suckling effectively (that is, slow deep
sucks, sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with
breastfeeding.
Look for ulcers or white patches in the mouth
(thrush).

If receiving other foods or drinks, counsel mother

about breastfeeding more, reducing other foods
or drinks, and using a cup.
If not breastfeeding at all:
- Refer for breastfeeding counseling and
possible relactation
- Advise about correctly preparing breastmilk
substitutes and using a cup.

Advise mother to give home care for the young

infant.
Fellow-up any feeding problems or thrush in 2
days.

Not low weight and no other

signs of inadequate feeding.

NO FEEDING
PROBLEM

Advise mother to give home care for the

young infant.
Praise the mother for feeding the infant well.

THEN CHECK THE YOUNG INFANT'S IMMUNIZA

TION STATUS:
IMMUNIZA
TIONSCHEDULE:

AGE

VACCINE

Birth
6 weeks

BCG
PENTAVLENT-1

ASSESS OTHER PROBLEMS

25

CHECK FOR FEEDING PROBLEMS

OPV-0
OPV-1

26

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

TO TREAT CONVULSIONS, SEE TREAT THE CHILD CHART

Give First Dose of Intramuscular Antibiotics
Give first dose of Ampicillin or benzylpenicillin intramuscularly.
Give first dose of Gentamicin intramuscularly.

WEIGHT

AMPICILLIN
Dose: 50 mg per kg
To a vial of 250 mg

BENZYLPENICILLIN
Dose: 50.000 mg per kg
To a vial of 600 mg
(1000000 units)

Add 1.3 ml sterile water =

250 mg / 1.5 ml

Add 1.6 ml sterile water =

500000 units / ml

GENTAMICIN
Undiluted 2 ml vial
containing
20 mg = 2 ml at 10 mg/ml

OR

Add 6 ml sterile water to 2 ml

vial containing
80 mg* = 8 ml at 10 mg/ml

Age < 7 days

Dose: 5 mg per kg

Age > 7 days

Dose: 7.5 mg per kg

1 - 1.5 kg

0.4 ml

0.2 ml

0.6 ml

0.9 ml

1.5 - 2 kg

0.5 ml

0.2 ml

0.9 ml

1.3 ml

2 - 2.5 kg

0.7 ml

0.3 ml

1.1 ml

1.7 ml

2.5 - 3 kg

0.8 ml

0.5 ml

1.4 ml

2.0 ml

3 - 3.5 kg

1.0 ml

0.5 ml

1.6 ml

2.4 ml

3.5 - 4 kg

1.1 ml

0.6 ml

1.9 ml

2.8 ml

4 - 4.5 kg

1.3 ml

0.7 ml

2.1 ml

3.2 ml

* Avoid using undiluted 40 mg/ml gentamicin. The dose is 1/4 of that listed.

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, give ampicillin
and gentamicin for at least 5 days. Give ampicillin every 2 times daily to infants less than one week of age and 3 times daily
to infants one week or older. Give gentamicin once daily.

Give an Appropriate Oral Antibiotic for local infection

AMOXYCILLIN
CEPHRADINE

FIRST-LINE ANTIBIOTIC:
SECOND-LINE ANTIBIOTIC:
AGE or WEIGHT

AMOXYCILLIN SYRUP
(125 mg / 5 ml)

Give two times daily for 5 days

CEPHRADINE SYRUP
(125 mg / 5 ml)
Give three times daily for 5 days

Birth up to 1 month
( <3 kg)

1.25 ml

2.5 ml

1 month up to 2 months
(3 - 4 kg)

2.5 ml

5 ml

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

To Treat Diarrhoea, See TREAT THE CHILD Chart.

Immunize Every Sick Young Infant, as Needed.

Teach the Mother to Treat Local Infections at Home

Explainhow the treatmentis given.
Watch her as she does the firsttreatmentin the clinic.
Tell her to do the treatmenttwice daily. She shouldreturnto the clinicif the infectionworsens.

To Treat Skin Pustules or Umbilical Infection

To Treat Thrush (ulcers or whitepatches in mouth)

The mothershould:
Wash hands
Gently wash off pus and crustswith soap and water
Dry the area
Paint with gentianviolet
Wash hands

The mothershould:
Wash hands
Wash mouthwith clean soft clothwrappedaroundthe finger
and wet with salt water
Paint the mouthwith half-strengthgentainviolet(0.25 %)
Wash hands

To Treat Eye Infection, See Treat the Child Chart

27

ANTIBIOTICS
LOCALINFECTIONS

TREAT AND COUNSEL

28

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding
Show the mother how to hold her infant
- with the infant's head and body straight
- facing her breast, with infant's nose opposite her nipple
- with infant's body close to her body
- supporting infant's whole body, not just neck and shoulders.
Show her how to help the infant to attach. She should:
- touch her infant's lips with her nipple
- wait until her infant's mouth is opening wide
- move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Advise Mother to Give Home Care for the Young Infant

EXCLUSIVELY BREATFEED THE YOUNG INFANT.
Give only breastfeeds to the young infant.
Breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and health.
MAKE SURE THE YOUNG INFANT STAYS WARM AT ALL TIMES.
In cool weather cover the infants head and feet and dress the infant with extra clothing.
WHEN TO RETURNED
Follow-up Visit
If the infant has:

LOCAL BACTERIAL INFECTION

DIARRHOEA
ANY FEEDING PROBLEM
THRUSH
LOW WEIGHT FOR AGE
LOW BIRTH WEIGHT

Return for follow-up in:

2 days

14 days

When to Return Immediately:

Advise the mother to return immediately if the
young infant has any of these signs:
Breastfeeding or drinking poorly
Becomes sicker
Develops a fever
Fast breathing
Difficult breathing
Depressed breathing

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

LOCAL BACTERIAL INFECTION
After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.
Treatment:
Ifumbilical pus or redness remains or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of
antibiotic and continue treating the local infection at home.
Ifskin 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.

DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped?
Treatment:
Ifthe diarrhoea has not stopped, assess and treat theyoung infant fordiarrhoea. >SEE Does the Young Infant Have Diarrhoea?
Ifthe diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.

29

LOCAL INFECTIONS

BREASTFEEDING
HOME CARE

FOLLOW-UP

30

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or low birth weight" above.
Ask about any feeding problems found on the initial visit.

Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding,
ask her to bring the young infant back again.
If the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young infant's weight gain.

Exception:
if you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

LOW WEIGHT
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 above.
If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within a
month or when she returns for immunization.
If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the
mother to return again in 14 days (or when she returns for immunization, if this is within 2 weeks). Continue to see the young infant
every few weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age.
Exception:
if you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or low birth weight or Low Weight" above.
If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.

I.D-No

MANAGEMENT OF THE SICK YOUNG INFANT AGE LESS THEN 2 MONTHS

Name:
weight)

Age:

Temperature:

days Present weight:

kg

Birth weight

kg (for baby less then 7 days, if birth weight not know use present weight as birth

F
Initial visit?

ASK: What are the infant's problems?

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Has the infant had convulsions (fits)?
Is the infant having difficultly in feeding?

Count the breaths in one minute. ________ breaths per minutes.

Repeat if elevated the count if elevated ________Fast breathing?
Look for severe chest indrawing.
Look and listen for grunting.
o
Fever (temperature 37.5 C or above)?
o
Low body temperature (less than 35.5 C)
Look at the young infant's movements.
Does the young infant move only when stimulated?
Does the young infant not moved even when stimulated?
Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.

THEN CHECK FOR JAUNDICE

ASK: LOOK, LISTEN, FEEL:
Look for jaundice
Look at the young infants palms and soles.
Are they yellow?

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ______ No ______

Look at the young infants general condition.
Does the infant move only when stimulated?
Does the infant not move even when stimulated?
Is the infant restless or imitable?

Look for sunken eyes.

Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

31

Follow-up Visit?

32

ASSESS (Circle all signs present)

CLASSIFY

TREAT

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

Is the infant breastfed? Yes _____ No _____
If Yes, how many times in 24 hours?____ Times

Determine wight for age. Low _____ Not Low _____.

Does the infnat usually receive any

other foods or drinks? Yes _____ No _____
If Yes, how often?

If the infant has no indications to refer urgently to hospital:

ASSESS BREASTFEEDING:
Has the infant breastfeed in the previous hour?

If infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
Is the infant able to attach? To check attachment, look for:
- Mouth wide open
Yes ___
No ___
- Lower lip turned outward
Yes ___
No ___
- More areola above than
below the mouth
Yes ___
No ___
- Chin touching breast
Yes ___
No ___
not well attached

good attachment

Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?
not suckling effectively

suckling effectively

Look for ulcers or white patches in the mouth (thrush).

CHECK THE YOUNG INFANTS IMMUNIZATION STATUS:

Circle immunization needed today

Return for next immunization on:

BCG

OPV-0

PENTAVLENT-1

OPV-1

immunization to given today

(Date)

ASSESS OTHER PROBLEMS

Advice mother when to return immediately
Return for follow-up in ........................ days

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Name:

Age:

months

Weight:
Initial visit?

ASK: What are the child's problems?

ASSESS (Circle all signs present)

LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
ANY DANGER SIGN PRESENT
Yes _____
No _____
Yes _____

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

For how long? ____ Days

No _____

Count the breaths in one minute. (childmust be calm)

_______ breaths per minute. Fast breathing?
Look for chest indrawing.
Look and listen for stridor.
Look and listen for wheeze

DOES THE CHILD HAVE DIARRHOEA?

Yes _____

For how long? _____ Days

Is there blood in the stools?

No _____

Look at the child's general condition. Is the child:

Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offerthe 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?

DOES THE CHILD HAVE THROAT PROBLEM:

Does the child have sore throat?
Is the child not able to drink?
Does the child have fever?

Yes ___ No___

o
Fever (temperature 37.5 C or above).
Feel for tender enlarged lymph nodes on the neck.
Look for red, enlarged tonsils.
Look for white exudate on the throat.

DOES THE CHILD HAVE AN EAR PROBLEM?

Yes ___

No___

Look for pus draining fromthe ear.

Feel for tender swelling behind the ear.

Is there severe ear pain?

Is there ear discharge?
IfYes, for how long? ___ Days

o
DOES THE CHILD HAVE FEVER? (byhistory/feels hot/t
emperature 37.5 C or above)
Yes ___ No___
Malaria transmission in the area = Yes
Transmission season = Yes
A patient presentingwithfever
Innon or low endemic areas travel history within the last 15-days to an area
(contin
uous or interm
ittent)
o
where malaria transmission occurs = Yes___ No___
(temp=
or >more then37.5 C)
(ifyes, use the relevant treatment instructions)
or history of feverwithin the

If the child has measles now

or within the last 3 months:

Fever For how long? ______ days

Ifmore than 7 days, has fever
been present every day?
Has the childhad measles within
the last 3 months?

Look or feel for stiffneck.

Look for runny nose.
Look for signs of MEASLES
Generalized rash of measles AND
One of these: cough, runny nose,
or red eyes.

Look for mouth ulcers.

Are they deep and extensive?
Look for pus draining fromthe eye.
Look for clouding of the cornea.

33

Follow-up Visit?
CLASSIFY

CHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINKOR BREASTFE ED
VOMITS EVERYTHING
CONVULSIONS

last3 days associated with

rigors,withno features of
otherdiseases and have one
or more of the follow
ing:
headache, nausea vomitin
g.

kg Temperature:

TREAT

34
Remember to refer any childwho has danger sign or severe classification

ASSESS (Circle all signspresent)

CLASSIFY

TREAT

THEN CHECK FOR MALNUTRITION

Look for visiblesevere wasting.

Look and feel for oedema of both feet.
Determineweightfor age. Very Low ___ Not Very Low ____
THEN CHECK FOR ANAEMIA

Look for palmar pallor

Severe palmar pallor?
Some palmar pallor?
CHECK THE CHILD'S IMMUNIZA
TION STATUS

Circle immunizationsneeded today.

Return for next immunizationon:

BCG

PENTAVALENT - 1

PENTAVALENT - 2

PENTAVALENT - 3

Measles-1

OPV 0

OPV 1

OPV 2

OPV 3

Measles-2

FOR CHILDREN 6 MONTHS OR ABOVE

CHECK THE CHILD'S VITAMINA
SUPPLEMENTATION STATUS

Has the childreceivedvitaminA in the last 6 months

Yes___

FOR CHILDREN 1 YEARS OR ABOVE

CHECK THE CHILD'S DEWORMINGSTATUS

Immunizationto be given today?

(Date)

Vitamin-A needed
Yes____
No ____

Vitamin-Ato be given today?

Yes____
No ____

No ___

Has the childreceived Mebendazole in the last 6 months

Yes___
No ___

Mebendazole needed
Yes____
No ____

Mebendazoleto be given today?

Yes____
No ____

ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old.

FEEDING PROBLEMS
Do you breastfeedyour child?
Yes____
If Yes, how many times in 24 hours?___ times.
Do you breastfeedduringthe night?
Yes____

No ____

Does the childtake any other food or fluids?

If Yes, what food or fluids?

No ____

Yes____

FEEDING ADVICE

No ____

How many times per day? ___ times What do you use to feed the child?
If very low weightfor age: How large are servings?
Does the childreceive his/herown servings?____Who feeds the childand how?
Duringthe illness,has the child'sfeedingchanged? Yes____
If Yes, how?

No ____

ASSESS OTHER PROBLEMS

Advice motherwhen to returnimmediately
Return for follow-upin ........................d.ays

Temperature
ConversionTable
o
o
C /F
o

Malaria Endemic Areas

H igh M alar ia Endemic A r eas

(Districts)

L ow M alar ia Endemic A r eas

M alar ia Non
endemic A r eas

to

-17.7

95

35.0

97

36.1

98

36.6

98.6

37.0

99

37.2

100

37.7

101

38.3

102

38.8

103

39.4

104

40.0

105

40.5

106

41.1

NOTES

35

36

WEIGHT FOR AGE CHART

Low weight
for age

Very Low
weight for
age

Low weight for age

Very Low
weight for age

AGE IN MONTHS