childhood illness1

© 2007 MKFC Stockholm College

Management of Childhood Illness up to 5 years age

Management of

Childhood Illness up to 5 years age

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Management of Childhood Illness up to 5 years agecontents

1. the health Worker and childhood illnesses

1.1. hoW to Work – a good strategy

1.2. the health status of children is important

1.3. good communication is important

1.3.1. The steps to good communication

2. children age 2 months up to 5 years

2.2. general danger signs

2.2.1. The following danger signs should be checked in all children

2.3. checking main symptoms

2.3.1. Cough or difficult breathing – Controll

2.3.2. Diarrhoea

2.3.2.1. How severe diarrhoea – dehydration

2.3.2.2. Recommended drinks for a child with diarrhoea

2.3.2.3. Classification of dysentery

2.4. fever

2.4.1. A child having fever should be controlled for

2.4.2. Measles

2.5. ear problems

2.5.1. Important to check

2.5.2. Treatment

2.5.3. Prevention

2.5.4. Infection in the ear canal

2.6. the nutritional status –

malnutrition and anaemia

2.6.1. Poor nutrition can result in the following health problems:

2.6.2. Assessing the child’s feeding

2.6.3. Council the mother or the caretaker

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2.7. checking immunization status

2.7.1. Vaccinations (Immunizations) – simple, sure protection

2.7.2. The most important vaccines

2.8. assessing other problems

2.9. if the children age 2 months

up to 5 years needs urgent medical care

2.9.1. Urgent pre–referral treatments

2.10. counselling a mother or caretaker

2.11. the advices health Worker can give

2.11.1. Advise to continue feeding and increase fluids

2.11.2. Teach how to give oral drugs or to treat local infection at home

2.11.3. Advice when to return

2.12. folloW–up care

3. young infants age 1 Week up to 2 months

3.1. assessment of sick young infants

3.2. checking for main symptoms

3.2.1. Bacterial infection


3.2.3. Diarrhoea

3.3. feeding problems or loW Weight


3.3.2. Feeding Problems or Low Weight?





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Sources: http://www.who.int/child-adolescent-health/integr.htm

http://www.hesperian.org/publications_download_wtnd.php

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2.7.1. Vaccinations (Immunizations) – simple, sure protection

2.7.2. The most important vaccines


2.9. if the children age 2 months

up to 5 years needs urgent medical care

2.9.1. Urgent pre–referral treatments


2.11. the advices health Worker can give

2.11.1. Advise to continue feeding and increase fluids

2.11.2. Teach how to give oral drugs or to treat local infection at home

2.11.3. Advice when to return



3.1. assessment of sick young infants

3.2. checking for main symptoms

3.2.1. Bacterial infection


3.2.3. Diarrhoea

3.3. feeding problems or loW Weight


3.3.2. Feeding Problems or Low Weight?





1.1. How to work – a good strategy

The goals are• improvmentinfamilyandcommunityhealthcarepractices• toreducedeathandthefrequencyandseverityofillnessanddisability• tocontributetoimprovedgrowthanddevelopmentinthecountry

Principles• Togettoknowwhatarethegeneraldangersigns.• Toassess,checkthepersonsmajorsymptoms.• Toclassifyhowseveretheperson´sconditionis.• Councellingthecaretakersabouthomecare,forexampleaboutfeeding,fluidsandwhentoreturntoahealthfacility.

1.2. The health status of children is importantChildren´s health – things that affect positively• Goodmotherandchildcare• Improvementsinbreastfeeding• Childhoodvaccinations•Oralrehydrationtherapy;thechildcangetenoughfoodandfluid–>re-ductionindiarrhoeadeaths

• Effectiveantibiotics

1.3. Good communication is importantA good communicationItisimportanttocommunicateeffectively,inagoodwaywiththechild>smotherorcaretaker.Goodcommunicationtechniquesandanabilitytoas-sess,toobserve,tonoticeandjudgethecommonproblemsorsignsofdis-easeormalnutritionareneeded.

Usinggoodcommunicationhelpsthemotherorcaretakertobesurethatthechildwillreceivegoodcare.Forexampleifthemotherorcaretakerknowshowtogivethetreatmentandunderstandsitsimportance–itcanbeasuc-cesfulhometreatment.

The strategy• preventiveandcurativehealthcare• toimproveandgetbetterpracticesinthehealthsystemandspeciallyathomes

1. the health Worker and childhood illnesses

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1.3.1. The steps to good communication• Listencarefullytowhatthecaretakersays.Thiswillshowthemthatyoutaketheirconcerns,problemsseriously.

• Usewordsthecaretakerunderstands.Trytouselocalwordsandavoidmedicalterminology.

• Givethecaretakertimetoanswerquestions.S/hemayneedtimetoreflect,tothinkanddecide.

• Askadditionalquestionswhenthecaretakerisnotsureabouttheanswer.Acaretakermaynotbesureifasymptomisnotsoobvious.Askadditional,morequestionstohelpher/himgiveclearanswers.

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2.1. Assessment of sick children includes• communicatewiththecaretaker–getthehistory;whoisthechild,howold,whendidthechildgetsicketc.

• checkthegeneraldangersigns;• checkthemainsymptoms;• checkthenutritionalstatus;• assessthechild’sfeeding;• checktheimmunizationstatus;and• assesstheotherproblems.

2.2. General Danger SignsAsickchildmayhavesignsthatclearlyindicateaspecificproblem.Forexam-ple,achildmayhavechestindrawingandcyanosis(cyanosismeansthatthechildgetsbluish),whichindicateseverepneumonia.

2.2.1. The following danger signs should be checked in all childrenThe child has had convulsions during the present illness Convulsionsmaybetheresultoffever.Convulsionsarewhenaperson’sbodyshakesrapidlyanduncontrollably.Allchildrenwhohavehadconvulsionsduringthepresentillnessshouldbeconsideredseriouslyill.

The child is unconscious or lethargic Anunconsciouschildislikelytobeseriouslyill.Alethargicchild,whoisawakebutdoesnottakeanynoticeofhisorhersurroundingsordoesnotrespondnormallytosoundsormovement,mayalsobeverysick.

The child is unable to drink or breastfeedAchildmaybeunabletodrinkeitherbecauses/heistooweakorbecauses/hecannotswallow.Donotrelycompletelyonthemother’sevidenceforthis,butobservewhileshetriestobreastfeedortogivethechildsomethingtodrink.

The child vomits everythingThevomitingitselfmaybeasignofseriousillness,butitisalsoimportanttonotebecausesuchachildwillnotbeabletotakemedicationorfluidsforrehydration.

2. children age 2 months up to 5 years

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Ifachildhasoneormoreofthesesigns,s/hemustbeconsideredseriouslyillandwillalmostalwaysneedtobecontrolledifitis– acuterespiratoryinfection(ARI),diarrhoea,andfever(especiallyassociatedwithmalariaandmeasles).

– Acheckingofnutritionalstatusisalsoimportant,asmalnutritionisan-othermaincauseofdeath.

2.3. Checking main symptomsAftercheckingforgeneraldangersigns,thehealthcareworkermustcheckformainsymptoms.

1)coughordifficultbreathing;2)diarrhoea;3)fever;and4)earproblems.

Thefirstthreesymptomsareincludedbecausetheyoftenresultindeath.Earproblemsareincludedbecausetheycancausedisabilitiesifnottreated.

2.3.1. Cough or difficult breathing – ControllThreesignsareusedtoassessasickchildwithcoughordifficultbreathing:• Respiratory rate,howmanytimesthechildbreathsperminute,whichdis-tinguisheschildrenwhohavepneumoniafromthosewhodonot;

• Lower chest wall indrawing,whichindicatesseverepneumonia;and• Stridor (noisybreathinginchildrenwhenchildbreathesin)whichindi-catesthosewithseverepneumoniawhorequirehospitalcare.

Thepointatwhichfast breathingisconsideredtobefastdependonthechild’sage.Normalbreathingratesarehigherinchildrenage2monthsupto12monthsthaninchildrenage12monthsupto5years.

Child’s Age Rate for Fast Breathing

2 months up to 12 months 50 breaths per minute or more

12 months up to 5 years 40 breaths per minute or more

Lower chest wall indrawing,definedastheinwardmovementofthebonystruc-tureofthechestwallwithinspiration,isausefulindicatorofseverepneu-monia.

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Stridorisaharshnoisemadewhenthechildinhales(breathesin).Sometimesawheezingnoiseisheardwhenthechildexhales(breathesout).Thisisnotstridor.Awheezingsoundismostoftenassociatedwithasthma.

2.3.2. DiarrhoeaWhenapersonhaslooseorwaterystools,hehasadiarrhoea.Diarrhoeacanbemildorserious.Diarrhoeaismorecommonandmoredangerousinyoungchildren,especiallythosewhoarepoorlynourished.

Althoughdiarrhoeahasmanydifferentcauses,themostcommonareinfec-tionandpoornutrition.Withgoodhygieneandgoodfood,mostdiarrhoeacouldbeprevented.Andiftreatedcorrectlybygivinglotsofdrinkandfood,fewerchildrenwhogetdiarrhoeawoulddie.

Mostchildrenwhodiefromdiarrhoeadiebecausetheydonothaveenoughwaterleftintheirbody.Thislackofwateriscalleddehydration.

Diarrhoeaisasymptomthatshouldbecheckedinevery childthatisnotfeel-ingwell.

Thecaretakerofachildwithdiarrhoeashouldbeaskedhowlongthechildhashaddiarrhoeaandifthereisbloodinthestool.Thiswillallowidentifica-tionofchildrenwithpersistentdiarrhoeaanddysentery.

Allchildrenwithdiarrhoeafor14daysormorewithsignsofdehydrationshouldgettothehospital.

2.3.2.1. How severe diarrhoea – dehydrationAllchildrenwithdiarrhoeashouldbecheckedhowlongtimetheyhavehaddiarrhoea,ifbloodispresentinthestoolandifdehydrationispresent.

Signs of how severe the dehydration is:– Child’sgeneralcondition. Ifthechildwithdiarrhoeaislethargicorunconsciousorlookrestless/irri-table.

– Sunkeneyes. Theeyesofadehydratedchildmaylooksunken.

– Child’sreactionwhenofferedtodrink. Achildisnotabletodrinkifs/heisnotabletotakefluidinhis/hermouthandswallowit.

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Forexample,achildmaynotbeabletodrinkbecauses/heislethargicorunconscious.Achildisdrinkingpoorlyifthechildisweakandcannotdrinkwithouthelp.S/hemaybeabletoswallowonlyiffluidisputinhis/hermouth–thisisabadsign.

Ifthechildisdrinkingeagerly,thirstythatisgood.Noticeifthechildreach-esoutforthecuporspoonwhenyouofferhim/herwater.Whenthewateristakenaway,seeifthechildisunhappybecauses/hewantstodrinkmore–thisisagoodsign.

– Elasticity of skin. Checkelasticityofskinusingtheskinpinchtest.Whenreleased,theskinpinchgoesbackeitherveryslowly(longerthan2seconds),orslowly(skinstaysupevenforabriefinstant),orimmediately.

How to do Skin Pinch Test • Locatetheareaonthechild’sabdomenhalfwaybetweentheumbili-cusandthesideoftheabdomen;thenpinchtheskinusingthethumbandfirstfinger.

• Itisimportanttofirmlypickupallofthelayersofskinandthetissueunderthemforonesecondandthenreleaseit.

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2.3.2.2. Recommended drinks for a child with diarrhoea– breastmilkmoreoftenthanusual– soups– ricewater– freshfruitjuices– weakteawithalittlesugar– cleanwaterfromasafesource.Ifthereisapossibilitythewaterisnotclean,itshouldbepurifiedbyboilingorfiltering.

– oralrehydrationsalts(ORS)mixedwiththeproperamountofcleanwater.

Drinksshouldbegivenfromacleancup.A feeding bottle should never be usedbecauseitishardertokeepcleanandmorelikelytocauseaninfection.

Ifthechildvomits,thecaregivershouldwaitfor10minutesandthenbeginagaintogivethedrinktothechildslowly,smallsipsatatime.

Diarrhoeausuallystopsafterthreeorfourdays.Ifitlastslongerthanoneweek,caregiversshouldseekhelpfromatrainedhealthworker.

Foods for a person with diarhhoea

Whenthepersoniswomit-ingorfeelstoosicktoeat,heshoulddrink– waterymushorbrothofrice,maizepowder,orpotato

– ricewater(withsomemashedrice)

– chicken,meat,egg,orbeanbroth

– Kool–Aidorsimilarsweeteneddrinks

– rehydrationdrink– breastmilk(smallbabies)

Assoonasthechildwillacceptfood,givefoodhelikesandaccepts.Followingfoodsorsimilarones:

Energyfoods– ripeorcookedbananas

– crackers– rice,oatmeal,orotherwell–cookedgrain

– freshmaize(wellcookedormashed)

– potatoes– applesauce(cooked)

– papaya(Ithelpstoaddalittlesugarorvegeta-bleoiltothecerealfoods.)

Body–buildingfoods– chicken(boiledorroasted)

– eggs(boiled)– meat(wellcooked,withoutmuchfatorgrease)

– beans,lentils,orpeas(wellcookedormashed)

– fish(wellcooked)

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2.3.2.3. Classification of dysenteryAchildishavingdysenteryifthemotherorcaretakerreportsbloodandmucusinthechild’sstool.Dysenteryisespeciallysevereininfantsandinchildrenwhoareundernourished,whodevelopadehydrationduringtheirillness,orwhoarenotbreast–fed.

Allchildrenwithdysentery(bloodydiarrhoea)shouldbetreatedpromptlywithanantibioticandthatiswhytheyhavetovisitadoctor.

2.4. FeverAllsickchildrenshouldbecheckedforfever.Itmaybecausedbyminorinfec-tions,butmayalsobeasignofspecificillness,particularlymalariaorothersevereinfections,includingmeningitis,typhoidfever,ormeasles.

2.4.1. A child having fever should be controlled for

Stiff neck.Astiffneckmaybeasignofmeningitis,cerebralmalariaoranotherveryseverefebriledisease.Ifthechildisconsciousandalert,checkstuffinessbyticklingthefeet,askingthechildtobendhis/hernecktolookdownorbyverygentlybendingthechild’sheadforward.Itshouldmovefreely.

Risk of malaria and other infections. Malariariskcanvarybyseasonorplaces.Thenationalmalariacontrolpro-grammenormallydefinesareasofmalariariskinacountry.

Runny nose. Whenmalariariskislow,achildwithfeverandarunnynosedoesnotneedanantimalarial.Thischild’sfeverisprobablyduetoacommoncold.

Duration of fever. Mostfeversgoawaywithinafewdays.Afeverthathaslastedeverydayformorethanfivedayscanmeanthatthechildhasamoreseverediseasesuchastyphoidfever.

Important to checkBodytemperatureshouldbecheckedinallsickchildren.Childrenareconsideredtohavefeveriftheirbodytemperatureisabove37.5°Caxil-lary(38°Crectal).Ifyoudon’thaveathermometer,childrenareconsid-eredtohavefeveriftheyfeelhot.

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2.4.2. MeaslesChildrenwithfevershouldbeassessedforsignsofcurrentorpreviousmeasles(withinthelastthreemonths).

Measlesisaseriousvirusinfection.Theusualsignsarefeverwithageneralisedrash,plusatleastoneofthefollowingsigns:redeyes,runnynose,orcough.Themothershouldbeaskedaboutifsomebodynearthefamily/childhashadmeaslesduringthelastthreemonths.

Thechildususallybecomesincreasinglyill.Themouthmaybecomeverysoreandhemaydevelopdiarrhoea.

After2or3daysafewtinywhitespotslikesaltgrainsappearinthemouth.Adayor2latertherashappears—firstbehindtheearsandontheneck,thenonthefaceandbody,andlastonthearmsandlegs.Aftertherashappears,thechildusuallybeginstogetbetter.Therashlastsabout5days.Sometimestherearescatteredblackspotscausedbybleedingintotheskin(‘blackmea-sles’).Thismeanstheattackisverysevere.Getmedicalhelp.

Treatment:– Thechildshouldstayinbed,drinklotsofliquids,andbegivennutritiousfood.Ifhecannotswallowsolidfood,giveherliquidslikesoup.Ifababycannotbreastfeed,givebreastmilkinaspoon.

– Ifpossible,givevitaminAtopreventeyedamage.– Forfeveranddiscomfort,giveacetaminophen(oribuprofen).– Ifearachedevelops,giveanantibiotic.– Ifsignsofpneumonia,meningitis,orseverepainintheearorstomachdevelop,getmedicalhelp.

Prevention of measles:Childrenwithmeaslesshouldkeepfarawayfromotherchildren,evenfrombrothersandsisters.Especiallytrytoprotectchildrenwhoarepoorlynour-ishedorwhohavetuberculosisorotherchronicillnesses.Childrenfromotherfamiliesshouldnotgointoahousewherethereismeasles.Ifchildreninafamilywherethereismeasleshavenotyethadmeaslesthemselves,theyshouldnotgotoschoolorintostoresorotherpublicplacesfor10days.

Topreventmeaslesfromkillingchildren,makesureallchildrenarewell-nourished.Haveyourchildrenvaccinatedagainstmeasleswhentheyare12to15monthsofage.

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2.5. Ear problemsEarproblemsarecommoninsmallchildrenandshouldbecheckedinallchildrenbroughttotheoutpatienthealthfacility.

Theinfectionoftenbeginsafterafewdayswithacoldorastuffyorpluggednose.Thefevermayrise,andthechildoftencriesorrubsthesideofhishead.Sometimespuscanbeseenintheear.Insmallchildrenanearinfectionsometimescausesvomitingordiarrhoea.Sowhenachildhasdiarrhoeaandfeverbesuretocheckhisears.

2.5.1. Important to checkWhenotoscopy(aninstrumentusedtolookintotheear)isnotavailable,lookforthefollowingsimpleclinicalsigns:

Tender swelling behind the ear. Themostseriouscomplicationofanearinfectionisadeepinfectioninthemastoidbone(thebonedirectlybehindtheear).Itcanbetenderswellingbehindoneofthechild’sears.Ininfants,thistenderswellingalsomaybeabovetheear.

Ear pain. Intheearlystagesofacuteotitis,achildmayhaveearpain,whichusuallycausesthechildtobecomeirritableandrub,touchtheearfrequently.

Ear discharge or pus. Thisisanotherimportantsignofanearinfection.Whenamotherreportsaneardischarge,thehealthcarepro-vidershouldcheckforpusdrainagefromtheearsandfindouthowlongthedischargehasbeenpresent.

2.5.2. Treatment• Itisimportanttotreatearinfectionsearly• Carefullycleanpusoutoftheearwithcotton,butdonotputaplugofcot-ton,astick,leaves,oranythingelseintheear.

• Childrenwithpuscomingfromanearshouldbatheregularlybutshouldnotswimordiveforatleast2weeksaftertheyarewell.

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2.5.3. Prevention• Teachchildrentowipebutnottoblowtheirnoseswhentheyhaveacold.• Donotbottlefeedbabies–orifyoudo,donotletbabyfeedlyingonhisback,asthemilkcangouphisnoseandleadtoanearinfection.

• Whenchildren’snosesarepluggedup,usesaltdropsandsuckthemucusoutofthenose.

2.5.4. Infection in the ear canalTofindoutwhetherthecanalortubegoingintotheearisinfected,gentlypulltheear.Ifthiscausespain,thecanalisinfected.Putdropsofwaterwithvinegarintheear3or4timesaday.(Mix1spoonofvinegarwith1spoonofboiledwater.)Ifthereisfeverorpus,getmedicalhelp.

2.6. The nutritional status – malnutrition and anaemiaGoodfoodisneededforapersontogrowwell,workhard,andstayhealthy.Manycommonsicknessescomefromnoteatingenough.Apersonwhoisweakorsickbecausehedoesnoteatenough,ordoesnoteatthefoodshisbodyneeds,issaidtobepoorlynourished–ormalnourished.Hesuffersfrommalnutrition.

2.6.1. Poor nutrition can result in the following health problems:• thechildisnotgrowingorgainingweightnormally• slownessinwalking,talking,orthinking• bigbellies,thinarmsandlegs• lackofenergy,childissadanddoesnotplay• swellingoffeet,face,andhands,oftenwithsoresormarksontheskin

2.6.2. Assessing the child’s feedingAgoodfooddoesnotonlyhelppreventdisease,ithelpsthesickbodyfightdiseaseandbecomewellagain.Sowhenapersonissick,eatingenoughnu-tritiousfoodisespeciallyimportant.

Unfortunately,somemothersstopfeedingachildorstopgivingcertainnu-tritiousfoodswhenheissickorhasdiarrhoea–sothechildbecomesweaker,cannotfightofftheillness,andmaydie.Sickchildrenneedfood!Ifasickchildwillnoteat,encouragehimtodoso.

2.6.3. Council the mother or the caretakerAllchildrenlessthan2yearsoldandallchildrenclassifiedasanaemiaorlow(orverylow)weightneedtobeassessedforfeeding.

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Councilthemotherorthecaretakertofeedthechildasmuchashewilleatanddrink.Andbepatient.Asickchildoftendoesnotwanttoeatmuch.Socounciltofeedhimsomethingmanytimesduringtheday.Also,trytomakesurethathedrinksalotofliquidsothathepees(passesurine)severaltimesaday.Ifthechildwillnottakesolidfoods,counciltomashthefoodandgivethemasamushorgruel.

Oftenthesignsofpoornutritionfirstappearwhenapersonhassomeothersickness.Forexample,achildwhohashaddiarrhoeaforseveraldaysmayde-velopswollenhandsandfeet,aswollenface,darkspots,orpeelingsoresonhislegs.Thesearesignsofseveremalnutrition.Thechildneedsmoregoodfood!Andmoreoften.

Feedthechildmanytimesduringtheday.Duringandafteranysickness,itisveryimportanttoeatwell.

2.7. Checking immunization statusTheimmunizationstatusofeverysickchildbroughttoahealthfacilityshouldbechecked.

2.7.1. Vaccinations (Immunizations) – simple, sure protectionVaccinesgiveprotectionagainstmanydangerousdiseases.Eachcountryhasitsownscheduleofvaccinations.Vaccinationsareusuallygivenfree.Ifhealthworkersdonotvaccinateinyourvillage,takeyourchildrentothenearesthealthcentertobevaccinated.Itisbettertotakethemforvaccina-tionswhiletheyarehealthythantotakethemfortreatmentwhentheyaresickordying.

2.7.2. The most important vaccines1. DPT,fordiphtheria,whoopingcough(pertussis),andtetanus.Forfullpro-tection,achildneeds4or5injections.Usuallytheinjectionsaregivenat2months,4months,6months,and18monthsold.Insomecountriesonemoreinjectionisgivenwhenachildisbetween4and6yearsold.

2. Polio(infantileparalysis).Thechildneedsdropsinthemouth4or5times.Insomecountriesthefirstvaccinationisgivenatbirthandtheother3dosesaregivenatthesametimeastheDPTinjections.Inothercountries,thefirst3dosesaregivenatthesametimeastheDPTinjections,thefourthdoseisgivenbetween12and18monthsofage,andafifthdoseisgivenwhenthechildis4yearsold.

3. BCG,fortuberculosis.Asingleinjectionisgivenundertheskinoftheleftarm.Childrencanbevaccinatedatbirthoranytimeafterwards.Ifany

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memberofthehouseholdhastuberculosis,itisimportanttovaccinateba-biesinthefirstfewweeksormonthsafterbirth.Thevaccinemakesasoreandleavesascar.

4. Measles. Achildneeds1injectiongivennoyoungerthan9monthsofage,andoftenasecondinjectionat15monthsorolder.Butinmanycoun-triesa‘3in1’vaccinecalledMMRisgiven,thatprotectsagainstmeasles,mumps,andrubella(Germanmeasles).Oneinjectionisgivenwhenthechildisbetween12and15monthsold,andthenasecondinjectionisgivenbetween4and6yearsofage.

5. HepB(HepatitisB).Thisvaccineisgiveninaseriesof3injectionsatinter-valsofabout4weeksaftereachother.GenerallytheseinjectionsaregivenatthesametimeasDPTinjections.InsomecountriesthefirstHepBisgivenatbirth,thesecondat2monthsold,andthethirdwhenthebabyis6monthsold.

6. Td or TT (Tetanustoxoid),fortetanus(lockjaw)foradultsandchildrenover12yearsold.Throughouttheworld,tetanusvaccinationisrecommendedwith1injectionevery10years.InsomecountriesaTdinjectionisgivenbetween9and11yearsofage(5yearsafterthelastDPTvaccination),andthenevery10years.Pregnantwomenshouldbevaccinatedduringeachpregnancysothattheirbabieswillbeprotectedagainsttetanusofthenewborn.

2.8. Assessing other problemsWehavetalkedaboutmainsymptoms.Nevertheless,healthcareprovidersstillneedtoconsiderothercausesofsevereoracuteillness.Itisimportanttocontrollalsothechild’sothercomplaintsandtoaskquestionsaboutthecaretaker’shealth(usually,themother’s).

2.9. If the children age 2 months up to 5 years needs urgent medical careAll infants and children with a severe problems shall be taken to a hospital assoonasassessmentiscompletedandnecessarypre–referraltreatmentisdone.

Itisimportanttocounselthecaretakereffectivelyifthechildisobviouslyseverelyill.Ifthemotherorcaretakerdoesnotacceptreferral,availableoptions(totreatthechildbyrepeatedclinicorhomevisits)shouldbeconsid-

Vaccinate your children on time.Besuretheygetthecompleteseriesofeachvaccinetheyneed.

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ered.Ifthecaretakeracceptsreferral,s/heshouldbegivenashort,clearrefer-ralnote,andshouldgetinformationonwhattododuringreferraltransport,particularlyifthehospitalisdistant.

2.9.1. Urgent pre–referral treatments for children age 2 months up to 5 years • Appropriateantibiotic• Quinine(forseveremalaria)• VitaminA• Preventionofhypoglycemiawithbreastmilkorsugarwater• Oralantimalarial• Paracetamolforhighfever(38.5°Corabove)orpain• ORSsolutionsothatthemothercangivefrequentsipsonthewaytothehospital

Note:Thefirstfourtreatmentsaboveareurgentbecausetheycanpreventseriousconsequencessuchasprogressionofbacterialmeningitisorcerebralmalaria,cornealruptureduetolackofvitaminA,orbraindamagefromlowbloodsugar.Theotherlistedtreatmentsarealsoimportanttopreventwors-eningoftheillness.

Ifachilddoesnotneedurgentreferral,checktoseeifthechildneedsnon–urgentreferralforfurtherassessment;forexample,foracoughthathaslastedmorethan30days,orforfeverthathaslastedfivedaysormore.Thesereferralsarenotasurgent,andothernecessarytreatmentsmaybedonebeforetransportingforreferral.

2.10. Counselling a mother or caretakerAchildwhoisseenattheclinicneedstocontinuetreatment,feedingandfluidsathome.Thechild’smotherorcaretakeralsoneedstorecognizewhenthechildisnotimproving,orisbecomingsicker.

Whenyouteachamotherhowtotreatachild,usethreebasicteachingsteps:• giveinformation;• showanexample;• letherpractice.

Whenteachingthemotherorcaretaker:• usewordsthats/heunderstands;• useteachingaidsthatarefamiliar;

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• givefeedbackwhens/hepractices,praisewhatwasdonewellandmakecorrections;

• allowmorepractice,ifneeded;and• encouragethemotherorcaretakertoaskquestionsandthenanswerallquestions.

Finally,itisimportanttocheckthemother’sorcaretaker’sunderstanding.

2.11. The advices health worker can giveWhatyouasahealthworkergiveasadvicewilldependonthechild’scondi-tion.Belowsomebasicthingsthatshouldbeconsideredwhencounsellingamotherorcaretaker:• Advisetocontinuefeedingandincreasefluidsduringillness;• Teachhowtogiveoraldrugsortotreatlocalinfection;• Counseltosolvefeedingproblems(ifany);• Advisewhentoreturn.

2.11.1. Advise to continue feeding and increase fluidsDuringillness,children’sappetitesandthirstmaybedecreased.However,mothersandcaretakersshouldbecounselledtoincreasefluidsandtoofferthetypesoffoodrecommendedforthechild’sage,asoftenasrecommended,eventhoughachildmaytakesmallamountsateachfeeding.Afterillness,goodfeedinghelpsmakeupforweightlossandhelpspreventmalnutrition.Whenthechildiswell,goodfeedinghelpspreventfutureillness.

2.11.2. Teach how to give oral drugs or to treat local infection at homeSimplestepsshouldbefollowedwhenteachingamotherorcaretakerhowtogiveoraldrugsortreatlocalinfections.Thesestepsinclude:– whatistherightdrugsanddosageforthechild’sageorweight;– tellthemotherorcaretakerwhatthetreatmentisandwhyitshouldbegiven;

– showhowtomeasureadose;– watchthemotherorcaretakerpractisemeasuringadose;– askthemotherorcaretakertogivethedosetothechild;– explaincarefullyhow,andhowoften,todothetreatmentathome;– explainthatAlloraldrugtabletsorsyrupsmustbeusedtofinishthecourseoftreatment,evenifthechildgetsbetter;

– checkthemother’sorcaretaker’sunderstanding.

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2.12. Follow–up careSomesickchildrenwillneedtoreturnforfollow–upcare.Atafollow–upvisit,seeifthechildisimproving,gettingbetteronthedrugorothertreat-mentthatwasprescribed.Somechildrenmaynotrespondtoaparticularantibioticorantimalarial,andmayneedtotryananotherdrug.Childrenwithpersistentdiarrhoeaalsoneedfollow–uptobesurethatthediarrhoeahasstopped.Childrenwithfeveroreyeinfectionneedtobeseeniftheyarenotimproving.Follow–upisespeciallyimportantforchildrenwithafeedingproblemtoensuretheyarebeingfedadequatelyandaregainingweight.

Whenachildcomesforfollow–upofanillness,askthemotherorcaretakerifthechildhasdevelopedanynewproblems.Ifsheanswersyes,thechildrequiresafullassessment:checkforgeneraldangersignsandassessallthemainsymptomsandthechild’snutritionalstatus.

2.11.3. Advice when to returnEverymotherorcaretakerwhoistakingasickchildhomeneedstobeadvisedaboutwhentoreturntoahealthfacility.– teachsignsthatmeantoreturnimmediatelyforfurthercare;– advisewhentoreturnforafollow–upvisit;and– tellwhenthenextwell–childorimmunizationvisitshallbedone.

Adviseamotherorcaretakertoreturntoahealthfacility:Anysickchild– Notabletodrinkordrinkorbreastfeed– Becomessicker– Developsafever

Ifchildhasnopneumonia:coughorcold,alsoreturnif:– Fastbreathing– Difficultbreathing

Ifchildhasdiarrhoea,alsoreturnif:– Bloodinstool– Drinkingpoorly

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3.1. Assessment of sick young infantsWhiletherearesimilaritiesinthecaretakingofsickyounginfants(age1weekupto2months)andchildren(age2monthsupto5years),somesignsobservedininfantsdifferfromthoseinolderchildren.

Assessmentincludesthefollowingsteps:• Checkingforpossiblebacterialinfection;• Assessingiftheyounginfanthasdiarrhoea;• Checkingforfeedingproblemsorlowweight;• Checkingtheyounginfant’simmunizationstatus;• Assessingotherproblems.

Itisimportanttorememberthattheguidelinesabovearenotusedforasicknew–bornwhoislessthan1weekold.Inthefirstweekoflife,new–borninfantsareoftensickfromconditionsrelatedtolabouranddelivery,orhaveconditionsthatrequirespecialmanagement.

3.2. Checking for Main Symptoms3.2.1. Bacterial infectionWhilethesignsofpneumoniaandotherseriousbacterialinfectionscannotbeeasilyseeninthisagegroup,itisrecommendedthatallsickyoungin-fantsbeassessedfirstforsignsofpossiblebacterialinfection.

3.2.2. Important to checkManysignspointtopossiblebacterialinfectioninsickyounginfants.Themostinformativeandeasytochecksignsare:

Convulsions (as part of the current illness). Assessthesameasforolderchildren.

Fast breathing. Younginfantsusuallybreathefasterthanolderchildrendo.Thebreathingrateofahealthyyounginfantiscommonlymorethan50breathsperminute.Therefore,60breathsperminuteisthecut–offratetoidentifyfastbreathinginthisagegroup.

Ifthecountis60breathsormore,thecountshouldberepeated,becausethebreathingrateofayounginfantisoftenirregular.Theyounginfantwilloccasionallystopbreathingforafewseconds,followedbyaperiodoffasterbreathing.Ifthesecondcountisalso60breathsormore,theyounginfanthasfastbreathing.


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Severe chest indrawing. Mildchestindrawingisnormalinayounginfantbecauseofsoftnessofthechestwall.Severechestindrawingisverydeepandeasytosee.Itisasignofpneumoniaorotherseriousbacterialinfectioninayounginfant.

Nasal flaring (whenaninfantbreathesin)andgrunting(whenaninfantbreathesout)areanindicationoftroubledbreathingandpossiblepneumo-nia.

A bulging fontanel(whenaninfantisnotcrying),skin pustules, umbilical redness or pus draining from the earareothersignsthatindicatepossiblebacterialinfection.

Lethargy or unconsciousness, or less than normal movementalsoindicateaseriouscondition.

Temperature (fever or hypothermia) mayalsoindicatebacterialinfection.Fever(axillarytemperaturemorethan37.5°Correctaltemperaturemorethan38°C)isuncommoninthefirsttwomonthsoflife.Feverinayounginfantmayindicateaseriousbacterialinfec-tion,andmaybetheonlysignofaseriousbacterialinfection.Younginfantscanalsorespondtoinfectionbydroppingtheirbodytemperaturetobelow35.5°C(36°Crectal).

3.2.3. DiarrhoeaAllsickyounginfantsshouldbecheckedfordiarrhoea.

3.3. Feeding problems or low weightAllsickyounginfantsseeninhealthfacilitiesshouldbeassessedforweightandadequatefeeding,aswellasforbreast–feedingtechnique.

3.3.1. Important to check• Determine weight for age.Assessthesameasforolderchildren.• Assessment of feeding.Assessmentoffeedinginyounginfantsissimilartothatinolderchildren.

Thehealthworkershouldaskabout:– breastfeedingfrequencyandnightfeeds;– whatothertypesfoodsorfluidsthechildhaseaten,howoftenandifthechildhaseatenlately;and

– howthechildhaseatennowduringthisillness.

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Ifaninfanthasdifficultyfeeding,orisbreastfedlessthan8timesin24hours,ortakingotherfoodsordrinks,orlowweightforage,thenbreast-feedingshouldbeassessed.Assessmentofbreastfeedinginyounginfantsincludescheckingiftheinfantisabletoattach,iftheinfantissucklingeffec-tively(slow,deepsucks,withsomepausing),andifthereareulcersorwhitepatchesinthemouth(thrush).

3.3.2. Feeding Problems or Low Weight?– Not able to feed – possible serious bacterial infection.Theyounginfantwhoisnotabletofeed,ornotattachingtothebreastornotsucklingeffectively,hasalife–threateningproblem.Thiscouldbecausedbyabacterialinfec-tionoranotherillness.Theinfantshouldbetakentoadoctor.

– Infantswithfeeding problems or low weightarethoseinfantswhohavefeed-ingproblemslikenotattachingwelltothebreast,notsucklingeffectively,gettingbreastmilkfewerthaneighttimesin24hours,receivingotherfoodsordrinksthanbreastmilk,orthosewhohavelowweightforageorthrush(ulcers/whitepatchesinmouth).

– Infantswithno feeding problemsarethosewhoarebreastfedexclusivelyatleasteighttimesin24hoursandwhoseweightisnotclassifiedaslowweightforageaccordingtostandardmeasures.

3.4. Checking immunization statusAsforolderchildren,immunizationstatusshouldbecheckedinallsickyounginfants.Equally,illnessisnotacontraindicationtoimmunization.

3.5. Assessing other problemsAsforolderchildren,allsickyounginfantsneedtobeassessedforotherpotentialproblemsmentionedbythemotherorobservedduringtheexami-nation.Ifapotentiallyseriousproblemisfoundorthereisnomeansintheclinictohelptheinfant,s/heshouldbereferredtohospital.

Breastfeeding - Signs that the baby is feeding well– thebaby’swholebodyisturnedtowardsthemother– thebabyisclosetothemother– thebabyisrelaxedandhappy– thebaby’smouthiswideopen– thebabytakeslong,deepsucks

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3.6. Counselling a mother or caretakerAswitholderchildren,thesuccessofhometreatmentdependsonhowwellthemotherorcaretakerknowshowtogivethetreatment,understandsitsimportance,andknowswhentoreturntoahealthcareprovider.

Counsellingthemotherorcaretakerofasickyounginfantincludesthefol-lowingessentialelements:• Teachhowtogiveoraldrugsortotreatlocalinfection.• Teachcorrectpositioningandattachmentforbreastfeeding: –showthemotherhowtoholdherinfant –withtheinfant’sheadandbodystraight –facingherbreast,withinfant’snoseoppositehernipple –withinfant’sbodyclosetoherbody –supportinginfant’swholebody,notjustneckandshoulders.• Lookforsignsofgoodattachmentandeffectivesuckling.Iftheattachmentorsucklingisnotgood,tryagain.

• Adviseaboutfoodandfluids:advisetobreastfeedfrequently,asoftenaspossibleandforaslongastheinfantwants,dayandnight,duringsicknessandhealth.

3.7. Follow–up careIfthechilddoesnothaveanewproblem• Assessthechildaccordingtotheinstructions;• Usetheinformationaboutthechild’ssignstoselecttheappropriatetreat-ment;

• Givethetreatment.

Advice when to return• teachsignsthatmeantoreturnimmediatelyforfurthercare;• advisewhentoreturnforafollow-upvisit;and• tellwhenthenextwell-childorimmunizationvisitshallbedone.

Advise to return immediately if the infant has any of these signs:• Breastfeedingordrinkingpoorly• Becomessicker• Developsafever• Fastbreathing• Difficultbreathing• Bloodinstool

childhood illness1

Education