imci day1

WHAT IS IMCI?WHAT IS IMCI?A strategy for reducing mortality and A strategy for reducing mortality and morbidity associated with major causes of morbidity associated with major causes of childhood illnesschildhood illness

A joint WHO/UNICEF initiative since 1992A joint WHO/UNICEF initiative since 1992

Currently focused on first level health Currently focused on first level health facilitiesfacilities

Comes as a generic guidelines for Comes as a generic guidelines for management which have been adapted to management which have been adapted to each countryeach country

INTEGRATED MANAGEMENT OF INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSCHILDHOOD ILLNESS

INTRODUCTIONINTRODUCTION

Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, measles and malnutrition cause more than 70% of the deaths in measles and malnutrition cause more than 70% of the deaths in children under 5 years of age. All these are preventable diseases children under 5 years of age. All these are preventable diseases in which when managed and treated early could have prevented in which when managed and treated early could have prevented

these deaths.these deaths.

There are feasible and effective ways that health worker in There are feasible and effective ways that health worker in health centers can care for children with these illnesses and health centers can care for children with these illnesses and

prevent most of these deaths. WHO and UNICEF used updated prevent most of these deaths. WHO and UNICEF used updated technical findings to describe management of these illnesses in a technical findings to describe management of these illnesses in a

set of integrated guidelines for each illness. They then set of integrated guidelines for each illness. They then developed this protocol to teach the integrated case developed this protocol to teach the integrated case

management process to health worker who see sick children and management process to health worker who see sick children and know which problems are most important to treat. Therefore, know which problems are most important to treat. Therefore, effective case management needs to consider all of a child’s effective case management needs to consider all of a child’s

symptoms.symptoms.

For those children who can be treated at home, For those children who can be treated at home, caregivers are taught how to provide treatment caregivers are taught how to provide treatment and when to seek care for their children. The and when to seek care for their children. The guidelines also identify actions to prevent illness guidelines also identify actions to prevent illness through the immunization of sick children, through the immunization of sick children, supplementation of micronutrients, promotion of supplementation of micronutrients, promotion of breastfeeding, and counseling of mothers to solve breastfeeding, and counseling of mothers to solve feeding problems. It is also an important factor to feeding problems. It is also an important factor to teach families when to seek care for a sick child teach families when to seek care for a sick child as part of the case management process. This as part of the case management process. This approach, which combines steps to manage and approach, which combines steps to manage and prevent several different conditions, is prevent several different conditions, is comprehensive and systematic.comprehensive and systematic.

DISTRIBUTION OF 11.6 MILLION DEATHS AMONG DISTRIBUTION OF 11.6 MILLION DEATHS AMONG CHILDREN LESS THAN 5 YRS OLD IN ALL CHILDREN LESS THAN 5 YRS OLD IN ALL

DEVELOPING COUNTRIES, 1995DEVELOPING COUNTRIES, 1995

MALNUTRITION 54%MALNUTRITION 54%Others 32%Others 32%ACUTE RESPIRATORY INFECTIONS ACUTE RESPIRATORY INFECTIONS (ARI) 19 %(ARI) 19 %DIARRHEA 19%DIARRHEA 19%Perinatal 18%Perinatal 18%MEASLES 7%MEASLES 7%MALARIA 5%MALARIA 5%

OBJECTIVES OF IMCIOBJECTIVES OF IMCI

To reduce significantly global To reduce significantly global morbidity and mortality associated morbidity and mortality associated with the major causes of illnesses in with the major causes of illnesses in childrenchildren

To contribute to healthy growth and To contribute to healthy growth and development of childrendevelopment of children

The The CASE MANAGEMENT PROCESSCASE MANAGEMENT PROCESS is used to is used to assess and classify two age groupsassess and classify two age groups::

age 1 week up to 2 monthsage 2 months up to 5 years

And how to use the process shown on the chart will help us to identify signs of serious disease such pneumonia, diarrhea, malaria, measles, DHF, meningitis, malnutrition and anemia.

THE CASE MANAGEMENT THE CASE MANAGEMENT PROCESSPROCESS

The charts describes the following steps;The charts describes the following steps; 1. assess the child or young infant1. assess the child or young infant 2. classify the illness2. classify the illness 3. identify the treatment3. identify the treatment 4. treat the child 4. treat the child 5. counsel the mother5. counsel the mother 6. give follow up care 6. give follow up care

THE CLASSIFICATION TABLETHE CLASSIFICATION TABLE

The classification tables on the assess The classification tables on the assess and classify have 3 ROWS .and classify have 3 ROWS .

COLOR of the row helps to IDENTIFY COLOR of the row helps to IDENTIFY RAPIDLY whether the child has a RAPIDLY whether the child has a SERIOUS DISEASE requiring SERIOUS DISEASE requiring

URGENT ATTENTION.URGENT ATTENTION.

Each row is colored either –Each row is colored either – PINKPINK – means the child has a severe classification and – means the child has a severe classification and needs urgent attention and referral or admission needs urgent attention and referral or admission for inpatient care.for inpatient care.

YELLOWYELLOW – means the child needs a specific medical – means the child needs a specific medical treatment such as an appropriate antibiotic, an oraltreatment such as an appropriate antibiotic, an oral anti-malarial or other treatment; also teaches theanti-malarial or other treatment; also teaches the mother how to give oral drugs or to treat localmother how to give oral drugs or to treat local infections at home. The health worker teaches theinfections at home. The health worker teaches the mother how to care for her child at home and whenmother how to care for her child at home and when she should return.she should return.

GREEN GREEN – not given a specific medical treatment such as– not given a specific medical treatment such as antibiotics or other treatments. The health workerantibiotics or other treatments. The health worker teaches the mother how to care for her child at teaches the mother how to care for her child at home.home.

Always start at the top of the classification table. If the child has signs from Always start at the top of the classification table. If the child has signs from more than 1 row always select the more serious classification. more than 1 row always select the more serious classification.

WHY NOT USE THE PROCESS FOR CHILDREN WHY NOT USE THE PROCESS FOR CHILDREN AGE 5 YEARS OR MORE?AGE 5 YEARS OR MORE?

The case management process is designed for children < 5yrs of The case management process is designed for children < 5yrs of age, although. Much of the advise on treatment of pneumonia, diarrhea, age, although. Much of the advise on treatment of pneumonia, diarrhea, malaria, measles and malnutrition, is also applicable to older children, the malaria, measles and malnutrition, is also applicable to older children, the ASSESSMENT AND CLASSIFICATION of older children would differ. For ASSESSMENT AND CLASSIFICATION of older children would differ. For example, the cut off rate for determining fast breathing would be different example, the cut off rate for determining fast breathing would be different because normal breathing rates are slower in older children. Chest because normal breathing rates are slower in older children. Chest indrawing is not a reliable sign of severe pneumonia as children get older indrawing is not a reliable sign of severe pneumonia as children get older and the bones of the chest become more firm.and the bones of the chest become more firm.

In addition, certain treatment recommendations or advice to mothers In addition, certain treatment recommendations or advice to mothers on feeding would differ for >5yrs old. The drug dosing tables only apply to on feeding would differ for >5yrs old. The drug dosing tables only apply to children up to 5yrs old. The feeding advice for older children may differ and children up to 5yrs old. The feeding advice for older children may differ and they may have different feeding problems.they may have different feeding problems.

Because of differences in the clinical signs of older and younger Because of differences in the clinical signs of older and younger children who have these illnesses, the assessment and classification children who have these illnesses, the assessment and classification process using these clinical signs is not recommended for older children.process using these clinical signs is not recommended for older children.

WHY NOT USE THIS PROCESS FOR WHY NOT USE THIS PROCESS FOR YOUNG INFANTS AGE < 1 WEEK OLD?YOUNG INFANTS AGE < 1 WEEK OLD?

The process on young infant chart The process on young infant chart is designed for infants age 1 week up is designed for infants age 1 week up to 2 months. It greatly differs from to 2 months. It greatly differs from older infants and young children. In older infants and young children. In the first week of life, newborn infants the first week of life, newborn infants are often sick from conditions related are often sick from conditions related to labor and delivery. Their conditions to labor and delivery. Their conditions require special treatment.require special treatment.

IDENTIFICATION AND IDENTIFICATION AND PROVISION OF TREATMENTPROVISION OF TREATMENT

Curative component adapted to address the Curative component adapted to address the most common life-threatening conditions most common life-threatening conditions in each countryin each country

Rehydration (diarrhea, DHF)Rehydration (diarrhea, DHF)

Antibiotics (pneumonia, “severe disease”)Antibiotics (pneumonia, “severe disease”)

Antimalarial treatmentAntimalarial treatment

Vitamin A (measles, severe malnutrition)Vitamin A (measles, severe malnutrition)

PROMOTIVE AND PREVENTIVE PROMOTIVE AND PREVENTIVE ELEMENTSELEMENTS

Reducing missed opportunities for Reducing missed opportunities for immunization (vaccination given if immunization (vaccination given if needed)needed)

Breastfeeding and other nutritional Breastfeeding and other nutritional counselingcounseling

Vitamin A and iron supplementationVitamin A and iron supplementation

Treatment of helminth infectionsTreatment of helminth infections

The Integrated Case

Management Process

Learning ObjectivesLearning Objectives

At the end of the session, the At the end of the session, the students will be able to:students will be able to:

(1) describe the overall case (1) describe the overall case management process; management process;

(2) state in order the steps in the (2) state in order the steps in the management processmanagement process

Overall Case Management Overall Case Management ProcessProcess

Outpatient Outpatient

1 - assessment1 - assessment

2 - classification and identification of treatment2 - classification and identification of treatment

3 - referral, treatment or counseling of the child’s 3 - referral, treatment or counseling of the child’s

caretaker (depending on the classification caretaker (depending on the classification

identified)identified)

4 - follow-up care4 - follow-up care

Referral Health FacilityReferral Health Facility

1 - emergency triage assessment and treatment 1 - emergency triage assessment and treatment

2 - diagnosis, treatment and monitoring of 2 - diagnosis, treatment and monitoring of

patient’s progresspatient’s progress

SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESSFor all sick children age 1 week up to 5 years who are brought to a first-level health facility

ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems.

CLASSIFY the child’s illnesses: Use a colour-coded triage system to classify the child’s main symptomsand his or her nutrition or feeding status.

IF URGENT REFERRAL is needed and possible IF NO URGENT REFERRAL isneeded or possible

IDENTIFY URGENTPRE-REFERRAL TREATMENT(S)needed for the child’s classifications..

IDENTIFY TREATMENT needed for the child’s classifications: Identify specific medical treatments and/or advice.

TREAT THE CHILD: Give urgent pre-referral treatment (s) needed.

TREAT THE CHILD: Give the first dose of oral drugs in the clinicand/or advise the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give immunizations.

REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital.

COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health.

FOLLOW-UP care: Give follow-up care when the child returns to the clinic and,if necessary, reassess the child for new problems.

Summary of the Integrated case Summary of the Integrated case Management ProcessManagement Process

For all sick For all sick children age 1 children age 1 week up to 5 week up to 5 years who are years who are brought to a first-brought to a first-level health level health facilityfacility

Summary of the Integrated case Summary of the Integrated case Management ProcessManagement Process

ASSESS the Child:ASSESS the Child: Check for danger signs Check for danger signs

(or possible bacterial (or possible bacterial infection). infection).

Ask about main symptoms. Ask about main symptoms. If a main symptom is If a main symptom is

reported, assess further. reported, assess further. Check nutrition and Check nutrition and immunization status.immunization status.

Check for other problems Check for other problems

Summary of the Integrated Case Summary of the Integrated Case Management ProcessManagement Process

Classify the child’s illness:Classify the child’s illness: Use a color-coded Use a color-coded triage system to classify triage system to classify the child’s main the child’s main symptoms and his or symptoms and his or her nutrition or feeding her nutrition or feeding status.status.

Summary of the Integrated Summary of the Integrated Case Management ProcessCase Management Process

IF URGENTIF URGENT

REFERRALREFERRAL

is needed and is needed and possiblepossible


IDENTIFY URGENT IDENTIFY URGENT PRE-REFERRAL PRE-REFERRAL TREATMENT(S)TREATMENT(S)

Needed prior to Needed prior to referral of the child referral of the child

according to according to classificationclassification


TREAT THE TREAT THE CHILD:CHILD:

Give urgent pre-Give urgent pre-referral referral treatment(s) treatment(s) needed.needed.


REFER THE CHILD:REFER THE CHILD:Explain to the child’s Explain to the child’s

caretaker the need for caretaker the need for referral. referral.

Calm the caretaker’s Calm the caretaker’s fears and help resolve fears and help resolve any problems. Write a any problems. Write a referral note. referral note.

Give instructions and Give instructions and supplies needed to care supplies needed to care for the child on the way for the child on the way to the hospitalto the hospital


IF NO URGENT IF NO URGENT REFERRAL REFERRAL

is needed oris needed orPossiblePossible


IDENTIFY IDENTIFY TREATMENT TREATMENT

needed for the needed for the child’s child’s

classifications: classifications: identify specific identify specific

medical medical treatments and/or treatments and/or

adviceadvice


TREAT THE CHILD:TREAT THE CHILD:Give the first dose of Give the first dose of

oral drugs in the clinic oral drugs in the clinic and/or advice the and/or advice the child’s caretaker.child’s caretaker.

Teach the caretaker Teach the caretaker how to give oral drugs how to give oral drugs and how to treat local and how to treat local infections at home.infections at home.

If needed, give If needed, give immunizations.immunizations.


COUNSEL THE MOTHER:COUNSEL THE MOTHER:Assess the child’s feeding, Assess the child’s feeding,

including breastfeeding including breastfeeding practices, and solve feeding practices, and solve feeding problems, if present. problems, if present.

Advise about feeding and Advise about feeding and fluids during illness and about fluids during illness and about when to return to a health when to return to a health facility.facility.

Counsel the mother about her Counsel the mother about her own health.own health.


FOLLOW-UP FOLLOW-UP CARE:CARE:

Give follow-up care Give follow-up care when the child when the child returns to the clinic returns to the clinic and, if necessary, and, if necessary, re-asses the child re-asses the child for new problems.for new problems.

SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS

FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic

ASK THE CHILD’S AGE

IF the child is from 1 week up to 2 monthsIF the child is from 2 months up to 5 years

USE THE CHART:œASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

USE THE CHART:œASSESS AND CLASSIFY THE SICK CHILDTREAT THE CHILDCOUNSEL THE MOTHER

THE SICK THE SICK CHILD AGE 2 CHILD AGE 2

MONTHS TO 5 MONTHS TO 5 YEARS: YEARS:

ASSESS AND ASSESS AND CLASSIFYCLASSIFY

Ask the mother or caretaker about the child’s problem.

If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to PART VII)

Check for general danger signs.

Ask the mother or caretaker about the four When a main symptom is present:main symptoms: œassess the child further for signs related toœcough or difficult breathing, the main symptom, andœdiarrhoea, œclassify the illness according to the signsœfever, and œ � ear problem which are present or absent.

Check for signs of malnutrition and anaemia and classify the child’s nutritional status

Check the child’s immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child(PART V), and Counsel the Mother (PART VI)

SUMMARY OF ASSESS AND CLASSIFY

Ask the mother or caretaker about the 4 main symptoms:cough or difficult breathingdiarrhoeafever, andear problem

SUMMARY OF ASSESS AND SUMMARY OF ASSESS AND CLASSIFYCLASSIFY

When a main symptom is present:

Assess the child further for signs related to the main symptom, and

Classify the illness according to the signs which are present or absent

FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC

GREET the mother appropriately andask about her child.LOOK to see if the child’s weight andtemperature have been recordedASK the mother what the child’s problems are

DETERMINE if this is an initial visit or a follow-up visit for this problem

IF this is an INITIAL VISIT for the problem

ASSESS and CLASSIFY the child followingthe guidelines in this part of the handbook (PART II)

GIVE FOLLOW-UP CARE according to the guidelines in PART VII of this handbook

When a child is brought to the clinic

IF this is a FOLLOW-UP VISIT for the problem

Use Good Communication skills:(see also Chapter 25)— Listen carefully to what the mother tells you. — Use words the mother understands— Give the mother time to answer the questions. ---Ask additional questions when the mother is not sure about her answer.Record Important Information

When the child is brought to the When the child is brought to the clinicclinic

Use Good Communication Use Good Communication Skills:Skills:

Listen carefully to what the Listen carefully to what the mother tells youmother tells youUse words the mother Use words the mother understandsunderstandsGive mother time to answer Give mother time to answer questionsquestionsAsk additional questions Ask additional questions when mother not sure of when mother not sure of answeranswer

Record important informationRecord important information

GENERAL DANGER SIGNS

For ALL sick children ask the mother about the child’s problem, thenCHECK FOR GENERAL DANGER SIGNS

CHECK FOR GENERAL DANGER SIGNS

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed

ASK: LOOK:Is the child able to drink or breastfeed? See if the child is lethargic or unconscious Does the child vomit everything?Is the child had convulsions?

Make sure that a child with any danger sign is referred after receiving urgent pre-referral treatment.

Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear problems.CHECK for malnutrition and anaemia, immunization status and for other problems.

GENERAL DANGER SIGNSGENERAL DANGER SIGNS

ASK:ASK:Is the child able to drink Is the child able to drink or breastfeed?or breastfeed?

Does the child vomit Does the child vomit everything?everything?

Has the child had Has the child had convulsions?convulsions?

LOOK:LOOK:See if the child is See if the child is lethargic or unconsciouslethargic or unconscious

Cough or Difficult Breathing

If NO

If YES

IF YES, ASK: LOOK, LISTEN, FEEL:

œFor how long? œCount the breaths in one minute. œLook for chest indrawing

œLook and listen for stridor

}ClassifyCOUGH orDIFFICULTBREATHING

If the child is: Fast breathing is:2 months up 50 breaths perto 12 months minute or more

12 months up 40 breaths perto 5 years minute or more

CHILD MUST BE CALM

CLASSIFY the child’s illness using the colour-coded classification table for cough or difficult breathing.

Then ASK about the main symptoms : fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems

For ALL sick children ask the mother about the child’s problem, check for general danger signs,

Ask about cough or difficult breathing and thenASK : DOES THE CHILD HAVE COUGH?

Cough or Difficult Breathing?Cough or Difficult Breathing?

IF YES, ASK:IF YES, ASK:For how long?For how long?

LOOK, LISTEN, FEEL:LOOK, LISTEN, FEEL:

Count the breaths in one minute.Count the breaths in one minute. 2-12 mos = fast breathing >/= 50/min2-12 mos = fast breathing >/= 50/min 12 mos-5yrs = fast breathing >/= 12 mos-5yrs = fast breathing >/= 40/min40/min

Look for chest indrawingLook for chest indrawingLook and listen for stridorLook and listen for stridor

Classify COUGH or DIFFICULT BREATHINGClassify COUGH or DIFFICULT BREATHING

•Any general danger sign or•Chest indrawing or•Stridor in calm child.

SEVEREPNEUMONIA

OR VERYSEVERE DISEASE

•Give first dose of an appropriate antibiotic.•Refer URGENTLY to hospital.

•Fast breathingPNEUMONIA

•Give an appropriate oral antibiotic for 5 days.•Soothe the throat and relieve the cough with a safe remedy.•Advise mother when to return immediately.•Follow-up in 2 days.

No signs of pneumoniaor very severe disease.

NO PNEUMONIA:COUCH OR COLD

•If coughing more than 30 days, refer for assessment.•Soothe the throat and relieve the cough with a safe remedy.•Advise mother when to return immediately.•Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING

SIGNS CLASSIFY ASIDENTIFY TREATMENT

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

DiarrheaFor ALL sick children ask the mother about the child’s problem, check for general danger signs,

ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHEA?

If NO If YES

Does the child have diarrhea?

IF YES, ASK: LOOK, LISTEN, FEEL:œFor how long? œLook at the child’s general condition. Is the child:œIs there blood in thestool Lethargic or unconscious? Restless or irritable?œLook for sunken eyes.

œOffer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty?

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

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

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition andanaemia, immunization status and for other problems.

Classify DIARRHEA

Child with dehydrationChild with dehydration

DiarrheaDiarrheaDoes the child have Does the child have diarrhea?diarrhea?IF IF YESYES,, ASK: ASK:

For how long?For how long?Is there blood in the Is there blood in the

stool?stool?

LOOK, LISTEN, FEEL:Look at the child’s general condition, is the child:Lethargic or unconscious?Restless or irritable?

Look for sunken eyesOffer the child fluid. Is the child: Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

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

Two of the following signs:Two of the following signs:

Lethargic or unconsciousLethargic or unconscious

Sunken eyesSunken eyes

Not able to drink or drinking Not able to drink or drinking poorlypoorly

Skin pinch goes back very Skin pinch goes back very slowlyslowly

SEVERESEVERE

DEHYDRATIONDEHYDRATION

If child has no other severe classification:If child has no other severe classification:

— — Give fluid for severe dehydration (Plan C).Give fluid for severe dehydration (Plan C).

OROR

If child also has another severe If child also has another severe classification:classification:

— — Refer URGENTLY to hospital with mother Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.giving frequent sips of ORS on the way.

Advise the mother to continue breastfeedingAdvise the mother to continue breastfeeding

If child is 2 years or older and there is If child is 2 years or older and there is cholera in your area, give antibiotic for cholera in your area, give antibiotic for cholera.cholera.

Two of the following signs:Two of the following signs:

Restless, irritableRestless, irritable

Sunken eyesSunken eyes

Drinks eagerly, thirstyDrinks eagerly, thirsty

Skin pinch goes back slowlySkin pinch goes back slowly

SOMESOME

DEHYDRATIONDEHYDRATION

Give fluid and food for some dehydration (Plan B).Give fluid and food for some dehydration (Plan B).

If child also has a severe classification:If child also has a severe classification:

— — Refer URGENTLY to hospital with motherRefer URGENTLY to hospital with mother

giving frequent sips of ORS on the way.giving frequent sips of ORS on the way.

Advise the mother to continue breastfeedingAdvise the mother to continue breastfeeding

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

Follow-up in 5 days if not improving.Follow-up in 5 days if not improving.

Not enough signs to Not enough signs to

classify as some or classify as some or

severe dehydration.severe dehydration. NO NO DEHYDRATIDEHYDRATI

ONON

Give fluid and food to treat diarrhoea Give fluid and food to treat diarrhoea at home (Plan A).at home (Plan A).

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

Follow-up in 5 days if not improving.Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR DEHYDRATION



Dehydration Dehydration presentpresent

SEVERESEVERE

PERSISTENTPERSISTENT

DIARRHEADIARRHEA

Treat dehydration before Treat dehydration before referral unless the child has referral unless the child has another severe classification.another severe classification.

Refer to hospital.Refer to hospital.

No dehydrationNo dehydration PERSISTENTPERSISTENT

DIARRHEADIARRHEA

Advise the mother on feeding a child Advise the mother on feeding a child who has PERSISTENT DIARRHOEA.who has PERSISTENT DIARRHOEA.

Follow-up in 5 days.Follow-up in 5 days.



CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

Blood in the Blood in the stoolstool

DYSENTERYDYSENTERY

Treat for 5 days with an Treat for 5 days with an oral antibioticoral antibiotic recommended for recommended for Shigella in your area.Shigella in your area.

Follow-up in 2 days.Follow-up in 2 days.

CLASSIFICATION TABLE FOR DYSENTERY

SIGNS CLASSIFY AS

IDENTIFY TREATMENT (Urgent pre-referral treatments are

in bold print.)

FeverFor ALL sick children ask the mother about the child’s problem, check for general

danger signs, askabout cough or difficult breathing, diarrhoea and then

ASK: DOES THE CHILD HAVE FEVER?

If NO

If YES

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

IF YES:Decide the Malaria Risk: high or low

THEN ASK: LOOK AND FEEL:œFor how long? œLook or feel for stiff neck.œIf more than 7 days, has œLook for runny nose.fever been present every day? Look for signs of MEASLESœHas the child had measles withinthe last 3 months? œGeneralized rash andœOne of these: cough, runny nose, or red eyes.

If the child has measles now or œLook for mouth ulcers.within the last 3 months: Are they deep and extensive?œLook for pus draining from the eye.œLook for clouding of the cornea.

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

Then ASK about the next main symptom: ear problem, and CHECK for malnutrition and anaemia,immunization status and for other problems.

FeverFeverDoes the child have FEVER?Does the child have FEVER?IF YES,IF YES, decide the malaria risk: high or decide the malaria risk: high or lowlowTHEN ASK:THEN ASK:

For how long?For how long?If more than 7 days, has fever been If more than 7 days, has fever been

present every day?present every day?Has the child had measles within Has the child had measles within

the the last 3 months?last 3 months?

If the child If the child LOOK AND FEEL:LOOK AND FEEL:Look for runny noseLook for runny noseLook or feel for stiff neckLook or feel for stiff neck

LOOK FOR SIGNS OF MEASLESLOOK FOR SIGNS OF MEASLEShas measles now or within the last 3 has measles now or within the last 3 monthsmonths-Rash-Rash -Mouth ulcers-Mouth ulcers-Cough-Cough -Pus from eyes -Pus from eyes-Runny nose -Clouding of cornea-Runny nose -Clouding of cornea

-Red eyes -Red eyes

LOOK FOR SIGNS OF DENGUE/DHF-bleeding tendencies-flushing-(+) tourniquet test-rash

•Any general danger sign•Stiff neck

VERY SEVEREFEBRILE DISEASE

•Give first dose of an appropriate antibiotic.•Treat the child to prevent low blood sugar.•Give one dose of paracetamol in clinic for high fever (38.5° C or above).•Refer URGENTLY to hospital.

•NO general danger sign AND•NO Stiff neck.

FEVER—MALARIA UNLIKELY

•Give one dose of paracetamol in clinic for high fever (38.5° C or above).•Advise mother when to return immediately.•Follow-up in 2 days if fever persists.•If fever is present every day for more than 7 days, REFER for assessment.



CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A MALARIA RISK AREA

•Any general danger sign or•Clouding of cornea or•Deep or extensive mouth ulcers.

SEVERE COMPLICATED

MEASLES***

•Give vitamin A.•Give first dose of an appropriate antibiotic.•If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment.•Refer URGENTLY to hospital.

•Pus draining from the eye or•Mouth ulcers

MEASLES WITH EYE OR MOUTH

COMPLICATIONS***

•Give vitamin A.•If pus draining from the eye, treat eye infection with tetracycline eye ointment.•If mouth ulcers, treat with gentian violet. •Follow-up in 2 days.

•Measles now or within the last 3 months. MEASLES

•Give vitamin A.



CLASSIFICATION TABLE FOR MEASLES (IF MEASLES NOW OR WITHIN THE LAST 3 MONTHS)

*** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in other tables.

Fever With RashesFever With Rashes

For ALL sick children ask the mother about the ask about cough or difficult breathing, diarrhoea, fever and then

ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

Does the child have an ear problem?

IF YES ASK:•Is there ear pain?•Is ther 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 the child’s illness using the colour-coded-classification table for ear problem.

Then CHECK for malnutrition and anaemia, immunization status and for other problems.

If NO If YES

Ear Problem

Ear ProblemEar Problem

Does the child have an EAR Does the child have an EAR PROBLEM?PROBLEM?IF IF YESYES, ASK, ASK

Is there ear pain?Is there ear pain?Is there ear discharge? Is there ear discharge?

If yes, for how long?If yes, for how long?

LOOK AND FEEL:LOOK AND FEEL:Look and pus draining Look and pus draining from the earfrom the earFeel for tender swelling Feel for tender swelling behind the ear.behind the ear.

•Tender swelling behind the ear. MASTOIDITIS

•Give first dose of an appropriate antibiotic. •Give first dose of paracetamol for pain. •Refer URGENTLY to hospital.

•Pus is seen draining from the ear and discharge is reported for less than 14 days, or •Ear pain.

ACUTE EAR INFECTION

•Give an oral antibiotic for 5 days.•Give paracetamol for pain. •Dry the ear by wicking. •Follow-up in 5 days.

•Pus is seen draining from the ear and discharge is reported for 14 days or more.

CHRONIC EARINFECTION

•Dry the ear by wicking. •Follow-up in 5 days.

•No ear pain and No pus seen draining from the ear.

NO EAR INFECTION

No additional treatment



CLASSIFICATION TABLE FOR EAR PROBLEM

For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea, fever, ear problem and then

CHECK FOR MALNUTRITION AND ANAEMIA.

THEN CHECK FOR MALNUTRITION AND ANAEMIA

CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition and anemia

Then CHECK immunization status and for other problems.

LOOK AND FEEL:•Look for visible severe wasting.•Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? •Look for oedema of both feet. •Determine weight for age.

Classify NUTRITIONAL

STATUS

Malnutrition and Anemia

Malnutrition and AnemiaMalnutrition and Anemia

CHECK FOR MALNUTRITION CHECK FOR MALNUTRITION AND ANEMIAAND ANEMIA

LOOK AND FEEL:LOOK AND FEEL:

Look for visible severe wastingLook for visible severe wasting

Look for palmar pallor. Is it:Look for palmar pallor. Is it:

Severe palmar pallor?Severe palmar pallor?

Some palmar pallor?Some palmar pallor?

Look for edema of both feetLook for edema of both feet

Determine weight for ageDetermine weight for age

CLASSIFY NUTRITIONAL CLASSIFY NUTRITIONAL STATUSSTATUS

Child with Anemia and Child with Anemia and MalnutritionMalnutrition

•Visible severe wasting or •Severe palmar pallor or •Oedema of both feet.

SEVERE MALNUTRITION OR SEVERE ANAEMIA

•Give Vitamin A.•Refer URGENTLY to hospital.

•Some palmar pallor or •Very low weight for age.

ANAEMIA OR VERYLOW WEIGHT

•Assess thefeeding according to the FOOD box on the COUNSEL

THE MOTHER chart.— If feeding problem, follow-up in 5 days.•If pallor:— Give iron.— Give oral antimalarial if high malaria risk.— Give mebendazole if child is 2 years or older andhas not had a dose in the previous 6 months.•Advise mother when to return immediately.•If pallor, follow-up in 14 days.If very low weight for age, follow-up in 30 days.

•Not very low weight for age and no other signs or malnutrition.

NO ANAEMIA AND NOT VERY LOW WEIGHT

•If child is less than 2 years old, assess thefeeding and counsel the mother on feedingaccording to the FOOD box on the COUNSEL THEMOTHER chart.— If feeding problem, follow-up in 5 days.•Advise mother when to return immediately.



CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA

THEN CHECK THE CHILD’S IMMUNIZATION STATUS

For ALL sick children ask the mother about the child’s about cough or difficult breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia

andCHECK IMMUNIZATION STATUS.

IMMUNIZATION SCHEDULE:

AGEBirth6 weeks10 weeks14 weeks 9 months

VACCINEBCGDPT-1DPT-2DPT-3Measles

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

DECIDE if the child needs an immunization today, or if the mother should be told to come back with the child at a later date for an immunization.

Note: Remember there are no contraindications to immunization of a sick child if the child is well enough to go home.

Then CHECK for other problems.

Immunization Status

Immunization StatusImmunization StatusCHECK IMMUNIZATION CHECK IMMUNIZATION STATUS:STATUS:

IMMUNIZATION IMMUNIZATION SCHEDULESCHEDULE

BirthBirth - BCG, HepB1 - BCG, HepB1 6 weeks6 weeks - DPT1, OPV1, - DPT1, OPV1,

HepB2HepB210 weeks -10 weeks - DPT2, DPT2,

OPV2, OPV2, HepB3HepB3

14 weeks14 weeks - DPT3, OPV3, - DPT3, OPV3, HepBboosterHepBbooster

9 mos9 mos - measles - measles

How to check the Immunization How to check the Immunization StatusStatus

If an infant has not If an infant has not received any received any immunization, then giveimmunization, then give– BCGBCG– DPT 1 , OPV 1DPT 1 , OPV 1– Hepatitis B 1 Hepatitis B 1

THE SICK YOUNG THE SICK YOUNG INFANT AGE 1 WEEK INFANT AGE 1 WEEK

UP TO 2 MONTHS:UP TO 2 MONTHS: ASSESS AND ASSESS AND

CLASSIFYCLASSIFY

Ask the mother or caretaker about the youngAsk the mother or caretaker about the young

If this is an INITIAL VISIT for the problem, follow the steps below.(If this is a follow-up visit for the problem, give follow-up care according to

PART VII)

Check for POSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker aboutDIARRHOEA:

If diarrhoea is present:•assess the infant further for signs related to diarrhoea, and •classify the illness according to the signs which are present or absent.

Check for FEEDING PROBLEM OR LOW WEIGHT and classify the

Check the infant’s immunization status and decide if the infant needs any immunization today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Infant (PART V), and Counsel the Mother (PART VI)

SUMMARY OF ASSESS AND CLASSIFY

CHECK FOR POSSIBLE BACTERIAL INFECTION

For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION

ASK:•Has the infant had convulsions?

LOOK, LISTEN, FEEL:•Count the breaths in one minute. Repeat the count if elevated.•Look for severe chest indrawing.•Look for nasal flaring•Look and listen for grunting.•Look and feel for bulging fontanelle.•Look for pus draining from the ear.•Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin?

•Measure temperature (or feel for fever or low body temperature)•Look for skin pustules. Are there many or severe pustules?•See if the young infant is lethargic or unconscious.•Look at the young infants’s movements. Are they less than normal?

YOUNG INFANT

MUST BE CALM

CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION.

Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other problems.

How to check a young infant for possible bacterial infection

•Convulsions or•Fast breathing (60 breaths per minute or more) or •Severe chest indrawing or •Nasal flaring or •Grunting or •Bulging fontanelle or •Pus draining from ear or •Umbilical redness extending to the skin or •Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or •Many or severe skin pustules or •Lethargic or unconscious or •Less than normal movement.

POSSIBLE SERIOUS

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 hospital.•Refer URGENTLY to hospital

•Red umbilicus or draining pus or •Skin pustules.

LOCAL BACTERIAL INFECTION

•Give an appropriate oral antibiotic.•Teach the mother to treat local infections at home. •Advise mother to give home care for the young infant.•Follow-up in 2 days



*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.

CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION

For ALL sick young infants check for signs of possible bacterial infection and then

ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSESS AND CLASSIFY the young infant’s diarrhoea using the DIARRHOEA box in the YOUNG INFANT chart. The

process is very similar to the one used for the sick child (see Chapter 8).

Then CHECK for feeding problem or low weight, immunization status and other problems.

How to assess and classify a young infant for diarrhea?

For ALL sick young infants check for signs of possible bacterial infection, ask aboutdiarrhoea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

ASK: LOOK, LISTEN, FEEL:œ Is there any difficulty feeding? œ Determine weight for age.� �œ Is the infant breastfed? If yes,how many times in 24 hours?�œ Does the infant usually receive any other foods or drinks?�If yes, how often?œ What do you use to feed the infant?�

IF AN INFANT: Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to hospital:ASSESS BREASTFEEDING:œ Has the infant If the infant has not fed in the previous hour, ask the mother to put her�breastfed in the infant to the breast. Observe the breastfeed for 4 minutes.previous hour? (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.) œ Is the infant able to attach?� no attachment at all not well attached good attachment

TO CHECK ATTACHMENT, LOOK FOR:— Chin touching breast— Mouth wide open— Lower lip turned outward— More areola visible above then below the mouth(All these signs should be present if the attachment is good.)Is the infant suckling effectively (that is, slow deep sucks,sometimes pausing)?no suckling at all not suckling effectively suckling effectivelyClear a blocked nose if it interferes with breastfeeding.œ Look for ulcers or white patches in the mouth (thrush).�

CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight.

Then CHECK immunization status and for other problems.

•Not able to feed or• No attachment at all or •Not suckling at all.

NOT ABLE TO FEED POSSIBLE

SERIOUS BACTERIAL INFECTION

•Give first dose of intramuscular antibiotics. •Treat to prevent low blood sugar.•Advise the mother how to keep the young infant warm on the way to hospital.•Refer URGENTLY to hospital.

•Not well attached to breast or •Not suckling effectively or •Less than 8 breastfeeds in 24 hours or •Receives other foods or drinks or •Low weight for age or •Thrush (ulcers or white patches in mouth).

FEEDING PROBLEM OR LOW WEIGHT

• Advise the mother to breastfeed as often and for as long as the infant wants, day and night.

-If not well attached or not suckling effectively, teach correct positioning and attachment.-If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding.

• 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 counselling and possible relactation.— Advise about correctly prepared breastmilk substitutes and using a cup.

• If thrush, teach the mother to treat thrush at home. • Advise mother to give home care for the young infant.•Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days.

•Not low weight for age 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.



CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT

Communicate and CounselCommunicate and Counsel

How will you prepare the ORS solution? Do you remember how to mix the ORS?

GOOD CHECKING QUESTIONS POOR QUESTIONS

How often should you breastfeed your child? Should you breastfeed your child?

On what part of the eye do you apply Have you used ointment on your child the ointment? before?

How much extra fluid will you give after each Do you know how to give extra loose stool? fluids?

Why is it important for you to wash your hands? Will you remember to wash your hands?

GIVE FOLLOW-UP GIVE FOLLOW-UP CARECARE

Follow-up care for the sick young Follow-up care for the sick young infantinfant

When to return immediatelyWhen to return immediately– Signs of any of the following:Signs of any of the following:

– Breastfeeding or drinking Breastfeeding or drinking poorlypoorly

– Becomes sickerBecomes sicker– Develops a feverDevelops a fever– Fast breathing Fast breathing – Difficult breathing Difficult breathing – Blood in the stool Blood in the stool

Follow-up care for the sick young Follow-up care for the sick young infantinfant

Follow-up in 2 daysFollow-up in 2 days – on – on antibiotics for local bacterial antibiotics for local bacterial infection or dysenteryinfection or dysentery

Follow-up in 2 daysFollow-up in 2 days - with a - with a feeding problem or oral thrushfeeding problem or oral thrush

Follow-up in 14 daysFollow-up in 14 days – with low – with low weight for ageweight for age

If the child has: Return for follow-up in:

PNEUMONIADYSENTERYMALARIA, if fever persistsFEVER—MALARIA UNLIKELY, if fever persistsMEASLES WITH EYE OR MOUTH COMPLICATIONS

2 days

PERSISTENT DIARRHOEA ACUTE EAR INFECTIONCHRONIC EAR INFECTIONFEEDING PROBLEMANY OTHER ILLNESS, if not improving

5 days

PALOR VERY

14 days

LOW WEIGHT FOR AGE 30 days

FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

CHECK FOR POSSIBLE BACTERIAL INFECTION•Has the infant had convulsions?

•Count the breaths in one minute. _______ breaths per minute Repeat if elevated ________ Fast breathing?•Look for severe chest indrawing. •Look for nasal flaring.•Look and listen for grunting.•Look and feel for bulging fontanelle. •Look for pus draining from the ear. •Look at umbilicus. Is it red or draining pus? Does the redness extend to the skin?•Fever (temperature 37.5 C or feels hot) or low body temperature (below 35.5° C or feels cool). •Look for skin pustules. Are there many or severe pustules?•See if young infant is lethargic or unconscious.•Look at young infant's movements. Less than normal?

DOES THE YOUNG INFANT HAVE DIARRHOEA?•For how long? _______ Days•Is there blood in the stools?

Yes _____ No ______•Look at the young infant's general condition. Is the infant: Lethargic or unconscious? Restless or irritable?•Look for sunken eyes.•Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

Name:___________ Age:___________ Weight:____________________ kg________________________Temperature:_______________C ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________ ASSESS (Circle all signs present) CLASSIFY

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT•Is there any difficulty feeding? Yes_____ No______•Is the infant breastfed? Yes_____ No_____•IfYes, how many times in 24 hours?_____ times•Does the infant usually receive any other foods or drinks? Yes_____ No_____ If Yes, how often?

•What do you use to feed the child?

ASSESS BREASTFEEDING:•Has the infant breastfed in the previous hour?

•Determine weight for age. Low _____ Not Low _____

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:

— Chin touching breast Yes _____ No _____— Mouth wide open Yes _____ No _____— Lower lip turned outward Yes _____ No _____— More areola above than below the mouth

Yes _____ No _____no attachment at all not well attached good attachment•Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?not suckling at all not suckling effectively suckling effectively•Look for ulcers or white patches in the mouth (thrush).

CHECK THE YOUNG INFANT'S IMMUNIZATION STATUSBCG DPT1 DPT2OPV 0 OPV 1 OPV 2

Circle immunizations needed today. Return for next immunization on:

(Date)

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

Name:___________ Age:___________ Weight:____________________ kg________________________Temperature:_______________C ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________ ASSESS (Circle all signs present) CLASSIFY

If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to hospital:

TREAT

Return for follow-up on _________________Give any immunization/s needed today.

CHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHINGCONVULSION

LETHARGIC OR UNCONSCIOUS

General danger signspresent?

Yes ___ No ___Remember to usedanger sign when

selecting classifications

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?•For how long? ____ Days

Yes ___ No ___•Count the breaths in one minute.________ breaths per minute. Fast breathing? •Look for chest indrawing.•Look and listen for stridor.

DOES THE CHILD HAVE DIARRHOEA?•For how long? _____ Days•Is there blood in the stools?

Yes ___ No ___•Look at the child's general condition. Is the child: Lethargic or unconscious? Restless or irritable?•Look for sunken eyes.•Offer the child fluid. Is the 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?

Name: ____________________________________________________________________Age:____________________Weight:_______kg Temperature:________ C ASK: What are the child's problems?_______________________________________________________________________Initial visit?________________Follow-up Visit?__________

ASSESS (Circle all signs present) CLASSIFY

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

Decide Malaria Risk: High Low•For how long? _____ Days•If more than 7 days, has fever been present every day?•Has child had measles within the last three months?

If the child has measles now or within the last 3 months:

•Look or feel for stiff neck.•Look for runny nose.Look for signs of MEASLES:Generalized rash andOne of these: cough, runny nose, or red eyes.

•Look for mouth ulcers.If Yes, are they deep and extensive? •Look for pus draining from the eye. •Look for clouding of the cornea.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___

DOES THE CHILD HAVE AN EAR PROBLEM?•Is there ear pain?•Is there ear discharge? IfYes, for how long? ___ Days

Yes___ No___•Look for pus draining from the ear. •Feel for tender swelling behind the ear.

THEN CHECK FOR MALNUTRITION AND ANAEMIA •Look for visible severe wasting. •Look for palmar pallor. Severe palmar pallor? Some palmar pallor? •Look for oedema of both feet.•Determine weight for age. Very Low ___ Not Very Low ___

CHECK THE CHILD'S IMMUNIZATION STATUS _____ ______ ______ ______ BCG DPT1 DPT2 DPT3

_______ _______ ______ ______ ________OPV 0 OPV 1 OPV 2 OPV 3 Measles

Circle immunizations needed today. Return for next immunization on:

(Date)

•Do you breastfeed your child? Yes____ No ____ IfYes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes___ No___ •Does the child take any other food or fluids? Yes___ No ___ IfYes, what food or fluids? ________________________________________________________________________________________________________How many times per day? ___ times. What do you use to feed the child? _____________________ If very low weght for age: How large are servings?_________________________________________________Does the child receive how own serving? ________________ Who feeds the child and how? ________________________

•During the illness, has the child's feeding changed? Yes ____ No ____ If Yes, how?

FEEDING PROBLEMS

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

TREAT

Return for follow-up on ______________Advise mother when to return immediately.Give any immunization/s needed today.

Feeding Advice

CATEGORIES OF PROVINCES CONSIDERED CATEGORIES OF PROVINCES CONSIDERED WITH MALARIAWITH MALARIA

Category A – Provincews with no significant improvement in Category A – Provincews with no significant improvement in malaria situation in the last 10 years or situation worsened in the malaria situation in the last 10 years or situation worsened in the last 5 yrs; average no. of cases >1000 in the last 10 yrslast 5 yrs; average no. of cases >1000 in the last 10 yrs

- Kalinga - Mindoro Occ - Compostela valley- Kalinga - Mindoro Occ - Compostela valley

- Apayao - Palawan - Saranggani- Apayao - Palawan - Saranggani

- Mt. Province - Quezon - Zamboanga del Sur- Mt. Province - Quezon - Zamboanga del Sur

- Ifugao - Misamis Or - Agusan del Sur - Ifugao - Misamis Or - Agusan del Sur

- Isabela - Davao del Norte - Agusan del Norte- Isabela - Davao del Norte - Agusan del Norte

- Cagayan - Davao del Sur - Surigao del Sur- Cagayan - Davao del Sur - Surigao del Sur

- Quirino - Davao oriental - Tawi-tawi- Quirino - Davao oriental - Tawi-tawi

- Zambales - Bukidnon - Sulu - Basilan- Zambales - Bukidnon - Sulu - Basilan

Category B – Provinces where situation has improved in the Category B – Provinces where situation has improved in the last 5yrs or average no. of cases 100 to <1000 cases/yrlast 5yrs or average no. of cases 100 to <1000 cases/yr

- Abra - Laguna- Abra - Laguna - Pangasinan - Camarines Norte- Pangasinan - Camarines Norte - Ilocos norte - Camarines Sur- Ilocos norte - Camarines Sur - Nueva Vizcaya - Sultan Kudarat- Nueva Vizcaya - Sultan Kudarat - Nueva Ecija - So. Cotabato- Nueva Ecija - So. Cotabato - Bulacan - North Cotabato- Bulacan - North Cotabato - Bataan - Lanao del Sur- Bataan - Lanao del Sur - Mindoro Or - Lanao del Norte- Mindoro Or - Lanao del Norte - Rizal - Maguindanao- Rizal - Maguindanao - Aurora - Zamboanga del Norte- Aurora - Zamboanga del Norte - Tarlac - Romblon- Tarlac - Romblon

Category C – Provinces with significant reduction Category C – Provinces with significant reduction in cases in the last 5 yrsin cases in the last 5 yrs

- Benguet - Antique- Benguet - Antique

- Ilocos Sur - Sorsogon- Ilocos Sur - Sorsogon

- La Union - Negros Occ- La Union - Negros Occ

- Pampanga - Negros Or- Pampanga - Negros Or

- Batangas - Eastern Samar- Batangas - Eastern Samar

- Cavite - Western Samar- Cavite - Western Samar

- Marinduque - Misamis Occ- Marinduque - Misamis Occ

- Masbate - Surigao del Norte- Masbate - Surigao del Norte

- Batanes - Albay- Batanes - Albay

Category D – Provinces that are malaria-free Category D – Provinces that are malaria-free although some are still potentially malarious sue to although some are still potentially malarious sue to

toe presence of the vector.toe presence of the vector.

Cebu Iloilo Biliran Cebu Iloilo Biliran

Bohol Capiz Leyte Norte and Bohol Capiz Leyte Norte and

and Surand Sur

Catanduanes GuimarasCatanduanes Guimaras

Aklan SiquijorAklan Siquijor

Northern Samar CamiguinNorthern Samar Camiguin

IMCIIMCI

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Health & Medicine

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