Chart Booklet: Integrated Management o F Childhood Illness

Integrated Management of Childhood Illness
Chart Booklet
March 2014
WHO Library Cataloguing-in-Publication Data:
Integrated Management of Childhood Illness: distance learning course.
15 booklets
Contents: - Introduction, self-study modules – Module 1: general danger signs for
the sick child – Module 2: The sick young infant – Module 3: Cough or difficult
breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition
and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9:
Care of the well child – Facilitator guide – Pediatric HIV: supplementary
facilitator guide – Implementation: introduction and roll out – Logbook – Chart
book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and

control. 4.Delivery of Health Care, Integrated. 5.Disease Management.
6.Education, Distance. 7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)
© World Health Organization 2014
All rights reserved. Publications of the World Health Organization are available on the WHO
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Printed in Switzerland
Integrated Management of Childhood Illness
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SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
ASSESS AND CLASSIFY THE SICK CHILD

ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE
Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS on
TREAT THE CHILD chart. if initial visit, assess the child as follows:
CHECK FOR GENERAL DANGER SIGNS
Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referal treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
3DJHRI
THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?
If yes, ask: Look, listen,
For how long? feel*: Any general danger Pink: Give first dose of an appropriate antibiotic
Count the sign or SEVERE Refer URGENTLY to hospital**
Classify Stridor in calm child. PNEUMONIA
breaths in
COUGH or OR
one
DIFFICULT VERY SEVERE
minute. BREATHING DISEASE
Look for
chest Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
CHILD Fast breathing. PNEUMONIA If wheezing (or disappeared after
indrawing. rapidly acting bronchodilator) give an
MUST BE inhaled
Look bronchodilator for 5 days****
andCALM If chest indrawing in HIV exposed/infected
listen for stridor. child, give first dose of amoxicillin and refer.
Look and Soothe the throat and relieve the cough with
listen for a safe remedy
wheezing. If coughing for more than 14 days or
If wheezing with either recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for Follow-up in 3 days
If the child is: up to three times 15-20 No signs of pneumonia or Green: If wheezing (or disappeared after rapidly
2 months up to 12 months minutes apart. Count the very severe disease. COUGH OR acting bronchodilator) give an inhaled
breaths and look for chest COLD bronchodilator for
12 Months up to 5 years indrawing again, and then 5 days****
classify. Soothe the throat and relieve the cough with
Fast breathing is: a safe remedy
If coughing for more than 14 days or
50 breaths per minute or recurrent
more
wheezing, refer for possible TB or asthma
40 breaths per minute or assessment
more Advise mother when to return immediately
*If pulse oximeter is available, determine oxygen saturation and refer if < 90%. Follow-up in 5 days if not improving
** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze.
3DJHRI
Does the child have diarrhoea?
Two of the following signs: Pink: If child has no other severe

Lethargic or SEVERE classification: Give fluid for severe
If yes, ask: Look and feel: unconscious DEHYDRATION dehydration (Plan C)
Sunken eyes OR
For how long? Look at the child's
for DEHYDRATION Not able to drink or If child also has another severe
Is there blood in the general condition. Is
drinking poorly classification:
stool? the child: Lethargic or
Skin pinch goes back very Refer URGENTLY to hospital with
unconscious? Classify
slowly. mother giving frequent sips of ORS on
Restless and DIARRHOEA the way
irritable? Look for Advise the mother to continue
sunken eyes. breastfeeding
Offer the child fluid. Is If child is 2 years or older and there is
the child: cholera in your area, give antibiotic for
Not able to drink or cholera
drinking poorly? Two of the following signs: Yellow: Give fluid, zinc supplements, and food for
Drinking eagerly, Restless, irritable some dehydration (Plan B)
SOME
thirsty? If child also has a severe classification:
Sunken eyes DEHYDRATION
Pinch the skin of the Refer URGENTLY to hospital with
Drinks eagerly, thirsty
abdomen. Does it go mother giving frequent sips of ORS on
Skin pinch goes back
back: Very slowly slowly. the way
(longer than 2 Advise the mother to continue
seconds)? breastfeeding
Slowly? Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to
as some or severe NO treat diarrhoea at home (Plan A)
dehydration. DEHYDRATION Advise mother when to return immediately
Dehydration present. Pink: Treat dehydration before referral unless the

SEVERE child
and if diarrhoea 14 PERSISTENT has another severe classification
DIARRHOEA Refer to hospital
days or more
No dehydration. Yellow: Advise the mother on feeding a child who
PERSISTENT has
DIARRHOEA PERSISTENT DIARRHOEA
Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days
Blood in the stool. Yellow: Give ciprofloxacin for 3 days
DYSENTERY Follow-up in 3 days
and if blood in stool
3DJHRI
Does the child have fever?
If yes: ok and feel:

Decide Malaria Risk: high or low Look or feel for stiff neck.
Then ask: LoLook for runny nose.
For how long? Look for any bacterial cause of High or Low Malaria
If more than 7 days, has fever fever**. Risk
been present every day? Look for signs of MEASLES.
Has the child had measles Generalized rash and
within the last 3 months? One of these: cough, runny nose, Classify FEVER
or red eyes.
fication
Do a malaria test***: If NO severe classi

In all fever cases if High malaria risk.
In Low malaria risk if no obvious cause of fever
present.
No Malaria Risk and No

Travel to Malaria Risk
Area
Look for mouth ulcers.

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

months, Classify
Any general danger sign or Pink: Give first dose of artesunate or quinine for severe malaria
Stiff neck. VERY SEVERE Give first dose of an appropriate antibiotic
FEBRILE DISEASE Treat the child to prevent low blood sugar
*LYHRQHGRVHRISDUDFHWDPROLQFOLQLFIRUKLJKIHYHUƒ& or
above)
Refer URGENTLY to hospital
Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
MALARIA *LYHRQHGRVHRISDUDFHWDPROLQFOLQLFIRUKLJKIHYHUƒ& or
E\KLVWRU\RUIHHOVKRWRUWHPSHUDWXUHƒ& RUDERYH above)
Give appropriate antibiotic treatment for an identified bacterial
cause of fever
7KHVHWHPSHUDWXUHVDUHEDVHGRQD[LOODU\WHPSHUDWXUH5HFWDOWHPSHUDWXUHUHDGLQJVDUHDSSUR[LPDWHO\ƒ&KLJKHU
Advise mother when to return immediately
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain
Follow-up in 3 days if fever persists
or pain on passing urine in older children. *** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria If fever is present every day for more than 7 days, refer for
risk AND NO obvious cause of fever - classify as MALARIA. assessment
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are Malaria test NEGATIVE Green: *LYHRQHGRVHRISDUDFHWDPROLQFOLQLFIRUKLJKIHYHUƒ& or
classified in other tables.
Other cause of fever PRESENT. FEVER: above)
NO MALARIA Give appropriate antibiotic treatment for an identified
bacterial cause of fever
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign Pink: Give first dose of an appropriate antibiotic.
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
DISEASE *LYHRQHGRVHRISDUDFHWDPROLQFOLQLFIRUKLJKIHYHUƒ& or
above).
Refer URGENTLY to hospital.
No general danger Green: FEVER *LYHRQHGRVHRISDUDFHWDPROLQFOLQLFIRUKLJKIHYHUƒ& or
signs No stiff neck. above)
Give appropriate antibiotic treatment for any identified
bacterial cause of fever
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign or Pink: Give Vitamin A treatment

Clouding of cornea or SEVERE Give first dose of an appropriate antibiotic
Deep or extensive mouth ulcers. COMPLICATED If clouding of the cornea or pus draining from the eye, apply
MEASLES**** tetracycline eye ointment Refer URGENTLY to hospital
Pus draining from the eye or Yellow: Give Vitamin A treatment

Mouth ulcers. MEASLES WITH EYE If pus draining from the eye, treat eye infection with
OR tetracycline eye ointment
MOUTH If mouth ulcers, treat with gentian violet
COMPLICATIONS**** Follow-up in 3 days
Measles now or within the last 3 Green: Give Vitamin A treatment

months. MEASLES
3DJHRI
Does the child have an ear problem?

If yes, ask: Look and feel:
Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Is Look for pus draining
from the ear. ear. MASTOIDITIS Give first dose of paracetamol for pain
there ear discharge?
Feel for tender swelling Refer URGENTLY to hospital
If yes, for how long? Classify EAR PROBLEM
behind the ear. Pus is seen draining Yellow: Give an antibiotic for 5 days
from the ear and ACUTE EAR Give paracetamol for pain
discharge is reported INFECTION Dry the ear by wicking
for less than 14 Follow-up in 5 days
days, or Ear
pain. Yellow: Dry the ear by wicking
Pus is seen draining CHRONIC EAR Treat with topical quinolone eardrops for 14
from the ear and discharge INFECTION days Follow-up in 5 days
is reported for 14 days or
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR
the ear. INFECTION
3DJHRI
3DJHRI
THEN CHECK FOR ANAEMIA

Check for anaemia
Look for palmar pallor. Is it: Severe palmar pallor Pink: Refer URGENTLY to hopsital
Severe palmar pallor*? SEVERE
ANAEMIA
Some palmar pallor? Classify
Some pallor Yellow: Give iron**
ANAEMIA Classification
arrow ANAEMIA Give mebendazole if child is 1 year or older
and has not had a dose in the previous 6
months
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother
according to the feeding recommendations
If feeding problem, follow-up in 5 days
*Assess for sickle cell anaemia if common in your area.

**If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.
3DJHRI
3DJHRI
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS
IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE
Birth BCG* OPV-0 Hep B0 VITAMIN A
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1*** SUPPLEMENTATION
Give every child a
10 weeks DPT+HIB-2 OPV-2 Hep B2 RTV2 PCV2 dose of Vitamin A
every six months

from the age of 6
months. Record the
dose on the child's
chart.
14 weeks DPT+HIB-3 OPV-3 Hep B3 RTV3 PCV3 ROUTINE WORM
TREATMENT
Give every child
mebendazole every 6
9 months Measles ** months from the age
of one year. Record
the dose on the
18 months DPT child's card.
*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated.
**Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.
ASSESS OTHER PROBLEMS:
after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED
blood sugar.
3DJHRI
3DJHRI
3DJHRI
TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table. Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION:
Determine the appropriate drugs and dosage for the child's age or weight.
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
Tell the mother the reason for giving the drug to the child. AMOXICILLIN*
Demonstrate how to measure a dose. Give two times daily for 5 days
Watch the mother practise measuring a dose by herself. AGE or WEIGHT
TABLET SYRUP
Ask the mother to give the first dose to her child. 250 mg 250mg/5 ml
Explain carefully how to give the drug, then label and package the drug. If more than one
2 months up to 12 months (4 - <10 kg) 1 5 ml
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 12 months up to 3 years (10 - <14 kg) 2 10 ml
treatment, even if the child gets better. 3 years up to 5 years (14-19 kg) 3 15 ml
* Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy and
Check the mother's understanding before she leaves the clinic.
increasing high resistance to cotrimoxazole.
FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:
ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
COTRIMOXAZOLE
(trimethoprim + sulfamethoxazole)
Give once a day starting at 4-6 weeks of age

AGE
Syrup Paediatric tablet Adult tablet
(40/200 mg/5ml) (Single strength 20/100 mg) (Single strength 80/400 mg)
Less than 6 months 2.5 ml 1 -
6 months up to 5 years 5 ml 2 1/2
FOR DYSENTERY give Ciprofloxacine
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
CIPROFLOXACINE
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet 500 mg tablet
Less than 6 months 1/2 1/4
6 months up to 5 years 1 1/2
FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
ERYTHROMYCIN TETRACYCLINE
Give four times daily for 3 days Give four times daily for 3 days
ජ AGE or WEIGHT
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1

3DJHRI
3DJHRI
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.
Give Iron*
Give one dose daily for 14 days.
IRON/FOLATE
IRON SYRUP
TABLET
AGE or WEIGHT Ferrous sulfate

PJ—J Ferrous fumarate 100 mg per 5 ml (20 mg
Folate (60 mg elemental iron per ml)
elemental iron)
2 months up to 4 months (4 -
1.00 ml (< 1/4 tsp. )
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp. )
(6 - <10 kg)
12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp. )
(10 - <14 kg )
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
19 kg)
* Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
not be given Iron.
3DJHRI
3DJHRI
GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC

Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately
Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHILDREN
Thereafter vitamin Aevery six months to ALL CHILDREN
VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) for
treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A within the past
month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
Always record the dose of Vitamin A given on the child's card.
AGE VITAMIN A DOSE
6 up to 12 months 100 000IU
One year and older 200 000IU
Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.
3DJHRI
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:
Ask the mother to breastfeed the child.
If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
If neither of these is available, give sugar water*.
Give 30 - 50 ml of milk or sugar water* before departure.
If the child is not able to swallow:
Give 50 ml of milk or sugar water* by nasogastric tube.
If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
water.
3DJHRI
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart) In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
PLAN A: TREAT DIARRHOEA AT HOME AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5 months
months years years
Counsel the mother on the 4 Rules of Home Treatment: In ml 200 - 450 450 - 800 800 - 960 960 - 1600
1. Give Extra Fluid * Use the child's age only when you do not know the weight. The approximate amount of ORS
required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
2. Give Zinc Supplements (age 2 months up to 5 years) 3.
If the child wants more ORS than shown, give more.
Continue Feeding
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
4. When to Return. period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
1. GIVE EXTRA FLUID (as much as the child will take)
Give frequent small sips from a cup.
TELL THE MOTHER: If the child vomits, wait 10 minutes. Then continue, but more slowly.
Breastfeed frequently and for longer at each feed. Continue breastfeeding whenever the child wants.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. AFTER 4 HOURS:
If the child is not exclusively breastfed, give one or more of the following: ORS solution, Reassess the child and classify the child for dehydration.
food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water. Select the appropriate plan to continue treatment.
It is especially important to give ORS at home when: Begin feeding the child in clinic.
the child has been treated with Plan B or Plan C during this visit. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
the child cannot return to a clinic if the diarrhoea gets worse. Show her how to prepare ORS solution at home.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF Show her how much ORS to give to finish 4-hour treatment at home.
ORS TO USE AT HOME. Give her enough ORS packets to complete rehydration. Also give her 2 packets as
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID recommended in Plan A.
INTAKE: Explain the 4 Rules of Home Treatment:
Up to 2 years 50 to 100 ml after each loose stool 1. GIVE EXTRA FLUID
2 years or more 100 to 200 ml after each loose stool 2. GIVE ZINC (age 2 months up to 5 years)
Tell the mother to: 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO
Give frequent small sips from a cup. RETURN
If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue
giving extra fluid until the diarrhoea stops.
2. GIVE ZINC (age 2 months up to 5 years)
TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
2 months up to 6 months 1/2 tablet daily for 14 days
6 months or more 1 tablet daily for 14 days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
ජ
3DJHRI
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
STAR Start IV fluid immediately. If the child can drink, give ORS by
Can you give T mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid HERE Solution (or, if not available, normal saline), divided as follows
immediately? AGE First give Then give
<(6ĺ 30 ml/kg in: 70 ml/kg in:
Infants (under 12 1 hour* 5 hours
NO months)
Ļ Children (12 months 30 minutes* 2 1/2 hours
up to 5 years)
* Repeat once if radial pulse is still very weak or not
detectable.
Reassess the child every 1-2 hours. If hydration status is
not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can
drink: usually after 3-4 hours (infants) or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B, or
C) to continue treatment.
Refer URGENTLY to hospital for IV treatment.

Is IV treatment If the child can drink, provide the mother with ORS solution
available nearby (within <(6ĺ and show her how to give frequent sips during the trip or give
30 minutes)? ORS by naso-gastric tube.
NO
Ļ Start rehydration by tube (or mouth) with ORS solution:
Are you trained to use give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
a naso-gastric (NG) <(6ĺ Reassess the child every 1-2 hours while waiting for
tube for rehydration? transfer:
NOIf there is repeated vomiting or increasing abdominal
Ļ distension, give the fluid more slowly.
Can the child drink? <(6ĺ If hydration status is not improving after 3 hours, send the
child for IV therapy.
NO
After 6 hours, reassess the child. Classify dehydration. Then
Ļ
choose the appropriate plan (A, B or C) to continue treatment.
Refer URGENTLY to NOTE:

hospital for IV or NG If the child is not referred to hospital, observe the child at least
treatment 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
3DJHRI
GIVE READY-TO-USE THERAPEUTIC FOOD
Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Wash hands before giving the ready-to-use therapeutic food (RUTF).
Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
Encourage the child to eat the RUTF without forced feeding.
*LYHVPDOOUHJXODUPHDOVRI587)DQGHQFRXUDJHWKHFKLOGWRHDWRIWHQ±PHDOVSH
UGD\ If still breastfeeding, continue by offering breast milk first before every RUTF
feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE
MOTHER chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other
foods. Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.
Recommended Amounts of Ready-to-Use Therapeutic Food

Packets per day
CHILD'S WEIGHT (kg) Packets per Week Supply
(92 g Packets Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
3DJHRI
TREAT THE HIV INFECTED CHILD
ජ
Steps when Initiating ART in Children

All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage.
Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
INFECTION Child is under 18 months: If child is less than 3 kg or has TB, Refer for ART initiation.
HIV infection is confirmed if virological test (PCR) is positive If child weighs 3 kg or more and does not have TB, GO TO STEP 4
Child is over 18 months:
Two different serological tests are positive
Send any further confirmatory tests required
If results are discordant, refer
If HIV infection is confirmed, and child is in stable condition, GO
TO STEP 2
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT
Check that the caregiver is willing and able to give ART. The CARD Record the following information:
FDUHJLYHUVKRXOGLGHDOO\KDYHGLVFORVHGWKHFKLOG¶V+,9VWDWXV Weight and height
to another adult who can assist with providing ART, or be part of Pallor if present
a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory
Caregiver not able: classify as CONFIRMED HIV INFECTION tests that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the caregiver. Follow-up
regularly. Move to the step 3 once the caregiver is willing and
able to give ART.
STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatement:
Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
Give co-trimoxazole prophylaxis
Give other routine treatments, including Vitamin A and immunizations
Follow-up regularly as per national guidelines
3DJHRI
3DJHRI

ජ
Give Antiretroviral Drugs

LOPINAVIR / RITONAVIR (LPV/r), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)
LOPINAVIR / RITONAVIR (LPV/r) NE VIRAPINE (NVP) EFAVIRENZ (EFV)

WEIGHT dĂƌŐĞƚĚŽƐĞϮϯϬͲϯϱϬ Ő ϸƚǁŝĐĞĚĂŝůǇ Target dose 15 mg/Kg once daily
(KG) 80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet 200 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Once daily
3 - 5.9 1 ml - 5 ml 1 - -
6 - 9.9 1.5 ml - 8 ml 1.5 - -
10 - 13.9 2 ml 2 10 ml 2 - 1
14 - 19.9 2.5 ml 2 - 2.5 - 1.5
20 - 24.9 3 ml 2 - 3 - 1.5
25 - 34.9 - 3 - - 1 2
ABACAVIR (ABC), ZIDOVUDINE (AZT or ZDV) & LAMIVUDINE (3TC)
ABAC AVIR (ABC ) ZIDOVUDINE (AZT or ZDV)

dĂƌŐĞƚĚŽƐĞϭϴϬͲϮϰϬ Ő ϸƚǁŝĐĞĚĂŝůǇ LAMIVUDINE (3TC )
WEIGHT Target dose: 8mg/Kg/dose twice daily
(KG) 20 mg/ml 60 mg dispersible tablet 300 mg 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml 30 mg 150 mg
liquid tablet liquid tablet tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
3DJHRI
ජ
Side Effects ARV Drugs

Very common side-effets: Potentially serious side effects: Side effects occurring later during
treatment:
warn patients and suggest ways patients can warn patients and tell them to seek care discuss with patients
manage;
manage when patients seek care
Abacavir (ABC) Seek care urgently:
Fever, vomiting, rash - this may indicate hypersensitivity to
abacavir
Lamivudine Nausea
(3TC) Diarrhoea
Lopinavir/ritonavir Nausea Changes in fat distribution:

Vomiting Arms, legs, buttocks, cheeks become
THIN
Diarrhoea
Breasts, tummy, back of neck become
FAT
Elevated blood cholesterol and glucose
Nevirapine (NVP) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Severe skin rash
Fatigue AND shortness of breath
Fever
Zidovudine Nausea Seek care urgently:
(ZDV or AZT) Diarrhoea Pallor (anaemia)
Headache
Fatigue
Muscle pain
Efavirenz (EFV) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Strange dreams Psychosis or confusion
Difficulty sleeping Severe skin rash
Memory problems
Headache
Dizziness
3DJHRI
ජ
Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS APPROPRIATE CARE RESPONSE
Yellow eyes (jaundice) or Stop drugs and REFER URGENTLY

abdominal pain
Rash If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is
associated with fever or vomiting: stop drugs and REFER URGENTLY
Nausea Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer.
Vomiting Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being
given.
If vomiting persists, the caregiver should bring the child to clinic for evaluation.
If vomiting everything, or vomiting associated with severe abdominal pain or difficulty breathing, REFER URGENTLY.
Diarrhoea Assess, classify, and treat using diarrhoea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If
not improved after two weeks, call for advice or refer.
Fever Assess, classify, and treat using feve chart.
Headache Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or
refer.
Sleep disturbances, This may be due to efavirenz. Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for
nightmares, anxiety advice or refer.
Tingling, numb or painful feet If new or worse on treatment, call for advice or refer.
or legs
Changes in fat distribution Consider switching from stavudine to abacavir, consider to viral load. Refer if needed.
3DJHRI
Give Pain Relief to HIV Infected Child

Give paracetamol or ibuprofen every 6 hours if pain
persists. For severe pain, morphine syrup can be given.
PARACETAMOL
ORAL MORPHINE
AGE or WEIGHT
TABLET (100 mg) SYRUP (120 mg/5ml) (0.5 mg/5 ml)
2 up to 4 months (4 - <6 kg) - 2 ml 0.5 ml
4 up to 12 months (6 - <10 kg) 1 2.5 ml 2 ml
12 months up to 2 years (10 - <12 kg) 1 1/2 5 ml 3 ml
2 up to 3 years (12 - <14 kg) 2 7.5 ml 4 ml
3 up to 5 years (14 -<19 kg) 2 10 ml 5 ml

Recommended dosages for ibuprofenPJNJRUDOO\HYHU\KWRDPD[LPXPRIPJSHUGD\LHóRIDPJWDEOHWEHORZNJòWDEOHWIRUXSWRNJRIERG\ZHLJKW$YRLG ibuprofen in children under the age
of 3 months.
IMMUNIZE EVERY SICK CHILD AS NEEDED
3DJHRI
FOLLOW-UP
3DJHRI
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
UNCOMPLICATED SEVERE ACUTE MALNUTRITION

After 14 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for oedema of both feet.
Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older.
Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION(WFH/L less than -3 z-scores or
MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION(WFH/L less than -3 z-scores
or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes
appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask
mother to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION(WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell
KHUWRUHWXUQDJDLQLQGD\V&RQWLQXHWRVHHWKHFKLOGHYHU\GD\VXQWLOWKHFKLOG¶V:)+/LV]
scores or more, and/or MUAC is 125 mm or more.
If the child has NO ACUTE MALNUTRITION(WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).
MODERATE ACUTE MALNUTRITION

After 30 days:
Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit:
If WFH/L, weigh the child, measure height or length and determine if WFH/L.
If MUAC, measure using MUAC tape.
Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Treatment:
If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and
encourage her to continue.
If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any
feeding problem found. Ask the mother to return again in one month. Continue to see the child monthly
until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or
MUAC is 125 mm. or more.
Exception:
If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has
diminished, refer the child.
3DJHRI
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD CONFIRMED HIV INFECTION NOT ON ART
Follow up regularly as per national guidelines.
At each follow-up visit follow these instructions:
HIV EXPOSED Ask the mother: Does the child have any problems?
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
Follow up regularly as per national guidelines. new problem
At each follow-up visit follow these instructions: Counsel and check if mother able or willing now to initiate ART for the child.
Ask the mother: Does the child have any problems? Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any counselling
new problem Continue cotrimoxazole prophylaxis if indicated.
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and Initiate or continue isoniazid preventive therapy if indicated.
counselling If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children)
Continue cotrimoxazole prophylaxis Monitor CD4 count and percentage.
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How $VNDERXWWKHPRWKHU¶VKHDOWKSURYLGH+,9FRXQVHOOLQJDQGWHV
often, if ever, does the child/mother miss a dose? WLQJ Home care:
$VNDERXWWKHPRWKHU¶VKHDOWK3URYLGH+,9FRXQVHOOLQJDQGWHVWLQJDQGUHIHUUDOLIQHFH Counsel the mother about any new or continuing problems
VVDU\ Plan for the next follow-up visit If appropriate, put the family in touch with organizations or people who could provide support
HIV testing: Advise the mother about hygiene in the home, in particular when preparing food
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Plan for the next follow-up visit
test result.
5HFKHFNFKLOG¶V+,9VWDWXVVL[ZHHNVDIWHUFHVVDWLRQRIEUHDVWIHHGLQJ5HFODVVLI\WKHFKLOGDFFR
UGLQJ to the test result.
If child is confirmed HIV infected Start on
ART and enrol in chronic HIV care.
Continue follow-up as for CONFIRMED HIV INFECTION ON ART
If child is confirmed uninfected
Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks of
cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about her own health ජ
3DJHRI
3DJHRI
COUNSEL THE MOTHER
FEEDING COUNSELLING
ජ
Assess Child's Appetite

All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (oedema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical
complication should be assessed for appetite.
Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed
to eating the RUTF. Usually the child eats the RUTF portion in 30 minutes.
Explain to the mother:

The purpose of assessing the child's appetite.
What is ready-to-use-therapeutic food (RUTF).
How to give RUTF:
Wash hands before giving the RUTF.
Sit with the child on the lap and gently offer the child RUTF to eat.
Encourage the child to eat the RUTF without feeding by force.
Offer plenty of clean water to drink from a cup when the child is eating the RUTF.
Offer appropriate amount of RUTF to the child to eat:

After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide:
Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
3DJHRI
FEEDING COUNSELLING
Assess Child's Feeding

Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED. Ask questions about the child's usual
feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age.
ASK - How are you feeding your child?
If the child is receiving any breast milk, ASK :
How many times during the day?
Do you also breastfeed during the night?
Does the child take any other food or fluids?

What food or fluids?
How many times per day?
What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What foods are available in the home?
During this illness, has the child's feeding changed?
If yes, how?
In addition, for HIV EXPOSED child:

If mother and child are on ARV treatment or prophylaxis and child breastfeeding, ASK:
Do you take ARV drugs? Do you take all doses, miss doses, do not take medication?
Does the child take ARV drugs (If the policy is to take ARV prophylaxis until 1 week after breastfeeding has stopped)? Does he or she take all doses, missed doses,
does not take medication?
If child not breastfeeding, ASK:
What milk are you giving?
How many times during the day and night?
How much is given at each feed?
How are you preparing the milk?
Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant.
Are you giving any breast milk at all?
Are you able to get new supplies of milk before you run out?
How is the milk being given? Cup or bottle?
How are you cleaning the feeding utensils?
ජ
3DJHRI
FEEDING COUNSELLING
ජ
Feeding Recommendations
Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis
Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months
Immediately after birth, put your baby in skin to Breastfeed as often Breastfeed as Breastfeed as often as
skin contact with you. as your child wants. often as your your child wants. Also
Allow your baby to take the breast within the Look for signs of child wants. give a variety of mashed
first hour. Give your baby colostrum, the first hunger, such as Also give thick or finely chopped family
yellowish, thick milk. It protects the baby from beginning to fuss, porridge or wellmashed food, including
many Illnesses. sucking fingers, or foods, including animalsource foods and
moving lips. animalsource foods and vitamin A-rich fruits and Give a variety of
Breastfeed day and night, as often as your
Breastfeed day and vitamin A-rich fruits and vegetables. Give 3/4 cup at family foods to
baby wants, at least 8 times In 24 hours.
night whenever your vegetables. Breastfeed as often each meal (1 cup = 250 your child,
Frequent feeding produces more milk. If your
baby wants, at least as your child wants. ml). including
baby is small (low birth weight), feed at least Start by giving 2 to 3
8 times in 24 hours. Also give a variety of animalsource
every 2 to 3 hours. Wake the baby for feeding after tablespoons of food. Give 3 to 4 meals
Frequent feeding mashed or finely foods and vitamin
3 hours, if baby does not wake self. Gradually increase each day.
produces more milk. chopped family food, A-rich fruits and
DO NOT give other foods or fluids. Breast milk to 1/2 cups (1 cup = Offer 1 to 2 snacks
Do not give other including vegetables. Give
is all your baby needs. This is especially foods or fluids. 250 ml). between meals.
animalsource foods at least 1 full cup
important for infants of HIVpositive mothers. Breast milk is all Give 2 to 3 meals Continue to feed
and vitamin A-rich (250 ml) at each
Mixed feeding increases the risk of HIV mother- your baby needs. each day. Offer 1 or 2 your child slowly,
snacks each fruits and vegetables.
day patiently. Encourage meal. Give 3 to 4
to-child transmission when compared to
exclusive breastfeeding. between meals when the Give 1/2 cup at each meals each day.
²EXWGRQRWIRUFH² your
child seems hungry. meal(1 cup = 250 ml). Offer 1 or 2
child to eat.
Give 3 to 4 meals snacks between
each day. meals.
Offer 1 or 2 snacks If your child
between meals. The refuses a new
child will eat if food, offer
hungry. "tastes" several
For snacks, give times. Show that
small chewable items you like the food.
that the child can Be patient. Talk
hold. Let your child with your child
try to eat the snack, during a meal,
but provide help if and keep eye
needed. contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
3DJHRI
3DJHRI
FEEDING COUNSELLING
Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup
)LQGDUHJXODUVXSSO\RUIRUPXODRURWKHUPLONHJIXOOFUHDPFRZ¶VPLON
Learn how to prepare a store milk safely at home
2. HELP MOTHER MAKE TRANSITION:

Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2
months)
Clean all utensils with soap and water
6WDUWJLYLQJRQO\IRUPXODRUFRZ¶VPLONRQFHEDE\WDNHVDOOIHHGVE\FXS
3. STOP BREASTFEEDING COMPLETELY:
Express and discard enough breast milk to keep comfortable until lactation stops
Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer breastfeeds, day and night.
If taking other milk:
replace with increased breastfeeding OR
replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food.
For other foods, follow feeding recommendations for the child's age.
3DJHRI
EXTRA FLUIDS AND MOTHER'S HEALTH
Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given.
Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.
FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B TREAT
on THE CHILDchart.
Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counselling on STD and AIDS prevention.
Give additional counselling if the mother is HIV-positive

5HDVVXUHKHUWKDWZLWKUHJXODUIROORZXSPXFKFDQEHGRQHWRSUHYHQWVHULRXVLOOQHVVDQGPDLQWDLQKHUDQGWKHFKLOG¶VKHDOWK
Emphasize good hygiene, and early treatment of illnesses
3DJHRI
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 the
child's problems.
If the child has: Return for follow-
up in:
PNEUMONIA 3 days
DYSENTERY
MALARIA, if fever persists
FEVER: NO MALARIA, if fever
persists
WHEN TO RETURN IMMEDIATELY
MEASLES WITH EYE OR MOUTH
COMPLICATIONS Advise mother to return immediately if the child has any of these signs:
MOUTH OR GUM ULCERS OR Any sick child Not able to drink or breastfeed
THRUSH Becomes sicker
PERSISTENT DIARRHOEA 5 days Develops a fever
ACUTE EAR INFECTION If child has COUGH OR COLD, also return if: Fast breathing
CHRONIC EAR INFECTION Difficult breathing
COUGH OR COLD, if not If child has diarrhoea, also return if: Blood in stool
improving Drinking poorly
UNCOMPLICATED SEVERE 14 days
ACUTE
MALNUTRITION
FEEDING PROBLEM
ANAEMIA 14 days
MODERATE ACUTE MALNUTRITION 30 days
CONFIRMED HIV According to national
INFECTION HIV EXPOSED recommendations
NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
3DJHRI
SICK YOUNG INFANT AGE UP TO 2 MONTHS
ASSESS AND CLASSIFY THE SICK YOUNG INFANT

ASSESS CLASSIFY IDENTIFY TREATMENT
DO A RAPID APRAISAL OF ALL WAITING INFANTS
ASK THE MOTHER WHAT THE YOUNG INFANT'S
PROBLEMS ARE USE ALL BOXES THAT MATCH THE
INFANT'S SYMPTOMS AND
Determine if this is an initial or follow-up visit for this
PROBLEMS TO CLASSIFY THE problem.
ILLNESS
if follow-up visit, use the follow-up instructions. if initial visit,
assess the child as follows:
3DJHRI
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL:
Is the infant Any one of the following Pink: Give first dose of intramuscular antibiotics
Count the
having difficulty in signs VERY SEVERE Treat to prevent low blood sugar
breaths in one Classify ALL YOUNG Not feeding well or DISEASE Refer URGENTLY to hospital **
feeding? Has the YOUN
infant had INFANTS Convulsions or Advise mother how to keep the infant warm
G minute. Repeat
convulsions (fits)? INFAN Fast breathing (60 on the way to the hospital
T the count if more breaths per minute or
MUST
than 60 breaths more) or Severe chest
BE per minute. indrawing or
CALM )HYHUƒ& RUDERYHor
Look for severe Low body temperature
chest indrawing. (less
Measure axillary WKDQƒ& or
temperature. Movement only when
Look at the umbilicus. stimulated or no movement
Is it red or draining at all.
pus? Look for skin Umbilicus red or draining Yellow: Give an appropriate oral antibiotic
pustules. pus Skin pustules LOCAL Teach the mother to treat local infections at
Look at the young infant's BACTERIAL home Advise mother to give home care for the
movements. INFECTION young infant
If infant is sleeping, Follow up in 2 days
ask the mother to
wake him/her. None of the signs of very Green: Advise mother to give home care.
severe disease or local SEVERE
Does the infant move
bacterial infection DISEASE
on his/her own?
OR LOCAL
If the young infant is not
INFECTION
moving, gently stimulate
UNLIKELY
him/her.
Does the infant not
move at all? 7KHVHWKUHVKROGVDUHEDVHGRQD[LOODU\WHPSHUDWXUH7KHWKUHVKROGVIRUUHFWDOWHPSHUDWXUHUHDGL
QJVDUHDSSUR[LPDWHO\ƒ&KLJKHU
** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
3DJHRI
CHECK FOR JAUNDICE
If jaundice present, LOOK AND FEEL:
ASK: When did the Look for jaundice (yellow Any jaundice if age less Pink: Treat to prevent low blood sugar
jaundice appear first? eyes or skin) than 24 hours or SEVERE Refer URGENTLY to hospital
Look at the young Yellow palms and soles JAUNDICE Advise mother how to keep the infant warm
CLASSIFY at any age on the way to the hospital
infant's palms and soles. Are
JAUNDICE
they yellow? Jaundice appearing after Yellow: Advise the mother to give home care for the
24 hours of age and JAUNDICE young infant
Palms and soles not Advise mother to return immediately if palms
yellow and soles appear yellow.
If the young infant is older than 14 days, refer
to a hospital for assessment
Follow-up in 1 day
No jaundice Green: NO Advise the mother to give home care for the
JAUNDICE young infant
THEN ASK: Does the young infant have diarrhoea*?
IF YES, LOOK AND FEEL:
Two of the following signs: Pink: If infant has no other severe
Look at the young infant's general condition:
Movement only when SEVERE classification: Give fluid for severe
Infant's movements
Classify stimulated or no DEHYDRATION dehydration (Plan C)
Does the infant move on his/her own?
for movement at all OR
Does the infant not move even when DIARRHOEA
Sunken eyes If infant also has another severe
stimulated but then stops? DEHYDRATION classification:
Does the infant not move at all? Skin pinch goes back
very slowly. Refer URGENTLY to hospital with mother
Is the infant restless and irritable? giving frequent sips of ORS on the way
Look for sunken eyes. Advise the mother to continue
Pinch the skin of the abdomen. Does it go breastfeeding
back: Two of the following signs: Yellow: Give fluid and breast milk for some
Very slowly (longer than 2 Restless and irritable SOME dehydration (Plan B)
seconds)? or slowly?
Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with
slowly. mother giving frequent sips of ORS on
the way
Advise the mother to continue
breastfeeding
Advise mother when to return
immediately
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO continue breastfeeding (Plan A)
dehydration. DEHYDRATION Advise mother when to return immediately
* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
3DJHRI
3DJHRI
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
Ask: LOOK, LISTEN, FEEL:

Is the infant breastfed? If Determine weight for
yes, how many times in age. Look for ulcers or
24 hours? white patches in the mouth
Does the infant usually (thrush). Classify FEEDING
receive any other foods
or drinks? If yes, how
often? If yes, what do
you use to feed the infant?
ASSESS BREASTFEEDING: Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed.
Has the infant breastfed in the previous hour? If For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING PROBLEM OR
the infant has not fed in the previous hour, ask the LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS" If an infant has no indications to refer
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes. Not well attached to Yellow: If not well attached or not suckling effectively,
(If the infant was fed during the last hour, ask the mother breast or FEEDING teach correct positioning and attachment
if she can wait and tell you when the infant is willing to Not suckling effectively or PROBLEM If not able to attach well immediately, teach
feed again.) Less than 8 breastfeeds OR the mother to express breast milk and feed by a
Is the infant well attached? in LOW WEIGHT cup If breastfeeding less than 8 times in 24 hours,
24 hours or advise to increase frequency of feeding. Advise
not well attached good attachment TO
Receives other foods or the mother to breastfeed as often and as long as
CHECK ATTACHMENT, LOOK FOR: drinks or the infant wants, day and night
Chin touching breast Low weight for age or If receiving other foods or drinks, counsel the
Mouth wide open Thrush (ulcers or white mother about breastfeeding more, reducing
Lower lip turned outwards patches in mouth). other foods or drinks, and using a cup If not
More areola visible above than below the mouth breastfeeding at all*:
(All of these signs should be present if the Refer for breastfeeding counselling and
attachment is good.) possible relactation*
Is the infant suckling effectively (that is, slow deep Advise about correctly preparing breast-milk
sucks, sometimes pausing)? substitutes and using a cup
not suckling effectively suckling effectively Advise the mother how to feed and keep the low
weight infant warm at home
Clear a blocked nose if it interferes with breastfeeding.
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 Green: Advise mother to give home care for the young
no other signs of NO FEEDING infant
inadequate feeding. PROBLEM Praise the mother for feeding the infant well
urgently to hospital:
* Unless not breastfeeding because the mother is HIV positive.

3DJHRI
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS
Use this chart for HIV EXPOSED infants not breastfeeding AND the infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL:

What milk are you Determine weight for Milk incorrectly or Yellow: Counsel about feeding
giving? age. Look for ulcers or unhygienically prepared or FEEDING Explain the guidelines for safe replacement
How many times during white patches in the mouth Giving inappropriate PROBLEM feeding Identify concerns of mother and family
Classify FEEDING OR
the day and night? (thrush). replacement feeds or Giving about feeding.
insufficient replacement LOW WEIGHT If mother is using a bottle, teach cup feeding
How much is given at
each feed? feeds or An HIV Advise the mother how to feed and keep the
How are you preparing positive mother mixing low weight infant warm at home
the milk? breast and other feeds If thrush, teach the mother to treat thrush at
Let mother demonstrate or home Advise mother to give home care for the
before 6 months or
explain how a feed is young infant
Using a feeding bottle
prepared, and how it is Follow-up any feeding problem or thrush in 2
or
given to the infant. days
Low weight for age or Follow-up low weight for age in 14 days
Are you giving any
Thrush (ulcers or white
breast milk at all?
patches in mouth).
What foods and fluids
in addition to Not low weight for age and Green: Advise mother to give home care for the young
replacement feeds is no other signs of NO FEEDING infant
given? How is the milk inadequate feeding. PROBLEM Praise the mother for feeding the infant well
being given?
Cup or bottle?
How are you cleaning
the feeding utensils?
3DJHRI
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:
IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN

A
Birth BCG OPV-0 Hep B0 200 000
IU to the
mother
within 6
weeks of
delivery
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1
Give all missed doses on this visit.

Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.
ASSESS OTHER PROBLEMS
$66(667+(027+(5¶6+($/7+1(('6
Nutritional status and anaemia, contraception. Check hygienic practices.
3DJHRI
TREAT AND COUNSEL

TREAT THE YOUNG INFANT
GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

Give first dose of both ampicillin and gentamicin intramuscularly.
AMPICILLIN
Dose: 50 mg per kg GENTAMICIN
To a vial of 250 mg
WEIGHT 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
Add 1.3 ml sterile water = 250 mg/1.5ml
AGE <7 days AGE >= 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
1.5-<2 kg 0.5 ml 0.9 ml* 1.3 ml*
2-<2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
2.5-<3 kg 0.8 ml 1.4 ml* 2.0 ml*
3-<3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
3.5-<4 kg 1.1 ml 1.9 ml* 2.8 ml*
4-<4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
* Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin
two times daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.
TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10 ml/kg) sugar (water
To make sugar water: Dissolve 4 level
teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.
3DJHRI
TREAT THE YOUNG INFANT
Immunize Every Sick Young Infant, as Needed
GIVE ARV FOR PMTCT PROPHYLAXIS

Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis*:
Nevirapine or zidovudine are provided to young infant classified as HIV EXPOSED to minimize the risk of mother-to-child HIV transmission (PMTCT).
If breast feeding: Give NVP for 6 weeks beginning at birth or when HIV exposure is recognized.
If not breast feeding: Give NVP or ZDV for 4-6 weeks beginning at birth or when HIV exposure is recognized.
NEVIRAPINE ZIDOVUDINE (AZT)
AGE
Give once daily. Give once daily
Birth up to 6 weeks:
Birth weight 2000 - 2499 g 10 mg 10 mg
Birth weight > 2500 g 15 mg 15 mg
Over 6 weeks: 20 mg -
* PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART PROPHYLAXIS:

OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR AZT FOR 4-6 WEEKS IF ON
REPLACEMENT FEEDING.
OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NV
AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.
3DJHRI
COUNSEL THE MOTHER
ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG

INFANT
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT
Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the
infant wants.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
Follow up visit
If the infant has: Return for first follow-up in:
JAUNDICE 1 day
LOCAL BACTERIAL INFECTION 2 days
FEEDING PROBLEM
THRUSH
DIARRHOEA
LOW WEIGHT FOR AGE 14 days
CONFIRMED HIV INFECTION According to national recommendations
HIV EXPOSED
WHEN TO RETURN IMMEDIATELY:

Advise the mother to return immediately if the young infant has any of these
signs:
Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow
3DJHRI
FOLLOW-UP
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT
LOCAL BACTERIAL INFECTION

After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.
Treatment:
If umbilicalpus or redness remains same or is worse , refer to hospital. Ifpus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
If skin pustules aresame or worse, refer to hospital. Ifimproved , 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
If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?"
If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
ජ
3DJHRI
JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?
Treatment:
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.
FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
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 of this follow up visit. Continue follow-up until the infant is gaining weight well.
Exception:
If you do not think that feeding will improve, or if the young infant has
lost weight, refer the child.
LOW WEIGHT FOR AGE

After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
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 14 days or when she returns for immunization, whichever is the
earlier.
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 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly and 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.
ජ
THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
If thrush is worse check that treatment is being given correctly.
If the infant has problems with attachment or suckling , refer to hospital.
If thrush is the same or better, and if the infant isfeeding well , continue half-stregth gentian violet for a total of 7 days.
CONFIRMED HIV INFECTION OR HIV EXPOSED

A young infant classified as CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits regularly as per national guidelines.
Follow the instructions for follow-up care for child aged 2 months up to 5 years.
3DJHRI
Annex:
Skin Problems
IDENTIFY SKIN PROBLEM ජ

3DJHRI
IDENTIFY SKIN PROBLEM

ජ
IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Itching rash with small PAPULAR Treat itching: Is a clinical stage 2 defining case
papules and scratch marks. ITCHING Calamine lotion
Dark spots with pale centres RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV
An itchy circular lesion with a RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
raised edge and fine scaly WORM patches existing nail infection which has to be treated
area in the centre with loss of (TINEA) If extensive refer, if not give: adequately to prevent recurrence of tinea
hair. May also be found on infections of skin.
Ketoconazole for 2 up to 12 months(6-10 kg)
body or web on feet Fungal nail infection is a clinical stage 2
40mg per day for 12 months up to 5 years
defining disease
give 60 mg per day or give griseofulvin
10mg/kg/day
if in hair shave hair treat itching as above
Rash and excoriations on SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals scabies may
torso; burrows in web space 25% topical Benzyl Benzoate at night, repeat for manifest as crust scabies.
and wrists. face spared 3 days after washing and or 1% lindane cream or Crusted scabies presents as extensive areas
lotion once wash off after 12 hours of crusting mainly on the scalp, face back
and feet. Patients may not complain of
itching. The scales will teeming with mites
3DJHRI
ජ
IF SKIN HAS BLISTERS/SORES/PUSTULES
AS:
Vesicles over body. CHIKEN POX Treat itching as above Presentation atypical only if
Vesicles appear Refer URGENTLY if pneumonia or child is
progressively over jaundice appear immunocompromised
days and Duration of disease longer
form scabs after they Complications more frequent
rupture Chronic infection with
continued appearance of new
lesions for >1 month; typical
vesicles evolve into
nonhealing ulcers that
become necrotic, crusted,
and hyperkeratotic.
Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease
on one side of body ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days longer Haemorrhagic
with intense pain or Give pain relief vesicles, necrotic
scars plus shooting Follow-up in 7 days ulceration
pain. Herpes zoster is Rarely recurrent, disseminated
uncommon in children or multi-dermatomal
except where they are
immuno- Is a Clinical stage 2 defining
compromised, for disease
example if infected
with HIV
Red, tender, warm IMPETIGO OR Clean sores with antiseptic

crusts or small lesions FOLLICULITIS Drain pus if fluctuant
Start cloxacillin if size >4cm or red streaks or tender nodes or
multiple
abscesses for 5 days ( 25-50 mg/kg every 6 hours)
Refer URGENTLY if child has fever and / or if
infection extends to the muscle.
3DJHRI
NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules MOLLUSCUM Can be treated by various Incidence is higher
with a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm
commonly seen on the face and trunk Leave them alone unless in size), or coalescent
in children. superinfected Pouble or triple lesions
Use of phenol: Pricking each may be seen
lesion with a needle or sharpened More than 100 lesions
orange stick and dabbing the may be seen.
lesion with phenol Lesions often chronic
Electrodesiccation and difficult to eradicate
Liquid nitrogen application Extensive molluscum
(using orange stick) Curettage contagiosum is a Clinical
stage 2 defining disease
The common wart appears as WARTS Treatment: Lesions more numerous

papules or nodules with a rough Topical salicylic acid preparations and recalcitrant to
(verrucous) surface ( eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is
Electrocautery a Clinical stage 2
defining disease
Greasy scales and redness on central SEBBHORREA Ketoconazole shampoo Seborrheic dermatitis
face, body folds If severe, refer or provide tropical may be severe in HIV
steroids infection.
For seborrheic dermatitis: 1% Secondary infection may
hydrocortisone cream X 2 daily be common
If severe, refer
3DJHRI
CLINICAL REACTION TO DRUGS
DRUG AND ALLERGIC REACTIONS
AS:
Generalized red, wide spread with small bumps or blisters; or FIXED Stop medications give Could be a sign of reactions to
one or more dark skin areas (fixed drug reactions) DRUG oral antihistamines, if ARVs
REACTIONS pealing rash refer
Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching
Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
3DJHRI
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Height/Length (cm): 7HPSHUDWXUHƒ& Ask: What are the child's problems? Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGN General danger
sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
Count the breaths in one minute: ___ breaths per minute. Fast
breathing?
Look for chest indrawing
For how long? ___ Days
Look and listen for stridor
Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Is there blood in the Look at the childs general condition. Is the child:
stool? Lethargic or unconscious? Restless and 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 then 2 seconds)? Slowly?
'2(67+(&+,/'+$9()(9(5"E\KLVWRU\IHHOVKRWWHPSHUDWXUHƒ&RUDERYH Yes __ No __
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
For how long? ___ Days Look for runny nose
If more than 7 days, has fever been present Look for signs of MEASLES:
every day? Has child had measles within the last Generalized rash and
3 months? Do a malaria test, if NO general danger One of these: cough, runny nose, or red eyes
sign in all cases in high malaria risk or NO obvious Look for any other cause of fever.
cause of fever in low malaria risk:
Test POSITIVE? P. falciparum P. vivax
NEGATIVE?
If the child has measles now or within the last Look for mouth ulcers. If yes, are they deep and extensive?
3 months: Look for pus draining from the eye.
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
Is there ear discharge? If Yes, for how long? ___ Feel for tender swelling behind the ear
Days
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
AND ANAEMIA Determine WFH/L z-score:
Less than -3? Between -3 and -2? -2 or more ?
Child 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or WFH/L Is there any medical complication: General danger sign?
less than -3 Z scores: Any severe classification? Pneumonia with chest indrawing?
Child 6 months or older: Offer RUTF to eat. Is the child:
Not able to finish? Able to finish?
Child less than 6 months: Is there a breastfeeding problem?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT
DONE If mother is HIV-positive and NO positive virological
test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on:
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ________________
Hep B0 Hep B1 Hep B2 Hep B3 (Date)
RTV-1 RTV-2 RTV-3
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, FEEDING
ANAEMIA, or is HIV exposed or infected PROBLEMS
Do you breastfeed your child? Yes ___ No ___
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes
___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food
or fluids?
How many times per day? ___ times. What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child receive his own serving? ___ Who feeds the child
and how? During this illness, has the child's feeding changed? Yes
___ No ___ If Yes, how?
ASSESS OTHER PROBLEMS: Ask about mother's own health
3DJHRI
TREAT
Remember to refer any child who has a danger sign and no other severe classification
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
3DJHRI
ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): 7HPSHUDWXUHƒ& Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positiveSend tests that are required ____
Check that child has not breastfed for at least 6 weeksSend confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____
NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB
If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5 Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS

Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other 2.
____________________________________________________________ recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
3DJHRI
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
3DJHRI
FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): 7HPSHUDWXUHƒ& Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ACTIONS
ASK: has the child received care at another health ___________________________________________________ YES ____ NO TAKEN:
facility since the last visit? ____
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING
CONVULSIONS If general danger signs or ART severe side effects, provide pre-referral treatment
LETHARGIC OR UNCONSCIOUS and REFER URGENTLY
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Difficulty breathing and severe abdominal pain
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Fever, vomiting, rash (only if on Abacavir) Refer if necessary.
Check for main symptoms:
Cough or difficulty breathing
Diarrhoea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
Takes all doses - Frequently misses doses - Not gaining weight for 3 months TAKEN:
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER ECORD ART DOSAGES:
MEDICATION 1. ____________________________________________________________
ABC+3TC+LPV/r R2. ____________________________________________________________
3. ____________________________________________________________
ABC+3TC+EFV
COTRIMOXAZOLE
Cotrimaoxazole
DOSAGE:_______________________________________
Vitamin A
VITAMIN A DOSAGE:
_____________________________________________ OTHER
Other Medication MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Sideeffects
and correct management
3DJHRI
RECORD ACTIONS TAKEN:
3DJHRI
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Age: Weight (kg): 7HPSHUDWXUHƒ&
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR SEVERE DISEASE AND LOCALACTERIAL INFECTION
B Count the breaths in one minute. ___ breaths per minute
Is the infant having difficulty in feeding? Repeat if elevated: ___ Fast breathing?
Has the infant had convulsions? Look for severe chest indrawing.
Look and listen for grunting.
Look at the umbiculus. Is it red or draining pus?
)HYHUWHPSHUDWXUHƒ&RUDERYHIHOOVKRWRU
ORZERG\WHPSHUDWXUHEHORZƒ&RUIHHOVFRRO
Look for skin pustules. Are there many or severe pustules?
Movement only when stimulated or no movement even when
stimulated?
THEN CHECK FOR JAUNDICE
Look for jaundice (yellow eyes or skin)
When did the jaundice appear first? Look at the young infant's palms and soles. Are they yellow?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___
move only when stimulated?
DIARRHOEA?
not move even when stimulated?
Is the infant restless and irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
If the infant has no indication to refer urgently to hospitalDetermine weight for age. Low ___ Not low
___ Is there any difficulty feeding? Yes ___ No ___Look for ulcers or white patches in the mouth (thrush).
Is the infant breastfed? Yes ___ No ___
If yes, 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?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status:
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV positive and and NO positive virological test in young infant:
Is the infant breastfeeding now?
Was the infant breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and infant on ARV prophylaxis?
ASSESS BREASTFEEDING
Has the infant breastfed in the previous hour? 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.
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 ___
not well attached good attachment
Is the infant sucking effectively (that is, slow deep sucks,
sometimes pausing)?
not sucking sucking effectively effectively
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U immunization on:
OPV-0 OPV-1 OPV-2 vitamin A to ________________
mother (Date)
ASSESS OTHER PROBLEMS: Ask about mother's own health
3DJHRI
TREAT
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
3DJHRI
Weight-for-age GIRLS
Birth to 6 mon th s (z-scores)
WHO ChildGrowth Standards
3 DJHRI
Weight-for-age BOYS
Birth t o 6 m on th s (z-scor es)
WHO Child Growth Standards
3 DJHRI
Weight-for-Iength GIRLS
Birth to 2 years (z-scores)
3 DJHRI
Weight-for-Iength BOYS i i
Birt h to 2 yea r s ( z-sco r es)
W HO Child Growth Standards
3 DJHRI
Weight-for-Height GIRLS Work!Health
Organization
2 to 5 years (z-sco r es)
WHO Chi ld Growth Standards
3 DJHRI
Weight-for-height BOYS
2 to 5 yea r s (z-scores)
3 DJHRI
3 DJHRI
3 DJHRI
3 DJHRI

Chart Booklet: Integrated Management o F Childhood Illness

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Integrated Management of Childhood Illness

Integrated Management of Childhood Illness: distance learning course.

1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and

ISBN 978 92 4 150682 3 (NLM classification: WS 200)

© World Health Organization 2014

SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD

CHECK FOR GENERAL DANGER SIGNS

THEN ASK ABOUT MAIN SYMPTOMS:

Two of the following signs: Pink: If child has no other severe

Dehydration present. Pink: Treat dehydration before referral unless the

If yes: ok and feel:

Do a malaria test***: If NO severe classi

No Malaria Risk and No

Look for mouth ulcers.

If MEASLES now or within last 3

Any general danger sign or Pink: Give Vitamin A treatment

Pus draining from the eye or Yellow: Give Vitamin A treatment

Measles now or within the last 3 Green: Give Vitamin A treatment

Does the child have an ear problem?

THEN CHECK FOR ANAEMIA

*Assess for sickle cell anaemia if common in your area.

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

IMMUNIZATION SCHEDULE: Follow national guidelines

every six months

ASSESS OTHER PROBLEMS:

TREAT THE CHILD

Give once a day starting at 4-6 weeks of age

2 years up to 5 years (10 - 19 kg) 1 1

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

AGE or WEIGHT Ferrous sulfate

GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC

Give Vitamin A Supplementation and Treatment

Treat the Child to Prevent Low Blood Sugar

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Refer URGENTLY to hospital for IV treatment.

Refer URGENTLY to NOTE:

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Recommended Amounts of Ready-to-Use Therapeutic Food

Steps when Initiating ART in Children

STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

TREAT THE HIV INFECTED CHILD

Give Antiretroviral Drugs

LOPINAVIR / RITONAVIR (LPV/r) NE VIRAPINE (NVP) EFAVIRENZ (EFV)

ABAC AVIR (ABC ) ZIDOVUDINE (AZT or ZDV)

Side Effects ARV Drugs

Lopinavir/ritonavir Nausea Changes in fat distribution:

Manage Side Effects of ARV Drugs

Yellow eyes (jaundice) or Stop drugs and REFER URGENTLY

Fever Assess, classify, and treat using feve chart.

Give Pain Relief to HIV Infected Child

2 up to 4 months (4 - <6 kg) - 2 ml 0.5 ml

4 up to 12 months (6 - <10 kg) 1 2.5 ml 2 ml

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

2 up to 3 years (12 - <14 kg) 2 7.5 ml 4 ml

3 up to 5 years (14 -<19 kg) 2 10 ml 5 ml

IMMUNIZE EVERY SICK CHILD AS NEEDED

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

MODERATE ACUTE MALNUTRITION