Integrated Management of Childhood Illness (IMCI) : Guide For Clinical Practice

GUIDEFORCLINICALPRACTICE
C ONDUCT CLINICAL COMPONENT OF ICATT BASED IMCI TRAINING
GUIDEFOR CLINICAL PRACTICE

DraftAugust2010
OBJECTIVESOFCLINICALPRACTICE

ICATTbasedIMCItraining
CLINICALPRACTICEOBJECTIVES
Clinical practice is an essential part of the IntegratedManagementofChildhoodIllness training. Inthe ICATTtrainingsetparticipantslearnabouttheskillsbyreadinginformationandseeing picturesandvideodemonstrations.Theythenusetheinformationbydoingwrittenexercisesor casestudies.Finallyandmostimportantly,inclinicalpractice,participantspracticeusingtheir skillswithrealsickchildrenandyounginfants. Generalobjectives:Duringclinicalpracticesessions,participantswill: seeexamplesofsignsofillnessinrealchildren. see demonstrations of how to manage sick children and young infants according to the casemanagementcharts. practiceassessing,classifyingandtreatingsickchildrenandyounginfantsandcounselling mothersaboutfood,fluids,andwhentoreturn. receivefeedbackabouthowwelltheyhaveperformedtheskillandguidanceabouthowto strengthenparticularskills. gain experience and confidence in using the skills as described on the case management charts. Outpatient sessions take place in outpatient clinics. The focus of the outpatient session is to providepracticeofthecasemanagementprocesswithsickchildrenandyounginfants. Inoutpatientsessions,participantswill: seesickchildrenandyounginfantswhohavebeenbroughttotheclinicbytheirmothers. practiseassessingandclassifyingsickchildrenandyounginfantsaccordingtothe ASSESS &CLASSIFYandYOUNGINFANTcharts. practiseidentifyingthechild'streatmentbyusingthe"Identifytreatment"columnonthe ASSESS&CLASSIFYandYOUNGINFANTcharts. practise treating sick children and young infants according to the TREAT and YOUNG INFANTcharts. practise counselling mothers about food, fluids, and when to return according to the COUNSELchart. practisecounsellingmothersofsickyounginfantsaccordingtotheYOUNGINFANTchart. practise using good communications skills when assessing, treating and counselling mothersofsickchildrenandyounginfants. Inpatient sessions take place on an inpatient ward. The focus of the inpatient sessions is to practiceassessingandclassifyingclinicalsigns,especiallysignsofsevereillness.
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GuideforclinicalpracticeObjectivesofclinicalpractice
Duringinpatientsessions,participantswill: see as many examples as possible of signs of severe classifications from the ASSESS & CLASSIFYandYOUNGINFANTcharts,includingsignsnotfrequentlyseen. practiseassessingandclassifyingsickchildrenandyounginfantsaccordingtothe ASSESS &CLASSIFYand YOUNGINFANTcharts,focusingespeciallyontheassessmentofgeneral danger signs, other signs of severe illness, and signs which are particularly difficult to assess(forexample,chestindrawingandskinpinch). practisetreatingdehydrationaccordingtoPlansBandCasdescribedontheTREATchart. practisehelpingmotherstocorrectpositioningandattachment. Onespecial sessionEssentialcare takesplaceinthedeliveryroom.Duringthissessionthe participantsobservehowpreparationsforadeliveryaredoneandwhatarethekeyelementsof essentialcarewhicheverynewbornshouldreceive. Participants practice the case management steps as part of a case management process. The clinical practice skills are presented in the order they are being learned in the ICATT. In each clinicalsession,participantsusetheskillstheyhavelearneduptothatday'ssession.Thisallows participants to gain experience and confidence in performing skills introduced in earlier sessions.DependingonthenumberofclinicalsessionsinaparticularICATTbasedIMCItraining, thecontentofsessionsdescribedinthisguidemaybecombined.
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LISTOFCLINICALPRACTICESESSIONS
Inyourtraining,therewillbeprobablyfewersessionsthandescribedinthisguide.Thetraining director will inform you about the number of sessions and their content according to the trainingschedule.Youwillthenneedtocombinethecontentofsomeofthesessionsdescribed inthisguideaccordingly. OutpatientSessions
OutpatientsessionChild1: Checkforgeneraldangersigns Assessandclassifycoughordifficult breathing OutpatientsessionChild2: Assessandclassifydiarrhoea OutpatientsessionChild3: Assessandclassifyfever OutpatientsessionChild4: Assessandclassifyearproblem Checkformalnutritionandanaemia OutpatientsessionChild5: Identifytreatment Teachthemothertogiveoraldrugs Advisemotherwhentoreturn immediately OutpatientsessionChild6: PlanA:Treatdiarrhoeaathome PlanB:TreatsomedehydrationwithORS OutpatientsessionChild7: Counselthemotheraboutfeeding problems
InpatientSessions
InpatientsessionChild1 Checkforgeneraldangersigns Assessandclassifycoughordifficult breathing InpatientsessionChild2: Assessandclassifydiarrhoea InpatientSessionChilds3: Assessandclassifyfever InpatientsessionChild4: Assessandclassifyearproblem Checkformalnutritionandanaemia
Careofsickchildage2monthsupto5years
InpatientsessionChild5: PlanB:TreatsomedehydrationwithORS PlanC:Treatseveredehydrationquickly Assessandclassifyadditionalchildren
Careofyounginfantupto2months
OutpatientsessionInfant1: Assessandclassifyyounginfantsfor bacterialinfectionanddiarrhoea OutpatientsessionInfant2: Assessbreastfeedingattachmentand suckling Correctpositioningandattachment InpatientsessionInfant1: Essentialcareforallyounginfants InpatientSessionInfant2: Assessandclassifyyounginfantsfor bacterialinfectionanddiarrhoea InpatientSessionInfant3: Assessbreastfeedingattachmentand suckling Assessandclassifyyounginfants
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GUIDELINESFORCLINICALPRACTICEINTHE OUTPATIENTCLINIC

CONTENTS
GUIDELINESFORCLINICALPRACTICEINTHEOUTPATIENTCLINIC.......................................................1 1. 2. Roleofthefacilitator ...............................................................................................................................................3 Generalprocedures.................................................................................................................................................3 Generalprocedures:Howtopreparefortheoutpatientsession.............................................................3 Generalprocedures:Conductingtheoutpatientsession.............................................................................4 Generalprocedures:Attheendofthesession................................................................................................8 3. Specificinstructionsforconductingoutpatientsessions........................................................................8 OutpatientsessionChild1:Checkforgeneraldangersigns,assessandclassifycoughor difficultybreathing..................................................................................................................................................9 OutpatientsessionChild2:Assessandclassifydiarrhoea.................................................................12 OutpatientsessionChild3:Assessandclassifyfever(andmeasles,ifpresent).......................14 OutpatientsessionChild4:Assessandclassifyearproblem,malnutritionandanaemia....16 OutpatientsessionChild5:Identifytreatment,teachthemothertogiveoraldrugs,advise motherwhentoreturnimmediately .............................................................................................................18 OutpatientsessionChild6:Giveincreasedfluidsfordiarrhoea:PlanAandPlanB...............20 OutpatientsessionChild7:Counselthemother.....................................................................................22 OutpatientsessionYounginfant1:Assessandclassifyyounginfantsforverysevere diseaseandlocalbacterialinfection,jaundice,anddiarrhoea...........................................................24 OutpatientsessionYounginfant2:Assessbreastfeedingandcounselthemother.................26
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GuideforclinicalpracticeGuidelinesforclinicalpracticeintheoutpatientclinic
1. ROLEOFTHEFACILITATOR
1. 2. 3. 4. 5. 6. 7. Doallnecessarypreparationsforcarryingouttheoutpatientsessions. Explainthesessionobjectivesandmakesuretheparticipantsknowwhattododuring eachoutpatientsession. Demonstratethecasemanagementskillsdescribedonthecharts.Demonstratetheskills exactlyasparticipantsshoulddothemwhentheyreturntotheirownclinics. Observetheparticipants'progressthroughouttheoutpatientsessionsandprovide feedbackandguidanceasneeded. Beavailabletoanswerquestionsduringtheoutpatientsessions. Leaddiscussionstosummarizeandmonitortheparticipants'performance. CompletetheChecklistformonitoringoutpatientsessionstorecordparticipants' performanceandthecasesmanaged.
2. GENERALPROCEDURES
GENERALPROCEDURES:HOWTOPREPAREFORTHEOUTPATIENTSESSION
1. Based on the visit you made to the clinic before the training began, plan to obtain the drugsandsuppliesyouwillneed.Makesureyoubringtherelevantsuppliestoeachday's session.Alistofsuppliesneededforeveryoutpatientsessionandforspecificsessionsis includedinAnnex1andAnnex2ofthisguide. Ifneeded,checkwiththetrainingdirectororotherdesignatedtrainingstafftofindoutthe transportationschedulefortraveltotheclinicalpracticesessions. Checkwithresponsibletrainingstaffthattheparticipantsareinformedwhereandwhen to meet for the clinical sessions. Also check that the participants are reminded to bring theirchartbooklets,pencils,andtimingdevices. Readtheparticipantobjectivesandfacilitatorproceduresforleadingthesessionthatare included with these guidelines. (The objectives and procedures are listed on onepage summary tables for your easy reference during the session.) Also read the special notes thatfolloweachtableandprovidesomemoredetailedinstructions. Whenyouarriveattheclinic,meetwiththeclinicstaffwhowillinterceptpatientsinthe triagearea.Explaintheobjectivesfortheday'ssessionandtelltheclinicstaffthetypeof casesparticipantswillneedtoseetoday.Anychildwithageneraldangersignshouldbe seenfirstbytheregularclinicstaff. Note:Youandthetrainingdirectormayhavealreadyestablishedcontactwithanurseor other clinic staff member who will help by identifying cases to send to the area where participants are working. Staff responsibilities often change in large clinics so you may
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need to explain again to clinic staff information such as the purpose of the training, arrangementsmade,andwhogavepermission. 6. You should check to see if all the necessary supplies for today's session are available wheretheparticipantswillbeworking.Youmayneedtofindatrayortableonwhichto setupanysuppliesorequipment;dothisbeforethesessionbegins. When you have finished discussing arrangements with the clinic staff, begin the day's session.
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GENERALPROCEDURES:CONDUCTINGTHEOUTPATIENTSESSION
1. Gather the participants together. Explain what will happen during the session. Describe the skills they will practice and answer any questions they might have. Be sure participantshavetheirchartbookletsandpencilswiththem. Distribute sufficient copies of the appropriate recording form (either for children 2 monthsupto5yearsorforyounginfantsageupto2months).Tellparticipantstheywill use the recording form to record information about the cases they see. Tell them they shouldassumeallthechildrentheyworkwithduringtheoutpatientsessionshavecome for an initial visit. Also explain that they will need to keep their recording forms from eachsessiontouselatertoenterthecasesintotheirindividualClinicalpracticesheetin theICATTand/ortocompleteaGroupchecklistofclinicalsigns. Before participants practice a clinical skill for the first time, they should see a demonstrationoftheskill.Toconductademonstration: Reviewthecasemanagementstepsthatwillbepracticedintoday'ssession.Showwhere thestepsarelocatedonthechart. Describe how to do the steps and review any special techniques to be practiced today suchasdoingaskinpinch,identifyingachild'streatment,orcounsellingamotherabout food,fluidsandwhentoreturn. As you demonstrate the case management steps, do them exactly as you want the participantstodothem.Describealoudwhatyouaredoing,especiallyhowyoudecide thatasignispresentandhowtoclassifytheillness. Attheendofyourdemonstration,giveparticipantsanopportunitytoaskanyquestions beforetheybeginpracticingwithpatients. Assign patients to participants.Participantsshouldpracticedoingthestepsrelevantto eachsession'sobjectiveswithasmanychildrenandyounginfantsaspossible.
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It is best if participants work individually. If necessary, participants can work in pairs. Whenworkinginpairs,theycantaketurnssothatoneparticipantassessesacasewhile the other observes. Or after one participant does the steps, the other participant also doesthem. When participants work in pairs, you are responsible for making sure that every participant, and not just each pair of participants, practices assessing, classifying, and treatingsickchildrenandyounginfantscorrectly.Everyparticipantshouldalsopractice counsellingmothers. 4|P a g e
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Stepssuchasidentifyingchestindrawingcanbedifficultforparticipantsatfirst.Thefirst timeaparticipantdoesanewstep,supervisehimcarefullytomakesurehecandothe stepcorrectly.Provideguidanceasneeded. Observe each participant working with his assigned patient. Make sure he is doing the clinicalskillscorrectly.Alsochecktheparticipant'srecordingformtoseeifheisrecording informationcorrectly.Providefeedbackasneeded.Remarkonthingsthataredonewellin additiontoprovidingguidanceabouthowtomakeimprovements. Attheendofthesession,youwillcompleteamonitoringchecklist(ifused)torecordeach participant's performance during the outpatient session. Detailed instructions for using theChecklistformonitoringoutpatientsessionsareintheAnnex4.
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Whenyouhavenotbeenabletoobservetheparticipant'sworkdirectly,takenoteofthe patient'sconditionyourself.Then: Asktheparticipanttopresentthecasetoyou.Heshouldrefertohisrecordingformand tell you the child's main symptoms, signs, and classifications. Later in the training, the participantshouldalsosummarizehistreatmentplan. If time is very limited, look at the participant's recording form. Compare your observation of the child's condition with the participant's findings. Ask clarifying questions as needed to be sure the participant understands how to identify particular signsandclassifythemcorrectly. Discussthecasewiththeparticipantandverifytheassessmentandclassificationofthe case. If treatment has been specified, verify that it is correct. In some clinics, the participantwillbeallowedtotreatthechild. Providespecificfeedbackandguidanceasoftenasnecessary.Providefeedbackforeach case that the participant sees. Mention the steps the participant does well and give additionalguidancewhenimprovementisneeded. Note: If any children requiring urgent referral are identified during the session, assist in transportifthisisfeasible.Makesureallurgentprereferraltreatmenthasbeengiven. When a participant finishes a case, assign him to another patient. If no new patient is available,asktheparticipanttoobservemanagementofotherpatients.Assoonasanother patient is available, assign a participant to that patient. Your emphasis should be on having participants see as many children as possible during the session. Do not let participantsbecomeinvolvedindiscussionsofcasesorwanderoffaftermanagingjustone ortwopatients. If a child has symptoms and signs which the participants are not yet prepared to assess and classify, return the child to regular clinic staff for continuation of assessment and treatment. If the child is returned to the regular clinic staff for treatment, you may need to write a briefnoteonthefindingsandlikelydiagnosisorbrieflydiscussthecasewiththeclinician inchargetomakesurethechildreceivescorrectandpromptcare.Itisimportantthatthe motherreceiveappropriatetreatmentforherchildbeforeleavingtheclinic.
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Atanytimeduringanysession,ifachildoryounginfantpresentswithasignwhichisseen infrequently(signsarelistedonthenextpage),orwithaparticularlygoodorinteresting exampleofasignbeingemphasizedthatday,callalltheparticipantstogethertoseethe signinthischildoryounginfant. If the participants have not yet learned the sign and how it is assessed and classified, showthemthesignandtellthemdiscussionofitsclassificationwilltakeplacelaterin thetraining.Somesignswhichareonlyusedintheclassificationofyounginfantscanbe observedinolderinfantsoryoungchildren,suchasjaundice. Participants can take part in the assessment of the child or young infant and, as time allows, observe the relevant therapy (as in the case of a child with diarrhoea with SEVEREDEHYDRATION). Returnthesechildrentoregularclinicstaffforfurtherassessmentandtreatment. Because local infections are seen infrequently, demonstrate treatment of any local infection which presents during an outpatient session. Gather participants and show the signs of the local infection (such as eye infection, mouth ulcers) and demonstrate their treatment(suchasdryingtheearbywicking,treatingskinorumbilicalinfectionorthrush inyounginfants). Make sure you have the supplies needed to provide treatment of local infection: tetracyclineeyeointment,gentianviolet,softclothsorgauzeforcleaningpusfromaneye andforapplyinggentianviolet.
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REMEMBERTHISWHENCONDUCTINGOUTPATIENTSESSIONS
TOCONDUCTASESSION HOWTOGIVEFEEDBACK
Tellclinicstaffcasestoselect. Demonstratetheclinicalskills. Assignpatients. Supervisecloselythefirsttimeskill ispracticed. Observeeachparticipantworking witheachpatientifpossible.Verify thattheassessmentisdone correctly. Makesurepatientsreceive treatments. CompletetheChecklistfor monitoringoutpatientsessions.
Tomonitorclinicalperformance: 1. Observetheparticipantdoingthe assessment,classification, treatmentandcounselling.Thisis thebestmethod. 2. Ifyoucannotobserveallthecase management,asktheparticipant topresentthecasetoyou,or 3. Lookatrecordingformanddiscuss thecasewithparticipant. Praisetheparticipantforwhathehas donewell. Giveguidanceabouthowtoimprove performance.
INFREQUENTLYSEENSIGNS Sickchildren stridorinacalmchild veryslowskinpinch stiffneck measlesrash mouthulcer severepalmarpallor cornealclouding pusdrainingfromeye yellowpalmsandsoles problemswithattachment orsuckling thrush manyorsevereskin pustules treatingskinorumbilical infectionorthrushin younginfants
2monthsupto5 years Younginfants upto 2months
severechestindrawing redumbilicusordraining pus movementonlywhen stimulatedornomovement atall
Treating localinfections
treatingeyeinfectionwith tetracyclineeyeointment dryingtheearbywicking treatingmouthulcers

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GENERALPROCEDURES:ATTHEENDOFTHESESSION
1. Leadadiscussiontosummarizethesession. Gather participants together and discuss the cases seen and specific skills practiced that day. If problems occurred, discuss what happened and how the problem was corrected. Encouragetheparticipantstodiscusstheirobservationsabouttheday'scases.Answerany questions and discuss any concerns that participants have about the case management skillsorcasesseenthatday. Reinforce the use of good communication skills. Discuss words that mothers understand fortermsusedonthecharts. Localtermswhicharewellunderstoodforcough,diarrhoea,feverandsignsforwhento returnareusuallyidentifiedbeforethetrainingandincludedontheMother'scard.They mayalsobeontheadaptedcharts.Brieflydiscussthenewtermsusedinthesessionwith participantsandobtaintheirfeedbackonwhetherthesearethewordstheynormallyuse totalkwithmothersandwhethertheyarewellunderstood. At the end of each session, you will do two steps for monitoring of the participants' performanceintheoutpatientsessions. Ifused,youwillcompletetheChecklistformonitoringoutpatientsessions. Youwillremindparticipantstokeeptheirrecordingformstouselatertoenterthecases seen into their individual Clinical practice sheet in the ICATT and/or to complete the Groupchecklistofclinicalsigns.DetailedinstructionsforusingthechecklistareinAnnex 6.
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3. SPECIFIC INSTRUCTIONS FOR CONDUCTING OUTPATIENT SESSIONS

Onthefollowingpagesyouwillfindsummarytablesthatdescribetheparticipantobjectivesand facilitator procedures for conducting each outpatient session. They are designed as 1page summariesforeasyreferencewhenyouareplanningandconductingoutpatientsessions. Eachday'ssummarytableisfollowedbynotesthatdescribeanyspecialinformationtohelpyou toconductthatday'ssession. Depending on the number of sessions in the ICATT based IMCI training, you may need to combinethecontentofsomesessionsdescribedintheseguidelines. Whenyouplanforeachsession,refertoAnnex2:Suppliestobringforeachsession.Itliststhe suppliesyouneedtobringtothecliniceveryday(unlessyouarecertaintheyareinclinic)and particularsuppliesyouwillneedforspecificsessions.
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OUTPATIENTSESSIONCHILD1:CHECKFORGENERALDANGERSIGNS,ASSESSANDCLASSIFY COUGHORDIFFICULTYBREATHING
Toprepare Participant objectives Facilitator procedures 7. 8. Attheend ofthesession: 4. 2. 3. 1. 6. 5. 2. 3. 4. Askparticipantstobringtheirchartbooklets. Bring8copiesofrecordingformperparticipant. Bringormakesureparticipantshavetimingdevices. Checkforgeneraldangersigns. Assessandclassifysickchildrenthroughcoughordifficulty breathing. Practiceusingrecordingforminoutpatientsetting. Usegoodcommunicationskills:Greetthemother,listencarefully,use clearlanguage,usewordsthemotherunderstands.
Choosesickchildrenwithcoughordifficultybreathingandanychildwitha generaldangersign. 1. Introduceclinicfacilityandstaff,describegeneralproceduresfor outpatientsessions,andshowwheresuppliesarelocated. Demonstratehowtocheckforgeneraldangersignsandhowtoassess andclassifychildforcoughordifficultybreathing. Assignpatientstoparticipants. Supervisecloselyfirsttimeparticipantcountschild'sbreaths,looks forchestindrawingandlistensforstridororwheezing. Ifachildwithwheezingandchestindrawingorfastbreathing presents,demonstrategivingthechildtherapidacting bronchodilatortrial. Observeeachparticipantasheworkswithapatient.Ifyoucannot observe,askparticipanttopresentcaseorlookatparticipant's recordingform.Recordcaseonmonitoringchecklist,ifused. Givefeedbackandguidanceasneeded. Returnpatienttoclinicstaffwithnotefortreatment,ortreat accordingtoarrangements. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discusswordsmothersunderstandfor:convulsions,difficulty breathing,fastbreathing,pneumonia. Tellparticipantstokeeptheirrecordingformstousewhenthey returntotheclassroom. Completethemonitoringchecklist.
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Descriptionofhowoutpatientsessionswork: When describing general procedures for outpatient sessions, refer to the general procedures sectionofthisguide.Besuretoexplaintoparticipantshowyouwilldiscussthecasewiththem. Answer any questions that participants have about general procedures, where they will be working,orhowtousetherecordingform.Thenbeginthesession. Demonstration of how to check for general danger signs and how to assess and classify childforcoughordifficultybreathing: Tell participants the objectives for today's session. Also review the following phrases that describeagegroupsinthistraining: "2monthsupto5years"referstochildrenwhoareatleast2monthsoldandalsoanyage between2monthsand5yearsofage.Itdoesnotincludethechildwhoisalready5yearsold. "Up to 2 months" includes infants who are any age up to 2 months. It does not include the infantwhoisalready2monthsold. "2 months up to 12 months" includes children who are at least 2 months old and any age between2monthsand12months.Itdoesnotincludeachildwhoisalready12monthsold. "12monthsupto5years"includeschildrenwhoareatleast12monthsoldandanyage between12monthsand5years.Itdoesnotincludeachildwhoisalready5yearsold.
Review the cutoffs for determining fast breathing. Ask several participants in turn to tell you thedefinitionoffastbreathinginachildwhois: atleast2monthsofageupto12monthsofage ANSWER:50breathsperminuteormore 12monthsupto5yearsofage ANSWER:40breathsperminuteormore. exactly12monthsold ANSWER:40breathsperminuteormore. Dothedemonstration.Makesureparticipantsknowwheretolookintheirchartbookletsforthe ASSESS&CLASSIFYboxesthatdescribehowtocheckforgeneraldangersignsandhowtoassess andclassifycoughordifficultybreathing. Askparticipantstotellyouiftheyidentifyachildwithageneraldangersignsoyoucanalertthe regularclinicstaff.
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Demonstrationoftherapidactingbronchodilatortrial: MakesureallparticipantsknowwheretolookintheirchartbookletsfortheASSESS&CLASSIFY boxthatdescribesthebronchodilatortrialandfortheGiveinhaledsalbutamolforwheezingon theTREATchart. Ifthechildhasfastbreathing,tellparticipantsthebreathrate.Demonstratethechestindrawing ifpresent.Askalltheparticipantstolistentothewheeze. Give 2 puffs of the salbutamol from metered dose inhaler (100 micrograms/puff). Explain the motherthatsheshouldwait.Asktheparticipantstocontinueworkingwithpatients. After1520minutesgathertheparticipantsagainandaskoneoftheparticipantstoreassessthe child.Ifthereisstillchestindrawingorfastbreathingandiftimeoftheclinicalsessionpermits, repeatthetestonemoretimebeforeclassifyingthechild.Returnthepatienttoclinicstaffwith notefortreatmentortreataccordingtoarrangements. Demonstrategivingthechildtherapidactingbronchodilatortrialifachildwithfastbreathing chestindrawingpresentsduringanyfollowingclinicalsession. Supervisionandfeedback: Watch each participant while he counts the number of breaths, looks for chest indrawing and listens for stridor and wheezing. If a participant's count is too high or too low, or if he had difficulty identifying chest indrawing, stridor or wheezing, give him guidance based on your observation of his work. For example, you may have noticed that the participant did not time oneminutecorrectlyandneedsinstructiononhowtotimeaminute.Oryoumayaskhimabout howhecounted(forexample,wherehewaswatchingformovement)andsuggesthowtodoit better.Ifthereareerrors,asktheparticipanttodothestepagain.
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OUTPATIENTSESSIONCHILD2:ASSESSANDCLASSIFYDIARRHOEA
Toprepare Participant objectives Facilitator procedures 8. Attheendof thesession 2. 3. 4. 1. 6. 7. 5. 2. 3. 4. Askparticipantstobringchartbooklets,pencils,timingdevices. Bring8copiesofrecordingformperparticipant. Makesurethefollowingareavailableineachroomwhere participantsareworking:cuporspoonandcleanwaterforoffering fluidtoassessdehydration. Assessandclassifysickchildthroughdiarrhoea. Userecordingform. Usegoodcommunicationskills.
Choosechildrenwithdiarrhoeaorwithcoughordifficultybreathing. 1. Demonstratehowtoassesschildfordiarrhoea.(Preferably,dothis demonstrationwithachildwhoisdehydrated.)Demonstrate techniquefordoingskinpinch. Reviewstepsforassessingcoughordifficultybreathing. Assignparticipantstopatients. IfchildwithSOMEDEHYDRATIONorSEVEREDEHYDRATION presentsduringsession,demonstratesignstoallparticipants. Supervisecloselyfirsttimeparticipantassessesachildwith diarrhoeatobesureassessmentisdonecorrectly(especiallyskin pinch). Observeeachparticipantasheworkswithacase.Ifyoucannot observe,askparticipanttopresentcaseorlookatrecordingform. Givefeedbackandguidanceasneeded.Reinforceskillsforassessing andclassifyingcoughordifficultybreathing. Returnpatientwithnotetoclinicfortreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discusswordsmothersunderstandfor:diarrhoea,bloodinthestool. Remindparticipantstokeeptheirrecordingformsforlateruse. Completemonitoringchecklist.
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Demonstration: If possible, do the demonstration with a child who has diarrhoea with dehydration. To do the demonstration: Explain to the participants that you will do the steps on the ASSESS & CLASSIFY chart throughassessingandclassifyingdiarrhoea. Review the assessment steps for checking for danger signs, and for assessing and classifyingcoughordifficultybreathing. Then describe the steps for assessing and classifying a child for diarrhoea. Mention the signsofdehydrationthatyouwillassess:thechild'sgeneralcondition,whetherthechild hassunkeneyes,thechild'sthirstandaskinpinch. Reviewthetechniquefordoingaskinpinch.Remindparticipantsthattheyshould: Usetheirthumbandfirstfinger. Locate the area on the child's abdomen halfway between the umbilicus and the side of theabdomen.Thefoldoftheskinshouldbeinalineupanddownthechild'sbody. Pickupallthelayersofskinandthetissueunderneaththem. Holdthepinchforonesecondandthenreleaseit. Looktoseeiftheskinpinchgoesbackveryslowly(morethan2seconds)orslowlyor immediately. Statebrieflythatdehydratedchildrenaretreatedwithfluids,butthatthispracticesession will focus on assessing and classifying signs of dehydration, dysentery, and persistent diarrhoea.
If a child with SOME DEHYDRATION or SEVERE DEHYDRATION presents during the practice session,gatheralltheparticipantstoobservethesigns. If during the clinical session a child can be rehydrated to the extent that participants can see improvement in his clinical signs, demonstrate reassessment of his signs and discuss the improvements. Sincetheparticipantsarenotyetpreparedtotreatpatientswithdiarrhoea,returnthechildren withanotetotheregularclinicstafffortreatment.Iftimeallowsandthereisnootherpatientto assessandclassify,theparticipantscanobserveachild'streatmentintheORTcorner.
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OUTPATIENTSESSIONCHILD3:ASSESSANDCLASSIFYFEVER(ANDMEASLES,IFPRESENT)
Toprepare Participant objectives Facilitator procedures Attheendof thesession
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Askparticipantstobringchartbooklets,pencils,timingdevices. Bring8copiesofrecordingformperparticipant. Makesureneededsuppliesareavailableinclinic: 1 Assessandclassifychildthroughfever. Usegoodcommunicationskills.
Choosechildrenwithfever;feverwithandwithoutmeasles,andfeverwith otherrashes.Alsochildrenwithdiarrhoeaorwithcoughordifficulty breathing. 2 1. Demonstratehowtoassessasickchildforfever,and,iffeasible,how toassesschildwithfeverwhohassignssuggestingmeasles.Review howtodecidemalariarisk. 3 Tellparticipantstheriskofmalariafor patientsattendingthisclinic. Assignpatientstoparticipants. Ifachildwithstiffneckormeaslespresents,demonstratesignstoall participants. Ifchildrenpresentwithrashesthatarenotmeasles,demonstrate nonmeaslesrashes. Supervisecloselythefirsttimeparticipantsassessfevertobesure participantsassessfevercorrectly,especiallystiffneck. Givefeedbackandguidanceasneeded. Returnchildtoclinicwithnotefortreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discusswordsmothersunderstandfor:measles,fever,isfever presenteveryday? Remindparticipantstokeeprecordingforms. Completemonitoringchecklist.
2. 3. 4. 5. 6. 7. 1. 2. 3. 4.
For this and remaining sessions, a cup or spoon and clean water need to be available for assessing diarrhoea. Children's temperatures should be taken before participants see them.
See ICATT part Care of sick child aged 2 months up to 5 years, section Assess and classify, training unit Fever, Key information for instructions how to decide on malaria risk.
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Demonstration: Beforeyoudemonstratetheassessment,reviewthetechniquesforassessingstiffneckandthe techniques for drawing the child's attention so you can observe if the child's neck can move freely: Watchthechildasyoutalkwiththemother.Canthechildmoveandbendhisneckashe watchesyoutalkorrespondstoothersoundsorsights? Draw the child's attention to his toes by tickling his toes. Or use a sounding timer or shineatorchsothechildhastolookdowntoseeit. Ifyoustillhavenotseenthechildmovehisneck,leanoverthechildandgentlysupport hisbackandshoulderswithonehand.Holdhisheadwiththeother hand.Gentlybend thechild'sheadforwardtowardthechest.Doestheneckbendeasily?Ifso,thechilddoes nothavethesign"stiffneck."Iftheneckfeelsstifforthereisresistancewhenyoutryto bendit,thechildhasthesign"stiffneck."
Ifachildwithstiffneckpresentsduringthesession,demonstratethesigntoalltheparticipants. (Ensurethatthechildwithstiffneckisurgentlyreferredtothehospital.)Alsodemonstratetoall participantsanychildwithmeasles,especiallyachildwhohascomplicationsofmeaslessuchas mouthulcers,pusdrainingfromtheeyeorcloudingofthecornea.
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OUTPATIENT SESSION CHILD4: ASSESS AND CLASSIFY EAR PROBLEM, MALNUTRITION AND ANAEMIA
Toprepare Participant objectives Facilitator procedures 6. 7. Attheendof thesession 2. 3. 4. 1. 5. 3. 4. Askparticipantstobringchartbooklets,pencils,timingdevices. Bring8copiesofrecordingformperparticipant. Makesurescalesforweighingchildrenandatapeformeasuringof theMUACareavailableinareaswhereparticipantswillwork 4 . Assessandclassifysickchildthroughearproblemandcheckfor malnutritionandanaemia. Usegoodcommunicationskills. Useweightforagechart.
Choosechildrenwithearproblemsandanychildwithoneormoreofthe following:visibleseverewasting,someorseverepalmarpallorandoedema ofbothfeet.Alsochoosechildrenwhomayhavemalnutritionoranaemia. 1. 2. Demonstratehowtoassessandclassifyearproblem. Demonstratehowtocheckformalnutritionandanaemia,measure MUAC,anduseweightforagechart. Conductpracticeforparticipantswhodonotknowhowto"zero"the scaletogetanaccuratereadingandhowtoweighchildren. Assignpatientstoparticipants.Participantsassessandclassify throughmalnutritionandanaemia.IfachildwithMUAClessthan110 mm,visibleseverewasting,palmarpallororoedemapresents,show toallparticipants. Observeeachparticipanttobesurechildhasbeenassessedand classifiedcorrectly.Ifyoucannotobserve,askparticipanttopresent case. Givefeedbackandguidanceasneeded. Returnchildtoclinicstaffwithnotefortreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discusswordsmothersunderstandforearproblem,earpain,ear discharge. Remindparticipantstokeeptheirrecordingforms. Completemonitoringchecklist.
Other supplies include: cup or spoon, clear water, torch (optional)
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Howto"zero"thescaleandmakesureitreadsaccurately: Intheparticipant'sworkarea,providepracticeinuseofascaleforthoseparticipantswhodo notknowhowtomakesurethescaleweighsaccurately. Withallweightremovedfromthescale,"zero"thescale.(Makesureitreadsatzero whennothingisonit;ifnot,thereisusuallyawaytoadjustthis.) Obtainanobjectthatweighsonekilogram.Onelitreofwaterweighsonekilogram.If possible,alsoobtainanobjectthatweighs5or10kilograms. Weightheobjectsonthescaletoseeifthescaleisweighingaccurately.
Ifthescaledoesnotweighaccurately,itshouldbereplaced.
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OUTPATIENTSESSIONCHILD5:IDENTIFYTREATMENT,TEACHTHEMOTHERTOGIVEORAL DRUGS,ADVISEMOTHER WHEN TORETURNIMMEDIATELY

Toprepare Participant objectives Facilitator procedures Attheendof thesession 3. 4. 6. 7. 1. 2. 4. 5. 2. 3. Askparticipantstobringchartbooklet,pencils,timingdevices. Bring8recordingformsperparticipant. Bring8Mother'scardsperparticipant. Placetabletsorsyrup,druglabel,envelopeorpapertowraptablets ontableortray. Assessandclassifyasickchild;practiceidentifyingthechild's treatment. Advisemotherswhentoreturnimmediately. Teachmothertogiveherchildanoraldrugathome. UseaMother'scardtoadviseandteachmothers. Usegoodcommunicationskills.
Choosesickchildrenwithoneormoremainsymptoms. 1. Assessandclassifyachildand,usingchartorchartbookletanda recordingform,demonstratehowtoidentifythechild'streatment. Demonstratehowtoadvisemotherwhentoreturnimmediately.Use therelevantpartoftheMother'scard. ReviewstepsonTREATchartanddemonstratehowtoteachmother togiveanoraldrugathome. Assignpatientstoparticipants. Superviseparticipantscarefullyastheypractice3newsteps: identifyingtreatment,advisingwhentoreturnimmediatelyand givingoraldrugs. Givefeedbackandguidanceasneeded. Returnchildtoclinicwithnotefortreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedanddemonstratedtoday. Discussproblemswithcomplianceandwordsthatmothers understandfor:becomessicker,developsafever,drinkingpoorly, tablet,syrup. Remindparticipantstokeeptheirrecordingforms. Completemonitoringchecklist.
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Ask clinic staff to select a child who has fast breathing, fever, or an ear problem. (This child wouldneedanoraldrug.)Usethischildwhenyoudemonstratehowtoteachamothertogivean oraldrugathome. Demonstration: Whenreviewingthestepsforidentifyingachild'streatment,mentionthesevereclassifications thatrequirereferralandremindparticipantsabouttheexceptions. Ifthechild'streatmentincludesoneormoreoraldrugs,demonstratehowtoteachthemotherto givetheoraldrugathome.Pointoutanddothegenericstepsonthe TREATchartforteachinga mothertogiveanoraldrug.Alsoremindparticipantsto: Usebasicteachingsteps:givethemotherinformation,showanexample,letherpractice.
Usegoodcommunicationskills:askquestions,praisethemotherforwhatshehasdone well,adviseherhowtotreatherchildathome,checkthemother'sunderstanding. When teaching the mother, use words she understands, use teaching aids that are familiar, give feedback when she practices, encourage her to ask questions, and answer her questions. Observingparticipants: Watch carefully whether participants teach each mother when to return immediately. If any participanthasacasewhosetreatmentincludesanoraldrug,observetheparticipantwhilehe teaches the mother. Provide feedback after the mother and child have been passed to regular clinicstaffforanyadditionaltreatment. Whenyouobserveparticipantsteachingmothers,payparticularattentiontowhethertheydoall the steps for teaching mothers to give oral drugs at home. Praise their use of appropriate communicationskillssuchasaskingmotherscheckingquestions. Attheendofthesession: Mentionanydifficultiesparticipantshadwithidentifyingtreatmentoradvisingmothers.
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OUTPATIENT SESSION CHILD6: GIVE INCREASED FLUIDS FOR DIARRHOEA: PLAN A AND PLANB
Toprepare Askparticipantstobringtheirchartbooklets. Bring8recordingformsforeachparticipant. Bring8Mother'scardsforeachparticipant. MakesureORTcornerhassufficientamountsofpreparedORS, packetsofORS,soapandwaterforwashinghands,cleancontainerfor mixingORS,acontainerformeasuring1litre,cleanwater,spoonfor mixing,cupsandspoonsforgivingORSsolution. TreatchildrenwhohavediarrhoeaandSOMEorNODEHYDRATION. ObservedemonstrationofchildreceivingPlanC,ifpossible. Usegoodcommunicationskills.
Participant objectives Facilitator procedures
ConductthissessionintheORTcorner.Choose2childrenfor demonstration:oneforPlanAandoneforPlanB.Youmayneedtoassess rapidlyforsignsofdehydration. 1. DemonstratehowtotreatachildwithSOMEDEHYDRATIONusing PlanB(alsoachildwithSEVEREDEHYDRATIONusingPlanC,if available). DemonstratehowtotreatachildwithNODEHYDRATIONusingPlan A. Assignpatientstoparticipants.Ifpossible,participantspracticegiving PlanAatleastonceandPlanBatleastonce.Ifonlyafewchildren needPlanB,someparticipantscanobservePlanBtreatmentbeing given. SuperviseparticipantscarefullythefirsttimetheyteachmothersPlan AandtreataccordingtoPlanB. Observeeachparticipantasheworkswitheachcase.Ifyoucannot observe,askparticipanttopresentcase. Givefeedbackandguidanceasneeded. Returnchildtoregularclinicstafftocontinuetreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday.Reinforcecommunicationskillsforteachingthe mother:giveinformation,showexamples,haveherpractice,check understanding,usetheMother'scard. Remindparticipantstokeeptheirrecordingforms. CompleteMonitoringchecklist.
2. 3.
4. 5. 6. 7.
Attheendof thesession
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1.
2. 3.
ThissessionshouldtakeplaceintheORTcorneroftheclinic. AsktheclinicstafftoselecttwochildrenwithdiarrhoeaandSOMEorNODEHYDRATION foryourdemonstration:onewhoisreadyforPlanAandonewhowillbegivenPlanB. If a severely dehydrated child presents during the session, and the clinic can provide treatmentaccordingtoPlanC,participantsshouldseeademonstrationofachildreceivingPlan Cfluids. Demonstration: WhendemonstratinghowtotreatachildaccordingtoPlanBmakesureto: demonstratehowtodeterminetheamountofORStogiveduringthefirst4hours.
demonstrate how to teach a mother to give ORS, including helping the mother start givingthetreatmentandwatchingherprogress. in an appropriate child (one who is near the end of the 4hour Plan B treatment) demonstratehowtoreassessthechild'sdehydration. Observingparticipants: Assign participants to children who have diarrhoea. Each participant should practice at least onceteachingamothertogivePlanAfluidsathomeandteachingamotherhowtogivePlanB. InthePlanBchild,theparticipantshould: calculatetheamountofORStogiveandteachthemotherhowtogivetheORS. continuecheckingonthePlanBcaseandencouragethemotherwhoisgivingORS. practicereassessingachildtodetermineifthechildisreadytogohome.
If a child with SEVERE DEHYDRATION presents during the session, call all the participants togethersotheycanobservethechild'ssigns.Iftimepermitstheycanalsoobserverehydration accordingtoPlanC.Whiletheyareobserving,theycanpracticecalculatingtheamountoffluid togive,observetheinsertionoftheneedleornasogastrictubeandobservethechild'sprogress.
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OUTPATIENTSESSIONCHILD7:COUNSELTHEMOTHER
Toprepare Participant objectives Facilitator procedures Attheendof thesession 3. 4. 2. 4. 5. 6. 1. Askparticipantstobringchartbooklets,pencils,timingdevices. Bring8recordingformsperparticipant. Bring8Mother'scardsperparticipant. Assessandclassifyasickchildandidentifythechild'streatment, includingfeedingadvice.Advisemotherwhentoreturn. Counselmotheraboutfeeding: Askfeedingquestions Identifyfeedingproblems Giveadviceonfeedingproblems Usegoodcommunicationskillsforcounsellingmothers.
Choosechildrenwhoappeartobeverylowweightforageoranaemic,or childrenwhoarelessthan2yearsold. 1. 2. 3. Demonstratehowtoassessfeedingandcounselthemotherabout food,fluidsandwhentoreturn. Assignparticipantstopatients. Superviseparticipantscloselywhentheyassessfeedingandcounsel themotheraboutfeedingforthefirsttime. Observeeachparticipantasheworkswithacase.Ifyoucannot observe,askparticipanttopresentthecase. Givefeedbackandguidanceasneeded. Returnpatientwithnotetoclinicstafftocontinuetreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discussfeedingproblemsidentifiedbyparticipantsandtheadvice given.Discusswhetheranycommonmodifiablefeedingproblems wereidentifiedthatarenotontheCOUNSELchart. Remindparticipantstokeeptheirrecordingforms. Completemonitoringchecklist.
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Observingparticipants: Supervisecloselythefirsttimeparticipantscounselmothers.Makesurethey: knowwheretorecordthemother'sanswersontherecordingform teachmothersthesignstoreturnimmediately checkthemothers'understanding
Ifyoucannotobserveallofaparticipant'sworkwithacase,checkhisrecordingformfor assessmentandclassification.Thenobservehimcounsellingthemother. Makesureparticipantsusegoodcommunicationskills.Theyshould: askallthequestionstoassessfeeding praisethemotherforwhatsheisalreadydoingwell limitfeedingadvicetowhatisrelevant giveaccurateadvice askcheckingquestions
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OUTPATIENTSESSIONYOUNGINFANT1:ASSESSANDCLASSIFYYOUNGINFANTSFORVERY SEVEREDISEASEANDLOCALBACTERIALINFECTION,JAUNDICE,ANDDIARRHOEA
Toprepare Participant objectives Facilitator procedures Attheendof thesession Whenyouarriveattheclinic,explaintotheclinicstaffthatparticipantswillassessandclassify young infants during today's session. Ask the clinic staff to select young infants age up to 2 months.Younginfantswithanyseveresignsshouldbeseenfirstbyclinicstaff. 5. 6. 7. 1. 2. 3. 2. 3. 4. Askparticipantstobringtheirchartbooklets. Bring8Younginfantrecordingformsforeachparticipant. Assessandclassifythesickyounginfantforveryseverediseasesand localbacterialinfection,jaundice,anddiarrhoea. Usegoodcommunicationskillswhentalkingwithmothers.
Chooseinfantsageupto2months.Anyinfantwithaseveresignshouldbe seenfirstbytheregularclinicstaff. 1. Demonstratehowtoassessandclassifyasickyounginfantforvery severediseasesandlocalbacterialinfection,jaundice,andfor diarrhoea. Assignpatientstoparticipants. Superviseparticipantscloselythefirsttimetheyassessandclassifya sickyounginfant. Ifayounginfanthassignsofveryseverediseaseorjaundice,show thesignstoallparticipants. Observeeachparticipantasheworkswithacase. Providefeedbackandguidanceasneeded. Returnyounginfanttoregularclinicstafffortreatment. Leadadiscussiontosummarizethesession. Reinforcestepsforassessingsickyounginfant,notingespeciallythe newsigns(thatis,signsnotassessedinsickchildren). Remindparticipantstokeeptheirrecordingforms. Completethemonitoringchecklist,Younginfantversion.
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Demonstration: Remind participants that they should use Young infant recording forms during this clinical session. Demonstratehowtoassessandclassifyayounginfant.Thisdemonstrationisimportanttohelp participantsrealizethedifferencesintheassessmentprocessfortheyounginfantascompared withtheprocessforachildaged2monthsupto5years. During the assessment, describe aloud what you are doing. Participants should record the findingsofthisassessmentonaYounginfantrecordingform. Observingparticipants: Supervise participants closely the first time they assess and classify young infants. There are signsonthe YOUNGINFANTchartwhichparticipantsmaynothaveseenorpracticedassessing before.Payparticularattentiontothesenewsignswhenparticipantsworkwithpatients.
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OUTPATIENTSESSIONYOUNGINFANT2:ASSESSBREASTFEEDINGANDCOUNSELTHE MOTHER
Toprepare: Participant objectives Facilitator procedures Attheendof thesession Ask the clinic staff to select young infants age up to 2 months. Ask them to especially look for breastfeeding mothers of young infants who may need some help with breastfeeding. Young infantswithanyseveresignsshouldbeseenbyclinicstafffirst.
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Askparticipantstobringtheirchartbookletsandpencils. Bring8Younginfantrecordingformsforeachparticipant. Bring8Mother'scardsforeachparticipant. Assess,classify,andidentifytreatmentforthesickyounginfant. Assessbreastfeedingattachmentandsuckling. Correctpositioningandattachment.
Chooseinfantsageupto2months.Lookforbreastfeedingmothersof younginfantswhomayneedhelp. 1. 2. 3. 4. Demonstratehowtoassessbreastfeeding. Demonstratehowtocounselmotheraboutcorrectpositioningand attachmentaccordingtostepsonYOUNGINFANTchart. Assignyounginfantstoparticipants. Superviseparticipantscloselytobesuretheyassessbreastfeeding andcounselthemothercorrectly.Beespeciallyattentivethefirst timeaparticipantcounselsamotheraboutcorrectpositioningand attachment. Observeeachparticipantasheworkswithayounginfant.Ifno observationisdone,askparticipanttopresentthecase. Givefeedbackandguidanceasneeded. Returnyounginfanttoclinicstaffwithnotetocontinuetreatment. Leaddiscussiontosummarizesessionandgivefeedbackonskills practicedtoday. Discusswaystoputthemotherateasewhencounsellingherto correctpositioningandattachment. Remindparticipantstokeeptheirrecordingforms. CompletetheMonitoringchecklist,Younginfantversion.
5. 6. 7. 1. 2. 3. 4.
Demonstration: Demonstratehowtohelpamotherimprovepositioningandattachmentforbreastfeeding. Ifawomanwhoneedsthishelphasbeenidentified,dothisdemonstrationatthebeginningof thesession.However,itislikelythatyouwillhavetowatchforawomanwhoneedshelpwith breastfeeding and call the participants together for this demonstration later in the clinical session. Before you begin the demonstration, review the chart booklet box Teach correct positioningandattachmentforbreastfeedingwiththeparticipants. During the demonstration, be sure that you talk gently to the mother. Explain what you are doing,andtalkinawaywhichbuildsherconfidence.(Alsoexplaintotheparticipantswhatyou aredoing.)Belowisalistofstepstohelpyoudothisdemonstrationifyouarenotexperienced. a) Greetthemother,introduceyourself,andaskhernameandherbaby'sname.
b) Assessabreastfeed.Askthemotherifyoumayseehow(baby'sname)breastfeeds,and askhertoputhimtoherbreastintheusualway.Observeherbreastfeedingforafewminutes. (Adjustthisstepappropriatelyifyouhavejustassessedthisinfant,includinghisbreastfeeding. However, remember that it is important that the participants who are observing see how the mother usually breastfeeds, so that they can see the difference after the mother receives guidance.) c) Explain that there are ways that might help the baby to breastfeed better. Ask if she wouldlikeyoutoshowher.Saysomethingencouraging,like: "Hereallywantsyourbreastmilk,doesn'the?"Thensay,"Breastfeedingmightbe (less painful/easier for the baby) if (baby's name) took a larger mouthful of breast when he suckles.Wouldyoulikemetoshowyouhow?" Ifsheagrees,youcanstarttoshowher.
d) Makesurethatthemotherissittinginacomfortable,relaxedposition.Sitdownyourself, sothatyoualsoarecomfortableandrelaxed,andinaconvenientpositiontohelp. e) Explaintothemotherhowtoholdherbaby.Showherwhattodoifnecessary.Makesure you make the 4 key points clear (they are listed in the box on the YOUNG INFANT chart). She shouldholdtheinfant: withtheinfantsheadandbodyinline. withtheinfantapproachingbreastwithnoseoppositetothenipple. withtheinfantheldclosetothemothersbody. withtheinfantswholebodysupported,notjustneckandshoulders.
f) Showherhowtohelptheinfanttoattach.Thesestepsarelistedintheboxonthechart. Sheshould: touchherinfant'slipswithhernipple, waituntilherinfant'smouthisopeningwide,

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move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple.
g) Notice how the mother responds. If the mother says nothing, ask her how her baby's sucklingfeels.Ifsucklingiscomfortableandthemotherlookshappy,herbabyisprobablywell attached.Ifsucklingisuncomfortableorpainful,herbabyisprobablynotwellattached. h) Lookforallthesignsofgoodattachment.Iftheattachmentisnotgood,tryagain.Explain totheparticipantsthatitoftentakesseveraltriestogetababywellattached. Assign young infants to participants as they are brought to the participants' work area. Emphasizetoparticipantsthatinthissessiontheywillassessandclassifyyounginfantsthrough assessing and classifying feeding. They will not give any other treatments so they can concentrateonpracticinghowtocounselmothersaboutcorrectpositioningandattachment. Attheendofthesession: Discuss ways of putting mothers at ease when assessing breastfeeding and counselling about breastfeeding.Askparticipantstodescribegoodexamplesofcommunicationskillstheyusedto putmothersatease.
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GUIDELINESFORCLINICALPRACTICEINTHE INPATIENTWARD

CONTENTS
GUIDELINESFORCLINICALPRACTICEINTHEINPATIENTWARD............................................................1 1. 2. Roleoftheinpatientinstructor..........................................................................................................................3 Generalprocedures.................................................................................................................................................3 Generalprocedures:Prepareforclinicalpracticeatinpatientward.....................................................3 Generalprocedures:Howtoprepareeachsession .........................................................................................5 Generalprocedures:Conducttheinpatientsession.......................................................................................9 3. Specificinstructionsforconductinginpatientsessions........................................................................11 InpatientsessionChild1:CheckforgeneraldangersignsAssessandclassifycoughor difficultybreathing...............................................................................................................................................12 InpatientsessionChild2:Assessandclassifydiarrhoea....................................................................15 InpatientsessionChild3:Assessandclassifyfever..............................................................................17 InpatientsessionChild4:Assessandclassifyearproblem,malnutritionandanaemia........19 InpatientsessionChild5:PlanBandCtreatdehydration..............................................................21 InpatientsessionYounginfant1:Essentialcare....................................................................................22 InpatientsessionYounginfant2:Veryseveredisease,localbacterialinfection,jaundiceand diarrhoea..................................................................................................................................................................25 InpatientsessionYounginfant3:Assessbreastfeeding,assessandclassifyyounginfants26
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GuideforclinicalpracticeGuidelinesforclinicalpracticeintheinpatientward
1.
1.
ROLEOFTHEINPATIENTINSTRUCTOR
Each morning, select children with appropriate clinical signs to be assessed by participants during the session. Prepare a recording form to show each child's history. Also identify any additional children with infrequently seen signs (listed in chapter Generalprocedures:Howtoprepareeachsession)toshowparticipants. At the beginning of each session, demonstrate any new clinical skill, such as a new partoftheassessmentprocess. Assign each participant to a child. Observe while participants assess and classify the children. Conductroundstoreviewthechildrenwhichparticipantshaveassessedandclassified. Have all participants practice assessing some signs, to give them more practice with severesignsandsignswhicharedifficulttoassess. Showparticipantsanyadditionalchildrenwithinfrequentlyseensigns. Summarize the session. Reinforce participants for new or difficult steps that they did correctly,andgivethemsuggestionsandencouragementtohelpthemimprove. RecordthecasesseenbyparticipantsonaChecklistformonitoringinpatientsessionsif used.Alsorecordclinicalsignsinadditionalcaseswhichwereseenbythegroup.
2. 3. 4.
5. 6. 7.
2. GENERALPROCEDURES
GENERALPROCEDURES:PREPAREFORCLINICALPRACTICEATINPATIENTWARD
Youandthetrainingdirectorshouldvisittogetherthehospitalwhereclinicalsessionsaretobe conducted to meet the director and staff and to discuss/confirm arrangements prior to the training. 1. First meet with the hospital director to obtain permission, then with the ward staff responsible for each ward needed during the training. In each ward, make sure your arrangementsincludetheseniorresponsiblenurse,notjustthedoctorincharge. Meet with the director of the paediatric inpatient ward. Explain to the ward director how inpatientsessionswork.Describewhattheinpatientinstructorandtheparticipantswoulddo. Askpermissiontoconductsessionsintheward.Ifthereareseparatemalnutrition,newbornand sick neonate wards, meet with the directors of these wards. Also meet with the director of maternitywardsessiononessentialcareforyounginfantswilltakeplacethere.
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Askthewarddirectorforaclinicalassistant.Thisshouldbesomeonewhoworksontheward fulltime.Askthedirectortoassigntheclinicalassistanttocomeatthetimeoftheearlymorning preparations (usually at 6:00 or 7:00 am depending on the schedule). Ask for a translator to helpinterviewmothersintheearlymorning,ifneeded.(Itwilloftenbenecessarytoprovidea stipendtothisindividual.) 2. Visittheward.Seehowthewardislaidout,thescheduleofadmissions,meals,etc.Find outtimespatientsareavailableornotavailable. 3. Fromthisinformation,planapossibleschedulefortheclinicalsessionsintheinpatient wardduringthetraining. 4. Togetherwiththetrainingdirector: Set the schedule for inpatient and outpatient sessions, so each group will visit one outpatientclinicandtheinpatientwardeachday. Reviewyourresponsibilitiesandplansforconductingtheinpatientsessions. Planthecontentofeachinpatientsessiondependingonthetrainingschedule.
5. Study the Guide for clinical practice to learn or review exactly what you should do to prepareforandconductinpatientsessions.Visittheinpatientwardtoplanhowandwhereyou cancarryoutthetasks. 6. Obtainnecessarysuppliesforinstruction.Theseinclude: Sickchildrecordingforms Younginfantrecordingforms Oneclipboardperparticipantinonegroup Stringortapetofastenclipboardstofootorheadofbed Highlighterpens Thermometers Scalesforweighingchildrenandinfants Cups,spoonsandcleanwater(forofferingfluidtoassessthirst) SuppliesfortreatingdehydrationaccordingtoPlanBandPlanC
7. Findaplacetohangthecasemanagementcharts(ifused).Ifitisnotpossibletohangall four charts, hang ASSESS & CLASSIFY THE SICK CHILD in the paediatric ward. Hang the YOUNG INFANTchartintheneonatessection. 8. Brief anystaffthatwill beintheinpatientwardaboutwhat youwillbedoing, andthe trainingsessionsthatwilltakeplacethere. 9. As a trial run, practice what you will need to do on the first morning, that is, select at least8childrenwithclinicalsignsappropriateforthesessionandprepareRecordingformsfor them.Thenshowthesetothetrainingdirector. 10. Supplementmedicalsuppliesoftheinpatientwardifnecessary(Annex3ofthisguide).
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11. Duringthefirstfewdaysofthetraining,selectcasesandconducttheinpatientsessions withsupervisionandfeedbackfromthetrainingdirectororanexperiencedinpatientinstructor. Thisshouldallowyoutoobtainexperienceinthisroleandtoworkoutanyproblems. 12. IfChecklistformonitoringinpatientsessionsisused,thetrainingdirectorwillteachyou howtouseitbeforethetrainingbegins.
GENERALPROCEDURES:HOWTOPREPAREEACHSESSION
1. Earlyinthemorningonthedayoftheclinicalsession,examineallchildrenadmittedto the paediatric wards to see if their signs are appropriate for the clinical session. This must be done in the morning as the clinical condition of hospitalized children can change very rapidly, evenovernight. 2. Identifychildrenthathavethesignsrelevanttotheobjectivesofthesessionforthatday. Identifyfreshcases,thatis,casesthatarrivedwithintheprevious13days.Theirhistoryshould bestillvalidsothatitmatchestheircurrentclassifications.Patientswithunambiguousclinical signs should be used for demonstration. This is particularly important for chest indrawing whereparticipantslearnthat,iftheyarenotcertain,chestindrawingisnotthere. 3. Identifychildrenwithinfrequentlyseensignslistedattheendofthischapter.Because thesesignsareinfrequentlyseen,youwanttoshowthemtoparticipantswheneverthereisan opportunity,andnotwaituntilthedaytheyarestudied.Thoughchildrenwiththesesignsmay notbeassignedtoparticipants,youwillshowthesignstoparticipantsattheendofthesession. 4. Ask the permission of the caretakers/parents to allow their children to be seen by participantsthatday.Trytoarrangethatthechildrenwillbeintheirbedsduringthesessions. 5. Select one case per participant in the group. Select cases who together have an appropriatevarietyofsignsforparticipantstoassess/classifyinthesessionsthatdayplusany other which provide good demonstrations of clinical signs. It is important to have a separate patientforeachparticipanttoassessandclassifyduringthesession.Selectchildrensothatthere aredifferingcombinationsofsignspresent,resultingindifferentclassifications.Alsoselectany additionalchildrenwithinfrequentlyseensignsthatyouwillshowtoparticipants,orwiththe signsyouareemphasizingduringthatday'ssession. 6. Keep a list with brief notes on each of these cases for your own reference during the session. Note the child's name, age, (location in the ward if necessary), and positive signs. However,keepinmindthatclinicalsignscanchangerapidlyinveryillchildrenfromonesession tothenext. 7. Partiallycompletearecordingformforeachoftheselectedchildrenandpostitonthe child'sbed.Obtainingandrecordingthehistoryinthiswaywillpreventrepetitivequestioningof mothersandwillexpeditetheassessmentandclassification.
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Howtopreparetherecordingform: Intheeveningbeforeeachsession,highlighttherelevantitemsonabout10copiesofthe form,thatis,highlightthetopsectionoftheformandallthemainsymptomquestionsto be covered that day plus their "Ask" questions. The highlighting will help you work quicklyasyoupreparerecordingformsfortheselectedchildreninthemorning. Highlight the top section of the form: Child's name, age, weight, temperature and main problem. Fill in this information. Make sure the child's weight and age are recorded. If these are not available from the patient chart, weigh the child and/or take the temperature. Highlightallmainsymptomquestionstobecoveredthatdayplustheir"Ask"questions. Fillinthisinformationbasedonthemother'sresponses.(Thoughoccasionallyyoumay needtomakeupsomeinformation,itisbetternottofabricatehistorytoavoidconfusing participantsiftheyinterviewthemother.)Donotfillinanyinformationaboutthechild's additionalclinicalsigns orclassifications.These willbedetermined bytheparticipants whentheyexaminethechild. Draw a line where you want the assessment to stop, or fold under that part of the recordingform.Seetheexampleformwhichhasbeenpreparedasdescribedabove. Puttheformonaclipboardorinaplasticsheetprotectorandtapeortieittothefootor headofthebed.Removeorturnoveranyhospitalrecordsthatareonornearthebedso thatparticipantscannotseethem.
Anexampleofarecordingformpreparedforaninpatientsessionisonthepage8. 8. Mark the beds of any additional children that you plan to show to participants, for example, by posting a coloured card at the foot of the bed. This will help you locate these childreneasily.
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INFREQUENTLYSEENSIGNS
Sickchildren stridorinacalmchild veryslowskinpinch stiffneck measlesrash mouthulcer severepalmarpallor cornealclouding pusdrainingfromeye yellowpalmsandsoles problemswithattachmentor suckling thrush manyorsevereskinpustules treatingskinorumbilicalinfection orthrushinyounginfants
2monthsupto5 years Younginfants upto 2months
severechestindrawing redumbilicusordraining pus movementonlywhen stimulatedornomovement atall
Treating localinfections
treatingeyeinfectionwith tetracyclineeyeointment dryingtheearbywicking treatingmouthulcers
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GENERALPROCEDURES:CONDUCTTHEINPATIENTSESSION
Eachinpatientsessionwilllastabout1hour.Allowabout20to30minutesfortheparticipants toassessandclassifytheirassignedpatients,andabout30minutesforreviewofparticipants' assessmentsanddemonstrationofclinicalsigns.Itisnecessarytokeepupthepaceofthereview session. 1. Tellparticipantstheobjectivesoftoday'sinpatientsession.
2. Demonstrate for the participants any new part of the assessment process. Before participants practice a clinical skill for the first time in the inpatient ward, they should see a demonstration of it done correctly. Explain and demonstrate the clinical skill exactly as you wouldlikeparticipantstodoit. 3. Assign each participant a case to assess and classify. Tell them how much of the assessment and classification you expect them to do (for example, through assessment and classificationofdiarrhoea.)Besurethateachparticipanthasablankrecordingformtouse. 4. Observe while the participants assess and classify the cases. Be available to assist or answer questions. Make sure they are circling the child's signs on the recording form and writingclassifications. Encouragethemtorefertothechart bookletortothechart whenthey classifythechild. Ifyouseeaparticipantinvolvedinalongdiscussionwiththemother,encouragehimto use the history provided and to concentrate on the assessment of clinical signs and the classification. 5. Makesureparticipantworkisnotinterferingtoomuchwiththewardroutine,especially provision of treatment. You or your assistant should make sure families understand what is goingon. 6. Conductroundswiththegroupofparticipants: Gathertheparticipantsandtakethegrouptothebedofthefirstcase.Asktheassigned participant to present the case, describing the signs found and the classifications. (Do notcommentnowonwhethertheassessmentiscorrect).Asktheparticipanttoreferto theclassificationboxinhischartbooklettoexplainhowhedeterminedtheclassification. This is important to do throughout the sessions since errors of classification occur almostasfrequentlyaserrorsofassessment. Ask all the participants to assess certain signs, for example, to determine if chest indrawing is present or absent. (Select certain signs which should be learned or reinforcedinthesession.Thus,bytheendofthesession,childrenwithandwithoutthe signareseenbyparticipants,sothedistinctionisclear.)Givethemachancetoexamine forthesign,forexample,tostandnearthechildtolookforchestindrawing,ortopinch the skin. (The instructor needs to assess the sign at the same time as the participants, sincesignsmaychangeovertime.)
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Ifnecessary,askparticipantstowritetheirindividualassessmentonaslipofpaperand hand or show it to you, so you are sure they are giving their own assessment, not influenced by others or fear of embarrassment. These problems will vary by group. Be awarethatsomepeoplearequiteshyanddonotliketohaveajokemadeiftheyhave made an error. With slips of paper, it is possible to talk about agreement of the group without singling out the wrong answer of any one participant. You will know which participantsareassessingcorrectlyandwhichneedmorepractice. Tell the correct assessment of the sign. If all participants did not assess it correctly, demonstrate or let participants assess again. Find out why they decided differently where they were looking, when they think breathing in or out is occurring, or other relevant factors. Treat their opinions with respect. Convey the fact that you might be wrong. "Let's look again." "Now is it more clear in this position?" "Abdi was correct to doubtchestindrawingifhewasnotsure.Let'slookinadifferentposition." Makesuretheatmosphereissupportive,soparticipantsdonotfeelbadiftheygetasign wrong.Youmaysay,"Ittakesawhiletolearnthesesigns.Donotfeelbadifyoumakea mistakeweallwill." Asktheparticipanttotellthechild'sclassificationsagain.Ifyourassessmentofanysign was different from his initial assessment, allow him a chance to decide how the classificationshouldchange. Summarizethecasesothatparticipantsunderstandthecorrectassessmentofthechild's signs and classifications. Thank the participant and praise him for any new or difficult tasksthathedidcorrectly.Thenmovethegrouptothenextcaseandreviewthecasein thesameway.
Whenconductingtheroundsofparticipants'cases,startwiththecaseswhoseclassificationsare simple (such as a child with no general danger signs and fast breathing classification PNEUMONIA). Cases with more complex classifications can be presented later, for example, a second case could have no general danger signs and fast breathing with chest indrawing (classification SEVERE PNEUMONIA), or could have general danger signs and chest indrawing (classification SEVERE PNEUMONIA/ SEVERE DISEASE). By having participants see children with increasingly complex classifications, a variety of signs and assessments can be demonstratedtoparticipants. 7. If in the early morning additional children were identified with signs that are infrequentlyseen(stridor,severepallor,etc.),demonstratethesesignstoparticipantsattheend ofthesession.Thiswillensurethatparticipantswillgettoseeinfrequentlyseensigns,whenever theopportunityarises. For certain signs such as chest indrawing and palmar pallor, it is important to show children with and without the sign. Putting several children's hands together who have no, some and severepalmarpallorcanbeveryhelpful.Itisimportantthatparticipantsavoidovercallingsigns in normal children. Therefore, include children with noisy breathing from blocked nose, no palmarpallor,etc.Participantsneedtobecomeconfidentinsayingasignisnotthere,notjustin recognizingtheabnormalsigns. 8. Attheendoftheclinicalsession,summarizetheimportantsignsandtaskscoveredinthe session and refer to common problems that participants encountered (for example, missing
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chest indrawing, or errors of classification). Ask participants to keep their recording forms so thattheycanrefertothemtoenterthecasesintoICATTClinicalpracticesheetandtocomplete theirGroupchecklistofclinicalsignsifused. Summarize for the participants the important signs and classifications that they saw in the session. Reinforce them for new and difficult steps that they did correctly, and give them suggestionsandencouragementtohelpthemimprove. 9. After the session, record on the Checklist for monitoring inpatient sessions the cases seenbytheparticipants. 10. During the training, participate in the meeting of facilitators at the end of each day. Report on the performance of each group at the inpatient session that day. Discuss whether participantsareseeingalltheclinicalsignsandclassifications.Determineiftherearechildren withcertainsignsthatyoushouldtrytolocateandincludeinthenextday'scases.
3. SPECIFICINSTRUCTIONSFORCONDUCTINGINPATIENT SESSIONS
Onthefollowingpagesaresummariesofeachsessionwhichlistthespecificinstructionsforthat session. Each summary table lists how to prepare, the participants' objectives, the instructor's procedures, and what to do to conclude the session. Following the summary table, there are additionalnotesaboutpreparingfororconductingthatparticularsession. The titles of sessions indicate activities which appears first in that session. It is desirable that theyareincludedinallsubsequentsessionsaswell. Depending on the number of sessions in the ICATT based IMCI training, you may need to combinethecontentofsomesessionsdescribedintheseguidelines.
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INPATIENT SESSION CHILD1: CHECK FOR GENERAL DANGER SIGNS ASSESS AND CLASSIFY COUGHORDIFFICULTYBREATHING
Toprepare Reviewthe"Generalprocedures:Howtoprepareeachsession"and "Conductingtheinpatientsession." Choosechildrenwithgeneraldangersignsand/orcoughordifficulty breathing.Includeachildwithstridorandwheezingifpossible. Identifyanychildrenwithinfrequentlyseensigns. Participant objectives Instructor procedures 1. 2. Assessgeneraldangersigns. Assessandclassifycoughordifficultybreathing. Obtainadditionalpracticeassessingchestindrawing. Recordfindingsontherecordingform;usethecharttochoose classifications;recordthem. Explaintoparticipantshowinpatientsessionswillwork. Demonstratetheassessmentofachildwithcoughordifficulty breathing(assessgeneraldangersignsandcough).Showhowtouse theinformationonthechild'shistorywhichisalreadywrittenonthe recordingform. Demonstrateachildwithnochestindrawing.Thendemonstratea childwithchestindrawing. Assignparticipantstopatients.Observeandassistasneededwhile participantsassessandclassify. Conductrounds.Haveallparticipantsassessanychildwithcoughor difficultybreathingforchestindrawing,andanychildwithnoisy breathingforstridororwheezing. Showanychildrenwithinfrequentlyseensigns.
3. 4. 5.
6. Attheendof thesession
Summarizethesessionwithparticipants. Completethemonitoringchecklist.
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Explanationofhowinpatientsessionswillwork: Explainthatthepurposeofseeingpatientsintheinpatientwardistogiveparticipantsseveral opportunitiestoseeandpracticeassessingasmanypatientsaspossible.Inaddition,childrenin the inpatient ward are more likely to have severe signs than the children who come to outpatient clinics. Seeing inpatients will give participants more experience with children with severesignsandclassifications. Theinpatientsettingisnotliketheclinicsettingwhereparticipantsusuallywork.Thechildren intheinpatientwardhavealreadybeenassessedbystaffandarereceivingtreatment.However, soyou(eachparticipant)cangetpractice,whenyouareassignedacase,assessandclassifythat childasifitisaninitialvisit.Writethefindingsonacleancopyoftherecordingform.Usethe informationaboutthechild'shistorywhichisrecordedontherecordingformatthefootofthe child's bed. Look, listen and feel to assess the child's signs. Classify the child and record the classificationontheform. Wheneveryonehasfinishedtheircases,therewillberounds,sothatallofyoucanseeallthe cases.The groupwillreviewthe assessmentfindings andclassifications. Thisisdifferent from clinicalroundsyoumayhaveexperienced.Noonewilllecture.Youneedonlytopresentbriefly, justasyoudotoyouroutpatientfacilitator.Youshouldnotfeelshy.Wearealllearning. Yourinteractionwiththemotherofyourassignedcaseherewillbedifferentthanwithamother who comes into your clinic. You may not be asking this mother questions about her child and willnotdiscusstreatmentasyouwouldwithamotherinyourclinic.Rememberthatwhenyou are managing sick children in your clinic, your communication with the mother is very important.Youshouldpracticeallyourcommunicationskillswhenyoucareforchildreninthe outpatient session each day. Of training, you may speak to a mother here, and if you do, you shouldbekindtoherandlistencarefullytoheranswers. Ifachildsuddenlybecomesmuchsicker,pleasebesuretoalertthewardstaff. Specialnotesforteachinggeneraldangersigns 1. Demonstrate the difference between a child who is drinking poorly and a child who is notdrinkingatall. 2. Demonstratethedifferencebetweenachildwhovomitsmanytimesadayandonewho vomitseverything. 3. Showthatforconvulsionsalone,thehistoryofconvulsionshastobeduringthecurrent illness;ahistorybeforethecurrentillnessdoesnotrelatetothisclassification. 4. Demonstrate the difference between a lethargic child and a child who is sleepy, and betweenandunconsciouschildandachildwhoisdrowsy. 5. A common mistake in demonstrating danger signs is to omit checking for them, or to forget them when classifying the illness. Thus a child with fever plus a general danger sign,orcoughplusageneraldangersign,maybemisclassified.Emphasizethatageneral danger sign gives a child with cough a pink classification. Further down the chart, a
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generaldangersignalsogivesachildwithfeverapinkclassification.Forexample,achild whoisvomitingeverythingandhasafevergetsapinkclassification. Specialnotesforteachingclassificationofcoughordifficultybreathing 1. Point out that chest indrawing is difficult to detect in a wellnourished or overweight child (false negatives) and is overcalled in children with severe malnutrition (false positives).Inchildrenwithseveremalnutrition,chestindrawingis oftenconfusedwith intercostalindrawing. 2. Trytoshowachildwithchestindrawingbutwithoutfastbreathing. 3. Demonstrate chest indrawing in a child with very fast breathing (>70 breaths/minute) whereitmaybedifficulttodetect. 4. Demonstrate that good lighting is crucial for detection of chest indrawing. If it is dark, movethepatientorparticipantstoseechestindrawingbetter. 5. Donotencourageparticipantstocallchestindrawingwhenonlyverysubtleindrawingis observed.Teachthemthat"Whenindoubtitisnotthere."Chestindrawingshouldbe definitetobecalledchestindrawing. 6. If possible, show a child who has chest indrawing when breastfeeding or because his nose is blocked. Demonstrate that when he finishes feeding or his nose is clear, chest indrawinggoesaway. 7. If possible, present a case who does not have cough but does have difficulty breathing withchestindrawing.Ifthechildshistorywerenotcarefullytaken,onemightfindthat thechildhasnocoughandskipthecoughsectionofthechart.However,thehistoryof difficultybreathingbringsthechildintothealgorithmandresultsinapinkclassification. Thisshowstheimportanceofaskingaboutdifficultybreathing. 8. If possible, demonstrate the differences between stridor, blocked nose, and audible wheeze. 9. Whenever possible, review the respiratory rate cutoffs for fast breathing given on the IMCIchart: forchildren2monthsupto12months:50breathsperminuteormore forchildren12monthsupto5years:40breathsperminuteormore Forexample,askthegroup:Howoldisthischild?Whatisthebreathingrate?Sodoesthe childhavefastbreathing?Emphasizethatarateofexactly50forachildupto12months,or exactly40forchildage12monthsupto2years,doescountasfastbreathing.
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INPATIENTSESSIONCHILD2:ASSESSANDCLASSIFYDIARRHOEA
Toprepare Selectchildrenwithgeneraldangersigns,coughordifficultybreathing, and/ordiarrhoea.Selectacasewithseverepersistentdiarrhoeaifpossible. Findadditionalchildrenifneededtodemonstrateslowandveryslowskin pinch,andallothersignsofdehydration(restlessandirritable,lethargicor unconscious,sunkeneyes,etc.)Identifyanychildrenwithinfrequentlyseen signs. Instructor procedures 1. 2. 3. 4. 5. Attheendof thesession Assesschildrenforgeneraldangersigns. Assessandclassifycoughordifficultybreathingand/ordiarrhoea. Recordfindingsontherecordingform;usethecharttochoose classifications;recordthem. Obtainadditionalpracticeassessingchestindrawing,skinpinch,and sunkeneyes. Demonstrateassessmentofachildwithdiarrhoea. Demonstratethetechniqueofskinpinch.Haveparticipantsperformit correctly. Assignparticipantstopatients.Observeandassistasneededwhile participantsassessandclassify. Conductrounds.Haveallparticipantsassessanychildwithdiarrhoea forskinpinch,andanychildwithcoughforchestindrawing. Showanychildrenwithinfrequentlyseensigns.
Participant objectives
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1. Choosechildrensothatslowskinpinch,veryslowskinpinchandothersignsofsomeor severedehydrationwillbeshown.Alsochoosechildrensothatthesignsandsymptoms demonstratedthepreviousdaycanbedemonstratedagain. 2. Demonstratethatahistoryofbloodinthestoolistheonlywaytoclassifyachildwith dysentery. Stress that one must ask about duration of diarrhoea to arrive at a classificationofpersistentorseverepersistentdiarrhoea. 3. Ifpossible,showamalnourishedchildwithsunkeneyesanddiarrhoeabutwithnoother signsofdehydration. 4. Ifpossible,alsopresentamalnourishedchildwithslowskinpinchbutnoothersignsof dehydration.(Theslowskinpinchisoftenmisleadinginamalnourishedchild.) 5. Showachildwithseveredehydrationwhoisunabletodrinkordrinkspoorly.Show,in contrast,achildwhowillreachtowardsaglass,drinkingeagerlyandthirstily. 6. Demonstrateaskinpinchondifferentsidesoftheabdomenandonthechestandother parts of the body to show that the result is only reproducible when the skin pinch is performedontheabdomen. 7. Showthedifferencebetweenpinchingtheskinandreleasingitslowlyandpinchingthe skinandreleasingitquickly. 8. Trytodemonstrateslowskinpinchinachubbychild. 9. Trytopresentachildwhohasonedehydrationsigninthepinkboxandothersignsin theyellowbox(forexample,achildwhoislethargicorunconsciousfromsepticaemiaor meningitis,butalsohasdiarrhoeaandaslowskinpinch).Eventhoughthischildhasone sign in the pink box, he will receive a yellow classification for dehydration, because it takes two pink signs for a pink classification. (The child will most likely receive a pink classificationelsewhereonthechart,forexample,inthefeversection.)Thissituationis rare,butitishelpfultopresenttheoccasionalchildwhohasdehydrationsignsinboth thepinkandyellowboxes. 10. Whenyouconductrounds,firstreviewthecaseswithonlycoughordifficultybreathing or with only diarrhoea, if possible. Then the cases with various combinations of diarrhoeaanddifficultybreathingand/orgeneraldangersignscanbepresented.
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INPATIENTSESSIONCHILD3:ASSESSANDCLASSIFYFEVER
Toprepare Choosechildrenwithfever,andifpossible,withgeneraldangersigns especiallyconvulsions,lethargicorunconscious,neckstiffness,measles. Alsochoosechildrenwithcoughordifficultybreathingand/ordiarrhoea. Identifyanychildrenwithinfrequentlyseensigns. Instructor procedures 1. 2. 3. 4. Checkforgeneraldangersigns. Assessandclassifycoughordifficultybreathing,diarrhoea,and/or fever. Recordfindingsontherecordingform;usethecharttochoose classifications;recordthem. Obtainadditionalpracticeassessingchestindrawing,skinpinch, sunkeneyes,andneckstiffness. Demonstrateassessmentofachildwithfever,andwithmeaslesif possible. Haveallparticipantspracticeassessingforstiffneck. Assignparticipantstopatients.Observeandassistasneededwhile participantsassessandclassify. Conductrounds.Haveallparticipantsassessanychildwithdiarrhoea forskinpinchandsunkeneyes,andanychildwithcoughforchest indrawing. Showanychildrenwithinfrequentlyseensigns.
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1. At this session, the same order of presentation of cases should be followed. Start with childrenwithsimpleclassificationssuchasfastbreathingaloneordiarrhoeawithnoor some dehydration, followed by cases who have various combinations. Children with generaldangersignsshouldbepresentedlast. 2. Demonstrate a child with a fever and history of convulsion (febrile seizures, without pneumonia). Because of this danger sign, this child should receive a VERY SEVERE FEBRILEDISEASEclassification,butthisclassificationisoftenmissed. 3. Present children who enter the fever box not by history or feeling hot but by taking temperatureof37.5Corabove. 4. Demonstratethedifferencesbetweenarectaltemperatureandanaxillarytemperature. 5. If you are in a low malaria risk area, try to present a child with fever who has either travelledtoorcomefromahighriskmalariaarea. 6. Demonstrate false positives for stiff neck, for example, a crying child or infant that resentsthephysicianandarcheshisorherbackasopposedtotrueneckstiffness. 7. Present fever cases with a history of fever more than 7 days. Point out that these children are referred for assessment of other causes of fever. (See Identify Treatment column,yellowandgreenboxesforMALARIAandFEVERMALARIAUNLIKELY.) 8. Trytopresentachildwhohadmeasleswithinthelast3months(butnoactivemeasles now)topointoutthatthesechildrenneedVitaminA. 9. Presentachildfromalowriskmalariaareawithanothercauseoffeverpresent(suchas diarrhoea,boils).ShowthattheclassificationwouldbeFEVERMALARIAUNLIKELY. Note:ForareasinwhichtheIMCIchartshavebeenadaptedtoincludedenguehaemorrhagic fever(DHF),pointoutthesignsofDHFandhowthesechildrenareclassified.Explainthata historyofmelenaneedstobetakenverycarefully,sincethismaybetheonlycluetoDHF.If possible, illustrate the differences between skin petechiae, mosquito bites (mosquito bites blanche),telangiectasia,andbirthmarks.
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INPATIENTSESSIONCHILD4:ASSESSANDCLASSIFYEARPROBLEM,MALNUTRITIONAND ANAEMIA
Toprepare Choosechildrenwithearproblem,signsofanaemiaorverylowweight. Alsochildrenwithgeneraldangersigns,andothermainsymptoms. Besuretowritethechild'sweightinkilogramsandthechild'sagetothe lastmonthontherecordingform(neededforassessingweightforage). Identifyanychildrenwithinfrequentlyseensigns. Participant objectives Instructor procedures 1. 2. 3. 4. Checkforgeneraldangersigns. Assessandclassifycoughordifficultybreathing,diarrhoea,fever,ear problem,malnutritionandanaemia. Recordfindingsontherecordingform;usethecharttochoose classifications;recordthem. Obtainadditionalpracticeassessingsomedifficultsigns. Demonstrateassessmentofearproblemandnutritionalstatus. Demonstratethetechniqueofassessingoedemaofbothfeet.Have participantsperformitcorrectly. Demonstratethetechniqueofmeasuringofthemiddleupperarm circumference(MUAC).Haveparticipantsperformitcorrectly. Assignparticipantstopatients.Eachparticipantchecksfor malnutritionandanaemiainadditiontoallpreviousassessmentsteps learned.Observeandassistasneeded. Conductrounds.Haveallparticipantsassessthecasesforpallorand visibleseverewasting.Stresscorrectplottingofweightforage. Additionalsignsavailable,suchaschestindrawingorneckstiffness, shouldbeassessedbyallparticipantsasinearliersessions. Showanychildrenwithinfrequentlyseensigns.
5.
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1. In a large hospital, there may be a separate ward where children with mastoiditis and chronic ear infection are treated. There may be a separate malnutrition ward which shouldbevisitedtoseechildrenwithclinicalsignsofmalnutritionoranaemia.Youmay alsofindchildrenwithachronicdrainingearinthemalnutritionward. 2. Demonstratethedifferencebetweenvisibleseverewastingandwasting. 3. When demonstrating pallor, show that it is preferable to compare the childs palms to the health workers palms rather than the mothers palms. If the mother herself were anaemic,thiswouldmakethechildspalmsappearnormal.Assumingthehealthworker is not anaemic, it is better to compare with the health workers palms. (Look at the participantspalmstodetermineifanyoneappearsanaemic;usuallysomeonewillhave somepallor,andthiscanbeagoodteachingpoint.) 4. Puttingseveralchildren'shandstogetherwhohaveno,some andsevere palmarpallor canbeveryhelpful. 5. Demonstratethedifficultyofobservingpallorinasmallbabywithaclenchedfistwhoon forcingopenthehandwouldappeartohavesomepallor. 6. Presentchildrenwhoareage2yearsorolderandwhohaveweightsjustaboveorjust below the line for VERY LOW WEIGHT on the Weight for age chart. This will illustrate how attention to careful weighing and attention to detail can make the difference betweengivingnutritionaladviceornot.
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INPATIENTSESSIONCHILD5:PLANBANDCTREATDEHYDRATION
Toprepare ChoosechildrenwithdehydrationwhoarebeingtreatedaccordingtoPlanB orPlanC.Alsochoosechildrenwithdifferentcombinationsofclinicalsigns andclassifications,orwithparticularsignsthatparticipantsneedto practice,forparticipantstoassessiftimeallows.Identifyanychildrenwith infrequentlyseensigns. Determinewhetherchildrenareadmittedduringthedaywithdehydration, andifso,whetherandwhereparticipantscanseethem. Participant objectives Instructor procedures 1. ObservechildrenbeingrehydratedwithPlanBorPlanCand,if possible,assistingivingthetreatment. BecomefamiliarwiththeformtomonitorIVorNGfluidinchildren receivingPlanC,ifavailable. Reassessdehydration. Iftimeallows,assessandclassifyasickchild. Recordfindingsontherecordingform;usethecharttochoose classifications;recordthem. Takeparticipantstoseesomechildrenwhoarereceivingtreatmentfor dehydration.Assignoneorapairofparticipantstositwitheachchildto observethetreatment. Askparticipantstoreassessthedehydration.Describetothemthe child'ssignsofdehydrationthismorningsothattheyunderstandthe improvements. Ifitispossibletoidentifychildrenwhoarenowbeingadmittedwith dehydration,assignpatientstoassessandclassifythemandassistwith theirtreatment. Iftherearenodehydratedchildren,oriftimeallows,assign participantstopatients.Observeandassistasneededwhile participantsassessandclassify. Conductrounds.Havetheparticipantsassessanysignsthattheyneed topractice,suchaschestindrawingorpalmarpallor. Showanychildrenwithinfrequentlyseensigns.
2.
3.
4.
5. 6. Attheendof thesession
1. Theremaybeadiarrhoeatreatmentunitordiarrhoeawardwhichshouldbevisitedto seechildrenreceivingtreatmentfordehydration.
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2. Ifparticipantshavenotyethadexperiencewithtreatmentoflocalinfection,havethem watchademonstrationoftreatmentofeyeinfectionwithtetracyclineointmentor treatmentofmouthulcerswithhalfstrengthgentianviolet.
INPATIENTSESSIONYOUNGINFANT1:ESSENTIALCARE
Toprepare Thissessionshouldtakeplaceinmaternityhospitalordepartment.Identify healthynewborns,fordemonstrationandobservation. Ideallytheparticipantsshouldobservepreparationsfordeliveryandcare foranewbornimmediatelyafterdelivery,thereforethetimingofthis sessionshouldbeflexible,toaccommodatethis. - Observehowdeliveryroomispreparedforthebirth Practicecorrecttechniqueforhandwashing Observe(provideifpossible)keycomponentsofessentialcareofthe newbornimmediatelyafterbirth: o o o Instructor Procedures Immediateskintoskincontact Initialeyecare Routinecordcare.
Observebreastfeedingofanewbornbaby.
1. Demonstratethekeystepsofpreparationsforthebirthindelivery room. 2. Discusswarmchainelementsandstresstheimportanceofwarmchain maintenance. 3. Demonstrateanddiscusscorrecthandwashingtechnique,let participantstopracticeit. 4. Discusskeycomponentsofessentialnewborncare.Givespecial attentiontoimportanceofimmediateskintoskincontact,initialeye andprinciplesofcordcare.Letparticipantsobserveandifpossible practicethesecomponents. 5. Discussimportanceofearlybreastfeedinginitiationandkeystepsto helpmothertostartbreastfeeding(withinonehourafterthebirth).Let participantsobserveatleastonecompletebreastfeeding,paying attentiontothetiming(whenbreastfeedingstarted),positioning, attachmentandsignsofeffectivesuckling.
Attheendof thesession
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Summarizethesessionwithparticipants.
1. Demonstrate the key steps of preparations for the birth in delivery room. During demonstrationstressthatdeliveryroom/areashouldbewarm(atleast25C)andfreeof draughts. The resuscitation equipment should be readily available in case it will be needed. The area should have clean warm towels or covers or cloths ready for the newbornatdeliverytodrythenewbornandkeephimorherwarm.Pointouttheneed to have a sterile kit to tie and cut the cord. Explain that everything should be ready to make immediate skintoskin contact of mother and newborn, stress that the mother shouldwearclotheswhichmakesuchcontacteasy. 2. Discuss warm chain elements and stress importance of warm chain maintenance. Duringthevisitofdeliveryroom/areadiscussanddemonstrate(whenpossible)thekey elementsofthewarmchain:warmfreeofdraughtsdeliveryroom,immediatedryingofa newborn and immediate skintoskin contact after birth, breastfeeding, bathing and weighing postponed, mother and newborn together, warm resuscitation and transportation if needed, appropriate clothes for the newborn, stress importance of appropriatetrainingofhealthworkers,whotakecareofnewbornbabies. 3. Demonstrate and discuss correct hand washing technique, let participants practice it.Discusswithparticipantstheimportanceofinfectioncontrolduringcareof newborns. Demonstrate appropriate hand washing technique, discuss all key elements andaskparticipantstopracticegoodhandwashingtechnique. 4. Discuss key components of essential newborn care. Stress there are six main components: Airtostimulateorresuscitateinfantswhoarenotbreathingatbirth Warmthensuringandmaintainingwarmchainduringandafterdelivery Breastfeedingmainsourceoffoodandenergyforanewborn Loveandsafetyclosecontactwithmotherimmediatelyafterdelivery Infectioncontrolpreventionofinfections Managementofcomplicationsafterbirth. 5. Reviewessentialinformationaboutcordcare:Thecordstumpisthemajormeansof entryforinfectionsafterbirth.Themosteffectiveprinciplesofcordstumpcarearekeep itdryanddonotapplyanythingonit.Theyapplyathomeaswellasinthehealthfacility. Thestumpwilldryandmummifybytheairwithoutanydressing,bindingandbandages; it will remain clean if it is protected with clean and dry clothes and is kept away from urineandsoiling.Ifsoiled,thecordshouldbewashedwithcleanwateranddriedwith clean cotton or gauze. No antiseptics are needed for routine care. Review the steps of routinecordcare:clampingthecordwithtiestightlyaroundthecordat2cmand5cm from the newborn's abdomen; cut between theties with a sterile instrument; no substance applied to the stump, stump left uncovered. If the routine cord care has not beenobserveddirectly,showtheparticipantshowthestumpsofnewbornsinmaternity wardlooklike.Pointoutthatredumbilicusordrainingpusisasignofinfection. 6. Review essential information about routine eye care: Eye care is given to protect a newborns eyes from infection. Bacteria may be transmitted from an infected mother duringbirthtothebabyseyesandcauseinflammationofeyes(conjunctivitis)whichcan result in blindness. Neisseria gonorrhoeae, Chlamydia trachomatis, and Staphylococcus aureusarethemostimportantcausesofeyeinfectioninanewbornchild.Topreventeye infection:Cleantheinfantseyesassoonaspossibleafterbirth.Applyanantimicrobial eyemedicine.Thiscanbedoneafterthenewbornhasbeendriedorwhenthenewborn 23|P a g e
is held by his or her mother. Remember that the antimicrobial should not be washed away.Drugswhichcanbeusedtopreventeyeinfectionatthetimeofbirthinclude:1% silver nitrate eye drops, 2.5% povidineiodine eye drops, 1% tetracycline ointment. Reviewthestepsofroutineeyecare:eacheyewipedwithaseparatepieceofdryclean clothortwodifferentcleancornersofthetowelusedtodrythenewborn;onedropof thesolutionorasmallamountofointmentputontheinsideofthenewbornslowereye lid. 7. Review importance of early breastfeeding initiation and key steps to help mother tostartbreastfeeding.Letparticipantsobservebreastfeedingofanewborn,ifpossible. Explain key elements of correct attachment and positioning. Demonstrate the signs of effective suckling. Explain how a health worker can help the mother to start breastfeedingcorrectly.Stressouttheimportanceofearlyinitiationofbreastfeeding.
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INPATIENTSESSIONYOUNGINFANT2:VERYSEVEREDISEASE,LOCALBACTERIALINFECTION, JAUNDICEANDDIARRHOEA
Toprepare Participant objectives Chooseyounginfantswithsignsofveryseverediseaseandlocalbacterial infectionorjaundiceordiarrhoea.Alsochoosesomenormalyounginfants. Instructor Procedures 1. 2. Assessandclassifyayounginfantforveryseveredisease,local bacterialinfection,jaundice,anddiarrhoea. Recordfindingsontheyounginfantrecordingform;usetheYOUNG INFANTcharttochooseclassifications;recordthem. Obtainadditionalpracticeassessingsomesigns. Demonstrateassessmentofayounginfantforveryseverediseaseand localbacterialinfection,jaundice,anddiarrhoea. Demonstrateinfantswithasmanysignsofveryseverediseaseand localbacterialinfection,jaundice,anddiarrhoeaasavailable:severe chestindrawingandmildchestindrawing;umbilicalrednessandpus; skinpustules;normalmovementandmovementonlywhenstimulated ornomovementatall.Alsoshowanormalinfant. Assignparticipantstoyounginfants.Observeandassistasneeded whileparticipantsassessandclassify. Conductrounds.Haveallparticipantsassessasmanyofthesigns aboveaspossible. Showanyyounginfantswithinfrequentlyseensigns.
3. 4. 5. Attheendof thesession 1.
Look for young infants throughout the hospital, in any areas where you may find young infants age up to 2 months (age 0 to 59 days). Check in areas such as neonatal unit, maternityward,andthepaediatricward. Demonstrate the difficulty of getting accurate respiratory rate counts for a sick young infant. Demonstratethedifferencebetweensomechestindrawingandseverechestindrawing. Showthedifferencebetweenskinpustulesandechthyma. Demonstratemovementonlywhenstimulatedornomovementatall. Thisis aparticularlyimportantsession.Ifthere aremany younginfantsintheinpatient wardandveryfewornoneintheoutpatientclinic,makethissessionlonger,iflogistically feasible.
2. 3. 4. 5. 6.
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INPATIENTSESSIONYOUNGINFANT3:ASSESSBREASTFEEDING,ASSESSANDCLASSIFY YOUNGINFANTS
Toprepare Chooseyounginfantswithsignsofveryseverediseaseandlocalbacterial infectionorjaundiceordiarrhoeaorfeedingproblemstodemonstrateas manyoftheclinicalsignsaspossible.Alsochoosesomenormalyoung infants.Identifyanyyounginfantswithinfrequentlyseensigns. Instructor procedures 1. 2. Assessayounginfantbreastfeeding. Ifpossible,counselthemothertoimprovepositioningandattachment forbreastfeeding. Assessandclassifyayounginfantforveryseverediseasesandlocal bacterialinfection,jaundice,diarrhoea,andfeeding. Recordfindingsontheyounginfantrecordingform;usethechartto chooseclassifications;recordthem. Demonstrateanormalyounginfantfeedingwell,emphasizingthe signsofattachmentandsuckling. Demonstrateayounginfantwithfeedingproblems.Ifpossible, demonstratecounsellingthemothertoimprovepositioningand attachmentforbreastfeeding. Assignparticipantstoyounginfants.Askthemtoassessandclassify theyounginfant.Observeandassistasneeded. Conductrounds.Haveallparticipantsassessasmanyofthesigns presentaspossible. Showanyyounginfantswithinfrequentlyseensigns.
3. 4. 5. Attheendof thesession
1. Look for young infants throughout the hospital, in any areas where you may find young infantsageupto2months(age0to59days).Checkinareassuchasneonatalunit,maternity ward,andthepaediatricward. 2. Itmaybenecessarytousenewbornprematureinfantstodemonstratepoorattachmentand suckling and correction of positioning. New mothers may provide opportunity for practice correctingpositioningandattachment.
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ANNEX1:LISTOFMATERIALS,DRUGS,ANDSUPPLIESNEEDEDFORCLINICALPRACTICEIN OUTPATIENTSESSIONS
Thefollowinginstructionalmaterialswillbeneededforclinicalpracticesessions. ITEMNEEDEDFORCLINICALPRACTICE SetofwallsizeCasemanagementcharts tohangatclinicalpracticesites CopiesofMother'scardtodistributeto mothers Sickchildrecordingforms Younginfantrecordingforms Drugenvelopesandlabels Clipboard Bagorboxofdrugsandotherclinical supplies(suchascups)forafacilitator fromeachgrouptocarrytooutpatient clinics* 1setforeachoutpatientclinicandthe inpatientward 2percounsellingsessionperparticipant 8perparticipantpersession 8perparticipantpersession 5perparticipant,ifsiteswillusethem 1perparticipant 1foreachsmallgroup NUMBERNEEDED
Essentialdrugsandsuppliesforoutpatientsessions Drugs: ORSpackets(lowosmolarityifavailable)1 atleast8per participant Firstlineoralantibioticforpneumonia Firstlineantimalarial Firstlineoralantibioticfordysentery Mebendazole VitaminAcapsules Paracetamol Iron(tabletandsyrupifpossible) Plasticcups(oneforeachparticipant to offerdrinkstochildwithdiarrhoea) Cleanwatersupply(formixingORS,offeringfluidtochild whenassessingsignsofdehydration;andmaking crushed drugs) Enoughwatchesorothertimingdevices(participantswill usuallyusetheirownwatches) Mother'scards(ifused) Bananaorotheracceptablefoodtousewhenmixingcrushed tablets.Bananaishandy,portableandchildrenlikeit. ContainersformixingORS Spoons Oralrehydrationsaltspremixedpackets1 Thermometer Washbasin,towel,soap Functionalscaleforweighingchildrenandaccurately TapeforthemeasuringofMUAC Tetracyclineeyeointment2 1tubepergroup Gentianviolet2smallbottleof0.5% Softclothsforapplyinggentianvioletandwashingeyeswith pus Ringer'slactatesolutionforIVadministration BedsortableswithwiresaboveforhangingbottlesofIV fluid IVsuppliessuchasscalpvein(butterfly)needles
Supplies:
Otheressential suppliesforORTCorner Otheressential clinicsupplies Desirableforusein clinicalpractice: DesirableforORT cornerifIVfluidstobe given:

1
If pre-mixed packets of either standard or low osmolarity ORS are not available, use the following ingredients with amounts specified for mixing with 1 litre of water (low osmolarity ORS): Glucose (13.5 g) -- (or 27 g sucrose), Sodium chloride (2.6 g), Trisodium citrate, dihydrate (2.9 g) - (or 2.5 g sodium bicarbonate), Potassium chloride (1.5 g)
2Theseareunlikelytobeusedduringthesession.However,instructorscankeepasmallsupplytousewhen demonstratingtreatmentsoflocalinfections.
Itwouldbeanidealsituationifclinicswhereoutpatientsessionsareheldarestockedwithall thedrugslistedonthenationallyadaptedcasemanagementchartsandwiththenecessary equipmentforadministeringthem.Thedrugswhichareneededfordoingallthestepsas describedonallofthecasemanagementchartsincludethefollowing(lesswouldberequired afterchartsareadapted):
ToprovidecareastaughtinthecourseIntegratedManagementofChildhoodIllness: Antibiotics: Cotrimoxazole o Adulttablet(80mgtrimethoprim+400mgsulphamethoxazole) o Paediatrictablet(20mgtrimethoprim+100mg sulphamethoxazole) o Syrup(40mgtrimethoprim+200mgsulphamethoxazole) Amoxycillin o Tablet(250mg) o Syrup(125mgper5ml) Ampicillinintramuscular(250mgvial) Gentamicinintramuscular o 2mlvialcontaining20mgOR o 2mlvialcontaining80mg Ciprofloxacinetablets(250mgOR500mg) Tetracyclinetablets(250mg) Erythromycintablets(250mg) Coartemethertablets(20mgartemetherand120mglumefantrine) QuinineIntramuscular o 300mg/ml(in2mlampoulesusingquininesalt)OR o 150mg/ml(in2mlampoulesusingquininesalt) Paracetamoltablets500mgOR100mg Smallbottlesofsafe,soothingcoughremedy(optional) AdequatesuppliesofBCG,OPV,DPT,HIB,HepB,andMeaslesvaccines Sugar Clothforwickingdrainingears Largedrum(5,10,or15litresize)withcoverandsidetapforholding largequantitiesofORSinORTcorner FoodtogivepatientsonPlanB Nasogastrictube Sterilesyringesandsterileneedles: o 5ccsterilesyringesandsterileneedles o 10ccsterilesyringesandsterileneedles SterilewaterfordilutingIMantibioticsandIMantimalarials Cottonswabsandalcoholorspirits Allappropriatecoldchainsuppliessuchasareliablerefrigeratoror coldbox,sterilizers,sterilesyringesandsterileneedles,immunization cards.
Antimalarials:
Antipyretic: Otherdrugs: Vaccines: Othersupplies:
ANNEX2:LISTOFSUPPLIESTOBRINGFOREACHOUTPATIENTSESSION
(UNLESSYOUARECERTAINTHEYAREINCLINIC) BRINGTO EVERY SESSION ____ Recordingforms:8copiesperparticipant ____ Remindparticipantstobringchartbooklets,pencilsandtiming devicestoeachsession ____ Clipboards:oneperparticipantdistributefirstday ____ 4to8extrapencils,2extrachartbooklets ____ 1tubetetracyclineointmentand1bottlegentianvioletto demonstratetreatmentoflocalinfections,ifachildpresentsduringany session ____ Checklistformonitoringoutpatientsessions:5copies Session2and ____ Cuporspoonforeachparticipantandcleanwaterforassessing allsubsequent dehydration.(Ifyouknowthatthewatersupplyattheclinicisnot reliable,bringwaterwithyou.) Session4and ____ TapeforeachparticipanttomeasureMUAC. allsubsequent Session5,6, ____ Mother'scards:8perparticipant ____ Drugsandsuppliesfordemonstratingandpracticinghowto and7 teachmothertogiveoraldrugathomeandforgivingtreatmentif clinicdoesnothaveanadequatesupply: essentialdrugsforclinicalpractice(seeAnnex2) acommonspoonusedbymothers cleanbowl druglabels envelopeorpapertowraptabletsin appropriatefood(suchasabanana)ifmotherisgoing togivefirstdoseofdruginfood.Ifmothergivesfirstdoseinexpressed breastmilk,useacleanbowlorspoon. Session6 ____ SuppliesforORTcorner,ifnotavailableinclinic: preparedORSandORSpackets soapforwashinghands drinkingwaterifclinicdoesnothavereliablesupply containerformixing1litre spoonformixingORS cupsandspoonsforgivingORSsolution Session7 ____ Cuporbowlfordemonstratingfeeding ____ Appropriatefoodfordemonstratingfeeding Sessionson ____ Younginfantrecordingforms:10perparticipant Younginfant
ANNEX3:LISTOFSUPPLIESNEEDEDFORCLINICALPRACTICEININPATIENTSESSIONS
Suppliesnecessaryforinstruction OnesetofwallsizeCasemanagementcharts Sickchildrecordingforms Younginfantrecordingforms Oneclipboardperparticipant Stringortapetofastenclipboardstofootorheadofbed Highlighterpens,pens Thermometers TapesformeasuringofMUAC Scalesforweighingchildrenandinfants Cups,spoonsandcleanwater(forofferingfluidtoassessthirst) SuppliesfortreatingdehydrationaccordingtoPlanBandPlanC Essentialpaediatricinpatientsupplies ForIM/IVadministration: Quinine Gentamicin Ampicillin Diazepam D50(50%dextrose,forinjection) Fororaladministration: Paracetamol Ironsyrup/tablets VitaminA ORS Firstandsecondlineoralantimalarialsandantibioticsforpneumoniaanddysentery Mebendazole Oxygenbycylinderorconcentratorplusoxygenadministrationequipment Nasogastrictubes DisinfectanttowashusedNGtubes,oxygentubing,etc. ORTcornersupplies: Cleanwater ORSpackets Cupsandspoons ContainersformixingORSsolution IVequipmentincludingwaystoregulateinfusionrateofIVandbedsortableswithwires aboveforhangingbottlesofIVfluid IVfluidsincludingRinger'slactatesolutionandD5W Cottonswabsandalcoholorspirits Thermometer Scalewhichcanbezeroedandweighsaccurately Appropriatefoodfortubefeeding(forseverelymalnourishedchildren,andchildrennot abletofeed) KClsolutionforIVandoraluse Availabilityofsafebloodtransfusion Sterileneedlesandsyringes FoodtogivetopatientsonPlanBandotherpatients ReasonableHIVprecautionsincludingsafedisposalofneedles 1
ANNEX4:CHECKLISTFORMONITORINGOUTPATIENTSESSIONS
You will use a Checklist for monitoring outpatient sessions to monitor each participant's progress in learning the case management process. Refer to the checklists which follow these instructionsasyoureadabouthowtousethem. There is a checklist to use in sessions with sick children (age 2 months up to 5 years) and a checklist to use in sessions with young infants. Each checklist is arranged so you can record resultsfor 3participantswho manageupto 6patientseach withoutturningthepage.Ifthere aremorethan6patientsmanagedbyaparticipantinamorning,useasecondchecklist. Do not spend all your time in the outpatient session completing the checklist. Concentrate on actually observing participants and giving feedback. You can complete the checklist for each child from memory after the case is completed since you only need to record the child's age, classificationsandtreatmentsorcounsellinggiven. Tousethechecklist: 1. 2. Tick(9)eachclassificationthechildactuallyhas(accordingtoyourassessment).Tickthe trueclassifications,nottheonesassignedbyaparticipantifheisinerror. Ifthereisanerrorintheparticipant'sclassification,circlethetickthatyouhaveentered bythecorrectclassification.Theparticipant'serrorcouldbeintheassessmentorcouldbe misclassificationbasedoncorrectassessment.Eveniftheclassificationiscorrect,ifthere wasanerrorintheassessment,circlethetickandannotatetheassessmentproblem. For the step "Identify treatment needed" tick if the participant performed this step and wrote the correct treatment on the recording form. If he made an error, circle the tick mark. (Common errors are skipping treatments, not crossing off treatments that are not needed, or recording treatments that are not needed because the conditional "if" was ignored.) Fortherowsfordoingtreatments(oraldrugs,PlanA,PlanBandtreatinglocalinfections), for "Counsel When To Return" and for the steps for counselling on feeding, tick if the participantactuallyperformedthestep.
3.
4.
Note: Giving the treatment means teaching the mother how to give it and administering first doseortheinitialtreatment. 5. Ifthereisanyerrorinthetreatmentorcounselling,circletherelevanttick.Therecouldbe anerrorinthetreatment(eitherthedosageorexplanationtothemother)orcounselling. Foreachcircledtick,notetheprobleminthespaceatthebottomofthechecklist.Notethe problemsverybriefly.Youcanuselettersornumbersnexttothecirclestoannotatethe problems.Thesenoteswillhelpyouwhenyoudiscusstheparticipants'performanceatthe instructormeeting.Thesenoteswillalsohelpyoukeeptrackoftheskillsthatneedfurther practice. If you did not see the participant manage the case, take note of the child's condition yourself. Then ask the participant to present the case or refer to the participant's Recordingform.Tickthechecklistasdescribedabove.
6.
7. Whenyoucompletethechecklistandrecordinformationaboutthecase: Ifthechilddoesnothaveamainsymptom,donottickthatsection.Thereisno classificationtorecord. Iftheparticipanthasnotyetlearnedthestepsrelatedtocertainrowsofthechecklist, leavetheserowsblank.Iftherewasnotimeforthetreatmentorcounselling,leavethese rowsblank. Drawalineundertherowforthelaststepthatthegrouppracticed. Anexampleofacompletedchecklistisonthenextpage.Pleasenotethatthechecklist needstobeadaptedaccordingtothenationalIMCIguidelines.
ExamplechecklistfortheCareoftheyounginfant PleasenotethatthechecklistneedstobeadaptedaccordingtothenationalIMCIguidelines.
ANNEX5:MONITORINGOFINPATIENTSESSIONS
You maybe askedtorecordinformationontheparticipants' performanceontheChecklistfor monitoring inpatient sessions. Refer to the checklists which follow these instructions as you readabouthowtousethem. There is a checklist to use in sessions with sick children (age 2 months up to 5 years) and a checklist to use in sessions with young infants. Each checklist is arranged so you can record resultsfor2groupsofupto6participantsononesheeteachday. Complete the checklist as you review cases or immediately after you have worked with the groupintheinpatientward,soyoucanrecalleachparticipant'sperformance.Youmightaskthe clinicalassistanttohelpfillthechecklist. Touseachecklist: 1. Record the group and each participant's initials under his group at the top. For each participant,reportonthechildthattheparticipantassessed,classifiedandpresentedtothe group(onechildperparticipant). Tick(9)eachclassificationthechildactuallyhas(accordingtoyourassessment).Tickthe true classification,nottheclassificationassignedbytheparticipantifheisinerror.Ifthe participantseesorparticipatesinPlanBorCtreatment,tickthisalso. Iftheparticipantmadeanerrorintheclassification(basedeitheronanerrorinassessment or misclassification based on a correct assessment), circle the tick you have made for the true classification. Note the problems in assessment and classification very briefly in the spaceatthebottomofthechecklist.Iftheclassificationwascorrect,buttherewasanerror inassessment,circlethetickfortheclassificationandnotetheassessmentproblem. If the participant made an error in treatment (either the dosage or explanation to the mother),circlethetickmarkandnotetheproblematthebottomofthechecklist. Youcanuselettersornumbersnexttothecirclestoannotatetheproblems.Theproblems notedwillhelpyouwhenyoudiscussparticipants'performanceatthefacilitatormeeting. Thesenoteswillalsohelpyoukeeptrackoftheskillsthatneedfurtherpractice. Iftheparticipantsarenotyetdoingthefullassessment,leavetheserowsblank.Drawaline underthelastclassificationincludedinthesessionobjectives. Atthebottomofthechecklist,listclinicalsignsinadditionalcaseswhichwereseenbythe entiregroup.
2.
3.
4. 5.
ANNEX6:GROUPCHECKLISTSOFCLINICALSIGNS
Participantswillmonitortheirownclinicalpracticeexperiencebyusingtheirrecordingformsto recordthecasesseenasrequiredintheClinicalpracticesheetintheICATT.Theymaybealsoasked tocompleteaGroupchecklistofclinicalsigns. Asamplechecklistisonthenexttwopages.Thefirstpagecontainsthesignstoobserveinchildren age2monthsupto5years.Thesecondpagelistsadditionalsignsthatareusuallyseeninyoung infantsageupto2months. Tousethegroupchecklist: 1. 2. Obtainormakeanenlargedversionofeachpageofthechecklistandhangitonthewallofthe classroom.(Youcancopyitontoflipchartpaper.) Whenparticipantsreturntotheclassroomafterclinicalpracticeeachday,theyshould indicatethesignstheyhaveseenthatdaybywritingtheirinitialsintheboxforeachsign. Theyshouldindicatesignsthattheyhaveseenineithertheoutpatientsessionorthe inpatientsession. Eachdaytheywilladdtothesamechecklist. MonitortheGroupchecklisttomakesurethatparticipantsareseeingallofthesigns. Ifyounoticethatparticipantshavenotseenmanyexamplesofaparticularsign,takeevery opportunitytoshowparticipantsthissignwhenachildwiththesignpresentsduringan outpatientsession. Or,infacilitatormeetings,talkwiththeinpatientinstructoranddiscusslocatinginthe inpatientwardachildoryounginfantwiththesigntheparticipantsneedtoobserve.
3. 4.
Sickchildaged2monthsupto5years Notabletodrinkor breastfeed Fastbreathing Sunkeneyes Slowskinpinch Redeyes Cloudingofthecornea Severepalmarpallor Somepalmarpallor Oedemaofbothfeet Pusdrainingfrom ear Tenderswelling behindtheear Visibleseverewasting Mouthulcers Deepandextensive mouthulcers Pusdrainingfromeye Stiffneck Runnynose Generalizedrashof measles Drinkingpoorly Drinkingeagerly, thirsty Veryslowskinpinch Chestindrawing Stridorincalmchild Restlessandirritable Vomitseverything Historyofconvulsions Lethargicor unconscious
Additionalsignsinyounginfantagedupto2months (Note:Thesesignsmayalsobeobservedinchildrenage2monthsupto5years) Mildchestindrawingin younginfant(normal) Fastbreathingin younginfant Severechestin drawinginyoung infant Skinpustules Nomovementseven whenstimulated Notwellattachedtobreast Goodattachment Movementsonly whenstimulated Notfeedingatall Sucklingeffectively Oralthrush Yellowpalmsand soles Yelloweyesandskin Notsuckling effectively Redumbilicusor drainingpus Noattachmentatall

Integrated Management of Childhood Illness (IMCI) : Guide For Clinical Practice

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Integrated Management of Childhood Illness (IMCI) : Guide For Clinical Practice

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GUIDEFORCLINICALPRACTICE

C ONDUCT CLINICAL COMPONENT OF ICATT BASED IMCI TRAINING

GUIDEFOR CLINICAL PRACTICE

InpatientsessionChild5: PlanB:TreatsomedehydrationwithORS PlanC:Treatseveredehydrationquickly Assessandclassifyadditionalchildren

2monthsupto5 years Younginfants upto 2months

severechestindrawing redumbilicusordraining pus movementonlywhen stimulatedornomovement atall

treatingeyeinfectionwith tetracyclineeyeointment dryingtheearbywicking treatingmouthulcers

3. SPECIFIC INSTRUCTIONS FOR CONDUCTING OUTPATIENT SESSIONS

Askparticipantstobringchartbooklets,pencils,timingdevices. Bring8copiesofrecordingformperparticipant. Makesureneededsuppliesareavailableinclinic: 1 Assessandclassifychildthroughfever. Usegoodcommunicationskills.

Other supplies include: cup or spoon, clear water, torch (optional)

OUTPATIENTSESSIONCHILD5:IDENTIFYTREATMENT,TEACHTHEMOTHERTOGIVEORAL DRUGS,ADVISEMOTHER WHEN TORETURNIMMEDIATELY

Participant objectives Facilitator procedures

Observingparticipants: Supervisecloselythefirsttimeparticipantscounselmothers.Makesurethey: knowwheretorecordthemother'sanswersontherecordingform teachmothersthesignstoreturnimmediately checkthemothers'understanding

Askparticipantstobringtheirchartbookletsandpencils. Bring8Younginfantrecordingformsforeachparticipant. Bring8Mother'scardsforeachparticipant. Assess,classify,andidentifytreatmentforthesickyounginfant. Assessbreastfeedingattachmentandsuckling. Correctpositioningandattachment.

f) Showherhowtohelptheinfanttoattach.Thesestepsarelistedintheboxonthechart. Sheshould: touchherinfant'slipswithhernipple, waituntilherinfant'smouthisopeningwide,

2monthsupto5 years Younginfants upto 2months

severechestindrawing redumbilicusordraining pus movementonlywhen stimulatedornomovement atall

treatingeyeinfectionwith tetracyclineeyeointment dryingtheearbywicking treatingmouthulcers

2. Ifparticipantshavenotyethadexperiencewithtreatmentoflocalinfection,havethem watchademonstrationoftreatmentofeyeinfectionwithtetracyclineointmentor treatmentofmouthulcerswithhalfstrengthgentianviolet.

Otheressential suppliesforORTCorner Otheressential clinicsupplies Desirableforusein clinicalpractice: DesirableforORT cornerifIVfluidstobe given:

Antipyretic: Otherdrugs: Vaccines: Othersupplies:

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