IMCI - Presentation Transcript

WHAT IS IMCI?

• A strategy for reducing mortality and morbidity associated with major causes of childhood illness
• A joint WHO/UNICEF initiative since 1992
• Currently focused on first level health facilities
• Comes as a generic guidelines for management which have been adapted to each country

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS INTRODUCTION

Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, measles and malnutrition cause more than 70% of the deaths
in children under 5 years of age. All these are preventable diseases in which when managed and treated early could have
prevented these deaths. There are feasible and effective ways that health worker in health centers can care for children with
these illnesses and prevent most of these deaths. WHO and UNICEF used updated technical findings to describe
management of these illnesses in a set of integrated guidelines for each illness. They then developed this protocol to teach
the integrated case management process to health worker who see sick children and know which problems are most
important to treat. Therefore, effective case management needs to consider all of a child’s symptoms.

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

DISTRIBUTION OF 11.6 MILLION DEATHS AMONG CHILDREN LESS THAN 5 YRS OLD IN ALL DEVELOPING
COUNTRIES, 1995

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

OBJECTIVES OF IMCI

• To reduce significantly global morbidity and mortality associated with the major causes of illnesses in
children
• To contribute to healthy growth and development of children

CASE MANAGEMENT PROCESS

is used to assess and classify two age groups : age 1 week up to 2 months age 2 months up to 5 years And how to use
the process shown on the chart will help us to identify signs of serious disease such pneumonia, diarrhea, malaria, measles,
DHF, meningitis, malnutrition and anemia.

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THE CASE MANAGEMENT PROCESS :

The charts describes the following steps;

1. assess the child or young infant

2. classify the illness

3. identify the treatment

4. treat the child

5. counsel the mother

6. give follow up care

THE CLASSIFICATION TABLE

The classification tables on the assess and classify have 3 ROWS . COLOR of the row helps to IDENTIFY RAPIDLY
whether the child has a SERIOUS DISEASE requiring URGENT ATTENTION.

Each row is colored either –

PINK – means the child has a severe classification and needs urgent attention and referral or admission for inpatient
care.

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

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

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

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

• The case management process is designed for children < 5yrs of age, although. Much of the advise on
treatment of pneumonia, diarrhea, malaria, measles and malnutrition, is also applicable to older children, the
ASSESSMENT AND CLASSIFICATION of older children would differ. For example, the cut off rate for
determining fast breathing would be different because normal breathing rates are slower in older children. Chest
indrawing is not a reliable sign of severe pneumonia as children get older and the bones of the chest become
more firm.
• In addition, certain treatment recommendations or advice to mothers on feeding would differ for >5yrs old.
The drug dosing tables only apply to children up to 5yrs old. The feeding advice for older children may differ and
they may have different feeding problems.
• Because of differences in the clinical signs of older and younger children who have these illnesses, the
assessment and classification process using these clinical signs is not recommended for older children.

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

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

IDENTIFICATION AND PROVISION OF TREATMENT

• Curative component adapted to address the most common life-threatening conditions in each country
• Rehydration (diarrhea, DHF)
• Antibiotics (pneumonia, “severe disease”)
• Antimalarial treatment
• Vitamin A (measles, severe malnutrition)

PROMOTIVE AND PREVENTIVE ELEMENTS

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

• Breastfeeding and other nutritional counseling
• Vitamin A and iron supplementation
• Treatment of helminth infections

The Integrated Case Management Process

Learning Objectives

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

o describe the overall case management process;
o state in order the steps in the management process

Overall Case Management Process

• Outpatient
o 1 - assessment
o 2 - classification and identification of treatment
o 3 - referral, treatment or counseling of the child’s
o caretaker (depending on the classification identified)
o 4 - follow-up care
• Referral Health Facility
o 1 - emergency triage assessment and treatment
o 2 - diagnosis, treatment and monitoring of
• patient’s progress

SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESS

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

• ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If
a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems .
• CLASSIFY the child’s illnesses : Use a colour-coded triage system to classify the child’s main symptoms
and his or her nutrition or feeding status.
• IF URGENT REFERRAL is needed and possible
• IF NO URGENT REFERRAL isneeded or possible
• IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) needed for the child’s classifications.
• IDENTIFY TREATMENT needed for the child’s classifications: Identify specific medical treatments and/or
advice.
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 • TREAT THE CHILD: Give urgent pre-referral treatment (s) needed.
• TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advise the child’s caretaker.
Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give
immunizations.
• REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and
help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the
way to the hospital.
• COUNSEL THE MOTHER : Assess the child’s feeding, including breastfeeding practices, and solve
feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health
facility. Counsel the mother about her own health.
• FOLLOW-UP care: Give follow-up care when the child returns to the clinic and,if necessary, reassess the
child for new problems.

SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS FOR ALL SICK CHILDREN age 1 week up to 5 years
who are brought to the clinic

ASK THE CHILD’S AGE IF the child is from 1 week up to 2 months IF the child is from 2 months up

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT œ to 5 years

USE THE CHART: ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD COUNSEL œ USE THE CHART:
THE MOTHER

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

Ask the mother or caretaker about the child’s problem. If this is an INITIAL VISIT for the problem, follow the steps below. (If
this is a follow-up visit for the problem, give follow-up care according to PART VII) Check for general danger signs. Ask the
mother or caretaker about the four When assess the child further for signs œ a main symptom is present: main symptoms:
œ cough or difficult breathing, the main symptom, and œ related to fever, and ﾁ œ œ classify the illness according
to the signs œ diarrhoea, ear problem which are present or absent. Check for signs of malnutrition and anaemia and
classify the child’s nutritional status Check the child’s immunization status and decide if the child needs any immunizations
today. Assess any other problems. Then : Identify Treatment (PART IV), Treat the Child (PART V), and Counsel the Mother
(PART VI)

SUMMARY OF ASSESS AND CLASSIFY Ask the mother or caretaker fever,◊ diarrhoea ◊ cough or difficult breathing ◊about
the 4 main symptoms: Assess the child further for◊ ear problem When a main symptom is present: ◊and Classify the illness
according to the◊signs related to the main symptom, and signs which are present or absent

FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC GREET the mother
appropriately and ask about her child. LOOK to see if the child’s weight and temperature have been recorded ASK the mother
what the child’s problems are DETERMINE if this is an initial visit or a follow-up visit for this problem IF this is an INITIAL
VISIT for the problem ASSESS and CLASSIFY the child following the guidelines in this part of the handbook (PART II) GIVE
FOLLOW-UP CARE according to the guidelines in PART VII of this handbook When a child is brought to the clinic IF this is a
FOLLOW-UP VISIT for the problem Use Good Communication skills: (see also Chapter 25) — Listen carefully to what the
mother tells you . — Use words the mother understands — Give the mother time to answer the questions . ---Ask additional
questions when the mother is not sure about her answer . Record Important Information

When the child is brought to the clinic

• Use Good Communication Skills:

• Listen carefully to what the mother tells you
• Use words the mother understands
• Give mother time to answer questions
• Ask additional questions when mother not sure of answer

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 • Record important information

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

CHECK FOR GENERAL DANGER SIGNS A child with any general danger sign needs URGENT attention;

complete the assessment and any pre-referral treatment immediately so referral

Is the child able to drink or breastfeed?

 See if is not delayed ASK: LOOK:

 Is Does the child vomit everything?

 the child is lethargic or unconscious

 the child had convulsions? Make sure that a child with any danger sign is referred after receiving urgent pre-referral
treatment. Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear problems.

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

GENERAL DANGER SIGNS

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

Cough or Difficult Breathing If YES

 IF YES, ASK: LOOK, LISTEN, FEEL:

 Count the breaths in one minute. For how long?
 Look for chest indrawing
 Look and listen for stridor

Classify COUGH or DIFFICULT BREATHING If the child is:

Fast breathing is

 2 months up 50 breaths per minute.

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

CHILD MUST BE CALM CLASSIFY the child’s illness using the color-coded classification table for cough or difficult
breathing.

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

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 For ALL sick children ask the mother about the child’s problem, check for general danger signs, Ask about cough or
difficult breathing and then

ASK : Cough or Difficult Breathing?

• IF YES, ASK:
• For how long?
• LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
• 2-12 mos = fast breathing >/= 50/min
• 12 mos-5yrs = fast breathing >/= 40/min
• Look for chest indrawing
• Look and listen for stridor
• Classify COUGH or DIFFICULT BREATHING

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING SIGNS CLASSIFY AS IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)

• If coughing more than 30 days, refer for assessment.

• Soothe the throat and relieve the cough with a safe remedy.
• Advise mother when to return immediately.
• Follow-up in 5 days if not improving .

NO PNEUMONIA: COUCH OR COLD No signs of pneumonia or very severe disease.

• Give an appropriate oral antibiotic for 5 days.

• Soothe the throat and relieve the cough with a safe remedy.
• Advise mother when to return immediately.
• Follow-up in 2 days.

PNEUMONIA

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

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

• Any general danger sign or

• Chest indrawing or
• Stridor in calm child.

Diarrhea

• For ALL sick children ask the mother about the child’s problem,
• check for general danger signs,
• ask about cough or difficult breathing and dehydration
• Does the child have diarrhea?
• IF YES , ASK:
• For how long?
• Is there blood in the stool?
• LOOK, LISTEN, FEEL: Look at the child’s general condition,
• is the child: Lethargic or unconscious?
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 • Restless or irritable? Look for sunken eyes Offer the child fluid.
• Is the child: Not able to drink or drinking poorly?
• Drinking eagerly, thirsty ?
• Pinch the skin of the abdomen.
• Does it go back: Very slowly (> than 2 secs)?
• Slowly?

CLASSIFICATION TABLE FOR DEHYDRATION SIGNS

CLASSIFY AS IDENTIFY TREATMENT

• Give fluid and food to treat diarrhoea at home

• (Plan A). Advise mother when to return immediately. Follow-up in 5 days if not improving.

• NO DEHYDRATION

Not enough signs to classify as some or severe dehydration.

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

o If child also has a severe classification:

— Refer URGENTLY to hospital with mother

o giving frequent sips of ORS on the way.

o Advise the mother to continue breastfeeding
o Advise mother when to return immediately.
o Follow-up in 5 days if not improving.

SOME DEHYDRATION

• Two of the following signs:

• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly

If child has no other severe classification:

— Give fluid for severe dehydration (Plan C). OR If child also has another severe classification:
— — Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the
mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for
cholera.

SEVERE DEHYDRATION

 Two of the following signs:

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  Lethargic or unconscious
 Sunken eyes
 Not able to drink or drinking poorly
 Skin pinch goes back very slowly

SIGNS CLASSIFY AS IDENTIFY TREATMENT

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

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

 Follow-up in 5 days.

PERSISTENT DIARRHEA

 No dehydration
 Treat dehydration before referral unless the child has another severe classification.
 Refer to hospital.

SEVERE PERSISTENT DIARRHEA

 Dehydration present

CLASSIFICATION TABLE FOR DYSENTERY

 Treat for 5 days with an oral antibiotic recommended for Shigella in your area.
 Follow-up in 2 days.

DYSENTERY

 Blood in the stool

FEVER

 For ALL sick children

 ask the mother about the child’s problem,
 check for general danger signs,
 ask about cough or difficult breathing, diarrhoea and then
 Does the child have FEVER?
 IF YES, decide the malaria risk: high or low
 THEN ASK:
 For how long?
 If more than 7 days, has fever been
 present every day?
 Has the child had measles within the
 last 3 months?
 If the child LOOK AND FEEL:
 Look for runny nose
 Look or feel for stiff neck
 LOOK FOR SIGNS OF MEASLES
 has measles now or within the last 3 months
 -Rash -Mouth ulcers
 -Cough -Pus from eyes

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  -Runny nose -Clouding of cornea
 -Red eye
 CLASSIFY the child’s illness using the œ colour-coded classification tables for fever.
 Then ASK about the next main symptom: ear problem,
 and CHECK for malnutrition and anaemia, immunization status and for other problems.
 LOOK FOR SIGNS OF DENGUE/DHF -bleeding tendencies -flushing -(+) tourniquet test -rash

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

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

FEVER— MALARIA UNLIKELY

 NO general danger sign

 AND
 NO Stiff neck.
 Give first dose of an appropriate antibiotic.
 Treat the child to prevent low blood sugar.
 Give one dose of paracetamol in clinic for high fever (38.5 ° C or above).
 Refer URGENTLY to hospital.

VERY SEVERE FEBRILE DISEASE

 Any general danger sign

 Stiff neck

SIGNS CLASSIFY AS IDENTIFY TREATMENT

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

Other important complications of measles

—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in other tables.

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

MEASLES WITH EYE OR MOUTH COMPLICATIONS***

 Pus draining from the eye or

 Mouth ulcers
 Give vitamin A.

MEASLES

 Measles now or within the last 3 months.

 Give vitamin A.

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

SEVERE COMPLICATED MEASLES***

 Any general danger sign or

 Clouding of cornea or
 Deep or extensive mouth ulcers.

Fever With Rashes

For ALL sick children ask the mother about the ask about cough or difficult breathing, diarrhoea, fever and then ASK: DOES
THE CHILD HAVE AN EAR PROBLEM?

 IF YES ASK:
 Is there ear pain?
 Is ther ear discharge?
 If yes, for how long?
 LOOK AND FEEL:
 Look for pus draining from the ear.
 Feel for tender swelling behind the ear.
 CLASSIFY the child’s illness using the colour-coded-classification table for ear problem. Then CHECK for
malnutrition and anaemia, immunization status and for other problems.

CLASSIFICATION TABLE FOR EAR PROBLEM

No additional treatment NO EAR INFECTION

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

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

CHRONIC EAR INFECTION

 Pus is seen draining from the ear and discharge is reported for 14 days or more.
 Give an oral antibiotic for 5 days.
 Give paracetamol for pain.
 Dry the ear by wicking.
 Follow-up in 5 days.

ACUTE EAR INFECTION

 Pus is seen draining from the ear and discharge is reported for less than 14 days, or
 Ear pain.
 Give first dose of an appropriate antibiotic.
 Give first dose of paracetamol for pain.
 Refer URGENTLY to hospital.

MASTOIDITIS =Tender swelling behind the ear.

Malnutrition and Anemia

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  CHECK FOR MALNUTRITION AND ANEMIA
 LOOK AND FEEL:
 Look for visible severe wasting
 Look for palmar pallor. Is it:
 Severe palmar pallor?
 Some palmar pallor?
 Look for edema of both feet
 Determine weight for age
 CLASSIFY NUTRITIONAL STATUS

Child with Anemia and Malnutrition

CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA

 If child is less than 2 years old,

 assess the feeding and counsel the mother on feeding
 according to the FOOD box on the COUNSEL THE
 MOTHER chart.

— If feeding problem, follow-up in 5 days.

 Advise mother when to return immediately.

NO ANAEMIA AND NOT VERY LOW WEIGHT

— Not very low weight for age and no other signs or malnutrition.
— Assess the feeding according to the FOOD box on the COUNSEL THE MOTHER chart.
— If feeding problem, follow-up in 5 days.
— If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk .
— Give mebendazole if child is 2 years or older and
— has not had a dose in the previous 6 months.
— Advise mother when to return immediately.
— If pallor, follow-up in 14 days.
— If very low weight for age, follow-up in 30 days.

ANAEMIA OR VERY LOW WEIGHT

— Some palmar pallor or

— Very low weight for age.
— Give Vitamin A.
— Refer URGENTLY to hospital.

SEVERE MALNUTRITION OR SEVERE ANAEMIA

— Visible severe wasting or

— Severe palmar pallor or
— Oedema of both feet.

Immunization Status

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THEN CHECK THE CHILD’S IMMUNIZATION STATUS For ALL sick children

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

CHECK IMMUNIZATION STATUS.

 OPV-0 OPV-1 OPV-2 OPV-3 VACCINE BCG DPT-1 DPT-2 DPT-3 Measles
 AGE Birth 6 weeks 10 weeks 14 weeks 9 months

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

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

Immunization Status

— CHECK IMMUNIZATION STATUS:

— IMMUNIZATION SCHEDULE
 Birth - BCG, HepB1
 6 weeks - DPT1, OPV1, HepB2
 10 weeks - DPT2, OPV2, HepB3
 14 weeks - DPT3, OPV3, HepBbooster
 9 mos - measles

How to check the Immunization Status

If an infant has not received any immunization, then give

— BCG
— DPT 1 , OPV 1
— Hepatitis B 1

THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS:

— ASSESS AND CLASSIFY

— Ask the mother or caretaker about the young
— If this is an INITIAL VISIT for the problem,
— follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to
PART VII)
— Check for POSSIBLE BACTERIAL INFECTION and classify the illness.
— Ask the mother or caretaker about DIARRHOEA :
 If diarrhoea is present:
 assess the infant further for signs related to diarrhoea, and
 classify the illness according to the signs which are present or absent.
 Check for FEEDING PROBLEM OR LOW WEIGHT and
 Check the infant’s immunization status and decide if the infant needs any immunization
today. Assess any other problems.
 Then : Identify Treatment (PART IV), Treat the Infant (PART V), and Counsel the Mother
(PART VI)

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YOUNG INFANT MUST BE CALM

How to check a young infant for possible bacterial infection?

CHECK FOR POSSIBLE BACTERIAL INFECTION

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

 ASK:
 Has the infant had convulsions?
 LOOK, LISTEN, FEEL:
 Count the breaths in one minute.
 Repeat the count if elevated.
 Look for severe chest indrawing.
 Look for nasal flaring
 Look and listen for grunting.
 Look and feel for bulging fontanelle.
 Look for pus draining from the ear.
 Look at the umbilicus. Is it red or draining pus?
 Does the redness extend to the skin?
 Measure temperature (or feel for fever or low body temperature)
 Look for skin pustules. Are there many or severe pustules?
 See if the young infant is lethargic or unconscious.
 Look at the young infant’s movements. Are they less than normal?
 CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE
BACTERIAL INFECTION.
 Then ASK about diarrhea.
 CHECK for feeding problem or low weight, immunization status and for other problems.
 These thresholds are based on axillary’s temperature.
 The thresholds for rectal temperature readings are approximately 0.5 ° C higher.

CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION

 Give an appropriate oral antibiotic.

 Teach the mother to treat local infections at home.
 Advise mother to give home care for the young infant.
 Follow-up in 2 days

LOCAL BACTERIAL INFECTION

 Red umbilicus or draining pus or

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

POSSIBLE SERIOUS BACTERIAL INFECTION

 Convulsions or
 Fast breathing (60 breaths per minute or more) or
 Severe chest indrawing or

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  Nasal flaring or
 Grunting or
 Bulging fontanelle or
 Pus draining from ear or
 Umbilical redness extending to the skin or
 Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or
 Many or severe skin pustules or
 Lethargic or unconscious or
 Less than normal movement.

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

 ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

 IF YES: ASSESS AND CLASSIFY the young infant’s diarrhoea using the DIARRHOEA box in the
YOUNG INFANT chart.
 The process is very similar to the one used for the sick child
 Then CHECK for feeding problem or low weight, immunization status and other problems.
 How to assess and classify a young infant for diarrhea?

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

 ask about diarrhoea and then

 CHECK FOR FEEDING PROBLEM OR LOW WEIGHT .
 THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT ASK: LOOK, LISTEN, FEEL:
 Is there any difficulty feeding?
 Determine weight for age.
 Is the infant breastfed?
 If yes,how many times in 24 hours?
 Does the infant usually receive any other foods or drinks?
 If yes, how often?
 What do you use to feed the infant?

IF AN INFANT:

• Has any difficulty feeding,

• Is breastfeeding less than 8 times in 24 hours,
• Is taking any other foods or drinks, or Is low weight for age,
• AND Has no indications to refer urgently to hospital:

ASSESS BREASTFEEDING:

• If the infant has not fed in the previous hour,

• ask the mother to put her breastfed in the infant to the breast.
• Observe the breastfeed for 4 minutes.
• previous hour? (If the infant was fed during the last hour, ask the mother if she can wait and tell you when
the infant is willing to feed again.)
• Is the infant able to attach? no attachment at all not well attached good attachment

TO CHECK ATTACHMENT, LOOK FOR:

o Chin touching breast

o Mouth wide open
o Lower lip turned outward
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 o More areola visible above then below the mouth (All these signs should be present if the attachment is good.)
• Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
• no suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with
breastfeeding.
• Look for ulcers or white patches in the mouth (thrush).
• CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or
low weight.
• CHECK immunization status and for other problems.

CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT

 Advise mother to give home care for the young infant.

 Praise the mother for feeding the infant well.

NO FEEDING PROBLEM

 Not low weight for age and no other signs of inadequate feeding.
 Advise the mother to breastfeed as often and for as long as the infant wants, day and night.
 -If not well attached or not suckling effectively, teach correct positioning and attachment.
 -If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding.
 If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or
drinks, and using a cup.

 If not breastfeeding at all:

 Refer for breastfeeding counselling and possible relactation.
 Advise about correctly prepared breastmilk substitutes and using a cup.
 If thrush, teach the mother to treat thrush at home.
 Advise mother to give home care for the young infant.
 Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days.

FEEDING PROBLEM OR LOW WEIGHT

 Not well attached to breast or

 Not suckling effectively or
 Less than 8 breastfeeds in 24 hours or
 Receives other foods or drinks or
 Low weight for age or
 Thrush (ulcers or white patches in mouth).
 Give first dose of intramuscular antibiotics.
 Treat to prevent low blood sugar.
 Advise the mother how to keep the young infant warm on the way to hospital.
 Refer URGENTLY to hospital.

NOT ABLE TO FEED POSSIBLE SERIOUS BACTERIAL INFECTION

 Not able to feed or

 No attachment at all or
 Not suckling at all.
 Communicate and Counsel

 How will you prepare the ORS solution?

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  Do you remember how to mix the ORS?
 GOOD CHECKING QUESTIONS POOR QUESTIONS
 How often should you breastfeed your child?
 Should you breastfeed your child

 Have you used ointment on your child the ointment?

 before?
 How much extra fluid will you give after each
 Do you know how to give extra loose stool?
 fluids?
 Why is it important for you to wash your hands?
 Will you remember to wash your hands?

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant When to return immediately

 Signs of any of the following:

o Breastfeeding or drinking poorly
o Becomes sicker
o Develops a fever
o Fast breathing
o Difficult breathing
o Blood in the stool

Follow-up care for the sick young infant

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

 Follow-up in 2 days - with a feeding problem or oral thrush
 Follow-up in 14 days – with low weight for age

FOLLOW-UP VISIT TABLE IN THE COUNSEL

 THE MOTHER CHART 30 days

 LOW WEIGHT FOR AGE 14 days
 PALOR EVERY 5 days
 PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING
PROBLEM ANY OTHER ILLNESS, if not improving 2 days
 PNEUMONIA DYSENTERY MALARIA,
 if fever persists FEVER—MALARIA UNLIKELY,
 if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS Return for follow-up in:

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

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Name:___________ Age:___________ Weight:____________________ kg________________________
Temperature:_______________ C ASK: What are the infant&apos;s problems?__________________________________
Initial visit?_________________ Follow-up Visit?______________ ASSESS (Circle all signs present) CLASSIFY

 Yes _____ No ______

 Look at the young infant&apos;s general condition.
 Is the infant: Lethargic or unconscious?
 Restless or irritable?
 Look for sunken eyes.
 Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)?
 Slowly?
 DOES THE YOUNG INFANT HAVE DIARRHOEA?
 For how long? _______ Days
 Is there blood in the stools?
 Count the breaths in one minute. _______ breaths per minute
 Repeat if elevated ________ Fast breathing?
 Look for severe chest in drawing.
 Look for nasal flaring.
 Look and listen for grunting.
 Look and feel for bulging fontanel.
 Look for pus draining from the ear.
 Look at umbilicus. Is it red or draining pus?
 Does the redness extend to the skin?
 Fever (temperature 37.5 C or feels hot) or low body temperature
 (Below 35.5° C or feels cool).
 Look for skin pustules. Are there many or severe pustules?
 See if young infant is lethargic or unconscious.
 Look at young infant&apos;s movements. Less than normal?
 CHECK FOR POSSIBLE BACTERIAL INFECTION
 Has the infant had convulsions?

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

Name:___________ Age:___________ Weight:____________________ kg________________________

Temperature:_______________ C ASK: What are the infant&apos;s problems?__________________________________
Initial visit?_________________ Follow-up Visit?______________

ASSESS (Circle all signs present)

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CLASSIFY

• If the infant has any difficulty feeding,

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

 Return for next immunization on: (Date)

 Circle immunizations needed today.
 CHECK THE YOUNG INFANT&apos;

 IMMUNIZATION STATUS BCG DPT1 DPT2 OPV 0 OPV 1 OPV 2

1. Determine weight for age. Low _____ Not Low _____

2. If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
3. Is the infant able to attach? To check attachment, look for:
4. Chin touching breast Yes _____ No _____
5. Mouth wide open Yes _____ No _____
6. Lower lip turned outward Yes _____ No _____
7. More areola above than below the mouth Yes _____ No _____
8. no attachment at all not well attached good attachment
9. Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
10. not suckling at all not suckling effectively suckling effectively
11. Look for ulcers or white patches in the mouth (thrush).
12. THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
13. Is there any difficulty feeding? Yes_____ No______
14. Is the infant breastfed? Yes_____ No_____
15. If Yes, how many times in 24 hours?_____ times
16. Does the infant usually receive any
 Other foods or drinks? Yes_____ No_____
 If Yes, how often?
 What do you use to feed the child?
 ASSESS BREASTFEEDING:
 Has the infant breastfed in the previous hour?

TREAT Return for follow-up on _________________ Give any immunization/s needed today.

Name: ___________________________________________________________________

Age:____________________Weight:_______kg Temperature:________

C ASK: What are the child&apos;s problems?

_______________________________________________________________________

Initial visit?________________Follow-up Visit?__________

ASSESS (Circle all signs present)

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

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

 Look at the child&apos;s general condition. Is the child:

 Lethargic or unconscious?
 Restless or irritable?
 Look for sunken eyes.
 Offer the child fluid. Is the child:
 Not able to drink or drinking poorly?
 Drinking eagerly, thirsty?
 Pinch the skin of the abdomen. Does it go back:
 Very slowly (longer than 2 seconds)?
 Slowly?
 DOES THE CHILD HAVE DIARRHOEA?
 For how long? _____ Days
 Is there blood in the stools?
 Yes ___ No ___
 Count the breaths in one minute.
 ________ Breaths per minute. Fast breathing?
 Look for chest in drawing.
 Look and listen for stridor.
 DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
 For how long? ____ Days

General danger signs present? Yes ___ No ___

Remember to use danger sign when selecting classifications

LETHARGIC OR UNCONSCIOUS CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING CONVULSION

 Look or feel for stiff neck.

 Look for runny nose.
 Look for signs of MEASLES:
 Generalized rash and
 One of these: cough, runny nose, or red eyes.
 Look for mouth ulcers.
 If Yes, are they deep and extensive?
 Look for pus draining from the eye.
 Look for clouding of the cornea.
 Decide Malaria Risk: High Low
 For how long? _____ Days
 If more than 7 days, has fever been present every day?
 Has child had measles within the last three months?
 If the child has measles now
 or within the last 3 months:

ASSESS CHILD&apos FEEDING

if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old FEEDING PROBLEMS

 Do you breastfeed your child? Yes____ No ____

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  If Yes, how many times in 24 hours? ___ Times.
 Do you breastfeed during the night? Yes___ No___
 Does the child take any other food or fluids? Yes___ No ___
 If Yes, what food or fluids?
__________________________________________________________________________________________
______________
 How many times per day? ___ Times.
 What do you use to feed the child? _____________________
 If very low weight for age: How large are servings?
 _________________________________________________
 Does the child receive how own serving? ________________
 Who feeds the child and how? ________________________
 During the illness, has the child&apos; s feeding changed?
 Yes ____ No ____
 If Yes, how?

Return for next immunization on: (Date)

Circle immunizations needed today

. CHECK THE CHILD&apos;

IMMUNIZATION STATUS

_____ ______ ______ ______ BCG DPT1 DPT2 DPT3

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

 Look for visible severe wasting.

 Look for palmar pallor.
 Severe palmar pallor? Some palmar pallor?
 Look for edema of both feet.
 Determine weight for age.
 Very Low ___ Not Very Low ___

THEN CHECK FOR MALNUTRITION AND ANAEMIA

 Yes___ No___
 Look for pus draining from the ear.
 Feel for tender swelling behind the ear.
 DOES THE CHILD HAVE AN EAR PROBLEM?
 Is there ear pain?
 Is there ear discharge?
 If Yes, for how long? ___ Days

TREAT Return for follow-up on ______________

Advice mother when to return immediately. Give any immunization/s needed today. Feeding Advice

CATEGORIES OF PROVINCES CONSIDERED WITH MALARIA

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

- Kalinga - Mindoro Occ - Compostela valley

- Apayao - Palawan - Saranggani
- Mt. Province - Quezon - Zamboanga del Sur
- Ifugao - Misamis Or - Agusan del Sur
- Isabela - Davao del Norte - Agusan del Norte
- Cagayan - Davao del Sur - Surigao del Sur
- Quirino - Davao oriental - Tawi-tawi
- Zambales - Bukidnon - Sulu - Basilan

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

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

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

- Benguet - Antique
- Ilocos Sur - Sorsogon
- La Union - Negros Occ
- Pampanga - Negros Or
- Batangas - Eastern Samar
- Cavite - Western Samar
- Marinduque - Misamis Occ
- Masbate - Surigao del Norte
- Batanes - Albay

Category D – Provinces that are malaria-free although some are still potentially malarious sue to toe presence of
the vector.

 Cebu Iloilo Biliran

 Bohol Capiz Leyte Norte and
 and Sur
 Catanduanes Guimaras
 Aklan Siquijor
 Northern Samar Camiguin

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