Department of Child and Adolescent

Health and Development (CAH)

INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

CHILD AGED 2 MONTHS UP TO 5 YEARS

TREAT THE CHILD, continued

ASSESS AND CLASSIFY THE SICK CHILD

Give Extra Fluid for Diarrhoea

and Continue Feeding
Plan A: Treat for Diarrhoea at Home........................ 14
Plan B: Treat for Some Dehydration with ORS ........ 14
Plan C: Treat for Severe Dehydration Quickly ......... 15

Assess, Classify and Identify Treatment

Check for General Danger Signs .................................. 2
Then Ask About Main Symptoms:
Does the child have cough or difficult breathing? ............. 2
Does the child have diarrhoea? ..................................... 3
Does the child have fever? ........................................... 4
Does the child have an ear problem?............................. 5
Then Check for Malnutrition and Anaemia .................... 6
Then Check the Childs Immunization Status ................ 7
Assess Other Problems ................................................. 7

TREAT THE CHILD

Teach the mother to give oral drugs at home:
Oral Antibiotic. ......................................................... 8
Ciprofloxacin............................................................ 8
Iron ......................................................................... 9
Co-artemether ........................................................ 9
Bronchodilator ......................................................... 9
Teach the Mother to Treat Local Infections at Home
Clear the ear by dry wicking and give eardrops .... 10
Treat for mouth ulcers and thrush ......................... 10
Soothe throat, relieve cough with safe remedy .... 10
Treat eye infection .10
Give Preventive Treatments in Clinic
Vitamin A 11
Mebendazole ....11
Give Emergency Treatment in Clinic only
Quinine for severe malaria .................................... 12
Intramuscular Antibiotic ........................................ 12
Diazepam for convulsions ..... 12
Treat low blood sugar ........................................... 13

Give Follow-up Care

Pneumonia ............................................................... 16
Dysentery ................................................................. 16
Persistent diarrhoea ................................................. 16
Malaria ..................................................................... 17
Fever malaria unlikely ............................................ 17
Measles with eye or mouth complications 17
Ear Infection ............................................................ 18
Feeding problem .................................................... . 18
Anaemia .................................................................. 18
Pallor 18
Very Low Weight ...................................................... 18
Severe uncomplicated malnutrition .18

SICK YOUNG INFANT AGED UP TO 2 MONTHS

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT
Assess, Classify and Identify Treatment
Check for Severe Disease and Local Infection. .....................................24
Then check for Jaundice . ......................................................................25
Then ask: Does the young infant have diarrhoea? .......................................26
Then check for Feeding Problem or Low Weight for Age.27
Then check the young infants immunization status. .............................28
Assess Other Problems ................................................................................28

Treat the Young Infant and Counsel the Mother

Intramuscular antibiotics..29
Treat the young infant to prevent low blood sugar..29
Keep the young infant warm on the way to hospital...30
Oral antibiotic30
Treat local infections at home.31
Correct positioning and attachment for breastfeeding32
Teach mother how to express breast milk ...32
Teach mother how to feed by cup......33
Teach the mother to keep the low weight infant warm at home33
Advice mother to give home care to the young infant....34

COUNSEL THE MOTHER

Assess the feeding of sick infants ............................ 19
Feeding Recommendations ..................................... 20
Counsel the mother about feeding Problems ........... 21
Counsel the mother about her own health ............... 22
Advise mother to increase fluids during illness ........ 23
Advise mother when to return to health worker 23
Advise mother when to return immediately .............. 23

Give Follow-up Care for the Sick Young Infant

Local Bacterial Infection .................................................................................. 35
Jaundice .......................................................................................................... 35
Diarrhea...................................................................................... ................ 35
Feeding Problem ............................................................................................. 36
Low Weight for age ......................................................................................... 37
Thrush.......................................................................................... .............. 37

Recording Forms: Sick Child........................................................................38

Sick young infant ..........................................................39

ASSESS AND CLASSIFY THE SICK CHILD

AGED 2 MONTHS UP TO 5 YEARS
CLASSIFY

ASSESS

IDENTIFY TREATMENT

ASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE

Determine whether this is an initial or follow-up visit for this problem.
- if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart
- if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

ASK:

LOOK:

Is the child able to drink or breastfeed?

Does the child vomit everything?
Has the child had convulsions?

See if the child is abnormally sleepy or

difficult to awaken.

USE ALL BOXES THAT MATCH THE

CHILDS SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS.

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

THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?
IF YES, ASK:

For how

long?

LOOK, LISTEN, FEEL:

Count the breaths

in one minute.
Look for chest indrawing.
Look and listen for stridor.
Look and listen for wheeze.

If wheezing and either fast

breathing or chest indrawing:
Give a trial of rapid acting
inhaled bronchodilator for up to
three times 15-20 minutes apart.
Count the breaths and look for
chest indrawing again, and then
classify.
If the child is:

Fast breathing is:

2 months up
to 12 months

50 breaths per
minute or more

12 months up
to 5 years

40 breaths per
minute or more

Classify
COUGH or
DIFFICULT
BREATHING

CHILD
MUST
BE CALM

SIGNS

CLASSIFY AS

Any general danger sign or

Chest indrawing or

Stridor in calm child

Fast breathing ( If wheezing,

go directly to treat
wheezing)

SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE

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

Give first dose of an appropriate antibiotic

Give Vitamin A
If chest indrawing & wheeze, go directly to treat wheezing
Treat the child to prevent low blood sugar
Refer URGENTLY to hospital
Give oral antibiotic for 3 days

PNEUMONIA

If wheezing (even if it disappeared after rapidly acting

bronchodilator) give an inhaled bronchodilator for five days
Soothe the throat and relieve the cough with a safe remedy
If coughing for more than 3 weeks or if having recurrent
wheezing, refer for assessment for TB or asthma
Advise the mother when to return immediately
Follow-up in 2 days

No signs of pneumonia
or very severe disease ( If
wheezing, go directly to
treat wheezing)

NO PNEUMONIA

If wheezing (even if it disappeared after rapidly acting

bronchodilator) give an inhaled bronchodilator for five days

COUGH OR COLD

Soothe the throat and relieve the cough

If coughing for more than 30 days refer for assessment
Advise mother when to return immediately

Follow-up in 5 days if not improving, if treated for wheeze followup in 2 days.

* In settings where inhaler is not available, oral salbutamol may be the second choice

Does the child have diarrhea?

Two of the following signs:

for
DEHYDRATION

IF YES,
ASK:
For how long?
Is there blood
in the stool?

LOOK AND FEEL:

Abnormally sleepy or difficult to

awaken
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly.

SEVERE
DEHYDRATION

If child is 2 years or older and there is cholera in your area,

give antibiotic for cholera

Look at the childs general condition.

Is the child:

Give ORS, zinc supplements and food for some dehydration (Plan
B)

Two of the following signs:

Abnormally sleepy or difficult to

awaken?
Restless and irritable?
Look for sunken eyes.

Classify

Offer the child fluid. Is the child:

Not able to drink or
drinking poorly?
Drinking eagerly, thirsty?

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

Not enough signs to classify as some

or severe dehydration

SOME
DEHYDRATION

If child also has a severe classification:

- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue breastfeeding
Advise mother when to return immediately

NO
DEHYDRATION

Give ORS, zinc supplements and food to treat diarrhea at home

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

Pinch the skin of the abdomen.

Does it go back:
Very slowly (longer than
2 seconds)?
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

and if diarrhea for

14 days or more

and if blood
in stool

Dehydration present

SEVERE
PERSISTENT
DIARRHEA

Treat dehydration before referral unless the child has another

severe classification
Give Vitamin A
Refer to hospital

No dehydration

PERSISTENT
DIARRHEA

Advise the mother on feeding a child who has PERSISTENT

DIARRHEA
Give multivitamins and minerals (including zinc) for 14 days
Follow up in 5 days
Advise mother when to return immediately

Blood in the stool

DYSENTERY

*If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child,
Annex: Where Referral Is Not Possible, and WHO guidelines for inpatient care.

Give ciprofloxacin for 3 days

Follow-up in 2 days
Advise mother when to return immediately

Does the child have fever?

MALARIA RISK
Any general danger sign or
Stiff neck.

(by history or feels hot or temperature 37.5C** or above)

Decide Malaria Risk
ASK:
Does the child live in a malaria
area?
Has the child visited/stayed
overnight in a malaria area in the
past 4 weeks? If yes to either,
obtain a blood smear
THEN ASK
For how long has the child had
fever?
If more than 7 days, has fever
been present every day?
Has the child had measles
within the last 3 months?

If the child has measles now or

within the last 3 months:

Malaria Risk

LOOK AND FEEL:

Look or feel for stiff neck.
Look for runny nose.
Look for signs of MEASLES

Classify
FEVER

**

MALARIA

Give quinine for severe malaria (first dose)

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
(38.5C or above)
Refer URGENTLY to hospital
Give oral co-artemether or other recommended antimalarial
Give one dose of paracetamol in clinic for high fever
(38.5C 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

Generalized rash and

NO MALARIA RISK

One of these: cough, runny

nose, or red eyes.

No
Malaria Risk

Any general danger sign or

Stiff neck

VERY SEVERE
FEBRILE
DISEASE

Look for mouth ulcers.

Are they deep and extensive?
Look for pus draining from the
eye.

NO runny nose and

NO measles and
NO other cause of fever

Look for clouding of the cornea.

Assess Dengue Hemmorrhagic Fever

ASK:
Has the Child had any bleeding
From the nose or gums, or in the
vomitus or stools?
Has the child had black
vomitus?
Has the child had black stools?
Has the child had persistent
abdominal pain?
Has the child had persistent
vomiting?

Blood smear (+)

Blood smear not done:
NO runny nose and
NO measles and
NO other causes of fever

VERY SEVERE
FEBRILE
DISEASE

MALARIA

if MEASLES
LOOK AND FEEL
Look for bleeding from nose or
gums.
Look for skin petechiae.
Feel for cold and clammy
extremities.
Check for slow capillary refill, If
none of the above ASK,
LOOK,
and FEEL signs are present &
the child is 6 months or older
& fever present for more than 3
3 days
Perform the tourniquet test.

now or within
last 3 months,
Classify

These temperatures are based on axillary temperature. Rectal temperature readings are
approximately 0.5C higher.
*** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and
malnutrition - are classified in other tables.

Runny nose PRESENT or

Measles PRESENT or
Other cause of fever
PRESENT

FEVER MALARIA
UNLIKELY

Any general danger sign or

Clouding of cornea or
Deep or extensive mouth
ulcers

SEVERE
COMPLICATED
MEASLES***

Pus draining from the eye or

Mouth ulcers

Measles
4 now or within the
last 3 months

MEASLES WITH
EYE OR MOUTH
COMPLICATIONS***
MEASLES

Give quinine for severe malaria (first dose) unless no malaria risk
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
(38.5C or above)
Refer URGENTLY to hospital
Give oral co-artemether or other recommended antimalarial
Give one dose of paracetamol in clinic for high fever
(38.5C 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
Give one dose of paracetamol in clinic for high fever
(38.5C 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

Give Vitamin A for treatment

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
Give Vitamin A for treatment
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.
Give Vitamin A for treatment

Does the child have an ear problem?

IF YES, ASK:

LOOK AND FEEL:

Is there ear pain?

Is there ear discharge?
If yes, for how long?

Look for pus draining from the ear.

Feel for tender swelling behind the ear.

Classify
EAR PROBLEM

Tender swelling behind the ear.

Pus is seen draining from the ear

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

No ear pain and

No pus seen draining from the ear.

MASTOIDITIS

ACUTE EAR
INFECTION

CHRONIC EAR
INFECTION

NO EAR
INFECTION

Give first dose of an appropriate antibiotic.

Give first dose of paracetamol for pain.
Refer URGENTLY to hospital.
Give an antibiotic for 5 days.
Give paracetamol for pain.
Dry the ear by wicking.
Follow-up in 5 days.
Advise mother when to return immediately
Dry the ear by wicking.
Instill otic drops for 2 weeks
Follow-up in 14 days.
Advise mother when to return immediately

No tadditional reatment.
Advise mother when to return immediately

THEN CHECK FOR MALNUTRITION AND ANEMIA

CHECK FOR MALNUTRITION
LOOK AND FEEL:
For all children
Detemine weight for age
Look for edema of both feet Look for visible severe wasting

CLASSIFY
NUTRITIONAL
STATUS

If age up to 6 months
-and visible severe wasting
-or edema of both feet
If age 6 months and above and:
-MUAC less than 110mm or edema
of both feet or visible severe wasting

SEVERE
MALNUTRITION

Very low weight for age

For children aged 6 months or more,

determine if MUAC* less than 110mm

VERY LOW
WEIGHT

Not very low weight for age and

no other signs of malnutrition

NOT VERY
LOW WEIGHT

Treat the child to prevent low sugar

Refer URGENTLY to a hospital

Assess the childs feeding and counsel the mother on feeding

according to the feeding recommendations.
Advise mother when to return immediately
Follow-up in 30 days
If child is less than 2 years old, assess the childs feeding and counsel
the mother on feeding according to the feeding recommendations
- If feeding problem, follow-up in 5 days
Advise mother when to return immediately

CHECK FOR ANEMIA

LOOK AND FEEL:

CLASSIFY
ANEMIA

Look for palmar pallor. Is it

- Severe palmar pallor?
- Some palmar pallor?

*MUAC is mid-upper arm circumference. If tapes are not available,

Severe palmar pallor

Some palmar pallor

No palmar pallor

look for visible severe wasting

SEVERE ANEMIA

ANEMIA

NO ANEMIA

Refer URGENTLY to a hospital

Give iron
Give oral antimalarial if malaria risk
Give mebendazole if child is 1 year or older and has not had
a dose in the previous six months
Advise mother when to return immediately
Follow up in 14 days
If child is less than 2 years old, assess the childs feeding and counsel
the mother on feeding according to the feeding recommendations
- If feeding problem, follow-up in 5 days

THEN CHECK THE CHILDS IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

IMMUNIZATION SCHEDULE:
AGE

VITAMIN A PROPHYLAXIS
VITAMIN A SUPPLEMENTATION SCHEDULE:
The first dose at 6 months or above.
Subsequent dose every 6 months

VACCINE

Birth

BCG

Hep B1

6 weeks

DPT1

OPV-1

Hep B2

10 weeks

DPT2

OPV-2

14 weeks

DPT3

OPV-3

Hep B3

9 months

Measles

ROUTINE WORM TREATMENT

Give every child mebendazole every 6 months from
the age of one year. Record the dose on the childs
card.

ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments.

TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON
THE ASSESS AND CLASSIFY CHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drugs dosage table.

Give an Appropriate Oral Antibiotic

FOR PNEUMONIA, ACUTE EAR INFECTION OR VERY SEVERE DISEASE:
FIRST-LINE ANTIBIOTIC:
SECOND-LINE ANTIBIOTIC:

Determine the appropriate drugs and dosage for the childs age or
weight

AMOXICILLIN

Demonstrate how to measure a dose

Watch the mother practice measuring a dose by herself

AGE or WEIGHT

Ask the mother to give the first dose to her child

Explain carefully how to give the drug, then label and package the drug.
If more than one drug will be given, collect, count and package each drug
separately

ADULT
TABLET
(250mg)

SYRUP
(125 mg/5ml)

1/2

5.0 ml

10 ml

1 1/2

15 ml

2 months up to 6
months
(3-5 kg)

Explain that all the tablets or syrup must be used to finish the course of
treatment, even if the child gets better
Check the mother's understanding before she leaves the clinic

6 months up to 12
months
(6-9 kg)
12 months up to 3
years
(10kg-14 kg)
3 years up to 5 years
(15-19 Kg)

For dysentery-Give antibiotic for Shigella in your area for 3 days

FIRST LINE ANTIBIOTIC: CIPROFLOXACIN

1/2 tablet

1/4 tablet

6 mos. Up to 12 mos.
(6-9 kg)

1 tablet

1/2 tablet

12 mos up to 3 years
(10-14 kg)

1 1/2 tablets

1/2 tablet

3 yrs up to 5 years
(15-19 kg)

2 tablets

1 tablet

TABLET
SYRUP
80 mg
40 mg
trimethoprim + 400
trimethoprim+
mg
200 mg
sulfamethoxazole sulfamethoxazole

1/2

5 ml

10 ml

FIRST-LINE ANTIBIOTIC FOR CHOLERA:

TETRACYCLINE
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ERYTHROMYCIN

250 mg TABLET
(Dose/tabs)

2 mos. up to 6 mos.
(3-5 kg)

Give two times daily for 3 days

Give three times a day for 5 days
(acute ear infection)

FOR CHOLERA:

CIPROFLOXACIN
- Give 2 times daily for 3 days
100 mg TABLET
(Dose/tabs)

COTRIMOXAZOLE

Give two times daily for 3 days

(pneumonia)
Give three times daily for 5 days
(acute ear infection)

Tell the mother the reason for giving the drug to the child

AGE or WEIGHT

AMOXICILLIN
COTRIMOXAZOLE

TETRACYCLINE

AGE or WEIGHT
2 years up to 5 years
(10-19 kg)

ERYTHROMYCIN

-Give 4 times daily for 3 days

-Give 4 times daily for 3days

TABLET
250 mg

TABLET
250 mg

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

GIVE INHALED SALBUTAMOL for WHEEZING

Give Iron
Give one dose daily for 14 days

USE OF A SPACER*
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No
child under 5 years should be given an inhaler without a spacer. A spacer works as
well as a nebuliser if correctly used.
From salbutamol metered dose inhaler (100ug/puff) give 2 puffs.
Repeat up to 3 times every 15 minutes before classifying pneumonia.
Spacers can be made in the following way:
Use a 500ml drink bottle or similar.
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler.
This can be done using a sharp knife.
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the bottle.
Cut a small V in the border of the large open part of the bottle to fit to the childs
nose and be used as a mask.
Flame the edge of the cut bottle with a candle or a lighter to soften it.
In a small baby, a mask can be made by making a similar hole in a plastic (not
polystyrene) cup.
Alternatively commercial spacers can be used if available.
To use an inhaler with a spacer:
Remove the inhaler cap. Shake the inhaler well.
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
The child should put the opening of the bottle into his mouth and breath in and out
through the mouth.
A carer then presses down the inhaler and sprays into the bottle while the child
continues to breath normally.
Wait for three to four breaths and repeat for total of five sprays.
For younger children place the cup over the childs mouth and use as a spacer in
the same way.
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs
from the inhaler.

IRON/FOLATE TABLET
Ferrous sulfate 200 mg +
250 mcg Folate
(60 mg elemental iron)

AGE or WEIGHT

IRON SYRUP
Ferrous fumarate
100 mg per 5 ml
(20 mg elemental iron per ml)

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

1.0 ml (< 1/4 tsp)

4 months up to 12 months (6 - <10kg)

1.25 ml (1/4 tsp)

12 months up to 3 years (10 - <14 kg)

1/2 tablet

2.0 ml (<1/2 tsp)

3 years up to 5 years (14 - 19 kg)

1/2 tablet

2.5 ml (1/2 tsp)

Give Oral Co-artemether

Give the first dose of co-artemether in the clinic and observe for one hour If child vomits
within an hour repeat the dose. 2nd dose at home after 8 hours
Then twice daily for further two days as shown below
Co-artemether should be taken with food
Co-artemether tablets
(20mg artemether and 120mg lumefantrine)
WEIGHT (age)

0hr

8h

24h

36h

48h

60h

5-15kg (<3 years)

15-24kg (4-8 years)

25-34 kg (9-14 years)

>34 kg (>14 years)

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given
Describe the treatment steps listed in the appropriate box
Watch the mother as she gives the first treatment in the clinic (except for remedy for cough or sore throat)
Tell her how often to do the treatment at home
If needed for treatment at home, give mother a tube of tetracycline ointment or a small bottle of gentian violet
Check the mothers understanding before she leaves the clinic

Dry the Ear by Wicking and Instill Quinolone Eardrops*

Treat for Mouth Ulcers with Gentian Violet (GV)

Dry the ear at least 3 times daily

Treat for mouth ulcers twice daily

Wash hands
Wash the childs mouth with a clean soft cloth wrapped around the finger
and wet with salt water
Paint the mouth with 1/2 strength gentian violet (0.25% dilution)
Wash hands again
Continue using GV for 48 hours after the ulcers have been cured
Give paracetamol for pain relief

Roll clean absorbent cloth or soft, strong tissue paper into a wick
Place the wick in the childs ear
Remove the wick when wet
Replace the wick with a clean one and repeat these steps until the ear is dry
Instill quinolone eardrops* after dry wicking three times daily for two weeks

* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin eardrops

Treat Eye Infection with Tetracycline Eye

Ointment

Soothe the Throat, Relieve the Cough with a Safe Remedy

Safe remedies to recommend:
- Breast milk for exclusively breastfed infant
- Tamarind, calamansi and ginger decoction

Clean both eyes 4 times daily.

Wash hands.
Use clean cloth and water to gently wipe away pus.

Harmful remedies to discourage:

- Codeine cough syrup
- Other cough syrups
- Oral and nasal decongestants

Then apply tetracycline eye ointment in both eyes 4 times daily.

Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Treat until there is no pus discharge.
10

Do not put anything else in the eye.

GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC

Explain to the mother why the drug is given
Determine the dose appropriate for the childs weight (or age)
Measure the dose accurately

Give Vitamin A every 6 months to all children

from 6 months of age
PREVENTION:
Give Vitamin A to all children to prevent severe illness:
- First dose to be given any time after 6 months of age
- Thereafter Vitamin A should be given every six months to ALL CHILDREN

Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
- hookworm/ whipworm is a problem in your area
- the child is 1 year of age or older, and
- has not had a dose in the previous 6 months

TREATMENT:
Give an extra dose of Vitamin A (same dose) for treatment if the child has
measles or PERSISTENT DIARRHEA. If the child has had
a dose of Vitamin A within the past month, DO NOT GIVE VITAMIN A

Give multivitamins and minerals for

Persistent Diarrhea

Always chart the dose of Vitamin A given on the childs chart

Age

VITAMIN A DOSE

6 up to 12 months

100 000IU

One year and older

200 000IU

All children with persistent diarrhea should received supplementary

multivitamins and minerals each day for two weeks. Locally available
preparation are often suitable, these should provide a broad range of
vitamins and minerals as possible including at least two recommended
Energy and Nutrient Intake (RENI) of folate, vitamin A, Zinc, magnesium
and copper.

11

GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY

Explain to the mother why the drug is given
Determine the dose appropriate for the childs weight (or age)
Use a sterile needle and sterile syringe when giving an injection
Measure the dose accurately
Give the drug as an intramuscular injection
If the child cannot be referred follow the instructions provided

Give An Intramuscular Antibiotic

Give Quinine for Severe Malaria

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Check which quinine formulation is available in your clinic
Give first dose of intramuscular quinine and refer child urgently to hospital

GIVE TO CHILDREN BEING REFERRED URGENTLY

Give Gentamicin (7.5mg/kg) and Benzyl Penicillin (50,000 units per kg)

AGE OR WEIGHT

GENTAMICIN
Dose: 7.5 mg/kg
80 mg vial (40 mg/ml)
undiluted

BENZYL PENICILLIN
Dose: 50,000 units per kg
To a vial of 600 mg
(I,000,000 units) = Add 1.6
ml sterile water to give
500,000 units/1 ml

0.5 ml 0.9 ml

0.4 ml

IF REFERRAL IS NOT POSSIBLE:

Give first dose of intramuscular quinine
The child should remain lying down for one hour
Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours
until the child is able to take an oral antimalarial. Do not continue quinine
injections for more than 1 week
If no malaria risk, do not give quinine to a child less than 4 months of age

3< 6 kg

AGE or WEIGHT
1.1 ml 1.7 ml

300 mg /ml* (in 2 ml )

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

0.4 ml

0.2 ml

4 months up to 12 months (6 - < 10 kg)

0.6 ml

0.3 ml

12 months up to 2 years (10 - < 12 kg)

0.8 ml

0.4 ml

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

1.0 ml

0.5 ml

3 years up to 5 years (14 - 19 kg)

1.2 ml

0.6 ml

0.75 ml

6- < 10 kg
1.9 ml2.6 ml

1.2 ml

2.8 ml<3.5 ml

1.7 ml

INTRAMUSCULAR QUININE
150 mg /ml* (in 2 ml)

10 -<15 kg
15- <20 kg

NOTE: Calculate EXACT DOSE of GENTAMICIN BASED ON BODY

WEIGHT

*quinine salt

12

Treat the Child to Prevent Low

Blood Sugar

Give Inhaled Salbutamol for Wheezing

Use of a Spacer*
A spacer is a way of delivering the bronchodilator drugs effectively into the
lungs. No child under 5 years should be given an inhaler without a spacer. A
spacer works as well as a nebulizer if correctly used.
From salbutamol metered dose inhaler (100ug/puff) give 2 puffs
Repeat up to 3 times every 15 minutes before classifying pneumonia

If the child is able to breastfeed:

Ask the mother to breastfeed the child

Spacers are made on the following way:

Use a 500ml drink bottle or similar
Cut a hole in the bottle base in the same shape as the mouthpiece of the
inhaler. This can be done using a sharp knife
Cut the bottle between the upper quarter and the lower 3/4 and discard the
upper quarter of the bottle
Cut a small V in the border of the large open part of the bottle to fit the
childs nose and be used as mask
Flame the edge of the cut bottle with a small candle or lighter to soften it
In a small baby, a mask can be made by making a similar hole in a plastic
(not polystyrene) cup
Alternatively commercial spacers can be used if available

If the child is not able to breastfeed but is able to

swallow:

Give expressed breast milk or breast-milk

substitute
If neither of these is available give sugar water
Give 30-50 ml of milk or sugar water before
departure
To make sugar water: Dissolve 4 level
teaspoons of sugar (20 grams) in a 200-ml cup
of clean water

To use an inhaler with a spacer

Remove the inhaler cap. Shake the inhaler well
Insert mouthpiece of the inhaler thorugh the hole in the bottle or plastic cup
The child should put the opening of the bottle into his mouth and breath in
and out through the mouth
A carer then presses down the inhaler and spray into the bottle while the
child continue to breath normally
Wait for three to four breaths and repeat for total of five sprays
For younger children place the cup over the child's mouth and use as a
spacer in the same way

If the child is not able to swallow:

* If a spacer is being used for the first time, it should be primed by 4-5 extra
puffs from the inhaler.

13

Give 50ml of milk or sugar water by nasogastric

tube

GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING

Plan B: Treat for Some Dehydration with Reformulated
ORS

Plan A: Treat for Diarrhea at Home

Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid
2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding
4. When to Return

In the clinic, give recommended amount of reformulated ORS over 4-hour

period
AGE*

Up to 4 months

4 months up
to 12 months

12 months up
to 2 years

2 years up
to 5 years

WEIGHT

< 6 kg

6 - < 10 kg

10 - < 12 kg

12 - <20kg

Amount of fluid
(ml) over 4 hours

200 - 450

450 - 800

800 - 960

960 - 1600

1. GIVE EXTRA FLUID (as much as the child will take)

TELL THE MOTHER:
Breastfeed frequently and for longer at each feed
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk
If the child is not exclusively breastfed, give one or more of the following:
food-based fluids (such as soup, rice water, and yoghurt drinks), or ORS

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

It is especially important to give ORS at home when:

the child has been treated with Plan B or Plan C during this visit
the child cannot return to a clinic if the diarrhea gets worse

* Use the childs age only when you do not know the weight. The approximate amount of ORS required (in
ml) can also be calculated by multiplying the childs weight in kg times 75.

If the child wants more ORS than shown, give more

For infants below 6 months who are not breastfed, also give 100-200ml clean
water during this period

TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2
PACKETS OF ORS TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:
Up to 2 years:
50 to 100 ml after each loose stool
2 years or more: 100 to 200 ml after each loose stool

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION:

Give frequent small sips from a cup
If the child vomits, wait 10 minutes then continue - but more slowly
Continue breastfeeding whenever the child wants

Tell the mother to:

Give frequent small sips from a cup.
If the child vomits, wait 10 minutes then continue - but more slowly
Continue giving extra fluid until the diarrhea stops

AFTER 4 HOURS:
Reassess the child and classify the child for dehydration
Select the appropriate plan to continue treatment
Begin feeding the child in clinic

2. GIVE ZINC SUPPLEMENTS (age 2 months up to 5 years)

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

Show her how to prepare ORS solution at home
Show her how much ORS to give to finish 4-hour treatment at home
Give her instructions how to prepare salt and sugar solution for use at home
Explain the 4 Rules of Home Treatment:

TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab) :

2 months up to 6 months - 1/2 tablet daily for 14 days
6 months or more - 1 tablet daily for 14 days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infantsdissolve tablet in a small amount of expressed breast milk, ORS
or clean water in a cup
Older children - tablets can be chewed or dissolved in a small amount of
clean water in a cup
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)

4. WHEN TO RETURN

14

1. GIVE EXTRA FLUID

2. GIVE ZINC SUPPLEMENTS (age 2 months up to 5 years)
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN

GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING

(see FOOD advice on COUNSEL THE MOTHER chart)

Plan C: Treat for Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS YES, GO ACROSS. IF NO, GO DOWN
Start

IV fluid immediately.
If the child can drink, give ORS by mouth while the drip is set up.
Give 100 ml/kg Ringers Lactate Solution (or, if not available, normal saline), divided as follows:

Can you give

intravenous (IV)
fluid immediately?

YES

First give 30ml/kg in:

1 hour*

Then give 70ml/kg in

5 hours

Children
(12 months up to 5 years)

30 minutes*

2 hours

Repeat once if radial pulse is still very weak or not detectable.

Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more
rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants)
or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose
the appropriate plan (A, B, or C) to continue treatment.

NO

Is IV treatment
available nearby
(within 30 minutes)?
NO
Are you trained to use
a naso-gastric (NG) tube
for rehydration?

NO

AGE
Infants
(under 12 months)

YES

Refer URGENTLY to hospital for IV treatment.

If the child can drink, provide the mother with ORS solution and show her how to give frequent sips
during the trip or give ORS by naso-gastic tube.

YES

Can the child drink?

Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours
(total of 120 ml/kg).
Reassess the child every 1-2 hours:
- If there is repeated vomiting or abdominal distension, give the fluid more slowly.
- If the hydration status is not improving after 3 hours, send the child for IV therapy.
After 6 hours reassess the child. Classify dehydration. Then choose the appropriate plan
(A, B, or C) to continue treatment.

NO
Refer URGENTLY to
hospital for IV or
NG treatment

NOTE:
If the child is not referred to hospital, observe the child at least 6 hours after rehydration to be sure
the mother can maintain hydration giving the child ORS solution by mouth.
15

IMMUNIZE EVERY SICK

CHILD AS NEEDED

GIVE VITAMIN A
SUPPLEMENTATION AS
NEEDED

GIVE MEBENDAZOLE/
ALBENDAZOLE AS
NEEDED

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the childs previous classification
If the child has any new problems, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart

PNEUMONIA

DYSENTERY:

After 2 days:
Check the child for general danger signs.
Assess the child for cough or difficult breathing.
Ask:
- Is the child breathing slower?
- Is there less fever?
- Is the child eating better?

After 2 days:

Assess the child for diarrhea > See ASSESS & CLASSIFY chart
See ASSESS & CLASSIFY chart.

Ask:
-

Treatment:
If chest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular Benzyl penicillin and Gentamicin. Then refer URGENTLY to hospital.

Treatment:

If breathing rate, fever and eating are the same, change to the second-line antibiotic
and advise the mother to return in 2 days or refer. (If this child had measles within the
last 3 months, refer.)

If the child is dehydrated, treat for dehydration.

If number of stools, blood in the stools, fever, abdominal pain, or eating is
worse or the same:

If breathing slower, less fever, or eating better, complete the 3 days of antibiotic.

Change to second-line oral antibiotic recommended for dysentery in your area.

Give it for 5 days. Advise the mother to return in 2 days. If you do not have the
second line antibiotic, REFER TO HOSPITAL.

PERSISTENT DIARRHEA

Exceptions: if the child is less than 12 months old or was dehydrated on the
first visit, or if he had measles within the last 3 months, REFER TO HOSPITAL.

After 5 days:
Ask:
- Has the diarrhea stopped?
- How many loose stools is the child having per day?

If fewer stools, less fever, less abdominal pain, and eating better, continue
giving the same antibiotic until finished.
Ensure that the mother understands the oral rehydration method fully and that
she also understands the need for an extra meal each day for a week.

Treatment:
If the diarrhea has not stopped (child is still having 3 or more loose stools per
day) do a full assessment of the child. Treat for dehydration if present. Then REFER to
hospital.
If the diarrhea has stopped (child having less than 3 loose stools per day), tell the
mother to follow the usual feeding recommendations for the childs age.

Are there fewer stools?

Is there less blood in the stool?
Is there less fever?
Is there less abdominal pain?
Is the child eating better?

16

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that
match the childs previous classification
If the child has any new problems, assess, classify and treat the new
problem as on the ASSESS AND CLASSIFY chart

FEVER-MALARIA UNLIKELY
If fever persists after 2 days:
Do a full reassessment of the child > See ASSESS & CLASSIFY chart.
Assess for other causes of fever.

Treatment:

MALARIA
If fever persists after 2 days, or returns within 14 days:
Do a full reassessment of the child > See ASSESS & CLASSIFY chart.
Assess for other causes of fever.

If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the child has any cause of fever other than malaria, provide treatment.
If malaria is the only apparent cause of fever:
-

Take a blood smear

Treat with the first-line oral antimalarial. Advise the mother to return again in 2 days if the fever
persists.

If fever has been present for 7 days, refer for assessment.

Treatment:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE.
If the child has any cause of fever other than malaria, provide treatment.
If malaria is the only apparent cause of fever:
- Take a blood smear
- Give second-line oral antimalarial without waiting for result of blood smear
- Advise mother to return in 2 days if fever persists
- I fever persists after 2 days treatment with second-line oral antimalarial, refer with
blood smear for reassessment.
- If fever has been present for 7 days, refer for assessment

MEASLES WITH EYE OR MOUTH COMPLICATIONS

After 2 days:
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth.

Treatment for Eye Infection:

If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If
treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct
treatment.
If the pus is gone but redness remains, continue the treatment.
If no pus or redness, stop the treatment.
Treatment for Mouth Ulcers:
If mouth ulcers are worse, or there is a very foul smell coming from the mouth, refer to hospital.
If mouth ulcers are the same or better, continue using 0.25% gentian violet for a total of 5 days.

17

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up using all the boxes that match the childs
previous classification
If the child has any new problems, assess, classify and treat the new problem as on
the ASSESS AND CLASSIFY chart

ANEMIA
After 14 days:
Give iron. Advise mother to return in 14 days for more iron.
Continue giving iron every 14 days for 2 months.
If the child has palmar pallor after 2 months, refer for assessment.

EAR INFECTION
After 5 days:

VERY LOW WEIGHT

Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the childs temperature.

After 30 days:

Treatment:

Weigh the child and determine if the child is still very low weight for age.
Reassess feeding. > See questions at the top of the COUNSEL chart.

If there is tender swelling behind the ear or high fever (38.5C or above), refer URGENTLY to
hospital.

Treatment:

Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the same antibiotic.
Continue wicking to dry the ear. Follow-up in 5 days.

If the child is no longer very low weight for age, praise the mother and encourage
her to continue.

Chronic ear infection: Check that the mother is wicking the ear correctly and instilling the quinolone
drops . Encourage her to continue. See the child again in 5 days.

If the child is still very low weight for age, counsel the mother about any feeding
problem found. Ask the mother to return again in one month. Continue to see the child
monthly until the child is feeding well and gaining weight regularly or is no longer very
low weight for age.

If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the
5 days of antibiotic, tell her to use all of it before stopping.

FEEDING PROBLEM

Exception:
If you do not think that feeding will improve, or if the child has lost weight, refer the child.

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE

INITIAL VISIT OR THIS VISIT, ADVISE THE MOTHER OF THE
NEXT FOLLOW-UP VISIT.

After 5 days:
Reassess feeding > See questions at the top of the COUNSEL chart.
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make
significant changes in feeding, ask her to bring the child back again.
If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure
the childs weight gain.

18

OR
ALSO ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.
(See the COUNSEL THE MOTHER chart)

COUNSEL THE MOTHER

Assess the Feeding of Sick Infants under 2 years

(or if child has very low weight for age)
Ask questions about the childs usual feeding and feeding during this illness. Compare the mothers answers to the Feeding
Recommendations for the childs age.

ASK How are you feeding your child?

If the infant is receiving any breast milk, ASK:

-

How many times during the day?

Do you also breastfeed during the night?

Does the infant take any other food or fluids?

- What food or fluids?
- How many times per day?
- What do you use to feed the child?
If low weight for age, ASK:
-

How large are servings?

Does the child receive his own serving?
Who feeds the child and how?

During this illness, has the infants feeding changed?

-

19

If yes, how?

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH

Up to 6 Months
of Age

Breastfeed as often as the child

wants, day and night, at least
8 times in 24 hours.
Do not give other foods or fluids.

6 Months up
to 12 Months

Breastfeed as often as the child wants.

Give adequate servings of:
___________________________
___________________________
___________________________
___________________________
-

12 Months
up to 2 Years

3 times per day if breastfed plus

snacks
5 times per day if not breastfed.

Breastfeed as often as the child

wants.
Give adequate servings of:
__________________________
__________________________
__________________________
__________________________

Give family foods at 3 meals

each day. Also, twice daily, give
nutritious food between meals,
such as:
__________________________
__________________________
__________________________
__________________________
__________________________

or family foods 3 or 4 times per day

plus snacks.

Feeding recommendations for a child who has SEVERE UNCOMPLICATED

MALNUTRITION
If still breast feeding, give more frequent, longer breast feeds, day and night
Feed the child with RUTF (ready-to-use therapeutic food) per day (corresponding to 40 g/
kg/day) for 2 months. Usually comes in sachets of 500 gms. NOTE: RUTF is a special food
for malnourished children aged more than 6 months and should not be shared with other
family members. Offer plenty of clean water to drink with RUTF

2 Years
and Older

Feeding Recommendations for a child who has PERSISTENT DIARRHOEA

20

If still breastfeeding, give more frequent, longer breastfeeds, day and night.

If taking other milk:

replace with increased breastfeeding OR
replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS

If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition:
If the mother reports difficulty with breastfeeding, assess breastfeeding (see YOUNG INFANT chart).
As needed, show the mother correct positioning and attachment for breastfeeding.
If the child is less than 6 months old and is taking other milk or foods*:
- Build mothers confidence that she can produce all the breast milk that the child needs.
- Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother to:
-

Breastfeed as much as possible, including at night.

Make sure that other milk is a locally appropriate breast milk substitute.
Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
Finish prepared milk within an hour.

If the mother is using a bottle to feed the child:

- Recommend substituting a cup for bottle.
- Show the mother how to feed the child with a cup.
If the child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and for longer if possible.
- Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer
frequent small feeds.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.
If the child has a poor appetite:
-

Plan small, frequent meals.

Give milk rather than other fluids except where there is diarrhoea with some dehydration.
Give snacks between meals.
Give high energy foods.
Check regularly.

If the child has sore mouth or ulcers:

-

Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
Avoid spicy, salty or acid foods.
Chop foods finely.
Give cold drinks or ice, if available.
21

COUNSEL THE MOTHER ABOUT HER OWN HEALTH

If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mothers immunization status and give her tetanus toxoid if needed.
Make sure she has access to:

Family planning
Counselling on STD and AIDS prevention.

22

FLUID
Advise the Mother to Increase Fluid During Illness
FOR ANY SICK CHILD:
If child is breastfed, breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase
the amount of milk given
Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.
FOR CHILD WITH DIARRHOEA:
Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on the TREAT THE CHILD chart

WHEN TO RETURN
Advise the Mother When to Return to Health Worker
FOLLOW-UP VISIT
If the child has:

PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVER-MALARIA UNLIKELY, if fever persists
MEASLES WITH EYE OR MOUTH COMPLICATIONS

PERSISTENT DIARRHOEA
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
COUGH OR COLD, if not improving

Return for first follow-up in:

2 days

5 days

WHEN TO RETURN IMMEDIATELY

SEVERE UNCOMPLICATED MALNUTRITION

ANAEMIA

VERY LOW WEIGHT FOR AGE

Advise mother to return immediately if the child has any of these signs:

7 days

Any sick child

Not able to drink or breastfeed

Becomes sicker
Develops a fever

If child has NO PNEUMONIA:

COUGH OR COLD, also return if:

Fast breathing
Difficult breathing

If child has Diarrhoea, also return if:

Blood in stool
Drinking poorly

14 days

30 days

Advise the mother to come for follow-up at the earliest time listed for
the childs problems.
23

ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

AGED UP TO 2 MONTHS
CLASSIFY

ASSESS
ASK THE MOTHER WHAT THE YOUNG INFANTS PROBLEMS ARE
Determine if this is an initial or follow-up visit for this problem.
- if follow-up visit, use the follow-up instructions
- if initial visit, assess the young infant as follows:

USE ALL BOXES THAT MATCH INFANTS

SYMPTOMS AND PROBLEMS TO
CLASSIFY THE ILLNESS.

CHECK FOR VERY SEVERE DISEASE AND

LOCAL INFECTION

SIGNS

CLASSIFY AS

Any one of the following signs

ASK:
Is the infant having
difficulty in feeding?

Has the infant had

convulsions (fits)?

LOOK, LISTEN, FEEL:

Count the breaths in one minute.
Repeat the count if 60 or more
breaths per minute.

Look for severe chest indrawing.

YOUNG
INFANT
MUST
BE
CALM

Measure axillary temperature.

Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.
Look at the young infants movements. If infant is

Classify
ALL
YOUNG
INFANTS

Not feeding well or

Convulsions or
Fast breathing (60 breaths per minute or
more) or
Severe chest indrawing or
Fever (37.5C* or above) or
Low body temperature (less than 35.5C*)
or
Movement only when stimulated or no
movement at all

Umbilicus red or draining pus or

Skin pustules

sleeping, ask the mother to wake him/her.

IDENTIFY
TREATMENT

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

Give first dose of intramuscular

antibiotics.

VERY
SEVERE
DISEASE

Treat to prevent low blood sugar.

Refer URGENTLY to hospital.**
Advise mother how to keep the infant
warm on the way to the hospital.

LOCAL
BACTERIAL
INFECTION

- Does the infant move on his/her own?

Give an appropriate oral antibiotic.

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

If the infant is not moving, gently stimulate him/her.

- Does the infant move only when stimulated but
then stops?

None of the signs of very severe disease

or local bacterial infection

- Does the infant not move at all ?

SEVERE DISEASE
OR LOCAL
INFECTION
UNLIKELY

* These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5C higher.
** If referral is not possible, see Integrated Management of Childhood Illness, Management of the sick young infant module, Annex 2 Where referral is not possible

24

Advise mother to give home care for

the young infant.

THEN CHECK FOR JAUNDICE

SIGNS
LOOK:
Look for jaundice (yellow eyes or
skin).

Any jaundice if age less than 24

hours or

Classify
Jaundice

CLASSIFY AS
SEVERE
JAUNDICE

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

Treat to prevent low blood sugar.

Refer URGENTLY to hospital.

Yellow palms and soles at any age

Advise mother how to keep the infant warm
on the way to the hospital.

Look at the young infants palms and

soles. Are they yellow?
Jaundice appearing after 24 hours of
age and

JAUNDICE

Advise the mother to give home care for the

young infant
Advise mother to return immediately if palms
and soles appear yellow.

Palms and soles not yellow

If the young infant is older than 14 days, refer

to a hospital for assessment.
Follow-up in 1 day.
No jaundice

25

NO
JAUNDICE

Advise the mother to give home care for the

young infant.

THEN ASK: Does the young infant have diarrhea?

SIGNS
IF YES, LOOK AND FEEL:
Look at the young infants general condition:

Classify
DIARRHEA

- Infants movements
- Does the infant move on his/her own?
- Does the infant move only when stimulated but then
stops?
- Does the infant not move at all ?
- Is the infant restless and irritable?

Look for sunken eyes.

CLASSIFY AS

Two of the following signs:

Movement only when
stimulated or no movement
at all
Sunken eyes
Skin pinch goes back very
slowly.

If infant has no other severe classification:

- Give fluid for severe dehydration (Plan C)

SEVERE
DEHYDRATION

Two of the following signs:

Restless, irritable
Sunken eyes
Skin pinch goes back
slowly.

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

OR
If infant 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
Give fluid and breast milk for some
dehydration (Plan B).

SOME DEHYDRATION
If infant has any sign of VERY SEVERE
DISEASE:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
- Advise mother to continue breastfeeding.

Pinch the skin of the abdomen.

Does it go back:
- Very slowly (longer than 2 seconds)?
- or slowly?

Advise mother when to return immediately

Follow-up in 2 days if not improving
Not enough signs to classify
as some or severe
dehydration.

* What is diarrhea in a young infant?

A young infant has diarrhea if the stools have changed from usual pattern
and are many and watery (more water than fecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not
diarrhea.

26

NO DEHYDRATION

Give fluids and breast milk to treat for

diarrhea at home (Plan A)
Advise mother when to return immediately
Follow up in 2 days if not improving

THEN CHECK FOR FEEDING PROBLEM OR

LOW WEIGHT FOR AGE IN BREASTFED INFANTS
SIGNS

If an infant has no indications to refer urgently to hospital:

ASK:

LOOK, LISTEN,FEEL:

Is the infant breastfed? If yes,

Determine weight for age.

how many times in 24 hours?

Classify
FEEDING

Look for ulcers or white patches in the

mouth (thrush).

Does the infant usually receive

CLASSIFY AS

Not well attached to

breast or

If not well attached or not suckling

effectively, teach correct positioning and
attachment.
If not able to attach well immediately,
teach the mother to express breast milk
and feed by a cup

Not suckling effectively,

or

any other foods or drinks?

If yes, how often?
Less than 8 breastfeeds
in 24 hours, or

If yes, what do you use to feed the infant?

ASSESS BREASTFEEDING:

FEEDING
PROBLEM
OR
LOW WEIGHT
FOR AGE

Receives other foods or

drinks, or

Has the infant breastfed in If the infant has not fed in the previous hour, ask the mother
to put her infant to the breast. Observe the breastfeed for
the previous hour?
4 minutes.
(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 well attached?
no attachment at all

not well attached

TO CHECK ATTACHMENT, LOOK FOR:

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 preparing
breastmilk substitutes and using a
cup.

If thrush, teach the mother to treat thrush

at home.

Thrush (ulcers or white

patches in mouth)

- More areola seen above infants top lip than below

bottom lip
- Mouth wide open
- Lower lip turned outwards
- Chin touching breast

If breastfeeding less than 8 times in 24

hours, advise to increase frequency of
feeding. Advise her to breastfeed as often
and for as long as the infant wants, day
and night.

Advise the mother how to feed and keep

the low weight infant warm at home

Low weight for age, or

good attachment

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

Advise mother to give home care for the

young infant.
Follow-up any feeding problem or thrush
in 2 days.

(All of these signs should be present if the attachment is good).

Follow-up low weight for age in 14 days.

Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling at all

not suckling effectively

Not low weight for age

and no other signs of
inadequate feeding.

suckling effectively

Clear a blocked nose if it interferes with breastfeeding.

27

NO FEEDING
PROBLEM

Advise mother to give home care for

the young infant.
Praise the mother for feeding the
infant well.

THEN CHECK THE YOUNG INFANTS IMMUNIZATION AND VITAMIN A STATUS:

IMMUNIZATION
SCHEDULE:

AGE

VACCINE

Birth
6 weeks
10 weeks

BCG
DPT
DPT

VITAMIN A

OPV-1
OPV-2

Hep B 1
Hep B 2

200 000 IU to the mother within four weeks of delivery

Give all missed doses on this visit.

Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.

ASSESS OTHER PROBLEMS

28

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give First Dose of Intramuscular Antibiotics
Give first dose of intramuscular ampicillin and gentamicin
AMPICILLIN
Dose: 50 mg per kg

WEIGHT

GENTAMICIN

To a vial of 250 mg

Undiluted 2 ml vial

Add 1.3 ml sterile water =

250 mg/1.5 ml

containing 20 mg = 2 ml
at 10 mg/ml

Add 6 ml sterile water to 2 ml

OR

vial containing
80 mg* = 8 ml at 10 mg/ml

AGE <7 days

Dose: 5 mg per kg

AGE>7 days
Dose: 7.5 mg per kg

1-<1.5 kg

0.4 ml

0.6 ml*

0.9 ml*

1.5-<2 kg

0.5 ml

0.9 ml*

1.3 ml*

2-<2.5 kg

0.7 ml

1.1 ml*

1.7 ml*

2.5-<3 kg

0.8 ml

1.4 ml*

2.0 ml*

3-<3.5 kg

1.0 ml

1.6 ml*

2.4 ml*

3.5-<4 kg

1.1 ml

1.9 ml*

2.8 ml*

4-<4.5 kg

1.3 ml

2.1 ml*

3.2 ml*

*Avoid using undiluted 40 mg/ml gentamicin.

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to
give ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3
times daily to infants one week or older. Give gentamicin once daily.

Treat the Young Infant to Prevent Low Blood Sugar

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breastmilk before departure. If not possible to give expressed breastmilk, give 20-50 ml (10
ml/kg) sugar water (To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric tube.
29

TREAT THE YOUNG INFANT

Teach the Mother How to Keep the Young Infant Warm on the way To the Hospital
Provide skin to skin contact, OR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing
including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.

Give an Appropriate Oral Antibiotic for local infection

For local bacterial infection:
First-line antibiotic :
___________________________________________________________________________________________
Second-line antibiotic: ___________________________________________________________________________________________
AMOXICILLIN
Give two times daily for 5 days

AGE or WEIGHT

Adult Tablet
single strength
(80 mg trimethoprim + 400
mg sulphamethoxazole)

Birth up to 1 month (<4 kg)

1 month up to 2 months (4-<6 kg)

1/4

COTRIMOXAZOLE
Give two times daily for 5 days

Pediatric Tablet
(20 mg trimethoprim
+100 mg
sulphamethoxazole)

Syrup
(40 mg trimethoprim
+200 mg
sulphamethoxazole)

Tablet

Syrup

250 mg

125 mg in 5 ml

1/2*

1.25 ml*

1/4

2.5 ml

2.5 ml

1/2

5 ml

* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.

30

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach the Mother How to Treat Local Infections at Home

Explain how the treatment is given.
Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.
To Treat Skin Pustules or Umbilical Infection

To Treat Thrush (ulcers or white patches in mouth)

The mother should do the treatment twice daily for 5 days:

The mother should do the treatment four times daily for 7 days:

Wash hands

Wash hands

Gently wash off pus and crusts with soap and water

Paint the mouth with half-strength gentian violet (0.25%) using a

clean soft cloth wrapped around the finger

Dry the area

Wash hands

Paint the skin or umbilicus/cord with full strength gentian

violet (0.5%)
Wash hands

To Treat Diarrhea, See TREAT THE CHILD CHART.

Immunize Every Sick Young Infant, as needed.

31

COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding
Show the mother how to hold her infant
- with the infants head and body in line
- with the infant approaching breast with nose opposite to the nipple
- with the infant held close to the mothers body
- with the infants whole body supported, not just neck and shoulders.
Show her how to help the infant to attach. She should:
- touch her infants lips with her nipple
- wait until her infants mouth is opening wide
- move her infant quickly onto her breast, aiming the infants lower lip well below the nipple.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

Teach the Mother How to Express Breast Milk

Ask the mother to:
Wash her hands thoroughly.
Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other
(at least 4 cm from the tip of the nipple).
Compress and release the breast tissue between her finger and thumb a few times.
If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before.
Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not to squeeze the
nipple or to rub the skin or move her thumb or finger on the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.
32

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach the Mother How to Feed by a Cup
Put a cloth on the infants front to protect his clothes as some milk can spill
Hold the infant semi-upright on the lap.
Put a measured amount of milk in the cup.
Hold the cup so that it rests lightly on the infants lower lip.
Tip the cup so that the milk just reaches the infants lips.
Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.

Teach the Mother How to Keep the Low Weight Infant Warm at Home
- Keep the young infant in the same bed with the mother.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing and
clothe the young infant immediately.
- Change clothes (e.g. diapers) whenever they are wet.
- Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mothers chest between the mothers breasts. Keep the infants head turned to one side
Cover the infant with mothers clothes (and an additional warm blanket in cold weather)
- When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing
including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket.
- Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
- Breastfeed (or expressed breast milk by cup) the infant frequently

Treat the Young infant to Prevent Low Blood Sugar

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-25 ml (10ml/kg) expresses breastmilk before departure. If not possible to give expressed breastmilk, give 20-50ml (10ml/kg) sugar water
(To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric
tube.
33

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Advise the Mother to Give Home Care for the Young Infant
1.

2.

EXCLUSIVELY BREASTFEED THE YOUNG INFANT

Give only breastfeeds to the young infant
Breastfeed frequently, as often and for as long as the infant wants,
MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infants head and feet and dress the infant with extra clothing.

3. WHEN TO RETURN:

WHEN TO RETURN IMMEDIATELY:

Follow up visit

If the infant has:

JAUNDICE

LOCAL BACTERIAL INFECTION

FEEDING PROBLEM
THRUSH
DIARRHEA

LOW WEIGHT FOR AGE

Return for first follow-up in:

Advise the caretaker to return immediately

if the young infant has any of these signs:
Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow

1 day
2 days

14 days

34

GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

ASSESS EVERY YOUNG INFANT FOR VERY SEVERE DISEASE DURING FOLLOW UP VISIT.
LOCAL BACTERIAL INFECTION
After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.
Treatment:
If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5
days of antibiotic and continue treating the local infection at home.
If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.

JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for
follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2
weeks of age. If jaundice continues beyond two weeks of age , refer the young infant to a hospital for further assessment.

DIARRHEA
After 2 days:
Ask: -Has the diarrhea stopped ?
Treatment:
If the diarrhea has not stopped, assess and treat the young infant for diarrhea. >SEE Does the Young Infant Have Diarrhea ?
If the diarrhea has stopped, tell the mother to continue exclusive breastfeeding.
35

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See Then Check for Feeding Problem or Low Weight above.
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding,
ask her to bring the young infant back again.
If the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young infants
weight gain.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

36

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

LOW WEIGHT FOR AGE
After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. > See Then Check for Feeding Problem or Low Weight above.
If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within a month
or when she returns for immunization.
If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother
to return again in 14 days (or when she returns for immunization, if this is within 14 days). Continue to see the young infant every few
weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See Then Check for Feeding Problem or Low Weight above.
If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.

37

Age: _____________ Weight: __________ kg

Temperature: ________C

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

Name: ___________________________________________

LETHARGIC OR UNCONSCIOUS
CONVULSING NOW

Yes ___ No ___

Look at the childs 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 eargerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?

Yes___ No___
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.

______
DPT2

_______
Measles

Circle immunizations needed today.

______
DPT3
______
OPV 3

Time taken:

General danger signs present?

Yes___ No___
Remember to use danger sign
when selecting classifications

ASK: What are the childs problems? ___________________________________________________ Initial visit? ___ Follow-up Visit? ___
ASSESS (Circle all signs present)
CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING
CONVULSIONS

Count the breaths in one minute.

_______ breaths per minute. Fast breathing?
Look for chest indrawing.
Look and listen for stridor
Look and listen for wheezing.

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes___ No___

For how long? ____ Days

DOES THE CHILD HAVE DIARRHOEA?

For how long? _____ Days
Is there blood in the stools?

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?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C or above)

If the child has measles now

or within the last 3 months:

Look for mouth ulcers.

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

DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No___

______
DPT1
______
OPV 2

For children < 6 months, Look for visible severe wasting.

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

Is there ear pain?

Look for pus draining from the ear.
Is there ear discharge?
Feel for tender swelling behind the ear.
If Yes,
for how long?
___ Days
For children
>6 months
old,
check if MUAC < 110 mm
THEN CHECK FOR MALNUTRITION AND ANAEMIA
Assess appetite

______
BCG
______
OPV 1

CHECK THE CHILDS IMMUNIZATION STATUS

______
OPV 0

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

Ask about mothers own health

Do you breastfeed your child? Yes____ No ____

If Yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes___ No___
Does the child take any other 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 weght for age: How large are servings? ___________________________________________
Does the child receive how own serving? ___ Who feeds the child and how? ______________________
During the illness, has the childs feeding changed? Yes ____ No ____ If Yes, how?

ASSESS OTHER PROBLEMS

FEEDING PROBLEMS

________________
(Date)

Return for next immunization on:

38

Age: ___________

Weight: ________ kg

Temperature: ________C

MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS

Name: _______________________________________

CLASSIFY

______________
(Date)

Return for next immunization on:

Classify all young infants

ASK: What are the infants problems? _________________________________________________ Initial visit? ___ Follow-up visit? ___
ASSESS (Circle all signs present)

Count the breaths in one minute. _______ breaths per minute

Repeat if 60 breaths or more ________ Fast breathing?
Look for severe chest indrawing.
Fever (temperature 37.5C or above).
Low body temperature (less than 35.5C)
Look at the umbilicus. Is it red or draining pus?
Look for skin pustules.
Look at the young infants movements.
Does the infant move only when stimulated?
Does the infant not move at all?

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Is the infant having difficulty in feeding?
Has the infant had convulsions (fits)?

Look for jaundice (yellow eyes or skin)

Look at the young infant's palms and soles. Are they yellow?

Look at the young infants general condition.

Yes _____ No ______

THEN CHECK FOR JAUNDICE

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Does the infant move only when stimulated?

Does the infant not move at all?
Is the infant restless or irritable?
Look for sunken eyes.

Pinch the skin of the abdomen. Does it go back:

Very slowly (longer than 2 seconds)?
Slowly?

Look for ulcers or white patches in the mouth (thrush).

Determine weight for age. Low ___ Not Low _____

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE

Is the infant breastfed? Yes _____ No _____
If Yes, how many times in 24 hours? _____ times
Does the infant usually receive any
other foods or drinks? Yes _____ No _____
If Yes, how often?
If yes, what do you use to feed the infant?

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.

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

good attachment

Is the infant able to attach? To check attachment, look for:

- More areola seen above infants top lip Yes ___ No ___
than below bottom lip
- Mouth wide open
Yes ___
No ___
- Lower lip turned outwards
Yes ___
No ___
- Chin touching breast
Yes ___
No ___
not well attached

Time taken:

suckling effectively

Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
not suckling effectively

Circle immunizations needed today.

Ask about mothers own health

CHECK THE YOUNG INFANTS IMMUNIZATION STATUS

______
______
BCG
OPV 0
______
______
______
OPV 1
DPT1 + HIB1
Hepatitis B1
______
______
______
OPV 2
DPT2 + HIB2
Hepatitis B2

ASSESS OTHER PROBLEMS

39

ISBN 92 4 159437 3

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