INTEGRATED MANAGEMENT

OF CHILDHOOD ILLNESSES

Rosechelle Siupan-Elarco,RN,MAN
CAUSES OF DEATH IN CHILDREN
Source: CHERG estimates of under-five deaths, 2000-03

Under-
nutritio
n
53%
Immediate causes…..
 Deaths in the perinatal and neonatal period dominate
 the perinatal period is also associated with the highest number of
disabilities
 highest risk is in the first day of life

 Malnutrition remains the highest attributable causal / associated factor of

all childhood deaths in children < 5 years

 40 - 80% of all neonatal deaths are associated with low birth weight

 The most important immediate causes of death from communicable

diseases remain to be diarrhea and ARI
 LEADING CAUSES OF DEATH
2014 UNICEF REPORT

1. Preterm birth complications (17%)

2. Pneumonia (15 %)
3. Labor and delivery complications (11%)
4. Diarrhea (9 %)
5. Malaria (7 %)

Almost half of under five deaths are associated

with malnutrition
Factors associated with mortality:
- Poorest households
- Rural areas
- Low rates of maternal education
Mortality also varies by country depending on the
prevalence of HIV and malaria
Children die from more than one condition at once
 WHY IMCI?

Children present with multiple potentially deadly conditions

at once
 - Lack of diagnostic tools (labs or radiology)
 - Providers rely on patient history, signs, and symptoms for
diagnosis
 - Need to refer to a higher level of care for serious illnesses

In 1995 WHO and UNICEF developed a strategy known as

Integrated Management of Childhood Illness (IMCI). IMCI
integrates case management of the most common childhood
problems, especially the most important causes of death.
• IMCI is an integrated approach to child health that focuses on the well -
being of the whole child.
• IMCI is a strategy for reducing mortality and morbidity associated with
major causes of childhood illness.
• IMCI was initiated jointly in 1992 by DOH, WHO and UNICEF.
• IMCI has already been introduced in more than 75 countries around the
world.
 IMCI: OVERVIEW

A more integrated approach in managing

sick children is needed to achieve better
outcomes.
Child health programs need to move
beyond addressing single diseases to
addressing the overall health and well-
being of the child.
Improvements in child health are not
necessarily dependent on the use of
sophisticated and expensive technologies.
IMCI – strategy to reduce mortality and morbidity associated
with major causes of childhood illness

Objectives:
- to reduce death
- to reduce frequency and severity of illness and
disability
- to contribute in the improvement of growth and
development

Healthy Filipino:
Well Educated
In control of their lives
Physically healthy
Productive
Empowered
 •Three major components of IMCI:

1. Improving
case management
skills of health
workers
2. Improving the
health system to
deliver IMCI
 3. Improving
family and
community health
practices
 IMCI IMPLEMENTATION IN THE Philippines
 Initiation Phase – IMCI adaptation,
meetings with key stakeholders
 Early implementation phase –
trainings
implementation in pilot areas
 Expansion phase
cascade to other areas
curriculum integration – nursing,
midwifery, medical schools
Common Problems That Affect the Quality of Care Provided to Sick Children
at Health Facilities

1. Health worker’s skills

• Incomplete examinations and counseling

• Poor communication between health

workers and parents

• Irrational use of drugs

Common Problems That Affect the Quality of Care Provided to
Sick Children at Health Facilities

2. Health system issues

• Location of health services and responsibility

(centralization)

• Availability of appropriate drugs and vaccines

• Supervision/division of labor/organization of
work
Common Problems That Affect the Quality of Care Provided to Sick Children
at Health Facilities
3. Community and family practices

• Poor knowledge of when to return to a health facility

• Seeking assistance from unqualified

providers

• Poor adherence to health worker advice and treatment

• Delayed careseeking
 Essential package of child survival interventions – why?

Vaccination against common vaccine preventable diseases would prevent

approximately 3% of child deaths

Case management of diarrhea would save approximately 21% of child lives

Case management of pneumonia and neonatal sepsis would prevent an

estimated 12% of child deaths

Use of insecticide treated bed nets and prompt treatment of malaria would
reduce child mortality by approximately 13%
ESSENTIAL PACKAGE OF CHILD SURVIVAL
INTERVENTIONS

1. Skilled attendance
during pregnancy,
childbirth and the
immediate postpartum
 Antenatal care

 Skilled attendance at
delivery

 Immediate postpartum
care
2. Care of the newborn

 Early initiation of
breastfeeding
(within one hour of
birth)

 Temperature
control

 Low-birth-weight
management
4. Micronutrient supplementation

 Vitamin A
supplementation (6-59
months-old)

 Iron supplementation

 Use of iodised salt –

iodine supplementation
5. Immunization of children and
mothers

Tetanus toxoid
tb, diptheria, pertussis, tetanus,
poliomyelitis, measles
6. Integrated management of
sick children
7. Use of insecticide treated bed nets
(in malarious areas)
 20 % sleeping under
ITN (Cambodia)

 20.6 % sleeping under

ITN (Laos)

 35% sleeping under

ITN (PNG)
 Too many different pieces…
Appropriate
Case Care seeking Anemia
management
Home
Nutrition HIV/AIDS care
Drug
Use
New born
Malaria care
Child Follow-up
rights
Health Safe and
system Mothers Supportive
Communication
health Environment
 “Golden” pediatric standard

Complete
examination
Preliminary Laboratory Differential
all signs
and Diagnosis examination Diagnosis
systems

Advise to
Treatment
Final Treatment caretakers
procedures
Diagnosis strategy Follow- up
IMCI brings them all together

IMPROVEMENT OF HEALTH SYSTEM

IMPROVEMENT OF CASE MANAGEMENT

FAMILY AND COMMUNITY PRACTICES

CHILD RIGHTS
 WHO CAN USE IMCI?

The IMCI process can be used by all doctors,

nurses and other health professionals who see
young infants and children less than five years
old.

It is a case management process for a first -level facility, such

as a clinic, health center or an outpatient department of a
hospital.
I. Assess the child or young infant
II. Classify the illness
III. Identify the treatment
IV. Treat the child/Refer
V. Counsel the mother
VI. Give follow-up care
IMCI Case Management
Classification
Focused Assessment
Need to Refer
Danger signs
Main Symptoms
Nutritional status Specific treatment
Immunization status
Other problems Home
management

Counsel & Follow-up Treatment

Counsel caretakers Identify treatment

Follow-up Treat
I. Assess the child or young infant

 taking a history and doing physical

examination.
II. Classify the illness
• Taking a decision on the severity of the illness
• Classifications are not specific disease diagnoses.
Instead, they are categories that are used to
determine treatment
• For effectively manage childhood illness, a color -
coded system has been utilized which represents:
GREEN YELLOW PINK
I M C I Color Coding
NEEDS URGENT ATTENTION AND
SEVERE
REFERRAL OR ADMISSION FOR IN-
PATIENT CARE.
This is a severe classification

Child needs an appropriate antibiotic,

MODERATE
an oral anti-malarial or other
treatment which can be given in
HEALTH CENTER

MILD Does not need specific medication /

treatment such as antibiotic. Can be
MANAGE AT HOME BY MOTHER
 II. Classify the illness

Classification of Disease Level of Management

Color Presentation

Green Mild Home Care

Yellow Moderate Management at the RHU

Pink Severe Urgent Referral

III. Identify Treatment
The chart recommends appropriate treatment for each
classification

When using this process, selecting a classification on the chart

is sufficient to allow you to “identify treatment”
IV. Treat the child
“Treat the child” means giving treatment in the health center

 prescribing drugs or other treatments to be given at home

 teaching the mother how to carry out the treatments.

V. Counsel the mother
“Counsel the mother” includes assessing how the child is
fed

 telling the mother about the foods and fluids to give the
child

Telling the mother when to bring the child back to the

health center.
VI. Give follow-up care
Specific instructions for conducting each follow -up visit

= explain to the mother the importance of follow-up care

= when to return for the scheduled follow-up care

= when to return immediately, in case the condition does

not improve or worsens
 2 Age Categories in IMCI:
1. Young Infant – less than 1 week up to 2
months (1 week up to 1 month and 29 days)

2. Young Child – 2 months up to 5 years (2

months up to 4 years and 11 months)

Target Children – less than 5 years old

 Management of
Children age 2
months up to 5 years
S teps:
1. AS K T HE MOT HER W HAT ’S T HE CHILD PROB LEMS ARE
a. Gr eet t he m ot her appr opriately and ask he r to si t w i t h he r chi l d
 Know t he chi l d’s age . De te rmine t he chi l d’s age i n m ont hs usi ng t he
bi r thdate
 Recor d t he w e i ght and te m perature m e asured

b. U si ng good com m unication sk i lls, ask t he m ot her w hat t he chi l d’s

pr oblems ar e and r e cord t he m on t he Re cor ding For m
 Li sten car e fully to w hat t he m ot her te l ls you
 U se wor ds t he m ot her under stand
 Gi ve t he m ot her to answ er t he que st i ons
 Ask addi t ional que st i ons w he n t he m ot he r i s not sur e about he r answ e r.
c. Determine if this is an initial visit or follow up visit for this
problem
 if this is the child’s first visit for this episode of an illness or
problem, then this is an INITIAL VISIT.
If the child was seen a few days ago for different illness, this
is still an INITIAL VISIT.
If the child was seen a few days ago for the same illness, this
is a FOLLOW –UP VISIT.
CASE STUDY
 Salina is 15 months old. She weighs 8.5 kilograms.
Her temperature is 38.5°C.
 The health worker asks, “What are the child’s
problems?” The mother says “Salina has been
coughing for 4 days, and she is not eating well.” This
is Salina’s initial visit for this problem.
 MANAGEMENT OF THE SICK CHILD AGED MONTHS UP TO 5 YEARS

salina 15 mos
8.5 38.5
Child’s Name __________________ Age_______ Wt_______ KG. Temp.____________
Cough, not eating well,
ASK: What are the child’s problems?_______________________ _________ Initial Visit?_____
does not breasfeed, fever Follow-up?______
a
Assess (Circle all signs present) Classify

Check for General Danger Signs General danger signs

present?
~ Not able to drink or breastfeed
~ Convulsions
Yes____ No____
~ Vomits everything
~ Abnormally sleepy or Difficulty awaken
 CHECK FOR GENERAL DANGER SIGNS

a. The child is not able to drink or breastfeed b. The child vomits everything

c. The child has had convulsion d. The child is abnormally sleepy or

(during this illness) difficult to awaken
 CHECK FOR GENERAL DANGER SIGN

A child with a general danger sign has a serious

problem. Most child with a general danger sign NEED
URGENT referral to a hospital.

They need life saving treatment with injectable

antibiotics, oxygen or other treatment.
 Case Study
 Salina is 15 months old. She weighs 8.5 kilograms. Her
temperature is 38.5°C.
 The health worker asks, “What are the child’s
problems?” The mother says “Salina has been coughing
for 4 days, and she is not eating well.” This is Salina’s
initial visit for this problem.
 The health worker checks Salina for general danger
signs. He asks, “Is Salina able to drink or breastfeed?”
The mother says “No, Salina does not want to
breastfeed.”
 The health worker gives Salina some water to drink. She
is too weak to lift her head. She is not able to drink from
a cup.
 Next he asks the mother, “Is she vomiting? The mother
says. “No.” He then asks, “Has she had convulsions?”
The mother says, “No.”
 The health worker looks to see if Salina is lethargic or
unconscious. When the health worker and the mother
are talking, Salina watches then looks around the room.
She is not lethargic or unconscious.
 salina 15 m 8.5 38.5
Child’s Name __________________ Age_______ Wt_______ KG. Temp.____________

Cough, not eating well,

ASK: What are the child’s problems?_______________________ a
_________ Initial Visit?_____
does not breasfeed, fever Follow-up?______

Assess (Circle all signs present) Classify

Check for General Danger Signs General danger signs

present?
~ Not able to drink or breastfeed?
~ Has had convulsions?
~ Vomits everything taken in? a
Yes____ No____
~ Abnormally sleepy or unconscious?
ASSESS AND CLASSIFY COUGH OR DIFFICULT Y
BREATHING
 A child with difficulty breathing or cough may have
Pneumonia or other severe respiratory infection.

 Bacteria and viruses causes Pneumonia

 Common bacteria are Streptococcus pneumonia and

Hemophilus influenzae

 A child with bacterial pneumonia may die from

HYPOXIA AND SEPSIS
 ASSESS COUGH OR DIFFICULT Y BREATHING

How long the child has had cough or

difficulty breathing

Fast breathing
Chest indrawing CHILD MUST
Stridor in a calm child BE CALM
wheeze in a calm child
Ask: Does the child have cough or difficulty breathing?

YES or NO
If YES

ASK: For how long?

 A child who has cough or difficult breathing for more than 30 days has a
chronic cough. This may be a sign of TB, asthma, whooping cough or
another problem

 COUNT THE NUMBER OF BREATHS IN ONE MINUTE

CLINICAL ASSESSMENT

CUT-OFF RATES FOR FAST BREATHING

Child’s Age Cut-off Rate for Fast
Breathing

2 months up to 12 months 50 breaths per minute or

more

12 months up to 5 years 40 breaths per minute or

more
 LOOK FOR CHEST INDRAWING

 Defined as the inward movement of the bony structure of the

chest wall with inspiration, is a useful indicator of severe
pneumonia.
more specific than “intercostal indrawing”

should only be considered present if it is consistently present in a

calm child.

 Agitation, a blocked nose or breastfeeding can all cause

temporary chest indrawing.
CHEST INDRAWING
LOOK AND LISTEN FOR STRIDOR AND WHEEZE

a harsh noise made when the child inhales

(breathes in).

Children who have stridor when calm have a

substantial risk of obstruction and should
be referred.

Some children with mild croup have stridor

only when crying or agitated.

Sometimes a wheezing noise is heard when

the child exhales (breathes out).
Again:
CLINICAL ASSESSMENT

Three key clinical signs are used to assess a

sick child with cough or difficult breathing:
Respiratory rate, which distinguishes
children who have pneumonia from those
who do not;
Lower chest wall indrawing, which indicates
severe pneumonia; and
Stridor, which indicates those with severe
pneumonia who require hospital admission.
 If wheezing and either fast breathing or chest
indrawing:
 Give a trial of rapid acting inhaled bronchodilator for
up to three times 15-20 mins apart.

Count the breaths and look for chest indrawing again

and then classify
 CLASSIFY COUGH OR DIFFICULT Y BREATHING
SIGNS CLASSIFY AS TREATMENT

 Any general SEVERE PNEUMONIA - Give first dose of an appropriate antibiotic

danger sign or or VERY SEVERE - Give vitamin A
chest indrawing DISEASE - If chest indrawing and wheeze, go directly to treat wheezing
or stridor in a - Treat the child to prevent low blood sugar
calm child - Refer urgently to the hospital

 Fast breathing PNEUMONIA - Give an appropriate antibiotic for 3 days

- If wheezing ( even if disappeared after rapid acting
bronchodilator), give an inhaled bronchodilator for 5 days
- Soothe the throat and relieve the cough with a safe remedy
- If coughing for more than 3 weeks of if having recurrent
wheezing refer for assessment for TB or asthma
- Advise the mother when to return immediately
- Follow up in 2 days
 CLASSIFY COUGH OR DIFFICULT Y BREATHING

SIGNS CLASSIFY AS TREATMENT

 No signs of NO PNEUMONIA - if wheezing ( even if it disappeared after rapid acting

pneumonia or COUGH and COLD bronchodilator), give an inhaled or oral bronchodilator
very severe for 5 days
disease - soothe the throat and relieve the cough with a safety
remedy
- If coughing for more than 30 days refer for assessment
- Advise the mother when to return immediately
- Follow up in days if not improving if treated for
wheeze, follow up in days.
 ANTI B I OTI C FOR PNE UMONI A , MASTOI DAI TI S, OR VE RY SE VE RE
DI SE ASE

 F i r s t l i n e a n t i b iot i c : A M OX I C I LL I N
 S e c o n d l i n e a n t i b i ot ic : C OT R I M OX A Z O LE
AMOXICILLIN COTRIMOXAZOLE
• Give two times daily for 3 days ( pneunonia) • Give two times daily for 3 days ( pneunomia)
• Give three times daily for 5 days ( mastoidaitis) • Give three times daily for 5 days ( mastoiditis)

AGE or WEIGHT ADULT SYRUP TABLET SYRUP

( 500mg) ( 100mg per ml) 80 mg trimethoprim + 400mg 40 mg trimethoprim + 200mg
sulphamethoxazole sulphamethoxazole

2 mos up to 6 mos 1/4 1.5 ml

( 3-5 kg)
1/2 5 ml
6 mos up to 12 mos 1/2 2.5 ml
( 6-9 kg)

12 mos up to 3 yrs 3/4 3.5ml

( 10-14 kg)
1 10 ml
3 yrs up to 5 yrs 1 5ml
( 15-19kg)
 VITAMIN A
Oral SALBUTAMOL FOR WHEEZING
Tr e a t m e nt
G i v e : 1 c a p t o d a y ( D AY 1 )
1 c a p t o m o r r o w ( D AY 2 )
AGE/ WEIGHT Salbutamol Salbutamol suspension 1 cap 2 weeks after day 2
suspension 2mg per 5 ml
2mg per 5 ml ( 3 times a day for 5
( 3 times a day for 5 days) S u p p l em en ta ti o n:
days)
Give one dose in the health center if:
- Child is 6 months of age or older and
- C h i l d h a s n o t r e c e i v e d a d o s e o f Vi t . A i n
2 mos to 11 mos 2.5 ml ½ tab the part 6 months.
( 5 to 9 kg)
VIT A CAPSULE
AGE
100,000 IU 200,000IU
10 kg and above 5 ml 1 tab
6 mos up to 12 months 1

12 mos up to 5 years 1
 SOOTHE THE THROAT AND RELIEVE COUGH WITH A
SAFE REMEDY
 Safe remedies to recommend
- Breastmilk for exclusively breastfed infant
- Calamansi juice

 Harmful remedies to discourage:

- Codeine cough syrup
- Other cough syrup
- Oral and nasal decongestants
 FOLLOW UP CARE

 PNEUMONIA
- C h e c k t h e c h i l d fo r g e n e r a l d a n g e r s i g n s
- A s s e s s t h e c h i l d fo r c o u g h o r d i f fi c u lt b r e a t hi ng

A s k : i s t h e c h i l d b r e a t h i n g s l ow e r ?
i s t h e r e l e s s fe ve r ?
i s t h e c h i l d e a t i n g b e t te r?
T R E AT M E N T:
 I f c h e s t i n d r a w i n g o r a g e n e r a l d a n g e r s i g n , g i ve a d o s e o f s e c o n d l i n e a n t i b io t ic o r I M B e n z y l Pe n i c il li n a n d
G e n t a m i c in . T h e n r e fe r U RG E N T LY t o h o s p it a l.
 I f b r e a t h in g r a t e , fe ve r, a n d e a t i n g a r e t h e s a m e c h a n g e t o t h e s e c o n d l i n e a n t i b iot ic a n d a d v i s e t h e m o t h e r t o
r e t u rn i n 2 d a y s o r r e fe r ( i f w i t h m e a s l e s fo r t h e l a s t t h r e e m o n t h s , r e fe r )
 I f b r e a t h in g s l ow e r, l e s s fe ve r, o r e a t i n g b e t te r, c o m p l e te t h e 3 d a y s o f a n t i b i ot ic t r e a t me n t .
 I f c o u g h i s m o r e t h a n 3 0 d a y s , r e fe r fo r f u r t h e r a s s e s s me nt .
Exercises: Case 1
Lupita is 8 months old. She weighs 6kg. Her temperature is 39 °C. Her
f a t h e r t o l d t h e w o r k e r, “ L u p i t a h a s h a d c o u g h f o r 3 d a y s . S h e i s h a v i n g
t r o u b l e b r e a t h i n g . S h e i s v e r y w e a k . ” T h e h e a l t h w o r k e r s a i d , “ Yo u h a v e
d o n e t h e r i g h t t h i n g t o b r i n g y o u r c h i l d t o d a y. I w i l l e x a m i n e h e r n o w. ”
T he health worker checked for general danger signs. T he mother said,
“ L u p i t a w i l l n o t b r e a s t f e e d . S h e w i l l n o t t a k e a n y o t h e r d r i n k s I o f f e r h e r. ”
Lupita does not v omit ev erything and not had conv ulsions. Lupita is
a b n o r m a l l y s l e e p y. S h e d i d n o t a l o o k a t t h e h e a l t h w o r k e r o r h e r p a r e n t s
when they talked.
T he health worker counted 55 breaths/min. He saw chest indrawing. He
decided Lupita had stridor because he heard a harsh noise when she
breathed in.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Child’s Name:________________Age:_____ Weight______kg. Temperature_______
ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________
Assess(Circle all signs present) Classify

CHECK FOR DANGER SIGNS General Danger

Signs Present?
YES___NO___
NOT ABLE TO DRINK OR BREASTFEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
VOMITS EVERYTHING
CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES____ NO____

•For how long? ______days •Count the breaths in one minute

____breaths per minute. Fast breathing?
•Look for chest indrawing
•Look and listen for stridor
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Child’s Name:________________Age:_____ Weight______kg. Temperature_______
ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________
Assess(Circle all signs present) Classify
CHECK FOR DANGER SIGNS General Danger
Signs Present?
YES_√__NO___
NOT ABLE TO DRINK OR BREASTFEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
VOMITS EVERYTHING
CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES__√__ NO____ Severe
Pneumonia or
•For how long? ____3__days •Count the breaths in one minute Very Severe
__55__breaths per minute. Fast breathing? Disease

•Look for chest indrawing

•Look and listen for stridor

Case 2
Bayani is 6months old. He weighs 5.5k g. His temperature is 38 °C. His
mother said he has had cough for 2 days.
The health worker checked for general danger signs. The mother said
that
Bayani is able to breastfeed . He has not vomited during this illness. He
has
not had convulsions. Bayani is not abnormally sleepy or dif ficult to
awaken.
The health worker said to the mother, “I want to check Bayani’s
cough.
You said he has had cough for 2 days now. I am going to count his
breathes.
He will need to remain calm while I do this.”
The health worker counted 58 breathes/min. He did not see chest
indrawing . He did not hear stridor.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Child’s Name:________________Age:_____ Weight______kg. Temperature_______
ASK:What are the child’s problems?______________Initial Visit_______follow-up visit__________
Assess(Circle all signs present) Classify
CHECK FOR DANGER SIGNS General Danger
Signs Present?
YES___NO__√_
NOT ABLE TO DRINK OR BREASTFEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
VOMITS EVERYTHING
CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING YES_√___ NO____

•For how long? ___2___days •Count the breaths in one minute

Pneumoni
__58__breaths per minute. Fast breathing? a
•Look for chest indrawing
•Look and listen for stridor
DOES THE CHILD HAVE DIARRHEAF COUGH
OR DIFFICULT BREATHING
Diarrhea is the next symptom that should
be routinely checked in every child
brought to the clinic. A child with diarrhea
may have three potentially lethal
conditions:
1.Acute watery diarrhea (including
cholera)
2.Dysentery (bloody diarrhea)
3.Persistent diarrhea (diarrhea that lasts
more than 14 days).
ASSESS AND CLASSIFY DIARRHEA
 Diarrhea occurs when stools contain more water than
normal.
 Defined as 3 or more loose or watery stools in a 24 -
hour period
 It is common in babies under 6months who are
drinking cow’s milk or infant feeding formulas
4.1 Assess Diarrhea
A child with diarrhea is assessed for
a. How long the child has diarrhea
b. Blood in the stool to determine if the child has
dysentery
c. Signs of dehydration
ASK: For how long?
To determine the type of diarrhea
Acute Diarrhea- diarrhea lasts for
less than 14 days

Persistent Diarrhea- diarrhea last

for 14 days or more
ASK: Is there blood in the stool?

Diarrhea with blood in the stool, with or without mucus

is called dysentery

The most common cause of dysentery is SHIGELLA

BACTERIA
Check for signs of dehydration
• Restless and irritable
• Abnormally sleepy or difficult to awaken
• Sunken eyes
• Child is not able to drink or drinking poorly or drinking eagerly , thirsty
• Pinch the skin of the abdomen. Does it goes back: Very slowly(longer
than 2 seconds);
• Slowly
4.2 Classify Diarrhea
• There are three classification tables for classifying diarrhea:

All children with diarrhea are classified for DEHYDRATION

If the child has had diarrhea for 14 days or more, classify the child for
PERSISTENT DIARRHEA

If the child has blood in the stool, classify the child for DYSENTERY.
Classify Diarrhea
Classify Dehydration
Two of the following signs:
•Abnormally sleepy or difficult to awaken
•Sunken eyes SEVERE DEHYDRATION
•Not able to drink or drinking poorly
•Skin pinch goes back very slowly

Two of the following signs

•Restless, irritable
•Sunken eyes SOME DEHYDRATION
•Drinks eagerly, thirsty
•Skin pinch goes back slowly
•Not enough signs to classify as some or severe dehydration NO DEHYDRATION
 If the child has no other severe classification
• Give fluid for severe dehydration (PLAN C) or
SEVERE
DEHYDRATION If the child also has another severe classification
• Refer URGENT to hospital with mother giving frequent sips of ORS on the way
• Advise the mother to continue breastfeeding
• If child is 2 years old or older and there is cholera in your area, give antibiotic for cholera

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

If the child also has another severe classification:
SOME DEHYDRATION  If the child also has another severe classification:
 Refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way.
 Advise the mother when to return immediately
 Follow up in 5 days if not improving

NO DEHYDRATION Give ORS zinc supplements and food to treat diarrhea at home ( PLAN A)
 Advise the mother when to return immediately
 Follow up in 5 days if not improving
Case 1: Joel
Joel has had diarrhea for five days. He has no
blood in the stool. He is irritable. His eyes is
sunken. His father and mother also think that
Joel’s eyes are sunken. The health worker offers
Joel some water, and the child drinks eagerly.
When the health worker pinches the skin on the
child’s abdomen, it goes back slowly.
 Record Joel’s signs of dehydration and classify
DOES THE CHILD HAVE DIARRHEA YES____ NO____ Joel has had diarrhea for five days. He ha
•For how long?______days •Look at the child’s general condition.
•Is there blood in the stool? Is the child:
blood in the stool. He is irritable. His eyes
Abnormally sleepy or difficult sunken. His father and mother also think
to awaken Joel’s eyes are sunken. The health worke
Restless and irritable? Joel some water, and the child drinks ea
•Look for sunken eyes
•Offer the child fluid. Is the child: When the health worker pinches the skin
Not able to drink or drinking poorly? child’s abdomen, it goes back slowly.
Drinking eagerly and thirsty?
•Pinch the skin of the abdomen . Does it
go back :
Very slowly? (longer than 2 seconds)
Slowly?
 Record Joel’s signs of dehydration and classify
DOES THE CHILD HAVE DIARRHEA YES__√_ NO____
•For how long?___5___days •Look at the child’s general condition.
•Is there blood in the stool? Is the child:
Abnormally sleepy or difficult
to awaken
Restless and irritable? Some
•Look for sunken eyes Dehydration

•Offer the child fluid. Is the child:

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

•Pinch the skin of the abdomen . Does it

go back :
Very slowly? (longer than 2 seconds)
Slowly?
 Treat dehydration before referral unless the child has another severe
classification
DEHYDRATION SEVERE Give Vitamin A
PRESENT PERSISTENT Refer to Hospital
DIARRHEA

NO DEHYDRATION  Advise the mother on feeding a child who has persistent diarrhea
 Give Vitamin A
PERSISTENT  Give multivitamins and minerals including Zinc for 14 days
DIARRHEA  Follow up in 5 days
 Advise the mother when to return immediately

IF BLOOD IN STOOL
BLOOD IN DYSENTERY GIVE ORS ZINC SUPPLEMENTS AND FOOD TO TREAT DIARRHEA AT
STOOL HOME ( PLAN A)
 ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY
 FOLLOW UP IN 5 DAYS IF NOT IMPROVING
4.2 Classify Diarrhea
4.2.2 Classify Persistent Diarrhea

• Dehydration present SEVERE PERSISTENT

DIARRHEA

•No dehydration PERSISTENT DIARRHEA

Case 2: Farida
Farida is 14 months old. She weighs 12 k g. Her temperature
is 37.5°C. Farida’s mother said the child has had diarrhea for 3
weeks.
Farida does not have any general danger signs. She does
not have cough or dif ficult breathing.
The health worker assessed her diarrhea. He noted she has
had diarrhea for 21 days. He asked if there had been blood in
the stool. The mother said, “No.” The health worker checked
Farida for signs of dehydration. The child is irritable
throughout the visit. Her eyes are not sunken. The skin pinch
goes
back immediately.
 Record Farida’s signs of and classify Persistent
Diarrhea
DOES THE CHILD HAVE DIARRHEA YES__√__ NO____
•For how long?___21___days •Look at the child’s general condition.
•Is there blood in the stool? Is the child:
Abnormally sleepy or difficult
to awaken
Restless and irritable? Persistent
•Look for sunken eyes
•Offer the child fluid. Is the child: Diarrhea
Not able to drink or drinking poorly?
Drinking eagerly and thirsty?
•Pinch the skin of the abdomen . Does it
go back :
Very slowly? (longer than 2 seconds)
Slowly?
4.2 Classify Diarrhea
4.2.3 Classify Dysentery

• Blood in the stool DYSENTERY

Give Ciprofloxacin for 3 days

Follow up in 2 days
Advise the mother when to return immediately
Case 3: Carlo
Carlo is 10 months old He weighs 8 kg. Her temperature is
38.5 °C. He is here today because he has had diarrhea for 3
days.
Carlo does not have any general danger signs. He does not
have cough or dif ficult breathing.
The health worker assesses the child for diarrhea. “You said
Carlo has had blood in the stool. I will checked for signs of
dehydration.” The child is not abnormally sleepy or dif ficult to awaken.
He is not restless nor irritable. He does not have a sunken eyes. The
child drank normally when of fered some water and does not seem
thirsty. The skin pinch goes back immediately.
 Record Carlo’s signs and classify
DOES THE CHILD HAVE DIARRHEA YES__√__ NO____
•For how long?____3__days
•Look at the child’s general condition.
•Is there blood in the stool? Is the child:
Abnormally sleepy or difficult Dysentery
to awaken
Restless and irritable?
•Look for sunken eyes
•Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly and thirsty?
•Pinch the skin of the abdomen . Does it
go back :
Very slowly? (longer than 2 seconds)
Slowly?