INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

- program based service given by the barangay health services which means it
follows a protocol

 Nursing Responsibility: ACT (Assess, Classify, Treat)

 CHILD – 2 MOS. UP TO 5 YEARS OF AGE

I. ASSESS

 General Danger Signs

 Convulsion
 Unable to drink or breastfeed
 Vomiting all intake
 Abnormally sleepy; difficult to arouse

 Main Symptoms

 Cough or Difficult Breathing

 Ask for how long?
 Count the breaths in one minute check for fast breathing
 2mos to 1yo: 50bpm
 1yo to 5yo: 40bpm
 Look for chest indrawing
 Look & listen for stridor and wheezes (musical sounds)
Check RR if there is fast breathing or chest indrawing

 Diarrhea
 Ask for how long?
 Look at the child’s general condition
 Abnormally sleepy or difficult to awaken?
 Restless or irritable?
 Sunken eyes?
 Offer child fluid (not able to drink or drinking poorly? or eagerly or
thirstily)
 Pinch the skin of the abdomen (color goes back very slowly – longer than 2
seconds; or slowly?
 Is there blood in the stool?

 Fever (temperature of 37.5°C or more) CBQ

 Malaria/Measles
 ASK
 Does the child live in a malaria area?
 Has the child visited 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?
 LOOK & FEEL
 Stiff neck, runny nose
 Signs of measles:
 Generalized rash
 One of these: cough, runny nose, or red eyes
 If the child has measles now or within the last three months:
 LOOK FOR:
 Mouth ulcers; are they deep & extensive?
 Pus draining from the eye
 Clouding of the cornea
  Dengue
 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 abdominal pain?
 Has the child been vomiting?
 LOOK & FEEL
 Look for bleeding from nose or gums
 Look for skin petechiae
 Feel for cold & clammy extremities
 Check for slow capillary refill
 If none of the above ASK or LOOK & FEEL signs are present & the
child is 6 months or older & fever is present for more than three days:
 Perform the tourniquet test

 Ear Problem (CBQ)

 ASK
 Is there ear pain?
 Is there ear discharge?
 If yes, for how long?
 LOOK & FEEL
 Look for pus draining from the ear
 Feel for tender swelling behind the ear

 Check Nutritional Status

 LOOK & FEEL
 Look for visible severe wasting
 Look for edema of both feet
 Look for palmar pallor (severe or some palmar pallor?)
 Determine weight for age

 Check Child’s Immunization Status

 Birth – BCG
 6wks – DPT, OPV, HEPA B (1st dose)
 10wks - DPT, OPV, HEPA B (2nd dose)
 14wks - DPT, OPV, HEPA B (3rd dose)
 9mos – Measles

 Check Vitamin A Status

 First Dose at 6 months or above
 Subsequent doses every 6 months

II. CLASSIFY & TREAT:

 General Danger Signs

 A child with any general signs needs URGENT attention; complete
assessment and any pre-referral treatment is given immediately so referral is
not delayed
 Referral is made after first dose of an appropriate antibiotic or other urgent
treatment
 Exception: Rehydration of the child according to Plan C may resolve danger
signs so that referral is no longer needed
 Cough & Difficult Breathing

CLASSIFICATION SIGNS TREATMENT

SEVERE PNEUMONIA Any of the ff: *Give 1st dose of appropriate antibiotic
OR VERY SEVERE *any danger sign *Give Vit.A regardless of last dose
DISEASE *chest indrawing *Treat child to prevent ↓ bld sugar
*stridor in calm child *Refer urgently to hospital
PNEUMONIA Fast Breathing *Give appropriate antibiotic for 5days
*Soothe the throat & relieve cough w/
a safe remedy
*Advise mother when to return ASAP
*Follow up in 2 days
NO PNEUMONIA; No signs of pneumonia or *If coughing is more than 30days,
COUGH OR COLD severe pneumonia refer for assessment
*Soothe the throat to relieve cough w/
safe remedy
*Advise mother when to return ASAP
*Follow up in 5 days if not improving

 Diarrhea

CLASSIFICATION SIGNS TREATMENT

SEVERE 2 of the ff signs: *If child has no other severe
DEHYDRATION *Abnormally sleepy or difficult classification – give fluid for
to arouse severe dehydration (PLAN C)
*Sunken eyes *If child also has another severe
*Not able to drink or drinking classification – refer urgently to
poorly hospital with mother giving
*Skin pinch goes back very frequent sips of ORS on the way;
slowly advise mother to continue breast-
feeding
*If child is 2yo or older & there is
cholera in your area, give
antibiotic for cholera
SOME 2 of the ff signs: *Give fluid & food for some
DEHYDRATION *Restless, irritable dehydration (PLAN B)
*Sunken eyes *If child also has a severe
*Drinks eagerly, thirstily classification – refer urgently to
*Skin pinch goes back slowly hospital with mother giving
frequent sips of ORS on the way;
advise mother to continue breast-
feeding
*Advise mother when to return
immediately
*Follow up in 5 days if not
improving
NO DEHYDRATION Not enough signs to classify as *Give fluid & food to treat
some or severe dehydration diarrhea at home (PLAN A)
*Advise mother when to return
immediately
*Follow up in 5 days if not
improving
SEVERE Diarrhea is 14 days or more *Treat dehydration before referral
PERSISTENT Dehydration is present unless child has another severe
DIARRHEA classification
*Give Vit.A if not given in the
last 30days
*Refer to hospital
PERSISTENT Diarrhea is 14 days or more *Advise the mother on feeding a
DIARRHEA No dehydration child who has persistent diarrhea
*Give Vit.A if not given in the
last 30days
*Follow up in 5 days
*Advise when to return
immediately
DYSENTERY Blood in the stool *Treat for 5 days with an oral
antibiotic for Shigella in your
area
*Follow up in 2 days
 *Advise when to return
immediately

 Fever

Malaria Risk
CLASSIFY SIGNS TREATMENT
VERY SEVERE Any general danger sign or *Give 1st dose of quinine (under
FEBRILE DISEASE/ Stiff neck medical supervision or if a
MALARIA hospital is not accessible within 4
hours)
*Give first dose of an appropriate
antibiotic
*Treat the child to prevent low
blood sugar
*Give one dose of paracetamol in
health center for high fever
(38.5°C or above)
*Send blood smear with the
patient
*Refer urgently to the hospital
MALARIA Blood smear (+) *Treat the child with an oral
If blood smear is not done: antimalarial
NO runny nose & *Give one dose of paracetamol in
NO measles & health center for high fever
NO other cause of fever (38.5°C or above)
*Advise mother when to return
-pt has fever but no signs of immediately
runny nose, no measles, or any *Follow up in 2 days if fever
other cause of fever persists
*If fever is present every day for
more than 7 days, refer for
assessment
FEVER; MALARIA Blood smear (-) or *Give one dose of paracetamol in
UNLIKELY Runny nose or health center for high fever
Measles or (38.5°C of above)
Other causes of fever *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
*Treat other causes of fever

No Malaria Risk
CLASSIFY SIGNS TREATMENT
VERY SEVERE Any general danger signs or *Give first dose of an appropriate
FEBRILE DISEASE Stiff neck antibiotic
*Treat the child to prevent low
blood sugar
*Give one dose of paracetamol in
health center for high fever
(38.5°C of above)
*Refer urgently to hospital
FEVER; NO No signs of very severe febrile * Give one dose of paracetamol
MALARIA disease in health center for high fever
(38.5°C of 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
 If measles now or within last 3 months
CLASSIFY SIGNS TREATMENT
SEVERE Clouding of cornea or *Give Vit.A regardless of the
COMPLICATED Deep or extensive mouth ulcers previous dose
MEASLES *Give 1st dose of an appropriate
w/ danger signs antibiotic
measles in the past 3 months *If clouding of the cornea or pus
draining from the eye, apply
tetracycline eye ointment
*If fever is present every day for
more than 7 days, refer for
assessment
MEASLES WITH Pus draining from eye or *Give Vit.A regardless of the
EYE OR MOUTH Mouth ulcers previous dose
COMPLICATIONS *If pus draining from the eye,
apply tetracycline eye ointment
*If with mouth ulcers, teach the
mother to treat with gentian
violet
*Follow up in 2 days
*Advise mother when to return
immediately
MEASLES Measles now or within the last 3 *Give Vit.A regardless of the
months previous dose
*Advise mother when to return
-just rashes immediately

Dengue Risk
CLASSIFY SIGNS TREATMENT
SEVERE DENGUE Bleeding from nose or gums or *If vomiting or abdominal pain or
HEMORRHAGIC Bleeding in stools or vomitus or skin petechiae or (+) tourniquet
FEVER Black stools or vomitus or test are the only positive signs;
Skin petechiae or give ORS as in Plan B
Cold & clammy extremities or *If any other signs are positive,
Capillary refill >3sec or give fluids rapidly as in Plan C
Abdominal pain or *Treat the child to prevent low
Vomiting or blood sugar
Tourniquet test (+) *Refer urgently to hospital
*Do not give ASPIRIN
FEVER: DENGUE No signs of severe dengue *Advise mother when to return
HEMORRHAGIC hemorrhagic fever immediately
FEVER UNLIKELY *Follow up in 2 days if fever
persists or child shows signs of
bleeding
*Do not give aspirin

 Ear Problem

CLASSIFICATION SIGNS TREATMENT

MASTOIDITIS Tender swelling behind the ear *Give 1st dose of an appropriate
antibiotic
*Give 1st dose of paracetamol for
pain
*Refer urgently to hospital
ACUTE EAR Pus is seen draining from the ear *Give antibiotic for 5 days
INFECTION & discharge is reported for less *Give paracetamol for pain
than 14 days or *Dry the ear by wicking
Ear pain *Follow up in 5 days; advise
when to report immediately
CHRONIC EAR Pus is seen draining from the ear *Dry the ear by wicking
INFECTION & discharge is reported for 14 *Follow up in 5 days
days or more *Advise when to return
immediately
NO EAR INFECTION No ear pain & no pus seen *No additional treatment
draining from the ear *Advise mother when to report
immediately
  Malnutrition & Anemia
MUAC = mid arms, upper arms, circumference[less than 110]

CLASSIFICATION SIGNS TREATMENT

SEVERE Visible severe wasting or *Give Vit.A if not given in the
MALNUTRITION OR Edema of both feet or last 30 days
SEVERE ANEMIA Severe palmar pallor *Refer urgently to hospital
ANEMIA OR VERY Some palmar pallor or *Assess the child’s feeding &
LOW WEIGHT Very low weight for age counsel the mother on feeding
according to the FOOD box on
the COUNSEL THE MOTHER
chart
-If feeding is a problem, follow
up in 5 days
*If some pallor:
- Give iron
- Give mebendazole if child is 2
years or older & has not had a
dose in the previous 6 mos.
-Follow up in 14 days
*If very low weight for age:
- Give Vit.A if not given in the
last 30 days
- Follow up in 30 days
- Advise mother when to return
immediately
NO ANEMIA & NOT Not very low weight for age & no *If the child is less than 2yo,
VERY LOW WEIGHT other signs of malnutrition assess the child’s feeding &
counsel the mother on feeding
according to the FOOD box on
the COUNSEL THE MOTHER
chart
- If feeding is a problem, follow
up in 5 days
*Advise mother when to return
immediately

TREAT THE CHILD

Carry out the Treatment Steps in the Classification Chart

 TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

 Determine the appropriate drugs & dosage for the child’s age or weight
 Tell the mother the reason for giving the drug to the child
 Demonstrate how to measure a dose
 Watch the mother practice measuring a dose by herself
 Ask the mother to give the first dose to her child
 Explain carefully how to give the drug, then label & package the drug
 If more than one drug will be given, collect, count & package each drug separately
 Explain that all the oral drug tablets or syrups must be used to finish the
course of treatment, even if the child gets better
 Check the mother’s understanding before she leaves the health center
 GIVE AN APPROPRIATE ORAL ANTIBIOTIC

For (1) Very Severe Disease, (2)Acute Ear Infection, (3) Mastoiditis
(4) Pneumonia

1st Line Antibiotic: AMOXYCILLIN

2nd Line Antibiotic: COTRIMOXAZOLE

COTRIMOXAZOLE AMOXYCILLIN
(Trimethroprim+sulphamethoxazone) Give 3x daily for 5days
Give 2x daily for 5days
AGE or WEIGHT Adult Tablet Tablet 250mg
- 80mg Trimethroprim Syrup 125mg per 5ml
- 400mg Sulphamethoxazone
Syrup
- 40mg Trimethroprim
- 200mg Sulphamethoxazone /5ml
2mos – 12 mos Adult Tablet: ½ Tablet: ½
(4 - <10kg) Syrup: 5ml Syrup: 5ml
12 mos – 5yo Adult Tablet: 1 Tablet: 1
(10-19kg) Syrup: 10ml Syrup: 10ml

For Dysentery
Give antibiotic recommended for Shigella in the area for 5 days
1st Line Antibiotic: CIPROFLOXACIN

Ciprofloxacin
Give 2x daily for 3 days
AGE or WEIGHT
2-4mos (4 -<6kg) See doses above
4-12mos (6 -<10kg) “ “ “
12mos – 5yo (10-19kg) “ “ “

For Cholera
Give antibiotic recommended for Cholera in the area for 3 days
1st Line Antibiotic: Tetracycline
2nd Line Antibiotic: Erythromycin
TETRACYCLINE
Give 4x daily for 3days
AGE or WEIGHT Capsule 250mg
2-4mos (4 -<6kg) Not recommended
4-12mos (6 -<10kg) ¼
12mos – 5yo (10-19kg) ½ “ “ “

 GIVE AN ORAL ANTIMALARIAL

1st Line Antimalarial: Artemeter –Lumefantrine high fat diet
2nd Line – CHLOROQUINE & PRIMAQUINE,
SULFADOXINE & PYRIMETHAMINE (single dose at health center
2 hours give chloroquine)

 If Chloroquine/Primaquine
 Explain to the mother that she should watch her child carefully for
30minutes after giving a dose of Chloroquine; if the child vomits within
30minutes, she should repeat the dose & return to the health center for
additional tablets
 Explain that itching is a possible side effect of the drug but it is not
dangerous.
 If Sulfadoxine/Pyrimethamine – give single dose in health center; well tolerared
w/in recommended dose;
 AGE CHLOROQUINE PRIMAQUINE PRIMAQUINE SULFADOXINE+
Give for 3days Give single dose Give daily for 14 PYRIMETHAMINE
(DAY 1, 2, 3) in health center of days for P. Vivax DAY 1
Tablet 150mg base P. Falciparum Tablet 15mg base Give single dose in
Tablet 15mg base DAY 4 health center
DAY 4 Tablet
Sulfadoxine 500mg
Pyrimethamine 25mg
2-5mos ½ tab per day ¼
5-12mos ½ tab per day ½
1-3yo 1tab (day 1&2); ½ ¼ ¾
½ tab (day 3)
3-5yo ½ tab (day 1&2); ¾ ½ 1
1tab (day 3)

Chloroquine for pregnant women with malaria.

Sulfadoxine

 GIVE VITAMIN A
 Treatment: Give one dose in the health center
 Supplementation: Give one dose
 As supplementation, give one dose in health center if:
 Child is six months of age or older &
 Child has not received a dose of Vit.A in the past nine months

AGE VITAMIN A CAPSULE

200,000 IU
6mos up to 12 mos ½ capsule
12 months up to 5yo 1 capsule

 GIVE PARACETAMOL FOR HIGH FEVER (38.5°C OR MORE) & EAR PAIN
 Give paracetamol every 6hours until high fever or ear pain is gone

AGE or WEIGHT TABLET (500mg) SYRUP (120mg/5ml)

2mos – 3yo (4-<14kg) ¼ 5ml (1tsp)
3yo – 5yo (14-19kg) ½ 10ml (2tsps)

 GIVE IRON
 Give one dose daily for 14 days

AGE or WEIGHT IRON/FOLATE TABLET IRON SYRUP

Ferrous SO4 200mg + Ferrous SO4 150mg per 5ml
250mcg Folate (6mg elemental iron per ml)
(60mg elemental iron)
2-4mos (4-<6kg) 2.5ml (1/2 tsp)
4-12mos (6-<10kg) 4ml (3/4 tsp)
1-3yo (10-<14kg) ½ 5ml (1 tsp)
3-5yo (14-19kg) 1 tablet 7.5ml (1½ tsp)

 GIVE MEBENDAZOLE/ALBENDAZOLE
 Give 500mg Mebendazole as a single dose in health center if:
 Hookworm/whipworm are a problem in children in the area &
 The child is 2yo or older &
 The child has not had a dose in the previous 6 months

 TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

 Explain to the mother what the treatment is & why it should be given
 Describe the treatment steps
 Watch the mother as she does the first treatment in the health center (except remedy
for cough or sore throat)
  Tell her how often to do the treatment at home
 If needed for treatment at home; give mother the tube of tetracycline ointment or a
small bottle of gentian violet
 Check the mother’s understanding before she leaves the health center

 TREAT EYE INFECTION WITH TETRACYCLINE OINTMENT

 Clean both eyes 3 times daily
 Wash hands
 Ask child to close eyes
 Use clean cloth & water to gently wipe away pus
 Then apply tetracycline eye ointment in both eyes 3 times daily
 Ask the child to look up
 Squirt a small amount of ointment on the inside of the lower lid
 Wash hands again
 Treat until redness is gone
 Do not use other eye ointments or drops or put anything else in the eye

 DRY THE EAR BY WICKING

 Dry the ear at least 3 times daily
 Roll clean absorbent cloth or soft, strong tissue paper into a wick
 Place the wick in the child’s ear
 Remove the wick when wet
 Replace the wick with a clean one & repeat these steps until the ear is dry

 TREAT MOUTH ULCERS WITH GENTIAN VIOLET

 Treat the mouth ulcers twice daily
 Wash hands
 Wash the child’s mouth with clean soft cloth wrapped around the finger &
wet with salt water
 Paint the mouth with half-strength gentian violet
 Wash hands again

 SOOTHE THE THROAT, RELIEVE COUGH WITH A SAFE REMEDY

 Safe remedies to recommend:
 Breastmilk for exclusively breastfed infant
 Tamarind, Calamansi & Ginger
 Harmful remedies to discourage:
 Codeine Cough Syrup
 Other Cough Syrups
 Oral & Nasal Decongestants

 GIVE THESE TREATMENTS IN HEALTH CENTER ONLY

 Explain to the mother why the drug is given
 Determine the dose appropriate for the child’s weight (or age)
 Use a sterile needle & sterile syringe; measure the dose accurately
 Give the drug as an IM injection
 If the child cannot be referred, follow the instructions provided

 GIVE AN INTRAMUSCULAR ANTIBIOTIC

 For children being referred urgently who cannot take an oral antibiotic, give
first dose of the IM Chloramphenicol & refer child urgently to hospital
 If referral is not possible:
 Repeat the Chloramphenicol injection every 12 hours for 5days
 Then change to an appropriate oral antibiotic to complete 10 days of
treatment

AGE OR WEIGHT CHLORAMPHENICOL

Dose: 40mg per kg
Add 5.0ml sterile water to vial containing
 1000mg = 5.6ml at 180mg/ml
2-4mos (4-<6kg) 1.0ml = 180mg
4-9mos (6-<8kg) 1.5ml = 270mg
9-12mos (8-<10kg) 2ml = 360mg
1-3yo (10-<14kg) 2.5ml =450mg
3-5yo (10-19kg) 3.5ml = 630mg

 GIVE QUINIE FOR SEVERE MALARIA

 For children being referred with very severe febrile disease/malaria, give first
does of IM Quinine & refer child urgently to hospital
 If referral is not possible:
 Give first dose of IM Quinine
 The child should remain lying down for one hour
 Repeat the Quinine injection at 4 & 8 hours later, & then every 12 hours
until the child is able to take an oral antimalarial; do not continue Quinine
injection for more than 1 week
 Do not give Quinine to a child less than 4 mos of age

AGE OR WEIGHT INTRAMUSCULAR QUININE

300mg/ml (in 2ml ampule)
4-12mos (6-<10kg) 0.3ml
1-2yo (10-<12kg) 0.4ml
2-3yo (12-<14kg) 0.5ml
3-5yo (14-19kg) 0.6ml

 TREAT THE CHILD TO PREVENT LOW BLOOD SUGAR

 If the child is able to breastfeed
 Ask the mother to breastfeed the child
 If the child is not able to breastfeed but is able to swallow
 Give expressed breastmilk or a breastmilk substitute
 If neither of these is available, give sugar water
 To make sugar water: Dissolve 4 level tsps of sugar (20grams) in a 200ml cup
of clean water
 If the child is not able to swallow
 Give 50ml of milk or sugar water by nasogastric tube

 GIVE EXTRA FLUID FOR DIARRHEA & CONTINUE FEEDING

 PLAN A: TREAT DIARRHEA AT HOME

 Counsel the mother on the 4 Rules on Home Treatment:
 Give extra fluid (as much as the child will take)
 Tell the mother
- Breastfeed frequently & for longer at each feed
- If the child is exclusively breastfed, give ORS or clean water in addition
to breastmilk
- If the child is not exclusively breastfed, give one or more of the ORS
solution, food-based fluid (such as soup, rice water, or “buko juice”) or
clean water
- 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 health center if the diarrhea gets worst
 Teach the mother how to mix & give ORS; give the mother 2 packets of
ORS to usual fluid intake
 Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g;
Glucose 20 g
 Homemade ORS: 1 glass of water, 1 pinch of salt and 2 tsp of sugar
1 liter of water, 2 tsp of salt; 8 tsp sugar
 Show the mother how much fluid to give in addition to the usual fluid
intake:
- Up to 2yo: 50-100ml after each loose stool
 - 2yo or more: 100-200ml after each loose stool
- Tell the mother to:
* Give frequent small sips from a cup
* If the child vomits, wait 10minutes, then continue but more slowly
* Continue to give extra fluid until the diarrhea stops

 Continue feeding (see Counsel for the Mother)

 When to return ( -same - )

 PLAN B: TREAT SOME DEHYDRATION WITH ORS

 Give in health center recommended amount of ORS over a 4-hour period
 Determine amount of ORS to give during first 4 hours

AGE Up to 4mos 4-12mos 1-2yo 2-5yo

WEIGHT <6kg 6-<10kg 10-<12kg 12-19kg
In ml 200-400 400-700 700-900 900-1400
*Use the child’s age only when you do not know the weight; this approximate
amount of ORS required (in ml) can also be calculated by multiplying the child
weight (in kg) x 75
*If the child wants more ORS than shown, give more
*For infants under 6mos who are not breastfed, also give 100-200ml clean water
during this period
 Show the mother how to give ORS solution
 Give frequent small sips from a cup
 If the child vomits, wait 10minutes; then continue, but more slowly
 Continue breastfeeding whenever the child wants
 After 4 hours:
 Reassess the child & classify the child for dehydration
 Select the appropriate plan to continue treatment
 Begin feeding the child in health center
 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 4hour treatment at home
 Give her enough ORS packets to complete rehydration; also give 2 packets
as recommended in Plan A
 Explain 4 Rules of Home Treatment
 Continue with Plan A treatment plan

 PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

 Ask the following questions:

 Can you give IV fluid immediately?

 IF YES
- Start IV fluid immediately
- If the child can drink, give ORS by mouth while the drip is set up
- Give 100 ml/kg Ringer’s Lactate Solution (or if not available, normal
saline) divided as follows:

AGE FIRST GIVE 30ML/KG IN: THEN GIVE 70ML/KG IN:

Infants (under 12mos) 1 hour* 5 hours
1-5yo 30 minutes* 2 ½ hours
*Repeat once if radial pulse is still very weak or not detectable
- Reassess the child every 1-2hours; if hydration status is not improving,
give the IV drip more rapidly
- Also give ORS (about 5ml/kg/hour) as soon as the child can drink;
usually after 3-4hours (infants) or 1-2hours (children)
- Reassess an infant after 6 hours & a child after 3 hours; classify
dehydration then choose the appropriate plan (A,B,C) to continue the
treatment

 IF NO, ASK THE NEXT QUESTION

  Is IV treatment available nearby (within 30 minutes)?

 IF YES
- Refer urgently to hospital for IV treatment
- If the child can drink, provide the mother with ORS solution & show her
how to give frequent sips during the trip

 IF NO, ASK THE NEXT QUESTION

 Are you trained to use a nasogastric (NG) tube for rehydration?

 IF YES
- Start rehydration by tube with ORS solution: give 20ml/kg/hour for 6
hours (total of 120ml/kg)
- Reassess the child every 1-2 hours:
* If there is repeated vomiting or increasing abdominal distention, give
the fluid more slowly
* If 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,C) to continue treatment

 IF NO, ASK THE NEXT QUESTION

 Can the child drink?

 IF YES
- Start rehydration by mouth with ORS solution: give 20ml/kg/hour for 6
hours (total of 120ml/kg)
- Reassess the child every 1-2 hours:
* If there is repeated vomiting or increasing abdominal distention, give
the fluid more slowly
* If 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,C) to continue treatment

 IF NO
- Refer urgently to the hospital for IV or NG tube treatment

NOTE: If possible, observe the child at least 6 hours after rehydration to be

sure the mother can maintain hydration giving the child ORS solution by
mouth

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up

 PNEUMONIA
 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?
 Treatment:
 If with chest indrawing or a general danger sign: give a dose of second-line
antibiotic or IM Chloramphenicol; then refer urgently to the hospital
 If breathing rate, fever & eating are the same: change to the second-line
antibiotic & advise mother to return in 2 days or refer if the child had measles
within the last 3 mos
  If breathing is slower, fever is less & eating is better: complete the 5 days of
antibiotic

 PERSISTENT DIARRHEA
 After 5 days:
 Ask:
 Has the diarrhea stopped?
 How many loose stools is the child having per day?
 Treatment:
 If the diarrhea has not stopped (child is still having 3 or more loose stools per
day): do a full reassessment of the child; give any treatment needed; then refer
to hospital
 If the diarrhea has stopped (child is having less than 3 loose stools per day): tell
the mother to follow the usual feeding recommendation for the child’s age

 DYSENTERY
 After 2 days:
 Assess the child for diarrhea
 Ask:
 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?
 Treatment:
 If the child is dehydrated, treat dehydration
 If number of stools, amount of blood in stools, fever, abdominal pain or eating
is the same or worse:
 Change to second-line oral antibiotic recommended for Shigella in the area;
give it for 5 days; advise mother to return in 2 days
 Exceptions if the child:
- Is less than 12 months old, or
- Was dehydrated on the first visit, or
- Had measles within the last 3 months
* Refer to hospital
 If fewer stools, less blood in the stools, less fever, less abdominal pain & eating
better: continue giving the same antibiotic until finished

 MALARIA
 If fever persists after 2 days, or returns within 14 days:
 Do a full assessment of the child
 Assess for other causes of fever
 Treatment:
 If the child has any general danger signs or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE/MALARIA
 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
 If 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

 FEVER-MALARIA UNLIKELY
 If fever persists after 2 days:
 Do a full reassessment of the child
 Assess for other causes of fever
 Treatment:
 If the child has any general danger sign or stiff neck, treat as VERY SEVERE
FEBRILE DISEASE/MALARIA
  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 first-line oral antimalarial
 Advise mother to return again in 2 days if fever persists
 If fever has been present for 7 days, refer for assessment

 FEVER (NO MALARIA)

 If fever persists after 2 days:
 Do a full reassessment of the child
 Make sure that there has been no travel to malarious area
 If there has been travel, take blood smear if possible
 Treatment:
 If there has been travel to a malarious area & the blood smear is positive or
there is no blood smear – classify according to fever with malaria risk & treat
accordingly
 If there has been no travel to malarious area or blood smear is negative:
 If child has any general danger signs or stiff neck: treat as VERY SEVERE
FEBRILE DISEASE/MALARIA
 If the child has any apparent cause of fever: provide treatment
 If there is no apparent cause of fever: advise mother to return again in 2 days
if fever persists
 If fever has been present for 7 days, refer for assessment

 MEASLES WITH EYE OR MOUTH COMPLICATIONS

 After 2 days:
 Look for red eyes & 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 the hospital
 If treatment has not been correct, teach the mother the correct treatment
 If the pus is gone & redness remains, continue the treatment
 If pus & redness is gone, stop the treatment
 Treatment for Mouth Ulcers:
 If mouth ulcers are worse, or there is a very foul smell of the mouth, refer to the
hospital
 If mouth ulcers are the same or better, continue using half-strength gentian
violet for a total of 5 days

 FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

 If fever persists after 2 days:
 Do a full reassessment of the child
 Assess for other causes of fever
 Treatment:
 If the child has any signs of bleeding, including petechiae or a positive
tourniquet test, or signs of shock or abdominal pain or vomiting: treat as
SEVERE DENGUE HEMORRHAGIC FEVER
 If the child has any other apparent cause of fever, provide treatment
 If fever has been present for 7 days, refer for assessment
 If there is no apparent cause of fever, advise the mother to return daily until
child has had no fever for at least 48 hours
 Advise mother to make sure child is given more fluids & is eating

 EAR INFECTION
 After 5 days:
 Reassess for ear problem
 Obtain child’s temperature
 Treatment:
  If there is tender swelling behind the ear or high fever, treat as Mastoiditis
 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
 Chronic ear infection: check that the mother is wicking the ear correctly;
encourage her to continue
 If no ear pain or discharge: praise the mother for her careful treatment; if she
has not yet finished the 5-day antibiotics, tell her to use all of it before stopping

 FEEDING PROBLEM
 After 5 days:
 Reassess feeding
 Ask about any feeding problems 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 weigh for age, ask the mother to return in 30 days after
the initial visit to measure the child’s weight gain

 ANEMIA
 After 14 days:
 Give iron; advise mother to return in 14 days for more iron
 Continue giving iron every day for 2 months with follow up every 14 days
 If the child has any palmar pallor after 2 months, refer for reassessment

 VERY LOW WEIGHT

 After 30 days:
 Weigh the child & determine if the child is still very low weight for age
 Reassess feeding
 Treatment:
 If the child is no longer very low weight for age, praise the mother & encourage
her to continue
 If the child is still very low weight for age, counsel the mother about any
feeding problems found; continue to see the child monthly until the child is
feeding well & gaining weight regularly or is no longer very low weight for age
 Exception: if you do not think that feeding will improve or if the child has lost
weight, refer the child

COUNSEL THE MOTHER

 FOOD

 ASSESS THE CHILD’S FEEDING

 Ask questions about the child’s usual feeding & feeding during this illness
 Compare the mother’s answers to the “Feeding Recommendations” for the
child’s age
 Ask:
 Do you breastfeed your child?
 How many times during the day?
 Do you also breastfeed during the night?
 Does the child take any other food?
 What food or fluids?
 How many times per day?
 What do you use to feed the child?
 If very low weight for age: How large are the servings? Does the child
receive his own serving? Who feeds the child & how?
 During this illness, has the child’s feeding changed? If yes, how?
 FEEDING RECOMMENDATIONS DURING SICKNESS & HEALTH

 Up to 4 months of age
 Breastfeed as often as the child wants, day & night, at least 8x in 24 hours
 Do not give other foods or fluids

 4 to 6 months
 Breastfeed as often as the child wants, day or night, at least 8x in 24 hours
 If the child shows interest in semisolid foods or appears hungry after
breastfeeding or is not gaining weight adequately:
 Give small amount of lugaw with added oil, mashed vegetables or beans,
steamed tokwa, flaked fish, pulverized roasted dilis, finely-ground meat,
eggyolk, mashed ripe fruit like banana, mango, avocado
 Give these foods 1 or 2 times per day after breastfeeding

 6 to 12 months
 Breastfeed as often as the child wants
 Give adequate amount of lugaw with added oil, mashed vegetables or beans,
steamed tokwa, flaked fish, pulverized roasted dilis, finely-ground meat,
eggyolk, bite-sized fruits
 Give these foods 3x per day if breastfed & 5x per day if not breastfed
 Feed the baby nutritious snacks like taho & fruits

 1 to 2 yo
 Breastfeed as often as the child wants
 Give adequate amount of family foods or give rice, camote, potato, fish,
chicken, meat, mongo, steamed tokwa, pulverized roasted dilis, milk &
eggs, dark green leafy & yellow vegetables (malunggay, squash); add oil &
margarine
 Give these foods 5x per day
 Feed the baby nutritious snacks like fruits

 2yo & older

 Give adequate amount of family foods at 3 meals each day
 Twice daily, give nutritious foods between meals such as boiled yellow
camote, boiled yellow corn, peanuts, boiled saba banana, taho, fruits, fruit
juices

 Feeding Recommendations for a Child with Persistent Diarrhea

 If still breastfeeding, give more frequent, longer breastfeeds, day & night
 If taking other milk such as milk supplements:
 Replace with increased breastfeeding or
 Replace half the milk with nutrient-rich semi-solid food
 Do not use condensed or evaporated milk
 For other foods, follow feeding recommendation for the child’s age

 FEEDING PROBLEMS

 If the mother reports difficulty with breastfeeding, assess breastfeeding; as

needed, show the mother correct positioning & attachment for breastfeeding

 If the child is less than 4mos old & is taking other milk or foods:
 Build mother’s confidence that she can produce all the breastmilk that the
child needs
 Suggest giving more frequent, longer breastfeeds, day & night & gradually
reducing other milk or foods
 If other milk needs are to be continued, counsel the mother to:
 Breastfeed as much as possible, including at night
 Make sure that other milk is a locally appropriate breastmilk substitute,
give only when necessary
 Make sure that other milk is correctly & hygienically prepared & given in
adequate amounts
  Prepare only an amount of milk which the child can consume within an
hour; if there is some left-over milk, discard

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

 Recommend substituting the bottle for a cup
 Show the mother how to feed the child with a cup

 If the child is not being fed actively, counsel the mother to:
 Sit with the child & encourage eating
 Give the child an adequate serving in a separate plate or bowl
 Observe what the child likes & consider these in the preparation of his/her
food

 If the child is not feeding well during illness, counsel the mother to:
 Breastfeed more frequently & for longer periods if possible
 Use soft, varied, appetizing, favorite foods to encourage the child to eat as
much as possible & offer frequent small feedings
 Clear a blocked nose if it interferes with feeding
 Expect that appetite will improve as child gets better

 Follow up any feeding problems in 5 days

 FLUID

 FOR ANY SICK CHILD:

 Breastfeed more frequently & for longer periods at each feeding
 Increase fluids (ex: give soup, rice water, buko juice, clean water)

 FOR CHILD WITH DIARRHEA:

 Giving extra fluid can be life-saving; give fluid according to Plan A or B

 WHEN TO RETURN

 FOLLOW UP VISITS

If the child has Return for follow up in:

Pneumonia
Dysentery
Malaria, if fever persists
Fever-Malaria Unlikely, if fever persists 2 days
Fever-No Malaria, if fever persists
Measles with Eye or Mouth Complications
Dengue Hemorrhagic Fever Unlikely, if fever persists
Persistent Diarrhea
Acute Ear Infection
Chronic Ear Infection 5 days
Feeding Problem
Any other illness, if not improving
Anemia 14 days
Very Low Weight for Age 30 days

 RETURN IMMEDIATELY

Any sick child *Not being able to drink or breastfeed

*Becomes sicker
*Develops a fever
If child has NO PNEUMONIA, COUGH, OR *Fast breathing
COLD, also return if: *Difficult breathing
If child has DIARRHEA, also return if: *Blood in the stool
*Drinking poorly
If child has FEVER, DENGUE *Any sign of bleeding
HEMORRHAGIC FEVER UNLIKELY, also *Abdominal pain
return if: *Vomiting

 ABOUT 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 & health
 Check the mother’s immunization status & give her Tetanus Toxoid if needed
 Make sure she has access to family planning & counseling on STD & AIDS
prevention