 Serves as a nutritional assessment tool for

case management of sick children seeking

services at the health center
 Used for: Management of sick young infant
 Aged 1 week to 2 months
 Aged 2 months to 5 years
 Develop by WHO in collaboration with
UNICEF and other agencies in mid 1990
 OBJECTIVES:
 Reduce death and frequency and severity of
illness
 Improved growth and development
 THREE COMPONENTS
 Upgrade case management and counseling skills
of health care provider
 Strengthen the health system for effective
management
 Improve family and community practices related
to child health and nutrition
 Six Childhood Illnesses
 Malnutrition
 Pneumonia
 Diarrhea
 Measles
 Dengue Hemorrhagic Fever
 Malaria
 A. ASSESS
 Check for dangers signs
 Assess questions about common condition
 Check nutrition and immunization status
 Check for other problems
 B. CLASSIFY
 Making decision as to the severity of the disease
 Use color coded triage system
 PINK – urgent, pre-referral treatment and referral
 YELLOW – specific medical treatment and advice
 GREEN – simple advice on home management
 C. IDENTIFY SPECIFIC TREATMENT
 Urgent referral
 Give essential treatment before transfer
 Treatment at home
 Develop integrated treatment plan
 Give first dose of drug
 If child is to be immunized, give immunization
 D. PROVIDE PRACTICAL TREATMENT
 Teach care taker how to:
 Give oral drugs
 Feed and give fluids during illness
 Treat local infection at home
 Recognized signs to return child immediately to the health
facility
 Return child for follow up on
 E. COUNSEL
 Tosolve any feeding problem
 Mother about own health
 FOLLOW-UP
 Give follow-up care
 Re-asses for new problem if necessary
 All sick must be examined for “general
danger signs”  which indicates the need for
immediate referral or admission to the
hospital
1. All sick child must be routinely assessed for
major symptoms.
- children 1 week – 2 months  bacterial
infection and cough
- children 2 months – 5 years  cough, DOB,
diarrhea, fever, ear problem
2. Only a limited number of carefully selected
clinical signs are used  based on evidence of
their sensitivity and specificity to detect
disease

3. A combination of individual sign leads to

classification rather than diagnosis

4. Guidelines address most, but not all of the

major reasons a sick child is brought to the
clinic
5. Management procedures use limited number
of essential drugs and encourage active
participation of caretaker in the treatment

6. An essential component of IMCI guideline is

the counseling of caretakers about home
management
 OUT PATIENT HEALTH FACILITY
CHECK FOR DANGER SIGNS

Convulsion Lethargy/unconsciousness Inability to drink/breastfeed

Vomiting
ASSESS MAIN SYMPTOMS
Cough DOB Diarrhea Fever Ear Problem

ASSESS NUTRITIONAL & IMMUNIZATION STATUS AND POTENTIAL

FEEDING PROBLEM

CHECK FOR OTHER PROBLEMS

CLASSIFY CONDITION AND IDENTIFY TREATMENT

 PINK YELLOW GREEN
Urgent Referral Treatment at Out Home Management
Patient facility
OUT PATIENT HEALTH OUT PATIENT HEALTH HOME
FACILITY FACILITY Caretaker is counseled
Pre-referral treatment Treat local infection on:
Advise Parent Give oral drugs When to refer child
Refer child Advise and teach care Home treatment
REFERRAL Facility taker When to return
Emergency Triage and Follow-up immediately
treatment Follow - up
Diagnosis
Treatment
Monitoring and Follow-
up
 ASK: What are the child’s problem?
 Greet mother appropriately
 Reassure the mother the child will receive good
care
 Listen to what the mother tells
 Use word that the mother understand
 Give mother time to answer
 Ask additional questions when mother is not sure
about the answer
 Check ALL sick children for danger signs
 Not able to drink or breastfed
 Vomits everything
 Has convulsion
 Abnormally sleepy or difficult to awaken
A child with ANY danger sign has serious problem
and needs URGENT referral to hospital
 ASK: Is the child not able to drink or breastfeed?
 Too
weak to drink and is not able to suck or swallow
when offered milk
  If
not sure  ask mother to offer child a drink
LOOK to see child’s response

 ASK: Does the child vomit everything?

A child is not able to hold anything down

 ASK: Has the child had convulsion?

 LOOK: See if the child is abnormally sleepy
or difficult to awaken
 Abnormally sleepy child  drowsy and does not
show interest in what is happening around
 Does not look at mother or watch face when you
talk
 Stare blankly and does not notice what is going
around
 Does not respond when touched, shaken or
spoken to.
 A child with cough or difficult breathing may have pneumonia
or another severe respiratory infection
 Identify all cases of pneumonia  checking 2 clinical signs:
 FASTBREATHING
 CHEST INDRAWING
 ASSESS FOR:
 How long the child has cough or difficult breathing
 Fast breathing
 Chest in-drawing
 Stridor in calm child
 Determine fast breathing – Count breaths/min
 Fast breathing is:

60 breaths/min & Above Young infant less than 2

months
50 breaths/min. & above 2-12 months infants
40 breaths/min.
 Look for chest& in-drawing
above 12 moths to 5 years old
 Remove shirt
 Chest in drawing  when the lower chest wall goes IN
when child breathes IN
 + Chest in-drawing  clearly visible and present
ALL THE TIME
 If seen only during feeding or crying  NO chest
in-drawing
 Inter-costal in-drawing is NOT chest in-drawing
 Look and Listen for stridor
 STRIDOR: harsh noise when child breathes in
 Caused by: swollen larynx, trachea, or epiglottis
 Life threatening – if child’s airway is blocked
 To listen for stridor
 Put ear near the child’s mouth and see if present as the child
breathes IN
 Listen only when the child is calm
 If sound is heard when child breathes OUT – wheezing not stridor

 CLASSIFY COUGH OR DIFFICULT BREATHING

 Make decision about severity of illness
 Use to determine appropriate action or treatment
 SIGNS CLASSIFY AS
Stopped feeding well VERY SEVERE DISEASE
Convulsion
Abnormally sleepy or
difficult to wake
Chest in-drawing, stridor or
wheezing
Fever or low body temp

Fast breathing OR SEVERE PNEUMONIA

Severe chest in-drawing
No fast breathing, severe in- NO PNEUMONIA; COUGH, OR
drawing or danger signs COLD

PRESENCE OF JUST ONE SIGN

IN EACH COLOR CODED BOX – IF CHILD HAS SIGNS FROM
PUT THE CHILD IN THAT MORE THAN ONE ROW –
CLASSIFICATION SELECT THE MORE SERIOUS
CLASSIFICATION
CLASSIFICATION TREATMENT FOR
VERY SEVERE DISEASE Give 1st dose of antibiotic
Keep warm
Refer urgently to hospital

SEVERE PNEUMONIA Give 1st dose of antibiotic

Keep warm
Refer urgently to hospital

NO PNEUMONIA, COUGH OR COLD Instruct on home care

Advise on when to return
immediately
No antibiotics needed
SIGNS CLASSIFY TREATMENT
Any DANGER SIGNS VERY SEVERE Give 1st dose of
Chest in-drawing OR DISEASE/PHNEUMONIA appropriate antibiotic
Stridor in calm child Give vitamin A
Treat the child to
prevent low blood
sugar
Refer urgently to
hospital

Fast breathing Pneumonia Give appropriate

antibiotic for 5 days
1st line: Co-
trimoxazole
2nd line -Amoxicillin
Soothe the throat and
relieve cough with
 COTRIMOXAZOLE – 1ST Line AMOXICILLIN – 2nd line
Trimethoprim + 3x daily x 5 days
sulphamethoxazole
2x daily x 5 days

Adult tab. Syrup Tablet 250 Syrup 125

80 mg 40 mg mg mg/5ml
trimethoprim trimethoprim
AGE OR + 400mg + 200 mg
WEIGHT sulphamethox sulphamethox
azole azole/5 ml

2 mos. – 1/2 5.0 ml 1/2 5 ml

12mos. (4 -
 If child is able to breastfeed  ask mother to
breastfeed the child
 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
 givesugar water: Dissolve 4 tsp or 20 grams of
sugar in 200 ml cup of clean water
 Give 30 -50 ml of milk or sugar water before
departure
 If the child is not able to swallow  give 50
ml of milk or sugar water by NGT
 SOOTHE THE THROAT, RELIEVE THE COUGH
WITH A SAFETY REMEDY
 Safe Remedies to Recommend:
 Breastmilk for exclusively breastfed infant
 Calamansi, tamarind and ginger juice
 Discourage Harmful Remedies:
 Codeinecough syrup, other cough syrup, oral and
nasal decongestants
SIGNS CLASSIFY TREATMENT
NO signs of pneumonia or NO PNEUMONIA: COUGH If coughing more than 30
very severe disease OR COLD days refer for re-
assessment
Soothe the throat and
relieve cough with safe
remedy
Advise mother when to
return immediately
Follow-up in 5 days if not
improving
ASSESS FOR DEHYDRATION – ASK-LOOK-FEEL
SIGNS CLASSIFY
TWO of the following: SEVERE DEHYDRATION
Abnormally sleepy or difficult to awaken
Sunken eyes
Skin pinch goes back vey slowly

TWO of the following: SOME DEHYDRATION

Restless
Irritable
Sunken eye
Skin pinch goes back slowly

NOT enough signs to classify as some or severe NO DEHYDRATION

dehydration
 Treatment DEHYDRATION
SEVERE DEHYDRATION
Infant can also have possible
serious bacterial infection or
dysentery – Give fluid for severe
dehydration – PLAN C
Refer urgently to hospital with
mother giving frequent sips of ORS
on the way
Advise mother to continue breast
feeding
 Treatment DEHYDRATION

SOME DEHYDRATION Give fluids for some dehydration –

PLAN B
Infant also has possible serious
bacterial infection or dysentery – Refer
urgently to hospital with mother giving
frequent sips of ORS on the way
Advise to continue breastfeeding

NO DEHYDRATION Give fluids to treat diarrhea at home –

PLAN A
 Counsel
mother on the 3 Rule of Home
Treatment:
 Give extra fluid
 Continue feeding
 When to return
 Give extra fluid – as much as the child will
take
 Tell mother:
 Breastfeed frequently and longer at each feeding
 If child is exclusively breastfed - give ORS or
clean water in addition to breast milk
 If child is not exclusively breastfed – give one or
more of the following:
 ORS solution
 Food based fluids  soup, rice water, buko juice
 Clean water
 It is especially important to give ORS at home
when the child:
 hasbeen treated with Plan B or Plan C during the visit
 Cannot return to health center if diarrhea gets worse
 Teach mother how to mix ORS – give 2 packs to
be use at home
 Show mother how much fluid to give in
addition to the usual fluid intake
 Up to 2 years 50 – 100 ml after each loose
stool
2 years & above 100 – 200 ml after each loose
stool
 Tell the mother to:
 Give frequent sips from cup
 If child vomits, wait for 10 minutes – then
continue slowly
 Continue giving extra fluids until diarrhea stops
 Give in health center recommended amount
of ORS over 4 hour period
 Determine amount of ORS to be given during
the first 4 hour
AGE Up to 4 4 months to 12 months 2 years to 5
months 12 months to 2 years years

WEIGHT < 6 kg 6 to < 10 kg 10 to < 12 kg 12 to 19 kg

Amount in 200 - 400 400 – 700 700 - 900 900 - 1400

ml
Use the child’s age only when weight is unknown
Approximate ORS can also be calculated by multiplying child’s
weight in kg x 75
 Ifthe child wants more ORS, give more
 For child under 6 months who are not
breastfed – give also 100 – 200 ml clean
water during this period
 Show mother how to give ORS
 Give frequent small sips from cup
 If child vomits, wait for 10 minutes – then
continue slowly
 Continue breast feeding whenever the child
wants
 After 4 hours
 Re-asses and classify for dehydration
 Select appropriate plan to continue
 Begin feeding the child in health center
 Ifmother must leave before completing
treatment
 Show how to prepare ORS solution at home
 Show how much ORS to give to finish 4 hour treatment
at home
 Give enough ORS packs to complete rehydration
 Give also 2 packs as recommended in PLAN A
 Explain the 3 rules of home treatment
 Can you give IVF immediately?
YES
Start IVF immediately
If the child can drink – give ORS/mouth while drip is set
up
Give 100 ml LR of if not available NSS divided as
follows:
Infants under 12 moths: give 30 ml/kg in 1 hour then
70 ml/kg in 6 hours
12 months up to 5 years: 30 ml/kg in 30 minutes then
70 ml/kg in 2.5 hours
Repeat once if radial pulse is still very weak or not
detectable
Re-asses child every 1-2 hours  if not improving 
give IV drip more rapidly
 Can you give IVF immediately?  NO  Is IV
treatment available nearby – with in 30
minutes  YES
•Refer urgently to the hospital for IV treatment
•If the child can drink, provide the mother with ORS and show her
how to give frequent sips during the trip
 NO  are you trained to use NGT for re-hydration 
YES

Start rehydration by tube with ORS solution give 20 ml/kg/hour

x 6 hours (total of 120 ml/kg)
Re-asses every 1-2 hours
If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly
If hydration status is not improving after 3 hours, send the
child for IV therapy
After 6 hours, re-assess and classify dehydration and choose
 NO  can the child drink? NO  refer to hospital for IV
appropriate plan to continue
or NGT
 CLASSIFY DIARRHEA

SIGNS CLASSIFY

Diarrhea lasting 14 days or more SEVERE PERSISTENT DIARRHEA

Presence of blood in stool DYSENTERY

 TREAT DIARRHEA
CLASSIFICATION TREATMENT
SEVERE PERSISTENT DIARRHEA If dehydrated, treat dehydration
before referral unless the infant has
also possible serious bacterial infection
Refer to hospital

DYSENTERY Refer urgently to hospital with mother

giving frequent sips of ORS on the way
Advise to continue breastfeeding
SIGNS CLASSIFICATION

Two of the following signs SEVERE DEHYDRATION

Abnormally sleepy or difficult to awaken
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly

Two of the following signs SOME DEHYDRATION

Restless, irritable, sunken eye, drinks eagerly,
thirsty, skin pinch goes back slowly

Not enough signs to classify as some or severe NO DEHYDRATION

dehydration
CLASSIFICATION TREATMENT
SEVERE If child has no other severe classification  give
DEHYDRATION fluid for severe dehydration – PLAN C
If child has another severe classification  refer
urgently to the hospital with mother giving
frequent sips of ORS on the way
Advise to continue breastfeeding
If child is 2 years or older and there is cholera in
your area  give antibiotic for cholera
SOME Give fluid and food for some dehydration – PLAN
DEHYDRATION B
If child has also severe classification  refer
urgently to hospital giving frequent sips of ORS on
the way
Advise to continue breastfeeding
Advise when to return immediately
Follow-up in 5 days if not improving
CLASSIFICATION TREATMENT

NO DEHYDRATION Give fluids and food to treat diarrhea at home –

PLAN A
Advise when to return the child immediately
Follow-up in 5 days if not improving
 SIGNS CLASSIFICATION

Diarrhea lasting 14 days or more SEVERE PERSISTENT

Dehydration present DIARRHEA

No signs of dehydration PERSISTENT DIARRHEA

Presence of blood in the stool DYSENTERY

CLASSIFICATION TREATMENT
SEVERE PERSISTENT DIARRHEA •TREAT DEHYDRATION BEFORE REFERRAL UNLESS
THE CHILD HAS ANOTHER SEVERE
CLASSIFICATION
•GIVE VITAMIN A
•REFER TO HOSPITAL
PERSISTENT DIARRHEA •ADVISE MOTHER ON FEEDING THE CHILD
•GIVE VITAMIN A
•FOLLOW-UP IN 5 DAYS
DYSENTERY •TREAT FOR 5 DAYS WITH ORAL ANTIBIOTIC
RECOMMENDED FOR SHIEGELLA IN YOUR AREA
•First line of antibiotic – Cotrimoxazole
•Second line – Nalidixic acid
•FOLLOW UP IN 5 DAYS
 Give1 dose of vitamin A if child is 9 months
of age or older and child has not received a
dose in the past 6 months

6 months to 12 months 100,000 IU

12 months to 5 years 200,000 IU

 COTRIMOXAZOLE NALIDIXIC ACID
Trimethoprim + suphamethoxazole Give 4x daily for 5
Give 2x daily for 5 days days

Age or Weight Adult tablet Syrup Syrup 250mg/5ml

80mg/400mg 40 mg/200mg/5 ml

2 mos. – 4 mos. 1.25 ml (1/4 tsp)

(4 - < 6 kg)
1/2 5.0 ml
4 mos. – 12 mos. 2.5 ml (1/2 tsp)
(6 - <10 kg)

12 mos. – 5 years 1 7.5 ml 5 ml (1 tsp)

(10 – 19 kg)
A child with fever may have:
 malaria
 Measles
 or other severe diseases
 Or cough or cold
 or other viral infections
 Measles now or within the last 3 months
 LOOK Assessment
 LOOK FOR:
 Mouth ulcers  are they deep and extensive
 Pus draining from the eye
 Clouding of the cornea
SIGNS CLASSIFICATION

CLOUDING OF CORNEA OR DEEP SEVERE COMPLICATED MEASLES

EXTENSIVE MOUTH ULCERS

PUS DRAINING FROM THE EYE OR MEASLES WITH EYE OR MOUTH

MOUTH ULCERS COMPLICATION

MEASLES NOW OR WITHIN THE MEASLES

LAST 3 MONTHS
CATEGORY TREATMENT
SEVERE COMPLICATED •GIVE VITAMIN A
MEASLES •GIVE FIRST DOSE OF APPROPRIATE ANTIBIOTIC
•IF CLOUDING OF THE CORNEA OR PUS DRAINS
FROM THE EYE  APPLY TETRACYCLINE EYE
OINTMENT
•REFER URGENTLY TO THE HOSPITAL
MEASLES WITH EYE OR MOUTH •GIVE VITAMIN A
COMPLICATION •IF PUS IS DRAINING FROM THE EYES  APPLY
TETRACYCLINE
•IF WITH MOUTH ULCERS  TEACH MOTHER TO
TREAT WITH GENTIAN VIOLET
•FOLLOW-UP IN TWO DAYS

MEASLES •GIVE VITAMIN A

 Treat
EYE INFECTION with tetracycline
ointment
 Clean both eyes 3x daily
 Apply tetracycline eye ointment in both eyes 3x
daily
 Treat until redness is gone
 Do not use other eye ointment or put anything
else in he eye
 TREAT MOUTH ULCERS WITH GENTIAN VIOLET
 Treat mouth 2x a day
 Wash hands
 Wash child’s mouth with clean soft cloth
wrapped around the finder and wet with salt
water
 Paint mouth with half strength gentian violet
 Wash hands
 FOR MALARIA RISK
 ASK – LOOK – FEEL ASSESSMENT
 ASK:
 Does the child live in a malaria area?
 Has the child visited a malaria area in the past 4 weeks?
 IfYES to either of the two  obtain blood smear
 The ASK:
 For how long the child has fever?
 If more than 7 days, has fever been present everyday
 Has the child had measles within the last 3 months
 LOOK and FEEL
 For stiff neck
 For runny nose
 For signs of measles:
 Generalized rash
 One of these:
 Cough
 Runny nose
 Red eyes
SIGNS CLASSIFICATION
ANY GENERAL DANGER SIGN OR STIFF VERY SEVERE FEBRILE DISEASE/MALARIA
NECK

BLOOD SMEAR (+), IF NOT DONE: MALARIA

NO RUNNY NOSE
NO MEASLES
NO OTHER CAUSE OF FEVER

BLOOD SMEAR (-) OR FEVER: MALARIA UNLIKELY

RUNNY NOSE
MEASLES
OTHER CAUSES OF FEVER
CLASSIFICATION TREATMENT
VERY SEVERE FEBRILE •GIVE 1ST DOSE OF QUININE – UNDER MEDICAL
DISEASE/MALARIA SUPERVISION OR IF A HOSPITAL IS NOT
ACCESSIBLE WITHIN 4 HOURS
•GIVE FIRST DOSE OF AN APPROPRIATE
ANTIBIOTIC
•TREAT THE CHILD TO TREAT LOW BLOOD
SUGAR
•GIVE 1 DOSE OF PARACETAMOL IN HEALTH
CENTER FOR HIGH FEVER – 38.5 & ABOVE
•SEND A BLOOD SMEAR WITH THE PATIENT
•REFER URGENTLY TO THEHOSPITAL
CLASSIFICATION TREATMENT
MALARIA •TREAT WITH ORAL ANTI MALARIAL
•GIVE I DOSE OF PARACETAMOL FOR FEVRE 38.5 &
ABOVE
•ADVISE MOTHER WHEN TO RETURN IMMEDIATELY
•FOLLOW-UP IN 2 DAYS IF FEVER PERSIST
•IF FEVER IS PRESENT EVERY DAY FOR 7 DAYS, REFER
FOR ASSESSMENT

FEVER: MALARIA •GIVE 1 DOSE OF PARARCETAMOL IN HEALTH CENTER

UNLIKELY FOR 38.5 & ABOVE
•ADVISE MOTHER TO RETURN IMMEDIATELY
•FOLLOW-UP IN TWO DAYS IF FEVER PERSIST
•IF FEVER IS PRESENT EVERY DAY FOR MORE THAN 7
DAYS, REFER FOR ASSESSMENT
 First line: Chloroquine and Primaquine
 Second line: Sulfadoxine and Pyrimethamine
 If Chloroquine:
 Explainto the mother that she should watch the
child carefully for 30 minutes after giving a dose of
chloroquine
 If the child vomits within 30 minutes  repeat the dose
and return to the health center for additional tablets
 Explainthat itchiness is a possible side effect of
the drug  but is not dangerous
 If sulfadoxine + Pyrimethamine:
 Give single dose in health center
 Give for 3 days: 150 mg base tablet

AGE Day 1 Day 2 Day 3

2 mos. – 5 mos. 1/2 1/2 1/2

5 mos. – 12 mos. 1/2 1/2 1/2

12 mos. – 3 years 1 1 1/2

3 years – 5 years 1 1/2 1 1/2 1

AGE PRIMAQUINE PRIMAQUINE SULFADOXINE+P
Give single dose Give daily for 14 YRIMEYTHAMINE
in HC for P. days for P. vivax Give single dose
falciparum in HC

15 mg base 15 mg base 500 mg

tablet tablet sulfadoxine
25 mg
pyrimrthamine

2 mos. – 5 mos. 1/4

5 mos. – 12 mos. 1/2

12 mos. – 3 years 1/2 1/4 3/4

3 years – 5 years 3/4 1/2 1

 Give first dose of IM Quinine and refer
urgently to the hospital
 If referral is not possible:
 Give first dose of IM quinine
 Let the child lying down for 1 hour
 Repeat quinine injection 4 – 8 hours later and
then every 12 hours until the child is able to take
oral anti-malaria  do not continue quinine for
more than 1 week
 Do not give to a child less than 4 mos. of age
 AGE OR WEIGHT IM QUININE

300 mg/ml Quinine salt in 2 ml

ampoule

4 months -12 mos. (6 - < 10 kg) 0.3 ml

12 mos. – 2 yrs. (10 - < 12 kg) 0.4 ml

2 yrs. – 3 years (12 - < 14 kg) 0.5 ml

3 yrs. – 5 yrs. (14 – 19 kg) 0.6 ml

SIGNS CLASSIFY

ANY GENERAL DANGER SIGNS OR VERY SEVERE FEBRILE DISEASE

STIFF NECK

NO SIGNS OF VERY SEVERE FEVER: NO MALARIA

FEBRILE DISIASE
CLASSIFICATION TREATMENT
VERY SEVERE FEBRILE DISEASE GIVE 1ST DOSE OF APPROPRIATE ANTIBIOTIC
TREAT TO PREVENT LOW BLOOD SUGAR
GIVE 1 DOSE OF PARACETAMOL FOR HIGH
FEVER
REFER URGENTLY TO THE HOSPITAL
FEVER: NO MALARIA  FOR GIVE 1 DOSE OF PARACETAMOL FOR HIGH
FEVER IN THE HEALTH CENTER
ADVISE MOTHER WHEN TO RETURN
IMMEDIATELY
FOLLOW-UP IN 2 DAYS IF FEVER PERSIST
IF FEVER IS PRESENT FOR MORE THAN 7 DAYS,
REFER FOR ASSESSMENT
 GIVE PARACETAMOL EVERY 6 HOURS UNTIL
FEVER IS GONE
AGE OR WEIGHT 500 MG TABLET 120MG/5ML SYRUP

2 MONTHS – 3 YEARS 1/4 5 ML (1 TSP)

4 TO < 14 KG

3 YEARS – 5 YEARS 1/2 10 ML (2 tsp)

14 TO 19 KG
 Decide Dengue Risk: YES or NO
 If Dengue Risk:
 ASK – LOOK – FEEL ASSESSMENT
 ASK:
 Has the child had any bleeding from the nose,
gums, vomitus or stools?
 Has the child had black vomitus, tarry stool,
abdominal pain?
 Has the child been vomiting?
 LOOK & FEEL
 LOOK for:
 Bleeding from the nose or gums
 Skin petechiae
 Feel for cold and clammy extremities
 Check for slow capillary refill
 If none of the above signs are present and
the child is 6 months or older and fever
present for more than 3 days perform
tourniquet test
SIGNS CLASSIFICATION
BLEEDING FROM THE SEVERE DENGUE HEMORRHAGIC FEVER
NOSE/GUMS/STOOL/VOMITUS
SKIN PETECHIAE
COLD CLAMMY EXTREMITIES
CAPILLARY REFILL MORE THAN 3
SECONDS
ABDOMINAL PAIN OR VOMITING
(+) TORNIQUET TEST

NO SIGNS OF SEVER DENGUE FEVER: DENGUE HEMORRHAGIC FEVER

HEMORRHAGIC FEVER UNLIKELY
CLASSIFICATION TREATMENT
SEVERE DENGUE HEMORHAGIC If skin petechiae or + tourniquet
FEVER test are the only positive signs 
GIVE ORS
If any other signs are positive,
give fluids rapidly as in Plan C
Treat the child to prevent low
blood sugar
Refer urgently to the hospital
Do not give aspirin

FEVER: DHF UNLIKELY Advise mother when to return

immediately
Follow up in 2 days if fever
persist or child shows signs of
bleeding
Do not give aspirin
 LOOK-FEEL Assessment
 Look for visible severe wasting, edema of both
feet, and palmar pallor
 Determine weight for age
 FOR YOUNG INFANT – Less than 2 months
 Check for feeding problem or Low Weight
 ASK-LOOK-LISTEN-FEEL Assessment
 Ask:
 Is there any difficulty feeding?
 Is the infant breastfed? If yes, how many times in
24 hours?
 Does the infant usually receive an other food or
drinks? If yes, how often?
 What do you use to feed the infant?
 Look, Listen, Feel: Determine weight for age
 Classify Feeding:
 NOT ABLE TO FEED – Possible Serious Bacterial
Infection
 Signs:not able to feed, no attachment at all or not
sucking at all
 Treatment:
 Give the 1st dose of IM antibiotics
 Treat to prevent low blood sugar
 Advise the mother how to keep the young infant warm on the
way to the hospital
 Refer urgently to hospital
 FEEDING PROBLEM or LOW WEIGHT
 Signs:
 Not well attached to breast
 Not sucking effectively – less than 8 breastfeed
in 24 hours
 Receives other foods or drinks
 Low weight for age
 Thrust
 Treatment:
 Advisemother to breastfeed often, as long as the
infant wants – day and night
 If not well attached or not sucking effectively  teach
correct positioning and attachment
 If breastfeeding < 8 times in 24 hours, advise to increase
frequency of feeding
 If receiving other food or drinks, counsel mother about
breastfeeding more, reducing other foods or drinks, and
using a cup
 If not breastfeeding at all:
 Refer for breastfeeding counseling and possible re-
lactation
 Advise about correctly preparing breastmilk substitutes
and using a cup
 Ifwith thrust: teach mother to treat thrush
at home
 Advise mother to give home care for the
young infant
 Follow-up any feeding problem or thrush in 2
days
 Follow-up low weight for age in 14 days
 NO FEEDING PROBLEM
 Signs: Not low weight for age and no other
signs of inadequate feeding
 Treatment:
 Advise mother to give home care for young
infant
 Praise mother for feeding the infant well
 TEACH MOTHER TO TREAT LOCAL INFECTION AT HOME
 Explain how the treatment is given
 Watch mother as she does the first treatment in Health
Center
 Tell mother to do the treatment 2x daily
 Return to the HC if infection worsen
 To Treat Skin Pustules
 Mother should wash hands
 Gently wash off pus and crusts with soap and water
 Dry the area; paint with gentian violet
 Wash hands
 TO TREAT UMBILICAL INFECTION
 Mother:
 Should wash hands
 Clean with 70% ethyl alcohol
 Paint with gentian violet
 Wash hands
 TO TREAT THRUSH
 Mother:
 Should wash hands
 Wash mouth with clean soft wrapped around the finger and
wet with salt water
 Paint mouth with half strength gentian violet
 Wash hands
 SHOW THE MOTHER HOW TO HOLD HER
INFANT
 HOLD INFANT
 With the infant’s head and body straight
 Facing the breast, with infant’s nose opposite
the nipple
 With infant’s body close to the mother’s body
 Supporting infant’s whole body  not just neck
and shoulder
 SHOW MOTHER HOW TO HELP INFANT TO
ATTACH
 Mother should:
 Touch her infant’s lip with her nipple
 Wait until the infant’s mouth is opening wide
 Move the infant quickly onto her breast, aiming the
infant’s lower lip well below the nipple
 Look for sign of good attachment and effective
sucking.
 If the attachment or sucking is not good, try
again.
 Breastfeeding frequently – as often and for as
long as the infant wants, day or night, -
during sickness and health
 Make sure the young infant stays warm at all
times
 In
cool weather  cover head and feed and dress
with extra clothing
 Adviseto return immediately if the young
infant has any of these signs:
 Breastfeeding or drinking poorly
 Becomes sicker
 Develops fever
 Fast breathing
 Difficult feeding
 Blood in stool
SIGNS CLASSIFICATION

Visible severe wasting SEVERE MALNUTRITION OR SEVERE

or edema of both feet ANEMIA
or severe palmar pallor

Some palmar pallor or ANEMIA OR VERY LOW WEIGHT

Very low weight for age

Not very low weight for age NO ANEMIA AND NOT VERY LOW
No other signs of malnutrition WEIGHT
CLASSIFICATION TREATMENT
SEVERE MALNUTRITION Give vitamin A
OR SEVERE ANEMIA Refer urgently to hospital
ANEMIA OR VERY LOW Assess the child’s feeding and counsel
WEIGHT mother on feeding
If with feeding problem – follow-up in 5
days
If with some pallor: GIVE
iron
mebendazole if child is 2 yrs.
or older and had not had a
dose in the past 6 months
Follow-up in 14 days
If very low weight for age: Give vit. A ;
follow up in 30 days
Advise mother when to return immediately
NO ANEMIA AND NOT VERY LOW If the child is less than 2 years
WEIGHT old, assess child’s feeding and
counsel mother on feeding
If feeding is a problem 
follow-up in 5 days
Advise mother when to return
immediately
 Give one dose of vitamin A in the health
center if: child is 9 months of age or older and
child has not received a dose of vitamin A in
the past 6 months
6 months up to 12 months : 100,000 IU
12 months up to 5 years : 200,00 IU
 Give 500 mg Mabendazole as a single dose in
HC if:
 hookworm/whipworm are a problem in children in
the area
 The child is 2 years of age or older
 The child has not had a dose in previous 6 mos.
AGE OR WEIGHT IRON/FOLATE TABLET IRON SYRUP
Ferrous Sulfate 200 Ferrous Sulfate 150
Give 1 dose daily x 14 mg + 250 mcg Folate mg/5 ml (6 mg
days (60 mg elemental elemental iron per
iron) ml)

2 months – 4 months 2.5 ml (1/2 tsp.)

(4 - < 6 kg)

4 months – 12 months 4 ml (3/4 tsp)

(6 - < 10 kg)

12 months – 3 years ½ tablet 5 ml (1 tsp)

(10 -14 kg)

3 years – 5 years ½ tablet 7.5 ml (1½ tsp.)

SIGNS CLASSIFY TREATMENT
With fast breathing POSSIBLE Give 1 dose of IM
Severe chest in-drawing SERIOUS antibiotic
Convulsion BACTERIAL Treat to prevent low
Nasal flaring or grunting INFECTION blood sugar
Bulging fontanel Advise mother how to
Pus draining from the ear keep infant warm on
Umbilical redness extending the way to the hospital
to the skin Refer urgently to the
Fever – 37.5 & above hospital
Low body temperature - <
35.5 or feels cold
Many or severe pustules
Abnormally sleepy or difficult
to awaken
Less than normal movement
 GENTAMICIN
Dose: 5 mg/kg

Undiluted 2 ml vial Add 6 ml sterile water to 2

containing 20 mg = 2 ml ml vial containing 80 mg =
WEIGHT at 10mg/ml 8 ml at 10 mg/ml

1 kg 0.5 ml
2 kg 1.0 ml
3 kg 1.5 ml
4 kg 2.0 ml
5 kg 2.5 ml
WEIGHT BENZYL PENICILLIN
Dose: 50,000 “U”/kg

To a vial of 600 mg (1,000,000 units

Add 2.1 ml of sterile Add 3.6 ml sterile
water = 2.5 ml at water = 4.0 ml at
400,000 “U”/ml 250,000 “U”/ml
1 kg 0.1 ml 0.2 ml
2 kg 0.2 ml 0.4 ml
3 kg 0.4 ml 0.6 ml
4 kg 0.5 ml 0.8 ml
5 kg O.6 ml 1.00 ml
Avoid using undiluted Give benzylpenicillin
Give 1st dose of both 40 mg/ml gentamicin every 6 hours plus
gentamicin and If referral is not gentamicin one dose
penicillin IM possible give benzyl daily
SIGNS CLASSIFY TREATMENT
Red umbilicus or LOCAL BACTERIAL Give appropriate oral
Draining pus or INFECTION antibiotic
Skin pustules Treat local infection in
the HC and teach mother
to treat local infection at
home
Advise mother to give
home care to young infant
Follow-up in two days
 Give appropriate oral antibiotic
 For local bacterial infection
 First
line: Cotrimoxazole
 Second line: Amoxycillin
 COTRIMOXAZOLE AMOXYCILLIN
Trimethoprim + 3x daily x 5 days
sulphametoxazole
2x daily x 5 days

AGE OR ADULT TAB SYRUP TABLET 250 MG SYRUP 125 MG

WEIGHT IN 5 ML
Birth – 1 mo. <3 1.25 ml 1.25 ml
kg
1 mo. – 2 mos. 1/4 2.5 ml 1/4 2.5 ml
3-4 kg
Avoid cotrimoxazole in infant less than 1 month of age who are premature or
jaundiced
SIGN CLASSIFICATION TREATMENT
Tender swelling MASTOIDITIS Give 1st dose of
behind ear appropriate antibiotic
Give first dose of
paracetamol for pain
Refer urgently to the
hospital

Pus draining from the ACUTE EAR INFECTION Give antibiotic for 5
ear days
Discharge reported Give paracetamol for
for < 14 days or pain
With ear pain Dry the ear by wicking
Follow-up in 5 days
SIGNS CLASSIFICATION TREATMENT
Pus is seen draining CHRONIC EAR Dry the ear by wicking
from the ear INFECTION Follow-up in 5 days
Discharge is reported
for 14 days or more

No ear pain and no NO EAR INFECTION No additional

pus seen draining from treatment
the ear
 DRY EAR BY WICKING
 Dry the ear at least 3x daily
 Rollclean absorbent cloth or soft strong tissue
paper into a wick
 Place the wick in the child’s ear
 Remove the wick when wet
 Replace wick with a clean one
 Repeat the steps until the ear is dry