INTEGRATED MANAGEMENT OF CHILDHOOD

ILLNESS
IMCI
PART 1: INTRODUCTION TO IMCI
Every year about 12 million children die before they reach their 5
th
birthday.
7 in 10 of these deaths are due to the 5 major killers of children: Acute respiratory infections
(mostly pneumonia), diarrhea, measles, malaria and malnutrition- and often to a combination of
these conditions.
Distribution of 10.5 million deaths
among children less than 5 years old
in all developing countries (WHO,
1999)
hese 5 conditions are also responsible for substantial illness: 3 in 4 of episodes of childhood
illness are caused by one or more of these conditions.
Proportion of Global Burden of Selected Diseases Born by Children Under 5 Years
[ Dark area =Children 0-4 years, White area = All other age groups ]
!ost sic" children present #ith si$ns % symptoms related to more than one condition (e.$. measles
& pneumonia or pneumonia & malnutrition). his overlap means that:
A sin$le dia$nosis may not be appropriate.
reatment needs to combine therapy for several conditions.
'o, an inte$rated approach to mana$in$ sic" children is more useful in order to $o beyond sin$le
diseases and to focus on the overall health of the child.
THE IMCI PROCESS: he inte$rated case mana$ement relies on:
1. Case detection using few simple clinical signs. hese si$ns are based on e(pert clinical
opinion and research results.
2. Empirical treatment developed accordin$ to action-oriented classifications rather than
e(act dia$nosis and coverin$ the most li"ely diseases covered by each classification.
he )!*) process can be used by doctors or nurses #ho see sic" children a$ed from birth up to 5
years at 1
st
level health facilities.
1
It is important to stress here that during the IMCI process, we are not dealing with accurate
diagnosis that sometimes cannot be reached without sophisticated investigations but we rather
depend on classifications based on the severity of the illness (depending solely on clinical criteria)
and helping the service provider to give the safest and most appropriate treatment available at the
level of a primary health facility.
Where shoul IMCI !e "##lie $ )!*) should be principally applied at 1
st
level health
facilities (clinics, rural and urban health centers, !*+ centers, outpatient departments of
hospitals, etc) since children #ith potentially fatal illnesses are often brou$ht to these 1
st
level
health facilities.
Ho% $ he ,orld +ealth -r$ani.ation (,+-) and the /nited 0ations *hildren1s 2und
(/0)*E2) developed $uidelines for )!*) at 1
st
level health facilities. hese $uidelines #ere
adapted to the 3a"istan situation by an adaptation $roup from the !inistry of +ealth and all
ma4or /niversities.
When &orre&'l( "##lie) IMCI:
1. 3romotes the accurate identification of childhood illnesses in outpatient settin$s.
2. Ensures appropriate combined treatment of all ma4or childhood illnesses.
5. 'tren$thens the counselin$ of mothers or careta"ers.
6. 'tren$thens the provision of preventive services.
5. 'peeds up the referral of severely ill children.
7. Aims to improve the 8uality of care of sic" children at the referral level.
DISEASES NOT CO*ERED +, IMCI :
he )!*) $uidelines address most, but not all, of the ma4or reason a sic" child is brou$ht to the clinic.
Althou$h the mana$ement of trauma, acute emer$encies due to accidents or in4uries, less common and
chronic health problems are not described in )!*), yet the )!*) still encoura$es the health #or"er to
assess them under the bo( 9*hec" for other problems
RO-E O. THE .AMI-, IN IMCI:
*ase mana$ement can only be effective to the e(tent that families brin$ their sic" children to a trained
health #or"er for care at the appropriate time. )f a family #aits until the child is e(tremely sic", or
ta"es the child to an untrained provider, the child is more li"ely to die from the illness. herefore,
teachin$ families #hen to see" care for a sic" child is an important part of the )!*) process.
A/E /ROUPS CO*ERED +, IMCI:
'ic" infants and children a$ed from Birth up to 5 years.
he case mana$ement process is presented in 2 different sets of charts:
1. A set for children a$e 2 months up to 5 years (up to 5 years means that the child has 0- yet
reached his or her 5
th
birthday. 2or e(ample a child #ho is 6 years 11 months but not a child
#ho is 5 years old). his set is presented on 5 charts titled:
!""#"" !$D %&!""'() *H# "'%+ %H'&D
*,#!* *H# %H'&D
%O-$%#& *H# .O*H#,
2. A set for youn$ infants a$e up to 2 months (up to 2 months means that the infant is 0- yet 2
months of a$e. An infant #ho is 2 months old #ould be included in the $roup 2 months up to 5
years). his set is presented on a chart titled:
!""#"", %&!""'() !$D *,#!* *H# "'%+ )O-$/ '$(!$*
WH, NOT TO USE IMCI .OR CHI-DREN A/E 5 ,EARS OR MORE$
!uch of the treatment advice in )!*) may be help for a child a$e 5 years or more. +o#ever, because
of differences in the clinical si$ns of older and youn$er children #ho have these illnesses, the
assessment and classification process, usin$ this clinical si$ns, is not recommended for older children.
2
SUMMARY OF IMCI PROCEDURES

.OR A-- SIC0 CHI-DREN A/E 1 WEE0 UP TO 5 ,EARS WHO ARE +ROU/HT
TO A 1
ST
-E*E- HEA-TH .ACI-IT,
ASSESS THE CHILD
Check for Danger Signs (or possible baterial in!etion"
Ask about the Main Symptoms# Cough or di!!iult breathing, Diarrhea, $ore throat, %ar proble& ' (e)er.
IF a &ain sy&pto& is reported, assess it !urther*
Check for Nutrition, Immunization and vitamin A status
Check for !ther "rob#ems
CLASSIFY THE CHILDS ILLNESSES
+se the olor-oded hart booklet or ,all harts to lassi!y the hild-s &ain sy&pto&s
and his or her nutrition or feeding status
IF URGENT REFERRAL
is needed and possible
IF NO URGENT REFERRAL
is needed or possible
IDENTIFY URGENT PRE-REFERRAL
TREATMENT(S)
needed for the childs classifications
IDENTIFY TREATMENT
needed !or the hild-s lassi!iations#
Identify specific medical treat. & /or advice
TREAT THE CHILD:
.i)e urgent pre-re!erral treat&ent(s" needed
TREAT THE CHILD:
.i)e the /
st
dose o! oral drugs in the lini and 0or
ad)ise the hild-s aretaker*
1eah the aretaker ho, to gi)e oral drugs and ho,
to treat local infections at home.
.i)e i&&uni2ations, i! needed
REFER THE CHILD:
%3plain to the aretaker the need !or re!erral
Cal& the aretaker-s !ears
4esol)e any proble&
Write a re!erral note
.i)e instrutions and supplies needed !or the are
o! the hild on the ,ay to the hospital*
COUNCEL THE MOTHER:
Assess the hild-s !eeding inluding breast!eeding
praties*
$ol)e !eeding proble&s (i! present"
Ad)ise about !luids ' !eeding during illness*
Ad)ise ,hen to return to a health !aility*
Counsel &other about her o,n health*
FOLLOW UP are is gi)en ,hen the hild returns to lini and, i! neessary, reassess the hild-s proble&s*
3
PART 2
ASSESS AND C-ASSI., THE SIC0 CHI-D
A/E 1 MONTHS UP TO 5 ,EARS
WHEN A MOTHER BRINGS HER SICK CHILD (age 2- !")TO THE CLINIC:
GREET the &other appropriately and
ask about her hild*
LOOK to see i! the hild-s ,eight and
te&perature ha)e been reorded
$se %ood Communication Ski##s&
- 5isten are!ully to ,hat the &other tells you
- +se ,ords the &other understands
- .i)e the &other ti&e to ans,er the 6uestions
- Ask additional 6uestions i! the &other is not
sure about her ans,er
'ecord Important Information
ASK the &other ,hat the hild-s proble&s are
DETERMINE i! this is an INITIA )isit or !""# UP )isit !or this proble&
7( this is an INITIAL #ISIT !or the proble& 7( this is a FOLLOW-UP #ISIT !or the proble&
CHEK !or general DAN%(' SI%NS
GI#E FOLLOW $UP CARE
(Disussed later in 8art 9"
ASK or CHECK about the ) main symptoms #hen a sy$pto$ is present %
Ask % Cou&h or difficult breathin& Assess the hild !urther !or the signs related to
Ask% Diarrhea
Ask% 'ar proble$
Check% Throat proble$
Ask% !e(er
the &ain sy&pto&, and
Classi!y the illness aording to the signs ,hih are
present or absent
CHECK !or signs o! )ANUT*ITI"N and AN')IA and CLASSIFY the hild-s nutritional status
CHECK the hild-s I))UNI+ATI"N and ,ITA)IN A supple&entation status and
deide i! the hild needs any i&&uni2ations or )ita&in A supple&entation today
ASSESS any "T-'* P*"B')S
Then# 7denti!y 1reat&ent (8art 4", 1reat the Child (8art :", and Counsel the ;other (in 8art <"
he table ASSESS AND CLASSIF !"E SIC# C"ILD A$E 2 %&N!"S '( !& ) EA*S is
used for Assessment, Classification and Identification of treatment as follo#s:
+
2.1 - CHECK FOR GENERAL DANGER SIGNS
For ALL sic, children, after ha-ing as,ed the mother a.out the child/s 0ro.lem1 2ou must
CHECK FOR GENERAL DANGER SIGNS
he 1
st
bo( in the !""#"" !$D %&!""'() chart is titled C"EC# F&* $ENE*AL DAN$E*
SI$NS. ASK the 8uestions and LOOK for the clinical si$ns described in this bo(:
A child #ith a $eneral dan$er si$n has a serious problem. !ost children #ith a $eneral dan$er si$n
need URGENT referral to hospital. hey may need lifesavin$ treatment #ith in4ectable antibiotics,
o(y$en or other treatments, #hich may not be available in your clinic. *omplete the rest of the
assessment immediately.
/r$ent pre-referral treatment(s) is described in the chart 'dentify *reatment.
HOW TO CHEC0 .OR /ENERA- DAN/ER SI/NS:
%& ASK: Is 'he &hil "!le 'o rin2 or !re"s'3ee$
A child has the si$n :not able to drin" or breastfeed: if the child is not able to suck or
swallow #hen offered a drin" or breast mil". )f you are not sure about the mother1s ans#er
as" her to offer the child a drin" of clean #ater or breast mil" and #atch him.
2& ASK: Does 'he &hil 4omi' e4er('hin5$
A child #ho 9vomits everythin$; #ill not be able to hold do#n food, fluids or oral dru$s. )f
you are not sure about the mother1s ans#er as" her to offer the child a drin". A child #ho
vomits several times but can hold do#n some fluids does not have this $eneral dan$er si$n.
'& ASK: H"s 'he &hil h" &on4ulsions$
<urin$ a convulsion, the child=s arms and le$s stiffen. he child may lose consciousness or
not be able to respond to spo"en directions. As" the mother if the child has had convulsions
during this current illness. /se #ords the mother understands. 2or e(ample, the mother
may "no# convulsions as :fits: or :spasms.:
(& LOOK: See i3 'he &hil is le'h"r5i& or un&ons&ious&
A lethar$ic child is not a#a"e and alert #hen he should be. +e is dro#sy and does not sho#
interest in #hat is happenin$ around him. -ften the lethar$ic child does not loo" at his
mother or #atch your face #hen you tal". he child may stare blan"ly and appear not to
notice #hat is $oin$ on around him. An unconscious child cannot be #a"ened. +e does not
respond #hen he is touched, sha"en or spo"en to.
As" the mother if the child seems unusually sleepy or if she cannot #a"e the child. >oo" if
the child #a"ens #hen the mother tal"s or sha"es the child or #hen you clap your hands.
)
ERA SMELBORP SDLIHC EHT TAHW REHTOM EHT KSA
.mel.or0 siht rof tisi- 0u34ollof ro laitini na si siht fi enimreteD
no snoitcurtsni 0u34ollof eht esu 1tisi- 0u34ollof fi 3 D&'H% #H* *!#,* .trahc
:s4ollof sa dlihc eht ssessa 1tisi- laitini fi 3
SNGIS REGNAD LARENEG ROF KCEHC
:0SA
5deeftsaer. ro ,nird ot el.a dlihc eht sI
5gniht2re-e timo- dlihc eht seoD
5snoislu-noc dah dlihc eht sa"
:0OO-
.suoicsnocnu ro cigrahtel si dlihc eht fi eeS
.4on gnislu-noc si dlihc eht fi eeS
!& LOOK: See i3 'he &hil is &on4ulsin5 no%&
<urin$ a convulsion, the child1s arms and le$s stiffen because the muscles are contractin$.
he child loses consciousness and is not able to respond to spo"en directions.
HOW TO C-ASSI., .OR /ENERA- DAN/ER SI/NS:
The child is classified as 0#,) "#0#,# D'"#!"# if he has O! or more of the following"
he child is not able to drin" or breastfeed.
he child vomits everythin$.
he child has had convulsions.
he child is lethar$ic or unconscious.
he child is convulsin$ no#.
I. THE CHI-D HAS ONE or MORE O. THE /ENERA- DAN/ER SI/N) HE IS
C-ASSI.IED AS 6*ER, SE*ERE DISEASE7. COMP-ETE THE REST O. THE
ASSESSMENT IMMEDIATE-,. THIS CHI-D HAS A SE*ERE PRO+-EM. THERE MUST
+E NO DE-A, IN HIS TREATMENT.
2&2- ASSESS AND CLASSIFY COUGH OR DIFFICULT
BREATHING
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems
And after ha-ing Chec,ed for $eneral Danger Signs1 then:
AS0: DOES THE CHILD HA#E COUGH OR DIFFICULT BREATHING

I) NO I) YES
:SMOTPMYS NIAM TUOBA KSA NEHT
*g+,-.ae/0 .123,)),4 /5 -g253 e6a- 41,-3 e-. 7e5D
:0SA)SE, .I
5gnol 4oh roF
!S'% DLI"C
%LAC E6
:-EE. )NETSI- )0OO-
.etunim eno ni shtaer. eht tnuoC
.gni4ardni tsehc rof ,ooL
.rodirts rof netsil dna ,ooL
e7eeh4 rof netsil dna ,ooL
CLASSIFY the child/s illness using the color3coded classification
ta.le for C&'$" AND DIFFIC'L! 6*EA!"IN$.
%o-e do4n to the follo4ing .o8 and
ASK a.out the ne8t main s2m0toms: D'!,,H#!1 etc.
9
SNGIS SA YFISSALC TNEMTAERT
(&.+,/8 4150 +, e/a 7.+e.ae/. 1a//e)e/-e/8 .+eg/U)
regnad lareneg 2nA
.ngis
YRE#
ERE#ES
ESAESID
.%on 'neser# 3i snoislu4no& '"erT
.(le'"iemmi 'nemssess" e'el#moC
.&i'oi!i'n" e'"ir#or##" n" 3o eso 'sri3 e4i/
.r"5us ool! %ol 'ne4er# o' lih& eh' '"erT
.8l"'i#soh o' ,-TNE/RU re3eR
HOW TO ASSESS A CHI-D WITH COU/H OR DI..ICU-T +REATHIN/
1. ASK: Does 'he &hil h"4e Cou5h or Di33i&ul' +re"'hin5$
<ifficult breathin$ is any unusual pattern of breathin$ (fast, noisy, interrupted).
2. .or ho% lon5$ A duration of more than 5? days may indicate that the child has @, asthma or
other chronic diseases.
5. Coun' 'he !re"'hs in one minu'e.
he child must be calm and 8uiet. )f the child is sleepin$, do not #a"e him. /se a timer
or a #atch havin$ a 9seconds; hand or a di$ital #atch to count the number of breaths in
one minute. >oo" for breathin$ movements any#here on the child1s chest or abdomen.
he cut-off for fast breathin$ depends on the child1s a$e:
I3 'he &hil is The &hil h"s 3"s' !re"'hin5 i3 (ou &oun'
2 months up to 12 months:
12 months up to 5 years:
50 breaths per minute or more
40 breaths per minute or more
ote! The child who is e#actly $% months old has fast breathing if you count &' breaths per min. or more
6. LOOK: 3or &hes' inr"%in5.
>oo" for chest indra#in$ durin$ inspiration (#hen the child breathes
)0). >oo" at the lo#er chest #all (lo#er ribs). he child has chest
indra#in$ if the lower chest wall goes " when the child breathes ".
*hest indra#in$ occurs #hen the effort the child needs to breathe in is
much $reater than normal. )n normal breathin$, the #hole chest #all
(upper and lo#er) and the abdomen move -/ #hen the child breathes
)0. ,hen chest indra#in$ is present, the lo#er chest #all $oes )0
#hen the child breathes )0.
2or chest indra#in$ to be present, it must be clearly visible and present
all the time. )f you only see chest indra#in$ #hen the child is cryin$ or
feedin$, the child does not have chest indra#in$.
)f only the soft tissue bet#een the ribs $oes in #hen the child breathes
in (also called intercostal indra#in$ or intercostal retractions), the child
does not have chest indra#in$.
)n this assessment, chest indra#in$ is lo#er chest #all indra#in$. )t
does not include :intercostal indra#in$.:
C-'ST IND*A#ING
5. LOOK "n LISTEN: 3or s'rior&
'tridor is a harsh noise made during inspiration #when the child breathes "$. 'tridor happens
#hen there is a narro#in$ of the laryn(, trachea or epi$lottis and can be life threatenin$. A
child #ho has stridor #hen calm has a dan$erous condition.
o loo" and listen for stridor, loo" to see #hen the child breathes )0. hen listen for stridor. 3ut
your ear near the child=s mouth because stridor can be difficult to hear.
'ometimes you #ill hear a #et noise if the nose is bloc"ed. *lear the nose, and listen
a$ain. A child #ho is not very ill may have stridor only #hen he is cryin$ or upset. @e
sure to loo" and listen for stridor #hen the child is calm.
)f you hear a #hee.in$ noise in e(piration (#hen the child breathes -/), this is not stridor.
9& LOOK "n LISTEN: 3or %hee9e&
,hee.e is a soft, musical noise heard during e%piration #when the child breathes
&'($. )t may be caused by s#ellin$ and narro#in$ of the air#ays of the lun$s or by a
contraction of the smooth muscles surroundin$ the air#ays in the lun$.
>oo" to see #hen the child is breathin$ -/. >isten for the #hee.e noise by holdin$ your ear
near the child1s mouth, since the noise may be difficult to hear.
:
>oo" to see if the breathin$ out phase re8uires $reat effort, and is lon$er than normal.
)f the child is #hee.in$, as" the mother if her child has had a previous episode of #hee.in$
#ithin the last year. A child #ith 9recurrent whee)e; has had more than one episode of #hee.e
in a 12-month period.
HOW TO C-ASSI., A CHI-D WITH COU/H OR
DI..ICU-T +REATHIN/
)f #e loo" to the classification table for cou$h or difficult breathin$ (see belo#), #e find that there
are three possible classifications for a child #ith cou$h or difficult breathin$:
AEBC 'EAEBE <)'EA'E or
30E/!-0)A or
0- 30E/!-0)A: *-/D+ -B *-><
Ho% 'o use 'he &l"ssi3i&"'ion '"!le:
After you assess for the main symptom and related si$ns, classify the child=s illness.
Signs Classif2 as !reatment
1. >oo" at the top ro#. <oes the child have a $eneral dan$er si$nE -r 'tridor in a calm child
)f the child has a $eneral dan$er si$n or 'tridor, classify as VERY EVERE !IEAE"
)2 the child has #hee.e 9$o to treat #hee.in$; directly before selectin$ the classification. *hildren
presentin$ #ith chest indra#in$ and fast breathin$ if accompanied #ith #hee.in$ should be
mana$ed differently since both pneumonia and #hee.in$ can cause chest indra#in$ and fast
breathin$. /se a nebuli.ed rapid actin$ bronchodilator to treat the #hee.e, then do further
assessment of child after treatment.
2. )f the child does not have the severe classification, loo" at the middle ro#. <oes the child have fast
breathin$E -r lo#er chest indra#in$ in a calm child. )f the child has fast breathin$, andFor lo#er
chest indra#in$, a si$n in the middle ro#, and the child does not have a severe classification, select
the classification in the middle ro#, #NEU$%NIA"
)2 the child has fast breathin$ & #hee.e, treat #hee.in$ immediately #ith a dose of nebuli.ed
rapid actin$ bronchodilator before selectin$ the classification.
5. )f the child does not have any of the si$ns in the top or middle ro#s, loo" at the bottom ro#, and
select the classification N% #NEU$%NIA& C%UG' %R C%(!.
;
2&'- ASSESS AND CLASSIFY DIARRHEA
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1 Chec,ed for
$eneral Danger Signs1 and As,ed a.out Cough and Difficult 6reathing1 then:
ASK: DOES THE CHILD HA#E DIARRHEA *

I) NO I) YES
D5e7 .-e 3-,14 -a6e 4,a//-ea*
I. ,ES) AS0 -OO0 AND .EE-:
(or ho, long = 5ook at the hild-s general ondition* 7s the hild #
7s there any blood in the stools=
5ethargi or unonsious=
4estless and irritable =
5ook !or sunken eyes*
>!!er the hild !luids* 7s the hild#
?ot able to drink or drinking poorly =
Drinking eagerly, thirsty =
8inh the skin o! the abdo&en* Does it go bak #
@ery slo,ly (longer than A seonds" =
$lo,ly =
CLASSIFY the child/s illness using the color3coded classification
ta.les for DIA**"EA <in the chart .oo,let=
%o-e do4n the follo4ing .o8 and
CHECK for the ne8t main 0ro.lem: !"*&A! (*&6LE%1 FE>E* etc
Di"rrhe" means an increase in volume, fre8uency or fluidity of stools relative to the usual
habits of each individual. 2re8uent passin$ of normal stools is not diarrhea. !others usually
"no# #hen their children have diarrhea.
T(#es o3 Di"rrhe"
A32.e 4,a//-ea: )f an episode of diarrhea lasts less than 16 days, it is ac)te diarrhea.
Pe/7,7.e+. 4,a//-ea: )f the diarrhea lasts 16 days or more, it is *ersistent diarrhea.
D"7e+.e/": <iarrhea #ith red fresh blood in the stool, #ith or #ithout mucus, is called d+senter+.
he most common cause of dysentery is (higella bacteria. Amoebic dysentery is not common in
youn$ children. A child may have both #atery diarrhea and dysentery.
HOW TO ASSESS A CHI-D .OR DIARRHEA
A child #ith diarrhea is assessed for:
+o# lon$ the child has had diarrhea E
@lood in the stool to determine if the child has dysentery, and for
'i$ns of dehydration.
A7: a052. D,a//-ea ,+ A-- 3-,14/e+
%& ASK: Does 'he &hil h"4e i"rrhe"$
)f the mother ans#ers 0-, *+E*G for the ne(t main problem 9+B-A 3B-@>E!;. Cou
do not need to assess the child further for si$ns related to diarrhea.
?
)f the mother ans#ers CE', record her ans#er. hen assess the child for si$ns of dehydration,
persistent diarrhea and dysentery.
2& ASK: .or ho% lon5$ <iarrhea #hich, lasts 1* days or more is persistent diarrhea.
'& ASK: I7 .-e/e 01554 ,+ .-e 7.551*
As" if the mother has seen fresh red blood in stools at any time durin$ this episode of
diarrhea.
(& CHECK 3or si5ns o3 eh(r"'ion. LOOK and FEEL for the follo#in$:
(%%, at the child1s -eneral condition& )s the child
>ethar$ic or unconscious E
Bestless and irritable E
(%%, for s)n.en e+es& <ecide if the eyes are sun"en or not.
%//ER the child fluid to drin. and #atch if the child is
0ot able to drin" or drin"in$ poorly E
<rin"in$ ea$erly, thirsty E
#INC' t0e s.in of the abdomen for 1 second, release it and observe ho# rapid it $oes
bac" to place. <oes it $o bac"
Aery slo#ly (lon$er than 2 seconds)E
'lo#ly E
)mmediately E
HOW TO C-ASSI., DIARRHEA
here are three classification tables for classifyin$ diarrhea.
All children #ith diarrhea are classified for dehydration.
)f diarrhea has lasted for 16 days or more, classify the child for persistent diarrhea.
)f the child has blood in the stool, classify the child for dysentery.
%& C1a77,)" De-"4/a.,5+:
here are three possible classifications of dehydration in a child #ith diarrhea:
EVERE !E'Y!RATI%N&
)f t1o or more of the si$ns in the top ro# are present, classify the child as havin$ severe
dehydration.
%$E !E'Y!RATI%N&
)f t1o or more of the si$ns are not present in the top ro#, loo" at the middle ro#. )f t1o or
more of the si$ns are present, classify the child as havin$ some dehydration.
1@
N% !E'Y!RATI%N&
)f less than t#o of the si$ns from the middle ro# are present, classify the child has
havin$ 0- <E+C<BA)-0. his child does not have enou$h si$ns to be classified as
havin$ some dehydration. 'ome of these children may have one si$n of dehydration or
have lost fluids #ithout sho#in$ si$ns.
2& C1a77,)" Pe/7,7.e+. D,a//-ea
After you classify the child=s dehydration, classify the child for persistent diarrhea if the child has had
diarrhea for 16 days or more. here are t#o classifications for persistent diarrhea.
SE#ERE PERSISTENT DIARRHEA:
)f a child has had diarrhea for 16 days or more and also has some or severe dehydration.
PERSISTENT DIARRHEA:
A child #ho has had diarrhea for 16 days or more and #ho has no si$ns of dehydration.

'&
C1a77,)" D"7e+.e/" : here is only one classification for dysentery:
DYSENTERY
*lassify a child #ith diarrhea and fresh red blood in the stool as havin$ <C'E0EBC.
2&(- CHECK FOR THROAT PROBLEM
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1
Chec,ed for $eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1 and
As,ed a.out
Diarrhea1 then:
CHECK FOR THROAT PROBLEM IN A-- CHILDREN
HOW TO CHEC0 .OR THROAT PRO+-EM
As" the mother if the child has throat problem. )f the mother ans#ers N%, record her ans#er. As"
about the ne(t main symptom, Ear problem. !o not assess the child for hroat problem.
)f the mother ans#ers yesH then asses for throat problem:
0ote: Bemember sometimes it is difficult, especially for the child less than 2 years, to "no# #hether
the child1s throat is sore. )f in doubt do assess all children for throat problem.
ASK: <oes the child have feverE I
<oes the child have sore throatE
Deh2dration 0resent.
SE#ERE
PERSISTENT
DIARRHEA
!reat deh2dration .efore referral unless the child has
another se-ere classification.
$i-e a00ro0riate dose of Ainc for 1@ da2s
*efer to hos0ital
No deh2dration
PERSISTENT
DIARRHEA
Ad-ise the mother on feeding a child 4ho has
(E*SIS!EN! DIA**"EA.
$i-e a00ro0riate dose of Ainc Sus0ension for 1@ da2s
$i-e multi-itamin3mineral su00lementation.
Ad-ise mother 4hen to return immediatel2
Follo4 u0 in ) da2s.
6lood in the stools.
DYSENTERY
Tre"' 3or : "(s %i'h "n or"l "n'i!io'i&
re&ommene 3or Shi5ell"
/i4e "##ro#ri"'e ose o3 ;in& sus#ension 3or 10
"(s
Ad-ise mother 4hen to return immediatel2.
Follo4 u0 in 2 da2s.
11
FEEL: 2or enlar$ed tender lymph node on the front of the nec".
LOOK: 2or red (con$ested) throat.
2or e(udate on throat and tonsils (#hite or yello# patches).
)!*!+1 means history of fever, or if the child feels hot or a#illary temperature is ,-..
o
C or more .
+ere is the bo( from the BAssessC column that tells you ho# to assess a child for sore throat.

C-e3: )5/ .-/5a. 8/501e:
AS0: -OO0 AND .EE-:
Cl"ssi3(
SORE THROAT
Does the child ha-e sore throat 5
Is the child not a.le to drin,
Does the child ha-e fe-er
Fe-er <3:.) C or a.o-e=
Feel for enlarged tender l2m0h nodes
on the front of the nec,.
Loo, for red <congested= throat.
Loo, for 4hite or 2ello4 e8udates on
the throat and tonsils.
HOW TO C-ASSI., A CHI-D .OR THROAT PRO+-EM $
here are 2-/B possible classifications of throat problem:
+B-A A@'*E''
'BE3-*-**A> '-BE +B-A
A)BA> '-BE +B-A
0- +B-A 3B-@>E!
+ere is the table for classification of sore throat.
12
2&!- ASSESS AND CLASSIFY EAR PROBLEM
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1 Chec,ed for
$eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1 As,ed a.out Diarrhea1
and Chec,ed for !hroat 0ro.lem1 then
AS0: DOES THE CHILD HA#E AN EAR PROBLEM
I) NO I) YES

CLASSIFY the child/s illness using the color3coded classificationt ta.le for Ear (ro.lem.
%o-e do4n to the follo4ing .o8 and AS0 a.out the ne8t main s2m0tom: FE>E*

13

D5e7 .-e 3-,14 -a6e a+ ea/ 8/501e*
I. ,ES) AS0:
Is there se-ere ear 0ain5
Is there ear discharge5
If 2es1 for ho4 long5
-OO0 AND .EE-:
Loo, for 0us draining from the ear.
Feel for tender s4elling .ehind the ear.
HOW TO ASSESS A CHI-D .OR EAR PRO+-EM
A child #ith ear problem is assessed for:
'evere ear pain
Ear dischar$e and
)f dischar$e is present, ho# lon$ the child has had dischar$e, and
ender s#ellin$ behind the ear, a si$n of mastoiditis.
%& ASK: Does 'he &hil h"4e "n e"r #ro!lem$
)f the mother ans#ers N%, record her ans#er. As" about the ne(t
main symptom, fever. !o not assess the child for ear problem.
)astoiditis .tender s/ellin&
behind the ri&ht ear01
)f the mother ans#ers YE, as" the ne(t 8uestion:
2& ASK: Does 'he &hil h"4e "n "5oni9in5 e"r #"in$
'evere a$oni.in$ ear pain can mean that the child has an ear infection. )f the mother is not
sure that the child has ear pain, as" if the child has been irritable and rubbin$ his ear.
'& ASK: Is 'here e"r is&h"r5e$ I3 (es) 3or ho% lon5$
Ear dischar$e is also a si$n of infection. he duration of dischar$e is important.
Ear dischar$e that has been present for 2 #ee"s or more is treated as a chronic ear infection.
Ear dischar$e that has been present for less than 2 #ee"s is treated as an acute ear infection.
(& LOOK: 3or #us r"inin5 3rom 'he e"r&
3us drainin$ from the ear is a si$n of infection, even if the child no lon$er has any pain. >oo"
inside the child=s ear to see if pus is drainin$ from the ear.
!& FEEL: 3or 'ener s%ellin5 !ehin 'he e"r&
@oth tenderness and s#ellin$ must be present to classify mastoiditis, a deep infection in the
mastoid bone. <o not confuse this s#ellin$ of the bone #ith s#ollen lymph nodes.
HOW TO C-ASSI., EAR PRO+-EM
here are four classifications for ear problem:
$AT%I!ITI: he child has a tender s#ellin$ behind the ear.
ACUTE EAR IN/ECTI%N: )f you see pus drainin$ from the ear and dischar$e has
been present for less than t#o #ee"s, or if there is ear pain.
C'R%NIC EAR IN/ECTI%N: <ischar$e is reported for more than 16 days (pus is
seen on not seen drainin$ from the ear)
N% EAR IN/ECTI%N: )f there is no ear pain and no pus is seen drainin$ from the ear.
+ere is the classification table for ear problem from the /((!(( 0 C1/((I)2 chart:
1+

1)
2&9- ASSESS AND CLASSIFY FE#ER
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1
Chec,ed for $eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1
As,ed a.out Diarrhea1 Chec,ed for !hroat 0ro.lem1 and As,ed a.out Ear (ro.lem1
then
ASK: DOES THE CHILD HA#E FE#ER *
I) NO I) YES
D5e7 .-e 3-,14 -a6e )e6e/ *
<.2 histor2 or feels hot or a8illar2 tem0erature 3:.)
o
C or more=.
AS0: -OO0 AND .EE-:
Cl"ssi3(
.E*ER
For ho4 long 5
If more than : da2s1 has fe-er
.een 0resent e-er2 da2 5
"as the child had measles 4ithin
the last 3 months 5
Loo, or Feel for stiff nec,.
Loo, for *unn2 Nose
L55: )5/ S,g+7 5) Mea71e7
$enerali7ed *ash of measlesD
&ne of these: Cough1 runn2 Nose or
red e2es
I3 MEAS-ES
No% or %i'hin l"'
: mon'hs)
Cl"ssi3(
I3 'he &hil h"s me"sles no%
or %i'hin 'he l"s' : mon'hs
Loo, for %outh 'lcers
Are the2 dee0 and e8tensi-e5
Loo, for (us draining from e2es
Loo, for Clouding of the Cornea

CLASSIFY the child/s illness using the color3coded Classification ta.les for FE>E*.
%o-e do4n to the follo4ing .o8 and
CHECK for %ALN'!*I!I&N1 ANE%IA1 I%%'NIAA!I&N S!A!'S1 etc.
HOW TO ASSESS A CHI-D .OR .E*ER
A &hil h"s 'he m"in s(m#'om 3e4er i3:
he child has a history of fever or
he child feels hot or
he child has an a(illary temperature of +,-5C or above (or 5J.5
o
* rectal temp.)
The assessment bo# shown above, lists the steps for assessing a child for fever.
There are two parts to the bo#. The top half of the bo# (above the bro3en line) describes how to assess
the child for signs of measles, meningitis and other causes of fever. The bottom half of the bo#
19
A patient presenting with
fever
(continuous or
intermittent)
(temp=or >more then
37.5 C)
or history of fever with in
the
last 3 days associated with
rigors with no features of
other diseases and have
IF YES:
!alaria transmission in the area
= "es
#ransmission season = "es
$n non or low endemic areas
travel
history within the last %5&days to
an area
where malaria transmission
occurs = "es
"es''''' (o'''''
describes how to assess the child for signs of measles complications if the child has measles now or
within the last , months
Assess 'he &hil %i'h 3e4er 3or:
+o# lon$ the child has had fever
+istory of measles
'tiff nec"
Bunny 0ose
'i$ns su$$estin$ measles (see belo#)
)f the child has measles no# or #ithin the last 5 months, assess for si$ns of measles
complications (see belo#).
%& ASK: Does 'he &hil h"4e 3e4er$
*hec" to see if the child has a history of fever, feels hot or has an a(illary temperature of
5K.5* or above.
)f the child does not have fever (by history, feels hot or temperature 5K.5* or above) do
not assess the child for si$ns related to fever. Do to the ne(t 8uestion and chec" for
malnutrition and anemia.
)f the child has fever (by history, feels hot or has a temperature 5K.5* or above), assess the
child for additional si$ns related to fever.
2. <ecide !alaria Endemicity
<ecide if !alaria may be the cuase of fever. <ecide if malaria transmission is "no#n in the
area.
+yperendemic: )f !alaria cases are more than 5 per 1??? $eneral population per year
!eso endemic: if !alaria cases are 1-5 per 1??? $eneral population per year
+ypoendemic: )f !alaria cases are less than 1 per 1??? $eneral population per year
:. ASK: .or ho% lon5$ I3 more 'h"n < "(s) h"s 3e4er !een #resen' e4er( "($I3
his'or( o3 l"s' e#isoe o3 3e4er is more 'h"n <1 hours) M"l"ri" is e=l&ue.
!ost fevers due to viral illnesses $o a#ay #ithin a fe# days. A fever, #hich has been present,
every day for more than K days can mean that the child has a more severe disease such as
typhoid fever. Befer this child for further assessment.
>. AS0: H"s 'he &hil h" me"sles %i'hin 'he l"s' : mon'hs$
!easles affects the immune system and leaves the child at ris" for other infections for many
#ee"s. A child #ith fever and a history of measles #ithin the last 5 months may have an
infection due to complications of measles such as an eye infection.
!& LOOK or FEEL 3or s'i33 ne&2&
A child #ith fever and stiff nec" may have menin$itis that needs ur$ent treatment #ith
in4ectable antibiotics and referral to a hospital.
7. >oo" for Bunny nose
'u$$ests a *ommon *old
;& LOOK 3or si5ns su55es'in5 MEAS-ES.
Assess a child #ith fever to see if there are si$ns su$$estin$ measles.
/ener"lise r"sh
Cou5h) Runn( Nose) or Re E(es
o classify a child as havin$ measles, the child #ith fever must have a $eneralised rash AN!
one of the follo#in$ si$ns: Cough, runny nose, or red eyes. he child has :red eyes: if there is
redness in the #hite part of the eye. )n a healthy eye, the #hite part of the eye is clearly #hite
and not discoloured.
1:
<& I3 'he &hil h"s MEAS-ES no% or %i'hin 'he l"s' : mon'hs= LOOK 'o see:
<oes the child have mouth ulcers, are they deep and e(tensive, or
<oes the child have pus drainin$ from the eye (con4unctivitis), or
<oes the child have cloudin$ (ha.iness) of the cornea, or
HOW TO C-ASSI., .E*ER
-)f the child has fe2er and no si$ns of measles, classify the child for fever onl+.
-)f the child has si$ns of both fever and measles, classify the child for fever and for measles.
1. C-ASSI., .E*ER
1;
!alaria
transmission
in the area =
"es
#ransmission
season = "es
$n non or low
endemic areas
travel
history within
the last %5&
days to an
1. C-ASSI., MEAS-ES
A child #ho has the main symptom :fever: and measles no# (or #ithin the last 5 months)
is classified 3ot0 for fever and for measles. 1
st
classify the child=s fever. Ne4t you classify
measles.
)f the child has no si$ns su$$estin$ measles, or has not had measles #ithin the last 5
months, do not classify measles. Do to the ne(t 8uestion and chec" for malnutrition and anemia.
he follo#in$ bo( of assessment table sho#s that there are three possible classifications for measles:
$eneral danger sign &*
Clouding of the cornea &*
Dee0 e8tensi-e mouth ulcers &*
%easles no4 AND (neumonia
SE#ERE
COMPLICATED
MEASLES>>>>
/i4e 3irs' ose o3 "n "##ro#ri"'e "n'i!io'i&.
/i4e one ose o3 #"r"&e'"mol in &lini& 3or 3e4er
?:@
o
C or "!o4eA.
Tre"' 'he &hil 'o #re4en' lo% !loo su5"r.
I3 &louin5 o3 'he &orne" or #us r"inin5 3rom 'he
e(e) "##l( 'e'r"&(&line e(e oin'men'.
/i4e 4i'"min A.
Re3er UR/ENT-, 'o hos#i'"l.
(us draining from the e2es &*
%outh ulcers.
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
>>>>
/i4e #"r"&e'"mol 3or 3e4er ?:@
o
C or "!o4eA.
I3 #us r"inin5 3rom 'he e(e) 're"' e(e in3e&'ion
%i'h 'e'r"&(&line e(e oin'men'.
/i4e 4i'"min A.
If mouth ulcers1 treat 4ith gentian -iolet.
Ad-ise mother 4hen to return immediatel2.
Follo43u0 in 2 da2s.
%easles no4 or 4ithin the last 3
months AND MEASLES
/i4e #"r"&e'"mol 3or 3e4er ?:@
o
C or "!o4eA
/i4e 4i'"min A.
Ad-ise mother 4hen to return immediatel2.
Follo43u0 in 2 da2s1 IF not im0ro-ing.
EEEE Other important complications of measles as stridor, diarrhea, ear infection and malnutrition, are classified in other tables
SE#ERE COMPLICATED MEASLES
)f the child has any general danger sign, clouding of cornea or deep or e#tensive mouth ulcers,
classify the child as havin$ 'EAEBE *-!3>)*AE< !EA'>E'. his child needs ur$ent
treatment and referral to hospital.
*hildren #ith measles may have other serious complications of measles. hese include stridor
in a calm child, severe pneumonia, pneumonia, severe dehydration, or severe malnutrition.
MEASLES WITH EYE OR MOUTH COMPLICATIONS
)f the child has pus draining from the eye or mouth ulcers, which are not deep or e#tensive,
classify the child as havin$ !EA'>E' ,)+ ECE -B !-/+ *-!3>)*A)-0'. A child
#ith this classification does not need referral.
1?
MEASLES:
A child #ith measles no# or #ithin the last 5 months and #ith none of the complications listed
in the pin" or yello# ro#s is classified as havin$ !EA'>E'. Dive the child vitamin A to help
prevent measles complications.
All &hilren %i'h me"sles shoul re&ei4e 4i'"min A.
2&;- CHECK FOR MALNUTRITION AND ANEMIA
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1
Chec,ed for $eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1
As,ed a.out Diarrhea1 Chec,ed for !hroat 0ro.lem1 As,ed a.out Ear (ro.lem and
As,ed a.out Fe-er1 then
CHECK FOR MALNUTRITION AND ANEMIA
THEN CHECK FOR MALNUTRITION AND ANEMIA
-OO0 AND .EE-:
Loo, for -isi.le se-ere 4asting.
Loo, and feel for edema of .oth feet.
Determine 4eight for age.
Cl"ssi3(
NUTRITIONA-
STATUS
-OO0:
Loo, for 0almar 0allor andF or mucous mem.rane (allor. Is it:
Se-ere 0almar andF or mucous mem.rane 0allor
Some 0almar and F or mucous mem.rane 0allor
Cl"ssi3(
ANEMIA
CLASSIFY the Child/s illness using the classification ta.les for %ALN'!*I!I&N and ANE%IA
!hen: CHECK Immuni7ation status1 >itamin A status and &ther 0ro.lems
HOW TO CHEC0 A CHI-D .OR MA-NUTRITION AND ANEMIA
%& LOOK: 3or 4isi!le se4ere %"s'in5&
Se(ere /astin& .)aras$us0
2@
o loo" for visible severe #astin$, remove the child=s clothes.
>oo" for severe #astin$ of the muscles of shoulders, arms, buttoc"s
and le$s.
>oo" to see if the outline of the child=s ribs is easily seen.
>oo" at the child=s hips. hey may loo" small #hen you compare
them #ith the chest % abdomen.
>oo" at the child from the side to see if the fat of the buttoc"s is
missin$. ,hen #astin$ is e(treme, there are many folds of s"in on
the buttoc"s and thi$h. )t loo"s as if the child is #earin$ ba$$y
pants.
he child=s abdomen may be lar$e or distended.
he face of a child #ith visible severe #astin$ may still loo"
normal.
2& LOOK "n FEEL 3or eem" o3 !o'h 3ee'&
/se your thumb to press $ently for a fe# seconds on the
topside of each foot. he child has edema if a dent remains in the
child=s foot #hen you lift your thumb. (See fi&ure% 2/ashior3or 0
'& De'ermine %ei5h' 3or "5e&
1. *alculate the child=s a$e in months.
2. ,ei$h the child accurately. he child should #ear li$ht clothin$.
5. /se the #ei$ht for a$e chart to determine #ei$ht for a$e.
6. <ecide if the child1s #ei$ht for a$e is above, on, or belo# the
bottom curve (#hich represents the 5
rd
percentile).
)f the point is belo# the bottom curve, the child is very
lo# #ei$ht for a$e.
)f the point is above or on the bottom curve, the child is
not very lo# #ei$ht for a$e.
(& LOOK: 3or #"lm"r #"llor.
o see if the child has palmar pallor, loo" at the s"in of the child=s palm. +old the child=s palm
open by $raspin$ it $ently from the side. <o not stretch the fin$ers bac"#ards. his may cause
pallor by bloc"in$ the blood supply. *ompare the color of the child=s palm #ith your o#n palm
and #ith the palms of other children.
HOW TO C-ASSI., NUTRITIONA- STATUS AND ANEMIA
A-- Chilren shoul !e &l"ssi3ie 3or +OTH nu'ri'ion"l S'"'us "n Anemi"
1. Cl"ssi3( 3or NUTRITIONA- STATUS) then
1. Cl"ssi3( 3or ANEMIA
he follo#in$ tables illustrates ho# to classify for nutritional status and for anemia.
There "re 'hree &l"ssi3i&"'ions 3or " &hilBs nu'ri'ion"l s'"'us. The( "re:
SE*ERE MA-NUTRITION: )f the child has visible severe #astin$ or edema of both feet.
*ER, -OW WEI/HT! )f the child is very lo# #ei$ht for a$e.
NOT *ER, -OW WEI/HT: )f the child is not very lo# #ei$ht for a$e and there are no other
si$ns of malnutrition.
21
There "re "lso 'hree &l"ssi3i&"'ions 3or "nemi". The( "re:
SE*ERE ANEMIA: )f the child has severe palmar pallor
ANEMIA: )f the child has some palmar pallor.
NO ANEMIA: )f the child has 0o palmar pallor.
22
Se-ere 0almar 0allor SE#ERE
ANEMIA
Tre"' 'he &hil 'o #re4en' lo% !loo su5"r.
Re3er UR/ENT-, 'o hos#i'"l.
Some 0almar 0allor
ANEMIA
Assess the child/s feeding and counsel the mother on the
feding according to the F&&D .o8 on the %O-$"#&
.O*H#, chart.
$i-e Iron.
$i-e &ral Antimalarial if high malaria ris,
De4orm the child if 2 2ears or older and has not had a dose
in 0re-ious @9 months1 or has e-idence of 4orm infestation
Ad-ise mother 4hen to return immediatel2.
No 0almar 0allor NO
ANEMIA
No Additional treatment
Be3a27e 3-,14/e+ a/e ,+4e8e+4e+.1" 31a77,),e4 )5/ N2./,.,5+a1 7.a.27 a+4 )5/ A+e,a=
.-e" a" 8/e7e+. ?,.- a+" 350,+a.,5+7 5) 31a77,),3a.,5+7= )5/ e@a81e:
'evere malnutrition and severe anemia, or
'evere malnutrition and anemia, or
0ot very lo# #ei$ht and severe anemia, etc.

2&<- CHECK THE CHILDAS IMMUNIBATION STATUS
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1 Chec,ed for
$eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1 As,ed a.out Diarrhea1
Chec,ed for !hroat 0ro.lem1 As,ed a.out Ear (ro.lem1 As,ed a.out Fe-er G Chec,ed for
%alnutrition and Anemia1 then
CHECK IMMUNIBATION STATUS
THEN CHECK THE CHILD IMMUNIBATION STATUS
DECIDE if the child needs an immuni7ation toda21 or if the mother should
.e told to come .ac, 4ith the child at a later date for an immuni7ation.
No'e: ,emember that there are $O contraindications to immuni2ation of a sic3 child
'f the child is 4ell enough to go home
!hen Chec, for >I!A%IN A su00lementation status1 De4orming Status G &!"E* (*&6LE%S
O+SER*E CONTRAINDICATIONS TO IMMUNI;ATION
1. here are only three situations at present #hich are contraindications to immuni.ation:
<o not $ive @*D to a child "no#n to have A)<'.
<o not $ive 3enta 2 or 3enta 5 to a child #ho has had convulsions or shoc" #ithin 5 days of 3enta 1.
<o not $ive 3enta to a child #ith recurrent convulsions or another active neurolo$ical disease.
2. )f a child is $oin$ to be referred, do not immuni.e the child before referral
5. *hildren #ith diarrhea #ho are due for -3A should receive a dose of -3A durin$ this visit.
+o#ever, do not count the dose. he child should return in 6 #ee"s for an e(tra dose of -3A.
TO DECIDE I. THE CHI-D NEEDS AN IMMUNI;ATION TODA,:
*ompare the child=s immuni.ation record #ith the recommended immuni.ation schedule. <ecide
#hether the child has had all the immuni.ations recommended for the child=s a$e.
23
*hec" all immuni.ations the child has already received.
<ecide on any immuni.ations the child needs today.
2+
2&C- CHECK THE #ITAMIN A SUPPLEMENTATION STATUS
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1
Chec,ed for $eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1
As,ed a.out Diarrhea1 Chec,ed for !hroat 0ro.lem1 As,ed a.out Ear (ro.lem1
As,ed a.out Fe-er1 Chec,ed for %alnutrition and Anemia1 and Chec,ed for
Immuni7ation status1 then
CHECK THE CHILDS #ITAMIN A SUPPLEMENTATION STATUS
#ITAMIN A SUPPLEMENTATION
SCHEDULE:
If Child is @9 months or older and has not
recei-ed a dose in the last @9 months1 gi-e a
dose of >itamin A in the clinic
T-e+ ASSESS De?5/,+g S.a.27 a+4 O.-e/ P/501e7
*i'"min A is 5i4en !o'h 'o 're"' "n 'o #re4en' ise"se:

To &he&2 " &hilCs 4i'"min A su##lemen'"'ion s'"'us:
LOOK a. .-e 3-,147 age:
Dive the vit. A supplement if the child is a$e 7 months or older.
LOOK a. .-e 3-,147 3a/4:
'ee if there is a record of previous vitamin A doses. )f no vitamin A has been $iven in the last 7
months, and the child is ?7 months or older, the child should receive a dose. Aitamin A
supplementation is $iven to children a$ed up to 5 +ears
2&%D A77e77 De?5/,+g S.a.27
!any children in 3a"istan have anemia that is caused or made #orse by hoo"#orm infection.
!ebenda.ole is a safe dru$ and #ill reduce or eliminate the infection. After 7 months children often
become reinfected and the treatment should be repeated. -nly children older than 12 months are $iven
this dru$.
2&%%-ASSESS OTHER PROBLEMS
For ALL Children1 after ha-ing As,ed the mother a.out the Child/s (ro.lems1 Chec,ed for
$eneral Danger Signs1 As,ed a.out Cough and Difficult 6reathing1 As,ed a.out Diarrhea1
Chec,ed for Sore throat1 As,ed a.out Ear (ro.lem1 As,ed a.out Fe-er1 Chec,ed for
%alnutrition and Anemia1 Chec,ed for Immunisation and >it. A Su00lementation status1 then
ASSESS OTHER PROBLEMS
ASSESS OTHER PROBLEMS
2)
TREAT &ther (ro.lems according to 2our
training1 e80erience and clinic 0olic2
OR
REFER the child 4ith B&ther (ro.lemsC
2ou cannot manage
he last bo( on the A''E'' A0< *>A'')2C chart reminds you to assess any other problems that the
child may have.
'ince the /((!(( 0 C1/((I)2 chart does not address all of a sic" child=s problems, you #ill no#
assess other problems the mother told you about. 2or e(ample, she may have said the child has a s"in
infection, itchin$ or s#ollen nec" $lands. -r you may have observed another problem durin$ the
assessment. )dentify and treat any other problems accordin$ to your trainin$, e(perience and clinic
policy. Befer the child for any other problem you cannot mana$e in clinic.
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an a00ro0riate anti.iotic
and other urgent treatments.
E@3e8.,5+: *eh2dration of the child according to (lan C ma2 resol-e danger signs so that referral is no longer needed.
29
PART '
ASSESS AND CLASSIFY THE SICK YOUNG INFANT
AGE UP TO 2 MONTHS
SUMMAR, O. ASSESS AND C-ASSI., SIC0 ,OUN/ IN.ANT
GREET the &other appropriately and
ask about her baby*
LOOK to see i! the in!ant-s ,eight and
te&perature ha)e been reorded
$se %ood Communication Ski##s&
- 5isten are!ully to ,hat the &other tells you
- +se ,ords the &other understands
- .i)e the &other ti&e to ans,er the 6uestions
- Ask additional 6uestions i! the &other is not
sure about her ans,er
'ecord Important Information
ASK the &other ,hat the in!ant-s
proble&s are
DETERMINE i! this is an INITIA )isit or !""# UP )isit !or this proble&
7( this is an INITIAL #ISIT !or the
proble&#
7( this is a FOLLOW-UP #ISIT
!or the proble&#
GI#E FOLLOW $UP CARE
(Disussed later in 8art 9"
Chek !or 8>$$7B5% BACTERIAL INFECTION and lassi!y the illness
Chek !or SIGNIFICANT EAUNDICE
Ask the &other or aretaker about
DIARRHEA
7! Diarrhea is present#
Assess !urther !or signs related to diarrhea
Classi!y the illness aording to the signs
,hih are present or absent
Chek !or FEEDING PROBLEM OR LOW WEIGHT and lassi!y the infants nutritional status
Chek the in!ant-s I2+,Fa.,5+ 7.a.27 and deides i! the in!ant needs any i&&uni2ations today
Assess any O.-e/ P/501e7
T-e+# 7denti!y 1reat&ent (8art 4", 1reat the 7n!ant (8art :", and Counsel the ;other (8art <"
2:
'&%- CHECK THE YOUNG INFANT FOR POSSIBLE
BACTERIAL INFECTION
For A-- sik young in!ants hek !or signs o! POSSIBLE BACTERIAL INFECTION
CHECK FOR POSSIBLE BACTERIAL INFECTION
CLASSIFY the infant/s illness using the color3coded classification ta.le
for 0ossi.le .acterial infection
!hen ASK a.out diarrhea1 CHECK for feeding 0ro.lems or lo4 4eight1
Immuni7ation status and for other 0ro.lems
HOW TO CHEC0 .OR POSSI+-E +ACTERIA- IN.ECTION:
his assessment step is done for every sic" youn$ infant. )n this step you are loo"in$ for si$ns of
bacterial infection, especially a serious infection. A youn$ infant can become sic" and die very
.uickly from serious bacterial infections such as pneumonia, sepsis and menin$itis.
)t is important to assess the si$ns in the order on the chart, and to "eep the youn$ infant calm. he
youn$ infant must be calm and may be asleep #hile you assess the first seven signs, that is, loo"in$
for convulsions, countin$ breathin$, loo"in$ for chest indra#in$ and nasal flarin$, loo"in$ and
listenin$ for $runtin$ and #hee.e, and loo"in$ and feelin$ for bul$in$ fontanelle.
o assess the ne(t fe# si$ns, you #ill pic" up the infant and then undress him, loo" at the s"in all over
his body and measure his temperature. @y this time he #ill probably be a#a"e. hen you can see
#hether he is lethar$ic or unconscious and observe his movements.
%& ASK: "s the infant is having difficulty in feeding *
2& ASK: /as the infant had convulsions*
'& LOOK: 0ee if the infant is convulsing now*
(& LOOK: Count the breaths in one minute- 1epeat the count if elevated&
2;
7? breaths per minute or more is the cutoff used to identify fast breathin$ in a youn$
infant. )f the first count is 7? breaths or more, repeat the count. his is important
because the breathin$ rate of a youn$ infant is often irre$ular.
!& LOOK: 2or severe chest indrawing&
!ild chest indra#in$ is normal in a youn$ infant because the chest #all is soft. 'evere
chest indra#in$ is a si$n of pneumonia and is serious in a youn$ infant.
9& LOOK "n LISTEN for grunting"
Druntin$ is the soft, short sounds a youn$ infant ma"es #hen breathin$ out. Druntin$
occurs #hen an infant is havin$ trouble breathin$.

;& LOOK at the umbilicus 5 is it red or draining pus6 !oes t0e redness e4tend to t0e s.in6
)f redness e(tends to the s"in of the abdominal #all, it is a serious infection.
<& FEEL: 3easure a%illary temperature #or feel for fever or low body temperature$-4eep
thermometer in a%illa for at least + minutes- (emp 5 +,-5
o
C is 2ever
2ever may be the only si$n of a serious bacterial infection. Coun$ infants can also respond to
infection by droppin$ their body temperature to belo# 55.5* (57* rectal temperature)..
C& LOOK: 2or skin pustules- 6re there pustules6
3ustules indicate a serious infection.
%D& LOOK: 0ee if the young infant is lethargic or unconscious"
A lethar$ic youn$ infant is not a#a"e and alert #hen he should be. +e may be dro#sy and may
not stay a#a"e after a disturbance. >oo" to see if the child #a"ens #hen the mother tal"s or
$ently sha"es the child or #hen you clap your hands.
An unconscious youn$ infant cannot be #a"ened at all. +e does not respond #hen he is
touched or spo"en to.
%9& LOOK: 6t the young infant7s movements- 6re they less than normal6 8oes the infant move
only when stimulated
An a#a"e youn$ infant #ill normally move his arms or le$s or turn his head several times in a
minute if you #atch him closely. -bserve the infant=s movements #hile you do the assessment.
HOW TO C-ASSI., .OR +ACTERIA- IN.ECTION
*lassify A(( sic" youn$ infants for bacterial infection.
*ompare the infant=s si$ns to si$ns listed and choose the appropriate classification.
)f the infant has any si$n in the top ro#, select AEBC 'EAEBE <)'EA'E.
)f the infant has any si$n in the middle ro#, select >-*A> @A*EB)A> )02E*)-0.
An infant #ho has none of the si$ns is classified as havin$ 9@A*EB)A> )02E*)-0
/0>)GE>C;. 'elect only one classification in this table.
2?
%& POSSIBLE #ERY SE#ERE DISEASE
his youn$ infant needs ur$ent referral to hospital.
@efore referral, $ive a first dose of intramuscular antibiotics.
reat to prevent lo# blood su$ar.
Advise the mother to "eep her sic" youn$ infant #arm is very important.
2& LOCAL BACTERIAL INFECTION
hese youn$ infants have an infected umbilicus or a s"in infection.
reatment includes $ivin$ an appropriate oral antibiotic at home for 5 days.
he mother #ill also treat the local infection at home and $ive home care.
2ollo#-up in 2 days to be sure the infection is improvin$.
'& BACTERIAL INFECTION UNLIKELY
hese youn$ infants have no si$ns, #hich indicate a bacterial infection.
Advise the mother on home care
2ollo#-up in 2 days to be sure that the infection is improvin$.
'&2& CHECK FOR SIGNIFICANT EAUNDICE
*hec" for 4aundice in all infants, particularly in ne#borns. >oo" to the palms and soles of the infant.
)f the 4aundice has started in the 1
st
26 hours after delivery, and is still present or if the 4aundice is
e(tendin$ from the infant1s body to include the limbs as #ell as the palms and soles, it is considered as
significant jaundice, and the infant should be /BDE0>C referred to the hospital.
3@
31
'&'- ASSESS DIARRHEA
For A-- sic, 2oung infants chec, for signs of 0ossi.le .acterial infection1 then
ASK: DOES THE YOUNG INFANT HA#E DIARRHEA
IF YES1 assess and classif2 the 2oung infant/s diarrhea using the DIA**"EA 6&H in
the SIC# &'N$ INFAN! chart. !he 0rocess is -er2 similar to that used for the SIC#
C"ILD A$E 2 months u0 to ) 2ears <(art 2.3=
!hen CHECK for feeding 0ro.lems or Lo4 4eight1 Immunisation status G other 0ro.lems
HOW TO ASSESS DIARRHEA IN A SICK YOUNG INFANT:
Aery similar to that used for the ')*G *+)>< ADE 2 months up to 5 years (3art 2.5)
HOW TO CLASSIFY DIARRHEA IN A SICK YOUNG INFANT:
32
N5.e that there is only one possible classification for persistent diarrhoea in a youn$ infant.
Coun$ infants #ith blood in the stool are classified as severely ill and are referred ur$ently.
)n this a$e $roup, blood in the stool may be caused by a problem, #hich may re8uire sur$ery.
'&(- CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
For A-- sic, 2oung infants chec, for signs of 0ossi.le .acterial infection1 As, a.out Diarrhea1 then
CHECK FOR FEEDING PROBLEMS OR LOW WEIGHT
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT:
AS0: -OO0) -ISTEN) .EE-:
Is the infant .reastfed5 If 2es1
"o4 man2 times in 2+ hours5

Does the infant recei-e an2 other foods or drin,s5 If 2es1 ho4 often5
Determine the 4eight for age.
CLAI!" the in!ant-s nutritional status using the lassi!iation table !or C(%%D7?. 84>B5%; >4 5>W W%7.D1
!hen CHECK Immuni7ation status and &ther 0ro.lems
33
HOW TO AS0 A+OUT .EEDIN/ AND DETERMINE WEI/HT .OR A/E
he assessment has t#o parts.
"n the first part, you as" the mother 8uestions. Cou determine if she is havin$ difficulty feedin$ the
infant, #hat the youn$ infant is fed and ho# often. Cou also determine #ei$ht for a$e.
"n the second part, if the infant has any problems #ith breastfeedin$ or is lo# #ei$ht for a$e, you
assess ho# the infant breastfeeds.
FIRST PART OF ASSESSMENT:
%& ASK: "s there any difficulty feeding6
)f a mother says that the infant is not a3le to feed, assess breastfeedin$ or #atch her try
to feed the infant #ith a cup to see #hat she means by this.
An infant #ho is not a3le to feed may have a serious infection or other life-threatenin$
problem and should be referred ur$ently to hospital.
2& ASK: "s the infant breastfed9 "f yes, how many times in 2* hours6
'& ASK: 8oes the infant usually receive any other foods or drinks9 "f yes, how often9
A youn$ infant should be e(clusively breastfed.
(& ASK: 70at do +o) )se to feed t0e infant6 a feedin$ bottleE or cupE.
!& LOOK: !etermine 1ei-0t for a-e"
/se a #ei$ht for a$e chart to determine if the infant is lo# #ei$ht for a$e.
Remem!er 'h"' 'he "5e o3 " (oun5 in3"n' is usu"ll( s'"'e in %ee2s.
Some (oun5 in3"n's %ho "re lo% %ei5h' 3or "5e %ere !orn %i'h lo% !ir'h%ei5h'.
Some i no' 5"in %ei5h' %ell "3'er !ir'h.
SECOND PART OF ASSESSMENT:
HOW TO ASSESS +REAST.EEDIN/:
2irst decide #hether to assess the infant=s breastfeedin$:
)f the infant is e(clusively breastfed #ithout difficulty and is not lo# #ei$ht for a$e, there
is no need to assess breastfeedin$.
)f the infant is not breastfed at all, do not assess breastfeedin$.
)f the infant has a serious problem re8uirin$ ur$ent referral to a hospital, do not assess
breastfeedin$.
he follo#in$ table (ne(t pa$e) is an illustration of the left part of the *+E*G 2-B 2EE<)0D
3B-@>E! -B >-, ,E)D+ section of the /((!((, C1/((I)2 /4 T+!/T T5! (IC6 2O78
I)/T C5/+T. )t clarifies ho# to chec" for breastfeedin$.
)n the follo#in$ situations, classify the feedin$ based on the information that you have already.
)f the infant=s #ei$ht indicates a difficulty, observe a breastfeed as described belo#.
%& ASK: H"s 'he in3"n' !re"s'3e in 'he #re4ious hour*
)f so, as" the mother to #ait until the infant is #illin$ to feed a$ain. )n the meantime, complete the
assessment of infant.
)f the infant has not fed in the previous hour, as" the mother to put her infant to the breast. -bserve a
#hole breastfeed if possible, or observe for at least 6 minutes.
3+
2& LOOK: Is 'he in3"n' "!le 'o "''"&h*
)f all of the follo#in$ 6 si$ns are present, the infant has /oo A''"&hmen'.
*hin touchin$ breast (or very close)
!outh #ide open
>o#er lip turned out#ard
!ore areola visible above than belo# the mouth
)f the infant is no' %ell "''"&he, you may see any of these si$ns :
*hin not touchin$ breast
!outh not #ide open, lips pushed for#ard
>o#er lip turned in, or
!ore areola (or e8ual amount) visible belo# infant=s mouth than above it.
)f a very sic" infant cannot ta"e the nipple into his mouth and "eep it there to suc",
he has no "''"&hmen' "' "ll- +e is not able to breastfeed at all.
3. L&&#: Is 'he in3"n' su&2lin5 e33e&'i4el(* he infant is 723:1,+g e))e3.,6e1" if:
+e suc"les #ith slo# deep suc"s and sometimes pauses.
,hen the breastfeed finishes, the infant is satisfied )f he releases the breast
spontaneously. he infant appears rela(ed, sleepy, and loses interest in the breast.
An infant is +5. 723:1,+g e))e3.,6e1" if
+e is ta"in$ only rapid, shallo# suc"s.
Cou may also see indra#in$ of the chee"s.
Cou do not see or hear s#allo#in$.
he infant is not satisfied at the end of the feed, and may be restless.
+e may cry, try to suc"le a$ain, or continue breastfeed for a lon$ time.
An infant #ho is no' su&2lin5 "' "ll is not able to suc" breastmil" into his mouth and
s#allo#. herefore he is not able to breastfeed at all.
)f a !lo&2e nose seems to interfere #ith breastfeedin$, clear the infant=s nose. hen chec" #hether
the infant can suc"le more effectively.
3)
(& LOOK: .or ul&ers or %hi'e #"'&hes in 'he mou'h ?'hrushA.
HOW TO C-ASSI., .EEDIN/ PRO+-EM OR -OW WEI/HT:
Accordin$ to the follo#in$ table, there are three possible classifications:
%& FEEDING PROBLEM OR LOW WEIGHT
his includes infants #ho are lo# #ei$ht for a$e or infants #ho have some si$n that their
feedin$ needs improvement. 'uch infant needs to return to the health #or"er for follo#-up.
2& NO FEEDING PROBLEM
39
'&!-CHECK THE YOUNG INFANTAS IMMUNIBATION STATUS
For A-- sic, 2oung infants chec, for signs of 0ossi.le .acterial infection1 As,ed
A.out Diarrhea and Chec,ed for Feeding (ro.lem1 then
CHECK FOR THE YOUNG INFANTS IMMUNIBATION STATUS
THEN CHECK THE YOUNG INFANTS IMMUNIBATION STATUS:
IMMUNIBATION SCHEDULE
AGE
6irth
9 Iee,s
#ACCINE
6C$ &(>3@
(enta-alent 1 &(>31
*hec" immunisation status 4ust as you #ould for an older infant or youn$ child.
'&9-ASSESS OTHER PROBLEMS
Assess any other problems mentioned by the mother or observed by you. Befer to any $uidelines on
treatment of the problems. )f you thin" the infant has a serious problem, or you do not "no# ho# to
help the infant, refer the infant to a hospital.
3:
PART (
IDENTIFY TREATMENT
ASSESS ALL Sic, Children and Sic, oung Infants1
CLASSIF their illness according to a00ro0riate classification ta.les1 then
DETERMINE IF URGENT REFERRAL IS NEEDED
I) YES I) NO
IDENTIFY 2/ge+. 8/e-
/e)e//a1 ./ea.e+.(7) +ee4e4
IDENTIFY ./ea.e+.(7) )5/ 8a.,e+.7
?-5 45 +5. +ee4 2/ge+. /e)e//a1
GI#E 8/e-/e)e//a1 ./ea.e+. (7)
,4e+.,),e4
TREAT .-e 7,3: 3-,14 5/ .-e 7,3:
"52+g ,+)a+.
REFER .-e 3-,14 5/ "52+g
,+)a+.
TEACH .-e 3-,14 3a/e.a:e/ -5? .5
G,6e ./ea.e+.7 a. -5e
COUNSEL .-e 3a/e.a:e/ a052.
)ee4,+g= )12,47 a+4 ?-e+ .5 /e.2/+
GI#E FOLLOW-UP CARE ?-e+ .-e ,+)a+. 5/ 3-,14 /e.2/+7 .5 .-e 31,+,3 a+4=
I) +e3e77a/"= /ea77e77 )5/ +e? 8/501e7 (Pa/. ;)
DETERMINE I. SIC0 ,OUN/ IN.ANT NEEDS UR/ENT RE.ERRA-
)f the sic" youn$ infant has 3-'')@>E 'EB)-/' @A*EB)A> )02E*)-0.
3-'')@>E 'EB)-/' @A*EB)A> )02E*)-0 & 'EAEBE <E+C<BA)-0.
'EAEBE <E+C<BA)-0 (and 0- serious bacterial infection): if i.v. therapy could not be $iven
at your clinic, refer to hospital.
DETERMINE I. SIC0 CHI-D NEEDS UR/ENT RE.ERRA-
All severe classifications on the /((!(( 0 C1/((I)2 chart are coloured pin" and include:
AEBC 'EAEBE <)'EA'E (children havin$ DE0EBA> <A0DEB ')D0).
'EAEBE 30E/!-0)A -B AEBC 'EAEBE <)'EA'E.
'EAEBE <E+C<BA)-0.
'EAEBE 3EB')'E0 <)ABB+EA.
+B-A A@'*E''.
!A'-)<))'.
AEBC 'EAEBE 2E@B)>E <)'EA'E.
'EAEBE *-!3>)*AE< !EA'>E'.
'EAEBE !A>0/B))-0 -B 'EAEBE A0E!)A.
-+EB 'EAEBE 3B-@>E!' that cannot be treated at the clinic.
0otice the instruction GRe)e/ URGENTLY .5 -578,.a1G in the lists of treatments for these
classifications. his instruction means to refer the child immediately after $ivin$ any necessary pre-
referral treatments.
E@3e8.,5+7: 2or 'EAEBE 3EB')'E0 <)ABB+EA or some -+EB 'EAEBE 3B-@>E!',
the instruction is simply to JRe3er 'o hos#i'"l.J his means that referral is needed, but not as
3;
ur$ently. here is time to identify treatments as described in section 2.? of this module and $ive all of
the treatments before referral.
3?
IDENTI., UR/ENT PREDRE.ERRA- TREATMENT?SA
Ur5en' #reDre3err"l 're"'men's 3or si&2 (oun5 in3"n's "5e u# 'o 1 mon'hs:
Dive 1
st
dose of intramuscular or oral antibiotics.
Advise the mother ho# to "eep the infant #arm on the #ay to hospital.
reat to prevent lo# blood su$ar ($ivin$ breastmil", mil", or su$ar #ater).
Befer ur$ently to hospital #ith mother $ivin$ fre8uent sips of -B' on the #ay.
Advise mother to continue breastfeedin$.
Ur5en' #reDre3err"l 're"'men's 3or si&2 &hilren "5e 1 mon'hs u# 'o 5 (e"rs:
reat convulsions if present no# ($ive sodium valproate rectally).
Dive an appropriate antibiotic.
Dive vitamin A.
reat the child to prevent lo# blood su$ar ($ivin$ breastmil", mil", or su$ar #ater).
reat #hee.in$ if present ($ive rapid actin$ bronchodilator).
Dive paracetamol for hi$h fever (5J.5* or above) or pain from mastoiditis.
Apply tetracycline eye ointment (if cloudin$ of the cornea or pus drainin$ from eye).
3rovide -B', so that mother can $ive fre8uent sips on the #ay to the hospital.
RE.ER THE CHI-D: <o four steps to refer a child to the hospital:
.1 !#plain to the mother the need for referral, and get her agreement to ta3e the child. If you
suspect that she does not want to ta3e the child, find out why.
.2 Calm the mother9s fears and help her resolve any problems.
.5 :rite a referral note for the mother to ta3e with her to the hospital. Tell her to give it to the
health wor3er there.
.6 8ive the mother any supplies and instructions needed to care for her child on the way to the
hospital.
IDENTI., TREATMENT .OR PATIENTS WHO DO NOT NEED
UR/ENT RE.ERRA-:
he treatments that may be needed are in the :)dentify reatment: column of the /((!(( 0
C1/((I)2 chart. Cou #ill consider only the treatments that apply to the specific child bein$ treated.
@e sure to include items that be$in #ith the #ords :2ollo#-up.: hese mean to tell the mother to
return in a certain number of days.
WHEN TO RETURN IMMEDIATE-,:
2or all children $oin$ home, you #ill advise the mother #hen to return immediately. his means to
teac0 the mother certain si$ns that mean to return immediately for further care. hese si$ns are listed
on the CO7(!1 T5! MOT5!+ chart in the section ,+E0 - BE/B0. /se local terms that the
mother #ill understand.
A46,7e 5.-e/ .5 /e.2/+ ,e4,a.e1" ,) .-e 3-,14 -a7 a+" 5) .-e7e 7,g+7 :
An2 sic, child Not a.le to drin, or .reastfeed
6ecomes sic,er
De-elo0s a fe-er
If child has N& (NE'%&NIA )
C&'$" &* C&LD1 also return if )
Fast .reathing
Difficult .reathing
If child has Diarrhea1 also return if ) 6lood in stool
Drin,ing 0oorl2
+@
PART !
TREAT THE SICK CHILD AGE 2 MONTHS UP TO ! YEARS
he )!*) chart titled TREAT THE CHI-D sho#s ho# to do the treatment steps identified on the
ASSESS AND C-ASSI., chart. !*EA! means $ivin$ treatment in the clinic, prescribin$ dru$s or
other treatments to be $iven at home, and also teachin$ the child1s mother or careta"er ho# to carry
out the treatments.
The TREAT THE CHI-D &h"r' es&ri!es ho% 'o
Dive oral dru$s,
reat local infections,
Dive intramuscular dru$s,
reat the child to prevent lo# blood su$ar,
Dive e(tra fluid for diarrhea and continue feedin$, and
Dive follo#-up care.
Tre"'men' in 'he &lini& "lso in4ol4es:
eachin$ the child1s mother or careta"er to $ive oral dru$s at home.
eachin$ the child1s mother or careta"er to treat local infections at home.
*ounsellin$ the mother or careta"er about feedin$ and fluids.
*ounselin$ the mother or careta"er #hen to return to the health facility.
TREAT THE SICK YOUNG INFANT AGE UP TO 2 MONTHS
'imilar instructions to those listed above, but more appropriate for youn$ infants, are included in the
TREAT THE ,OUN/ IN.ANT AND COUNSE- THE MOTHER section of the ASSESS)
C-ASSI., AND TREAT THE SIC0 ,OUN/ IN.ANT chart.
PART 9
COUNSEL THE MOTHER
)t is important to have $ood communication #ith the mother or careta"er from the be$innin$ of the
visit. /sin$ $ood communication helps to reassure the mother or careta"er that the child #ill receive
$ood care. A youn$ infant or child #ho is treated at clinic needs to continue treatment at home. he
success of home treatment depends on ho# #ell you communicate #ith the child1s mother or
careta"er. 'he needs to "no# ho# to $ive the treatment. 'he also needs to understand the importance
of the treatment.
Counsellin5 'he mo'her in4ol4es 'he 3ollo%in5 '"s2s:
1. Assessin$ the child=s feedin$.
2. )dentifyin$ feedin$ problems.
5. *ounsellin$ the mother about feedin$ problems.
6. Advisin$ the mother to increase fluid durin$ illness.
5. Advisin$ the mother #hen to return to health #or"er. his includes:
Advisin$ the mother #hen to return for follo#-up visits.
Advisin$ the mother #hen to return immediately for further care.
Advisin$ the mother #hen to return for immuni.ations.
7. *ounselin$ the mother about her o#n health.
9&%- ASSESSING THE CHILDAS FEEDING: "ssess 3eein5 o3 &hilren %ho:
are classified as havin$ A0E!)A -B >-, ,E)D+, or
are less than 2 years old.
+1
o assess feedin$, as" the mother the follo#in$ 8uestions. hese 8uestions are at the top of the
CO7(!1 T5! MOT5!+ chart and also at the bottom of the ')*G *+)>< BE*-B<)0D 2-B!.
hese 8uestions #ill help you find out about the child=s usual feedin$ and feedin$ durin$ this illness:
FOOD
Assess 'he ChilCs .eein5
As, Kuestions a.out the child/s usual feeding and feeding during this illness.
Com0are the mother/s ans4ers to the .eein5 Re&ommen"'ions
for the child/s age in the .o8 .elo4.
AS0 D Do 2ou .reastfeed 2our child5
3 "o4 man2 times during the da25
3 Do 2ou also .reastfeed during the night5
Does the child ta,e an2 other food or fluids5
3 Ihat food or fluids5
3 "o4 man2 times 0er da25
3 Ihat do 2ou use to feed the child5
3 If lo4 4eight for age: "o4 large are ser-ings5
Does the child recei-e his o4n ser-ing5 Iho feeds the child and ho45
During this illness1 has the child/s feeding changed5 If 2es1 ho45
>isten for correct feedin$ practices as #ell as those that need to be chan$ed. Cou may loo" at the
feedin$ recommendations for the child=s a$e on the CO7(!1 T5! MOT5!+ chart as you listen to
the mother. )f an ans#er is unclear, as" another 8uestion. 2or e(ample, if the mother of a lo#-#ei$ht
child says that servin$s are :lar$e enou$h,: you could as", :,hen the child has eaten, does he still
#ant moreE:
9&2- IDENTIFYING FEEDING PROBLEMS
)t is important to complete the assessment of feedin$ and identify all the feedin$ problems before
$ivin$ advice. @ased on the mother=s ans#ers to the feedin$ 8uestions, identify any differences
bet#een the child=s actual feedin$ and the recommendations. )n addition to differences from the
feedin$ recommendations, some other problems may become apparent from the mother=s ans#ers.
E(amples of such problems are:
D,)),321." 0/ea7.-)ee4,+g
he mother may mention that breast-feedin$ is uncomfortable for her, or that her child seems
to have difficulty breast-feedin$. )f so, you #ill need to assess breast-feedin$ as described on
the /((!((, C1/((I)2 /4 T+!/T T5! (IC6 2O78 I)/T chart.
U7e 5) )ee4,+g 05..1e
2eedin$ bottles should not be used. hey are often contaminated, and or$anisms easily $ro#
in them. Also, suc"in$ on a bottle may interfere #ith the child=s desire to breast-feed.
La3: 5) a3.,6e )ee4,+g
Coun$ children often need to be encoura$ed and assisted to eat. his is especially true if a
child has lo# #ei$ht. )f a youn$ child is left to feed himself, or if he has to compete #ith
siblin$s for food, he may not $et enou$h to eat. @y as"in$, :,ho feeds the child and ho#E:
you #ill find out if the child is actively bein$ encoura$ed to eat.
N5. )ee4,+g ?e11 42/,+g ,11+e77
he child may be eatin$ much less, or eatin$ different foods durin$ illness. *hildren often
lose their appetite durin$ illness. +o#ever, they should still be encoura$ed to eat the types of
food recommended for their a$e, as often as recommended, even if they do not eat much.
U7e 5) 5.-e/ ,1: 5/ )5547 0e)5/e 9 5+.-7
+2
)nfants youn$er than 7 months should receive only breastmil". !other usually offers other
mil" #hen she thin"s that her mil" is insufficient. @uild the mother1s confidence that she can
produce all the mil" that her child needs. 'u$$est more fre8uent and lon$er breast-feeds,
includin$ at ni$ht. Dradually reduce other mil"s or food.
I+72)),3,e+. 0/ea7. ,1:
)n such case, teach the mother ho# to increase the mil" supply as follo#s: -
Apply moist heat to breasts 5-5 minutes before feedin$.
!assa$e breasts before and durin$ feedin$.
Dently stimulate the nipple and areola.
2eed or e(press mil" fre8uently (J-12 times in 26 hours).
E(press or pump mil" bet#een feedin$s.
Eat a nutritious food.
<rin" fluids each time you feed your baby or pump mil".
I+)a+. 5.-e/ 7e8a/a.,5+
his problem is common for #or"in$ mother #ho leaves her child in the e(clusive breast-
feedin$ period. 'o instead of offerin$ other mil" or food to the child, teach the mother ho#
to e(press the breast mil" and the #ay of stora$e and feedin$ of the e(pressed breast mil".
Fee4,+g .55 7a11 a52+.7
!others often do not reco$nise that increased amounts of food are re8uired as the child
$ro#s. )ncreasin$ the amount of food that is actively offered to the child, food inta"e #ill
usually increase.
9&'- COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS
his section covers the third section of the CO7(!1 chart. 'ince you have identified feedin$
problems, you #ill be able to limit your advice to #hat is most relevant to the mother.
E.:.1D /I*E RE-E*ANT AD*ICE
)f the feedin$ recommendations are bein$ follo#ed and there are no problems, *raise the mother
for her $ood feedin$ practices. Encoura$e her to "eep feedin$ the child the same #ay durin$
illness and healthL
)f the feedin$ recommendations for the child=s a$e are not bein$ follo#ed, e(plain those
recommendations.
)f you have found any of the problems listed on the chart in the section :Counsel the Mother /bout
)eeding ;roblems,: $ive the mother the recommended advice:
Cou learned to chec" and improve positionin$ and attachment in the part on: Management of the
(ic3 2oung Infant. )f the mother has a breast problem, such as en$or$ement, sore nipples, or a
breast infection, then she may need referral to a specially trained breast-feedin$ counsellor.
)f a child under 6 months old is receivin$ food or fluids other than breastmil", the $oal is to
$radually chan$e bac" to more or e(clusive breast-feedin$. 'u$$est $ivin$ more fre8uent, lon$er
breast-feeds, day and ni$ht. As breast-feedin$ increases, the mother should $radually reduce other
mil" or food. 'ince this is an important chan$e in the child=s feedin$, be sure to as" the mother to
return for follo#-up in 5 days.
)n some cases, chan$in$ to more or e(clusive breast-feedin$ may be impossible (for e(ample, if the
mother never breast-fed, if she must be a#ay from her child for lon$ periods, or if she #ill not
breast-feed for personal reasons). )n such cases, the mother should be sure to correctly prepare
co#=s mil" or other breastmil" substitutes and use them #ithin an hour to avoid spoila$e. )t is
important to use the correct amount of clean, boiled #ater for dilution. A cup is better than a bottle.
A cup is easier to "eep clean and does not interfere #ith breast-feedin$.
+3
)f you find that the mother is not actively feedin$ her child: Even thou$h children often lose their
appetites durin$ illness, they should be encoura$ed to eat the types of food recommended for their
a$e, as often as recommended. -ffer the child=s favourite nutritious foods to encoura$e eatin$.
++
-ffer small feedin$s fre8uently. After illness, $ood feedin$ helps ma"e up for any #ei$ht loss and
prevent malnutrition.
E.:.1D USE /OOD COMMUNICATION S0I--S
ASK a+4 LISTEN: 2ou have already learned the importance of as3ing <uestions to assess the
child9s feeding. 1isten carefully to find out what the mother is already
doing for her child. Then you will 3now what she is doing well, and what
practices need to be changed.
PRAISE: It is li3ely that the mother is doing something helpful for the child, for
e#ample, breast=feeding. ;raise the mother for something helpful she has
done. >e sure that the praise is genuine, and only praise actions that are
indeed helpful to the child.
AD#ISE: 1imit your advice to what is relevant to the mother at this time. 7se
language that the mother will understand. If possible, use pictures or real
ob?ects to help e#plain. )or e#ample, show amounts of fluid in a cup or
container.
/dvise against any harmful practices that the mother may have used.
:hen correcting a harmful practice, be clear, but also be careful not to
ma3e the mother feel guilty or incompetent. !#plain why the practice is
harmful.
CHECK MOTHERS
UNDERSTANDING:
/s3 <uestions to find out what the mother understands and what needs
further e#planation. /void as3ing leading <uestions (that is, <uestions
which suggest the right answer) and <uestions that can be answered with
a simple yes or no.
!#amples of good chec3ing <uestions are" @:hat foods will you give your
childA@ @5ow often will you give themA@ If you get an unclear response,
as3 another chec3ing <uestion. ;raise the mother for correct
understanding or clarify your advice as necessary.

E.:.:D USE /OOD COMMUNICATION S0I--S
A !other=s *ard can be $iven to each mother to help her remember appropriate food and fluids, and
#hen to return to the health #or"er. he !other=s *ard has #ords and pictures that illustrate the main
points of advice.
9&(- AD#ISE THE MOTHER TO INCREASE FLUID DURING ILLNESS
<urin$ illness a child loses fluid due to fever, fast breathin$, or diarrhea. he child #ill to
drin" e(tra fluid to prevent dehydration. *hildren #ith diarrhea should be $iven fluid
accordin$ to 3lan A or @ as described on the T+!/T chart.
!others of breast-feedin$ children should offer the breast fre8uently.
Advice about fluid is summari.ed in the bottom part of T+!/T chart.
9&!- AD#ISE THE MOTHER WHEN TO RETURN
EAEBC mother #ho is ta"in$ her child home needs to be advised #hen to return to the health #or"er.
'he may need to return:
+)
2or a .O--OWDUP *ISIT in a specific number of days (for e(ample, #hen it is necessary to
chec" pro$ress on an antibiotic),
+9
IMMEDIATE-,, if si$ns appear that su$$est the illness is #orsenin$, or
2or the child=s ne(t IMMUNI;ATION (the ne(t WE--DCHI-D *ISIT=.
)t is especially important to teach the mother the si$ns to return immediately. Cou learned these si$ns
in part 6 9Identify TreatmentB. hese si$ns mean that additional care is needed for serious illness.
9&9- COUNSEL THE MOTHER ABOUT HER OWN HEALTH
<urin$ a sic" child visit, listen for any problems that the mother herself may be havin$. he mother
may need treatment or referral for her o#n health problems.
PART ;
GI#E FOLLOW-UP CARE
'ome sic" children need to return to the health #or"er for follo#-up. heir mothers are told #hen to
come for a follo#-up visit (such as in 2 days, or 16 days).
At a follo#-up visit, you should do different steps than at a child=s initial visit for a problem.
reatments $iven at the follo#-up visit are often different than those $iven at an initial visit.
Where is .ollo%Du# Dis&usse on 'he C"se M"n"5emen' Ch"r's$
1. .or 'he si&2 &hil:
)n the :)dentify reatment: column of the 600E00 : C;600"2< chart, some classifications have
instructions to tell the mother to return for follo#-up. he :,hen to Beturn: bo( on the C&'0E;
(/E 3&(/E1 chart summari.es the schedules for follo#-up visits.
'pecific instructions for conductin$ each follo#-up visit are in the :Dive 2ollo#-/p *are: section of
the TREAT THE CHI-D chart. he bo(es have headin$s that correspond to the classifications on the
ASSESS F C-ASSI., chart. Each bo( tells ho# to reassess and treat the child. )nstructions for
$ivin$ treatments, such as dru$ dosa$es for a second-line antibiotic, are on the TREAT THE CHI-D
chart.
1. .or 'he si&2 (oun5 in3"n':
2ollo#-up instructions are on the 8I*! )O11O:=7; C/+! )O+ T5! (IC6 2O78 I)/T part
of the ASSESS1 C-ASSI., AND TREAT THE SIC0 ,OUN/ IN.ANT chart.
Ho% 'o M"n"5e " Chil Who Comes 3or .ollo%Du#:
'teps for conductin$ a follo#-up visit:
<ecidin$ if the child=s visit is for follo#-up.
)f the child has been brou$ht for follo#-up, assessin$ the si$ns specified in the follo#-up bo( for
the child=s previous classification.
Assessin$ ne1 problems other than the specified classification are present.
'electin$ treatment based on the child=s si$ns.
)f the child has any ne# problems, assessin$ and classifyin$ them as you #ould in an initial visit.
Divin$ the treatment.
I85/.a+.: )f a child or youn$ infant #ho comes for follo#-up has several problems and is $ettin$
#orse1 RE.ER TO HOSPITA-. Also refer the child or infant to hospital if a second-line dru$ is not
available, or if you are #orried about the child or do not "no# #hat to do for the patient. )f a child or
infant has not improved #ith treatment, he or she may have a different illness than su$$ested by the
chart and may need other treatment.
+: