Integrated Management of Childhood Illness

Assessandclassifythesickchildaged2monthsupto5years
ASSESSANDCLASSIFY
CHECKFORGENERALDANGERSIGNS THENASKABOUTMAINSYMPTOMS: Doesthechildhavediarrhoea? 4 5 6 Doesthechildhavefever? Doesthechildhaveanearproblem? THENCHECKFORMALNUTRITIONANDANAEMIA 7 8 9 CHECKFORHIVINFECTION WHOPAEDIATRICCLINICALSTAGINGFORHIV THENCHECKTHECHILD'SIMMUNIZATION,VITAMINAAND DEWORMINGSTATUS 10 11 12

TREATTHECHILD
TEACHTHEMOTHERTOGIVEORALDRUGSATHOME GiveanAppropriateOralAntibiotic GiveanAppropriateOralAntibioticforDYSENTERY Givecotrimoxazoleprophylaxis GiveOralAntimalarial GiveparacetamolforFeverorEarpain GiveVitaminA Giveironandorfolate GiveMebendazoleoralbendazole GiveInhaledSalbutamolforWheezing 14 14 14 14 15 15 15 15 16 16

Giveoralsalbutamol TeachCaretakertoGiveARVs GivepainreliefforChronicPain TreatOpportunisticInfections TEACHTHEMOTHERTOTREATLOCALINFECTIONSATHOME TreatEyeInfectionwithTetracyclineEyeOintment CleartheEarbyDryWickingandGiveEardrops* TreatMouthUlcerswithGentianVioletGV TREATTHRUSHWITHORALNYSTATIN SoothetheThroat,RelievetheCoughwithaSafeRemedy GIVETHESETREATMENTSINTHECLINICONLY

16 18 18 18 19 19 19 19 19 19 20

GiveanIntramuscularAntibiotic Giveintramuscularquinine GiveDiazepamtoStopConvulsions TreattheChildtoPreventLowBloodSugar Giveepinephrine GIVEEXTRAFLUIDFORDIARRHOEAANDCONTINUEFEEDING PlanA:TreatDiarrhoeaatHome PlanB:TreatSomeDehydrationwithORS PlanC:TreatSevereDehydrationQuickly IMMUNIZEANDGIVEVITAMINATOEVERYSICKCHILD,AS NEEDED

20 20 20 21 21 21 22 22 23 23

FOLLOWUP
GIVEFOLLOWUPCARE PNEUMONIA PERSISTENTDIARRHOEA DYSENTERY 24 24 24 26

ORALTHRUSH MALARIA MEASLESWITHEYEORMOUTHCOMPLICATIONS EARINFECTION

26 26 27 27

FEEDINGPROBLEM VERYLOWWEIGHT ANAEMIA HIVINFECTION

27 27 27 28

COUNSEL
FOOD AssesstheFeedingofSickchildUnder2Yearsorifchildhasverylow weightforage FeedingRecommendationsDuringSicknessandHealth FOOD 29 30 31 32 67

FeedingRecommendationsForaChildWhoHasPERSISTENT DIARRHOEA CounseltheMotherAboutFeedingProblems Counsel CounseltheMotheraboutherOwnHealth

32 32 33 33

FLUID AdvisetheMothertoIncreaseFluidDuringIllness WHENTORETURN

33 33 34

RecordingForm

MaryGenericJune2011

Assess,classifyandtreatthesickyounginfantagedupto2months
ASSESSANDCLASSIFY
CHECKFORVERYSEVEREDISEASEANDLOCALBACTERIAL INFECTION THENASK:Doestheyounginfanthavediarrhoea*? CHECKFORJAUNDICE 36 37 37 THENCHECKFORHIVINFECTION THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFOR AGE:FORBREASTFEEDINGINFANTS THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFOR AGEinNONbreastfedinfants 38 39 40 THENCHECKTHEYOUNGINFANT'SIMMUNIZATIONANDVITAMIN ASTATUS: ASSESSOTHERPROBLEMS 41 41

TREATANDCOUNSEL
TREATTHEYOUNGINFANTANDCOUNSELTHEMOTHER GiveFirstDoseofIntramuscularAntibiotics TreattheYoungInfanttoPreventLowBloodSugar TeachtheMotherHowtoKeeptheYoungInfantWarmontheWayto theHospital GiveanAppropriateOralAntibioticforLocalBacterialInfection 42 42 43 43 44

TeachtheMothertoTreatLocalInfectionsatHome ToTreatDiarrhoea,SeeTREATTHECHILDChart. ImmunizeEverySickYoungInfant,asNeeded COUNSELTHEMOTHER TeachCorrectPositioningandAttachmentforBreastfeeding

45 45 45 46 46

TeachtheMotherHowtoExpressBreastMilk TeachtheMotherHowtoFeedbyaCup TeachtheMotherHowtoKeeptheLowWeightInfantWarmatHome AdvisetheMothertoGiveHomeCarefortheYoungInfant

46 46 46 46

FOLLOWUP
GIVEFOLLOWUPCAREFORTHEYOUNGINFANT ASSESSEVERYYOUNGINFANTFOR"VERYSEVEREDISEASE" DURINGFOLLOWUPVISIT LOCALBACTERIALINFECTION 47 47 47 69

DIARRHOEA JAUNDICE FEEDINGPROBLEM

48 48 49

LOWWEIGHTFORAGE THRUSH

50 50

RecordingForm

Annex
AnnexA:SkinandMouthConditions
IdentifySkinProblem Ifskinisitching IdentifySkinProblem Ifskinhasblisters/sores/pustules 51 52 53 53 IdentifyPapularLesions NonItchy MouthProblems Thrush 54 54 55 55 HerpesSimplex ASSESS,CLASSIFYANDTREATSKINANDMOUTHCONDITIONS Clinicalreaction DrugandAllergicReactions 56 57 58 58

AnnexB:ARVdosagesand combinations
ARVdosagetables EfivarenzEFV AbacavirABC Stavudined4T 59 59 59 59

Lamivudine3TC LamivudineforPMTCTprophylaxisinnewborns CombinationARVdosages DualFDCs

59 59 60 60

DualFDCs TripleFDCs TripleFDCs

60 60 60

AnnexC:ARVsSIDEEFFECTS AnnexD:DRIEDBLOODSPOTDBS COLLECTIONFORPCRSUMMARY AnnexE:TOMEASUREMIDUPPER ARMCIRCUMFERENCEMUAC

HOWTOMEASUREMIDUPPERARMCIRCUMFERENCEMUAC STEPSFORMEASURINGMIDUPPERARM CIRCUMFERENCEMUAC 65 65

SideEffects*

61

AgoodhealthcareworkercarryingoutDBSprocedurewill:

62

Assess and classify the sick child aged 2 months up to 5 years

ASSESS AND CLASSIFY ASSESS
ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS problem. TO CLASSIFY THE ILLNESS if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. if initial visit, assess the child as follows:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS

Ask: Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions? Look: See if the child is lethargic or unconscious. Is the child convulsing now?

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

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THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing?
If yes, ask: For how long? Look, listen, feel: Count the breaths in one minute. Look for chest indrawing. Look and listen for stridor. Look and listen for wheezing. CHILD MUST BE CALM No signs of pneumonia or very severe disease. Green: COUGH OR COLD Classify COUGH or DIFFICULT BREATHING Any general danger sign or Chest indrawing or Stridor in calm child. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA Give first dose of an appropriate antibiotic If wheezing give a rapid acting bronchodilator or subcutanousadrenaline Refer URGENTLY to hospital* Give oral antibiotic for 5 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 2 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 3 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 5 days if not improving

Fast breathing.

If wheezing and either fast breathing or chest indrawing: Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again, and then classify. If the child is: 2 months up to 12 months 12 Monts up to 5 years Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more

* If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care. ** In settings where inhaled bronchodilator is not available, oral salbutamol may be the second choice.

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Does the child have diarrhoea?

If yes, ask: Look and feel: For how long? Look at the child's general condition. Is the child: Is there blood in the stool? Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If child has no other severe classification: Give fluid for severe dehydration (Plan C) OR If child also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for cholera Give fluid, zinc supplements, and food for some dehydration (Plan B) If child also has a severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving Give fluid, zinc supplements, and food to treat diarrhoea at home (Plan A) Advise mother when to return immediately Follow-up in 5 days if not improving Treat dehydration before referral unless the child has another severe classification Refer to hospital Give fluids Plan A Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give Vitamin A, multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

for DEHYDRATION Classify DIARRHOEA

Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

Dehydration present. and if diarrhoea 14 days or more No dehydration.

Pink: SEVERE PERSISTENT DIARRHOEA Yellow: PERSISTENT DIARRHOEA

and if blood in stool

Blood in the stool.

Yellow: DYSENTERY

Give ciprofloxacin for 3 days Treat dehydration and gve zinc Follow-up in 2 days

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Does the child have fever?

(byhistoryorfeelshotortemperature37.5C*orabove) If yes: Then ask: Look and feel: Classify For how long? Look or feel for stiff neck. FEVER If more than 7 days, has Do Rapid Diagnostic Test fever been present every (RDT) or Microscopy if NO day? general danger sign or Has the child had measles stiff neck. If malaria test is within the last 3 months? negative look for other causes of fever*** Look for signs of MEASLES. Generalized rash and One of these: cough, runny nose, or red eyes. Look for any other cause of fever. Malaria test NEGATIVE. Runny nose PRESENT or Measles PRESENT or Other cause of fever PRESENT Green: FEVER : NO MALARIA Any general danger sign or Stiff neck. Pink: VERY SEVERE FEBRILE DISEASE Give first dose of quinine or artesunate for severe malaria Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar Give one dose of paracetamol in clinic for highfever(38.5Corabove) Refer URGENTLY to hospital Give recommended first line oral antimalarial Give one dose of paracetamol in clinic for highfever(38.5Corabove) Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment Assess for possible bacterial cause of fever*** and treat with appropriate drugs Give one dose of paracetamol in clinic for high fever(38.5Corabove) Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days, refer for assessment Give Vitamin A treatment Give first dose of an appropriate antibiotic If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment Refer URGENTLY to hospital Give Vitamin A treatment If pus draining from the eye, treat eye infection with tetracycline eye ointment If mouth ulcers, treat with gentian violet Follow-up in 2 days Give Vitamin A treatment

Malaria test POSITIVE.**

Yellow: MALARIA

If the child has measles now or within the last 3 months:

Look for mouth ulcers. Are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea.

If MEASLES now or within last 3 months, Classify

Any general danger sign or Clouding of cornea or Deep or extensive mouth ulcers.

Pink: SEVERE COMPLICATED MEASLES****

Pus draining from the eye or Mouth ulcers.

Yellow: MEASLES WITH EYE OR MOUTH COMPLICATIONS**** Green: MEASLES

Measles now or within the last 3 months.

*Thesetemperaturesarebasedonaxillarytemperature.Rectaltemperaturereadingsareapproximately0.5Chigher. ** If no malaria test available and NO obvious cause of fever - classify as MALARIA. ***Look for local tenderness, refusal to use a limb, hot tender swelling, red tender skin or boils, lower abdominal pain or pain on passing urine. **** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.

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Does the child have an ear problem?

If yes, ask: Is there ear pain? Is there ear discharge? If yes, for how long? Look and feel: Look for pus draining from the ear. Classify EAR PROBLEM Feel for tender swelling behind the ear. Tender swelling behind the ear. Pus is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain. Pus is seen draining from the ear and discharge is reported for 14 days or more. No ear pain and No pus seen draining from the ear. Pink: MASTOIDITIS Yellow: ACUTE EAR INFECTION Give first dose of an appropriate antibiotic Give first dose of paracetamol for pain Refer URGENTLY to hospital Give an antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Follow-up in 5 days Dry the ear by wicking Treat with topical quinolone eardrops for 2 weeks Follow-up in 5 days No treatment

Yellow: CHRONIC EAR INFECTION Green: NO EAR INFECTION

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THEN CHECK FOR MALNUTRITION AND ANAEMIA

CHECK FOR MALNUTRITION LOOK AND FEEL: For all children Determine weight for age Look for oedema of both feet Look for visible severe wasting For children aged 6 months or more Determine if MUAC* less than 110 mm Pink: If age up to 6 months: and visible severe SEVERE wasting MALNUTRITION or oedema of both feet If age 6 months and above and: MUAC less than 110 mm or oedema of both feet or visible severe wasting Very low weight for age Yellow: VERY LOW WEIGHT Treat the child to prevent low blood sugar Refer URGENTLY to hospital

CLASSIFY NUTRITIONAL STATUS

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

Not very low weight for age and no other signs of malnutrition

Green: NOT VERY LOW WEIGHT

CHECK FOR ANAEMIA LOOK AND FEEL: Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? CLASSIFY

Severe palmar pallor

ANAEMIA Some palmar pallor

Pink: SEVERE ANAEMIA Yellow: ANAEMIA

Refer URGENTLY to hospital

Give iron Give oral antimalarial if high malaria risk Give mebendazole if child is 1 years or older and has not had a dose in the previous 6 months Advise mother when to return immediately Follow-up in 14 days If child is less than 2 years old, assess the child's feeding and counsel the mother on feeding according to the feeding recommendations If feeding problem, follow-up in 5 days

No palmar pallor

Green: NO ANAEMIA

* MUAC is mid-upper arm circumference. If tapes are not available, look for oedema of both feet or visible severe wasting.

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CHECK FOR HIV INFECTION

If a child is already on ART or is HIV infected do not enter this box. Positive HIV antibody test in a child 18 months old or stopped breastfeeding 3 months ago OR Positive HIV virological test Yellow: CONFIRMED HIV INFECTION Treat counsel and follow up other classifications Give cotrimoxazole porphylaxis daily Check immunisation status Give vitamin A supplement every 6 months from 6 months of age Assess the child's feeding and counsel on feeding according to the FOOD BOX on the Counsel the caretaker chart Stage the disease and refer for further assessment including HIV care/ART Advise the caretaker on home care Treat counsel and follow up other classifications Give cotrimoxazole porphylaxis daily Check immunisation status Give vitamin A supplement every 6 months from 6 months of age Assess the child's feeding and counsel on feeding according to the FOOD BOX on the Counsel the caretaker chart test to confirm HIV INfection Stage disease and refer for further assessement including HIV care/ART If child less than 18 months collect dried blood spot sample and refer sample for PCR (check annex for DBS procedure) Advise the caretaker on home care Treat counsel and follow up other classifications Give cotrimoxazole porphylaxis daily Check immunisation status Give vitamin A supplement every 6 months from 6 months of age Assess the child's feeding and counsel on feeding according to the FOOD BOX on the Counsel the caretaker chart Confirm HIV infection status of child as soon as possible with best available test Treat counsel and follow-up other classifications. Advice the caretaker about feeding and about her/his own health Counsel and offer HIV testing Treat, counsel and follow-up other classifications Counsel the caretaker about feeding and about her/his own health

NOTE OR ASK IF CHILD HAS:

LOOK AND Classify FEEL for HIV Any enlarged Child HIV status Mothers HIV infection lymph glands is: status now in two or seropositive Seropositive more of the PCR positive Seronegative following Seronegative Unknown* sites: Neck, PCR negative axilla or unknown* groin? Is there oral; Pnuemonia thrush? Persistent diarrhoea now Check Chronic ear infection now for parotid Very low weight or growth faltering enlargement Is there parotid enlargment for 14 days or more

No test done or no test results in a child with 2 or more conditions OR Positive antibody test in a child less than 18 months with 2 or more conditions

Yellow: SUSPECTED SYMPTOMATIC HIV INFECTION

Mother HIV positive and no test result on child with less than 2 conditions OR Child less than 18 months with positive antibody test with less than 2 conditions

Yellow: POSSIBLE HIV INFECTION or HIV EXPOSED

No test done or no test results Green: in child or mother OR less than SYMPTOMATIC two conditions HIV INFECTION UNLIKELY Negative HIV test in the mother or child Green: HIV INFECTION UNLIKELY

*If the HIV status is unknown and the child has no severe classification offer PITC.

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WHO PAEDIATRIC CLINICAL STAGING FOR HIV

Has the child beeen confirmed HIV infection? If yes, perform clinical staging: any one condition in the highest staging determinanes stage, If no, you cannot stage the patient. WHO Paediatric Clinical stage 1Asymptomatic Growth WHO Paediatric Clinical stage 2- mild Disease WHO Paediatric Clinical stage 3 - Moderate Disease WHO Paediatric Clinical stage 4 - Severe Disease (AIDS)

Moderate unexplained malnutrition not responding to standard therapy

Severe unexplained wasting/stunting/severe malnutrition not responding to srtandard therapy

Symptoms/ No symptoms or only: signs Persistant Generalised Lymphadenopathy (PGL)

unexplained persistent enlarged liver and/or spleen Unxeplained persistent enlarged parotid glands Skin conditions (prurigo, seborrhoeic dermatitis, extensive molleuscum contegiosum or warts, fungal nail infections, herpes zoster) Mouth conditions (recurrent mouth ulcerations, gingival erythema) Recurrent or chronic RTI (sinusitis, ear infections, tonsilitis, otorrhoea) Indicated only if CD4 or TLC# is available: Same as stage 1 OR 11moand TLC3000 cells 36 - 59 mo and TLC 2500cells 58 years and TLC 2000cells* *There is not adequate data for children older than 8 years.

Oral thrush ( outside neonatal period) Oral hairy leucoplakia Unexplained and unresponsive to standard therapy; Diarrhoea > 14 days Fever more than 1 month thrombopcytopeania* (< 50,000/mm3 for more than 1 month) Neutropenia* (< 500/mm3 for 1 month Aneamia for > 1 month (heamoglobin < 8gm)* Recurrent severe bacterial pneumonia Pulmonary TB Lymphonoid TB Symptomatic LIP* Acute necrotising ulcerative givingivitis/periodontitis Chronic HIV assosiated lung disease including bronchiectasis*

Oesophageal thrush More than 1 month of herpes simplex ulcerations Severe multiple or recurrent bacterial infections2episodesinayear(not includinig pneumonia) Pneumocystis pneumonia (PCP)* Kaposis sarcoma Extra pulmonary TB Toxoplasma brain abcess* Cryptococcal meningitis* Chronic cryptosporidiosis Chronic isosporiasis Acquired HIV-associated rectal fistula HIV encephalopathy* Cerebral B cell non-Hodgkins lymphoma* Symptomatic HIV associated cardiomyopathy/nephropathy*

ARV Therapy

Indicated only if CD4 is available: 11moand CD4 25%(or1500 cells) 12 - 35 mo and CD4 20%(or750 cells ) 36 - 59 mo and CD415%(or 350cells) 5yearsand CD415% (<200 cells/mm3)

ART is indicated ; ART is indicted: Child less than 12 Irrespective of the CD4 count, and shoulkd months, regardless of be started as soon as possible CD4 Child is over 12 months usually regardless of CD4 but if LIP/ TB/ Oral hairy leucoplakia - ART Initiation may be delayed if CD4 obove age related threshhold for advanced or severe imune deficiency

Notethattheseareinterimrecommendationsandmaybesubjecttochange. # Total lymphocyte count (TLC) has been proposed as surrogate marker or an alternative to CD4 cell count or CD4% in resource - constrained settings *conditions requiring diagnosis by a Doctor or medical officer - should be refered for appropriate diagnosis and treatment InachildwithpresumptivediagnosisofsevereHIVdisease,whereitisnotpossibletoconfirmHIVinfection,ARTmaybe initiated .

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THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

IMMUNIZATION SCHEDULE: If the child did not receive OPV- 0 at birth or within 13 days after birth, give OPV- 4 at 9 months with measles VITAMIN A SUPPLEMENTATION VITAMIN A SUPPLEMENTATION SCHEDULE AGE BIRTH to 6 months 6 months up to 5 years FREQUENCY NONE* Every 6 months Follow national guidelines AGE VACCINE Birth BCG 6 weeks DPT-Hib-HepB1 10 weeks DPT-Hib-HepB2 14 weeks 9 months 15 Months DPT-Hib-HepB3 Measles 1 Measles 2

OPV-0 OPV-1 OPV-2 OPV-3

Rota vacine1 Pnuemo1 Rota vacine 2 Pnuemo2 Pnuemo3

*Exception: Give 50,000 IU for infants less than 6 months who are not breastfed. Record the dose on the child's card. ROUTINE WORM TREATMENT Give every child mebendazole every 6 months from the age of one year. Record the dose on the child's card. * Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.

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THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

ASSESS AND LOOK IF THE CHILD HAS OTHER PROBLEMS MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Exception: Rehydration of the child according to plan C may resolve danger signs so that referral is no longer needed. check the blood sugar in all children with a general dangar sign and treat or prevent low blood sugar ASSESS THE CARETAKER'S HEALTH NEEDS ASK Do you have any health problems yourself? . Do you want help with family planning Did you bring your health card? If yes, may I please look at the card? If applicable check whether the caretaker needs Tetanus toxoid or vitamin A supplementation

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TREAT THE CHILD

CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.
Determine the appropriate drugs and dosage for the child's age or weight. Tell the mother the reason for giving the drug to the child. Demonstrate how to measure a dose. Watch the mother practise measuring a dose by herself. Ask the mother to give the first dose to her child. Explain carefully how to give the drug, then label and package the drug. If more than one drug will be given, collect, count and package each drug separately. Explain that all the oral drug tablets or syrups must be used to finish the course of treatment, even if the child gets better. Check the mother's understanding before she leaves the clinic.

Give an Appropriate Oral Antibiotic for DYSENTERY

Give antibiotic recommended for Shigella in your area for 3 days. FIRST-LINE ANTIBIOTIC FOR SHIGELLA: Ciprofloxacin. SECOND-LINE FOR SHIGELLA: ___________ CIPROFLOXACINE 15mg/kg/dose Give 2 times daily for 5 days ADULT TABLET (250mg) 1/4 1/2 1 SYRUP (?mg/5ml) 5.0ml 5.0ml 10ml

AGE or WEIGHT

2 months up to 4 months (4 - < 6 kg) 4 months up to 12 months (6 - < 10 kg) 12 months up to 5 years (10 - < 19kg)

Give an Appropriate Oral Antibiotic

FOR PNEUMONIA, ACUTE EAR INFECTION: FIRST-LINE ANTIBIOTIC: AMOXICILLIN SECOND-LINE ANTIBIOTIC: ERYTHROMYCIN AGE or WEIGHT 2 months up to 4 months (4 - <6kg) 2 months up to 12 months (4-<10kg) 4 months up to 12 months (6 - <10kg) 12 months up to 5 years (10-19kg) AMOXICILLIN Give 3 times daily for 5 days Tablet 250mg Syrup 125mls/5mls 1/2 1 5mls 10mls 1/2 1 5mls 10mls ERYTHROMYCIN Give four times daily for 5 days Tablet 250mg Syrup 125mls/5mls 1/4 2.5mls

Give cotrimoxazole prophylaxis

FOR CHILDRN WITH HIV INFECTION COTRIMOXAZOLE Trimethoprim + sulphamethoxazole Give once a day for life Adult tablet 80mg trimethoprim + 400mg sulphamethoxazole 6 weeks up to 2 months (2.5 <5kg) 2 monhts up to 12 months (5 -<10kg) 12 months up to 3 years (10 - <14kg) 3 years up to 5 years (14 -20kg) 1/4 1/2 1/2 1 Paediatric tablet 20mg trimethoprim + 100mg sulphamethoxazole 1 2 2 3 Suspension 40mg trimethoprim + 200mg sulphamethoxazole per 5mls 2.5mls 5mls 5mls 7.5mls

AGE or WEIGHT

FOR CHOLERA: FIRST-LINE: ERYTHROMYCIN (There maybe some variation depending on the vibrio cholerae sensitivity) Give four times daily for 3 days SEE DOSES ABOVE___________________________________________ NOTE: Remember that the most important life saving interventions for cholera patients is immediate and appropriate rehydration

NOTE: Remember that cotrimoxazole prophylaxis should only be given to children who are exposed to HIV infection or have confirmed HIV infection.

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TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.

Give paracetamol for Fever or Ear pain

For high fever (38.5 C and above) or ear pain Give every 6 hours until high fever or ear pain is gone AGE or WEIGHT 2 months up to 3 years (4 -<14kg) 3 years up to 5 years (14 -<19kg) PARACETAMOL Tablet 100mg Tablet 500mg 1 1/4 2 1/2 1/2

Give Oral Antimalarial

FIRST-LINE ANTIMALARIAL: ARTEMETHER-LUMEFANTRINE (AL) Give Sulfadoxine + Pyrimethamine if cjild is less than 5kg or AL is not available SECOND - LINE ANTIMALARIAL: ORAL QUININE If Artemether-Lumefantrine (AL) Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child vomits within an hour repeat the dose. Give second dose at home after 8 hours. Then twice daily for further two days as shown below. Artemether-lumefantrine should be taken with food. Explain to the caretaker to watch the child carefully for 30 minutes after giving a dose of artemether-lumefantrine. If the child vomites within 30 minutes, inform the caretaker to repeat the dose and return to the clinic for additional tablets If Sulfadoxine + Pyrimethamine: Give single dose in the health center per table below using the fixed dose combination Artemether-Lumefantrine tablets (20 mg artemether and 120 mg lumefantrine) Give first dose in the clinic, 2nd dose after 8 hours Then twice daily for 2 days TABLET (Give twice daily) 2 months up to 12 months (5 <10kg) 2 months up to 3 years (5 <15 kg) 12 months - 3 years (10 <14kg) 3 years to 5 years (15 - <25 kg) SYRUP

Give Vitamin A
Explain to the mother why the drug is given Determine the dose appropriate for the child's weight (or age) Measure the dose accurately VITAMIN A SUPPLEMENTATION: Give first dose any time after 6 months of age to ALL CHILDREN Thereafter vitamin A every six months to ALL CHILDREN VITAMIN A TREATMENT: For measles and persistent diarhoea Give three doses: First dose in the clinic Second dose to be given at home the next day Third dose to be given at home at least two weeks after the first dose For severe measles and severe persistent diarrhoea Give one dose before referral If the child has had a dose of vitamin A within the past month, DO NOT GIVE VITAMIN A. Always record the dose of Vitamin A given on the child's card. AGE 200 000 IU Capsule VITAMIN A CAPSULES 100 000 IU Capsule 1/2 1 2 50 000 IU Capsule 1 2 4

AGE or WEIGHT

Sulfadoxine + Pyrimethamine (give single dose in the clinic)

TABLET (500mg sulfadoxine + pyrimethamine) 1/2

Up to 6 months 6 up to 12 months One year and older 1/2 1

1 1 2

7-12mls 14-17mls 20-28mls 3/4 1

Give iron and or folate

for pallor unless the child is severely ill or is known to have sickle cell anaemia Give one dose daily for 14 days AGE or WEIGHT 2 months up to 4 months (4 -<6kg) 4 months up to 12 months (6 -<10kg) 12 months up to 3 years (10 -<14kg) 3 years up to 5 years (14 - 19kg) IRON/FOLATE TABLET (60mg elemental iron) IRON FOLATE Iron Syrup - Ferrous sulphate 100mg Iron tablet - Ferrous sulphate TABLET 5mg per 5 mls (20mg elemental iron per ml) 50mg (10mg elemental iron) 1ml (<1/4tsp) 1.25mls (1/2 tsp) 1/2 1/2 2ml (<1/2tsp) 2.5ml (1/2tsp) 2 2 4 5 1 1 1 1

NOTE: Artemeter-lumefantine is not recommended for children below 5kg. It is more accurate to use body weight than age to determine dosage If ORAL QUININE: Show the caretaker to give the medicine by giving the first dose in clinic. Give the doses for 7 days for the caretaker to give at home. Explain to the caretaker to watch the child carefully for 30 minutes after giving a dose of quinine. if the child vomits within 30 minutes inform the caretaker to repeat the dose and return to the clinic for additional tablets AGE or WEIGHT 2 months up to 4 months (4 - <6kg) 4 months up to 12 months (6 - <10kg) 12 moths up to 3 years (10 - <14kg) 3 years up to 5 years (14 - 19kg) QUININE (10mg/kg) Give three times daily for 7 days (with the first dose in clinic) TABLET 300mg TABLET 100mg SYRUP (100mg per 5mls) 1/4 1/2 2.5mls 1/4 3/4 3.75mls 1/2 1 5mls 1/2 1 1/2 7.5mls

Page15of74

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.

Give oral salbutamol

For wheezing with no respiratory distress (chest indrawing) AGE or WEIGHT 2 months up to 12 months (<10kg) 12 months up to 5 years (10-19kg) SALBUTAMOL Give three times a day TABLET (2mg) TABLET (4mg) 1/2 1/4 1 1/2

Give Mebendazole or albendazole

Give 500 mg mebendazole as a single dose in clinic if: the child has palmar pallor the child is 1 years of age or older, and the child has not had a dose in the previous 6 months. AGE or WEIGHT 12 up to 24 months (10 - 12kg) 24 months or more (>12kg) MEBENDAZOLE Tablet 500mg tablet 100mg tablet 1 5 1 5 ALBENDAZOLE 200mg tablet 400mg tablet 1 1/2 2 1

Teach Caretaker to Give ARVs

ARV DOSAGES Efavirenz (EFZ) 15 mg/kg/day (capsule or tablet) for age 3 years or more Once daily Capsule 200mg 1 1 1 1 2 3 Capsule 100mg Capsule 50mg 1 1 1 1 OR STAVUDINE (d4T) 1mg/kg/dose (to maximum 30mg dose) Give dose twice daily Solution 6mls Capsule 15mg Capsule 20mg 1/2 1 1 1 ABACAVIR (ABC) 8mg/kg/dose (to maximum dose of 300mg/dose) Give dose twice daily Syrup 20mg/ml 2mls 3mls 4mls 5mls 5mls 6mls If no syrup give tablet Tablet 300mg Capsule 30mg 1 If no capsule give tablet Tablet 600mg

WEIGHT (kg)

Give Inhaled Salbutamol for Wheezing

Inhaled salbutamol is given to a child with weezing who has chest indrawing. Inhaled salbutamol should be given with a spacer USE OF A SPACER* A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. Fromsalbutamolmetereddoseinhaler(100g/puff)give2puffs. Repeat up to 3 times every 15 minutes before classifying pneumonia. Spacers can be made in the following way: Use a 500ml drink bottle or similar. Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. This can be done using a sharp knife. Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the bottle. Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as a mask. Flame the edge of the cut bottle with a candle or a lighter to soften it. In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. Alternatively commercial spacers can be used if available. To use an inhaler with a spacer: Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. The child should put the opening of the bottle into his mouth and breath in and out through the mouth. A carer then presses down the inhaler and sprays into the bottle while the child continues to breath normally. Wait for three to four breaths and repeat. For younger children place the cup over the child's mouth and use as a spacer in the same way. * If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler. INHALED SALBUTAMOL MDI - Metered dose inhaler 100ng/puff Nebulised salbutamol (2.5ml nebule) 2 - 5 puffs using a spacer in the clinic Dilute 0.5 ml in 2ml saline Nebulise in the clinic

10-13.9 14-19.9 20-24.9 25-29.9 30-39.9 40 and over

WEIGHT (kg)

5-5.9 6-9.9 10-13.9 14-24.9 25 and above

WEIGHT (kg)

5-5.9 6-6.9 7-9.9 10-10.9 11-11.9 12-13.9 14-19.9 20-24.9 25 and above

OR OR

1/2 1/2 1/2 1 AM and 1/2 PM 1

WEIGHT (kg)

LAMIVUDINE (3TC) I4mg/kg/dose (to maximum 150mg dose) Give dose twice daily Syrup 10mg/ml If no syrup give tablet Tablet 150mg

30 DAYS OR OLDER 5-6.9 7-9.9 10-11.9 12-13.9 14-19.9 20-24.9 25kg and above

3mls 4mls 5mls 6mls

OR

1/2 1/2 1 AM and 1/2 PM 1

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TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.

Teach Caretaker to Give ARVs

ARV DOSAGES Efavirenz (EFZ) 15 mg/kg/day (capsule or tablet) for age 3 years or more Once daily Capsule 200mg 1 1 1 1 2 3 Capsule 100mg Capsule 50mg 1 1 1 1 OR STAVUDINE (d4T) 1mg/kg/dose (to maximum 30mg dose) Give dose twice daily Solution 6mls Capsule 15mg Capsule 20mg 1/2 1 1 1 ABACAVIR (ABC) 8mg/kg/dose (to maximum dose of 300mg/dose) Give dose twice daily Syrup 20mg/ml 2mls 3mls 4mls 5mls 5mls 6mls If no syrup give tablet Tablet 300mg Capsule 30mg 1 If no capsule give tablet Tablet 600mg

WEIGHT (kg)

10-13.9 14-19.9 20-24.9 25-29.9 30-39.9 40 and over

WEIGHT (kg)

5-5.9 6-9.9 10-13.9 14-24.9 25 and above

WEIGHT (kg)

5-5.9 6-6.9 7-9.9 10-10.9 11-11.9 12-13.9 14-19.9 20-24.9 25 and above

OR OR

1/2 1/2 1/2 1 AM and 1/2 PM 1

WEIGHT (kg)

LAMIVUDINE (3TC) I4mg/kg/dose (to maximum 150mg dose) Give dose twice daily Syrup 10mg/ml If no syrup give tablet Tablet 150mg

30 DAYS OR OLDER 5-6.9 7-9.9 10-11.9 12-13.9 14-19.9 20-24.9 25kg and above

3mls 4mls 5mls 6mls

OR

1/2 1/2 1 AM and 1/2 PM 1

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WEIGHT Syrup 10mg/ml 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 11.9 12 - 13.9 14 - 19.9 20 - 24.9 25 - 29.9 6 ml 7 ml 8 ml 9 ml 10 ml 11 ml

zidovudine (AZT or ZDV) TREATMENT DOSE: 180-240 mg/meter square/dose Give dose twice daily If no syrup give capsule or tablet Capsule 100mg/ Tablet 300mg

Give pain relief for Chronic Pain

Safe doses of paracetamol can be slightly higher for pain. use the table and teach mother to measure the right dose Give paracetamol every 6 hours if pain persists Stage 2 pain is chronic severe pain as might happen in illness such as HIV infection Start treating Stage 2 pain with regular paracetamol In older children, 1/2 tablet of paracetamol can replace 10mls syrup If the pain is not controlled, add regular codeine 4 hourly For severe pain morphine syrup can be given 1/2 1/2 1AM & 1/2 PM AGE or WEIGHT 2 months up to 4 months (4 -<6kg) 4 months up to 12 months (6 <10kg) 12 months up to 2 years (10 -<12kg) 2 to 3 years (12 -<14kg) 3 to 5 years (14 -<19kg) Syrup (120mg/5mls) 2mls 2.5mls 5mls 7.5mls 10mls PARACETAMOL TABLET 100mg 1 1 2 2 1/2 2 1/2 TABLET 500mg 1/4 1/4 1/4 1/2 1/2 CODEINE ORAL MORPHINE 30mg Tablet 5ng/5mls 1/4 1/4 1/2 1/2 3/4 0.5mls 2mls 3mls 4mls 5mls

or or or

1 1 1 2 2 2

WEIGHT

Neverapine (NVP) TREATMENT: Maintenence dose: 160 - 200mg/msq/ dose (To maximum 200mg twice daily dose) Maintenwence dose - give dose twice daily Lead - in dose during weeks 1 and 2 = only give AM dose Syrup 10 mg/ml 6 ml 7 mls 8 mls 9 mls 9 mls 10 mls 11 mls If no syrup give tablet Tablet 200mg

5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10 - 11.9 12 - 13.9 14 - 24.9 25 and above PMTCT prophylaxis in newborns

Treat Opportunistic Infections

or or or 1/2 1/2 1/2 1 AM & 1/2 PM For oral thrush or oesophageal candidiasis. WEIGHT (Kg) 3 - < 6 kg 6 - < 10 Kg 10 - < 15 Kg 15 - < 20 Kg 20 - < 29 Kg 50 mg Tablet Fluconazole dosage 50 mg/5ml oral suspension 5 ml once a day 7.5 ml once a day 12.5 ml once a day 50 mg capule 1 1-2 2-3 Nystin oral suspension 100000 unit/ml 1 - 2 ml four times per day for all age group " " " "

weight in kgs Unknown weight 1 -1.9 2 -2.9 3 - 3.9 4 - 4.9 COMBINATION ARV DOSAGES

Niverapine 2 mg/kg/dose Give within 72 hours of birth once daily Dose 0.6 ml 0.2 ml 0.4 ml 0.6 ml 0.8 ml Stavudine + Lamivudine (d4T - 3TC) 30 mg d4T/ 150 mg 3TC tablet AM 1/2 1 1 PM 1/2 1/2 1

Zidovidine 10mg /ml Give 4 mg/kg/ dose twice daily Dose 0.4 ml 0.8 ml 1.2 ml 1.6 ml

FOR FUNGAL SKIN AND NAIL INFECTION Weight 3 - < 6 kg 6 - < 10 kg 10 - 19 kg Griseofulvin 10 mg/kg/ day 10 mg/kg/day once a day 10 mg/ kg/ day once a day 10 mg/ kg/day once a day Acyclovir dosage Dose, frequence and duration 200mg 8 hourly for 5 days 400mg 8 hourly for 5 days Cloxacillin / Flucloxacillin dosage every 6 hour for 5 days Capsule 250 mg 1 1 2 Suspension 125 mg / 5 mls 5 mls 10 mls 10 mls 20 mls Ketaconazole 20 mg once daily 40 mg once daily 60mg once daily

FOR HERPES SIMPLEX OR HERES ZOSTER INFECTION Stavoidine + Lamividine + Niverapine (d4T - 3TC - NVP) 30 mg d4T/ 150 mg 3TC/ 200mg NVP tablets AM 1/2 1 1 PM 1/2 1/2 1 Age of child < 2 years > 2 years

Weight (Kg)

10 - 13.9 14 - 24.9 25 - 34.9 WEIGHT (Kg) 14 - 19.9 20 - 29.9 30 or above

FOR SEVERE STAPHYLOCOCAL INFECTION OF MOUTH OF SKIN WEIGHT 3 - < 6 kg 6 - < 10 kg 10 - < 15 kg 15 - < 20 kg

Zidovidine + Lamivudine (ZDV- 3TC = AZT- Zidovudine + Lamivudine + Abacavir(ZDV-3TC-ABC = AZT-3TC 3TC) ABC) 300mg ZDV/ 150 mg 3TC tablet 300 mg ZDV/150mg 3TC/ 300mg ABC tablet AM PM AM PM 1/2 1/2 1/2 1/2 1 1/2 1 1/2 1 1 1 1

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TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

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

TREAT THRUSH WITH ORAL NYSTATIN

Treat thrush four times daily for 7 days: Wash hands. Wetacleansoftclothwithsaltwateranduseittowashchildsmouth. Instill nystatin 1 ml four times a day Avoid feeding for 20 minutes after medication. If breastfed, check mothers breast for thrush. If present, treat with nystatin. Advise mother to wash breast after feed. If bottle fed advise change to cup and spoon If severe, recurrent or pharyngeal thrush consider symptomatic HIV and refer Give paracetamol if needed for pain (Page 14) Follow-up if not improving.

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 3 times daily. Wash hands. Use clean cloth and water to gently wipe away pus. Then apply tetracycline eye ointment in both eyes 3 times daily. Squirt a small amount of ointment on the inside of the lower lid. Wash hands again. Treat until there is no pus discharge or redness is gone. Do not use other ointments or drops, or put anything else in the eye.

Soothe the Throat, Relieve the Cough with a Safe Remedy

Safe remedies to recommend: Breast milk for a breastfed infant. Tea with sugar or honey Lemon drink Cough syrup with codein, ephedrine, atropine or alcohol

Harmful remedies to discourage:

Clear the Ear by Dry Wicking and Give Ear drops*

Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, strong tissue paper into a wick. Place the wick in the child's ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry. If chronic ear infection, instill quinolone eardrops after dry wicking three times daily for two weeks. * Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.

Treat Mouth Ulcers with Gentian Violet (GV)

Treat mouth ulcers twice daily. Wash hands. Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water. Paint the mouth with half-strength gentian violet (0.25% dilution). Wash hands again. Continue using GV for 48 hours after the ulcers have been cured. Give paracetamol for pain relief.

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GIVE THESE TREATMENTS IN THE CLINIC ONLY

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

Give intramuscular quinine

FOR VERY SEVERE FEBRILE ILLNESS For children being referred with very severe febrile disease: Check which quinine formulation is avaiable in your clinic Give first dose of intramuscular quinine and refer child urgently to hospital. If referral is not possible: Give first dose of intramuscular quinine The child should remain lying down for at least one hour Repeat the quinine injection at 4 and 8 hours later and then every 8 hours until the child is able to take an oral antimalarial INTRAMUSCULAR QUININE 300mg/ml (in 2ml ampoules) Give 10mg/kg/dose Draw up this dose of undiluted quinine in a syringe 2 months up to 4 months (4-<6kg) 4 months up to 12 months (6 -<10kg) 12 months up to 2 years (10 -<12kg) 2 years up to 3 years (12 <14kg) 3 years up to 5 years (14 19kg) 0.2ml 0.3ml 0.4ml 0.5ml 0.6ml Add this amount of normal saline 0.8ml 1.2ml 1.6ml 2ml 2.4ml Total diluted solution to administer (60mg/ml) 1ml 1.5ml 2ml 2.5ml 3ml

Give an Intramuscular Antibiotic

FOR SEVERE PNEUMONIA OR SEVERE DISEASE OR VERY SEVERE FEBRILE ILLNESS OR MASTOIDITIS For children being referred urgently: Give first dose of intramuscular benzylpenicillin and gentamicin and refer child urgently to hospital. If referral is not possible: Repeat the benzylpenicillin every 6 hours and gentamicin injection every 8 hours for 5 days. Then change to an appropriate oral antibiotic to complete 10 days of treatment. Do not attempt to treat with benzylpenicillin alone. GENTAMICIN BENZYLPENICILLIN 2ml/40mg/ml To a vial of 600mg (1 000 000 IU): add 2.1ml vial of sterile water = 2.5mls at 400 000IU/ml Give 2.5mg Give 50 000IU per kg exactly per kg 0.3 ml 0.45 ml 0.55 ml 0.75 ml 1 ml 0.8 ml 1 ml 1.2 mls 1.5 ml 2 ml CHLORAMPHENICOL 40mg/kg Add 5.0ml sterile water to vial containing 1 000mg = 5.6ml at 180mg/ml 1 ml = 180mg 1.5 ml = 270mg

AGE or WEIGHT

AGE or WEIGHT

2 up to 4 months (4 <6 kg) 4 up to 9 months (6 <8 kg) 9 months up to 12 months (8-<10kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg)

Give Diazepam to Stop Convulsions

Manage the airway: Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. If the lips and tongue are blue, open the mouth and make sure the airway is clear If necessary, remove secretions from the throat through a catheter inserted through the nose Draw up the dose of diazepam into a small syringe and remove the needle Insert approximately 5cm of nasogastric tube into the rectum Inject the diazepam solution int the nasogastric tube and flush it with room-temperature water. Hold buttocks together for a few minutes.

2ml = 360mg 2.5 ml = 450mg 3.5 ml = 630mg Give diazepam rectally

Check for low blood sugar, then treat or prevent. If high fever (38.5 C or above): Sponge the child with luke warm water Give oxygen and REFER If convulsions have not stopped after 10 minutes repeat diazepam dose AGE or WEIGHT <6months (<5 kg) 6 months up to 12months (5-<10 kg) 12 months up to 3 years (10-<14 kg) 3 years up to 5 years (14-19 kg) DIAZEPAM 10mg/2mls Dose 0.5mg/kg 0.5 ml 1.0 ml 1.25 ml 1.5 ml

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GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed: If the child is not able to breastfeed but is able to swallow: Ask the mother to breastfeed the child. Give expressed breast milk or a breast-milk substitute. If neither of these is available, give sugar water*. Give 30 - 50 ml of milk or sugar water* before departure. Give 50 ml of milk or sugar water* by nasogastric tube. (See severe malnutrition guidelines for IV Dextrose) To treat low sugar give 2ml/kg body weight of 10% dextrose

If the child is not able to swallow:

* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water.

Give epinephrine
For wheezing with respiratory distress PREPARATION Subcutaneous ephinephrine (adrenaline) 1:1 000= 0.1% DOSE 0.01ml per kg body weight

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

(See FOOD advice on COUNSEL THE MOTHER chart)

Plan B: Treat Some Dehydration with ORS

In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS WEIGHT AGE* In ml < 6 kg Up to 4 months 200 - 450 6 - <10 kg 4 months up to 12 months 450 - 800 10 - <12 kg 12 months up to 2 years 800 - 960 12 - 19 kg 2 years up to 5 years 960 - 1600

Plan A: Treat Diarrhoea at Home

Counsel the mother on the 4 Rules of Home Treatment: 1. Give Extra Fluid 2. Give Zinc Supplements 3. Continue Feeding 4. When to Return.
1. GIVE EXTRA FLUID (as much as the child will take) TELL THE MOTHER: Breastfeed frequently and for longer at each feed. If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water. It is especially important to give ORS at home when: the child has been treated with Plan B or Plan C during this visit. the child cannot return to a clinic if the diarrhoea gets worse. TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME. SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother to: Give frequent small sips from a cup. If the child vomits, wait for 10 minutes. Then continue, but more slowly. Continue giving extra fluid until the diarrhoea stops. 2. GIVE ZINC TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab): Up to 6 months 1/2 tablet daily for 10 days 6 months or more 1 tablet daily for 10 days SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup. Older children - tablets can be chewed or dissolved in a small amount of water. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN

* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75. If the child wants more ORS than shown, give more. For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this period if you use standard ORS. This is not needed if you use new low osmolarity ORS. SHOW THE CARETAKER HOW TO GIVE ORS SOLUTION. Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding whenever the child wants. AFTER 4 HOURS: Reassess the child and classify the child for dehydration. Select the appropriate plan to continue treatment. Begin feeding the child in clinic. IF THE CARETAKER MUST LEAVE BEFORE COMPLETING TREATMENT: Show her how to prepare ORS solution at home. Show her how much ORS to give to finish 4-hour treatment at home. Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A. Explain the 4 Rules of Home Treatment: 1. GIVE EXTRA FLUID 2. GIVE ZINC (age 2 months up to 5 years) 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN

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GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO DOWN.
START HERE Can you give intravenous (IV) YES fluid immediately? NO Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normal saline), divided as follows AGE First give 30 ml/kg Then give 70 ml/kg in: in: Infants (under 12 months) 1 hour* 5 hours Children (12 months up to 5 30 minutes* 2 1/2 hours years) * Repeat once if radial pulse is still very weak or not detectable. Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip or give ORS by naso-gastric tube. Start rehydratin by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours while waiting for transfer: 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, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment. NOTE: If the child is not referred to hospital, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.

Is IV treatment available nearby (within 30 minutes)? NO

YES

Are you trained to use a nasoYES gastric (NG) tube for rehydration? NO Can the child drink? NO Refer URGENTLY to hospital for IV or NG treatment YES

IMMUNIZE AND GIVE VITAMIN A TO EVERY SICK CHILD, AS NEEDED

When immunizing, make sure you explain to the caretaker: Type of immunization and protection side effects of the vaccines When to return for the next immunization(s) How to give the vitamin A capsule at home When to return for the next vitamin A supplementation

When give vitamin A, make sure you explain to the caretaker:

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FOLLOW-UP
GIVE FOLLOW-UP CARE
Care for the child who returns for follow-up using all the boxes that match the child's previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

PERSISTENT DIARRHOEA
After 5 days: Ask: Has the diarrhoea stopped? How many loose stools is the child having per day? Check for HIV infection if it was not done before Treatment: If the diarrhoea has not stopped(child is still having 3 or more loose stools per day), do a full reassessment of the child. Treat for dehydration if present. Then refer to hospital. If the diarrhoea has stopped(child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child's age. SHE SHOULD CONTinue giving zinc and multivitamins

PNEUMONIA
After 2 days:

Check the child for general danger signs. Assess the child for cough or difficult breathing. Ask:

See ASSESS & CLASSIFY chart.

Is the child breathing slower? Is there less fever? Is the child eating better? Treatment: If chest indrawing or a general danger sign, give a dose of second line antibiotic or intramuscular chloramphenicol. Then refer URGENTLY to hospital. If breathing rate, fever and eating are the same, change to the second-line antibiotic and advise the mother to return in 2 days or refer. (If this child had measles within the last 3 months or is known to have HIV infection , refer.) If the child has wheezing, give oral salbutamol If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.

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GIVE FOLLOW-UP CARE

Page25of74

DYSENTERY
After 2 days:

ORAL THRUSH
AFTER 2 DAYS: Look for mouth ulcers or thrush. If thrush is worse, give 100,000IU of oral nystatin orally 4 times daily for 7 days If thrush is the same or better, continue half-strength gentian violet for a total of 7 days

Check the child for general danger signs. Assess the child for diarrhoea

See ASSESS & CLASSIFY chart

MALARIA
If fever persists after 2 days or returns after 14 days:

Ask: Are there fewer stools? Is there less blood in the stool? Is there less fever? Is there less abdominal pain? Is the child eating better? Treatment: If the child is dehydrated, treat dehydration. Advise caretaker to continue giving zinc supplements until it is given for 14 days If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or the same: Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days. Advise the mother to return in 2 days. If you do not have the second line antibiotic, REFER to hospital. Exceptions - if the child: is less than 12 months old, or was dehydrated on the first visit, or if he had measles within the last 3 months

Do a full reassessment of the child. Measure the child's temperature Assess for other problems

See ASSESS & CLASSIFY chart.

> DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit. Treatment: If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If the child has any cause of fever other than malaria, provide appropriate treatment. If there is no other apparent cause of fever: If fever has been present for 7 days, refer for assessment. Do a microscopy to look for malaria parasites. If parasites are present and the child has finished a full course of the first line antimalarial, give oral quinine, if available, or if quinine not available refer the child to a hospital. If there is no other apparent cause of fever and you do not have a microscopy to check for parasites, refer the child to a hospital.

REFER to hospital.

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

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GIVE FOLLOW-UP CARE

FEEDING PROBLEM MEASLES WITH EYE OR MOUTH COMPLICATIONS

After 2 days: Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth. Treatment for eye infection: If pus is draining from the eye, ask the caretaker to describe how she has treated the eye infection. If treatment has been correct, refer to hospital. If treatment has not been correct, teach caretaker correct treatment. If the pus is gone but redness remains, continue the treatment. If no pus or redness, stop the treatment. Treatment for mouth ulcers: If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days. After 5 days: Reassess feeding. See questions at the top of the COUNSEL chart. Ask about any feeding problems found on the initial visit. Counsel the caretaker about any new or continuing feeding problems. If you counsel the caretaker to make significant changes in feeding, ask him/her to bring the child back again in 5 days. If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child's weight gain.

VERY LOW WEIGHT

After 30 days: Weigh the child and determine if the child is still very low weight for age or faltering. Reassess feeding. See questions at the top of the COUNSEL chart. Treatment: If the child is no longer very low weight for age or growth faltering, praise the caretaker and encourage him/her to continue feeding the child appropriately. If the child is still very low weight for age or growth faltering, counsel the caretaker about any feeding problem found. Ask the caretaker to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weight regularly or is no longer very low weight for age. Exception: If you do not think that feeding will improve, or if the child has lost weight, refer the child.

EAR INFECTION
After 5 days:

ANAEMIA
After 14 days: Give iron and or folate. Advise mother to return in 14 days for more iron. Continue giving iron and or folate every 14 days for 2 months. If the child has palmar pallor after 2 months, refer for assessment. Reassess for ear problem. Measure the child's temperature. See ASSESS & CLASSIFY chart.

For chronic ear infection check for HIV infection if it was done Treatment: If there is tenderswellingbehindtheearorhighfever(38.5Corabove), refer URGENTLY to hospital. Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days. Chronic ear infection: Check that the caretaker is wicking the ear correctly and instilling ciprofloxacin drops tree times a day. Encourage her to continue. Explain to the caretaker the importance of keeping the ear dry and instilling ear drops. If no ear pain or discharge, praise the caretaker for his/her careful treatment. For acute ear infection if the caretaker has not yet finished the 5 days of antibiotic, tell him/her to use all of it before stopping. For a child with chronic ear infection tell the caretaker to continue instilling ciprofloxacin ear drops for a total of 14 days.

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GIVE FOLLOW-UP CARE

HIV INFECTION
FIRST FOLLOW UP Check if the child has had an HIV test and the result has been received. Make sure that the care taker receive appropriate post-test counseling. Assess the child's general condition.Do a full assessment > see Assess and Classify Pages 2 to 6 Treat the child for any classification found. Check for oral thrush and mouth ulcers Ask for any new feeding problems.Counsel the caretaker about any new or continuing feeding problems. Check the child's weight and refer if there is growth faltering despite adequate diet Check if the child is due for Vit A and de - worming or any immunizations. Give dose if due Advise caretaker when to return immediately. If HIV test positive Continue cotrimoxazole prophylaxis for PCP. Counsel caretaker on importance of contnuing treatment Counsel caretaker on any other problems and ensure community support is being given. Refer for further counselling if necessary Follow up monthly after follow up If HIV test is negative Discountnue cotrimoxazole prophylaxis If HIV test is not done Continue cotrimoxazole prophylaxis for PCP REPEAT FOLLOW UP EVERY MONTH Asses the child's generalk condition. Do a full asssessment < see Assess and Clasify pages 2 - 6 Treat the Child for any classifications found Check for oral thrush and mouth ulcers Ask for any new feeding problems. Counsel ythe caretaker aboout any new or continuing feeding problems Check the child's weight and refer if there is growth faltering despite adequate diet Check if child is due for Vitamin A and de-worming or any immunisation. Give dose if due Advise caretaker when to return immediately Give supply of cotrimoxazole for prophylaxis for PCP. Cousell caretaker on importance of continuing treatments Counsel caretaker on any other problems and ensure community support is being given. Refer for further copunseling if necessary Folllow - up monthly IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE CARETAKER OF THE NEXT FOLLOW-UP VISIT ALSO, ADVISE THE CARETAKER WHEN TORETURN IMMEDAITELY . (SEE CPUNSEL CHART)

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COUNSEL

FOOD

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FOOD
Assess the Feeding of Sick child Under 2 Years (or if child has very low weight for age)
Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age. ASK - How are you feeding your child? If the child is receiving If the receiving replacement millk, Ask; any breast milk, ASK: What replacement milk are you giving? How many times during the day? How many times during day and night? Do you also breastfeed during How much is given at each feed? the night? How is the milk prepared and who prepares it? What do you use to feed the child? How are you cleaning the utensils? Does the child take any other food or Health worker to encourage care taker to fluids? give extra feeds and discourage mixied What food or fluids? feeing How many times per day? What do you use to feed the child? If very low weight for age, ASK: How large are servings? Does the child receive his own serving? Who feeds the child and how? During this illness, has the child's feeding changed? If yes, how?

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FOOD
Feeding Recommendations During Sickness and Health
Up to 6 Months of age 6 Months up to 12 months 12 months up to 2 years 2 years and older Breastfeed as often as the child Continue breast feeding Breastfeed as often as the child wants. Give family foods at least 3 meals wants, day and night, at least 10 day and nightr - at least 8 each day. Actively feed the child at least 5 times a day. times in 24 hours. times in 24 hours Give11cups(200300ml)ofthefollowing Also, twice daily, give nutritious Do not give other foods or fluids.(not Breastfeed as often as the per feeding: fruits/foods between meals, (such even water, traditional medice, child wants. as: banana, avocado, oranges, Nshima with mashed or pounded relish. glucose, gripe water, other milks or mango, pawpaw, guava), samp, Give adequate servings of Do not feed only the soup. porridge unless medically advised) fried sweet potatoes, bred, rice, with complementary foods at Thick porridge enriched with one or more sugar or oil, egg or beans. least 3 times per day of the following: sugar, oil, pounded if breastfed plus snacks. kapenta, g/nuts, or dried catapillars, 5 times per day if not mashed beans, egg, milk. breastfed plus snacks. In between main meals give other foods such Giveto1cup(150 as fruits, samp, boiled casava, mashed beans 200ml) per feeding of: , g/nuts, pumpkins, sweet potatoes, rice with sugar or oil. Thick porridge enriched with suger, oil, pounded Serve the child separetly and encourage or ground nuts or Kapenta supervise the eating. mashed beans or avocado, soya flour, egg, pounded dried catapillars or green leafy vigitables or Nshima mashed with , relish cooked in oil or pounded g/nuts Between main meals give other foods, such as fruits (banana, mango, avocado, etc) or chikanda, mashed pumpkins, beans, g/nuts or boiled sweet potatoes, milk, munkoyo or fiseke. serve and feed the child separately in own dish.

* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables. Feeding recommendation for a child who is not feeding well during or after an illness If still breast feeding, give more frequent, longer breast feeds, day and night. Offer frequent small feedings Use soft, varied, appetizing, favourite foods. Clear a blocked nose if it interfers with the feeding. Encourage andd assist the chilkd to eat if necessary For a week after the illness is over, offer increased amount of food and continue to give favourite food and encourage the cjhild to feed as much as possible Feeding recommendations for a child who has PERSISTANT DIARRHOEA If still breastfeeding, give more frequent, longer breastfeeds, day and night. If taking other milk: Replace with increased breastfeeding OR Replace witgh fermented milk products, such as sour milk and yoghurt OR Replace half the milk with thick porridge and added vegetable oil mixt with well cooked and mashed beans, vegetables and finely ground chicken or fish OR For other foods, follow feeding recomendation for the child's age.

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FOOD

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer breastfeeds, day and night. If taking other milk: replace with increased breastfeeding OR replace with fermented milk products, such as yoghurt OR replace half the milk with nutrient-rich semisolid food. For other foods, follow feeding recommendations for the child's age.

Counsel the Mother About Feeding Problems

If the child is not being fed as described in the above recommendations, counsel the mother accordingly. In addition: If the mother reports difficulty with breastfeeding, assess breastfeeding. (See YOUNG INFANT chart.) As needed, show the mother correct positioning and attachment for breastfeeding. If the child is less than 6 months old and is taking other milk or foods: Build mother's confidence that she can produce all the breast milk that the child needs. Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods. If other milk needs to be continued, counsel the mother to: Breastfeed as much as possible, including at night. Make sure that other milk is a locally appropriate breast milk substitute. Make sure other milk is correctly and hygienically prepared and given in adequate amounts. Finish prepared milk within an hour. If the mother is using a bottle to feed the child: Recommend substituting a cup for bottle. Show the mother how to feed the child with a cup. If the child is not feeding well during illness, counsel the mother to: Breastfeed more frequently and for longer if possible. Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feedings. Clear a blocked nose if it interferes with feeding. Expect that appetite will improve as child gets better. If the child has a poor appetite: Plan small, frequent meals. Give milk rather than other fluids except where there is diarrhoea with some dehydration. Give snacks between meals. Give high energy foods. Check regularly. If the child has sore mouth or ulcers: Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado. Avoid spicy, salty or acid foods. Chop foods finely. Give cold drinks or ice, if available.

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Counsel

Counsel the Mother about her Own Health

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

FLUID

Advise the Mother to Increase Fluid During Illness

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

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WHEN TO RETURN

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the child's problems. If the child has: Return for follow-up in: 2 days WHEN TO RETURN IMMEDIATELY Advise mother to return immediately if the child has any of these signs: Any sick child Not able to drink or breastfeed Becomes sicker Develops a fever If child has COUGH OR COLD, Fast breathing also return if: Difficult breathing If child has Diarrhoea, also return Blood in stool if: Drinking poorly

PNEUMONIA DYSENTERY FEVER: NO MALARIA, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS MALARIA, if fever persists PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEM COUGH OR COLD, if not improving ANAEMIA VERY LOW WEIGHT FOR AGE

3 days 5 days

14 days 30 days

NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to immunization schedule.

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Assess, classify and treat the sick young infant aged up to 2 months
ASSESS AND CLASSIFY ASSESS
DO A RAPID APRAISAL OF ALL WAITING INFANTS ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this problem. if follow-up visit, use the follow-up instructions. if initial visit, assess the child as follows:

CLASSIFY

IDENTIFY TREATMENT

USE ALL BOXES THAT MATCH THE INFANT'S SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS

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CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

ASK: Is the infant having difficulty in feeding? Has the infant had convulsions (fits)? LOOK, LISTEN, FEEL: Count the breaths in one minute. Repeat the count if more than 60 breaths per minute. Look for severe chest indrawing. YOUNG INFANT MUST BE CALM Classify ALL YOUNG INFANTS Any one of the following signs Not feeding well or Convulsions or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or Fever(37.5C*orabove) or Low body temperature (lessthan35.5C*)or Movement only when stimulated or no movement at all. Umbilicus red or draining pus Skin pustules Pink: VERY SEVERE DISEASE Give first dose of intramuscular antibiotics Treat to prevent low blood sugar Refer URGENTLY to hospital ** Advise mother how to keep the infant warm on the way to the hospital

Yellow: LOCAL BACTERIAL INFECTION Green: SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

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

None of the signs of very severe disease or local bacterial infection

Measure axillary temperature. Look at the umbilicus. Is it red or draining pus? Look for skin pustules. Look at the young infant's movements. If infant is sleeping, ask the mother to wake him/her. Does the infant move on his/her own? If the young infant is not moving, gently stimulate him/her. Does the infant not move at all? *Thesethresholdsarebasedonaxillarytemperature.Thethresholdsforrectaltemperaturereadingsareapproximately0.5Chigher. ** If referral is not possible, see Integrated Management of Childhood Illness, Management of the sick young infant module, Annex 2 "Where referral is not possible".

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THEN ASK: Does the young infant have diarrhoea*?

IF YES, LOOK AND FEEL: Look at the young infant's general condition: Infant's movements Does the infant move on his/her own? Does the infant not move even when stimulated but then stops? Does the infant not move at all? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? or slowly? Two of the following signs: Movement only when stimulated or no movement at all Sunken eyes Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If infant has no other severe classification: Give fluid for severe dehydration (Plan C) OR If infant also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Give fluid and breast milk for some dehydration (Plan B) If infant has any severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 2 days if not improving Give fluids to treat diarrhoea at home and continue breastfeeding (Plan A) Advise mother when to return immediately Follow-up in 2 days if not improving

Classify DIARRHOEA for DEHYDRATION

Two of the following signs: Restless and irritable Sunken eyes Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

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

CHECK FOR JAUNDICE

If jaundice present, ASK: When did the jaundice appear first? LOOK AND FEEL: Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Any jaundice if age less than 24 hours or Yellow palms and soles at any age Jaundice appearing after 24 hours of age and Palms and soles not yellow Pink: SEVERE JAUNDICE Yellow: JAUNDICE Treat to prevent low blood sugar Refer URGENTLY to hospital Advise mother how to keep the infant warm on the way to the hospital Advise the mother to give home care for the young infant Advise mother to return immediately if palms and soles appear yellow. If the young infant is older than 14 days, refer to a hospital for assessment Follow-up in 1 day Advise the mother to give home care for the young infant

CLASSIFY

JAUNDICE

No jaundice

Green: NO JAUNDICE

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THEN CHECK FOR HIV INFECTION

ASK Has the mother and/or young infant had an HIV test? IF YES: Then note mother's and/or young infant's HIV status Mother's HIV status: Serological test POSITIVE or NEGATIVE Young infant's HIV status: Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE If mother is HIV positive and NO positive virological test in child ASK: Is the young infant breastfeeding now? Was the young infant breastfeeding at the time of test or before it? Is the mother and young infant on ARV prophylaxis?* Mother HIV positive AND negative virological test in young infant breastfeeding or if only stopped less than 6 weeks ago. OR Mother HIV positive, young infant not yet tested OR Positive serological test in young infant Negative HIV test in mother or young infant No HIV test in the child or mother. Green: HIV INFECTION UNLIKELY Green: HIV INFECTION STATUS UNKNOWN Treat, counsel and follow-up existing infections Yellow: POSSIBLE HIV INFECTION or HIV EXPOSED Classify HIV status Positive virological test in young infant Yellow: CONFIRMED HIV INFECTION Give cotrimoxazole prophylaxis from age 4-6 weeks Give HIV care/ART Advise the mother on home care Consider presumptive severe HIV disease as described before If infant less than 3 days old give Nevirapine and start AZT if not yet administered Follow-up in one month. Give cotrimoxazole prophylaxis from age 4-6 weeks Start or continue ARV prophylaxis as per national recommendations* Do virological test at age 4-6 weeks or repeat 6 weeks after the child stops breastfeeding Advise the mother on home care Follow-up regularly as per national guidelines

IF NO test: Mother and young infant status unknown Perform HIV test for the mother; if positive, perform virological test for the young infant

Treat, counsel and follow-up existing classification. Advise the mother about feeding and about her health. Refer/do counselling and testing for HIV.

* PMTCT for breastfed child: OPTION A - If the mother is already on AZT prophylaxis and the baby is on NVP prophylaxis, continue until 1 week after breastfeeding has stopped. OPTION B - If the mother is already on triple ARV regime, continue until 1 week after breastfeeding has stopped and give the baby AZT or NVP from birth until 4-6 weeks of age. PMTCT for non-breastfed child: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.

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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE: FOR BREAST FEEDING INFANTS
If an infant has no indications to refer urgently to hospital: Ask: LOOK, LISTEN, FEEL: Is the infant breastfed? If Determine weight for age. yes, how many times in 24 Look for ulcers or white hours? patches in the mouth Does the infant usually (thrush). receive any other foods or drinks? If yes, how often? If yes, what do you use to feed the infant? Not well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24 hours or Receives other foods or drinks or Low weight for age or Thrush (ulcers or white patches in mouth). Yellow: FEEDING PROBLEM OR LOW WEIGHT If not well attached or not suckling effectively, teach correct positioning and attachment If not able to attach well immediately, teach the mother to express breast milk and feed by a cup If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. Advise the mother to breastfeed as often and as long as the infant wants, day and night If receiving other foods or drinks, counsel the mother about breastfeeding more, reducing other foods or drinks, and using a cup If not breastfeeding at all: Refer for breastfeeding counselling and possible relactation Advise about correctly preparing breastmilk substitutes and using a cup Advise the mother how to feed and keep the low weight infant warm at home If thrush, teach the 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 Advise mother to give home care for the young infant Praise the mother for feeding the infant well

Classify FEEDING

Not low weight for age and no other signs of inadequate feeding.

Green: NO FEEDING PROBLEM

ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.) Is the infant well attached? not well attached good attachment TO CHECK ATTACHMENT, LOOK FOR: Chin touching breast Mouth wide open Lower lip turned outwards More areola visible above than below the mouth (All of these signs should be present if the attachment is good.) Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding.

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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in NON-breastfed infants
Use this chart for HIV EXPOSED infants when the national authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding AND the infant has no indications to refer urgently to hospital: Ask: LOOK, LISTEN, FEEL: What milk are you giving? Determine weight for age. How many times during Look for ulcers or white the day and night? patches in the mouth (thrush). How much is given at each feed? How are you preparing the milk? Let mother demonstrate or explain how a feed is prepared, and how it is given to the infant. Are you giving any breast milk at all? What foods and fluids in addition to replacement feeds is given? How is the milk being given? Cup or bottle? How are you cleaning the feeding utensils? Milk incorrectly or unhygienically prepared or Classify FEEDING Giving inappropriate replacement feeds or Giving insufficient replacement feeds or An HIV positive mother mixing breast and other feeds before 6 months or Using a feeding bottle or Low weight for age or Thrush (ulcers or white patches in mouth). Not low weight for age and no other signs of inadequate feeding. Green: NO FEEDING PROBLEM Yellow: FEEDING PROBLEM OR LOW WEIGHT Counsel about feeding Explain the guidelines for safe replacement feeding Identify concerns of mother and family about feeding. If mother is using a bottle, teach cup feeding Advise the mother how to feed and keep the low weight infant warm at home If thrush, teach the 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 Advise mother to give home care for the young infant Praise the mother for feeding the infant well

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THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:

S
IMMUNIZATION SCHEDULE: AGE Birth 6 weeks 10 weeks VACCINE BCG DPT+HIB-1 DPT+HIB-2 VITAMIN A 200 000 IU to the mother within 6 weeks of delivery Hepatitis B1 Hepatitis B2

OPV-0 OPV-1 OPV-2

Give all missed doses on this visit. Include sick infants unless being referred. Advise the caretaker when to return for the next dose.

ASSESS OTHER PROBLEMS

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TREAT AND COUNSEL

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give First Dose of Intramuscular Antibiotics

Give first dose of ampicillin intramuscularly and Give first dose of gentamicin intramuscularly. AMPICILLIN Dose: 50 mg per kg To a vial of 250 mg WEIGHT Add 1.3 ml sterile water = 250 mg/1.5ml GENTAMICIN Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml AGE <7 days AGE >= 7 days Dose: 5 mg per kg Dose: 7.5 mg per kg 0.6 ml* 0.9 ml* 0.9 ml* 1.3 ml* 1.1 ml* 1.7 ml* 1.4 ml* 2.0 ml* 1.6 ml* 2.4 ml* 1.9 ml* 2.8 ml* 2.1 ml* 3.2 ml*

1-<1.5 kg 1.5-<2 kg 2-<2.5 kg 2.5-<3 kg 3-<3.5 kg 3.5-<4 kg 4-<4.5 kg

0.4 ml 0.5 ml 0.7 ml 0.8 ml 1.0 ml 1.1 ml 1.3 ml

* Avoid using undiluted 40 mg/ml gentamicin.

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

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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Treat the Young Infant to Prevent Low Blood Sugar

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

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

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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Give an Appropriate Oral Antibiotic for Local Bacterial Infection

First-line antibiotic: ___________________________________________________________________________________________ Second-line antibiotic:_________________________________________________________________________________________ COTRIMOXAZOLE AMOXICILLIN trimethoprim + sulphamethoxazole Give 2 times Give 2 times daily for 5 days daily for 5 days AGE or WEIGHT Adult Tablet Pediatric Tablet Syrup Syrup single strength Tablet (20 mg trimethoprim + (40 mg trimethoprim + 125 mg (80 mg trimethoprim + 250 mg 100 mg sulphamethoxazole) 200 mg sulphamethoxazole) in 5 ml 400 mg sulphamethoxazole) Birth up to 1 month 1/2* 1.25 ml* 1/4 2.5 ml (<4 kg) 1 month up to 2 1/4 1 2.5 ml 1/2 5 ml months (4-<6 kg)
* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.

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TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

Teach the Mother to Treat Local Infections at Home

Explain how the treatment is given. Watch her as she does the first treatment in the clinic. Tell her to return to the clinic if the infection worsens. To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth) The mother should do the treatment twice daily for 5 The mother should do the treatment four times daily for 7 days: days: Wash hands Wash hands Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth Gently wash off pus and crusts with soap and water wrapped around the finger Dry the area Wash hands Paint the skin or umbilicus/cord with full strength gentian violet (0.5%) Wash hands

To Treat Diarrhoea, See TREAT THE CHILD Chart.

Immunize Every Sick Young Infant, as Needed

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COUNSEL THE MOTHER

Teach Correct Positioning and Attachment for Breastfeeding

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

Teach the Mother How to Keep the Low Weight Infant Warm at Home
Keep the young infant in the same bed with the mother. Keeptheroomwarm(atleast25C)withhomeheatingdeviceandmakesurethatthereisnodraughtofcoldair. Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing and clothe the young infant immediately. Change clothes (e.g. nappies) whenever they are wet. Provide skin to skin contact as much as possible, day and night. For skin to skin contact: Dress the infant in a warm shirt open at the front, a nappy, hat and socks. Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's head turned to one side. Cover the infant with mother's clothes (and an additional warm blanket in cold weather). When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket. Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact. Breastfeed the infant frequently (or give expressed breast milk by cup).

Advise the Mother to Give Home Care for the Young Infant Teach the Mother How to Express Breast Milk
Ask the mother to: Wash her hands thoroughly. Make herself comfortable. Hold a wide necked container under her nipple and areola. Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other (at least 4 cm from the tip of the nipple). Compress and release the breast tissue between her finger and thumb a few times. If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before. Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on the skin. Express one breast until the milk just drips, then express the other breast until the milk just drips. Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes. Stop expressing when the milk no longer flows but drips from the start. 1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the infant wants. 2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES. In cool weather cover the infant's head and feet and dress the infant with extra clothing. 3. WHEN TO RETURN: Follow up visit If the infant has: JAUNDICE LOCAL BACTERIAL INFECTION FEEDING PROBLEM THRUSCH DIARRHOEA LOW WEIGHT FOR AGE WHEN TO RETURN IMMEDIATELY: Advise the mother to return immediately if the young infmant has any of these signs: Breastfeeding poorly Reduced activity Becomes sicker Develops a fever Feels unusually cold Fast breathing Difficult breathing Palms and soles appear yellow 1 day 2 days Return for first follow-up in:

14 days

Teach the Mother How to Feed by a Cup

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

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FOLLOW-UP

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT

LOCAL BACTERIAL INFECTION

After 2 days: Look at the umbilicus. Is it red or draining pus? Look at the skin pustules. Treatment: If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home. If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

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GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

DIARRHOEA
After 2 days: Ask: Has the diarrhoea stopped? Treatment If the diarrhoea has not stopeed, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?" If the diarrhoea has stopeed, tell the mother to continue exclusive breastfeeding.

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

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GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

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

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GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

LOW WEIGHT FOR AGE

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

THRUSH
After 2 days: Look for ulcers or white patches in the mouth (thrush). Reassess feeding. > See "Then Check for Feeding Problem or Low Weight". If thrush is worse check that treatment is being given correctly. If the infant has problems with attachment or suckling, refer to hospital. If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.
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Annex
Annex A: Skin and Mouth Conditions

Identify Skin Problem

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Identify Skin Problem

If skin is itching
SIGNS Itching rash with small papules and scratch marks. Dark spots with pale centres CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV Is a clinical stage 2 defining case PAPULAR Treat itching: ITCHING Calamine lotion RASH Antihistamine oral (PRURIGO) If not improves 1% hydrcortisone Can be early sign of HIV and needs assessment for HIV RING WORM (TINEA) Whitfield ointment or other antifungal cream if few patches If extensive refer, if not give: Ketokonazole for 2 up to 12 months(610 kg) 40mg per day for 12 months up to 5 years give 60 mg per day or give griseofulvin 10mg/kg/day if in hair shave hair treat itching as above Treat itching as above manage with anti scabies: 25% topical Benzyl Benzoate at night, repeat for 3 days after washing and or 1% lindane cream or losion once wash off after 12 hours

An itchy circular lesion with a raised edge and fine scaly area in the centre with loss of hair. May also be found on body or web on feet

Extensive: There is ahigh incidence of co existing nail infection which has to be treated adequately to prevent reccurencies of tinea infections of skin. Fungal nail infection is a clinical stage 2 defining disease

Rash and excoriations on torso; burrows in web space and wrists. face spared

SCABIES

In HIV positive individuals scabies may manaifest as crust scabies. Crusted scabies presents as extensive areas of crusting mainly on the scalp, face back and feet. Patients may not complain of itchting. The scales will teeming with mites

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Identify Skin Problem

If skin has blisters/sores/pustules
SIGNS Vesicles over body. Vesickles appear progressively over days and formscabs after they rupture CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV Presentation atypical only if child is immunocompromised Duration of disease longer Complications more frequent Chronic infection with continued appearance of new lesions for >1 month; typical vesicles evolve into nonhealing ulcers that become necrotic, crusted, and hyperkeratotic. Duration of disease longer Hemorrhagic vesicles, necrotic ulceration Rarely recurrent, disseminated or mult idermatomal Is a Clinical stage 2 defining disease CHIKEN POX Treat itching as above Refer URGENTLY if pneumonia or jaundice appear

Vesicles in Keep lesions clean and dry. Use local HERPES one area on antiseptic ZOSTER one side of If eye involved give acyclovir 20 mg /kg body with 4 times daily for 5 days intense pain or Give pain relief scars Follow-up in 7 days plus shooting pain. Herpes zoster is uncommon in children except where they are immunocompromised, for example if infected with HIV Red, tender, IMPETIGO OR Clean sores with antiseptic warm crusts or FOLLICULITIS Drain pus if fluctuant small lesions Start cloxacillin if size >4cm or red streaks or tender nodes or multiple abscesses for 5 days ( 25-50 mg/kg every 6 hours) Refer URGENTLY if child has fever and / or if infection extends to the muscle.

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Identify Papular Lesions

Non-Itchy
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV Incidence is higher Giant molluscum (>1cm in size), or coalescent Pouble or triple lesions may be seen More than 100 lesions may be seen. Lesions often chronic and difficult to eradicate Extensive molluscum contagiosum is a Clinical stage 2 defining disease Lesions more numerous and recalcitrant to therapy Extensive viral warts is a Clinical stage 2 defining disease Seborrheic dermatitis may be severe in HIV infection. Secondary infection may be common

Skin coloured pearly white MOLLUSCUM Can be treated by papules with a central CONTAGIOSUM various modalities: umblication. It is most Leave them alone commonly seen on the unless superinfected face and trunk in children. Use of phenol: Pricking each lesion with a needle or sharpened orange stick and dabbing the lesion with phenol Electrodesiccaton Liquid nitrogen application (using orange stick) Curettage

The common wart appears as papules or nodules with a rough (verrucous) surface

WARTS

Treatment: Topical salicylic acid preparations ( eg. Duofilm) Liquid nitrogen cryotherapy. Electrocautery

Greasy scales and redness on central face, body folds

SEBBHORREA Ketoconazole shampoo If severe, refer or provide tropical steroids For seborrheic dermatitis: 1% hyrdocortisone cream X 2 daily If severe, refer

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Mouth Problems
Thrush
Mouth problems: Thrush Presenting signs Not able to swallow CLASSIFY AS: TREATMENT

SEVERE Refer URGENTLY to hospital. If not able to refer, give OESOPHAGEAL fluconazole. THRUSH If mother is breasfeeding, check and treat the mother for breast thrush. (Stage 4 disease) OESOPHAGEAL Give fluconazole THRUSH Give oral care to young infant or child. If mother is breasfeeding, check and treat the mother for breast thrush. Tell the mother when to come back immediately. Once stabilized, refer for ART initiation (Stage 4 disease) ORAL THRUSH Teach the mother to treat oral thrush at home. The mother should: Wash hands Wash the young infant/child's mouth with a soft clean cloth wrapped around her finger and wet with salt water Instill 1 ml of nystatin four times per day or paint with 1/2 strength gentian violet for 7 days Wash her hands after providing treatment for the young infant or childAvoid feeding for 20 minutes after medication If breastfed, check mother's breast for thrush. If present (dry, shiny scales on nipple and areola) treat with nystatin or GV Advise the mother to wash hands breasts after feeds. If bottle fed, advise to change to cup and spoon If severe, recurrent or pharyngeal thrush, consider symptomatic HIV give paracetamol if needed for pain (Stage 3 disease) ORAL HAIRY Does not independently require treatment, but resolves LEUCOPLAKIA with ART and Acyclovir (Stage 2 disease)

Pain or difficulty swallowing

White patches in mouth which can be scraped off

White patches in mouth most frequently seen on the sides of the tongue, a white plaquewith a a corrugated appearance.

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Mouth Problems

Herpes Simplex
SIGNS Vesicular lesion or sores, also involving lips, mouth and or gums. The lesions can be deep and extensive CLASSIFY AS: HERPES SIMPLEX TREATMENT If child is unable to feed, and classified as SEVERE MOUTH/GUM INFECTION, give first dose of acyclovir then refer If referal is not possible give oral Metronidazole 7.5 mg/kg 8 hourly for 7 days If it is a first episode and lesions are not severe give acyclovir 20 mg/kg 4 times daily for 5 days UNIQUE FEATURES IN HIV Extensive area of involvement Large ulcers Delayed healing (often greater than a month) Resistance to Acyclovir common. Therefore continue treatment till complete healing of ulcer Chronic HSV infection (>1 month) is a Clinical stage 4 defining disease

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Mouth Problems

ASSESS, CLASSIFY AND TREAT SKIN AND MOUTH CONDITIONS

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Clinical reaction
Drug and Allergic Reactions
SIGNS Generalized red, wide spread with small bumps or blisters; or one or more dark skin areas (fixed drug reactions) CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV Stop medications Could be a sign of FIXED give oral reactions to ARVs DRUG antihistamines, if REACTIONS pealing rash refer

Wet, oozing sores or escoriated, thick patches

ECZEMA

Soak sores with clean water to remove crusts(no soap) Dry skin gently Short time use of topical steriod cream not on face. Treat itching The most lethal reaction to NVP, Cotrimoxazolen or even Efavirens

Severe reaction due to cotrimoxazole or STEVEN Stop medication NVP involving the skin as well as the eyes JOHNSON refer urgently and the mouth. Might cause difficulty in SYNDROME breathing

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Annex B: ARV dosages and combinations

ARV dosage tables

Lamivudine (3TC) Efivarenz (EFV)

WEIGHT (kg) Efivarenz TREATMENT DOSE: 15 mg/kg/day if capsule or tablet Once daily Combination of 200,100,and 50 mg capsules one 200 mg one 200 mg + one 50 mg one 200 mg + one 100 mg one 200 mg + one 100 mg + one 50 mg two 200 mg three 200 mg or 600 mg tablet TREATMENT DOSE: 4mg/kg/dose (to maximum 150mg dose) - give dose twice daily Lamuvidine WEIGHT 5 - 6.9 7 -9.9 10 - 11.9 12 -13.9 14 - 19.9 20 -24.9 25 kg and over Syrup 10 mg/ ml 12 hourly 3 ml 4 ml 5 ml 6 ml 150 mg tablet AM PM

10 - 13.9 14 - 19.9 20 - 24.9 25 - 29.9 30 - 39.9 40 and over

0.5 0.5 1 1

0.5 0.5 0.5 1

one

* This is not usually recommended for use in this age or formulation ** This is the closest dosing possible using the specified formulation

Lamivudine for PMTCT prophylaxis in newborns

DOSE FOR PROPHYLAXIS: Give 2 mg/kg/dose twice daily for 1 week. Start within 72 hours of birth. Lamivudine WEIGHT 1 -1.9 2 - 2.9 3 -3.9 4 - 4.9 ------- /ml twice daily for 1 week 0.1 ml 0.8 ml 1.2 ml 1.6 ml

Abacavir (ABC)
TREATMENT DOSE: 8mg/kg/dose (to maximum dose >16years or > 37.5 kg: 300 mg/dose given twice daily) - Give dose twice daily Abacavir WEIGHT 5 - 5.9 6 - 9.9 7 - 9.9 10 - 10.9 11 - 11.9 12 - 13.9 14 - 19.9 20 - 24.9 25 and above Syrup 20 mg/ml 12 hourly 2 ml 3 ml 4 ml 5 ml 5 ml 6 ml 0.5 tablet 0.5 tablet 0.5 tablet 1 tablet 1 tablet 0.5 tablet 0.5 tablet 0.5 tablet 0.5 tablet 1 tablet 300 mg tablets AM PM

Stavudine (d4T)
TREATMENT DOSE: 1mg/kg/dose (to maximum 30 mg dose) -give dose twice daily Stavudine WEIGHT 5 -5.9 6 - 9.9 10 - 13.9 14 - 24.9 25 and above Solution 1 12 hourly 6 ml 15 mg, 20 mg , 30 mg capsules 12 hourly 0.5 20 mg capsule one 15 mg capsule one 20 mg capsule one 30 mg capsule

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Combination ARV dosages

Dual FDCs
Weight (kg) AM 0.5 0.5 1 1 Stavudine + lamivudine (d4T-3TC) 30 mg d4T + 150 mg 3TC) Give twice daily PM 0.5 0.5 0.5 1

5-5.9 17-19.9 20-24.9 30-34.9

Dual FDCs
Weight (kg) zidovudine + lamivudine (ZDV-3TC = AZT-3TC) 300 mg ZVD + 150 mg 3TC Give twice daily AM 0.5 1 1 PM 0.5 0.5 1

14-14-9 20-34.9 35 or above

Triple FDCs
Weight (kg) stavudine + lamivudine + nevirapine (d4T-3TC-NVP) 30 mg d4T + 150 mg 3TC + 200 mg NVP Give twice daily AM 0.5 1 1 PM 0.5 0.5 1

10-13.0 14-19.0 20 or above

Triple FDCs
Weight (kg) zodovudine + lamivudine + abacavir (SDV-3TC-ABC = AZT-3TC-ABC) 300 mg ZDV + 150 mg 3TC + 300 mg ABC Give twice daily AM 0.5 1 1 1 PM 0.5 0.5 0.5 1

14-19.9 20-24.9 25-34.9 35 or above

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Annex C: ARVs SIDE EFFECTS

Side Effects*
Very common side-effets: warn patients and suggest ways patients can manage; also be prepared to manage when patients seek care d4T Nausea Stavudine Diarrhoea Potentially serious side effects: warn patients and tell them to seek care Seek care urgently: Severe abdominal pain Fatigue AND shortness of breath Seek advice soon: Tingling, numb or painful feet or legs or hands. 3TC Nausea Lamivudine Diarrhoea NVP Nausea Nevirapine Diarrhoea Seek care urgently: Yellow eyes Severe skin rash Fatigue AND shortness of breath Fever Seek care urgently: Pallor (anaemia) Side effects occurring later during treatment: discuss with patients Changes in fat distribution: Arms, legs, buttocks, cheeks become THIN Breasts, belly, back of neck become FAT

ZDV Zidovudine (Also known as AZT) EFV Efavirenz

Nausea Diarrhoea Headache Fatigue Muscle pain Nausea Diarrhoea Strange dreams Difficulty sleeping Memory problems Headache Dizziness

Seek care urgently: Yellow eyes Psychosis or confusion Severe skin rash

* For more guidance, refer to IMAI chronic care guideline module

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Annex D: DRIED BLOOD SPOT (DBS) COLLECTION FOR PCR - SUMMARY

A good health care worker carrying out DBS procedure will:

Welcome the care giver into the DBS COLLECTION ROOM. Ensure the caregiver has come with a referral or request note or form sepcific for DBS. Ensure that the care giver has undergone HIV counselling and has given consent to the rocedure to be performed. Ensure the note/form is adequately and appropriately filled-out with the necessary information Confirm the infant's name or ID with the caregiver. Exlain to the caregiver the significance of the procedure. Show them how the infant/child appropriately to facilitate easy. DBS sample collection After the procedure, ask the caregiver if they have any questions or concerns regarding the DBS or the DNA PCR test, and answer and address their questions accordingly. After the procedure, advise the caregiver when he or she should return to the health facility to receive the results of the DNA PCR test.

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A good health care worker carrying out DBS procedure will:

Steps for Collection of DBS for DNA PCR

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Annex E: TO MEASURE MID UPPER ARM CIRCUMFERENCE(MUAC)

HOW TO MEASURE MID UPPER ARM CIRCUMFERENCE(MUAC)

To measure Mid upper arm circumference (MUAC) MUAC: MUAC is the circumference of the left upper arm, measured at the mid-point between the tip of the shoulder and the tip of the elbow (olecranon process and the acromion). In children, MUAC is useful for the assessment of nutritional status. This measurement is not significant for children aged less than 6 months. How to measure Mid Upper Arm Circumference for children There is a special tool called Arm circumference insertion tape, however a normal tape measure can function similarly. Make sure the child has undressed the whole of left arm. Flexthechildsarmtolieonhisorherabdomentomakeanangleof90. Locate the tip of the shoulder and the elbow. Measure the length from the ti of the shoulder to the tip of the elbow. Look for place on the upper arm where way half of the distance of the measured length and put a mark. Then remove the tape. Let the child extend the arm straight before uting the tape for measurement. Encircle the tape arround the arm at the part where you put the mark. Makesurethetapeisnotverytightornotverylooseonthechilds.
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Read the measurement on the tape at the corresponding point. Record the measurement in centimetres(cms) in single decimal places.

STEPS FOR MEASURING MID UPPER ARM CIRCUMFERENCE(MUAC)

Look at the following pictures in the steps for easy understanding.

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

Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature(C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes ___ No ___

CHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

DOES THE CHILD HAVE DIARRHOEA?

For how long? ___ Days Is there blood in the stool? Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes ___ No ___

DOESTHECHILDHAVEFEVER?(byhistory/feelshot/temperature37.5Corabove)
Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? TestNEGATIVE? Look or feel for stiff neck Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes ___ No ___

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM?
Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes ___ No ___ Look for pus draining from the ear Feel for tender swelling behind the ear For children <6 months: Look for visible severe wasting. For children 6 months and older: check if MUAC <110 mm. Look for oedema of both feet. Determine weight for age. Very Low ___ Not Very Low ___ Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Any enlarged lymph glands now in two or more of the following sites: Neck, axilla or groin? Is there oral; thrush? Check for parotid enlargement

THEN CHECK FOR MALNUTRITION AND ANAEMIA

CHECK FOR HIV INFECTION: For all children who are not on already on ART.
Child HIV status is: Mothers HIV status seropositive Seropositive PCR positive Seronegative Seronegative Unknown* PCR negative unknown* Pnuemonia Persistent diarrhoea now Chronic ear infection now Very low weight or growth faltering Is there parotid enlargment for 14 days or more

CHECK THE CHILD'S IMMUNIZATION DEWORMING AND VITAMIN A STATUS (Circle immunizations needed today)
BCG DPT+HIb- DPT+HIbOPV- HB-1 HB-2 0 OPV-1 OPV-2 Rota-1 Rota-2 Pneumo- Pneumo1 2 DPT+HIb- Measles1 Measles 2 HB-3 OPV-3 Rota-3 Pneumo3 Vitamin A need today: Yes___ No___ Mebendazole needed today: Yes___ No ___

Return for next immunization Vitamin A or Deworming on: ________________ (Date)

ASSESS THE CHILD'S FEEDING if the child has VERY LOW WEIGHT, ANAEMIA or is less then 2 years old.
Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If very low weight for age: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how?

FEEDING PROBLEMS

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ASSESS OTHER PROBLEMS:

Ask about mother's own health

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TREAT Remember to refer any child who has a danger sign and no other severe classification

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.

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MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS

Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Is the infant having difficulty in feeding? Has the infant had convulsions? Age: Weight (kg): Initial Visit? Temperature(C): Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever(temperature38Corabovefellshot)or lowbodytemperature(below35.5Corfeelscool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR JAUNDICE

When did the jaundice appear first?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

ASSESS BREASTFEEDING
Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively 200,000 I.U vitamin A to mother 50,000 I.U to non brest feeding infant from 6 weeks age. Ask about mother's own health Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today)

BCG DPT+HIb- DPT+HIb- Rota 1 Rota 2 OPV- HB-1 HB-2 Pneumo Pneumo 0 OPV-1 OPV-2 1 2

ASSESS OTHER PROBLEMS:

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TREAT

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.

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