World Health Organisation

Integrated Management of Childhood Illnesses

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JOB AID

World Health Organisation

This desk calenadr is for use by health care workers as a quick reference aid when attending to patients

Table of Contents
Recording Form for a Sick Child 2 Months to 5 Years. Recording Form for a Sick Young Infant age up to 2 Months. Charting and Abbreviations in IMCI. Key on Abbreviations Used in IMCI. Weight For Age. Boys Diagram. Girls Diagram.
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o Good Home Care For Your Child

o Good Positioning For Breastfeeding

o When to Return Immediately

o Feeding Recommendations During Sickness and Health. o Boy

o Girl

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Recording form for a sick child 2 months to 5 years

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

DOES THE CHILD HAVE DIARRHOEA?

For how long? ___ Days Is there blood in the stool?

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 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? 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 ___

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?

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. 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 Yes ___ No ___

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-2 OPV-1 Rota-2 Rota-1 Pneumo- Pneumo2 1 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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Recording form for a sick child young infant age up to 2 months

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature(C): Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Is the infant having difficulty in feeding? Has the infant had convulsions?

DOES THE YOUNG INFANT HAVE DIARRHOEA?

THEN CHECK FOR JAUNDICE

When did the jaundice appear first?

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).

Yes ___ No ___

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?

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

BCG OPV0 DPT+HIb- DPT+HIb- Rota 1 Rota 2 HB-2 HB-1 Pneumo Pneumo OPV-2 OPV-1 1 2

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. Return for next immunization on: ________________ (Date)

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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1. Hold baby close to her. 2. Face the baby to the breast. 3. Hold the babys body in a straight line with the head. 4. Support the babys whole body. 5. Make sure that the baby is wellattached to the breast.

Mother should not squeeze the breast itself, for example, with a scissors hold. Squeezing will interfere with the flow of milk

Good position

Poor position

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EXAMPLE OF CHARTING IN IMCI 1. Sex/Age: F 8/12 2. Bwt: 9Kg 3. Temp.: 37.8C 7. P/S: Cough x 2/7 4. Fever x 2/7 5. NOS 6. No GDS 7. Cough x 2/7; B/min 54Pneumonia 8. CI; S; W F/up 2/7 9. Fever x 2/7; SN; RDT ve 10. Malnutrition: VSW; OBF Not very low wt for age, & 10. GF; Not VLWA No growth faltering 12. MUAC - green 13. Aneamia: PP No Anaemia 14. HIV/AIDs; Mother ve HIV infection unlikely 15. Immunization up-todate 16. Measles vaccine at 9/12 17. No feeding problem 18. R/:Amoxicillin 125mg tds x 5/7 19. Sooth throat with safe remedy 20. F/up 2/7 21. Advised when to return immediately

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KEY ON ABBREVIATION USED IN IMCI

E. P/S F. NOS G. GDS H. B/min I. CI J. S K. W L. F/up M. SN N. RDT O. VSW P. OBF Q. MUAC R. GF S. VLWA T. PP U. PP+ V. PP+++ W. R/ Presenting symptoms No other symptoms General danger sign Breath per minute No chest in-drawing No stridor No wheeze Follow up No stiff neck Rapid diagnostic test No visible severe wasting No Oedema of both feet Mid-Upper Arm Circumference No growth faltering Very low weight for age; No palmer pallor Some palmer pallor Severe palmer pallor Treatment

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NOT FOR SALE

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Facilitated by Moyo wa Bana Capacity Building Initiative through CARE with funding fron CIDA

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NOT FOR SALE

Facilitated by Moyo wa Bana Capacity Building Initiative through CARE with funding fron CIDA

World Health Organisation

Facilitated by Moyo wa Bana Capacity Building Initiative through CARE with funding fron CIDA

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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 fever?
(byhistoryorfeelshotortemperature37.5C*orabove) If yes: Then ask: Look and feel: For how long? Look or feel for stiff neck. 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 Classify FEVER 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

Green: FEVER : NO 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 CLASSIFY NUTRITIONAL STATUS If age up to 6 months: and visible severe wasting 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 Pink: SEVERE MALNUTRITION Treat the child to prevent low blood sugar Refer URGENTLY to hospital

Yellow: VERY LOW WEIGHT

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 ANAEMIA

Severe palmar pallor

Pink: SEVERE ANAEMIA Yellow: ANAEMIA

Refer URGENTLY to hospital

Some palmar pallor

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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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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MANAGEMENT OF DIARRHOEA
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: When give vitamin A, 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

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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 FEEL Any enlarged Child HIV status Mothers HIV 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

Classify for HIV infection

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 in child or mother OR less than two conditions

Green: SYMPTOMATIC HIV INFECTION UNLIKELY Green: HIV INFECTION UNLIKELY

Negative HIV test in the mother or child

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

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World Health Organisation

WHO PAEDIATRIC CLINICAL STAGING FOR HIV
WHO Paediatric Clinical stage 1Asymptomatic No symptoms or only: Persistent Generalised Lymphadenopathy (PGL) WHO Paediatric Clinical stage 2- Mild Disease Unexplained persistent enlarged liver and or spleen. Unexplained persistent enlarged parotid glands, Skin conditions (prurigo, seborrhoeic dermatis, extensive molleusoum contegiosum or warts, fungul nail infections, herps zoster). Mouth conditions ( recurrent mouth ulcerations, gingival erythema), Recureent or chronic RTI (Sinusitis, ear infections, tonsillitis, otorrhoea) Has the child been confirmed HIV infection? if yes, perform clinical staging: any one condition in the highest staging determines stage, If no, you cannot stage the patient. WHO Paediatric Clinical stage 3Moderate Disease Moderate unexplained malnutrition not responding to standard therapy Oral thrush (outside neonatal period). Oral hairy leucoplakia Unexplained and unresponsive to standard therapy: - Diarrohoea > 14 days - Fever more than one mouth * 3 - Thrombopsytopenia (50,000/mm for more than 1 mouth), Neutropenia 3 (500/mm for 1 mouth) - Aneamia for > 1 month (heamoglobin * < 8gm) Recurrent severe bacterial pneumonia Pulmonary TB, Lymphomoid TB, * Symptomatic LIP Acute necrotizing ulcerative gingivitis/ periodontitis, Chronic HIV associated lung disease * including bronchiectasis ART is indicated; Child less than 12 months regardless of 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 immune deficiency WHO Paediatric Clinical stage 4- Severe Disease (AIDS) Severe unexplained Wasting/ Stunting/Severe malnutrition not responding to standard therapy Oesophageal thrush, More than 1 month of herps simplex ulcerations, Severe multiple or recurrent bacterial infections 2 episodes in a year ( not including pneumonia) * Pneumocystis pneumonia (PCP) Kaposis Sarcoma, Extra pulmonary TB, Toxoplasma brain * abscess Cryptococcal meningitis, Chronic cryptosporidioasis, Chronic isosporiasis Acquired HIV associated rectal fistula, * HIV encephalopathy * Cerebral B cell non- hodgkins lymphoma Symptomatic HIV associated cardiomyopathy/nephropathy

Growth Symptoms / Signs

ARV therapy

Indicated only if CD4 is available: 11 month and DC4 25% ( or 1500 cells) 12 35 months and CD4 20% ( or 750 cells) 36 59 months and CD4 15% ( or 360 cells) 5 years and CD4 15% (< 200 cells/mm3 )

Indicated only if CD4 or TLC# is available: Same as stage 1 OR 11 month TLC 3000 cells 36 59 moth and TLC 2500 cells 5 - 8 years and TLC 2000 cells* *There is not adequate data for children older than 8 years.

ART is indicted: Irrespective of the CD4 count, and should be started as soon as possible

Note that these are interim recommendations and may be subject to change. # 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 In a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated
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