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SICKCHILDAGE2MONTHSUPTO5YEARS
ASSESSANDCLASSIFYTHESICKCHILD
CHECKFORGENERALDANGERSIGNS 1 Doesthechildhaveanearproblem? 5 THENCHECKTHECHILD'SIMMUNIZATION,VITAMINA, 8
THENCHECKFORANEMIA 5 DEWORMINGSTATUS,andORALHEALTH
THENASKABOUTMAINSYMPTOMS: 2
THENCHECKFORACUTEMALNUTRITION 6 ASSESSOTHERPROBLEMS: 8
Doesthechildhavediarrhea? 3
THENCHECKFORHIVINFECTION 7 HIVTESTINGANDINTERPRETINGRESULTS 9
Doesthechildhavefever? 4
WHOPEDIATRICSTAGINGFORHIVINFECTION 10
TREATTHECHILD
TEACHTHEMOTHERTOGIVEORALDRUGSATHOME 11 CleartheEarbyDryWickingandGiveEardrops* 14 PLANB:TREATSOMEDEHYDRATIONWITHORS 18
GiveanAppropriateOralAntibiotic 11 TreatforMouthUlcerswithGentianVioletGV 14 PLANC:TREATSEVEREDEHYDRATIONQUICKLY 19
GiveInhaledSalbutamolforWheezing 12 TreatThrushwithNystatinOralSuspension 14 GIVEREADYTOUSETHERAPEUTICFOOD 20
GiveOralAntimalarialforP.falciparumMALARIA 12 GIVEVITAMINAANDMEBENDAZOLEorALBENDAZOLEINTHE 15 GiveReadytoUseTherapeuticFoodforSEVEREACUTE 20
HEALTHCENTER MALNUTRITION
TreatmentScheduleforconfirmedP.vivaxorP.OVALECases 12
GiveVitaminASupplementationandTreatment 15 TREATTHEHIVINFECTEDCHILD 21
TreatmentScheduleforPlasmodiummalariaeMalaria 13
GiveMebendazoleorAlbendazole 15 StepswhenInitiatingARTinChildren 21
TreatmentScheduleformixedP.falciparumandP.vivaxinfection 13
GIVETHESETREATMENTSINTHEHEALTHCENTERONLY 16 PreferredandAlternativeARVRegimens 22
GiveParacetamolforHighFever>38.5CorEarPain 13
GiveIntramuscularAntibiotics 16 GiveAntiretroviralDrugsFixedDoseCombinations 22
GiveIron* 13
GiveDiazepamtoStopConvulsions 16 GiveAntiretroviralDrugs 23
GiveMicronutrientPowder 13
GiveArtesunateSuppositoriesorOralQuinineforSevereMalaria 17 SideEffectsARVDrugs 24
TEACHTHEMOTHERTOTREATLOCALINFECTIONSATHOME 14
TreattheChildtoPreventLowBloodSugar 17 ManageSideEffectsofARVDrugs 25
SoothetheThroat,RelievetheCoughwithaSafeRemedy 14
GIVEEXTRAFLUIDFORDIARRHEAANDCONTINUEFEEDING 18 GivePainRelieftoHIVInfectedChild 26
TreatEyeInfectionwithTetracyclineEyeOintment 14
PLANA:TREATDIARRHEAATHOME 18 IMMUNIZEEVERYSICKCHILDASNEEDED 26
FOLLOWUP
GIVEFOLLOWUPCAREFORACUTECONDITIONS 27 FEVER:NOMALARIA 28 MODERATEACUTEMALNUTRITION 29
PNEUMONIA 27 MEASLESWITHEYEORMOUTHCOMPLICATIONS,GUMOR 28 GIVEFOLLOWUPCAREFORHIVEXPOSEDANDINFECTED 30
MOUTHULCERS,ORTHRUSH CHILD
PERSISTENTDIARRHEA 27
EARINFECTION 28 HIVEXPOSED 30
DYSENTERY 27
FEEDINGPROBLEM 28 CONFIRMEDHIVINFECTIONNOTONART 30
MALARIA 28
ANEMIA 28 CONFIRMEDHIVINFECTIONONART:THEFOURSTEPSOF 31
UNCOMPLICATEDSEVEREACUTEMALNUTRITION 29 FOLLOWUPCARE
COUNSELTHEMOTHER
FEEDINGCOUNSELLING 32 RecommendationforFeedingandCareforDevelopment 35 EXTRAFLUIDSANDMOTHER'SHEALTH 38
AssessChild'sAppetite 32 FeedingRecommendationsforHIVEXPOSEDChildonInfantFormula 36 AdvisetheMothertoIncreaseFluidDuringIllness 38
Only CounseltheMotheraboutherOwnHealth 38
AssessChild'sFeeding 33
StoppingBreastfeeding 37 WHENTORETURN 39
FeedingRecommendationsDuringSicknessandHealth 34
FeedingRecommendationsForaChildWhoHasPERSISTENT 37
DIARRHEA
RecordingForm:Recordingform 60
RecordingForm:ARTinitiationsteps 62
RecordingForm:HIVonARTfollowupsteps 64
PHVersion,October2014
SICKYOUNGINFANTAGEUPTO2MONTHS
ASSESSANDCLASSIFYTHESICK
THENCHECKFORHIVINFECTION 43 THENCHECKTHEYOUNGINFANT'SIMMUNIZATIONAND 46
YOUNGINFANT THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFOR 44 VITAMINASTATUS:
CHECKFORVERYSEVEREDISEASEANDLOCALBACTERIAL 41 AGE ASSESSOTHERPROBLEMS 46
INFECTION THENCHECKFORFEEDINGPROBLEMORLOWWEIGHTFOR 45 ASSESSTHEMOTHERSHEALTHNEEDS 46
CHECKFORJAUNDICE 42 AGEINNONBREASTFEDINFANTS
THENASK:Doestheyounginfanthavediarrhea*? 42
TREATANDCOUNSEL
TREATTHEYOUNGINFANT 47 TEACHTHEMOTHERTOTREATLOCALINFECTIONSATHOME 48 TEACHCORRECTPOSITIONINGANDATTACHMENTFOR 50
ToTreatDiarrhea,SeeTREATTHECHILDChart. 48 BREASTFEEDING
GIVEFIRSTDOSEOFINTRAMUSCULARANTIBIOTICS 47
ImmunizeEverySickYoungInfant,asNeeded 49 TEACHTHEMOTHERHOWTOEXPRESSBREASTMILK 50
TREATTHEYOUNGINFANTTOPREVENTLOWBLOODSUGAR 47
GIVEARVFORPMTCTPROPHYLAXIS 49 TEACHTHEMOTHERHOWTOFEEDBYACUP 50
TEACHTHEMOTHERHOWTOKEEPTHEYOUNGINFANTWARM 48
ONTHEWAYTOTHEHOSPITAL COUNSELTHEMOTHER 50 TEACHTHEMOTHERHOWTOKEEPTHELOWWEIGHTINFANT 50
WARMATHOME
GIVEANAPPROPRIATEORALANTIBIOTICFORLOCAL 48
BACTERIALINFECTION ADVISETHEMOTHERTOGIVEHOMECAREFORTHEYOUNG 51
INFANT
FOLLOWUP
GIVEFOLLOWUPCAREFORTHEYOUNGINFANT 52 DIARRHEA 52 LOWWEIGHTFORAGE 53
ASSESSEVERYYOUNGINFANTFOR"VERYSEVEREDISEASE" 52 JAUNDICE 53 THRUSH 54
DURINGFOLLOWUPVISIT FEEDINGPROBLEM 53 CONFIRMEDHIVINFECTIONORHIVEXPOSED 54
LOCALBACTERIALINFECTION 52
RecordingForm:Younginfantrecordingform 66
Annex:
SkinProblems
IDENTIFYSKINPROBLEM 55
IFSKINISITCHING 56
IFSKINHASBLISTERS/SORES/PUSTULES 57
NONITCHY 58
CLINICALREACTIONTODRUGS 59
DRUGANDALLERGICREACTIONS 59
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS
on TREAT THE CHILD chart.
if initial visit, assess the child as follows:
Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referral treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
Page1of76
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
If yes, ask: Look, listen, feel: Any general danger sign Pink: Give first dose of an appropriate antibiotic
For how long? Count the or SEVERE Refer URGENTLY to hospital*
Classify
breaths in COUGH or Stridor in calm child. PNEUMONIA OR
one minute. DIFFICULT VERY SEVERE
Look for BREATHING DISEASE
chest Yellow:
CHILD Chest indrawing or Give oral Amoxicillin for 5 days**
indrawing.
MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
Look and
CALM acting bronchodilator) give an inhaled
listen for
bronchodilator for 5 days***
stridor.
If chest indrawing in HIV exposed/infected child,
Look and
give first dose of amoxicillin and refer.
listen for
Soothe the throat and relieve the cough with a
wheezing.
safe remedy
If wheezing with either If coughing for more than 14 days or recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for up Follow-up in 3 days
to three times 15-20 minutes Green:
No signs of pneumonia or If wheezing (or disappeared after rapidly acting
apart. Count the breaths and
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
look for chest indrawing
5 days***
again, and then classify.
Soothe the throat and relieve the cough with a
If the child is: Fast breathing is: safe remedy
2 months up to 12 months 50 breaths per minute or more If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
12 Months up to 5 years 40 breaths per minute or more assessment
Advise mother when to return immediately
Follow-up in 5 days if not improving
* If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
**Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
*** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatment of severe acute wheeze.
Page2of76
Does the child have diarrhea?
Two of the following signs: Pink: If child has no other severe classification:
If yes, ask: Look and feel:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
For how long? Look at the child's general
for DEHYDRATION Sunken eyes DEHYDRATION OR
Is there blood in the stool? condition. Is the child:
Not able to drink or drinking If child also has another severe
Lethargic or
poorly classification:
unconscious? Classify DIARRHEA
Skin pinch goes back very Refer URGENTLY to hospital with mother
Restless and irritable? giving frequent sips of ORS on the way
slowly.
Look for sunken eyes. Advise the mother to continue
Offer the child fluid. Is the breastfeeding
child: If child is 2 years or older and there is
Not able to drink or cholera in your area, give antibiotic for
drinking poorly? cholera
Drinking eagerly,
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some
thirsty?
Restless, irritable SOME dehydration (Plan B)
Pinch the skin of the
Sunken eyes DEHYDRATION If child also has a severe classification:
abdomen. Does it go back:
Drinks eagerly, thirsty Refer URGENTLY to hospital with mother
Very slowly (longer
Skin pinch goes back giving frequent sips of ORS on the way
than 2 seconds)?
slowly. Advise the mother to continue
Slowly? breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify as Green: Give fluid, zinc supplements, and food to treat
some or severe dehydration. NO DEHYDRATION diarrhea at home (Plan A)
Advise mother when to return immediately
Follow-up in 5 days if not improving
Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhea 14 SEVERE has another severe classification
days or more PERSISTENT Refer to hospital
DIARRHEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHEA
DIARRHEA Give multivitamins and minerals (including zinc) for
14 days
Give Vitamin A.
Follow-up in 5 days
Page3of76
Does the child have fever?
(byhistoryorfeelshotortemperature37.5C*orabove)
Any general danger sign or Pink: Give first dose of artesunate or oral quinine for severe
If yes:
Stiff neck. VERY SEVERE FEBRILE malaria (under medical supervision)
Decide Malaria Risk:
Malaria Risk DISEASE Give first dose of an appropriate antibiotic
Ask: Treat the child to prevent low blood sugar
Does the child live in a malaria area? Giveonedoseofparacetamolinclinicforhighfever(38.5C
Classify FEVER
Has the child travelled during the past 3 weeks and, if so, where? or above)
Then ask: Look and feel: Refer URGENTLY to hospital
For how long? Look or feel for stiff neck. Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
If more than 7 days, has fever been Look for runny nose. MALARIA Giveonedoseofparacetamolinclinicforhighfever(38.5C
present every day? Look for any bacterial cause of or above)
Has the child had measles within the fever**. Give appropriate antibiotic treatment for an identified bacterial cause
last 3 months? Look for signs of MEASLES. of fever
Generalized rash and Advise mother when to return immediately
One of these: cough, runny nose, Follow-up in 3 days if fever persists
or red eyes. If fever is present every day for more than 7 days, refer for
Do a malaria test***: If NO severe classification assessment
In all fever cases with malaria risk. Malaria test NEGATIVE Green: Giveonedoseofparacetamolinclinicforhighfever(38.5C
If no obvious cause of fever present. Other cause of fever PRESENT. FEVER: or above)
NO MALARIA Give appropriate antibiotic treatment for an identified bacterial
cause of fever
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
Any general danger sign or Pink: Give first dose of an appropriate antibiotic.
No Malaria Risk and No
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
Travel to Malaria Risk
DISEASE Giveonedoseofparacetamolinclinicforhighfever(38.5C
Area
or above).
Refer URGENTLY to hospital.
No general danger signs Green: Giveonedoseofparacetamolinclinicforhighfever(38.5C
No stiff neck. FEVER or above)
Give appropriate antibiotic treatment for any identified bacterial
cause of fever
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 Dengue Hemorrhagic Fever Bleeding from nose or gums or Pink: If persistent vomiting or persistent abdominal pain or skin petechiae or
ASK: LOOK AND FEEL: Bleeding in stools or vomitus or SEVERE positive torniquet test are the only positive signs, give ORS(Plan B)
Has the child had any bleeding from Look for bleeding from nose or gums. Black stools or vomitus or DENGUE If any other signs of bleeding are present, give fluids rapidly(Plan C).
Classify Dengue Treat the child to prevent low blood sugar.
the nose or gums or in the vomitus or Look for skin petechiae. Skin petechiae or HEMORRHAGIC
stools? Hemorrhagic Fever Cold and clammy extremities or Refer all children URGENTLY to hospital.
Feel for cold and clammy extremities. FEVER
Has the child had black vomitus? Check for slow capillary refill. Capillary refill more than 3 seconds or DO NOT GIVE ASPIRIN.
Has the child had black stools? if none of above ASK or LOOK and FEEL persistent abdominal pain
Has the child had persistent signs are present and the child is 6 Persistent vomiting or
abdominal pain? months or older and fever is present for Touriquet test positive
Has the child had persistent vomiting more than 3 days. No signs of severe dengue hemorrhagic Green: Give ORS
Perform the tourniquet test. fever FEVER:DENGUE Advise mother when to return immediately.
HEMORRHAGIC FEVER Follow-up in 3 days if fever persists or child shows signs of
UNLIKELY bleeding.
DO NOT GIVE ASPIRIN.
*Thesetemperaturesarebasedonaxillarytemperature.Rectaltemperaturereadingsareapproximately0.5Chigher.
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
*** If no malaria test available: If in malaria risk area - classify as MALARIA; If NO obvious cause of fever - classify as MALARIA.
**** Other important complications of measles - pneumonia, stridor, diarrhea, ear infection, and acute malnutrition - are classified in other tables.
Page4of76
Does the child have an ear problem?
If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain
Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital
If yes, for how long? Feel for tender swelling
Pus is seen draining from Yellow: Give an antibiotic for 5 days
behind the ear.
the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR INFECTION
the ear.
Check for anemia Severe palmar pallor Pink: Refer URGENTLY to hopsital
Look for palmar pallor. Is it: SEVERE ANEMIA
Severe palmar pallor? Classify
Some pallor Yellow: Give iron*
Some palmar pallor? ANEMIA Classification
arrow ANEMIA Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days
Give micronutrient powder (MNP)
*If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.
Page5of76
THEN CHECK FOR ACUTE MALNUTRITION
CHECK FOR ACUTE MALNUTRITION Edema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar
STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Look for edema of both feet.
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
complication present
If WFH/L less than -3 z-scores or MUAC less than 115 or
mm, then: Not able to finish RUTF
Check for any medical complication present: or
Any general danger sign Breastfeeding
Any severe classification problem.
Pneumonia with chest indrawing WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
If no medical complications present: scores UNCOMPLICATED Continue breastfeeding
Child is 6 months or older, offer RUTF*** to eat. OR SEVERE ACUTE Give ready-to-use therapeutic food if available
Is the child: MUAC less than 115 mm MALNUTRITION for a child aged 6 months or more
Not able to finish RUTF portion? Counsel the mother on how to feed the child.
AND
Able to finish RUTF portion? Assess for possible TB infection
Able to finish RUTF.
Child is less than 6 months, assess Advise mother when to return immediately
breastfeeding: (see page 45 of 77) Follow up in 5 days
Does the child have a breastfeeding WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
problem? 2 z-scores MODERATE ACUTE mother on the feeding recommendations
OR MALNUTRITION If feeding problem, follow up in 5 days
MUAC 115 up to 125 mm. Assess for possible TB infection.
Advise mother when to return immediately
Follow-up in 30 days
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
more NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
recommendations
MUAC 125 mm or more.
Give micronutrient powder supplement.
If feeding problem, follow-up in 5 days
*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.
Page6of76
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care.
Positive virological test in Yellow: Initiate ART treatment and HIV care
ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis*
Classify OR INFECTION Assessthechildsfeedingandprovideappropriate
Has the mother or child had an HIV test? HIV counselling to the mother
status Positive serological test in a
IF YES: child 18 months or older Advise the mother on home care
Decide HIV status: Assess or refer for TB assessment and INH
Mother: POSITIVE or NEGATIVE preventive therapy
Child: Follow-up regularly as per national guidelines
Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status**
unknown, ASK: ago Assessthechildsfeedingandprovideappropriate
Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother
the test? Mother HIV-positive, child Advise the mother on home care
Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines
If breastfeeding ASK: Is the mother and child on ARV OR
prophylaxis?
Positive serological test in a
IF NO, THEN TEST: child less than 18 months
Mother and child status unknown: TEST mother. old
Mother HIV positive and child status unknown: TEST child.
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
or child HIV INFECTION
UNLIKELY
* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children until confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breastfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
Page7of76
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A, DEWORMING STATUS, and
ORAL HEALTH
12 months - MMR
15 months
*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated with BCG. Infant born to mother with TB disease, do not give BCG first, instead
give Isoniazid Preventive therapy {IPT} for 3 months. If TST negative after 3 months, give BCG.
**DPT+HIB+HepB is available as pentavalent vaccine
***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.
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.
****Rotavirus Vaccine is given to children in selected areas due to limited supplies; Rotavirus Vaccine is available as 2 dose or 3 dose schedule
*****Pneumococcal Conjugate Vaccine ( PCV ) is given to children in selected areas only due to limited supplies.
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
blood sugar.
Page8of76
HIV TESTING AND INTERPRETING RESULTS
HIV testing is RECOMMENDED for:
AllchildrenwithunknownHIVstatusespeciallythoseborntoHIVpositivemothers.(Ifyoudonotknowthemothersstatus,testthemotherfirst,ifpossible)
Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age
Breastfeeding status POSITIVE (+) test NEGATIVE (-) test
NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected
last 6 weeks Repeat test at 18 months.
BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been
could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks.
breastfeeding has been discontinued for more than 6 weeks.
Page9of76
WHO PEDIATRIC STAGING FOR HIV INFECTION
ThisisusedformonitoringchildrenduringfollowuptodetermineclinicalresponsetoARVtreatment.Determinetheclinicalstagebyassessingthechildssignsandsymptoms.Lookattheclassificationforeach
stage.Decidewhatisthehigheststageapplicabletothechildwhereoneormoreofthechildssymptomsarerepresented.
Symptoms/Signs No symptoms, or only: Enlarged liver and/or spleen Oral thrush (outside neonatal Esophageal thrush
Persistent generalized Enlarged parotid period). More than one month of herpes simplex ulcerations.
lymphadenopathy (PGL) Skin conditions (prurigo, seborrheic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacterial infections > 2
molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis
herpes zoster) to standard pneumonia (PCP)*
Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma.
gingival Erythema) Diarrhea for over 14 days Extrapulmonary tuberculosis.
Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess*
(sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis*
otorrhea) 50,000/mm3 for 1month Acquired HIV-associated rectal
Neutropenia* (under fistula
500/mm3 for 1 month) HIV encephalopathy*
Anemia for over 1 month
(hemoglobin under 8 gm)*
Recurrent severe bacterial
pneumonia
Pulmonary TB
Lymph node TB
Symptomatic lymphoid
interstitial pneumonitis (LIP)*
Acute necrotising ulcerative
gingivitis/periodontitis
Chronic HIV associated lung
diseases including
bronchiectasis*
*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.
Page10of76
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
Page11of76
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Give Oral Antimalarial for P. falciparum MALARIA
Also follow the instructions listed with each drug's dosage table.
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 Inhaled Salbutamol for Wheezing Give second dose at home after 8 hours.
Then twice daily for further two days as shown below.
USE OF A SPACER* Artemether-lumefantrine should be taken with food.
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years Advice patient to take AL with milk or fat containing food ("gata"or coconut milk, buko, or suman
should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. sa latik and cookies)particularly on the 2nd and 3rd days of treatment.
Fromsalbutamolmetereddoseinhaler(100g/puff)give2puffs. Since lumefantrine is highly lipophilic, its absorption is enhanced by co-administration of fat.
Repeat up to 3 times every 15 minutes before classifying pneumonia. low blood levels would resultant treatment failure could potentially result from inadequate fat
intake.
Spacers can be made in the following way:
Use a 500ml drink bottle or similar. WEIGHT (age)
ARTEMETHER-LUMEFANTRINE TABLETS PRIMAQUINE
(20mg artemether and 120 mg lemefantrine) (1 tablet contains 15mg base of primaquine)
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. (1) use body weight in kgs as basis
(2) If weight cannot be taken, use age as basis
This can be done using a sharp knife. 0H 8H Day 2 Day 3 Day 4
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the 5 - <15 kg (6months up to 3years old) 1 1 1 tab BID 1 tab BID Give PRiMAQUINE only to > 1 yr old, 1/2 tab single dose (contraindicated in <1 year old)
bottle. 15 - <25 kg (4 - 8 years old) 2 2 2 tabs BID 2 tabs BID 1 tab single dose
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. Treatment Schedule for confirmed P. vivax or P. OVALE Cases
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.
PRIMAQUINE
No. of CHLOROQUINE Tablet (15 mg/tablet)
To use an inhaler with a spacer:
(150 mg base/tablet) No. of Tablet
Remove the inhaler cap. Shake the inhaler well. Age(years)
Day 1 - 10 mg base/kg BW Day 4-17
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. (1) Use weight in kgs as basis
The child should put the opening of the bottle into his mouth and breath in and out through the mouth. Day 2 - 10 mg base/kg BW treatment
(2) If weight cannot be taken, use age
A carer then presses down the inhaler and sprays into the bottle while the child continues to breath Day 3 - 5 mg base/kg BW use 0.5 mg base per kg
as basis
normally. per day
Wait for three to four breaths and repeat. Day
For younger children place the cup over the child's mouth and use as a spacer in the same way. Day 2 Day 3 Day 4 -17
1
0-11 mos. 1/2 1/2 1/2 contraindicated
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
1-3 years 1 1 1/2 1/2 daily
1
4-6 years 1 1/2 1 1/2 daily
1/2
1. Chloroquine remains highly effective against vivax malaria. Hence, it remains the recommended drug of
choice for P. ovale. However, in the absence of CQ and in case of treatment failure, AL can be used.
2. Primaquine must not be given to infants <1 year old
3. Primaquine should be taken with meals {causes abdominal discomfort taken on an empty stomach}
4. Primaquine can induce hemolysis in people with glucose-6-phosphate dehydrogenase {G6PD}
deficiency. Consider G6PD test if available. If G6PD test is not available, observe a change in urine
color.
Stop Primaquine intake if urine turns dark {tea-colored}
Page12of76
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. GiveParacetamolforHighFever(>38.5C)orEarPain
Also follow the instructions listed with each drug's dosage table. Give paracetamol every 6 hours until high fever or ear pain is gone.
PARACETAMOL
AGE or WEIGHT SYRUP(120 mg / 5 SYRUP [250 DROPS [100
Treatment Schedule for Plasmodium malariae Malaria ml) mg/5ml] mg/ml]
2 months up to 3 years (4 - 1/2 teaspoon [2.5
PRIMAQUINE 1 teaspoon [5ml] 1.2 ml
<14 kg) ml]
No. of CHLOROQUINE Tablet (15 mg/tablet)
(150 mg base/tablet) No. of Tablet 3 years up to 5 years (14 -
2 teaspoon [10 ml] 1 teaspoon [5 ml] -----
Age(years) <19 kg)
Day 1 - 10 mg base/kg BW Day 4
(1) Use weight in kgs as basis
Day 2 - 10 mg base/kg BW treatment
(2) If weight cannot be taken, use
Day 3 - 5 mg base/kg BW use 0.75 mg base per kg
age as basis
per day
Give Iron*
Day
Day 2 Day 3 Day 4
1 Give one dose daily for 14 days.
0-11 mos. 1/2 1/2 1/2 contraindicated IRON/FOLATE
IRON SYRUP
TABLET
1-3 years 1 1 1/2 1/2 tablet single dose
AGE or WEIGHT Ferrous sulfate
1
4-6 years 1 1/2 1 1 tablet single dose 200mg+250g Ferrous fumarate 100 mg per 5 ml (20 mg
1/2
Folate (60 mg elemental iron per ml)
Perform thick and thin blood film including parasite count (for RHU, hospital and laboratory facilities elemental iron)
only) after completing treatment on Day 3 then on Day 7, 14, 21 and 28. Refer to the next level of
2 months up to 4 months (4 -
health care if parasitemia is still present. 1.00 ml (< 1/4 tsp.)
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp.)
(6 - <10 kg)
Treatment Schedule for mixed P. falciparum and P. vivax 12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp.)
infection (10 - <14 kg)
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
ARTEMETHER - PRIMAQUINE 19 kg)
LUMEFANTRINE tablets (15 mg/tablet) * Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
AGE
(20mg artemether and 120 mg No. of Tablet not be given Iron.
(years) lumefantrine) for 14 days
1 8H1 Day 2 Day 3 Day 4
5 - <15 kg Give PRIMAQUINE only to > 1 yr old, 1/2 Give Micronutrient Powder
(6months up to 3 1 1 1 tab BID 1 tab BID tablet single dose
years old) (contraindicated in <1 yr. old) Give Micronutrient Powder Supplement or (MNP) daily to children 6 - 23 months old
Use this at 6 months of age during the introduction of complementary feeding
15 - <25 kg
2 2 2 tab BID 2 tab BID 1 tablet single dose Mix MNP into complementary food preferably soft or semi-solid before feeding it to the child
(4 - 8 years old) Do not add MNP to food before or during cooking
* Treatment should be given after meals for 6 - 11 months infant, give a total of 60 sachets over a period of 6 months
* First day of treatment should be under the supervision of the health worker for 12 - 23 months children, give 60 sachets every 6 months for a total of 120 sachets in a
year
Page13of76
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
Treat for Mouth Ulcers with Gentian Violet (GV)
Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box. Treat for mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except for remedy for Wash hands.
cough or sore throat). Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
Tell her how often to do the treatment at home. Paint the mouth with half-strength gentian violet (0.25% dilution).
If needed for treatment at home, give mother the tube of tetracycline ointment or a Wash hands again.
small bottle of gentian violet. Continue using GV for 48 hours after the ulcers have been cured.
Give paracetamol for pain relief.
Check the mothers understanding before she leaves the clinic.
Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin Oral Suspension
Safe remedies to recommend: Treat thrush four times daily for 7 days
Breast milk for a breastfed infant. Wash hands
Increase fluid intake. Wetacleansoftclothwithsaltwateranduseittowashthechildsmouth
Give calamansi juice. Give nystatin 1ml four times a day
Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
Ifbreastfedcheckmothersbreastsforthrush.Ifpresenttreatwithnystatin
Don't give cough syrups or mucolytics. Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
Don't give nasal decongestant like phenylpropanolamine. Give paracetamol if needed for pain
Page14of76
GIVE VITAMIN A AND MEBENDAZOLE or ALBENDAZOLE IN THE HEALTH CENTER
Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately
Page15of76
GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY
Give Diazepam to Stop Convulsions
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Turn the child to his/her side and clear the airway. Avoid putting things in the mouth.
Use a sterile needle and sterile syringe when giving an injection. Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a
Measure the dose accurately. tuberculin syringe) or using a catheter.
Give the drug as an intramuscular injection. Check for low blood sugar, then treat or prevent.
Give oxygen and REFER
If child cannot be referred, follow the instructions provided.
If convulsions have not stopped after 10 minutes repeat diazepam dose
DIAZEPAM
AGE or WEIGHT
10mg/2mls
Give Intramuscular Antibiotics 2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
GIVE TO CHILDREN BEING REFERRED URGENTLY
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). 12 months up to 3 years (10 - <14 kg) 1.5 ml
Alternate drug for Ampicillin is Benzyl Penicillin 500,000 units/ml 3 years up to 5 years (14-19 kg) 2.0 ml
BENZYL PENICILLIN
Add 8 ml sterile water to vial of 5 million units
AMPICILLIN
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times.
GENTAMICIN
7.5 mg/kg/day once daily
Benzyl
Penicillin
AMPICILLIN GENTAMICIN
AGE or WEIGHT 5 million
500 mg vial 40 mg/ml vial
units
vial
2 up to 4 months (4 - <6 kg) 1 ml 0.5-1.0 ml 0.3 ml
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml 0.6 ml
12 months up to 3 years (10 -
3 ml 1.9-2.7 ml 1.0 ml
<14 kg)
3 years up to 5 years (14 -
5 ml 2.8-3.5 ml 1.5 ml
19 kg)
Page16of76
GIVE THESE TREATMENTS IN THE HEALTH CENTER ONLY
Treat the Child to Prevent Low Blood Sugar
If the child is able to breastfeed:
Give Artesunate Suppositories or Oral Quinine for Severe Ask the mother to breastfeed the child.
Malaria If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
If neither of these is available, give sugar water*.
Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
artesunate injection or quinine). Give 30 - 50 ml of milk or sugar water* before departure.
Artesunate suppository: Insert first dose of the suppository and refer child urgently If the child is not able to swallow:
Oral quinine: Give first dose and refer child urgently to hospital. Give 50 ml of milk or sugar water* by nasogastric tube.
IF REFERRAL IS NOT POSSIBLE: If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
.For artesunate suppository:
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
Give first dose of suppository water.
Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
Give full dose of oral antimalarial as soon as the child is able to take orally
For Quinine:
Give first dose of oral Quinine.
Pulverize tablet and give through NGT
RECTAL ARTESUNATE
ORAL QUININE SULFATE*
SUPPOSITORY
AGE or 50 mg 200 mg
WEIGHT suppositories suppositories 300 mg /tablet
Dosage 10 Dosage 10 Dosage: 10 mg/kg body weight
mg/kg mg/kg
0 months up
to 12
1 ------- 1/4 tablet
months (5 -
8.9 kg)
13 months
up to 42
2 ------- 1/4 -3/4 tablet
months (9 -
19 kg)
43 months
up to 60
4 1 3/4 - 1 tablet
months
(20 - 29 kg)
* quinine salt
Page17of76
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart)
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
PLAN A: TREAT DIARRHEA AT HOME WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
Counsel the mother on the 4 Rules of Home Treatment: AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5
months months years years
1. Give Extra Fluid In ml 200 - 450 450 - 800 800 - 960 960 - 1600
2. Give Zinc Supplements (age 2 months up to 5 years) * Use the child's age only when you do not know the weight. The approximate amount of ORS
3. Continue Feeding required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
4. When to Return. 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
1. GIVE EXTRA FLUID (as much as the child will take)
period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
TELL THE MOTHER:
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Breastfeed frequently and for longer at each feed.
Give frequent small sips from a cup.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.
If the child vomits, wait 10 minutes. Then continue, but more slowly.
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 Continue breastfeeding whenever the child wants.
water. AFTER 4 HOURS:
It is especially important to give ORS at home when: Reassess the child and classify the child for dehydration.
the child has been treated with Plan B or Plan C during this visit. Select the appropriate plan to continue treatment.
the child cannot return to a clinic if the diarrhea gets worse. Begin feeding the child in clinic.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
ORS TO USE AT HOME. Show her how to prepare ORS solution at home.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID Show her how much ORS to give to finish 4-hour treatment at home.
INTAKE: Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
Up to 2 years 50 to 100 ml after each loose stool in Plan A.
2 years or more 100 to 200 ml after each loose stool
Explain the 4 Rules of Home Treatment:
Tell the mother to:
1. GIVE EXTRA FLUID
Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more slowly. 2. GIVE ZINC (age 2 months up to 5 years)
Continue giving extra fluid until the diarrhea stops. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
2. GIVE ZINC (age 2 months up to 5 years)
4. WHEN TO RETURN
TELL THE MOTHER HOW MUCH ZINC TO GIVE :
ZINC
ZINC ZINC
TABLET
AGE SYRUP 20 DROPS 10
20 mg
mg / 5 ml mg / ml
tablet
1/2 tsp
2 months 1.0 ml daily 1/2 tablet
{2.5 ml}
up to 6 for 14 daily for 14
daily for 14
months days days
days
1 tsp {5 ml} 2.0 ml daily 1 tablet
6 months
daily for 14 for 14 daily for 14
or more
days days 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
Page18of76
GIVE EXTRA FLUID FOR DIARRHEA AND CONTINUE FEEDING
Page19of76
GIVE READY-TO-USE THERAPEUTIC FOOD
Page20of76
TREAT THE HIV INFECTED CHILD
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
caregivershouldideallyhavedisclosedthechildsHIVstatus Weight and height
to another adult who can assist with providing ART, or be part Pallor if present
of a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests
Caregiver not able: classify as CONFIRMED HIV INFECTION that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.
Page21of76
TREAT THE HIV INFECTED CHILD
Birth up to 3 YEARS ABC or AZT + 3TC + LPV/r ABC or AZT + 3TC + NVP ABC or AZT + 3TC + NVP
AZT + 3TC + ABC
3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP ABC or AZT + 3TC + EFV
AZT + 3TC + ABC
Page22of76
TREAT THE HIV INFECTED CHILD
ABACAVIR (ABC)
ZIDOVUDINE (AZT or ZDV)
Targetdose180240mg/mtwicedaily LAMIVUDINE (3TC)
WEIGHT (KG) Target dose: 8mg/Kg/dose twice daily
20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml liquid 30 mg tablet 150 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
Page23of76
TREAT THE HIV INFECTED CHILD
Page24of76
TREAT THE HIV INFECTED CHILD
Page25of76
TREAT THE HIV INFECTED CHILD
Page26of76
FOLLOW-UP
PERSISTENT DIARRHEA
After 5 days: MALARIA
Ask:
Has the diarrhea stopped? If fever persists after 3 days:
How many loose stools is the child having per day? Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Treatment:
If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full Treatment:
reassessment of the child. Treat for dehydration if present. Then refer to hospital.
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the diarrhea has stopped (child having less than 3 loose stools per day), tell the mother to follow
If the child has any othercause of fever other than malaria, provide appropriate treatment.
the usual feeding recommendations for the child's age.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or 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.
Page27of76
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is tenderswellingbehindtheearorhighfever(38.5Corabove), refer URGENTLY to
hospital.
Treatment: Acute ear infection:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. 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.
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
days if the fever persists.
finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the child has any other cause of fever other than malaria, provide treatment. Chronic ear infection:
If there is no other apparent cause of fever: Check that the mother is wicking the ear correctly and giving quinolone drops three times a day.
If the fever has been present for 7 days, refer for assessment. Encourage her to continue.
Page28of76
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or edema of both feet AND has developed a medical complication
or edema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or edema of both feet but NO medical complication and passes appetite
test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask mother
to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell
hertoreturnagainin14days.Continuetoseethechildevery14daysuntilthechildsWFH/Lis2z
scores or more, and/or MUAC is 125 mm or more.
If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).
Page29of76
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
CONFIRMED HIV INFECTION NOT ON ART
Follow up regularly as per national guidelines.
HIV EXPOSED At each follow-up visit follow these instructions:
Follow up regularly as per national guidelines. Ask the mother: Does the child have any problems?
At each follow-up visit follow these instructions: Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
new problem
Ask the mother: Does the child have any problems?
Counsel and check if mother able or willing now to initiate ART for the child.
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
new problem
counselling
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
Continue cotrimoxazole prophylaxis if indicated.
counselling
Initiate or continue isoniazid preventive therapy if indicated.
Continue cotrimoxazole prophylaxis
If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children)
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How
Monitor CD4 count and percentage.
often, if ever, does the child/mother miss a dose?
Askaboutthemothershealth,provideHIVcounsellingandtesting.
Askaboutthemothershealth.ProvideHIVcounsellingandtestingandreferralifnecessary
Home care:
Plan for the next follow-up visit
Counsel the mother about any new or continuing problems
HIV testing:
If appropriate, put the family in touch with organizations or people who could provide support
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Advise the mother about hygiene in the home, in particular when preparing food
test result. Plan for the next follow-up visit
RecheckchildsHIVstatussixweeksaftercessationofbreastfeeding.Reclassifythechildaccording
to the test result.
If child is confirmed HIV infected
Start on ART and enrol in chronic HIV care.
Continue follow-up as for CONFIRMED HIV INFECTION ON ART
If child is confirmed uninfected
Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks
of cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about her own health
Page30of76
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
Page31of76
COUNSEL THE MOTHER
FEEDING COUNSELLING
Page32of76
FEEDING COUNSELLING
Page33of76
FEEDING COUNSELLING
Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child butdonotforce "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
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.
Page34of76
FEEDING COUNSELLING
Exclusively breastfeed as often as the Breastfeed as often as the child wants. Breastfeed as often as the child wants. Give adequate amount of family food at 3
child wants, day and night, at least 8 times Add any of the following Give adequate amount of family foods meals a day.
in 24 hours. Lugaw with added oil, mashed vegetables such as: rice, camote, potato, fish, Give twice daily nutritious food between
Do not give other foods or fluids or beans, steamed tokwa, flaked fish, chicken, meat, mongo, steamed tokwa, meals such as:
pulverized roasted dilis, finely ground pulverized roasted dilis, milk and eggs, Boiled yellow camote, boiled yellow corn,
meat, eggyolk, bite-sized fruits dark green leafy and yellow peanuts, boiled saba, banana, taho, fruits
3 times per day if breastfeed vegetables(malunggay, squash), fruits and fruits juices.
5 times per day if not breastfeed (papaya, banana)
Add oil or margarine
5 times per day
Feed the baby nutritious snacks like fruits
Birth up to 4 months of age 6 months to 12 months 12 months and 2 years 2 years and older
Play: Provide ways for your child to see, Play: Play: Play:
hear, feel and move Give your child clean, safe house hold Give your child things to stack up, and to Help your child count, name and compare
things to handle, bang and drop. put into container and take out. things. Make simple toys for your child.
4 months to 6 months
Play: Have large colourful things for your child
to reach for, and new things to see.
Page35of76
FEEDING COUNSELLING
Infant formula
Always use a marked cup or glass and
spoon to measure water and the
scoop to measure the formula
powder.
Wash your hands before preparing a
feed.
Bring the water to boil and then let it
cool. Keep it covered while it cools.
FORMULA FEED exclusively. Do not give Give 1-2 cups (250 - 500 ml) of infant Give 1-2 cups (250 - 500 ml) of boiled,
Measure the formula powder into a
any breast milk. Other foods or fluids formula or boiled, then cooled, full then cooled, full cream milk or infant
marked cup or glass. Make the scoops
are not necessary. cream milk. Give milk with a cup, not a formula.
level. Put in one scoop for every 25 ml
Prepare correct strength and amount bottle. Give milk with a cup, not a bottle.
of water.
just before use. Use milk within two Give: Give: Add a small amount of the cooled
hours.Discardanyleftoverafridge
boiled water and stir. Fill the cup or
can store formula for 24 hours.
glass to the mark with the water. Stir
Cup feeding is safer than bottle
well.
feeding. Clean the cup and utensils * * Feed the infant using a cup.
with hot soapy water.
Start by giving 2-3 tablespoons of food 2 or family foods 3 or 4 times per day. Give Wash the utensils.
Give the following amounts of formula 8 - 3 times a day. Gradually increase to 1/2 3/4 cup (1 cup = 250 ml) at each meal.
to 6 times per day: cup (1 cup = 250 ml) at each meal and to
Offer 1-2 snacks between meals. Cowsmilk
Age in months Approx. amount and times giving meals 3-4 times a day.
Continue to feed your child slowly, Cow' s or other animal milks are not
per day Offer 1-2 snacks each day when the
patiently. suitable for infants below 6 months of
0 up to 1 60 ml x 8 child seems hungry.
Encourage - but do not force - your child age (even modified).
1 up to 2 90 ml x 7 For snacks give small chewable items
to eat. For a child between 6 and 12 month of
2 up to 4 120 ml x 6 that the child can hold. Let your child try to
4 up to 6 150 ml x 6 age: boil the milk and let it cool (even if
eat the snack, but provide help if needed.
pasteurized).
Feed the baby using a cup.
* 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.
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FEEDING COUNSELLING
Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup
Findaregularsupplyorformulaorothermilk(e.g.fullcreamcowsmilk)
Learn how to prepare a store milk safely at home
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EXTRA FLUIDS AND MOTHER'S HEALTH
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WHEN TO RETURN
ANEMIA 14 days
MODERATE ACUTE MALNUTRITION 30 days
CONFIRMED HIV INFECTION According to national
HIV EXPOSED recommendations
NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
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SICK YOUNG INFANT AGE UP TO 2 MONTHS
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CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
ASK: LOOK, LISTEN, FEEL: Any one of the following Pink: Give first dose of intramuscular antibiotics
Is the infant having Count the signs VERY SEVERE Treat to prevent low blood sugar
Classify ALL YOUNG
difficulty in feeding? breaths in one DISEASE Refer URGENTLY to hospital **
YOUNG INFANTS Not feeding well or
Has the infant had minute. Repeat Advise mother how to keep the infant warm
INFANT Convulsions or
convulsions (fits)? the count if more on the way to the hospital
MUST Fast breathing (60 breaths
than 60 breaths
BE per minute or more) or
per minute.
CALM Severe chest indrawing or
Look for severe
Fever(37.5C*orabove)or
chest indrawing.
Low body temperature (less
Measure axillary than35.5C*)or
temperature. Movement only when
Look at the umbilicus. Is it stimulated or no movement
red or draining pus? at all.
Look for skin pustules.
Umbilicus red or draining pus Yellow: Give an appropriate oral antibiotic
Look at the young infant's
or LOCAL Teach the mother to treat local infections at home
movements.
Skin pustules BACTERIAL Advise mother to give home care for the young
If infant is sleeping, ask
INFECTION infant
the mother to wake
him/her. Follow up in 2 days
Does the infant move None of the signs of very Green: Advise mother to give home care.
on his/her own? severe disease or local SEVERE DISEASE
If the young infant is not bacterial infection OR LOCAL
moving, gently stimulate INFECTION
him/her. UNLIKELY
Does the infant not
move at all?
*Thesethresholdsarebasedonaxillarytemperature.Thethresholdsforrectaltemperaturereadingsareapproximately0.5Chigher.
** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
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CHECK FOR JAUNDICE
If jaundice present, ASK: LOOK AND FEEL: Any jaundice if age less Pink: Treat to prevent low blood sugar
When did the jaundice Look for jaundice (yellow than 24 hours or SEVERE JAUNDICE Refer URGENTLY to hospital
appear first? eyes or skin) CLASSIFY Yellow palms and soles at Advise mother how to keep the infant warm
Look at the young infant's JAUNDICE any age on the way to the hospital
palms and soles. Are they
Jaundice appearing after 24 Yellow: Advise the mother to give home care for the
yellow?
hours of age and JAUNDICE young infant
Palms and soles not yellow 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
No jaundice Green: Advise the mother to give home care for the
NO JAUNDICE young infant
IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification:
Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C)
Infant's movements Classify stimulated or no movement DEHYDRATION OR
Does the infant move on his/her own? DIARRHEA for at all If infant also has another severe
Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification:
then stops? Skin pinch goes back very Refer URGENTLY to hospital with mother
Does the infant not move at all? slowly. giving frequent sips of ORS on the way
Is the infant restless and irritable? Advise the mother to continue
breastfeeding
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back: Two of the following signs: Yellow: Give fluid and breast milk for some dehydration
Very slowly (longer than 2 seconds)? Restless and irritable SOME (Plan B)
or slowly? Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with mother
slowly. 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
Not enough signs to classify Green: Give fluids to treat diarrhea at home and continue
as some or severe NO DEHYDRATION breastfeeding (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 2 days if not improving
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THEN CHECK FOR HIV INFECTION
Positive virological test in Yellow: Give cotrimoxazole prophylaxis from age 4-6
ASK young infant CONFIRMED HIV weeks
Classify INFECTION Give HIV ART and care
Has the mother and/or young infant had an HIV test? HIV Advise the mother on home care
status
Follow-up regularly as per national guidelines
IF YES: Mother HIV positive AND Yellow: Give cotrimoxazole prophylaxis from age 4-6
What is the mother's HIV status?: negative virological test HIV EXPOSED weeks
Serological test POSITIVE or NEGATIVE in young Start or continue PMTCT ARV prophylaxis as per
What is the young infant's HIV status?: infant breastfeeding or if national recommendations**
Virological test POSITIVE or NEGATIVE only stopped less than 6 Do virological test at age 4-6 weeks or repeat 6
Serological test POSITIVE or NEGATIVE weeks ago. weeks after the child stops breastfeeding
OR Advise the mother on home care
If mother is HIV positive and NO positive virological test Mother HIV positive, young Follow-up regularly as per national guidelines
in child ASK: infant not yet tested
Is the young infant breastfeeding now? OR
Was the young infant breastfeeding at the time of test Positive serological test in
or before it? young infant
Is the mother and young infant on PMTCT ARV
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
prophylaxis?*
or young infant HIV INFECTION
UNLIKELY
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THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING
PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS"
If an infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL: Not well attached to breast Yellow: If not well attached or not suckling effectively,
Is the infant breastfed? If Determine weight for age. or FEEDING PROBLEM teach correct positioning and attachment
yes, how many times in 24 Look for ulcers or white Classify FEEDING Not suckling effectively or OR If not able to attach well immediately, teach the
hours? patches in the mouth Less than 8 breastfeeds in LOW WEIGHT mother to express breast milk and feed by a cup
Does the infant usually (thrush). 24 hours or If breastfeeding less than 8 times in 24 hours,
receive any other foods or Receives other foods or advise to increase frequency of feeding. Advise
drinks? If yes, how often? drinks or the mother to breastfeed as often and as long as
If yes, what do you use to Low weight for age or the infant wants, day and night
feed the infant? Thrush (ulcers or white If receiving other foods or drinks, counsel the
patches in mouth). 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 breast-milk
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
Not low weight for age and Green: Advise mother to give home care for the young
no other signs of inadequate NO FEEDING infant
feeding. PROBLEM Praise the mother for feeding the infant well
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 not breastfeeding AND the infant has no indications to refer urgently to hospital:
Ask: LOOK, LISTEN, FEEL: Milk incorrectly or Yellow: Counsel about feeding
What milk are you giving? Determine weight for age. unhygienically prepared or FEEDING PROBLEM Explain the guidelines for safe replacement feeding
How many times during the Look for ulcers or white Classify FEEDING OR Identify concerns of mother and family about
Giving inappropriate
day and night? patches in the mouth replacement feeds or LOW WEIGHT feeding.
How much is given at each (thrush). If mother is using a bottle, teach cup feeding
Giving insufficient
feed? Advise the mother how to feed and keep the low
replacement feeds or
How are you preparing the weight infant warm at home
milk? An HIV positive mother
If thrush, teach the mother to treat thrush at home
mixing breast and other
Let mother demonstrate or Advise mother to give home care for the young
feeds before 6 months or
explain how a feed is infant
prepared, and how it is Using a feeding bottle or
Follow-up any feeding problem or thrush in 2 days
given to the infant. Low weight for age or Follow-up low weight for age in 14 days
Are you giving any breast Thrush (ulcers or white
milk at all? patches in mouth).
What foods and fluids in Not low weight for age and Green: Advise mother to give home care for the young
addition to replacement no other signs of inadequate NO FEEDING infant
feeds is given? feeding. PROBLEM Praise the mother for feeding the infant well
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
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THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:
ASSESSTHEMOTHERSHEALTHNEEDS
Nutritional status and anemia, contraception. Check hygienic practices. Smoking cessation in the family.
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TREAT AND COUNSEL
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TREAT THE YOUNG INFANT
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.
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 days: The mother should do the treatment four times daily for 7 days:
Wash hands Wash hands
Gently wash off pus and crusts with soap and water Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger
Dry the area An alternative treatment to gentian violet is Nystatin oral suspension 100,000 units/ml. Give 1-2 ml into
Paint the skin or umbilicus/cord with full strength gentian violet (0.5%) OR the mouth for 7 days
Mupirocin cream 2x a day until dry (usually in 3 days) Wash hands
Wash hands
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TREAT THE YOUNG INFANT
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COUNSEL THE MOTHER
TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT
WARM AT HOME
TEACH CORRECT POSITIONING AND ATTACHMENT FOR
Keep the young infant in the same bed with the mother.
BREASTFEEDING Keeptheroomwarm(atleast25C)withhomeheatingdeviceandmakesurethatthereisnodraught
of cold air.
Show the mother how to hold her infant.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm
with the infant's head and body in line. water, dry immediately and thoroughly after bathing and clothe the young infant immediately.
with the infant approaching breast with nose opposite to the nipple. Change clothes (e.g. nappies) whenever they are wet.
with the infant held close to the mother's body. Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
with the infant's whole body supported, not just neck and shoulders. 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
Show her how to help the infant to attach. She should: head turned to one side.
touch her infant's lips with her nipple Cover the infant with mother's clothes (and an additional warm blanket in cold weather).
wait until her infant's mouth is opening wide When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all
move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple. 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.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
again. Breastfeed the infant frequently (or give expressed breast milk by cup).
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FOLLOW-UP
ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT
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.
DIARRHEA
After 2 days:
Ask: Has the diarrhea stopped?
Treatment
If the diarrhea has not stopped, assess and treat the young infant for diarrhea. >SEE "Does the Young Infant Have Diarrhea?"
If the diarrhea has stopped, tell the mother to continue exclusive breastfeeding.
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GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
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.
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.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
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GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
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:
Skin Problems
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IDENTIFY SKIN PROBLEM
IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Itching rash with small papules PAPULAR Treat itching: Is a clinical stage 2 defining case
and scratch marks. Dark spots ITCHING Calamine lotion
with pale centers RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV
An itchy circular lesion with a RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
raised edge and fine scaly area WORM patches existing nail infection which has to be treated
in the center with loss of hair. (TINEA) adequately to prevent recurrence of tinea
If extensive refer, if not give:
May also be found on body or infections of skin.
web on feet Ketoconazole
Fungal nail infection is a clinical stage 2
for 2 up to 12 months(6-10 kg) 40mg per day
defining disease
for 12 months up to 5 years give 60 mg per
day or give griseofulvin 10mg/kg/day
if in the hair, shave hair treat itching as above
Rash and excoriations on torso; SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals, scabies may
burrows in web space and 25% topical Benzyl Benzoate at night, repeat for 3 manifest as crust scabies.
wrists. face spared days after washing and/ or 1% lindane cream or
Crusted scabies presents as extensive areas
lotion once, wash off after 12 hours
of crusting mainly on the scalp, face back and
feet. Patients may not complain of itching. The
scales will be teeming with mites
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IDENTIFY SKIN PROBLEM
Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease longer
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Hemorrhagic vesicles, necrotic
body with intense pain Give pain relief ulceration
or scars Follow-up in 7 days Rarely recurrent, disseminated
plus shooting pain. or multi-dermatomal
Herpes zoster is
uncommon in
Is a Clinical stage 2 defining
children except where
disease
they are
immuno-compromised,
for example
if infected with HIV
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IDENTIFY SKIN PROBLEM
NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules with MOLLUSCUM Can be treated by various Incidence is higher
a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm in
commonly seen on the face and trunk in Leave them alone unless size), or coalescent
children. superinfected Double or triple lesions
Use of phenol: Pricking each lesion may be seen
with a needle or sharpened More than 100 lesions
orange stick and dabbing the lesion may be seen.
with phenol Lesions often chronic and
Electrodesiccation difficult to eradicate
Liquid nitrogen application (using Extensive molluscum
orange stick) contagiosum is a Clinical
stage 2 defining disease
Curettage
The common wart appears as papules WARTS Treatment: Lesions more numerous
or nodules with a rough (verrucous) Topical salicylic acid preparations ( and recalcitrant to
surface eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is a
Electrocautery Clinical stage 2 defining
disease
Greasy scales and redness on central SEBORRHEA Ketoconazole shampoo Seborrheic dermatitis may
face, body folds If severe, refer or provide tropical be severe in HIV
steroids infection.
For seborrheic dermatitis: 1%
Secondary infection may
hydrocortisone cream X 2 daily
be common
If severe, refer
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CLINICAL REACTION TO DRUGS
Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching
Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
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MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Sex: Weight (kg): Height/Length (cm): Temperature(C):
Ask: What are the child's problems? Initial Visit? Follow-up Visit? Date:
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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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ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): Temperature(C): Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positive Send tests that are required ____
Check that child has not breastfed for at least 6 weeks Send confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____ NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5
Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS
Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other
2. ____________________________________________________________
recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
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RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
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FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): Temperature(C): Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ___________________________________________________ ACTIONS
ASK: has the child received care at another health YES ____ NO ____ TAKEN:
facility since the last visit?
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING If general danger signs or ART severe side effects, provide pre-referral treatment
CONVULSIONS and REFER URGENTLY
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Difficulty breathing and severe abdominal pain Refer if necessary.
Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms:
Cough or difficulty breathing
Diarrhea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
TAKEN:
Takes all doses - Frequently misses doses - Not gaining weight for 3 months
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER MEDICATION
ABC+3TC+LPV/r RECORD ART DOSAGES:
ABC+3TC+EFV 1. ____________________________________________________________
Cotrimoxazole 2. ____________________________________________________________
Vitamin A 3. ____________________________________________________________
Other Medication COTRIMOXAZOLE DOSAGE:_______________________________________
VITAMIN A DOSAGE: _____________________________________________
OTHER MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Side-
effects and correct management
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RECORD ACTIONS TAKEN:
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MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Age: Sex: Weight (kg): Temperature(C):
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit? Date:
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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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