Ministry of Health Sultanate of Oman

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Integrated Management of Childhood Illnesses & Comprehensive Child Care

CHART BOOK
Second Edition, 2005

Directorate General of Health Affairs

Ministry of Health Sultanate of Oman

Integrated Management of Childhood Illnesses & Comprehensive Child Care

CHART BOOK
Second Edition, 2005

Directorate General of Health Affairs

TABLE OF CONTENTS
Page No. SECTION 1 : STEPS OF INTEGRATED CARE........................................1 SECTION 2 : CHILD (2 MONTHS UPTO 5 YEARS)..................................3 2.1 TRIAGE & NUTRITION ASSESSMENT..........................................5 2.1.1 Triage ...................................................................................7 2.1.2 Assess nutrition status ............................................................8 2.1.3 Check immunization status .....................................................8 CHILD HEALTH ROUTINES ...........................................................9 2.2.1 Routine clinical checks ............................................................9 2.2.2 Feeding assessment .............................................................10 2.2.3 Psychosocial assessment .....................................................11 ASSESSMENT & CLASSIFICATION ............................................13 2..3.1Main symptoms .....................................................................14 Cough or difficult breathing ..................................................15 Ear problem...........................................................................16 Throat problem ......................................................................17 Diarrhea.................................................................................18 Fever ....................................................................................19 2.3.2 Other problems......................................................................20 2 .4 TREATMENT..................................................................................21 2.4.1 Treatment of emergent situations .........................................22 2.4.2 Treatment of non-emergent situations ..................................22 2.4.3 Treatment of local conditions ................................................23 COUNSELING ...............................................................................25 2.5.1 Home care.............................................................................26 2 6: Page No. 2.5.2 Danger signs .........................................................................26 2.5.3 Future prevention ..................................................................26 2.5.4 When to return.......................................................................27 FOLLOW UP CARE.......................................................................28 Feeding problems ..........................................................................28 PEM & Anemia ..............................................................................28 Pneumonia......................................................................................28 Ear problem ....................................................................................29 Throat problem ...............................................................................29 Dysentery & Persistent diarrhea.....................................................29 Febrile illness .................................................................................29

2.2

2. 3

SECTION 3: INFANT (1 WEEK UPTO 2 MONTHS) ...............................30 3.1 Classification...................................................................................31 Bacterial infection ..........................................................................31 Coryza ............................................................................................31 Local infections..............................................................................31 Jaundice .........................................................................................32 Feeding problems / low weight.......................................................32 Diarrhea ..........................................................................................32 3.2 Counseling .....................................................................................33 3.3 Follow up ........................................................................................34 SECTION 4 : ANNEXURES ......................................................................35 1. Accidents injuries............................................................................36 2. Poisonings ....................................................................................38 3 Common emergencies ...................................................................41 4. Emergency procedures ..................................................................42 5. Emergency drugs ...........................................................................43 6. Non- emergency drugs .................................................................44 7 Illustrations ..................................................................................45

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Section 1

STEPS OF INTEGRATED MANAGEMENT(IMCI)

STEPS OF INTEGRATED MANAGEMENT (IMCI)

IMCI takes an evidence-based, syndromic approach to case management that supports the rational, effective and affordable use of drugs. Evidence-based medicine stresses the importance of evaluation of evidence from clinical research. Careful and systematic assessment of common symptoms and well-selected clinical signs provide sufficient information to guide rational and effective actions. The following steps are to be carried for every child visiting a health facility: Look for general danger signs and provide urgent management or referral Assess the child further If the child does not have any danger signs Check nutrition status Check the child card and see if the child is due for the following routine baby checks Head circumference Eye check Dental check Cardiac check Hip check Check the child health card and see if the child is due for feeding and psychosocial assessment . If the child is due, do the assessment as per the instructions on the pink card and document the findings on the card Check the childs health card for immunization status and immunize the child if due. Remind the care giver about the next due date if any Assess, classify and identify treatment for main symptoms as described in this chart book . Counsel parents on home care, danger signs, future prevention and when to return

Use IMCI Form A for infants aged 1 week upto 2 months and IMCI Form B for children aged 2 months upto 5 years

Refer section 2 for a child aged 2 months upto 5 years and section 3 for an infant aged 1 week upto 2 months

Section 2

CARE OF CHILD (2 MONTHS UPTO 5 YEARS)

Section 2.1 & 2.2

TRIAGE & NUTRITION ASSESSMENT

2.1.1 DO TRIAGE AS FOLLOWS:

Record personal data, vitals and reasons for visit to the clinic Ask and record the main complaints If the child has cough or difficult breathing count Respiratory Rate for 1 minute and observe for chest in drawing. Check for General Danger Signs for all children as follows:

ASK
Is the child able to drink well today? Does the child vomits persistently (everything)? Has the child had any convulsion recently?

Examine for Lethargy

If the child has any ONE of the General Danger Signs, take the child for urgent assessment, pre-referral treatment and referral to hospital. If the child has no danger signs and not seriously ill proceed as follows Ask for the babys health card (pink card) Check the pink card panel no. 3 to see if the child has any reasons for special care such as congenital anomalies, genetic blood disorders, hypothyroidism or any other chronic illness Check status of child health routines Check if the child is due for routine physical checks. (Refer pink card panel no.4). If due proceed as in section 2.2. Check if the child is due for feeding and psychosocial assessment (refer pink card panel 5 ), if due proceed as in section 2.3 If care giver prefers to have consultation for the childs illness first, send the child to the doctor for assessment and treatment as in section 2.3 Other wise proceed with routine check / feeding & psychosocial assessment as in section 2.2.1

If the child has no dangers and not seriously ill and if the child is due for any routine checks / assessment proceed as in section 2.2.1

2.1.2 CHECK NUTRITION STATUS (Refer PEM manual second edition for details)
Check babys weight, enter on the card and plot the curve on panel no.9 (if not plotted in the current month). Assess the weight and classify as below: SIGNS
Weight for age below -ve 3 SD RED ZONE s Weight for age between ve 2nd and -ve 3rd SD ORANGE ZONE
s
rd

CLASSIFY AS
PEM Severe PEM moderate

TREATMENT
s Refer to hospital for further assessment s Check for parasitic infestations s Treat any other illness the child may have such as diarrhea, ARI or worm infestation s Refer the child to community dietitian or nutrition focal point for feeding assessment

& counseling
s If any feeding problem detected, follow up in 5 days s Start child on a follow up plan s Advise mothers when to return immediately s

Weight above -ve 2 SD

nd

No PEM

s Praise the care giver s Do feeding assessment for all children less than two years if due . s Counsel mothers on feeding s Follow up in 5 days If feeding problem is present

Check for pallor and if pallor is observed ask for Hb and classify as follows: SIGNS
s s

CLASSIFY AS
Severe anemia Anemia

TREATMENT
Refer to hospital for further assessment
s Start oral iron 3-6mg /kg of elemental iron s Advise the care-give to give iron rich foods s Follow up and redo Hb after 2 weeks s If Hb raises by 0.5 g 1 G continue iron for 3-4 months as necessary s If there no raise in Hb refer to hospital for investigations

Hb below 7 gms per dl Hb from 7 > 11 gms /dl

Hb 11 gms /dl or more

No anemia

Praise care giver

2.1.3 CHECK IMMUNIZATION STATUS

Check if the child is due for any immunization or Vitamin A dose and give if due. Tell the caregiver when to come for the next dose. (Refer pink card for schedule and due ages of immunization)

2.2.1 ROUTINE CHECKS

2B.1 Do the routine checks as below and document the findings on the child health card on panel no.4 Head circumference ( At 6 weeks, 3 months 5 months, 7 months & 9 months) Measure the head circumference with a metallic tape passing over the most prominent bony prominences on the forehead and on the occiput. Repeat measurements and record on the head circumference chart in the pink card . If abnormal (outside the green zone) refer to a pediatrician for further assessment Cardiac check (At 6 weeks, 3 months 5 months & 7 months) Auscultate the pre- cardial area for a cardiac murmur. If a significant murmur is heard refer to a pediatrician for confirmation Hip Check ( At 6 weeks, 3 months, 5 months, 7 months & 9 months) Place the baby supine on a firm surface. Flex hips and knees at 90 degrees and abduct the thigh. A click is felt if the hip is dislocated. Repeat the procedure to confirm the finding. If test is positive refer to an orthopedic surgeon. Eye checks ( At 6 weeks, 5 months & 18 months ) 1. Nystagmus : Look for rapid involuntary movements of eye balls. Refer to an ophthalmologist if nystagmus is observed 2. White pupil : Look for white pupils as in the diagram. Refer to an ophthalmologist if white pupil is observed Normal

White pupil

.. ....

3. Squint: Shine a pen torch light from 30 cms distance with the light beam pointing between the eyes brows . If squint is present corneal reflections are seen not in the centre in one or both eyes. Cover the affected eye and refer to an ophthalmologist as soon as possible Normal Dental check The dental check should be done at 18 months and there after once in 6 months. Examine the teeth by shining a torch light into the mouth of the child. Look for any decayed (black spots), filled teeth (silver spots) or missing teeth. Record the findings by entering the code (1= Decay, 2= Filled, 3= Missing) on the dental chart (A&B Incisors, C= Canine, D&E =Molars) on the child health card. Counsel the mother on dental and oral hygiene after dental check is done. If decayed and unfilled teeth are seen refer to a dentist for treatment Squint

2.2.2 FEEDING ASSESSMENT (To be done at 6 weeks, 3months , 5 months 7 months , 9 months, 18 months & 24 months)
Use the feeding assessment section of the table on the child health card ( panel 5A) for doing the assessment and documentation :. Ask the mother what the child ate yesterday. if yesterday was unusual , ask for the usual day 1. 2. 3. 4. 5. 6. 7. 8. Did child receive breast milk ? How many times during day? How many times during night? Did the child take any other food or fluid ? Did the child eat 3 meals of thick consistency? Did the child eat an animal food, a milk product , pulses, nuts (or seeds) and vegetable ( or fruit) ? Did the child eat sufficient number of meals and snacks for his/ her age as per the table in the pink card ? Was quantity of food eaten at main meals appropriate for childs age as in the table above? Do you encourage the child to feed by him/herself? During illness do you feed the child as usual and try to give extra foods and fluids?

If the answers to all questions are YES, enter [] mark in the appropriate column opposite to the child age. If the answers to any of questions are NO, enter the code number of the corresponding key message/s on panel no.8 Assess the breast feeing technique if the child has low weight or the mother complaints of feeding difficulty and the baby is under 6 months. Check for correctness of position as follows: 1. Infants neck straight or bent slightly backward 2. Infants body close to mothers body 3. Infants body turned towards mothers body 4. Infants whole body supported

Check for correctness of attachment as follows: 1. Chin touching breast 2. Mouth wide-open 3. Lower lip turned outward 4. More areola seen above than below the infants mouth

Check for effective suckling Slow & deep; sometimes pausing

10

Teach mother to correctly attach as follows (If attachment is incorrect) Touch infants lip with her nipple, wait until infants mouth is wide open and move infant quickly onto her breast, aiming the infants lower lip well below the nipple. If there is a feeding problem, counsel appropriately. If there is no feeding problem praise the caregiver

2.2.3 PSYCHOSOCIAL ASSESSMENT (To be done at at 6 weeks, 3months, 5 months, 7 months, 9 months, 18 months & 24 months)
Use the psychosocial assessment section of the table on the childs pink card ( panel no.5B) for doing the assessment and documentation as below. Check if the child has achieved the expected miles stones for motor, communication and play. Eg: for a child 9 months old ask if the child is able to sit with support, able to say dada mama, bye bye and bangs objects. If the answers to all questions are YES, enter [] mark in the column opposite to the child age. If the answers are NO to more than ONE question, mark x and recommend play activities appropriate for the childs age as given in the table in the following page. Check again after 2 weeks and refer if improvement is not seen.

11

Psychosocial stimulation (Recommendations upto 2 years)

Upto 4 months Play 1. Keep child close to face and tap on the chin 2. Dangle bright colored objects in front of babys eyes 3. Makes noises with rattles and rings 5 months 4 Play: 1. Move bright colored objects in front of babys eyes horizontally (180 degrees) and vertically Offer objects in hand to grasp 7 months 4 Play 1. 2. Give your child clean, safe household things to handle, bang and make noise Let the child play splashing water while giving bath

2.

4 Communicate Look into your childs eyes and smile at him or her.

4 Communicate: Talk to your child and get a conversation going with sounds or gestures

4 Communicate: Talk to your child and get a conversation going with sounds such as dadada mamada kakaka

9- 11 months 4Play 1. 2. Give your child clean, safe household things to handle, bang and drop. Put small object in front and let the baby pick them up

12 17 months Play: 1. 2. 3. Give your child things to stack up Let child put into objects in and out of container Let the child copy mother in house work like dusting

18-24 months Play 1. Let the child sit on your lap and let him turn pages of picture book. You name the objects in the picture and let the child repeat Le the child put on shoes socks pants Throw things on the stair and let child go upstairs and pick them

2. 3.

4Communicate: 1. Tell child dada & mama for parents 2. Tell the child bye. Bye waiving

4Communicate 1. Tell the child about parts of body 2. Let the child play with doll. Let the child identify his body parts and body parts of doll 3. Name objects and people

4Communicate: Ask your child simple questions. Respond to your childs attempts to talk to you. 1. Encourage your child to talk and answer questions 2. Give simple commands and let the child obey them

12

Section 2.3

ASSESSMENT, CLASSIFICATION & TREATMENT

2.3.1 MAIN SYMPTOMS

In the integrated management child hood Illnesses after checking for general danger signs the health care provider should ask the following questions to check for main symptoms. It should not be assumed that the care giver will always remember and tell all the problems the child may have for eg. chronic ear infections, persistent diarrhea are sometimes forgotten by parents. Ask the care giver the following questions:
s s s s s

Does the child have cough or difficult breathing? Does the child have any ear problems? Does the child have diarrhea? Does the child have fever? Does the child have any other problem ?

Check for throat problem if the care giver complains that the child has a throat problem or if the child has fever. Throat examination should be done last since it may make child irritable and further examinations difficult. Further questions and examinations should depend on the main symptoms or other problems reported by the care giver.

Use the following charts in this section to do further assessment and classification

14

If the child have cough or difficult breathing:

ASK For how long?

EXAMINE FOR (CHILD MUST BE CALM)

s s

SIGNS
s Any general danger

CLASSIFICATION TREATMENT
Severe pneumonia
s s

sign OR
s Chest in-drawing

Stabilize as necessary Give single dose of Ceftriaxone 50mg /kg IV/IM If a delay of more than 2 hours is anticipated for reaching the hospital Refer urgently to hospital Give Paracetamol for fever Ask care-giver to put normal saline nasal drops for relief of blocked nose Prescribe Amoxycillin orally for 5 days. Follow up after 2 days Advise care-giver when to return immediately Give nebulised salbutamol and reassess Respiratory Rate If RR is still above normal for age prescribe Salbutamol & treat as pneumonia as above If RR is normal after nebuized Salbutamol treat as cough cold with wheeze as below Give salbutamol syrup for wheeze Give paracetamol if child has fever. Ask care-giver to put normal saline nasal drops for relief of blocked nose Ask care-giver to give cough remedy at home Advise care-giver when to return immediately Praise care- giver for bringing child early Give paracetamol if child has fever Ask care-giver to put normal saline nasal drops for relief of blocked nose Ask care-giver to give cough remedy at home Advise care-giver when to return immediately

Fast breathing Chest in drawing/Wheeze

s Fast breathing *

Pneumonia

s s

If childs age is: 2 Months up to 12 months

*Fast breathing 50/ minute or more

s s s

12 months up to 5 years 40/ minute or more

s Fast breathing s Wheeze

Pneumonia with Wheeze

Notes: Chest in-drawing is inward movement of the whole lower chest wall when the child breathes IN Supra-clavicular and intercostal retractions are not considered as chest in-drawing. Mild chest indrawing is normal in young infants since their chest wall is soft, but severe chest in-drawing (very deep and easy to see) is a sign of severe pneumonia. Make sure that the child is not upset or crying and tell the mother not to wake up or undress the child Count the number of breaths in one minute with -out undressing the child. Count a second time if in doubt after undressing the child If child has fever, give paracetamol to reduce temperature and recount number of breaths Look for the chest in-drawing by asking the mother to lift the clothes so that you can see the lower part of the chest. Listen for stridor. If stridor is present at rest treat as severe croup (Refer Annexure 3)

s Wheeze

Coryza with wheeze

s s s

s
q

s No chest in- drawing s No fast breathing s No wheeze

Coryza

s s s

s s

Children with pneumonia can develop hypoxia due poor gas exchange in the lungs. If untreated child with severe pneumonia can develop respiratory failure
15

If the child has ear problem:

ASK
Is there pain ? Is there discharge? If yes, for how long?

EXAMINE FOR
s s

SIGNS
s Tender swelling

CLASSIFICATION TREATMENT
Acute mastoiditis
s

Refer hospital urgently

Pus discharge from ear Tender swelling behind the ear (Over the mastoid)

behind the ear (over the mastoiid bone)

s s

Severe ear pain OR Pus discharge for less than 14 days

Acute otitis media

s s s

Prescribe Amoxycillin for 5 days Give Paracetamol for pain relief Follow up in 2 days and change to second line antibiotic (Amoxy + cluvanic acid) if no clinical improvement If improved continue treatment for 5 more days Tell caregiver to bring the child back if she observes swelling behind the ear and any one of the general danger signs Teach caregiver how to keep ear dry by using a wick Refer to ENT specialist Treat as usual

s s

s Pus discharge for 14

Chronic otiits media

days or more
s

s No signs as above

Other problems

Note :- Otoscopy may be used for confirmation whenever necessary

16

Check for throat problem (if child has fever or if the child is above 2 years)

EXAMINE FOR
s

SIGNS
s

CLASSIFICATION
Streptococcal sore throat
s

TREATMENT
Obtain throat swab for culture if facility is available Prescribe oral Penicillin for 10 days (Erythromycin if child is sensitive to penicillin) Give Paracetamol for fever Advise mother when to return immediately Review in 5 days Discontinue treatment if culture is negative Give paracetamol to relieve fever Advise mother when to return immediately Follow up after 5 days, if no improvement refer to pediatrician Treat as usual

s s

Enlarged tender lymph nodes in front of the neck White/yellow exudates on the tonsils Congestion

Enlarged tender lymph nodes in front of the neck AND White/yellow exudates on the throat

s s s s s

Congestion of throat with NOT enough signs to classify as streptococcal sore throat Any other signs

Non- streptococcal sore throat

s s s

Other problems

Note: Classify as streptococcal sore throat if the throat is severely congested (red hot throat) and the child has high fever ( 38 degree C or more) even if the other signs are absent)

17

If the child has diarrhea :

ASK
s s

SIGNS
Diarrhea of less than 14 days & (Any 2 of the following) s Lethargic or unconscious s Sunken eyes s Not able to drink or drinks poorly s Skin pinch goes back very slowly (more than 2 seconds) Diarrhea of less than 14 days & (Any 2 of following) s Irritable or restless s Sunken eyes s Drinks eagerly or thirsty s Skin pinch goes back slowly Diarrhea of less than 14 days & s Not enough signs to classify as mild to moderate dehydration
s

CLASSIFICATION
Acute diarrhea & Severe Dehydration
s s

TREATMENT
Treat as per plan C Refer hospital as necessary

For how long? Is there blood in stool?

EXAMINE FOR
s s

s s

Irritability Not able to drink / drinks poorly or drinks eagerly Sunken eyes Skin pinch goes back slowly / very slowly/ normally

Acute diarrhea & Mild to moderate dehydration

s s s

Treat as per plan B Demonstrate how to mix and give ORS Counsel the mother about home care

Acute diarrhea & Mild to moderate dehydration Persistent diarrhea

s s s s s s s

Treat as per plan A Demonstrate how to mix and give ORS Counsel the mother about home care Classify for dehydration as for acute diarrhea Recommend low lactose diet as shown in the box below Review in 5 days Refer hospital if no improvement Do stool microscopy & culture if facility is available Treat dehydration if present Prescribe Nalidixic acid / Cephradine for 5 days Treat with Metronidazole if amoebae or giardia is detected on stool test Refer to hospital if child has PEM or if child is less than 1 year

Diarrhea of 14 days or more

Diarrhea & Blood in stool

Dysentery

s s s s

Diet for persistent diarrhea Continue breast feeding if the child is breastfed. If the child is on other milk reduce amount to 50ml/kg and use fermented milk. If the child is above 6 months of age give other foods as recommended for the age ( Refer oink card panel no.5 B)

18

If the child has fever : (by history or axillary temperature of 37.50C or above)

ASK
For how long? Has traveled to malaria area ? Has dysuria or increased frequency of micturation ? (for a child more than 2

SIGNS
"Any general danger signs OR stiff neck" OR bulging fontanelle
s s

CLASSIFICATION
Meningitis / Sepsis
s s s

TREATMENT
Stabilize child ( ABC) 1 Give inj. Ceftriaxone IM 50 mg /Kg Refer to hospital urgently Check on immunization of the case & contacts Give Vitamin A if not given already Refer to pediatrician for confirmation & urgent notification Check blood smear for malarial parasite and if positive: Refer to hospital for admission Refer to malaria management guidelines of M.O.H

Generalized rash AND Runny nose or red eyes Has traveled to malaria zone OR No cough or runny nose or red eyes AND No obvious cause detected for fever No cause identified for fever OR Dysuria or increased frequency of micturation (Rarely seen in infants under 2 years) Already classified* Fever & no cause identified AND Urine microscopy negative AND MP negative

Measles

s s s

s s s

Malaria

s s s

years)

EXAMINE FOR
s s s s s

Urinary Tract Infection

s s s

General danger signs Neck stiffness Runny nose Generalized rash Irritability

Do urine microscopy If urine microscopy shows 20 WBC or more per cubic mm, refer for pediatric consultation If urine microscopy shows less than 20 WBCs per cubic mm, manage as fever cause unknown (see last row ) Treat as per classification If more than 5 days refer, if 5 days or less Do CBC (if facility available ) Refer for urgent pediatric consultation if : x child is less than 1 year OR x temperature is 39 or more OR x child is irritable OR x TLC is less than 5000 or more than 15000/cubic mm. Otherwise give paracetamol to relieve fever and review in 2 days

s s s s

Fever cause known Fever cause unknown

s s s s

*Classify as fever cause known if child has already been classified as Cough cold / pneumonia / throat infection, diarrhea / dysentery, measles, malaria or UTI. Manage child as per classification.

If a delay of more than 2 hours is anticipated for reaching the hospital

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2.3.2 CHECK FOR OTHER PROBLEMS

Ask caregiver if the child has any other symptoms Do assessment and diagnosis the usual way

If the child has any other problem assess and treat as usual

20

Section 2.4

TREATMENT

2.4.1 PRE-REFERRAL TREATMENTS FOR EMERGENT SITUATIONS

Give pre-referral treatment to all children classified in the pink row ( see chart below) & treat other emergent situations such as convulsion, severe croup, severe wheeze etc. identified during assessment. (refer annexure No. 3) Ensure that airway is patent and administer oxygen at the rate of 5-6 liters per minute if child has signs of hypoxia such as cyanosis or irritability Start CPR if child is not breathing Maintain circulation: by securing IV line and infusing normal saline or Ringer lactate at the rate of 20 ml /kg (over 5 minutes) Repeat 1 or 2 doses of Ringer lactate if necessary to stabilize the circulation Keep the child warm Pass nasogastric tube and aspirate stomach contents (use size 8 up to 1 year of age) If IV access is not possible, give ORS through the nasogastric tube at the rate of 10 ml /kg/hour to prevent hypoglycemia and hypovolemia Collect blood for culture studies to send along with the patient(if facility is available) Give one dose of a broad spectrum antibiotic. as such as ceftriaxone 50 mg/kg IM/IV if a severe infection is suspected Give starting dose of other specific therapy as per the classification Prevent hypoglycemia Control temperature as necessary e.g. paracetamol for high fever (38. 5C or above) Classification PEM Severe Severe pneumonia Management
s s s s

Refer to hospital for further assessment Stabilize the child ( ABC) as necessary and give inj. Ceftriaxone IV/iM Give nebilised salbutamol if wheezing is present Refer to hospital urgently Refer to hospital urgently Start plan C Refer to hospital urgently If there is severe dehydration, give plan C & refer to hospital urgently If there is mild to moderate dehydration , give plan B & refer to hospital. Stabilise child ( ABC) Give inj. Ceftriaxone IM 50 mg /Kg Refer to hospital urgently
2

Acute Mastoiditis Acute diarrhea & Severe Dehydration Persistent diarrhea & dehydration Meningitis / Sepsis

s s s s s s s s

2.4.2 TREATMENT FOR NON-EMERGENT SITUATIONS (REFER CHARTS IN THE PREVIOUS SECTION). IF THE REQUIRED DRUGS ARE NOT AVAILABLE, REFER

3 If a delay of more than 2 hours is anticipated for reaching the hospital

22

2.4.3 TREATMENT OF LOCAL INFECTIONS & COUGH

q q q q q

Explain to the caregiver what the treatment is and why it is given Describe the treatment steps given in appropriate box Watch as she gives the first treatment at the clinic (except cough remedy) Tell her how often to give treatment at home Check the care- givers understanding

Dry the ear by using a wick

Dry the ear at least 3 times daily as follows
s s s s

Treat eye infections

Clean both eyes 2-3 times daily
s s s

Roll soft tissue paper into a wick Place the wick in childs ear Remove the wick when wet Replace the wick with a clean one and repeat the above steps until the ear is dry

Wash hands Ask child to close eyes Use clean tissue and water to wipe away pus

Put antibiotic eye drops ( 2 drops in each eye) 4 6 times in the day Apply eye ointment to both eyes at night s Ask the child to look up s Squirt a small amount of ointment on the lower lid s Wash hands again

Treat mouth ulcers

s s s s

Soothe the throat and relieve cough with a safe remedy

s s s

Treat the mouth ulcers 3 times daily Wash hands Clean the childs mouth with clean water Paint the mouth with mycostantin suspension if oral thrush is suspected (white patches)

Mix Juice of one lemon Add equal amount of honey and twice the amount of clean water Give the child 1 teaspoon 3-4 times a day

Discourage cough medications

s

Otherwise paint mouth with boroglycerine

s

Avoid cough syrup or mixtures containing codeine (because they cause constipation) Avoid antihistaminic medications (because they cause side effects such as drowsiness/ dryness and have not been proven to be very effective in evidence based reviews)

23

Plan A
COUNSEL MOTHER ON THE 3 RULES OF HOME TREATMENT GIVE EXTRA FLUID, CONTINIE FEEDING & WHEN TO RETURN 1 GIVE EXTRA FLUID (as much as child will take) TELL THE CARE-GIVER q Breast feed frequently and longer at each feed q If child is breastfed, give ORS in clean water in addition to breastfeeding q If child is not exclusively breast fed give one or more of the following :ORS, food based solutions (such as soup, rice water and yogurt drinks or clean water) It is specially important to give ORS at home when:
q q

Plan B
Give in the clinic 75 mls /kg of ORS over 4 hour period
q q

If the child want more ORS give more For infants under 6 months who are not breast fed, give also 100-200 mls of clean water during this period

SHOW CARE-GIVER HOW TO GIVE ORS SOLUTION q Give frequent small sips from a cup q If the child vomits wait 10 minutes, continue but slowly q Continue breast feeding when ever the child wants AFTER 4 HOURS q Reassess the child and classify for dehydration q Select the appropriate plan to continue treatment q Begin feeding the child in the clinic IF CARE-GIVER MUST LEAVE BEFORE COMPLETING TREATMENT q Show her how to prepare ORS at home q Show her how much more ORS to give to finish 4 hour treatment q Give her enough ORS to finish the treatment in addition to 2 packets as per plan A q Explain home treatment 1. GIVE EXTRA FLUID 2. CONTINUE FEEDING see counsel care-giver (section 3)

The child has been treated with plan B or C this time The child cannot return to clinic if diarrhea goes worse

TEACH CARE-GIVER HOW TO MIX AND GIVE ORS.

GIVE MOTHER 2 PACKET OF ORS TO USE AT HOME

SHOW CARE-GIVER HOW MUCH FLUID TO GIVE IN

ADDITION TO THE USUAL FLUID INTAKE Up to 2 years 2 years or more 50- 100 mls after each loose stool 100-200 mls after each loose stool

Tell the care-giver to : s Give frequent small sips from a cup s If the child vomits, wait 10 minutes, continue but slowly s Continue giving extra fluids until the

24

Section 2.5 & 2.6

COUNSELING CARE- GIVER ABOUT HOME CARE, DANGER SIGNS, FOLLOW UP AND FUTURE PREVENTION

When counseling caregiver: (1) use words that s/he understands (2) use teaching aids that are familiar (3) give feedback when s/he practices (4) praise what was done well and make corrections; (5) allow more practice, if needed and (6) encourage to ask questions and answer all questions. Finally check on the caregivers understanding. The caregiver should be counseled on home management, danger signs, prevention of the problem and when to return. Use local terminology for illnesses whenever possible.

2.5.1 HOME CARE

Teach how to give oral drugs or to treat local infections. Advise to continue feeding and increase it if necessary. The following steps should be followed when teaching caregiver how to give oral drugs:
s s s s s s s s

Determine the appropriate drugs and dosage for the childs age or weight Tell the mother or care-giver what the treatment is and why it should be given Demonstrate how to measure a dose Watch the mother or caregiver practice measuring a dose Ask the mother or caregiver to give the dose to the child Explain carefully how, and how often, to give the treatment at home Explain that all oral drug must be used until the course of treatment is finished even if the child gets better Check the care-givers understanding.

2.5.2 DANGER SIGNS

Tell the caregiver about the four main danger signs viz not able to feed , vomiting everything , convulsions and lethargy Teach the caregiver the following specific danger sings related to the child illness:
s s s s

Sunken eyes and blood in stools for diarrhea Fast breathing for cough & cold Difficult breathing for pneumonia Tender swelling behind the ear for ear infections

2.5.3 FUTURE PREVENTION

Whenever possible the care-giver should be educated about the cause of the childs illness and how the illness can be prevented in future in a manner she can understand it. The following are examples:
s s

Cough and cold are caused through contact with other persons with influenza and can be prevented by avoiding such contacts Diarrhea is caused by infection and can be prevented by hand washing

26

Accident prevention Children are prone to accidents in and around home. Parents should be educated about accident prevention. The following safety measures should be recommended for all children.
s s s s

Keep medicines and other chemicals such as detergents out of reach of children Do not use beverage bottles for storing kerosene or petrol Keep electrical appliances and switches boards above the reach of children Avoid keeping poisonous indoor plants inside the house.

2.5.4 WHEN TO RETURN

s

Tell the caregiver when to come for a return visit as in the following table: Any sick child Not able to drink or breast feed Becomes more sick or there is worsening Cough & cold Fast breathing Difficulty in breathing Diarrhea Blood in stool Drinking poorly Sunken eyes Pneumonia Dysentery Persistent diarrhea Fever cause not known Feeding problem Sore throat Low weight ( PEM) 2 days Return Immediately

5 days 14 days

27

2.6 GIVE FOLLOW UP CARE

Provide care for the child who returns for follow-up using the boxes that match the childs previous classification If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY CHART. Please note that there is no definite follow up recommended for children with cough & cold and diarrhea. However the caregivershould be told about danger signs and to return if any of the danger signs are observed.

Feeding problem
After 5 s Reassess feeding s Ask about any feeding problem detected on the initial visit s Counsel the care-giver about new feeding problems if any s Review again after 14 days Moderate PEM After 14 days s Weigh child and see if there is improvement s Reassess feeding s Counsel on feeding problems identified earlier s Counsel on feeding problems newly identified s If no improvement or worsened refer to pediatrician s Review every month till childs weight is normal

Anemia
After 14 days s Reassess s Repeat Hb If due to nutritional anemia s If improved, continue oral iron for 3 months after Hb returns to normal value s Review every month for 3 months s If there is no improvement or if there is worsening refer to pediatrician If due to sickle cell disease anemia After 5 days Ask about pain relief s If improved, counsel care-giver about folic acid treatment and oral penicillin prophylaxis s Review every 3 months
s

Pneumonia
After 2 days Ask s Is the child breathing slower? s Is there less fever ? s Is the child eating better ? Reassess the child Look for danger signs s If child is breathing slower and eating better , praise care-giver continue antibiotics for 3 days more s If breathing rate is same or temperature persists change antibiotic to second line and review after 2 days s Child is worse with rapid breathing or chest in-drawing , admit/refer

28

GIVE FOLLOW UP CARE (CONTINUED) Ear infection

After 2 days Reassess for the ear problem Measure temperature If no pain or ear discharge praise care-giver and continue antibiotics for 3 days more If there is swelling behind the ear or tenderness over mastoid with temperature above 38.5 C refer urgently to hospital
q

Sore throat After 5 days

q q q q q

Ask if the fever is less Reassess child Check for other problems Continue treatment for 10 days if response is good If no response change to second line antibiotic such as cephradine

If pain or ear discharge is present, change to a second line antibiotic such as Augmentin and review after 5 days again If no improvement after 5 days refer to ENT specialist

Dysentery
After 2 days Ask s Is s Is s Is s Is s Is the frequency of stools less ? the fever less ? the child eating better? there blood in stools? the abdominal pain less?

Persistent diarrhea
After 5 days Ask
s s

Febrile Illness (Fever cause not known) If fever persists after 2 days
s s s

Has the diarrhea stopped? How many loose stools the child is having each day

Do a full reassessment of the child Assess for other causes of fever Do urine microscopy and CBC if not done If child has danger signs or neck stiffness, admit or refer If cause of fever still remains unknown refer to pediatrician for a consultation

Reassess the child s Look for danger signs s If child is having fewer stools and eating better, praise care-giver, continue antibiotics for 5 days more s Refer to hospital if: - The number of stools are same or more or - Blood in the stool persists or - Abdominal cramps persists

Treatment s if diarrhea has NOT stopped ( more than 3 loose stools per day: Refer to hospital
s

If diarrhea has stopped ( 3 or less than 3 loose stools per day : Tell the care-giver to follow feeding recommendation for the childs age

29

Section 3

CARE OF YOUNG INFANT (1 WEEK UPTO 2 MONTHS)

Please note that these guidelines are not to be used for newborns upto 7 days of age. Please refer to neonatal manual for this age.

3.1 ASSESSMENT & CLASSIFICATION

Check for infections in a young infant up to 2 months of age
SIGNS
ANY ONE OF THE FOLLOWING

CLASSIFICATION
Severe bacterial infection / sepsis
s s s s s

TREATMENT
Stabilize the child as necessary (ABC) Prevent low blood sugar Prevent hypothermia Give single doses of Penicillin & Gentamycin IV/IM Refer to hospital urgently

ASK Has the infant had convulsions? Does the infant refuse to feed? Does the child vomit persistently?

s s s s s s s s

s s

EXAMINE FOR
Convulsions s Bulging fontanel s Severe chest in drawing s Grunting/ wheeze /Nasal flaring s Pus discharging from eye /ear s Redness around umbilicus s Multiple pustules s Purulent eye discharge s Lethargy or unconsciousness s Hypotonia Measure temperature in the axiila
s

s s s

Lethargy/unconsiousness Convulsions Not able to suck Persistent vomiting Severe chest indrawing Grunting Fast breathing ( RR 60 or more) Wheeze / nasal flaire /Grunting Redness around umbilicus extending to skin and tissue (more than 1 cm) Multiple pustules Pus discharging from ear Severe purulent eye discharge Hpotonia Temperature between 37.6 .to 37.9 with any ONE of the above signs Temperature above 37.9 C or below 35 C Running nose / Nasal discharge Mild fever (37.6 to 37.9) No other signs as in the pink row except mild elevation of temperature Baby active & feeding well

s s s

Coryza

s s s s

Prescribe saline nasal drops Review in 2 days Teach mother how to keep nose clean Tell mother when to return

Any ONE of the following s Redness and swelling of skin extending less than 1 cm beyond umbilicus s Some skin pustules s Some purulent eye discharge
s

Local infection of Umbilicus Skin Eyes

s s s s

Give oral cloxacillin for 5 days to treat umbilical and skin infection Prescribe antibiotic eye drops for 5 days Teach mother how to treat local infection at home Review in 2 days

None of the above

No infection

No treatment

31

Look for jaundice & classify

SIGNS
s

CLASSIFICATION
Significant jaundice

TREATMENT
Increase breast feeding Refer to hospital urgently

Jaundice extending to palm and soles

Check for feeding problem

SIGNS
Not able to suck or feed
s s s s s

CLASSIFICATION
Severe bacterial infection Feeding problem
s s s

TREATMENT
Stabilize and refer to hospital Teach mother how to breast feed Treat thrush with nystantin local application to infants mouth Follow up in 5 days

Is there any difficulty in problem feeding? How often is the child breast fed ? Any additional food or drink given? Determine the weight Check breastfeeding technique

ANY ONE OF THE FOLLOWING s Poor position s Not well attached s Not sucking effectively s Less than 8 feeds in a 24 hours s Receives other food or drinks s Thrush s Low weight No signs of feeding problems & not low weight

No feeding problem

Praise the mother

Assess and classify diarrhea in a sick young infant

Assessment & classification is similar to child 2 months up to 5 years EXEPT drinking eagerly is NOT used as sign in a young infant Any TWO of the following is classified as SEVERE DEHYDRATION in a young infant ( up to 2 months ) 1. 2. 3. Any TWO 1. 2. 3. Lethargic or unconscious Sunken eyes Skin pinch goes very slowly of the following is classified as SOME DEHYDRATION in a young infant ( up to 2 months ) Restless or irritable Sunken eyes Skin pinch goes slowly

32

3.2 3.3

TREATMENT

(See Section 3.1)

COUNSELING

3.3.1 HOME CARE

Teach how to give oral drugs or to treat local infection.
s s s

Teach correct positioning and attachment for breastfeeding: show the mother how to hold her infant with the infants head and body straight, facing her breast, infants nose opposite her nipple, infants body close to her body and supporting infants whole body, not just neck and shoulders. Show her how to help the infant to attach. She should: a) touch her infants lips with her nipple b) wait until her infants mouth is opening wide Advise to breastfeed frequently, as often as possible and for as long as the infant wants, day and night, during sickness and health.

Counsel on feeding problems Appropriate counseling of the mother should be based on the feeding problem identified. Advice how to prepare a breast-milk substitute if the infant cannot be breast fed. Teach the caregiver how to treat thrush (If the infant has thrush ) with mycostatin suspension. Ensure follow-up for any feeding problem or low weight as recommended in the following page. .

3.3.2 Danger signs

Ask care-giver to obseve for the following signs
s s s s s s

Not breastfeeding or drinking poorly Becomes sicker Develops fever Fast breathing Difficult breathing Blood in stool

3.3.3 Future prevention

Whenever possible the caregiver should be educated about the cause of the childs illness and how the illness can be prevented in future in a manner she can understand it .The following are examples:
s s

Cough cold are caused through contact with other persons with influenza and can be prevented by avoiding such contacts Diarrhea is caused by infection and can be prevented by hand washing

33

3.3.4. FOLLOW UP CARE

Advice for follow-up visit If the infant has: Local bacterial infection Any feeding problem Thrush Low weight for age Return for follow-up not later than:

2 days 14 days

Advise mother about birth spacing and refer to birth spacing clinic Advise when to return for the next immunization according to immunization schedule

34

Section 4

ANNEXURES

Annexure 1: Accidents and Injuries

INJURIES
Signs of severe injuries
s s s s s

Treatment Treatment If bleeding is present, apply sterile gauze and press for 5 minutes to control bleeding s Immobilize the affect part by splinting s Refer to hospital urgently
s

General danger signs OR Severe bleeding OR Inability to move limbs OR Pallor OR Abdominal guarding

Signs of moderate injuries Any ONE of the following s Wounds with signs of local inflammation s Deep and contaminated wound s Wounds with pus formation

Treatment
s s s s s

Wash the wound well with saline Carefully remove all bits of dirt, blood clots, dead or badly damaged tissue (in contaminated wounds) Treat with an appropriate antibiotic such as Cloxacilin or Amoxicilin if wound is infected or contaminated Dress the wound daily until healed. Tell caregiver when to return

Signs of mild injuries

s

Treatment
s s s

No bleeding or minor bleeding

Examine the wound daily and check for signs of infection If the dressing gets wet, remove it and apply a new one. Continue dressing till the wound forms a scab Tell caregiver when to return

BURNS
Signs of severe burns
s s s s s s

Treatment
s s s s

Danger signs OR any one of the following Large area affected with partial thickness (15 % or above) Full thickness burn Affected underlying structures and tissues Burns around face, ears, hands, feet and genitalia Electric burns

Stabilize the child as necessary Do not break blisters Cover the burnt area with sterile gauze Refer to hospital urgently.

Signs of moderate burns

s s

Treatment
s s s s s

Partial thickness with less than 15 % area affected AND No damage to deeper layers of skin

Do not puncture blisters Keep the burnt area clean and dry and protect it with a loose bandage. Apply antiseptic cream such as silver sulfadiazine Give paracetamol for pain Follow up 2 days

Signs of mild injuries

s

Treatment
s s

Superficial (No blisters)

Clean the burn area with antiseptic Follow up 2 days

36

Annexure 1: Accidents and Injuries

BITES & STINGS
Signs of snake bite with systemic or local envenomation
1

Treatment
s s s s s

History of snake bite and any ONE of the following s General danger signs s Bleeding tendency s Severe local pain s Difficulty in swallowing or breathing s Positive clot test s Bites on head, neck & trunk s Local pain & edema Signs of snake bite with NO envenomation History of snake bite for 6 or more hours AND none of the above signs Signs of scorpion sting with systemic envenomation History of scorpion bite with Any ONE of the following s Signs of shock s High or low BP s Excessive sweating, excessive salivation , Bronchial congestion s Extreme irritability, Nystagmus s Muscle twitching

Reassure the parents. Immobilize the bitten limb with a splint (leg) or sling (arm) Do not apply a tourniquet Do not make incision over the bite Refer to hospital urgently

Treatment
s s

Reassure mother Observe /Review in 8-12 hours

Treatment
s s s s s s s s s

Stabilize as necessary ( use _ stenth saline) Give Inj. Adrenaline ( if BP is not elevated or low ) Give Inj . chlorphenalime Give inj. Hydrocortisone Adminster Antiscrpion venom IV 5 vials diluted with 150 mls of Pediatric saline Clean the site of sting Inject lignocaine 1 % 2-3 ml into the site of sting ( if there is pain) Check TT status Refer to hospital urgently

Signs of scorpion sting NO systemic2 or local envenomation Signs of scorpion sting with NO systemic or local envenomation

Treatment
s s s s

Clean the site of sting Inject lignocaine 1 % 2-3 ml into the site of sting ( if there is pain) Check TT status Observe and refer to hospital as necessary

Clot test: Draw 5 mls of blood using a glass syringe. Keep the sample for 10 minutes undisturbed. If clot formation does not take place in 10 minutes the test is positive

1 2

Anti-snake venom may be administered if facilities are available at your facility. Follow the standard precautions provided in the product leaflet Anti-scorpion venom may be administered if facilities are available at your facility. Follow the standard precautions provided in the product leaflet

37

Annexure 2: Poisonings
KEROSENE
Signs of severe poisoning
s s

If the required drugs are not available, refer

Treatment
s s s s

Cough and difficult breathing after kerosine ingestion OR General danger signs

Stabilize child as necessary (ABC) Do not induce vomiting or wash stomach Do chest X-ray if facility is available Refer urgently to hospital

Signs of moderate poisoning

s

Treatment
s s s s

Ingestion of kerosene less than 6 hours and NO sings as above

Do not induce vomiting or wash stomach Observe for 6 hours Tell mother to return if there is cough or difficulty breathing Review in 24 hours

Signs of mild poisoning

s s

Treatment Do not induce vomiting or wash stomach Tell mother to return if there is cough or difficulty breathing

Ingestion of kerosene more than 6 hours before AND NO signs as above

PESTICIDE (Oragananophospahtes)
Signs of severe poisoning
s s s

Treatment
s s s s s s s s

General danger signs Cholinergic symptoms Pinpoint pupils

Stabilize as necessary (ABC) Give stomach wash Give activated charcoal Undress and clean the childs skin with water and soap if some of the insecticide has fallen onto his/her cloths or skin. Give Inj. atropineIV 0.02 mg/kg per dose diluted in 1- 2 ml of normal saline. Repeat the dose every 5- 10 minutes until bronchial secretions disappear Give rectal diazepam if child has seizures Refer to hospital

Signs of moderate poisoning

s

Treatment
s s s

Ingestion pesticides less than 6 hours AND none of the above signs

Give stomach wash Give activated charcoal Observe for 6 hours and watch for danger signs

Signs of mild poisoning

s s

Treatment Reassure Review in 24 hours

Ingestion pesticides more than 6 hours AND None of the above signs

38

Annexure 2: Poisonings
IRON
Signs of severe poisoning Any ONE of the following s Ingestion of more than 50mg/kg of elemental iron s General danger signs s Bloody vomiting s Signs of shock Treatment
s s s s s s s

If the required drugs are not available, refer

Stabilize as necessary (ABC) Give stomach wash Collect blood sample for serum Fe Do plain X-ray of abdomen Start injection Desferrioxamine as infusion 15 mg/kg /per hour Start I .V. Fluids Refer urgently to hospital

Signs of moderate poisoning

s s s

Treatment
s s s s s

Ingestion of more than 20- 50mg/kg of elemental iron OR Plain X-ray of abdomen shows specs of iron OR Symptoms of vomiting or diarrhea

Give stomach wash if child brought within one hour Start injection Dysferal as infusion 15 mg/kg /per hour Observe for 4 hours at the clinic If urine is clear, review in 12 hours If urine is pink refer urgently

Signs of mild poisoning

s s s

Treatment
s

Ingestion of more than 20- 30mg/kg of elemental iron Plain X-ray of abdomen shows no specs of iron NO symptoms of vomiting or diarrhea.

Give stomach wash if child brought within one hour

PARCETAMOL
Signs of severe poisoning Any ONE of the following s Ingestion of more than 140mg/kg of paracetamol s General danger signs s Signs of shock Signs of moderate poisoning
s s s

Treatment
s s s s s

Stabilize as necessary (ABC) Give stomach wash Give activated charcoal Give start dose of N-acetyl cysteine Refer urgently to hospital

Treatment
s s s s s s

Ingestion of more than 140g/kg of paracetamol Symptoms of vomiting No signs of shock

Give stomach wash Give activated charcoal Take blood sample for aceteaminophen ( 4 hour post ingestion) Give N-acetyl cysteine 140mg /kg diluted in juice orally Observe/review in 4 hours Refer urgently to hospital if necessary

Signs of mild poisoning

s s

Treatment
s s s

Ingestion of less than 140g/kg of paracetamol NO vomiting or other symptoms 39

Stomach wash Activated charcoal Review in 12 24 hours

Annexure 2: Poisonings
ASPIRIN
Signs of severe poisoning
s s s s

If the required drugs are not available, refer

Treatment
s s s s s s

Ingestion more than 300 mg/kg of aspirin OR General danger signs OR Difficult breathing OR tachycardia Hyperhermia (temp of 42 C or above)

Stabilize as necessary (ABC) Colect blood samples for saycylates, BUN and electrolytes Give Na bicarb 1 2 ml kg necessary Give stomach wash Give activated charcoal Refer urgently to hospital

Signs of moderate poisoning

s s

Treatment
s s s s

Ingestion of 150 -300 mg/kg of aspirin OR Some symptoms AND no danger signs

Give stomach wash if child brought after 1 hour Give activated charcoal Observe for 6 hours at the clinic Refer if symptoms persist

Signs of mild poisoning

s s

Treatment
s

Mild Ingestion of less than 150 mg/kg of aspirin AND/OR No symptoms

Induce vomiting if child brought within 1 hour

IBUPROFEN AND OTHER NSAIDS

Signs of severe poisoning
s s

Treatment
s s s s

Ingestion of more than 5-10 times the therapeutic dose of ibuprofen AND General danger signs

Stabilize as necessary (ABC) Give stomach wash Give activated charcoal Refer urgently to hospital

Signs of moderate poisoning

s s s

Treatment
s s s s

Ingestion of less than 200 mg/kg of ibuprofen Some symptoms AND No general danger signs

Give stomach wash Give activated charcoal Observe in the clinic for 4 6 hours If child symptoms persist refer urgently to hospital

Signs of mild poisoning

s s

Treatment
s s s

Ingestion of less than 200 mg/kg of ibuprofen AND No signs or symptoms

Stomach wash Activated charcoal Review in 12 24 hours

40

Annexure 3. Common emergencies

CONDITION 1 Convulsion TREATMENT
s s s s s s s

Turn the child to his or her side to aid breathing during a convulsion Rest his or her head on a soft object and to clear the surrounding area of any dangerous objects. Do not force objects into the childs mouth during a convulsion. Stabilize the child (ABC). Try to get a venous access and do dextrostix Give I V diazepam 0.2 mg /per kg if IV access is possible and give 4 ml/kg of 10% dextrose if dextrostix shows low glucose ( <2.6 mmol) If IV access is not possible in 10 minutes give rectal diazepam 0.5 mg /kg If the convulsion does not stop transfer the child to hospital after stabilizing Check for signs of esophageal obstruction such as vomiting, dysphagia and drooling of saliva Check for impacted foreign body in the esophagus by taking a AP & lateral chest x-ray films Refer urgently if child has esophageal obstruction or if foreign body is seen in the esophagus If the object is below the esophagus and the object is not of high risk category, send the child home If the object is of high risk type (battery, sharp objects , long objects) refer urgently to hospital Ask parents to watch the stool daily for foreign body for the next 7 days. If foreign body is not passed in 7 day repeat x-ray and refer if necessary Give 10 % dextrose or breast- milk substitutes 50 mls /kg by nasogastric tube Ask mother to give expressed milk or breast milk by cup If mothers milk is not available give 30-50 mls/kg of 10% dextrose or breast- milk substitutes by cup Start IV fluid immediately and give Ringer lactate or Normal saline Give 30 mls per kg in 1/2 hour (If infants under 1 year in 1 hour) Start IV fluid immediately and give Ringer lactate or Normal salineRepeat the dose if the child is not improved Start IV fluid immediately and give Ringer lactate or Normal salineRefer the child to hospital after stabilizing Start IV fluid immediately and Start IV fluid immediately and the rate of 5-6 liters / minute Start IV fluid immediately and Start IV fluid immediately and refer hospital give Ringer lactate or Normal salineStabilize ABC as necessary give Ringer lactate or Normal salineGive nebulized salbutamol and ipatropium with oxygen at give Ringer lactate or Normal saline Repeat 2 additional doses if necessary give Ringer lactate or Normal salineIf no improvement give one dose of hydrocortisone and

Swallowed foreign body

s s s s s s s

Low blood sugar

s s s

Severe dehydration (PLAN C)

s s s s

Severe asthma

s s s s

Severe croup

s s

Start IV fluid immediately and give Ringer lactate or Normal salineRule out acute epiglotitiis by looking for drooping of saliva and high fever If epiglotitis is excluded proceed as follows s Administer single dose of dexamethasone (0.5 mg/kg) IM s Administer nebulised adrenaline (1-2 ml of 1:1000 solution) in 2 ml of saline over 10 minutes by face mask with Oxygen flow of at least 6 liters /minute s If no response REFER URGENTLY

41

Annexure : 4 Emergency procedures

1. Percutanious Transtracheal Ventilation ( PTV)

Aim : To secure air way in emergencies

2. Intraosseous Infusion ( I O)
Aim : To secure IV access for volume replacement in shock or when IV line is not easily accessible ( after 3 trials in 90 seconds in emergencies) Summary of Steps 1. 2. 3. 4. 5. 6. 7. 8. 9. Restrain the patent appropriately Choose the site : Proximal tibia (upto 3 years) 1- 2 cm below the tibial tuberosity Choose distal tibia for children above 3 years Provide local anesthesia for wake patients Insert needle perpendicular to bony cortex or slightly angled away from joint space Use steady back and & forth rotational movements rather than rocking needle from side to side Aspirate marrow to confirm needle placement or infuse small amount of saline and aspirate looking for pink fluid Attach IV infusion set and secure the line Monitor for extravasation and swelling of tissues

Steps 1. 2. 3. Hold the trachea in place with thumb and middle finger of the non dominant hand Feel from the tracheal rings and go upwards until cricoid cartilage if felt Advance the canula ( No.16 .or 18 on cricothyroid membrane just above the cricoid cartilage in a downward direction at an angle of 30-40 degrees Attach a 5 ml syringe with 2 mls of saline to the canula & confirm position by air bubbles in the syringe Remove the syringe and connect the ambu bag to IV canula (see below) Confirm correct placement and begin bagging Assess the patient response and secure with suture around catheter to prevent air leak and secure position of canula with adhesives Ventilate at appropriate rate of 22-30 breaths per minute with the ambu bag. Call for help or transfer urgently to a hospital

4. 5. 6. 7.

8. 9.

10. Infuse Ringer lactate and give emergency medications as necessary until IV line is accessible

How to make connection for I V canula placed in the trachea to Ambu bag ( see illustrations below) 1. 2. 3. 4. 5. Remove set Connect Connect Connect Connect the distal rubber tubing with plastic end from any adult IV the base of ET No.3.5 to Ambu bag the rubber end of IV tubing to nostle of the ET tube the oxygen supply to the Abmu bag the plastic end to the IV canula placed in the trachea

42

Annexure: 5 Emergency medications

Drug Diazepam Adrenaline 1:1000 Route IV /Rectal SC/ IM/ Nebulised IV/IM IM/IV Nebulized Nebulized IV/IM Mix the dose in 3.5 ml of normal saline Mix the dose in 3.5 ml of normal saline Method of preparation Dosage 0.2mg /kg IV, 0.5 mg /kg rectal 0.01ML /Kg, SC/IM 2.5 ML OF 1.1000 SOLN + NS = 5ML [NEB. FOR CROUP] 0.5 mg/kg single dose 5 mg/kg 200 mcg / kg/ given every 20 minutes Maximum 3 doses 0.25 mg / doses every 20 minutes Maximum 3 doses 1-2 mg IV/IM or 0.1 MG/KG/ as stat dose

Dexamethzone Hydrocortisone Salbutamol Nebullised Ipatropium bromide Chlorpheniramine maleate

Pre-referral antibiotic
Drug Ampicillin Ceftriaxon ( eg.Rocephin) Penicillin Benzyl Gentamycin Route IV/IM IV/IM IV/IM IV/IM Method of preparation Dosage 50 mg/kg as stat dose 50 mg/kg as stat dose 25000 IU /kg as stat dose 2 mg/kg single dose as start dose

Drug for treating poisons at Clinic

Drug Activated charcoal Atropine sulphate N- acetyl -Cysteine (Pavolex) Desferrioxamine ( Desferal) Route Oral IM IV IM Method of preparation Mixed in glass of water and given by nasogastric tube after stomach aspiration. Dosage 0.25 gm/ kg per dose 0.05mg/kg 1-2 doses 150 mg /kg in 5% dextrose water to be given over 1 hour 50 mg /kg as start dose

43

Annexure: 6 Non-Emergency medications

Drug Amoxycillin Cephradine ( eg.Velosef) Chloroquine Cloxacillin Cotrimoxazole ( eg.Septrin) Erythromycin Penicillin V Nalidixic acid Paracetamol syrup Metronidazol Salbutamol syrup Salbutamol Inhaler Dosage 15/kg/dose 10- 25 mg/kg/dose 10 mg/kg as first dose, subsequent 3 doses 5mg/kg 15 25 mg/kg/dose 5 mg/kg/ dose of Trimethoprim 10 mg/kg/ dose 7.5 15 mg/kg 15 mg/kg /per dose 15 mg/kg /dose 10 mg/kg 1 mg /dose ( age less than 1 yr) 2 mg/dose ( age 1 yr or more) 200 mcg As necessary Folic acid Iron Syrup Lavendazole 0.01- .03 mg/ kg 6 mg /kg of elemental iron 400 mg for children above 2 years 200 mg for children 1-2 years Once daily Once daily Single dose Single dose Long term 3 months Frequency 3 times a day 3 times a day First dose 10 mg /kg , second dose 5mg/kg after 6 hours , then 5mg/kg for 2 days 3 times a day 2 times a day 4 times daily 3 times a day 3-4 times a day As necessary upto 4 times daily 3 times a day 3-4 times a day 3- 4 times day 7 days As necessary 5 days 5 days 5 days 5 days Duration 5 days 5 days

44

Annexure : 7 Illustrations
1. Percutanious Transtracheal Ventilation (PTV)

a) Items required

b) Assembled set

c) Connected to baby

2. Diagram for calculation of area of burns

Use the table for calculation of percentage of total body surface area in burns. Take only partial Diagram area A= 1/2 head B= 1/2 of thigh C= 1/2 of leg 0 9.5 2.75 2.5 Age in years 1 8.5 3.25 2.5 5 6.5 4 2.75

thickness and full thickness burns. Ignore simple erythema. Palm of the child is equal to 1% surface area and it can be used to assess the extent of burns.

3.

X-Ray pictures showing swallowed disc batteries. Notice the peripheral transparent ring characteristic of disc batteries

45