IMCI Chart Booklet

7/31/2019 IMCI Chart Booklet

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ASSESS AND CLASSIFY THE SICK CHILDAGE 2 MONTHS UP TO 5 YEARS

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CHECK FOR GENERAL DANGER SIGNSASK: Is the child able to drink or breastfeed?

Does the child vomit everything?

Has the child had convulsions during this illness? (if convulsing now see p.13)=

LOOK: Is the childa) lethargic or

b) unconscious

THEN ASK ABOUT MAIN SYMPTOMS:Does the child have cough or difficult breathing?

A child with any general danger sign requires urgent attention: complete the assessment, start pre-referral treatment and refer urgently. Test for low blood sugar then treat or prevent.

KZN IMCI guideline September 2002Danger signs/CoughAssess and classify

DO RAPID APPRAISAL ON ALL WAITING CHILDRENASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE. Determine if this is an initial or follow-up visit for this problem if follow-up visit use the follow-up instructions on pages 17-20 If initial visit assess the child as follows:

RESPIRATORY RATEIf the child is: Fast breathing is:

2 months up to 12 months: 50 or more breaths per minute

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Fast breathing.

No signs of pneumonia or very sev ere disease.

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Count the breaths in one minute. Look for chestindrawing. Look and listenfor stridor or wheeze.

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Does the child have frequent cough at night? Has the child had a wheeze for more than a week? Is the child a known asthmatic?

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==Does the child have an ear problem?

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Tender swelling behindthe ear

Pus seen draining fromthe ear and discharge isreported for less than 14days,OR

Ear pain=

Pus is seen drainingfrom the ear and

discharge is reported for14 days or more=

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No ear pain AND no pusseen draining from theear

No additional treatment=

IF YES, ASK:====== Is there ear pain?

Is there eardischarge?If yes, for howlong?

LOOK AND FEEL:=

Look for pus draining fromthe ear.

Feel for tender swellingbehind the ear.

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Ear problemAssess and classify

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KZN IMCI guideline September 2002

Classify

EAR PROBLEM

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Give ampicillin IM OR ceftriaxone IM (p.13) Give first dose of paracetamol (p.10) Refer URGENTLY to hospital

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Give amoxycillin for 5 days (p.9) If ear discharge:

- Teach mother to clean ear by dry wicking (p.11)- Consider symptomatic HIV (p.7)

Give paracetamol for pain (p.10) Follow-up in 5 days if pain or discharge persists

Teach mother to clean ear by dry wicking (p.11) Consider symptomatic HIV (p.7) Tell the mother to come back if she suspects hearing loss Follow up in 14 days if discharge persists

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Very low weight OR Visible severe wasting OR

Oedema of both feet

Not low weight AND Good weight gain

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GROWING

WELL

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SEVERE

MALNUTRITION

Malnutrition/ AnaemiaAssess and classify


ASK:=

Has the childlost weight?=

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If child is less than 2 years, assess and counsel on feeding (p.21) If feeding problem, check for thrush, and treat (p.11). Follow-up in

five days Give mebendazole if the child is older than one year and has not

had a dose in the past six months (p.12) Follow Vitamin A schedule (p.12)=

Give Vitamin A unless a dose has been given in past month(p.12)

Test for low blood sugar, then treat or prevent (p.14) Refer URGENTLY to hospital Keep the child warmLOOK and FEEL:

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GROWTHPlot the weight on the growth chart: Is the child:

Low weight (below 3rd centile) Very low weight (below 60% of

expected weight)

Look at the shape of the weight curve: Is the child:

Gaining weight well? Gaining weight but curve is

flattening? Losing weight ?

Look for visible severe wasting

Feel for oedema of both feet

ANAEMIA Look for palmar pallor. Is it:

Severe palmar pallor? Some palmar pallor?

If any pallor check the haemoglobin(Hb) level

Give iron (p.10) Do a feeding assessment and counsel about feeding Follow-up in 14 days

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Refer URGENTLY to hospital Keep the child warm

No additional treatment

Severe palmar pallor OR Hb < 6g/dl

Some palmar pallor OR Hb


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IF THE CHILD- has a classification today of PNEUMONIA or PERSISTENT DIARRHOEA or NOT GROWING WELL

OR

Has had an episode of persistent diarrhoea in the past three months

OR Has had a discharging ear at any time

OR If the mother is known to be HIV positive*

ASSESS FOR SYMPTOMATIC HIV INFECTION *:

Discuss reasons for classification with mother and adviseher to take the child for HIV testing

Arrange pre-test counselling and HIV testing Assess feeding and counsel (p.21) Counsel mother about her own health Follow-up in 14 days as follows:

- if mother agrees to have the child tested, discuss theresult and arrange regular follow up if positive (p.20)

- if mother refuses testing, review the child and forfurther discussion. Offer treatment to the child

including regular follow-up and co-trimoxazoleprophylaxis if HIV testing is refused (p.20).

three or morepositive findings SUSPECTED

SYMPTOMATICHIV

If the mother is known HIV positive:- give appropriate feeding advice (p. 23)

- if the child is under one yearstart co-trimoxazoleprophylaxis (p. 9) and test to determine whether thechild is infected at age 12 months

- if the child is over one yeararrange testing todetermine if the child is infected

Counsel mother about her own health and about preven tionof HIV infection

If breastfeeding counsel about importance of safe sexduring breastfeeding to prevent HIV transmission to thebaby if the mother becomes infected while breastfeeding


*If the child has been classified as symptomatic HIV in the past and had a positive HIV test, do not assess again - give follow-upcare for confirmed symptomatic HIV (p. 20)

less than threepositive findings SYMPTOMATIC

HIVUNLIKELY

NOTE (as above):

Does the child have

any PNEUMONIA now? ear discharge now OR in the

past? low weight for age? poor weight gain or weight

loss? Any episode of persistent diar-

rhoea in the past three months?

LOOK AND FEEL FOR:

enlarged lymph glands intwo or more of the followingsites:neck, axilla or groin?

oral thrush? parotid gland enlargement?

CLASSIFYby countingthe number

of positivefindings

Symptomatic HIVAssess and classify


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ASSESS OTHER PROBLEMS:Remember to ask if the child has any other problems like skin sores not covered in the IMCI assessment

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments.Check the blood sugar in all children with a general danger sign and treat or prevent low blood sugar. =

=THEN CHECK THE CHILDS IMMUNISATION STATUS Give all missed immunisations today. This includes sick children (unless being referred) and those

without their cards If there is no RTHC give a new one today Advise the mother when to come for the next immunisation

VITAMIN A PROPHYLAXIS

Give every child a dose of vitamin A everysix months from the age of 6 months (p.12).

Record the dose on the RTHC

ROUTINE WORM TREATMENTGive every child mebendazole every 6months from the age of one year. Recordthe dose on the RTHC.

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KZN IMCI Guideline September 2002

ImmunisationAssess and classify


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Local infections at homeTreat the child

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==TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should begiven

Describe the treatment steps listed in the appropriate box

Watch the mother as she does the first treatment in the clinic(except remedy for cough or sore throat)

Tell her how often to do the treatment at home.

If needed for treatment at home, give mother a small bottle of

gentian violet or nystatin

Check the mothers understanding before she leaves the clinic

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Clear the Ear by Dry Wicking

Dry the ear at least 3 times daily Roll clean absorbent cloth or soft, strong tissue paper into a wick Place the wick in the childs ear Remove the wick when wet Replace the wick with a clean one and repeat these steps until the ear is dry= The ear should not be plugged between dry wickings=

Treat for Mouth Ulcers with Gentian Violet

Treat for mouth ulcers twice daily Wash hands Wet a clean soft cloth with salt water and use it to wash the childs mouth Paint the mouth with 0,5 % gentian violet (GV) Wash hands again Continue using GV for 48 hours after the ulcers have been cured Give paracetomol for pain relief (p.10)

Soothe the Throat, Relieve the Cough with a SafeRemedy

Safe remedies to recommend:- Breastmilk for exclusively breastfed infant- Honey and lemon

Harmful remedies to discourage:- Herbal smoke inhalation- Vicks drops by mouth

Treat for Thrush with Nystatin or Gentian Violet

Treat for thrush four times daily for 7 days Wash hands Wet a clean soft cloth with salt water and use it to wash the childs mouth Instill nystatin 1ml four times a day or paint with GV as above for 7 days Avoid feeding for 20 minutes after medication If breastfed check mothers breasts for thrush. If present treat with nystatin

or GV Advise mother to wash breasts after feeds. If bottle fed advise change to cup

and spoon If severe, recurrent or pharyngeal thrush consider symptomatic HIV (p. 7) Give paracetamol if needed for pain (p.10)



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GIVE THESE PREVENTIVE TREATMENTS IN CLINIC

Explain to the mother why the drug is given

Determine the dose appropriate for the childs weight (or age)

Measure the dose accurately

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Give treatments in clinic onlyTreat the child

Give Vitamin A to all Children every 6 months

PREVENTION: Give Vitamin A to all children toprevent severe illness- First dose at 6 weeks in a child that is not being breastfed- First dose in breastfed children to be given any time after 6 months of age- Thereafter vitamin A should be given every six months to ALL CHILDREN

TREATMENT: Give an extra dose of Vitamin A (same dose) fortreatment if the child has

SEVERE MALNUTRITION or PERSISTENT DIARRHOEA. If the child has had adose of vitamin A within the past month, DO NOT GIVE VITAMIN A.

Check the strength of Vitamin A:- Vitamin A capsules come in 50 000IU, 100 000IU, and 200 000IU- If 100 000IU is required, and only the 200 000IU capsules are available, cut

open the capsules using a sterile needle and given the child every seconddrop

Always chart the dose of Vitamin A given on the RTHC.

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GIVE THESE TREATMENTS IN CLINIC ONLY = Explain to the mother why the treatment is being given==

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Low blood sugarTreat the child

Treat the child for Low Blood Sugar

LOW BLOOD SUGAR IS LESS THAN 3 mmol/l IN A CHILD OR LESS THAN 2.5 mmol/l IN A YOUNG INFANT

Suspect low blood sugar in any infant or child that: is convulsing or unconscious OR has a temperature below 35,5C, OR is drowsy and sweating OR is lethargic, floppy or jittery particularly when less than 2 months old Children with kwashiorkor are particularly likely to be hypoglycaemic

Confirm low blood sugar using blood glucose testing strips

Treat with: 10% Glucose - Give 5ml 10% Glucose for every kilogram body weight - by nasogastric tube OR intravenous line Keep the child warm Refer urgently and continue feeds during transfer To make 10% glucose if this is not available:

mix 4 mls of 50% glucose with 16 mls sterile water in a 20 ml syringe ormix 2 mls of 50% glucose with 18 mls of 5% glucose in a 20 ml syringe

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Prevent Low Blood Sugar (Hypoglycaemia) during Transfer to Hospital=

If the child is able to swallow: If breastfed: ask the mother to breastfeed the child, or give expressed breastmilk If not breastfed: give a breastmilk substitute or sugar water. Give 30-50 ml of milk or sugar water before departure

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

If the child is not able to swallow: Insert nasogastric tube and check the position of the tube= Give 50mls of milk or sugar water before transfer=


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Diarrhoea-plan CTreat the child

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

Plan C: Treat for Severe Dehydration Quickly=

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Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 20 ml/kg Ringers Lactate Solution (or, if not available, normal saline) every hour

Arrange urgent referral to hospital for further managementReassess the child every 1- 2 hours while awaiting transfer. If hydration status is not improving, give

the IV drip more rapidly.

Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2hours (children).

Reassess an infant after 3 hours if he is still at the clinic. Classify dehydration. Then choose theappropriate plan (A, B, or C) to continue treatment.

If you cannot refer observe for at least 6 hours after the child has been fully rehydrated

Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during

the trip or give ORS by naso-gastic tube.

Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120ml/kg).

Arrange urgent referral to hospital for further management Reassess the child every 1-2 hours while waiting transfer:

-If there is repeated vomiting or abdominal distension, give the fluid more slowly. After 6 hours reassess the child if he is still at the clinic. Classify dehydration. Then choose the

appropriate plan (A, B, or C) to continue treatment.

NOTE: If the child is not referred to hospital, observe the child at least 6 hours after rehydration to be sure the

mother can maintain hydration giving the child ORS solution by mouth.

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In the first half hour: Plan for the next 5 hours:

Give 20 ml IV for each kilogram weight, before referral

Repeat this amount if brachial pulse is weak or notdetectable.

Give 20 ml IV for each kilogram weight, every hourwhile the child is in the clinic awaiting transfer.

Monitor and record how much fluid the child receives


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GIVE FOLLOW-UP CARE Care for the child who returns for follow-up using all the boxes that match the childs

previous classifications.

If the child has any new problem, assess, classify and treat for the new problem as ontheASSESS AND CLASSIFYchart.

FEEDING PROBLEM

After 5 days:- Assess feeding (p.21) and counsel (p.21-24).- Review the feeding problem identified at the last visit- If you counsel her to make further changes to her childs feedingfollow up again in another 5 days- Check on available resources and ensure that advice is appropriate

Review every 30 days until the child is gaining weight

ANAEMIA

After 14 days:- Check haemoglobin,

Treatment:

If haemoglobin lower than before, REFER

If the haemoglobin has not improved or the child has palmar pallor afterone month, REFER for assessment

Ifhaemoglobin is higher than before, continue iron. Review in 14 days. Continuegiving iron every day for 2 months

NOT GROWING WELL

After 14 days:- Weigh the child and determine if the child is still low weight for age.- Determine weight gain- Reassess feeding (p.21) and counsel (p.21-24)

Treatment: If the child gaining weight well, praise the mother. Review monthly for growth monitoring.

If the child is still low weight for age, counsel the mother about feeding. Ask the mother

to return in 14 days. Review monthly until the child is feeding well and gaining weightregularly or is no longer low weight for age.

If the child has not gained weight or has lost weight, check for possible symptomaticHIV (p.7). Assess feeding and if there is a feeding problem counsel and review in further14 days. If poor weight gain continues after another 14 days REFER

Exception: If you do not think that feeding will improve, refer the child.

IF ANY MORE FOLLOW-UP VISITS ARE NEEDED, ADVISE THE MOTHER OF THE NEXT FOLLOW-UP VISITADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY (p.26)

Chronic Ear infection, feeding problem, Anaemia, Not growing wellFollow up care KZN IMCI guideline September 2002


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Feeding adviceCounsel the mother

Assess the Feeding of Sick Children under 2 years(or if ANAEMIA or NOT GROWING WELL )Ask questions about the childs usual feeding and feeding during this illness. Compare the mothers answers to the FeedingRecommendations for the childs age on p 19

If the baby is receiving anybreastmilk, ASK:

- How many times during the day?- Do you also breastfeed during the night?

Does the child take any other food or fluids?- What food or fluids?- How many times per day?- What do you use to feed the child?

If low weight for age, ASK:- How large are servings?- Does the child receive his own serving?- Who feeds the child and how?

During this illness, has the childs feeding changed? If yes, how

If baby is receiving replacement milk, ASK:

- What replacement milk are you giving?- How many times during the day and night?- How much is given at each feed?- How is the milk prepared?- How is the milk being given? Cup or bottle?- How are you cleaning the utensils?- If still breastfeeding as well as givingreplacement milk could the mother give extrabreastmilk instead of replacement milk (especiallyif the baby is below 6months)

ASK How are you feeding your child?=

KZN IMCI guideline August 2002


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Breastfeed as often as the child wants,day and night,

Feed at least 8 times in 24 hours.

Do not give other foods or fluids

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FEEDING RECOMMENDATIONS IN SICKNESS AND IN HEALTH

Feeding recommendationsCounsel the mother KZN IMCI guideline September 2002

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Continue to breastfeed asoften as the child wants

Give 3 servings ofnutritious complementary foods. Always mixmargarine, fat, oil, peanut butter or ground nuts

with porridge.Also add: chicken, egg, beans, fish or full cream milk,

or mashed fruit and vegetables, at least once

each day.

If baby is not breastfed, give 3 cups (3 x 200 ml)of full cream milk as well.

If baby gets no milk, give 6 complementary feedsper day

Continue to breastfeedas often as the childwants. Breastmilk is still an important foodat this age and helps prevent infections

Give at least 5 adequate nutritious feeds.

Increase the variety and quantity withfamily foods:

Mix margarine, fat, oil, peanut butteror ground nuts with porridge

Give egg, meat, fish or beans daily Give fruit or vegetables twice every

day Give milk every day, especially if no

longer breast feeding.

Feed actively with her own serving

2 Years

and Older

Give the child her own serving offamily foods 3 times a day.

In addition, give 2 nutritious snackssuch as bread with peanut butter,full cream milk or fresh fruit be-tween meals

Continue active feeding

NOTE: These feeding recommendations should be followed for infants of all mothers who DO NOT KNOW their HIV status

6 Months up

to 12 Months

12 Months up

to 2 Years


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Special Feeding Recommendations=

= Feeding Advice for the Mother of a Child with SYMPTOMATIC HIV INFECTION The child with symptomatic HIV infection should be encouraged to breastfeed. There is no danger of infection through breastmilk when the child has symp-

toms

The child should be fed according to the feeding recommendations for his age (p.22)

These children often suffer from poor appetite and mouth sores, give appropriate advice (this page)

If the child is being fed with a bottle encourage the mother to use a cup as this is more hygienic and will reduce episodes of diarrhoea

Inform the mother about the importance of hygiene when preparing food because her child can easily get sick. She should wash her hands after going to thetoilet and before preparing food If the child is not gaining weight well, the child can be given an extra meal each day and the mother can encourage him toeat more by offering him snacks that he likes if these are available

Advise her about her own nutrition and the importance of a well balanced diet to keep herself healthy. Encourage her to plant vegetables to feed her family.

KZN IMCI guideline September 2002Feeding advice for HIV InfectionCounsel the mother

If the child has a poor appetite:

Plan small frequent meals. Give milk rather than other fluids except where there is diarrhoea with some dehy-

dration Give foods with a high energy content. Give snacks between meals. Check for oral thrush or mouth ulcers. Consider HIV if the appetite remains persistently poor.

If the child has mouth sores:

Recommend soft foods that dont burn the mouth e.g. eggs, mashed potatoes,pumpkin or avocado. Avoid spicy, salty and rough foods.

Chop foods finely and give cold drinks or crushed ice, if available.

Feeding Recommendations ForPERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer breastfeeds, day andnight.

If taking other milk:- 1st choice: replace with increased breastfeeding OR- 2nd choice: replace with fermented milk products, such as amasi

(maas) or yoghurt OR- 3rd choice: replace half the milk with nutrient-rich semisolid food

(like mashed fruit or vegetables.)

For other foods, follow feeding recommendations for the childs age

Avoid very sweet foods or drink Give small, frequent meals at least 6 times a day


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Advise the Mother When to Return to Health WorkerFOLLOW-UP VISITAdvise the mother to come for follow-up at the earliest timelisted for the childs problems.

NEXT WELL-CHILD VISITAdvise mother when to return for next immunisationaccording to immunisation schedule. Encourage monthlyvisits for growth monitoring

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD: If child breastfed, breastfeed more frequently and for longer at each feed. If child is taking breastmilk substitutes, increase the amount of milk

given Increase other fluids. For example, give soft porridge, amasi, SSS or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B (p.15)

If the child has: Return for follow-up in:

PNEUMONIADYSENTERYMALARIA,FEVER OTHER CAUSE, if fever persists

2 days

PERSISTENT DIARRHOEACHRONIC EAR INFECTIONFEEDING PROBLEMWHEEZE (FIRST EPISODE), if still wheezing

ANY OTHER ILLNESS, if not improving

5 days

ANAEMIA 14 days

NOT GROWING WELL - but no feeding problem 14 days

SUSPECTED SYMPTOMATIC HIVSYMPTOMATIC HIV (confirmed)

14 daysmonthly

WHEN TO RETURN IMMEDIATELY

Any sick child Becomes sicker Not able to drink or breastfeed

Vomiting everything Develops a fever

If child has COUGH OR COLD, returnif:

Fast breathing

Difficult breathing

Wheezing

If child has Diarrhoea, return if: Blood in stool

Advise mother to return immediately if the child has any of these signs:

When to returnCounsel the mother KZN IMCI guideline September 2002


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Mothers healthCounsel the mother

Counsel the mother About Her Own Health=

If the mother is sick, provide care for her, or refer her for help.

If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help (p.35).

Advise her to eat well to keep up her own strength and health.

Check the mothers immunisation status and give her tetanus toxoid if needed.

Make sure she has access to:

- Family planning

- Counselling on STD and AIDS prevention

Encourage mother to speak about social problems

If the mother is HIV positive give her advice about her own health and consider starting her on co-trimoxazole

REMEMBER THAT THE HEALTH OF A CHILD DEPENDS ON THE HEALTH OF THE MOTHER.

ALWAYS THINK OF THE MOTHERS HEALTH WHEN YOU ARE CARING FOR A SICK CHILD



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Does the young infant have diarrhoea?

IF YES, ASK:

For how long?

Is there blood inthe stool?

LOOK AND FEEL:

Look at the young infants generalcondition. Is the infant:

-Lethargic or unconscious?-Restless and irritable?

Look for sunken eyes.

Pinch the skin of the abdomen.Does it go back:

-Very slowly (longer than 2seconds)?-or Slowly?

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DiarrhoeaAssess and classify: The Young Infant

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=

=


Refer URGENTLY to hospital withintravenous infusion (see plan Cp.16 ).

Give the first dose of ceftriaxoneIMI (p.33) Give frequent sips of ORS on the

way, if possible. Breastfeeding cancontinue

Keep the child warm.

Give fluid for some dehydration (PlanB p.15 )

Advise the mother to continue

breastfeeding Follow up in 2 days

Give fluids to treat for diarrhoea athome (Plan A p.15)

Follow up in 2 days. If exclusively breastfed do not give

other fluids except SSS

REFER and treat for dehydration ifpresent.

Keep the baby warm on the way tohospital.

Refer URGENTLY to hospital Keep warm on the way to hospital

Two of the following signs:

Lethargic or unconscious

Sunken eyes Skin pinch goes back

very slowly.

DIARRHOEA WITHSEVERE DEHYDRATION

Two of the following signs:

Restless, irritable

Sunken eyes Skin pinch goes back

slowly.

DIARRHOEA WITHSOME DEHYDRATION

Not enough signs toclassify as some orsevere dehydration.

NO VISIBLE DEHYDRATION

Diarrhoea lasting 14days or more.=

=

SEVERE PERSISTENT

DIARRHOEA

Blood in the stool.`

POSSIBLE SERIOUSABDOMINAL PROBLEM=

=

=

=

=

forDEHYDRATION

andif diarrhoea14 days or more

andif blood instool

ClassifyDIARRHOEA


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31

THEN CHECK FOR FEEDING PROBLEM ORLOW WEIGHT IN BABIES RECEIVING NO BREASTMILK*:

ASK:

How are you feeding thebaby?

How is feeding going?

What made you decide not tobreastfeed*?

What milk are you giving?

How many times during the day andnight?

How much is given at each feed?

How are you preparing the milk?

- Let mother demonstrate or

explain how a feed is prepared,and how it is given to the baby

What foods and fluids in addition toreplacement milk is given?

How is the milk being given? Cup orbottle

How are you cleaning the utensils?

LOOK, LISTEN,FEEL:

Plot the weight on the RTHC todetermine the weight for age.

Look for ulcers or white patches in

the mouth (thrush).

Treat as possible severe bacterialinfection (p.28)

Give first dose of ceftriaxone IMI(p.33)

Refer URGENTLY to hospital

Not able to feed or

Not sucking at all.

NOT ABLE TOFEED -

ClassifyFEEDING

Milk incorrectly orunhygienically prepared or

Giving inappropriatereplacement milk or otherfoods/fluids or

Giving insufficientreplacement feeds or

Using a feeding bottle or

Thrush (ulcers or whitepatches in the mouth) or

Low weight for age or

Weight gain isunsatisfactory

Counsel about feeding

Explain guidelines for safe replacementfeeding (p.36)

Identify mothers and familys concernsabout feeding. Suggest that mothergradually decreases the amount of food orfluids other than milk being given

Advise the mother to use a cup rather thana bottle to feed the baby and show herhow to do this (p.36)

If thrush, teach the mother to treat forthrush at home (p.34)

Follow-up any feeding problem in 2days

Follow up in 7 days

Not low weight for age andno other signs ofinadequate feeding.

NO FEEDINGPROBLEM

Advise mother to continue feeding, andensure good hygiene

Praise the mother

Feeding problem non breastfed infantsAssess and classify the Young Infant


*NOTE: A child may not be breastfed because the mother is HIV infected. If this is notthe reason, consider restarting breastfeeding or referral to a breastfeeding counsellorif available

FEEDINGPROBLEMOR NOT

GROWINGWELL


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32

ASSESS OTHER PROBLEMS

THEN CHECK THE YOUNG INFANTS IMMUNISATION STATUS:

= ASSESS THE MOTHERS HEALTH NEEDSeg. Nutritional status and anaemia, contraception etc. Check hygiene practises

Give all missed doses on this visit. Include sick babies and those without a

RTHC If the child has no RTHC, issue a new one

to-day. Advise the caretaker when to return for thenext dose.

Special risk factorsImmunisation status

Assess and classify Young Infant

THEN CHECK IF THE YOUNG INFANT HAS ANY SPECIAL RISK FACTORS

Thisinfant is at high risk and special care should be taken to ensure thatthere are no feeding problems and the child is gaining weight well.Arrange appropriate regular follow-up with the motherRefer to an appropriate support group if possible.

IF

the infant was premature or low birth weight there was birth asphyxia the infant is not breastfed the mother is a young adolescent the mother is known to be HIV positive there is severe socioeconomic deprivation

}

IMMUNISATIONSCHEDULE:

AGE

Birth6 weeks10 weeks

VACCINE VITAMIN A

BCG OPV-0 200 000 IU to the mother at deliveryDPT+HIB-1 OPV-1 Hep B 1 50 000 IU for infants at 6 weeks ifnot breastfed

DPT+HIB-2 OPV-2 Hep B 2



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33

TREAT THE YOUNG INFANT

Treat LOCAL BACTERIAL INFECTION with Erythromycin syrup

Treat POSSIBLE SERIOUS BACTERIAL INFECTION with Intramuscular Ceftriaxone

Give first dose of Ceftriaxone IMI before the infant is referred urgently. Give a single dose of cetfriaxone to an infant with pus draining from the

eye

The dose of Cefriaxone is 50mg per kilogram==

Dilute 250mg vial with 1ml of sterile water

==

=

AGE or WEIGHT ErythromycinSyrup

125 mg in 5 ml

Birth up to 1 month (< 3 kg) 1.25 ml

1 month up to 2 months (3-4kg) 2.5 ml

ERYTHROMYCIN SYRUP Give three times daily for seven days

AntibioticsTreat the young infant

WEIGHT Ceftriaxone250mg in 1ml

2 -3 kg 0.5 ml

>3 - 6 kg 1 ml

CEFTRIAXONE INJECTION



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34

TREAT THE YOUNG INFANT

To Treat for Diarrhoea, See TREAT THE CHILD, p.15-16If there is DIARRHOEA WITH SEVERE DEHYDRATION or DIARRHOEA WITH SOME DEHYDRATION (p.15-16).If there is severe dehydration commence intravenous rehydration, give the first dose of ceftriaxone IMI (p.33) and REFER urgently.

Immunise Every Sick Young Infant, as Needed.

Teach the Mother to treat Local InfectionsAt home

Explain how the treatment is given.

Watch her as she does the first treatment in the clinic.

She should return to the clinic if the infection worsens.

To Treat for Skin Pustules or Umbilical Infection

The mother should do the treatment twice daily: Wash hands

Gently wash off pus and crusts with soap and water Dry the area Paint with polyvidone iodine lotion or gentian violet Wash hands

Treat for Thrush with Nystatin or Gentian Violet

The mother should: Wash hands

Wash mouth with clean soft cloth wrapped around the finger and wet with saltwater Give nystatin 1 ml 4 times a day or paint with diluted 0.5% gentian violet Wash hands Advise the mother on breast care Check bottle or other utensil in use for hygiene.

DiarrhoeaLocal infections at homeTreat the young infant


Treat for Eye Infection with Chloramphenicol Eye Ointment

The mother should wash hands before and after treatment The eyes must be cleaned with a clean cloth then Chloramphenicol or tetracycline eye ointment is instilled inside the

lower eyelid }Four timesper day


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COUNSEL THE MOTHER


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36

COUNSEL THE MOTHER

BreastfeedingWhen to returnCounsel the mother


How to feed a baby with a cup

Hold the baby sitting upright or semi-upright on your lap

Hold a small cup of milk to the babys lips- tip the cup so the milk just touches the babys lips- the cup rests gently on the babys lower lip and the edges of the cup and

touch the outer part of the babys upper lip- the baby becomes alert and opens his mouth and eyes

Do not pour the milk into the babys mouth. Just hold the cup to his lips and

let him take it himself

When the baby has had enough he closes his mouth and will not take anymore

Safe Preparation of Formula Milk

Always use a marked cup or

glass and spoon to measure

water and the scoop to meas-

ure the formula powder.

Wash your hands before pre-

paring a feed

Bring the water to the boil and

then let it cool. Keep it cov-

ered while it cools.

Measure the formula powder

into a marked cup or glass.

Make the scoops level.

Put in one scoops for every 25

mls of water.

Add a small amount of the

cooled boiled water and stir.

Fill the cup or glass to the

mark with the water. Stir well.

Feed the baby using a cup.

Wash the utensils.

Approximate amount of formula needed per day

Age inmonths

Weight inkilos

Approx. amount offormula in 24 hours

Previouslyboiled water

per feed

Number ofscoops per

feed

Approx. num-ber of feeds

Birth 3 400 ml 50 2 8 x 50 ml

2 weeks 3 400 ml 50 2 8 x 50 ml

6 weeks 4 600 ml 75 3 7 x 75 ml

10 weeks 5 750 ml 125 5 6 x 125 ml

14 weeks 6.5 900 ml 150 6 6 x 150 ml

4 months 7 1050 ml 175 7 6 x 175 ml

5 months 8 1000ml 200 8 5 x 200 ml


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37

Advise Mother to Give Home Care for the Young Infant

If the infant has: Return for follow-up in:

LOCAL BACTERIAL IN-FECTION

ANY FEEDING PROBLEM THRUSH

=

O=~

LOW WEIGHT FOR AGE T=~

===Advise the caretaker to return immediately ifthe young infant has any of these signs:

Breastfeeding poorly or drinking poorly Becomes sicker Develops a fever Fast breathing Difficult breathing Blood in stool Vomits everything Irritable or lethargic Convulsions

1. FLUIDS Breastfeed frequently, as often and for as long as the infantwants, day or night, during sickness and health.=

When to Return Immediately:

3. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.In cool weather cover the infants head and feet and dress the infant with extra clothing.

2. WHEN TO RETURNFollow-up Visit



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GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

If there is a new problemassess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart

LOCAL BACTERIAL INFECTION

After 2 days:Look at the umbilicus. Is it red or draining pus? Does redness extend to the skin?Look at the skin pustules. Are there many or severe pustules?Look at the pus draining from the eye. Has the eye improved? Is there less pus draining?

Treatment:

Ifcondition remains the same or is worse, refer to hospital.

Ifcondition is improved, tell the mother to continue giving the 5 days of antibiotic and continue treating for the local infection at home.

THRUSH

After 2 days:Look for white patches in the mouth (thrush).Reassess feeding. > See Then Check for Feeding Problem or Low Weight above (p. 30).

Ifthrush is worse check that treatment is being given correctly, consider HIV (p.7)

If the infant has problems with attachment or suckling, refer to hospital.

If thrush is the same or better, and the baby is feeding well , continue with nystatin (or gentian violet) for a total of 5 days.

Local bacterial infection

ThrushFollow up care



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GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

FEEDING PROBLEMAfter 2 days:Reassess feeding p.30Ask 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 infeeding, ask her to bring the young infant back again after 5 days.

If the young infant is low weight for age, ask the mother to return after a further 5 days after the initial visit to measure the young

infants weight gain. Continue follow-up until the infant is gaining weight well.

if the young infant has lost weight, REFER the child.

Exception:If you do not think that feeding will improve, refer the child.

NOT GROWING WELL

After 7 days:Weigh the young infant and determine if the infant is still low weight for age.Reassess feeding. > See Then Check for Feeding Problem or Low Weight above.

If the infant is no longer low weight for age, praise the mother and encourage her to continue.

If the infant is still low weight for age, but is gaining weight,praise the mother. Ask her to have her infant weighed again within14 days or when she returns for immunisation., whichever is the earlier.

If the infant is still low weight for age and has not gained weight REFER.

Exception:If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

Feeding problem

Low weightFollow up care


IMCI Chart Booklet

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