ATUCU5 - 20191018 - FA Edit 11.11.2020 - Compressed PDF

MOH/K/ASA/97.
18 (HB)
TRAINING MANUAL ON
APPROACH TO UNWELL CHILDREN
UNDER 5 YEARS
Family Health Development Division

Ministry Of Health
In Collaboration with World Health Organization (WHO)
FOREWORD ATUCU5
Foreword
Director General of Health Malaysia
Child mortality rate is a measurement of child wellbeing and is also recognised as one of the
indicators for assessment of a country’s overall development.
The target for child health under the Sustainable Development Goals (SDG) is to end all
preventable deaths of newborn and children under 5 years old, by the year 2030. The Promise Renewed
Progress Report 2013 by UNICEF also reported that more than 80% of all newborn deaths resulted from
three preventable and treatable conditions, namely complications due to prematurity, intrapartum-
related deaths (including birth asphyxia) and neonatal infections.
In Malaysia, preventable death for children under 5 years varies across states from as low as
5% to as high as 30%. Analysis of the Under 5 Mortality data in 2015 showed 30% of the mortality
cases among children under 5 years of age in Malaysia are preventable. Medical factors contribute to
under-5 mortality where quality of care was the main issue. Other contributing factors include facility
or equipment problems and failure of transportation system.
WHO in collaboration with UNICEF, developed the Integrated Management of Childhood

Illness (IMCI) strategy and it aims at reducing childhood deaths, illness, and disability, and improving
growth and development. It combines improved management of childhood illness with aspects of
nutrition and immunization in children below the age of five years.
In line with the SDG, Ministry of Health Malaysia aims to end all preventable deaths among
newborn and children under 5 years and developed the ‘Training Manual on Approach to Unwell
Children under 5 years’ (ATUCU5) based on the WHO IMCI strategy. ATUCU5 is meant for training
of our health care providers on three main components, which includes early detection of danger signs,
improvements in the case management skills and proper immediate treatment.
I would like to express my sincere appreciation to World Health organization (WHO) for
giving us the permission to adapt the IMCI Program. I would also would like to congratulate the
Family Health Development Division for organising and developing this module. Thank you to all the
committee members involved in the development of the module.
Datuk Dr Noor Hisham bin Abdullah

Director General of Health Malaysia
Ministry of Health Malaysia
3
FOREWORD
Foreword
Director of Family Health Development Division
Child health care services focus on comprehensive services towards prevention of morbidity
and mortality, health promotion and curative interventions. The strategies are strengthening of infant
and childcare through newborn screening, regular child health attendances, high immunization
coverage, and reviews and monitoring of Under 5 Mortality and, capacity building in early
identification and referral of cases.
Our analysis of the Under 5 Mortality in Malaysia showed that about 30% of death among
children under 5 years are preventable. Reports from the state show that preventable factors can
be classified as medical and non-medical factors. Medical factors include quality of care, facility
and transport system whilst non-medical factors identified are patient/ family factors and social
problems.
With these findings, Training Manual on Approach to Unwell Children under 5 years
(ATUCU5) was developed. Training Manual on ATUCU5 focuses on three main components namely
early detection of danger signs, improvements in the case management skills and proper immediate
treatment. The manual also includes health education for caregivers to empower them in the care of
an unwell child.
The development of Training Manual on Approach to Unwell Children under 5 years

(ATUCU5) was to complement the existing IMCI Training Program. Ministry of Health conducts
IMCI Training Program for paramedics in rural areas where clinics are manned by paramedics only.
While the training manual on ATUCU5 is designed to cater for all healthcare workers including
doctors, especially those in primary care and emergency departments.
My sincere gratitude to all the committee members involved in the development of the module.
I hope this manual will be used by all at the clinic and hospital either private or government setting
in order to reduce the morbidity and mortality of our children.
Dr. Hjh. Faridah binti Abu Bakar

Director of Family Health Development Division
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ATUCU5
Table of
CONTENT
FOREWORD BY GENERAL DIRECTOR OF HEALTH
FOREWORD BY DIRECTOR OF FAMILY HEALTH DEVELOPMENT DIVISION

(PUBLIC HEALTH)
1 INTRODUCTION 4 DIARRHOEA 7 IMMUNISATION
2 GENERAL DANGER
SIGNS
5 FEVER 8 ASSESSMENT
OF YOUNG
INFANTS
3 COUGH OR DIFFICULT
BREATHING IN
CHILDREN 6 STATUS 9
NUTRITIONAL LOCAL
INFECTION
10 MOTHERS
CARD
5
INTRODUCTION
TRAINING MANUAL ON
APPROACH TO UNWELL
CHILDREN UNDER 5 YEARS
INTRODUCTION
6
ATUCU5
1. INTRODUCTION
1.1 Approach to Unwell Child under 5 years
One of the goals in Sustainable Development Goals (SDG) is to end
all preventable deaths among newborns and children under 5 years of age by
2030. About 30% of the mortality cases among children under 5 years old in
Malaysia are preventable.
An audit of the preventable cases showed that 57% of the cases were
due to medical factors. Among the medical factors that contributed to the
mortality, more than half (53%) were linked to issues of quality of care, whilst
only 8% was attributed to facility/equipment problems and 1% due to failure
of transportation system.
Quality of care, which is one of the modifiable medical factors for

preventable death includes; delay in referral, failure to appreciate severity,
failure to diagnose, inadequate/inappropriate/delay therapy and inadequate
resuscitation.
Analysis of under 5 mortality data in 2017 shows that preventable

deaths increases with age.
PREVENTABILITY BY AGE GROUP (2017)

100%
48 19 36 30
90%
80%
70% 383
429 737
60% 1370
50%
40%
30%
428
20%
207 306
10% 423
0%
0 - 6 DAYS 7 - <28 DAYS 28 DAYS - < 1 YEAR 1 YEAR - < 5 YEAR
PREVENTABLE NOT PREVENTABLE UNDETERMINED UNKNOWN
PREVENTABLE deaths increasing with age
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INTRODUCTION
Top three causes of preventable deaths among infants (28days – < 1 year) and toddlers ( 1- <5years) are
respiratory system illnesses, infections & parasitic disease and injuries.
TOP CAUSES OF PREVENTABLE DEATHS
28 DAYS TO
EARLY NEONATAL LATE NEONATAL TODDLER
< 1 YEAR
Condition From Condition From Injuries & External

1 Respiratory
Perinatal Period Perinatal Period Causes
Congenital Congenital Certain Infections &

2 Respiratory
Malformation Malformation Parasitic Disease
Injuries & External Certain Infections &

3 Unknown Respiratory
Causes Parasitic Disease
Thus, in order to end all preventable death and subsequently reduce under 5-mortality rate,
improvement in quality of health care is needed.
The approach to unwell children under 5 years (ATUCU-5) is a guideline for frontline health
staff, adapted from the Integrated Management of Childhood Illness (IMCI) programme.
It incorporates IMCI contents with additional points related to diseases, which are common
among children under 5 years in Malaysia.
The main objective of this training manual is to improve the quality of care by addressing
the modifiable medical factors. This manual is meant for training of healthcare providers
in hospital and health clinics.
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ATUCU5
1.2 Importance of Child Health Record Book in Management of Unwell

Child
Child attendance to health clinics for regular growth and development monitoring during well baby
clinic visit is recorded in the home based child health record Buku Rekod Kesihatan Kanak-Kanak 0-6 tahun
(BRKK). Appointments are given according to schedule visits and children are seen and assessed mainly by
nurses and community nurses. In addition, there are 3 scheduled visits for examination by doctors at 1 month,
18 months and 4 years. Appointments are also given for at least 3 dental visits.
However, outside of the scheduled visits when child is not well, they are taken to outpatients clinics and
seen by either the doctor or paramedics. The home based BRKK is a necessary tool to ensure seamless care
and continuity of care. Health staff must advise parents to bring the BRKK for all visits to the clinic.
At any time when a child visits the outpatient clinic, if the child is stable and not seriously ill, a holistic
assessment child must be done for:
(1) Presenting complain and issues,
(2) Assessment for growth and development and
(3) Check for immunisation status.
9
INTRODUCTION
1.3 The elements of integrated case

management in ATUCU-5
THE ELEMENTS OF INTEGRATED CASE MANAGEMENT

IN ATUCU-5
Assess And Classify
Identify Treatment
Treat
Counsel The Caregiver
Follow-Up
The elements of integrated case management in ATUCU-5 include:
• Assess and classify: This will guide you in deciding the severity of the illness. Health
care provider (HCP) need to know how to assess a child by checking for danger signs,
asking questions about common conditions examining the child, checking nutrition and
immunization status (using the checklist).
• Identify treatment: HCP need to know how to identify appropriate treatment for a sick
child eq: essential treatment in case a child requires urgent referral or home treatment plan
in case child needs treatment at home
• Treat: HCP need to know how to treat a sick child and give practical treatment instructions
to parents
• Counsel the mother/caregiver: HCP need to know how to effectively counsel caregivers
using the Ask, Praise, Advice (Tell, Show, Practice), Check understanding (APAC)
• Follow-up: HCP need to know how to provide follow-up care. During follow-up care if
there is a new problem, a full assessment as in an initial visit must be done.
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ATUCU5
1.4 Outline of management of unwell child
Age < 2 months Use Checklist <

Note : Management of the
young infant age up to 2 months
Management Of is somewhat different from
Unwell Child older infants and children. It
is described in the ASSESS AND
Use Checklist < 2 TREAT THE SICK YOUNG INFANT
Age 2 months months - < 5 Years module.
Management of Unwell Child ( Age 2 Months - < 5 Years)
Ask the caregiver about the

child’s problems
Check for general danger

sign
Cough or difficulty
Assess and treat main breathing
symptoms:
Management Of Age 2 months - Check for malnutrition and

Diarrhoea
Unwell Child < 5 years anaemia
Check immunization
Status
Fever
Treat local infection
Counsel using the mother’s

card
Management of Unwell Child (Age <2 Months)
Ask the caregiver about the

child’s problems
Check for very
Assess and treat the sick severe disease
young infant
Check for local
infection
Management Of Check immunization
Age < 2 months
Unwell Child Status
Check for the
jaundice
Assess breastfeeding
Diarrheoa
Counsel using the mother’s

card
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INTRODUCTION
2. ASK THE MOTHER/CAREGIVER ABOUT THE CHILD’S

PROBLEMS
Learning Objectives
• How to greet a caregiver and get important information
ASK THE MOTHER ABOUT THE CHILD’S PROBLEMS
• Great the mother appropriately

• Use good communication skill
• Find out the child’s age
• Ask the mother what the child’s problems are
• Find out if this is an initial or follow-up visit for this problem
• Make sure the child’s weight and temperature is measured and recorded
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ATUCU5
3. Good Communication
Why Is Good Communication With A Caregiver Important?
1. Caring for an ill child could cause caregivers to be very stressed and
emotional. It is important to communicate concern and care for the child’s
health, and the family’s situation.
2. Good communication helps to reassure the caregiver that her child will
receive good care.
3. Good communication and trust between HCP and caregiver will result in
better care of the sick child at home
What Are Good Communication Skills?

Good communication skills involve the following:
GOOD COMMUNICATION SKILL
LISTEN
SIMPLIFY WORDS
GIVE HER TIME
BE CLEAR
PRAISE
ADVICE
• LISTEN – Listen carefully to what the caregiver tells you. This shows you are taking her
concerns seriously.
• SIMPLIFY WORDS – Use simple language. Use words the caregiver understands. If she does
not understand what you ask her, she cannot give the information you need to assess and
classify the child correctly.
Do Not Use Medical Terms.
• GIVE HER TIME – Give the caregiver time to answer the questions.
She might need time to decide if a sign you are asking about is present.
• BE CLEAR – Ask additional questions when the caregiver is not sure about her answer. If she is
not sure that a certain symptom or sign is present, ask additional questions. Help her make her
answers clearer.
• PRAISE – Praise the caregiver for what she is doing right. This will reinforce good practices.
• ADVICE – if the caregiver practises inappropriate/wrong management, Do Not Scold/Criticise
them. Give appropriate advice clearly
13
INTRODUCTION
COUNSEL CAREGIVERS USING APAC

(Ask, Praise, Advice, Check)
APAC (ASK, PRAISE, ADVICE, CHECK)

Ask and Listen
• Ask and listen to find out what the child's problem are
Praise
▪ Praise the caregiver for what she has done well
Advice
• Advice caregiver to care for her child at home
Check
▪ Check the caregivers understanding
WHAT IS THE IMPORTANT INFORMATION YOU GATHER

DURING A GREETING?
IMPORTANT INFORMATION
Definition of age
Age 1. A sick child is 2 months up to 5 years of age : the
child has not had his 5th birthday
2. A sick young infant is birth up to 2 month of age :
infant has not had his 2nd month birthday.
Child’s Problem
Number of visits
- Ask if this is first visit or repeated visit for this
Number of Visit current problem
- Repeated visit is 2 or more visits for the same
Weight And problem at ANY health centre including private
facilities
Temperature - For repeated visits, consider admission
Important information to ask the caregiver about the child:

•Age
- The child’s age determines which treatment module to use – the sick child or the young infant.
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ATUCU5
•Child’s problem
- Ask why the caregiver is bringing the child to the clinic
- By asking this you can make note of the symptoms or health problems that are worrying them
- You may also ask for further details, example, ask how long the symptom has been present, or has
it been getting worse
- You can also ask the caregiver how she has been addressing the health problem thus far. This will
give you a background about previous care given at home, community, or other facilities.
•Number of visits
- Ask if this is first visit or repeated visit for this current problem
- Repeated visit is 2 or more visits for the same problem at ANY health centre including private
facilitiesor any private pharmacy
- For repeated visits, consider admission
•Weight and temperature
- Determine the child’s weight and temperature
- Check if this is already recorded on the child’s card. If not, weigh the child and measure his
temperature later when you assess and classify the child’s main symptoms.
6. Make sure the

child’s weight 1. Great the caregiver
and temperature appropriately
is measured and
recorded
2. Use good
5. Find out if this is communication
an initial or follow-up skill
visit for this problem
4. Ask the caregiver 3. Find out the

what the child’s child’s age
problems are
YOU SHOULD ALWAYS:

• Greet the caregiver appropriately
• Use good communication skills
• Find out the child's age
• Ask the caregiver what the child's problems are
• Find out the number of visit for this problem
• Make sure the child's weight and temperature is measured and recorded
15
GENERAL DANGER SIGNS
TRAINING MANUAL ON
APPROACH TO UNWELL
CHECK FOR
GENERAL
DANGER SIGNS
16
ATUCU5
2. CHECK FOR GENERAL

DANGER SIGNS
2.1 Learning Objectives:
• Recognize general danger signs in a sick child
• Provide urgent pre-referral treatment
• Refer a child when danger signs are present
2.2 General Danger Signs
5. Child Is 1. Child Is Not

Convulsing Able To Drink Or
Now Breastfeed
2. Child Vomits
4. Child Is Everything
Drowsy Or Or Greenish
Unconscious Vomitus
3. Child Has Had

Convulsions
During This
Illness
• The following are general danger signs in young children:

- The child is not able to drink or breastfeed
- The child vomits everything or greenish vomitus
- The child has had convulsions during this illness or convulsing now
- The child is drowsy or unconscious
• Presence of general danger signs means a child is in a serious problem and require urgent hospital
referral.
• When a general danger sign is present immediately complete the rest of the assessment and give
urgent pre-referral treatment.
• A sick child may have signs that clearly point to a disease. For example, a child may present with
cough and chest indrawing, which indicate severe pneumonia.
• Some children may present with serious, non-specific signs that do not point to a particular
disease. For example, a child who is drowsy or unconscious may have meningitis, severe
pneumonia, cerebral malaria or other severe diseases.
• Great care should be taken to ensure that these general danger signs are not overlooked. General
danger signs suggest that a child is severely ill and needs urgent attention.
17
General Danger Signs

ALL SICK CHILDREN MUST CHECK FOR GENERAL DANGER SIGNS
Ask Look
Is the child able to drink

or breastfeed
Is the child drowsy or
unconscious?
Does the child vomits
everything or greenish
vomitus?
Is the child convulsing
now?
Has the child had
convulsion during this
illness
• All sick children should be routinely checked for general danger signs
• If you have found during the assessment that the child has a general danger sign, complete
the rest of the assessment IMMEDIATELY.
• Remember that a child with any general danger sign has a severe problem. There must be
NO DELAY IN TREATMENT
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ATUCU5
2.3 ASK: Is the child able to drink or breastfeed?

Definition: A child who is not able to suck or swallow when offered water or breastmilk because he or she is too
weak or cannot swallow
• Ask the caregiver if the child is able to drink or

GENERAL DANGER SIGNS breastfeed. Make sure that the caregiver understands
the question.
ASK: Is the child able to drink or breastfeed? • If she says that the child is not able to drink or
breastfeed, ask her to describe what happens when
Child not able to drink or breastfeed : she offers the child water to drink. For example, ask:
• Not able to suck or swallow when offered water or “Is the child able to take fluid that put into his or her
breast milk mouth and swallow it?" (passive drinking)
• Because the child is too weak to suck or swallow • If you are not sure about the caregiver's answer,
ask her to offer the child a drink of clean water or
(If history is not clear - offer fluid to child and observe) breastmilk. Look to see if the child is swallowing the
water or breastmilk.
• Ask the amount, frequency and duration of not able

GENERAL DANGER SIGNS to drink or breastfeeding.
• Feeding less than half of the child’s usual oral intake in
ASK: Is the child able to drink or breastfeed? more than 12 hours is considered as unable to drink
or breastfeed.
Is the child not able to drink or breastfeed :
• Ask the amount, frequency and duration of not able
to drink or breastfeeding. Remember: A child who is breastfeed may have
• Feeding less that half of the child’s usual oral intake difficulty suckling when the nose is blocked. If the
in more than 12 hours is considered presence of the nose is blocked, clear it. If the child can breastfeed
sign. after the nose is cleared, the child does not have the
danger sign "not able to drink or breastfeed".

ASK: Is the child able to drink or breastfeed?
• Not able to drink or breastfeed
Video GDS Not able to drink or breastfeed.mpg
19
2.4 ASK: Does the child vomit everything or

greenish vomitus?

ASK: Does the child vomit everything?
• Does the child vomits all the drink / food given?
• Does the child vomits everytime after feeding?
• Ask the amount, frequency and duration
(If history is not clear - offer fluid to child and observe)
Definition: A child who vomits every time after feeding and not able to hold anything down at all.
What goes down comes back up. A child who vomits everything will not be able to hold
down food, fluids or oral drugs.
Ask the amount, frequency and duration of “vomit everything”. Vomit more than half
of the child’s usual oral intake in more than 12 hours is also considered as
vomit everything.
• Ask the caregiver if the child vomits everything or greenish vomitus. When you
ask the question, use words the caregiver understands.
• When you or the caregiver is not sure if the child is vomiting everything, then
ask the caregiver: “How often the child vomits? Also ask: “Each time the child
swallows food or fluids, does the child vomit?”
• If you are still not sure of the caregiver’s answers, ask her to offer the child a
drink. See if the child vomits.

ASK: Does the child vomits evertyhing?
• Greenish vomitus (Bile content) indicates intestinal obstruction in child (surgical
emergency)
• Ask what did the child take prior to vomiting?
- not to confuse with greenish food particles eg: green vegetable or other food colourings,
sputum
A child who “vomits greenish vomitus” has a severe illness. He may not vomit everything but
greenish vomitus (bile content) may indicate intestinal obstruction and child will need to be referred
urgently. Ask what did the child take prior to the vomiting? This is not to be confused with greenish
food particles eg: green vegetables, other food colourings or sputum.
20
ATUCU5
2.5 ASK: Has the child had convulsions during

this illness?

ASK: Has the child had convulsion during this illness ?
• Ask mother to describe what is convulsion or how does the convulsion occurs?
• Clarify with mother on the history
Use words the caregiver
understands/local dialect. For
example, the caregiver may
know convulsions as “fits” or
“spasms” (“tarik”, “sawan”)

Description of Convulsion :
• Unconscious
• Not responding to surrounding
• Child’s arms / legs become stiff or jerky movements, localized / generalized
• Up rolling eyeballs
• May have :
• Drooling of saliva
• Urinary / bowel incontinence
• Post-ictal drowsiness
• During a convulsion, the child's arms and legs stiffen because the muscles are contracting.
• The child will lose consciousness for a period of time or not be able to respond to spoken
directions.
• Loss of consciousness with ONLY uprolling of eyeballs without tonic-clonic jerk also may be
considered as convulsion.
• The child may have drooling of saliva, urinary or bowel incontinence and/or post-ictal drowsiness.
21

Possible causes of convulsion :
• Infection : meningitis / encephalitis / cerebral malaria
• Space occupying lesion : tumour / abscess
• Head injury : Accidental or non-accidental injuries (NAI)
• Fever : Febriles Fits
• Convulsions may be the result of fever.

• Convulsions may be associated with serious infection (meningitis, encephalitis, cerebral malaria)
or other life threatening conditions such as space occupying lesion or head injury.
• All children who have convulsions now or have had convulsions during this illness should be
considered seriously ill.

Ask :
1 Is the child able to drink or breastfeed?
2 Does the child vomits everything or greenish vomitous?
3 Has the child had convulsion during this illness
Look :
4 Is the child Drowsy or Unconscious?
5 is the child convulsing now?
This slide is to recheck understanding of participants

Drill 1:
• What are the questions to ask in history taking for GDS?
• What is the definition of not able to drink / breastfeed
• What does it means by vomits everything?
• Greenish vomitus means?
• Definition of vomits everything
• Describe convulsion
Next ask participants how do they assess a child for drowsiness / unconscious
22
ATUCU5
2.6 LOOK: Is the child drowsy or unconscious?

ASK : Has the child had convulsion during this illness?
Drowsy Child :
• Not alert to surrounding

• Stare blankly and not to notice what is going on around him / her
• Not responding to sound / movement
• Not looking at the mother’s / caregivers face or health worker when stimulated
• A drowsy or unconscious child is likely to be seriously ill.

• A drowsy child is not awake and alert when he or she should be.
• The child is drowsy and does not show interest in what is happening around her. She does not
respond normally to sounds or movement.
• Often the drowsy child does not look at his or her caregiver or watch your face when stimulated.
• The child may stare blankly and appear not to notice what is going on around him or her.

Look : Is the child Drowsy or Unconscious ?
Unconscious Child :
• Unconscious child cannot be awakened and does not respond when he or she is called /
touched / shaken
• Ask mother is the child unusually sleepy or if she cannot wake up the child
• An unconscious child cannot be awakened. The child does not respond when he or she is called,
touched or shaken.
• Ask the caregiver if the child seems unusually sleepy or if she cannot wake the child.
• Look to see if the child awakens when the caregiver talks or shakes the child or when you clap
your hands. (Example: call name -> clap our hands -> shake child’s hand)
• Remember: If the child is sleeping and has cough or has difficulty breathing, count the number
of breaths per minute first before you try to wake the child.
• To give scenarios :
i. What if the child is sleeping and mom says he just had his feeding & slept – What would
you do?
• ask mom to wake up child
• Mom says no need doctor. Would you follow the mothers’ wish?
• Steps to assess :
i. Ask caretaker to wake the child up
ii. Make noise eg clapping our hands
iii. Health worker wake up child gently by shaking the hands
23

LOOK : Is the child Drowsy or Unconscious?
Drowsy & Unconscious.mpg
• In the video, lethargy is drowsy

• Show from the video & asks participants
i. Why do you say that child is not drowsy / unconscious?
ii. Show stare blankly
iii. Child not responding to sound
• Watch the video and decide if the child is drowsy or convulsion

Excercise :
GDS Excercise.wmv
2.7 LOOK: Is the child convulsing now?

LOOK : Is The Child Convulsing Now?
What are the clinic feature?
• Any child who has convulsions now should be considered seriously ill.
• Let the participant describe convulsion (refer point 2.5 ASK: Has the child had convulsions during
this illness?)
• Watch the 3 videos and describe the convulsion

LOOK : Is the Child Is Convulsing Now?
Convulsions during this illness :
Febrile convulsion.mp4-1
Infant seizures.mp4
Infant convulsive seizure.mp4
All sick children should be routinely checked for general danger signs
• If you have found during the assessment that the child has a general danger sign, complete the rest of
the assessment IMMEDIATELY.
• Remember that a child with any general danger sign has a severe problem. There must be NO DELAY IN
TREATMENT.
24
ATUCU5
3. REFERRAL FOR GENERAL DANGER SIGNS

• A child with any general danger sign needs urgent attention and pre-referral treatment.
• You should complete the rest of assessment immediately and give urgent pre-referral treatment
then referred urgently.
• Do not give treatments that would unnecessarily delay referral
• Most children who have a general danger sign also have a severe classification. They are referred
for their severe classification.
4. URGENT PRE-REFERRAL TREATMENT FOR GENERAL

DANGER SIGNS
4.1 TREAT THE CONVULSING CHILD

Managing the airway, giving diazepam, lowering the fever and preventing low blood sugar are important
steps in managing a convulsing child before referral to hospital.
1. AIRWAY MANAGEMENT
o Turn the child to the side
o Extend the neck slightly to open the airway
o Clear the airway -remove secretions by suction or manually
o Give oxygen
o Do not insert anything in the mouth

Urgent Pre-Referral Treatment for Convulsion
Diazepam given rectally
Diazepam RECTAL TUBE
AGE OR WEIGHT 10mg /2ml solution
(5mg/tube)
(Dose 0.3-0.5 mg/kg)
2 mths to < 4 mths
0.5 ml ½ tube
(3kg - < 6kg)
4 mths to < 12mths
0.75 ml ½ tube
(6kg - < 10kg)
12 mths to < 3 yrs
1 ml 1 tube
(10kg - < 14kg)
3 yrs to < 5 yrs
1 ml 1 tube
(14kg - < 19kg)
2. RECTAL DIAZEPAM
• Give Diazepam rectally according to dosage
• Dosing of medication will be based on child’s weight.
o Eg a child who is 12 mths & weighs 9.3 kg. How much diazepam to give?
Show on the table : 0.75ml.
o Or a child who is 10 mths & weighs 11kg. How much diazepam to give? Show on table 1 ml
• If convulsions have not stopped after 5 minutes, give a second dose of diazepam rectally
• Maximum 2 doses of Diazepam are allowed
• Do not give oral medication until convulsions have stopped
25
3. Methods of giving Rectal Diazepam:

Urgent Pre-Referral Treatment for Convulsion
Rectal Diazepam ( Diazepam Vial)
• Use tuberculin syringe (1ml) to withdraw diazepam solution - based on weight of child
• Removed needle
• Insert syringe 4-5cm into rectum and inject Diazepam solution
• Hold buttocks together for few minutes
Rectal Diazepam ( Diazepam Vial)

• Insert nozzle of tube into rectum and squeeze amount according to appropriate dose
• Hold buttocks together for few minutes
1. Give Diazepam Rectally

• Draw up the dose from an ampoule of diazepam into a tuberculin (1ml) syringe. The dose of the
diazepam will be based on the weight of the child, when possible
• Then remove the needle
• Insert the syringe 4-5 cm into the rectum and inject the diazepam solution
• Hold buttocks together for a few minutes
OR
2. Give Commercial Rectal Tube Diazepam If Available
• Insert the nozzle of the tube into the rectum and squeeze the amount according to the appropriate dose
• Hold the buttocks together for a few minutes
4.2 TREAT THE CHILD TO PREVENT LOW BLOOD SUGAR

Urgent Pre-Referral Treatment: to Prevent Low Blood Sugar
• 30-50 mls breast milk / breast milk substitube / Dextrose 10% if child is able to swallow
• If child not able to swallow may need to insert NG tube
• Low blood sugar occurs in serious infections such as severe malaria or meningitis. It also occurs
when a child has not been able to eat for many hours. It is dangerous because it can cause brain
damage.
• Giving some breastmilk, breastmilk substitute, or 10% Dextrose provides some glucose to treat and
prevent low blood sugar. This treatment is given once, before the child is referred to the hospital.
• Low blood sugars is when Hypocount/Dextrostix is < 2.6 mmol/L
• If the child is able to breastfeed:

o Ask the mother to breastfeed the child
• If the child is not able to breastfeed but is able to swallow:
o Give 30-50 ml of expressed breastmilk or a breastmilk substitute.
o If neither of these is available, give 30-50 ml of 10% dextrose orally before departure
• If the child is not able to swallow and you know how to use a nasogastric (NG) tube
o Give 30-50 ml of milk or 10% dextrose solution by nasogastric tube
• If not able to swallow and able to insert IV line
o Give IV Dextrose 10% 2-3 ml/kg
26
ATUCU5

SUMMARY
ALL SICK CHILDREN MUST CHECK GENERAL DANGER SIGNS
Ask :
1 Is the child able to drink or breastfeed?
2 Does the child vomits everything or greenish vomitous?
3 Has the child had convulsion during this illness
Look :
4 Is the child Drowsy or Unconscious?
5 is the child convulsing now?
Drill 2 : Recap with the participants on:
• What are the 3 questions that we should ask ourselves when assessing the unwell child?
• What further clarifying questions to ask – child’s feeding / fluid intake in terms of frequency &
amount over 12-24 hrs.
• What does not able to drink or breastfeed means?
o Not able to suck or ability to swallow is weak OR amount / frequency of feeding will be less
than half over a period of 12-24 hrs.
• What does it means by vomits everything?
o what goes in, goes out OR frequency / amount of vomiting is more than half from the
intake over 12-24hrs
• What could greenish vomitus mean?
o Bile content that indicates intestinal obstruction
• History of convulsion during this illness – let participant describe convulsion & what questions
need to be asked
• LOOK for:
o Drowsy / Unconscious – Definition?
o Steps on how to assess:
1. Ask caretaker to wake up the child
2. Make sounds eg by clapping hands
3. Healthcare provider gently shake the child’s hand
o Describe convulsions
27
COUGH OR DIFFICULT
BREATHING IN CHILDREN
TRAINING MANUAL ON
APPROACH TO UNWELL
COUGH OR
DIFFICULT
BREATHING
IN CHILDREN
28
ATUCU5
4. COUGH OR DIFFICULT
History of cough should be elicated in all
children
Ask the caregiver

about the child’s
problems
Check for general

danger sign
Assess and treat

main symptoms: Cough or difficulty
breathing
Check for
Diarrhoea
Management Age 2 malnutrition and
Of Unwell months - anaemia
Child < 5 years
Fever
Check
immunization
Status
Treat local
infection
Counsel using
the mother’s card
29
COUGH OR DIFFICULT
COUGH OR DIFFICULT BREATHING
Age 2 Months up to 5 Years

• Cough is the most common complaint
• Cough can be due to airway, lung or heart problems
• Respiratory infection can occur at any part of respiratory tract.
• Pneumonia can cause death due to hypoxia or sepsis and is one of the common cause of
preventable death in Under 5.
30
ATUCU5

Need to Assess for
2. 3. 4.
1. 5.
Fast Chest Stridor in
Duration Wheeze
breathing indrawing calm child
Drill 3:
COUGH OR Before assessing cough, GDS should be assess first
DIFFICULT Ask participants about GENERAL DANGER SIGNS
1.ASK : - Is the child able to drink or breastfeed?
BREATHING - Does the child vomit everything?
What is General Danger - Has the child had convulsion during this illness?
2.LOOK : - See if the child is drowsy or unconcious?
Signs? - See if the child is convulsing now?
All unwell child should be assess for general

danger signs
Ask Look

or breastfeed
unconscious?
vomitus?
now?
Has the child had
illness
Drill 3:
Before assessing cough, GDS should be assess first
Ask participants about GENERAL DANGER SIGNS
31
COUGH OR DIFFICULT

Assess
Does the child have cough or difficult breathing (YES / NO)
• For how long?........days

• Count the breaths in one minute.
•........ breath per minute fast breathing
• Look for the chest indrawing
• Look and listen for stridor
• Look and listen for wheeze
• Check spO2 (if available)
• Ask for how long? – child who has had cough or difficult breathing for more than 14 days has
chronic cough.
• Ask participants what are the common causes of chronic cough ˃ This may be a sign of PTB,
Asthma , Whooping cough, foreign body

Must count the breath in one minute
• Look for breathing movement anywhere on the child’s chest or abdomen

• Child must be calm
• Focus point for counting
• Cut off rates for fast breathing depends on child’s age
Child’s age Fast breathing

2 months up to 12 months ≥ 50 breath /minute
12 months up to 5 years ≥ 40 breath/minute
To emphasize on the need to count for 1 minute as breathing pattern in children is irregular
• Look for breathing movement in a well exposed child
• Focus point for counting ˃ on the child’s chest or abdomen
• Child must be calm
• Not to count during feeding
• Cut off rates for fast breathing depends on child’s age
32
ATUCU5

Counting the number of breath in 1 minute:
• Exercise 1
• Exercise 2
Watch the video and count the number of breath

Look for chest indrawing
• Chest indrawing – Lower chest wall goes IN when the child breathes IN
(both intercostal muscle and the ribs)
1. Lift the child’s shirt

2. Must be calm, not during feeding or crying
3. Adequate lighting
4. Look for CHEST INDRAWING
5. If unsure, examiner to change position and observe again

• In normal breathing, the whole chest wall upper and lower and abdomen moves out when the
child breathes in
• Chest indrawing – Lower chest wall goes IN when the child breathes IN
(both intercostal muscle and the ribs)
• Chest indrawing should be persistent during observation

Chest in drawing
Chest wall indrawing (5 Cases).wmv
Chest wall indrawing (5 Cases ans.wmv
33
COUGH OR DIFFICULT

Look and Listen for stridor
• Stridor is a harsh noise / sound when the child breathes IN
• Stridor happens when there is a swelling of the larynx, trachea or epiglottis. This swelling
interferes with air entering the lung. It can be life-threatening when the swelling causes the
child’s airway to be blocked.
• A child who has stridor when calm has a dangerous condition.
Assessment (Look and listen)
1. Child must be calm
2. Look to see when the child breathes IN
3. Listen for stridor
Look and Listen for stridor

• Stridor is a harsh noise /sound when the child breathes IN
• Stridor happens when there is a swelling of the larynx, trachea or epiglottis. This swelling
interferes with air entering the lung. It can be life-threatening when the swelling causes the
child’s airway to be blocked.
• A child who has stridor when calm has a dangerous condition.
Assessment (Look and listen)

1. Child must be calm
2. Look to see when the child breathes IN
3. Listen for stridor
If there is noisy breathing and unsure if stridor is present, clear the nose with wet cotton swab and
listen again.

Stridor explanation
Video\14_ Exercise Stridor.MPG
34
ATUCU5

Look and Listen for wheeze
• Wheeze is a musical noise heard when the child breathes OUT.
• Wheezing occurs when the air flow from the lung is obstructed due to narrowing of the
small airways.
Assessment (Look and Listen)

1. Look to see when the child breathes OUT
2. Listen for wheeze.
** Hold your ear near the child’s mouth because wheezing sound can be difficult to hear. Breathing
out phase requires great effort and is longer than normal. You may also use a stethoscope to
listen for rhonchi

Look and Listen for wheeze.wmv
Wheeze Excercise.wmv

Noisy Breathing
• Snoring
• Nasal
Secretion
• Stridor
Wheeze Rhonchi
(audible) (stethoscope)
These location produces sounds

• Snoring is from the pharynx
• Nasal secretions from any part of the upper airways
• Stridor is from any part of the upper airway
• Wheezing if from lower airways (bronchus, bronchioles)
35
COUGH OR DIFFICULT
CHECKLIST
APPROACH TO UNWELL CHILDREN UNDER FIVE YEARS
THE unwell child age 2 months up to 5 years
Name: ……….…………………………............ Age:…………............ Weight: Temperature: ………….. ˚C
................................................ …………….
Ask: What are the child’s problem?................................................. Visit: 1st /2nd/3rd/4th/5th

ASSESS( Circle all signs present)
ASK LOOK AND FEEL REFER FOR ADMISSION IF
PRESENT
CHECK FOR GENERAL DANGER SIGNS
• NOT ABLE TO DRINK OR BREASTFEED • DROWS OR UNCONSCIUS • General danger sign
• VOMIT EVERYTHING OR GREENISH • CONVULSING NOW
VOMITUS
• CONVULSIONS DURING THIS ILLNESS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING (YES/NO)
• Count the breaths in one minute • Chest in drawing
• For how long?...................days …………breath per minute Fast • Stridor in calm child
breathing?
• Check SP02 (if available) • Fast breathing
• Look for chest indrawing • SP02 < 96%
Checklist for unwell child 2months till < 5 years
To emphasize on criteria for admission
*If pulse oximeter is available, determine oxygen saturation and refer if < 95%.
Salbutamol Neb:
0.5ml Salbutamol solution + 3.5 ml Normal Saline • Neb until liquid is used up or at least 15
minutes
• Neb with Oxgen flow 6-8 Litre / min
• Neb until liquid is used up or at least 15 minutes
• After 15 minutes have to reassess
• Neb can be given up to 3 times if rhonchi or wheeze still present
Salbutamol Neb:
0.5ml Salbutamol solution + 3.5 ml Normal Saline Neb with Oxygen flow 6-8 litre / min
• Neb until liquid is used up or at least 15 minutes
• Reassess After 15 minutes of completion of neb
• Neb can be given up to 3 times if rhonchi or wheeze still present
36
ATUCU5

• The use of MDI with aerochamber
device as alternative mode of
treatment is easy and available.
• 2 puffs every 10-15 minutes
interval up to 3 times. If not
improving, refer to hospital
Aerochamber
Alternative To Nebulization
(Modified Spacer/Aerochamber
+ MDI Salbutamol)
Treatment.mpg
Remember Not To Use Cough Syrup

Baecause they may cause
• Sedation to the child - Not able to assess the true severity
• interfere with child’s feeding
• Interfere with child’s ability to cough up secretions from the lungs
• Abdominal distension

Adam is 6 months old and weighs 5.5 kg. His temperature is 38 0C.
His mother said he has had cough for 2 days.
The healthcare provider checked for general danger signs/ The mother said that Adam is able
to breastfeed. He has not vomited during this illness. He has not had convulsions. Adam is not
lethargic or unconscious.
The healthcare said to the mother, “I want to check Adam’s cough. You said he has had cough
for 2 days now. I am going to count his breaths. He will need to remain calm while I do this.” The
HCP counted 58 breaths per minute. he didn not see chest indrawing or hear stridor.
1. What signs does Adam have?

2. Definiton of stridor, wheeze, chest indrawing and fast breathing
3. Where to refer
Drill 4
• Scenario to check on participants understanding
37
COUGH OR DIFFICULT
CHECKLIST
APPROACH TO UNWELL CHILDREN UNDER FIVE YEARS
THE unwell child age 2 months up to 5 years
Name: ……….…………………………............ Age:…………............ Weight: Temperature: ………….. ˚C
................................................ …………….
Ask: What are the child’s problem?................................................. Visit: 1st /2nd/3rd/4th/5th

ASK LOOK AND FEEL REFER FOR ADMISSION IF
PRESENT
• NOT ABLE TO DRINK OR BREASTFEED • DROWS OR UNCONSCIUS • General danger sign
• VOMIT EVERYTHING OR GREENISH • CONVULSING NOW
VOMITUS
• CONVULSIONS DURING THIS ILLNESS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING (YES/NO)
• Count the breaths in one minute • Chest in drawing
• For how long?...................days …………breath per minute Fast • Stridor in calm child
breathing?
• Check SP02 (if available) • Fast breathing
• Look for chest indrawing • SP02 < 96%
• Use the checklist to discuss on the answers for the drill

Need to assess for:
1. Duration 2.Fast 3. Chest 4. Stridor 5. Wheeze

breathing Indrawing
Count the
breath for 1 A harsh noise/
minute sound when
the child
breathes IN
ASK: how long In child 2 Lower chest A musical
the child has months – 12 wall goes IN noise heard
cough months : > 50 when child when the child
breath/min breathes IN breathes OUT
Child must be
In child 12 calm during
months – 5 assessment
years: > 40
breath/min
38
ATUCU5
ADVISE WHEN TO RETURN IMMEDIATE
Tidak boleh
Sakit semakin Mengalami demam
minum atau Sawan
teruk sekarang
menyusu
Susah bernafas Bernafas laju
39
TRAINING MANUAL ON
APPROACH TO UNWELL
DIARRHOEA
40
ATUCU5
4. DIARRHOEA
Ask the caregiver about
the child’s problems
Check for general

danger sign Cough or difficulty
breathing
Assess and treat
main symptoms:
Management Diarrhoea
Age 2 months
Of Unwell Check for malnutrition
- < 5 years
Child and anaemia
Check immunization
Fever
Status
Counsel using the

mother’s card

All Sick Children Must Check For General Danger Signs
Ask Look

or breastfeed
unconscious?
vomitus?
now?
Has the child had
illness
Recap on general danger signs – ask participant what is GDS?
41
DIARRHOEA
Definition Of Diarrhoea
DIARRHOEA
Definition
• Loose or watery stools ≥ 3 x in a 24-hour period

• Common in age 6 months- 2yrs old
• More common in babies aged < 6 months who are drinking infant formulas
• Frequent passing of normal stools is not diarrhoea.
• Babies who are exclusively breast fed often have soft stools; this is not diarrhoea.
Types Of Diarrhoea
DIARRHOEA
Types Of Diarrhoea
• Diarrhoea less than 14 days is acute diarrhoea

• Diarrhoea 14 days or more is persistent diarrhoea
• Diarrhoea with blood in stool with or without mucus is called dysentery (Shigella bacteria)
Complications Of Dehydration
DIARRHOEA
Complications of Dehydration
• Seizures
• Shock with tachycardia, fast breathing
• Kidney failure (no urination)
• Brain oedema
• Coma and death
42
ATUCU5
DIARRHOEA
Assessment
• History
• Days, Frequency, blood in stool
Physical Examination - Signs of dehydration
• General condition
• Sunken eyes
• Offer child fluid
• Skin Pinch at Abdomen
ASK LOOK AND FEEL

DOES THE CHILD HAVE DIARRHOEA? ( YES / NO )
• For how long? …………… days • Look at the child’s general condition. Is the child:
• Is there blood in the stool Drowsy or unconcious?
Restless or irritable?
• Look for sunken eyes.
• Offer thr child fliuds. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back:
very slowly (longer than 2 seconds)?
slowly?
Important questions to ask during assessment of diarrhoea
• Ask duration of diarrhoea
• Ask presence of blood in stool
General Condition to look for in children with diarrhoea
ASSESS DIARRHOEA
Look for General Condition

1.Drowsy or unconscious
• Severe dehydration may cause the child to become drowsy or unconscious. This is one
of the general danger sign.
2.Restless or irritable.
• A child is restless or irritable all the time, or every time he or she is touched and handled.
• If the infant or child is calm when breastfeeding but again restless or irritable when he
or she stops breastfeeding, he or she has the sign “restless or irritable“
• Many children are upset when in the clinic. If they can be consoled and calmed – Not
“restless or irritable”
43
DIARRHOEA
DIARRHOEA
Look For Sunken Eyes
• Decide if you think the eyes are sunken

• If unsure, ask the mother if she thinks her child’s eyes look unusual
• Diarrhoea sunken eyes.mpg
DIARRHOEA
Look For Sunken Eyes
Video\19_ExerciseSunkenEyes.MPG
DIARRHOEA
Offer Child Fluid
1. Is the child not able to drink?

• A child is not able to drink if he or she is not able to suck or swallow when offered a drink
• A child may not be able to drink because he or she is drowsy or unconscious
2. Is the child drinking poorly

• A child drinking poorly if he or she is weak and cannot drink without help
• He may be able to swallow only if fluid is put in his or her mouth
Emphasize offering fluid is one of the compulsory assessment. Offer only clear fluid as to reduce risk
of aspiration
44
ATUCU5
DIARRHOEA
Offer Child Fluid

3. Is the child drinking eagerly, thirsty?
A child has the sign drinking eagerly, thirsty if it is clear that the child wants to drink. Look
to see if the child reaches out for the cup or spoon when you offer him water. When the
water is taken away, see if the child is unhappy because he or she wants to drink more.
If the child takes a drink only with encouragement and does not want to drink more, he
or she does not have the sign “drinking eagerly, thirsty.“
Video - Diarrhoea Assess Drinking.wmv
DIARRHOEA
Pinch The skin of the Abdomen

Method
• Lie the child flat
• Locate the area halfway between umbilicus and the side of abdomen
• Use the thumb & first finger and pick all layers of skin
• Pinch the skin for one second and then release it.
When you release the skin, see if the skin pinch goes back:
• Very slowly (> 2 seconds) or
• Slowly (skin stays up even for a brief instant)
Pinch the skin.mpg
• Ask the caregiver to place the child on the examination table so that the child is flat on his or her
back with arms at sides (not over head) and legs straight. Otherwise ask the caregiver to hold
the child so that he or she is lying flat on the caregiver's lap.
• Locate the area on the child's abdomen halfway between the umbilicus and the side of the
abdomen.
• To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will
cause pain.
• Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down
the child's body and not across the child's body.
• Firmly pick up all of the layers of skin and the tissue under them.
• Count 001 - 002
• May be difficult to elicit in obese child
45
DIARRHOEA
MANAGEMENT OF DIARRHOEA
Aim of
Assessment Classification Treatment
Treatment
≥ 2 signs
- Drowsy or unconscious
-Sunken eyes Plan C
Severe Fluid
-Not able to drink or drinking Refer Urgently
Dehydration resuscitation
poorly IV Fluid
-Skin pinch goes back very
slowly
≥ 2 signs
- Restless or irritable
-Sunken eyes Some Plan B To treat the
-Drinks eagerly, thirsty Dehydration Refer hospital dehydration
-Skin pinch goes back
slowly
- Not enough signs to To prevent
NO Plan A
classify as some or severe from
Dehydration Home care
dehydration. dehydration
• To explain to participant why each classification needs to be treated, especially for

the one with no dehydration (so they can explain to the parents/caretaker as well)
IF DIARRHOEA > 14 DAYS & BLOOD IN STOOL
SIGNS CLASSIFICATION MANAGEMENT
PERSISTENT > Refer for further

With or without
DIARRHOEA investigation depending on
dehydration present
(> 14 days) local setting
> Refer for further
• Blood in the stool DYSENTERY investigation depending on
local setting
Diarrhea > 14 days & blood in stool

• Refer for further investigation depending on local setting
46
ATUCU5
DIARRHOEA
Plan C For Severe Dehydration
• REFER URGENTLY
• Treat with intravenous (IV) NS 0.9% quickly (Plan C)
Age 20mls/kg 80mls/kg
Under 12 months 1 hour 5 hours
12 months - 5 years 1/2 hour 2 1/2 hours
1 Give 20mls/kg fluid

2 Check for radial pulse, if present continue with 80mls/kg
3 If radial pulse absent, repeat 20mls/kg, refer urgently and continue
80mls/kg along the way
DIARRHOEA
Plan C For Severe Dehydration
If not able to insert IV line, use naso-gastric tube (NG) or by mouth

• Give ORS 20mls/kg/hr for 6 hours (total 120ml/kg)
• Reassess every 1 hour
- If repeated vomiting or increasing abdominal distension, give the fluid more slowly
- If hydration status is not improving after 3 hours, try to set IV line and give IV fluid if
immediate referral not possible
Refer the child as soon as possible
47
DIARRHOEA
GIVE EXTRA FLUID FOR DIARRHOEA

AND CONTINUE FEEDING
PLAN C : Treat Severe Dehydration Quickly
FOLLOW THE ARROW. IF THE ANSWER IS “YES” , GO ACROSS. IF “NO”, GO DOWN
Can you give •Start IV fluid immediately while arranging to hospital.

intravenous (IV) fluid YES •If child drink, give ORS by mouth while the drip is set up.
immediately ? •Give 100ml/kg Normal Saline divided as follow
First give Then give

AGE
20 ml/kg in: 80 ml/kg in :
Infants
NO (under 12 months)
1 hour* 5 hours
Children
30 minutes* 2 ½ hours
(12 months up to 5 years)
Are you trained to use 1. Give 20 ml/kg IV fluid (refer table)

nasogastric (NG) tube for 2. Feel for radial pulse after completion of above bolus.
3. If radial pulse not detectable, repeat 20ml/kg IV fluid.
4. Refer URGENTLY to hospital once transport is available.
5. Continue IV fluids 80ml/kg along the way.
6. If urgent referral not possible or while awaiting transport,
see the box on the right.
NO
• REFER URGENTLY to Hospital

YES • Start Rehydration by tube (or mouth) with ORS
solution : give 20 ml/kg/hour for 6 hours
• If urgent referral is not possible or while awaiting
Can the child drink ?
transport, see the box on the right
NO
Refer URGENTLY to hospital

for treatment
Sumber: Chart Booklet IMCI KKM National Adaption January 2011

48
ATUCU5
IF Urgent Referral is NOT possible or appropriate plan (A, B or C) to give the fluid more slowly.
while awaiting transport : continue treatment. • After 6 hours, reassess the child.
• Observe the child at least 6 hours Classify dehydration.
A. If you can give IV fluid : after rehydration to be sure the Then choose the appropriate plan
• Proceed to give remaining IV fluid caregiver can maintain hydration (A, B, or C) to continue treatment.
80 ml/kg (refer table) giving the child ORS by mouth. • Observe the child at least 6 hours
• Review the child every 1 hour. after rehydration to be sure the
• Also give ORS (about 5 ml/kg/ B. If you are trained to use naso- caregiver can maintain hydration
hour) as soon as the child can gastric tube or if the child can drink : giving the child ORS by mouth.
drink : usually after 3-4 hours • Give ORS 20 ml/kg/hour for 6
(infants) or 1-2 hours (children). hours (total 120 ml/kg). NOTE:
• Reassess an infant after 6 hours • Review the child every 1 hour. At all time, all efforts should
and a child after 3 hours. Classify • If there is repeated vomiting or be made to send the child to
dehydration. Then choose the increasing abdominal distention, hospital as soon as possible.
Plan B : Treat Some Dehydration with ORS

In the clinic, give recommended amount of ORS over 4-hour period
 DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS.
Up to 4 4 months up 12 months up 2 years up to

AGE*
months to 12 months to 2 years 5 years
WEIGHT < 6 kg 6 - < 10 kg 10 - < 12 kg 12 - < 20 kg
AMOUNT OF FLUID (ML)

200 - 450 450 - 750 750 - 900 900 - 1500
OVER 4 HOURS
* Use the child’s age only when you do not know the weight. The approximate amount of ORS
required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75.
• If the child wants more ORS than shown, give more.


SHOW THE MOTHER/CAREGIVER HOW TO GIVE ORS SOLUTION.
• Give frequent small sips from a cup or spoon.
• If the child vomits, wait 10 minutes. Then continue, but more slowly.
• Continue breastfeeding whenever the child wants.
AFTER 4 HOURS:
• Reassess the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.
IF THE MOTHER/CAREGIVER MUST LEAVE BEFORE COMPLETING TREATMENT:
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration. Also give
another 8 packets to use at home (Plan A)
• Explain the 4 Rules of Home Treatment:
1.GIVE EXTRA FLUID
2.GIVE ZINC if available for those diarrhoes more than 5 days (age 2 months up to 5 years)
3.CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4.WHEN TO RETURN
Sumber: Chart Booklet IMCI KKM National Adaption January 2011

49
DIARRHOEA
DIARRHOEA
Plan B : Treat Some Dehydration with ORS in the Clinic
• Treat a child who has diarrhoea and SOME DEYHRATION for an initial period of 4 hours in
the clinic
• Heath worker to prepare the ORS amount needed in 4 hours
• Mother to focus in giving ORS (not learning how to prepare ORS)
Determine the amount of ORS to give during the first 4 hours

Child’s weight (in kilograms) multiply by 75.
• No other food or fluid in the first 4 hours

• Continue breastfeeding whenever the child wants.
• Emphasize-plan B should be started in clinic while awaiting referral

• NO other fluid other than ORS & breastmilk
DIARRHOEA

Up to 4 4 months up 12 months up 2 years up to
AGE
months to 12 months to 2 years 5 years
WEIGHT < 6 kg 6 - < 10 kg 10 - < 12 kg 12 - < 20 kg
AMOUNT OF FLUID (ML)

200 - 450 450 - 750 750 - 900 900 - 1500
OVER 4 HOURS
• Approximate amount of ORS required (in ml) is calculated by:

Body Weight (kg) x 75 or refer to table above if weight is not known.
• Give frequent small sips from a cup or spoon
• If the child vomit, wait 10 minutes. Then continue, but more slowly
• Continue breastfeeding whenever the child wants
• Preferably use weight rather than age
50
ATUCU5
DIARRHOEA
• After 4 hours, reassess hydration status
• If no dehydration, switch to Plan A
• If there is still some dehydration, repeat Plan B. Begin feeding the child in clinic. Observe
the child in clinic for another 4 hours to reassess later.
• If the child now has SEVERE DEHYDRATION, give Plan C and refer urgently to hospital.
• During subsequent cycle of Plan B, allow other fluids in addition to ORS
DIARRHOEA
Plan A : Treat Diarrhoea At Home
Treat child who has diarrhoea with NO DEHYDRATION

1. Give extra fluid (as much as the child will take)
• Breast feeding
• ORS solution
• Food-based fluid (such as soup)
• Cooled boiled water
2. Continue feeding
3. When to return
51
DIARRHOEA
DIARRHOEA
• It is especially imprtant to give ORS at home when:

• The child has been treated with Plan B or Plan C during this visit
• The child cannot return to the clinic if the diarrhoea get worse
• Show the mother how much fluid to give in addition to the usual fluid
intake:
• Up to 2 years : 50 to 100 mls after each loose stools
• 2 years or more : 100 to 200 mls after each loose stools
• Give frequent small sips from a cup or spoon.

• If the child vomit, wait 10minutes. Then continue, but more slowly
• Continue giving extra fluid until the diarrhoea stops.
DIARRHOEA
• Wash your hands

• Pour ORS into a clean container - check ORS powder expiry date and the
condition of the ORS powder
• Mix ORS with 250ml of cooled boiled water
• Mix well until the powder is completely dissolved
• Taste the solution so you know how it tastes.
• Tell mother to keep fresh ORS in a clean covered container, throw away
any remaining solution after 24 hours
• Give the mother 8 sachets of ORS to use at home
52
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DIARRHOEA
When to return immediately
• Not able to drink or breastfeed

• Become sicker
• Develops a fever
• Has blood in stool
• Drinking poorly
Use a Mother’s Card and Check the Mother’s Understanding
WARNING
• Antibiotics should not be used

• Most diarrhoeal episodes are caused by viruses
• Only give antibiotics to diarrhoea cases with SEVERE DEHYDRATION with

cholera and DYSENTERY
• Do Not Give --Maxolon, Buscopan, Stemetil, Promethazine Kaolin,

Lomotil and Charcoal ---
NO benefits and has dangerous side-effects.
53
DIARRHOEA
Scenario on Diarrhoea
DIARRHOEA
Case study
Video\22_Excercise G Case Study Josh.MPG
Scenario 1
Mother complains her daughter Mary, 9 months old has diarrhea and this is their first
time coming to the clinic for this diarrhoea.
Mary weight, 8.2 kg and temperature, 37 0C. Mary is able to drink milk and take
porridge. She does not vomit. She has not had convulsions. You watch Mary. She looks very
tired in mother's arms, but she watches you as you speak. When you reach out to her to take
her hand, she grabs your finger. No cough.
Mother has already reported that Mary has diarrhoea. You ask mother how many days
Mary has had diarrhoea, and she tells you 3 days. You ask mother if there is blood in her
daughter's stool, and she tells you no.
Now you will examine Mary's condition. She seems restless and irritable, especially
when you touch her. You begin to examine Mary for signs of dehydration. You check to see if
she has sunken eyes, and it appears that she does. Mother agrees that her daughter's eyes look
unusual. You offer her some water to drink and notice how she responds. She drinks poorly.
Next, you give Mary a pinch test to determine how dehydrated she is. You ask Mom to place
Mary on the examining table so that she is flat on her back with her arms at her sides, and her
legs straight. You pinch the skin of Mary's abdomen, and it goes back in 1 second.
Drill 5 .
1. Does Mary have any general danger signs?
2. Classify the hydration status
3. How would you manage
54
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Scenario 2
Mother tells you that Ahmad is 11 months old and has diarrhoea. This is their first time
coming to the clinic for this diarrhoea.
You take Adam's weight, 10.5 kg, and temperature, 37 0C. Adam is able to drink milk
and take porridge. He does not vomit. He has not had convulsions. You watch Adam. He looks
very tired in mother's arms, but he watches you as you speak. When you reach out to him to
take his hand, he grabs your finger. No cough
Mother has already reported that Adam has diarrhoea. You ask mother how many days
Adam has had diarrhoea, and she tells you 3 days. You ask mother if there is blood in her son's
stool, and she tells you no.
Now you will examine Adam's condition. He seems alert and calm. You begin to examine
Adam for signs of dehydration. You check to see if he has sunken eyes, and it appears that he
does. Mother agrees that her son's eyes look unusual. You offer him some water to drink and
notice how he responds. He drinks calmly. Next, you give Adam a pinch test to determine how
dehydrated he is You ask Mom to place Adam on the examining table so that he is flat on his
back with his arms at his sides, and his legs straight. You pinch the skin of Adam's abdomen,
and it goes back in 1 second
1. Does Adam have any general danger signs?

2. Classify the hydration status
3. How would you manage
Summary
Summary
Diarrhoea in children
- Proper history
- Correct assessment
- Hydration status
- Treatment- Plan A,B,C
- Counsel mother when to return
- REFER if unsure
55
DIARRHOEA
DIARRHOEA
Advise When To Return Immediately For All Children
Tidak berupaya Menjadi semakin Mengalami deman Mengalami sawan

untuk minum atau lemah atau tenat panas (angat) atau atau kejang atau
kerap muntah, atau asyik tidur ruam kulit mengeras (luput)
air kencing yang atau menangis
sedikit berterusan
Najis bercampur Hanya minum

dengan darah sedikit atau tidak
mahu minum atau
air kencing yang
sedikit
56
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57
FEVER
TRAINING MANUAL ON
APPROACH TO UNWELL
FEVER
58
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FEVER
• Fever is a very common condition
• Fever may be caused by:
 Simple cough or cold or other viral infection

 Local infections
 Severe infections eg. Meningitis, Typhoid fever and Measles
Dengue, Malaria
• Fever is very common presentation of an unwell child.

• Every sick child must be asked whether there is fever or not.
• Fever may be caused by local infection such as cellulitis, impetigo, lymphadenitis, otitis media
etcc
ASSESSMENT OF FEVER
When a child comes with fever how would you
assess?
Ask the caregiver about
the child’s problems
Check for general

danger sign
Cough or difficulty
breathing
Assess and treat
main symptoms:
Management Diarrhoea
Age 2 months Check for malnutrition
Of Unwell
- < 5 years and anaemia
Child
Check immunization
FEVER
Status
Counsel using the

mother’s card
• This is the continuation from yesterday assessment. When a child comes with fever how would
you assess.
• Participant should be able to answer: assess GDS, ask about cough, diarrhea (it has to be in order)
59
FEVER

All Sick Children Must Check For General Danger Signs
Ask Look

or breastfeed
Is The Child Drowsy Or

Unconscious?

vomitus?
Is The Child Convulsing
Now?
Has the child had

illness
Recap on general danger signs – ask participant what is GDS?
FEVER
A Child Has Fever If Any Of The Following ls Present
• History of fever
OR
• Axillary/ forehead temp of ≥ 37.5°C
OR
• This is the definition of fever

• To stress to participants the importance of taking history of fever during this illness, although at
clinic temperature recorded is afebrile (may be after PCM)
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FEVER ASSESSMENT
• Fever duration
• History of Measles within the last 3 months
• History of contact with child having HFMD
• Staying in Dengue / Malaria endemic area
• Look and feel for stiff neck
• Look for petechial or purpuric rash
• Look for maculopapular rash on palms or soles
• Look for other causes of fever
• Check nose, ear and throat
• Check CCTVR (colour,capillary refill time, temperature, pulse volume and HR)
• Signs suggesting measles
• This is the list of assessment that we do for a child who present with fever.
• The main objective of this Fever module is to teach HCP how to look for certain signs that indicate
severe disease. Eg Dengue, Malaria, Meningitis
• Depending on the disease endemic to your area eg - Typhoid, Leptospirosis, Melioidosis
FEVER ASSESSMENT
FEVER
Duration
> 7 days (present

< 7 days
everyday)
Follow fever Refer to look for

assessment other causes of fever
• Fever more than 7 days is define as prolonged fever and would require further assessment
61
FEVER
FEVER ASSESSMENT
Look and feel for stiff neck
• 3 steps of assessing Neck Stiffness:
1. Observe : Look if the child moves and bends his/her neck easily when looking up and
looking down (chin touching chest)
2. Attraction : Draw the child attentions to his/her umbilicus or toes E.g Shine a flashlight
on child's toes or umbilicus.
3. Manoeuvre: Lean over the child, gently support the child's back and shoulder with one
hand. Other hand to hold the child's head. Carefully bend the child's head
forward towards his/her chest.
• This slide, we want our participants to understand and able to perform the three ways of
assessing for Neck Stiffness.
• The aim is to assess for neck stiffness when the child is calm and not crying.
• Most important movement is looking up and looking down (chin to chest)
• Explain the 3 steps on how to assess neck stiffness (as in the slides).
o Step 1: observe the child bending the neck (The best method).
o Step 2: If unable to observe the child bending the neck, then proceed by using a toy/
flashlight to attract the child to move the neck up and down.
o Step 3: If step 1 and step 2 fail, proceed to maneuver below:
■Lean over the child
■Gently support the child’s back and shoulder with one hand
■Other hand to hold the child’s head.
■Carefully bend the child’s head forward towards his/her chest
■Do not force the movement
• Most important movement is looking up and looking down (chin to chest).
• If there is no neck stiffness the child will be able to flex the neck with the chin touching chest.
• If the neck feels stiff, and there is resistance to flexion – means the child has a Stiff neck. The
child will cry if there is neck stiffness.
•Presence of Stiff neck means:

 Sign of meningitis, cerebral malaria (encephalitis) or very severe febrile disease
•Video-stiff neck Video\23_ASSESS NECK STIFFNESS.mpg

•Exercise-Video\24 Neck Stiffness Exercise.mpg
•Demonstration of 3 ways of neck stiffness assessment using the video

1.Observation
2.Attraction
3.Maneuver
•Notes :
- Emphasize on the correct technique
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FEVER ASSESSMENT
Look for petechial or purpuric rash
• Spontaneous bleeding into the skin.
• Does not blanch on pressure (glass test)
• Petechiae- small pin point hemorrhages (1- 2 mm in diameter)
• Purpura-purplish skin lesion 2-10 mm in diameter
• On trunk or limbs
• Simple bruises-does not blanch on pressure, usually associated with history of blunt trauma
Glass Test
Petechial and Purpuric
Rash NOT blanch by
pressure
• Explain to participants, what is petechiae, what is purpuric rash.

• How to differentiate this rash with other types of rash eg maculopapular rash.
• Mention about bruises and hematoma, which also does not blanch on pressure.
•Glass test:
o Use a transparent and firm object, such as clear glass, plastic ruler/container
o Choose an area where rash is present
o Using the object press firmly against the skin until the surrounding skin turn pale
o If the rash does not fade(non blanching), it is petechiae/purpura
•Ask participants; what is the significance of Petechial or purpuric rash with Fever.
•Eg : Dengue, Meningococcaemia
FEVER ASSESSMENT
Examples of Petechial and Purpuric rash with fever :
• Dengue fever
• Meningococcemia
•Ask participants; what is the significance of Petechial or purpuric rash with Fever.
•Eg : Dengue, Meningococcaemia
63
FEVER
FEVER ASSESSMENT
Examples of Petechial and Purpuric rash with fever:
• Dengue fever
• Meningococcemia
FEVER ASSESSMENT
Petechial and Purpuric Rashes
• These pictures shows petechial and purpuric rashes.

• Ask participant how to assess these rashes:
- Using Glass test
- Petechial and purpuric rashes does not blanch on pressure
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FEVER ASSESSMENT
Look for maculopapular rash on palm or soles
• Macular rash - flat, red area on skin, size <1cm, well defined border.
• Papular rash - small (pin head size), raised well defined border, typically inflamed, feels
like sand paper to touch. Papular rash may have a variety of shapes in profile (domed, flat-
topped, umbilicated)
• When present together : Maculopapular rashes.
• Both blanch on pressure
• Presence of maculopapular rash on palm and soles with fever-likely to be HFMD
• Explain what is macular and papular rashes (refer slide).

• Participants should be able to recognize maculopapular rash and differentiate it from petechiae/
purpura. Important to highlight maculopapular rash is not blancheble
• May ask the participants, what are the examples of maculopapular rash with fever. Eg: Measles,
Other viral exanthems, HFMD
• Distribution of the rashes is very important because different types of disease may present with
typical distribution of rashes
FEVER ASSESSMENT
Other Rashes
Macular Rash Papular Rash
• Ask participant how to differentiate macular & papular rashes

- Macular : flat rash
- Papular : raised
65
FEVER
FEVER ASSESSMENT
HFMD Case Definition :
Any child with:
 mouth/tongue ulcer and
• multiple painful mouth ulcers occurs over lips, buccal mucosa, gingival and posterior
part of oral cavity
 maculopapular rashes and/or vesicles on palms and soles
• rashes sometimes at buttocks, knees & elbows)
• rashes-not usually itchy or painful.
 with or without history of fever
*may present with maculopapular rashes without mouth ulcer
• Explain to participants differences between HFMD & Herpangina (painful mouth ulcer associated
with sore throat & fever, caused by Coxsakie Group A virus)
FEVER ASSESSMENT
Hand Foot Mouth Rash
Rashes on sole
Rashes on palm
Mouth ulcers
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FEVER
Hand Foot Mouth Disease
IMPORTANT HISTORY-To assess severity of disease
• Date of onset Fever, mouth ulcer, rash/vesicles
• Vomiting, poor feeding, lethargy, drowsiness, fits
• Repeated Startling during sleep/awake (myoclonus seizure)
• History of travelling within last 1 week & any contact with other children with HFMD
• Once HFMD suspected, participants need to ask further questions to:

1. Assess the disease severity
2. Travelling history – to identify locality based on present epidemic.
3. To notify
• Explained to participants that the Management of HFMD is not covered in this module.
• Criteria for admission, warning signs in HFMD and Further management: To follow HFMD
Guidelines KKM 2007.
FEVER
Dengue Rash
• Maculopapular rash or macular
confluent rash over the face,
thorax and flexor surface with
islands of skin sparing
• Typically begin on day 3 and
persists 2-3 days
• Explain about dengue rash (island of white in the sea of red)and how it is different from HFMD
rash and other types of rash.
67
FEVER
FEVER
Dengue Rash
• Maculopapular rash or macular confluent rash over the face thorax and flexor surface with
islands of skin sparing
• Typically begin on day 3 and persists 2-3 days
• Explain about dengue rash (island of white in the sea of red) and how it is different from HFMD
rash and other types of rash.
FEVER
Dengue fever in children
• Fever with any 2 following criteria
 Nausea, vomiting
 Rash
 Aches and pains
 Leucopoenia
 Any Dengue warning signs
• Any child with the above signs & symptoms need to consider dengue especially during dengue
outbreak or in dengue endemic area
FEVER
Dengue Fever in Children
•Warning signs
 Abdominal pain or tenderness
 Persistent vomiting (>3x/day)
 Persistent diarrhoea (>3x/day)
 Mucosal bleeding
 Clinical fluid accumulations
 Increased HCT with decrease platelet
 Lethargy, confusion or restless
 Tender liver
 Abnormal CCTVR (colour,capillary refill time, temperature, pulse volume and HR)
•Suspect Dengue
 for Dengue Combo Test NS-1 Combo test
 Refer for further management
Further detail on Management-Refer Paeds Protocol
• Further management of Dengue-to refer to Paeds Protocol.

• To emphasize on warning signs: abdominal pain (including tender liver), mucosal bleeding,
abnormal CCTVR.
• Suspected dengue to refer for further management
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FEVER
Diagnosis of Measles
• History of measles for past 3 months or currently having measles?
• Progression of Measles Rash:
 Within 3/7-maculopapular rash begins behind ears and neck then spreads to face and
whole body
 Next 3/7-fading of the rashes
 Last 3 days, peeling of skin and brownish discoloration
 Rash lasted 7-9 days (not itchy)
 Rash with 3C's either cough/conjunctivitis /coryza (running nose)
• Ask the participants- Why is history of measles in past 3 months is significant?

o Answer: Measles damages the child’s immune system and leaves the child at risk for other
infections for many weeks. Untreated severe measles can caused complications such as an eye
infection and corneal ulcer.
• Diagnosis of measles based on the characteristic of rash, onset of fever and presence of any of
the 3C’s - Cough, Conjunctivitis, Coryza
• Make sure the participants understand the distribution and progression of measles rash.
• Presence of rash MUST be accompanied by any one of the 3C’s - Cough, Conjunctivitis, Coryza
(runny nose)
FEVER
Measles Rash
Koplik’s Spot
• Explain characteristic of the Measles rash
69
FEVER
FEVER ASSESSMENT
Measles Assessment
•Child with measles, look for any complication of measles:
 Clouding of cornea
 Pus draining from the eyes
 Extensive mouth ulcers (>5 deep extensive mouth ulcers affecting feeding)
 Other complications eg: stridor, pneumonia, diarrhoea, malnutrition and ear infection
• Once suspected to have measles, need to do further assessment to look for:

1. Severity of the disease - Conjunctivitis, mouth ulcer
2. Complications of disease eg - clouding of cornea, may be worse in children with Vitamin A
deficiency.
• Therefore in severe measles - Vitamin A is given to prevent severe complications.
FEVER ASSESSMENT
Measles Complications
• To show:
- Clouding of cornea
- Mouth ulcer
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ATUCU5
FEVER ASSESSMENT
• Video – assess measles Video\25_LOOK FOR SIGN OF MEASLES.mpg
FEVER ASSESSMENT
Other causes of fever with rashes
Other causes of fever with rash

• Explain different types of rashes with fever and how to differentiate them.
• Eg :
- Heat rash is a maculopapular rash, can be localise or generalise and usually child is well with no
fever.
- Chicken pox present with fever and vesicular papular rashes. The vesicles are on a red base (“Dew
drop on a rose petal”) and pruritic.
71
FEVER
FEVER ASSESSMENT
Urticaria following allergy reactions Impetigo pustule, vesicles, honey

crusted erythematous lesion.
FEVER ASSESSMENT
Pustular rashes are circumscribed elevated Vesicular rashes are raised lesions less than 1
lesions that contain pus. They are most cm in diameter that are filled with clear fluid.
commonly infected (as in folliculitis) but
may be sterile.
FEVER ASSESSMENT
Other causes of fever
Examine for other causes of fever
 General examinations-cellulitis, abscesses,
skin infection,septic arthritis osteomyelitis
 Ear-Ear infection
 Throat-Pharyngitis, Tonsillitis
 Lung-Pneumonia
 Abdomen Acute Appendicitis
 Other causes: Diarrhoea, URTI, UTI, TB,
Viral fever, Dengue, Malaria
• To do thorough physical examination for a child with fever.

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FEVER ASSESSMENT
CCTVR (colour, capillary refill time, temperature, pulse volume
and rate)
2. Capillary
1. Colour 3. Temperature 4. Pulse volume 5. Pulse rate
refill time
Colour and temperature

• Look and feel at the palm of the hand
• Temperature line
Lower Upper
Fingers Palm
forearm forearm
CRT
• Use thumb to put pressure over sternum for 5 sec
• Release thumb and count for 2 sec
• Observe the return of colour while counting
• Normal:<2 sec
• CCTVR : colour, capillary refill time, temperature, pulse volume and HR

• Colour and temperature:
o Look and feel at the palm of the hand
o In a normal child it should be pink and warm
o Practical tip for temperature: Temperature line refers to the demarcation
area of cold peripheries. The level of temperature line indicates severity
of haemodynamic compromise (vasoconstriction)
o Areas of temperature line:
■ Fingers
■ Palm
■ Lower forearm
■ Upper forearm
• Capillary refill time (CRT):
o Use thumb to put pressure over sternum for 5 seconds (001-002-003-
004-005)
o Release thumb and count for 2 seconds (001-002)
o Observe the return of colour while counting
o CRT < 2sec is normal. If CRT > 2 sec indicates patient in shock
73
FEVER
FEVER ASSESSMENT
CCTVR (colour, capillary refill time, temperature, pulse volume
and rate)
2. Capillary
1. Colour 3. Temperature 4. Pulse volume 5. Pulse rate
refill time
Pulse Volume and rate

• Child< 1year old: use brachial pulse to check for pulse volume
• Child>1 year old: use radial pulse
• Feel for strong or weak pulse and count the rate
• Pulse volume & rate:

o Child < 1 year old: use brachial pulse to check for pulse volume
o Child > 1 year old: use radial pulse
o Feel for strong or weak pulse and count the rate
o Practical tip to examine pulse volume: compare with your own radial
pulse while examining child’s radial/brachial pulse. The normal child’s
pulse volume is as strong as your own pulse volume. If the child’s pulse
volume is weaker than your own pulse, it is considered low pulse volume
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FEVER ASSESSMENT
Check ear, nose and throat

• Fever with only runny nose-very likely due to common cold.
• When runny nose is the only symptom associated with fever, then the child’s fever is
probably caused by common cold.
• Look into the child’s nostril area-any nasal discharge, any crust at nostril.
FEVER ASSESSMENT

Throat Examination
Tonsilitis Pharynx
• To explain to the participants-how to do proper throat examination.

- Explain proper way of holding child
- To look at pharynx, tonsils & buccal mucosa
• Show to them which is pharynx, tonsils, buccal mucosa.
75
FEVER
FEVER ASSESSMENT

Throat Examination
Acute Tonsillitis Acute Pharyngitis
• To explained differences between pharyngitis, tonsilitis.

• Acute tonsilitis – presence of exudates at the tonsils
FEVER ASSESSMENT

Assessment of Ear Problem
•Ask
• Any ear pain
• Any ear discharge
• Duration of ear discharge
•Look & Feel :

• Pus draining from ear
• Tender swelling behind the ear
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ATUCU5
ASSESSMENT FOR EAR PROBLEM
Signs Ear Problem Action
Tender swelling
Mastoiditis Refer urgently
behind the ear
Start antibiotics-National
Pus draining
Antibiotic Guidelines
from the ear less
Acute ear infection Sy. PCM for pain
than 14 days or
Dry ear by wicking
ear pain
F/U 5 days
Refer CPG Management of

Pus draining Otitis
from the ear 14 Chronic ear infection Media with Effusion in
days or more Children
Dry ear by wicking
77
FEVER
FEVER ASSESSMENT
Signs Ear Problem Action
Check For General Danger Signs
Not Able To Drink Or Breastfeed Drowsy Or Unconscius ● General Danger Sign

Vomit Everything Or Greenish
Vomitus Convulsing Now
Convulsions During This Illness
DOES THE CHILD HAVE FEVER? (history/ temperature > 37.5°C (axillary/forehead) or > 38°C (ears)) (YES / NO )
● For how long? …………… ● Look and feel for stiff neck. ● General danger sign
days ● Look for petechial or purpuric ● Stiff neck
● If more than 7 days, has fever rash ●Petechial/purpuric rash
been present every day? ● Look for maculopapular rash on ● Dengue
● Coming from Dengue palms or soles ● Malaria
Endemic area ● Look for other causes of fever ● HFMD with myoclonic jerk
● Recent HFMD outbreak ● Check nose, ear and throat ● Mastoiditis
● Check CCTVR (colour,capillary ● Unsure cause of fever (for further
refill time, temperature, pulse assessment
volume and HR)
* BFMP: Positive (Falciparum/
Vivax)/ Negative/ Not done/
pending
Does the child has measles now ● Look for signs of MEASLES now: ● Measles with eyes and mouth
or within the last 3 months: * Generalized measles rash complications
* Triad : cough/ runny nose/ red eyes
● Look for mouth ulcers.
If Yes, are they deep or extensive?
● Look for pus draining from the eye.
● Look for clouding of the cornea.
FEVER ASSESSMENT
Fever Management
• If no indication for urgent referral, allow home with Sy.Paracetamol
• 1st dose at clinic if temp ≥ 38.5 °C
• Follow up in 2/7 if fever persist
• Fever > 7 days - refer for further assessment
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FEVER ASSESSMENT
Management : Paracetamol Dose – 10 -15mg/Kg/Dose (4-6 hourly)
Age Or Weight Syrup (120mg/5ml) Tablet (500mg)
2/12 up to 4/12 (4 - <6kg) 2.0 ml
4/12 up to 12/12 (6 - <10kg) 4.0 ml ¼ tab
1 year up to 3 year (10 - <14kg) 7.5ml ½ tab
3 year up to 5 years (14 - <19kg) 10ml ½ tab
• In giving medication to children, dosage is based on child’s weight. The table

is a guide to the estimated of the common weight in the population.
• Eg : Child aged 1 year and weighing 9kg, the Paracetamol dosage will be (let
participant show on the white board)
-9 x 10 = 90mg 4-6 hrly
-90/120 x 5ml = 3.75 ml
-Or can use the table – according to weight = 4ml
• To check different strength in Sy. Paracetamol 250mg/5ml or 120mg/5ml
Advice When To return immediately
Not able to drink

Becomes sicker Develop fever Having seizures
or breastfeed
• As patient had already presented with fever as the initial symptom,

therefore the fever box is not circled.
• To ask participant what are the local layman terms for above symptoms
• Eg
• Not able to drink / breastfeed : Tak nak minum / menyusu
• Becomes sicker : semakin lemah, tak aktif, tidur sahaja, tak nak main
• Seizures : Sawan , Tarik, Luput
79
ASSESSMENT OF NUTRITIONAL STATUS:
MALNUTRITION & ANAEMIA
TRAINING MANUAL ON
APPROACH TO UNWELL
ASSESSMENT OF
NUTRITIONAL
STATUS:
MALNUTRITION &
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ANAEMIA
ATUCU5
5. MALNUTRITION AND ANAEMIA

5.1 Malnutrition
MALNUTRITION : INTRODUCTION
Lacks of:
• Essential vitamins
• Minerals
Causes of Acute Malnutrition

(Appetite↓ & food consumed not efficiently)
- Frequent illness
- HIV infection
- Tuberculosis
SEVERE ACUTE MALNUTRITION - SAM

Clinical Signs
Severely wasted (sign of marasmus)
Oedema (sign of kwashiorkor)
81
Kwashiorkor Clinical signs

• Thin, sparse & pale (yellowish or reddish)
hair that easily falls out
• Dry, scaly skin especially on the

arms & legs
• A puffy or 'moon' face
• Swelling of ankles &/or feet
Marasmus: Clinical signs

• Very thin body with reduced subcutaneous fat:
especially on the arms, legs & buttocks
• The belly may be distended
• The face may appear the same
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ATUCU5
5.2 Malnutrition
Malnutrition
For ALL sick children-ask the caregiver about the child's problems,
check for general danger signs, assess and classify for main symptoms, then
CHECK ALL CHILDREN FOR MALNUTRITION AND ANAEMIA
ASSESS & CLASSIFY nutrition status for all children.
CHECK immunization status and other problems.
Check for Malnutrition
Take Weight Look for Check for

for Age / visible severe Oedema of
MUAC wasting both feet
Now we are focusing on weight for age then MUAC
83
Measure Weight
Measure
Weight
•Beam /Spring types
•Stable
•Flat
•Easy
Measure Length / Height
• Alat pengukur
panjang Seca
• Pengukur Tinggi • Bodymeter • Infantometer
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ATUCU5
Interpreting Growth Indicators
Weight for Height for BMI for

z-score
age age age
Low weight < -2 Stunting Wasting
Very low Severe

< -3 Severe wasting
weight stunting
Recording for Malnutrition
Assess acute Malnutrition and Determine weight for age

anaemia Children >6 months MUAC
Look Look for oedema of Both feet and
Feel visible severe wasting
If Child MUAC< 115 mm Is There medical Complication?

OR - General Danger Signs
Weight for Age in Red Zone
OR For a child less than 6 months is
Oedema of Both Feet there a breast feeding problem?
85
Weight for Age

Weight : White
for AgeZone (Normal)
: White Zone (Normal)
Explain the Z score
clearly to the participant
x
x
x
x x
x
Weight for Age : Yellow Zone

Weight for Age : Yellow Zone
(Uncomplicated SAM (Uncomplicated
& ModerateSAM & Moderate
AM)
AM)
Explain clearly to the
participants regarding
the 3 zone :
1. Red Zone
2. Yellow Zone
3. White Zone
x x x x x
x
x
x x
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Weight for Age

Weight : Red
for Age ZoneZone
: Red (Complicated SAM)
(Complicated SAM)
x x x x x x x
x x
Explain clearly to the participant, when a child’s weight chart crosses zone, she/he
must be refer. EG here: at 5 month should have been referred
MALNUTRITION ASSESSMENT (MUAC)

Important indicator of acute malnutrition
Window for Slit for inserting
reading mm the strip
REMEMBER! MUAC below 115 mm (RED) means severe acute malnutrition
This measurement is red on the MUAC strip. These children need special treatment.
87
STEP 3: MEASURE MUAC (only for children 6-59 months)

WHAT IS MUAC?
The measurement around the middle of a child's upper arm is
an important indicator of acute malnutrition in a child. This is
called mid-upper arm circumference (MUAC). The MUAC strip
is a flexible measuring tape that measures in millimetres (mm).
MUAC can only be used for children 6-59 months.
Window for
Slit for inserting the strip
reading mm
HOW DO YOU READ THE MUAC STRIP

Examine your own MUAC strip, and refer to the picture below. The first thing you should note about
your MUAC strip is that there are three different colours: green, yellow, and red to note danger of
child's MUAC
There are two important pieces of the MUAC strip you should note in the picture above. The first is
the slit where you will insert the MUAC strip. The next is the window where you will read the child's
MUAC in mm.
MALNUTRITION ASSESSMENT (MUAC)

1. Find the mid point of child's upper arm between the shoulder and elbow
2. Hold the large end of the strap around child's arm
3. Put the other end of the strap around the child's arm. Thread the end up though the second
small slit in the strap
4. Pull both ends until the strap fits closely
5. It should not so tight that it makes skin folds and it should also not too loose
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Look for visible severe wasting

• Remove all the child’s clothes
to check for wasting
89

• A child has visible severe wasting if the child looks all skin and bones.
• The outline of ribs is easily seen.

• Wasting of the muscles of
the shoulder and arms
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• The arms and legs of a severely wasted child look like sticks.

• The buttocks are wasted and
there are skin folds
(baggy pants).
91

• Abdomen may be large or distended.

• Face may still looks normal.
92
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Baby boy BW 2.2 kg, discharged hospital day 10 and died on day 15.
Clinically marasmic but asymptomatic prior to death.
Wt 1.9 kg at time of death.

93
MALNUTRITION: ASSESSMENT
• Fluid accumulation in child's tissue

• Look & Feel For Oedema Of Both Feet
 Using thumb, press the dorsum of both feet simultaneously for 5 seconds
 A shallow pit remains in the child's foot when you lift your thumb
• A child with oedema of both feet may have kwashiorkor or other form of severe malnutrition
Check for oedema of both feet
Swelling is present if there is depression left in

the place where you pressed. This should be
checked on the other foot also
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Comment on this child
• 4 months old baby boy, first

child to a teenage OA mother
living with poverty.
• Mum gave him condensed

milk after breastfeeding
ceased.
• WFA coming down from <

-2SD to < -3 SD but skin looks
oedematous. Face chubby.
Pitting oedema present.
• Admitted and treated for

Kwarshiorkor.
OEDEMA
Pitting oedema present but mild

and hard to elicit.
But the tell tale sign was the
shiny skin in a very low weight
baby.
95
Check for Malnutrition (Normal)
Condition at 6 months old. Given infant formula feed.

WFA returned to < - 2SD
Photo Of
Oedema On
The Foot
(Kwashiorkor)
REMEMBER! Oedema of both feet means severe acute malnutrition.

ALL CHILDREN WITH OEDEMA OF BOTH FEET SHOULD BE REFERRED
TO A HOSPITAL.
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SIGNS OF SAM
<6 months
Oedema of both feet
Weight for Age - RED ZONE
>6 months
Oedema of both feet
Weight for Age - RED ZONE
MUAC- ≤ 115mm or below
FLOWCHART FOR INTEGRATED MANAGEMENT OF

CHILDREN UNDER 5 WITH MALNUTRITION
Active screening of child for malnutrition by JM/JT
• Take Weight for Age /MUAC
• Check for oedema of both feet
• Look for visible severe wasting
Yellow Zone: MUAC 115- Red Zone: MUAC < 115mm Red Zone: MUAC < 115mm
125mm AND Well; And No AND Well; And No Oedema AND Not Well; OR No
Oedema Or wasting
If Indicated
• Assess feeding Refer to nearest
• Assess feeding • Counsel feeding hospital,
• Counsel feeding • Refer FMS/Medical Refer to hospital • treat for shock /
• Refer PSP/Dietician Officer AND with Paediatrician dehydration / prevent
AND JT • PSP/Dietician hypoglycaemia /
(within 2 weeks) hypothermia
Discharge from
hospital
YES
Reassess in 2 weeks WHZ >-2
NO
Refer to Nutritional Rehabilitation Program
NO
Improve
If Indicated
YES
Reassess 2 to 4 weekly until Weight for Age normal (white zone) OR Weight for Height (WHZ)>-1 (white zone)
97
OUTPATIENT MANAGEMENT
RED ZONE; MUAC < 115 AND Refer urgently
Unwell OR Visible severe Follow Inpatient
to hospital with
wasting OR Edema management
paeditrician
of both feet
• Assess and counsel

RED ZONE: MUAC < 115 AND
feeding
Well AND NO severe wasting Reassess 2 weekly
• Refer FMS/MO
AND NO edema of both feet
• Refer PSP/dietician
• Refer MO
YELLOW ZONE; MUAC 115-
• Assess and counsel
125 AND NO severe wasting Reassess 2-4 weekly
feeding
NO edema of both feet
• Refer PSP/dietician
If the child continues to lose weight, please REFER to HOSPITAL
Criteria for normal child health follow up

• 2 readings in White Zone
ANAEMIA : DEFINITION
- Reduced Hb or Hct below level normal for that of Age & Sex
- Normal Hb level-11g/dL
- WHO Hb threshold used to define anaemia:
AGE Hb (g/dl)
Children (6 m/o-5y/o) 11
Children (5-12 y/o) 11.5
Teens (12-15 y/o) 12
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ANAEMIA: SIGNS &SYMPTOMS
ALL children MUST BE CHECKED for Anaemia

• Look for palmar pallor
• Look at the skin of the child's palm
• Hold the palm open by grasping it gently from the side
• Do not stretch the fingers backward this may cause pallor by blocking the blood supply.
• Compare the color of the child's palm with your own palm
• Refer all anaemic child to nearest clinic/hospital for further assessment
Palmar pallor
• LOOK at the skin of the child’s palm.

• Hold the child’s palm open by grasping it gently from the side.
• Do not stretch the fingers backwards - this may cause pallor by blocking the
blood supply.
• Compare the colour of the child’s palm with your own palm
99
Look for Palmar pallor
Why palmar pallor?
• Simple
• Less traumatic to the child
• Less transmissions of eye
pathogens
• Conjunctiva hyperaemia can
obscure anaemia
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ANAEMIA: MANAGEMENT
Anaemia
Palmar Pallor Actions
Sevrity
Severe Hb < 6gm/dl Severe Refer URGENTLY to hospital
1. Assess feeding & counsel based on “Counsel
The Mother-chart”
2. Give iron
Some (*pls do FBC
3. Give Albendazole : ≥ 1 y/o & not received
if available) Hb: Anaemia
deworming in previous 6 months
6-8gm/dl
4. If feeding problem present : follow-up in 5 days
5. No feeding problem, Follow-up in 2 weeks
**If any failure symptom is present, please refer STAT

**If there is visible severe palmar pallor-classify it as SEVERE ANAEMIA
**Children with severe anaemia are at risk of death
ANAEMIA : IRON DOSAGES

Iron Syrup Ferrous
**Iron Syrup Ferrous
Age or Weight Ammonium Citrate (FAC)
Fumarate (FF) Mixture
Mixture
2 m/o-4m/o (4-<6 kg) 2.5 ml 2 ml
4 m/o -12 m/o (6-<10 kg) 3.5 ml 3 ml
12 m/o-3 y/o (10-<14 kg) 5 ml 4 ml
3 y/o-5 y/o (14-<19 kg) 6 ml 5 ml
**FF only last for 14 days Preparation: 6 mg/kg of elemental iron

**One dose daily for 14 days
Iron/folate tablet grams per

Iron syrup sachets per day
day
Age or Weight Ferrous sulfate 200 mg + 250 Ferrous fumarate 100 mg per
µg folate 5 ml
(60 mg elemental iron) (20 mg elemental iron per ml)
2–4 mths or 4-6kg 1 ml (< ¼ tsp)
4-12 mths or 6-10kg 1.25 ml ( ¼ tsp.)
12 mths-3 yrs or 10-14 kg ½ tablet 2ml (< ½ tsp.)
3-5 years or 14-19kg ½ tablet 2.5ml ( ½ tsp.)
• Note Children with Severe Acute Mainutrition and on RUTF should not be given
iron
• To check with local preparation of Ferrous Fumarate, different centre has different
preparation 101
ANAEMIA:PREVENTION BY DEWORMING
For every child > 1 y/o:
To give Albendazole 400 mg single dose every 6 months (WHO)
Usual dosage :
1-2 y/o : 200 mg stat

≥ 2 y/o : 400 mg stat
FEEDING ASSESSMENT
For WHOM & WHEN to do?
All Children 2 years old
Very low weight for age
Anaemia
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FEEDING ASSESSMENT
Do you breastfeed your child?
How many times during the day?

Breastfeed during the night?
Does the child take any other food or fluids?
Variety-type of food?
Frequency?
Amount?
•Inadequate frequency
•Inadequate amount
•Lack of variety
•Not exclusively breastfeeding

Identifying
•Difficulty breastfeeding
Feeding
Problem •Use of feeding bottle
•Lack of active feeding

(share portion)
•Not feeding well during illness
•Sore mouth or ulcers
103
Mother’s Card On Feeding Assessent
TCA 5 days to see whether problem has solved
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105
FEEDING PROBLEMS
Newborn, birth up to 1 week

• Immediately after birth, put your baby in skin to skin contact with you
• Allow your baby to take the breast within the first hour. Give your baby colostrum, the
first yellowish, thick milk. It protects the baby from many illnessess
• Breastfeed day and night, as often as your baby wants, at least 8 times in 24 hours.
Frequent feeding produces more milk.
• If your baby is small (low birth weight), feed at least every 2 to 3 hours.
• DO NOT give other foods or fluids. Breast milk is all your baby need
• All baby born to HIV positive mother are given infant formula and not allowed to breastfeed
according to the national breastfeeding policy
1 week up to 6 months
• Breastfeed as often as your child wants. Look for signs of hunger, such as beginning to fuss
sucking fingers, or moving lips.
• Breastfeed day and night whenever your baby wants, at least 8 times in 24 hours. Frequent
feeding produces more milk.
• Do not give other foods or fluids Breast milk is all your baby needs.
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FEEDING RECOMMENDATIONS
Up To 6 Months Of Age
Breastfeed as often as the child wants, day and night at least 8 times in 24 hours
Do not give other foods or fluids
Complementary foods can be given when child is above 4 months of age

(DOCTOR’S PRESCRIPTION)
Only if the child:

-shows interest in semisolid foods, or
-appears hungry after breastfeeding, or
-is not gaining weight adequately
Give these foods 1 or 2 times per day after breastfeeding
SIGNS OF GOOD ATTACHMENT

The four signs of good attachment are:
• more areola seen above infant's top lip than below bottom lip
• mouth wide open
• lower lip turned outward
• chin touching breast
107
FEEDING ASSESSMENT
9 up to 12 months
• Breastfeed as often as your child wants.
• Also give a variety of mashed or finely chopped family food, including

animal-source foods and vitamin A-rich fruits and vegetables.
• Give 1/2 cup at each meal (1 cup = 250 ml).
• Give 3 to 4 meals each day
• Offer 1 or 2 snacks between meals. The child will eat if hungry.
• For snacks, give small chewable items that the child can hold. Let your
child try to eat the snack, but provide help if needed
6 up to 9 months
• Breastfeed as often as your Feeding Recommendations For Aged 6
child wants. Months-12 Months
• Also give thick porridge or Children begin to need complementary or weaning foods
well-mashed foods including • The mother should continue to breastfeed as often as the child wants
animal-source foods and
vitamin A-rich fruits and Start giving 1 or 2 tablespoons of complementary foods 1 or 2 times
vegetables per day and gradually increase the frequency and amount given.
• Practise responsive feeding (for example, feed infants directly and
•
Start by giving 2 to 3 assist older children. Feed slowly and patiently, encourage them to eat
tablespoons of food. but not force them, talk to the child and maintain eye contact).
Gradually increase to 1/2cups
(1 cup = 250ml). By the age of 12 months, complementary foods are the main source
of energy.
• Offer 1 or 2 snacks between • 6 to 8 months: complementary food can be mashed

meals. When the child seems After 8 months: complementary food can be mashed
hungry
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THIN THICK
MASHED CHOPPED
FINGER FOOD FAMILY FOOD

109
AMOUNTS OF FOODS TO OFFER

Amount of food an
average child will
Age Texture Frequency
usually eat at each
meal
2-3 meals per day plus
frequent breastfeeds Start with 2-3
Mashed food tablespoonfuls per feed
6-8 months
Depending on the child's increasing gradually to ½
appetite 1-2 snacks may of a 250 ml cup
be offered
Finely chopped or
3-4 meals plus
9-11 months mashed foods, and foods ½ of a 250 ml cup/bowl
breastfeeds
that baby can pick up
Depending on the child's
Family foods, chopped
12-23 months appetite 1-2 snacks may ¾ to one 250 ml cup/bowl
or mashed if necessary
be offered
If baby is not breastfeed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day.
12 months up to 2 years
• Breastfeed as often as your child wants
• Also give a variety of mashed or finely chopped family food, including animal-source foods
and vitamin A-rich fruits and vegetables.
• Give 3/4 cup at each meal (1 cup = 250ml).
• Offer 1 to 2 snacks between meals.
• Continue to feed your child slowly, patiently. Encourage -but do not force- your child to eat
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FEEDING RECOMMENDATIONS
For Aged 12 Months-2 Years
If the child is breastfeed, give complementary foods 3 to 4 times daily plus 1-2 snacks
If the child is not breastfeed, give complementary foods 5 to 6 times daily actively feed the
child
The child should not have to compete with older brothers and sisters for food from a common
plate
The child should have his or her own adequate serving. An adequate serving means that the
child does not want any more food after active feeding
111
2 years and older

• Give a variety of family foods to your child including
animal- source foods and vitamin A-rich fruits and
vegetables
• Give at least 1 full cup (250 ml) at each meal.
• Give 3 to 4 meals each day.
• Offer 1 or 2 snacks between meals.
• If your child refuses a new food, offer tastes several

times. Show that you like the food. Be patient.
• Talk with your child during a meal, and keep eye

contact.
Feeding Recommendations For More than 2 Years

• Child should be given variety of family foods in 3 meals per day
• The child should also be given 2 extra feeding per day
• It should be family food or nutritious food
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Feeding Advice During IlIness Sick Child Aged Less Than 6 Months
• Encourage them to breastfeed as often as the child wants
• For non breastfeeding children, increase milk intake
• If a sick child needs referral-advise mother to keep breastfeeding till arrives at health facility
Feeding Advice During IlIness Sick Child Aged More Than 6 Months
• Continue breastfeeding on demand
• More frequent than usual, smaller amount of soft, favourite food
• When during recovery period -give extra portion at each meal, or add extra meal/snack
Correct Feeding Practices

• Still breastfeeding
• Uses spoon or cup rather than feeding bottle
Cooking Demonstration & Recipe

• Best way attracting patient
• 2 weekly or monthly
Advise When To Return Immediately For All Children
BRING ANY SICK CHILD IF –
Not able to drink

Becomes sicker Develops fever Seizure
or breastfeed
113
CHILD'S IMMUNIZATION STATUS
TRAINING MANUAL ON
APPROACH TO UNWELL
CHILD'S
IMMUNIZATION
STATUS
114
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Introduction
• In Malaysia, every child must complete vaccination by 2 years old.
• They need to be checked whether they have been vaccinated up to
the appropriate schedule, and if not, they should be given the missed
vaccinations on the day of the visit.
• The recommended vaccine should be given when the child reaches
the appropriate age for each dose. If vaccination is administered
too early, protection may not be adequate. If there is any delay in
giving the appropriate vaccine, this will increase the risk of the child
developing the disease.
CHECK IMMUNIZATION STATUS AND

DETERMINE VACCINATION NEEDED
1. Compare the child's vaccination record (and the dates) with the recommended schedule.
2. Decide if the child has had all vaccinations recommended for his/her age. Identify any
vaccination the child needs today (either due vaccine or missed vaccine)
3. Give the required vaccination needed today unless the child is being referred to hospital.
4. Record the immunization and date on the child's book.
115
CURRENT NATIONAL IMMUNIZATION SCHEDULE

Age Vaccination
BCG
At birth
Hepatitis B1
1 month Hepatitis B2
2 month (DTaP-IPV//Hib) 1
Measles (Orang Asli, Penan / Sabah)
6 month
Hepatitis B3
MMR 1
9 month
IMOJEV 1 (Sarawak only)
12 month MMR 2
18 month (DTaP -IPV//Hib) 4
21 month IMOJEV 2 (Sarawak only)
• This is our current National Immunisation schedule for children

• There are additional immunization given to certain vulnerable population groups. Eg: JE given
in Sarawak because it is endemic there. Measles given early in Sabah because it is endemic.
Measles given for OA and penan because lack of herd immunity
WHAT DISEASES DO IMMUNIZATIONS PROTECT

CHILDREN FROM?
Types of vaccine Role When to give
Strain of the attenuated

Given at birth but for premature
BCG (Bacille Calmette- (weakened) live bovine
baby to be given at 1.8kg upon
Guérin) tuberculosis bacillus against
discharge
tuberculosis
a mixture of 5 vaccines
- Given at 2, 3, 5 month old
Immunize against
- Booster dose given at 18-24
• Diphtheria
months
• pertussis (whooping cough),
Remark :
• tetanus
(DTaP-IPV//Hib) - DtaP-IPV//Hib can be given at 7
• invasive Haemophilus
weeks of age if opportunistic
influenza type B disease
immunization is indicated eg.
• poliomyelitis (IPV or
remote area or difficult patient
inactivated polio vaccine
replaces OPV)
BCG
•Check BCG scar at 3 month old, if no scar or pin point scar- to repeat BCG vaccination
• Recheck the scar after 3 month- if no scar, need to refer MO/ FMS (may consider repeat in high
risk area/ case dependent)
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WHAT DISEASES DO IMMUNIZATIONS

PROTECT CHILDREN FROM?
Given at 0, 1,6 month
-vaccine against hepatitis •For premature baby to
Hepatitis B
B be given at 1.8kg upon
discharge
•is a live-attenuated
vaccine-immunize •Given at 9 month old
IMOJEV (in Sarawak only)
against Japanese and 21 month
encephalitis
•Given at 9 and 12
•is a live-attenuated
month old
MMR (Measles, Mumps & vaccine to immunize
•The highest priority
Rubella) against measles,
to be given in case of
mumps & rubella
missed immunisation
Hepatitis B
- for child of Hep B positive mother, Hep B immunoglobulin should be given prior to first dose
of Hep B (within 24 hours; the earlier the better)
ADVERSE EVENT
• Adverse event following immunization (AEFI) is an unwanted or unexpected event occurring
following administration of vaccine(s)
• Majority cause minor adverse events including low-grade fever, or pain or redness at the
injection site. Therefore these should be explained to the caregivers.
• All AEFI cases must be reported to NPRA using ADR form
• Common adverse events also not contraindicated to subsequent vaccination.
• Acute Drug Reaction Form see Appendix 7. Please refer to Panduan Program Immunisasi
Kebangsaan Bayi dan Kanak-kanak, 2017 for further management on AEFI
117
WHAT ARE COMMON ADVERSE EVENTS?
Common event, should Uncommon, return to

Vaccine(s)
not last long facility
• Swelling at injection site
• Redness, soreness at
injection site
• Low-grade fever
• Extensive swelling of
• Crying and irritability (in
• DTap-IPV//Hib limb, not just injection
infants)
site
• Injection site nodules
are not as common,
but do not require
treatment
HOW DO YOU MANAGE FEVER FOLLOWING

VACCINATION?
• If a child develops fever of over 38.5 °C following vaccination, give oral paracetamol at a
dose of 10-15 mg/kg/dose given 4-6 hourly. This can be given for up to 2 days if child is still
with high fever
• DO NOT GIVE PARACETAMOL IF FEVER < 38.5 °C
• ROUTINE PROPHYLACTIC PARACETAMOL IS NO LONGER RECOMMENDED
• DO NOT OVER WRAP THE CHILD
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CONTRAINDICATION
• A contraindication is a condition when the vaccine is not advised due to some potential
and serious adverse effects.
• First, it is important to note that common illnesses are not a contraindication to

vaccination. Therefore no sick child, including the malnourished child, should miss
vaccination. A child should only miss the vaccination if there is a clear contraindication
ABSOLUTE CONTRAINDICATION
•Situations that are contraindications to vaccination. These are important to remember:
1. Do not give to children with history of severe anaphylaxis following vaccination

2. Do not give live attenuated vaccine to severely immunocompromise child. Eg: Do not give
BCG to a child with AIDS
3. Do not give whole cell pertussis to a child who has had convulsions or shock within 7 days
of the last dose of the vaccine.
4. Do not give pertussis vaccination to a child with recurrent convulsions or another active/
progressive neurological disease of the central nervous system.
119
IMMUNISATION POSTPONEMENT -
ACUTE ILLNESS
1. Temperature >38.5 C.
2. Malnourished child with complications
3. Baby who are suspected to have congenital TB should delay BCG vaccination and refer
paediatrician
IMMUNISATION POSTPONEMENT-
CHRONIC ILLNESS
1. Children who have received IvIg or blood products should have their live vaccine (MMR,
IMOJEV, BCG) given 3 months after their treatment.
2. Children who have received steroids (Eg: Nephrotic syndrome, ITP, Immune haemolytic
anaemia) with a dose of Predinisolone >2mg/kg/day for >7 days or lower dose for >2 weeks,
vaccination should be given after 6 months only.
3. Child born to mother with active TB, BCG vaccination is delayed for 6 months to allow
completion of isoniazide prophylaxis therapy (IPT)
PRECAUTION
Child with bleeding tendency vaccination should consult paediatrician
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HOW WILL YOU HANDLE IMMUNIZATIONS IN A

SICK CHILD?
• Before giving a child any vaccination use 'senarai semak buku rekod kesihatan'
that is in the clinic copy of BRKK
• There are two good rules to remember:
1. If a sick child is well enough to go home, there are no contraindications to

vaccination.
2. If a child require referral for admission, to postpone the immunisation until

after discharge
121
SELF-ASSESSMENT EXERCISE
COMPLETE THE QUESTIONS ABOUT IMMUNIZATIONS.
1. In the scenarios below, decide if a contraindication is present, and if you will

vaccinate today or not. If you decide that the child should not be vaccinated,
make a note giving your reasons.
Do not
Vaccinate today
IF THE CHILD: vaccinate Reasons:
(if due)
today
a. Will be treated at home with
antibiotics
b. Has a local skin infection
c. Had convulsion immediately after
DtapT-IPV//Hib Dose 1, and needs
DTap-IPV//Hib Dose 2 today
d. Has diarrhoea
e. Older brother had convulsion last
year
f. Is premature with VERY LOW
WEIGHT, 1.78kg
g. Is known to have AIDS and has not
received any immunizations at all
h. Has NO PNEUMONIA: COUGH OR
COLD
CATCH UP IMMUNIZATION
• Rule No.1: Immunization must be at least 4/52 apart
• Rule No.2: Practice Opportunistic Immunization
• Rule No.3: (DTaP-IPV//Hib 1 can be given at 7/52 old if Opportunistic Immunization is
indicated*
• Rule No.4: Many vaccines can be given together simultaneously but must be given at
different sites
If the child does not come for an immunization at the recommended age, give the necessary
immunizations any time after the child reaches that age. Give the remaining doses at least 4 weeks
apart. You do not need to repeat the whole schedule. Refer to catch up immunization schedule
below
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Recommended Interval Between Doses For Catch Up
Immunization Schedule For 2 Month Up To 6 Year-old
Recommended Interval between dose

Vaccine Min age for dose
Dose 1-2 Dose 2-3 Dose 3-4
Hepatitis B Birth 4-6 week 5-12 months
DTaP-IPV//Hib 8/52 4-6 week 4-6 week 6-12 month
Japanese
9/12 12-24 month
Encephalitis
MMR 9/12 1-3 months
Minimum age to receive the 1st dose as stated as above

For Hep B dose 3 – should be given at least 8 weeks after Hep B 2 and /at least 16 weeks after Hep B 1
Scenario 1
Question 1
• Baby was born on 1st January 2017. She was given BCG and Hepatitis B1, then
defaulted.She came to see you today (1st August 2017):
• What do you plan to give her today?
• How to follow up subsequent visits?
• What would be the catch-up immunization for this patient?
123
Scenario 1
Answer 1
• 7 month old child only received BCG and Hep B 1 at birth. By right at this age she should
have received HepB 2,3 and DTap-IPV//Hib 1,2,3.
• Plan of immunization schedule:
Date Age Type of vaccine
• Hep B2
1st Aug 2017 (today) 7 month
• DTaP-IPV//Hib 1
1st September 2017 8 month • DTaP-IPV//Hib 2
• MMR 1
1st October 2017 9 month • DTaP -IPV//Hib 3
• IMOJEV1 (In Sarawak only)
• MMR 2
1stJanuary 2018 1 year
• Hep B 3
Scenario 2
Question 2
• Baby was born on 1st June 2014. He was given BCG and Hep B1 then defaulted. He came back
on 1st August 2015:
• What immunization you would give?
• How would you follow up subsequent visits?
• What would be the catch-up immunization for this patient?
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Scenario 2
Answer 2
• 1 year 2 month old child received BCG and Hep B1. By right at this age she should have
received HepB 2,3, DtaP/Hib/IPV 1,2,3 and MMR 1,2.
Date Age Type of vaccine
• MMR 1
• DTaP-IPV//Hib 1
1st Aug 2015 (today) 1year 2 month
• Hep B2
• IMOJEV1 (In Sarawak only)
• MMR 2
1st September 2015 1year 3 month
• DTaP-IPV//Hib 2
1st October 2015 1year 4 month • DTaP-IPV//Hib 3
1st January 2016 1year 7 month • Hep B 3
1stApril2016 1year 10 month • DTaP-IPV//Hib (booster)
1stAugust 2016 2year 2 month • IMOJEV (In Sarawak only)
Scenario 3
Question 3
• Baby was born on 1st May 2015. He received BCG and Hep B1, then defaulted. He
came to clinic on 1st August 2015.
• What immunization you would give?
• How to follow up subsequent visits?
Scenario 3
Answer 3
• 3 month old child received BCG and Hep B1 at birth. She missed Hep B2 at 2 month old
and due for DTaP-IPV//Hib 1 at 3 month old. Therefore, on this visit she should be given
Heb B2 and DTaP-IPV//Hib 1 and later follow the routine immunization schedule.
• She also should be checked for BCG scar. If there is no scar or pinpoint scar, a repeat BCG
vaccine should be given and should recheck the scar after 3 months. If the scar is not
present, patient need to refer to MO/ FMS (may need to consider repeat BCG in high risk
area/ case dependent).
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TREATING LOCAL INFECTION
TRAINING MANUAL ON
APPROACH TO UNWELL
TREATING LOCAL
INFECTION
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OBJECTIVES
1. Advise the mother on how to treat her child at home
2. Teach the mother how to treat local infection at home
3. Check the mother's understanding with good checking questions
LOCAL INFECTIONS
Local infections includes:
a. Eye or Ear infection
b. Mouth ulcers
c. Oral Thrush
d. Skin pustules
e. Umbilical infection
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EYE INFECTION
(pus discharge from the eyes, conjunctivitis)
Home treatment
1.Clean both eyes 4 times daily
•Wash hands
•Use clean cloth and water to gently wipe away pus
2. The apply Chloramphenicol eye ointment in both eyes 4 times daily

•Squirt a small amount of ointment on the inside of the lower
•Wash hands again
3. Treat until there is no pus discharge

•Do not put anything else in the eyes
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EAR INFECTION
(ear discharge, ear pain)
Home treatment
1. Dry the ear at least 3 times daily
• Roll clean absorbent cloth or soft, strong tissue into a wick
• Place the wick in the child's ear
• Remove the wick when wet
• Replace the wick with a clean one and repeat these steps until the ear is dry
• do not use cotton buds
DO NOT USE COTTON BUDS
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MOUTH ULCERS
Home treatment
1. Treat for mouth ulcers twice daily
• Wash hands
• Wash the child's mouth with clean soft cloth wrapped around the finger and wet with
sodium bicarbonate solution (if available), if not available use salt water
• Wash hands again
• Give paracetamol for pain relief
• 1 teaspoon sodium bicarbonate/salt in 250ml cool boiled water

• Change the solution every 24 hours
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ORAL TRUSH
Home treatment
1. Treat thrush four times daily for 7 days
• Wash hands
• Wet a clean soft cloth with salt water and use it to wash the child's mouth.
• Instill nystatin 1ml four times a day
• Avoid feeding for 20 minutes after medication
• If breastfed check mother's breasts for thrush. If present treat with nystatin
• Advise mother to wash breasts after feeds. If bottle fed advice change to cup and
spoon
• Give paracetamol if needed for pain.
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SKIN PUSTULES
Home treatment
1. Wash hands
2. Gently wash pus and crusts with soap and water
3. Dry the area
4.Wash hands
• To do the treatment twice daily for 5 days

• Do not rupture any pustules
• Depends on local setting, may use normal saline or potassium permanganate solution
• Preparation for potassium permanganates solution:
o 1 part potassium to 9 part of water OR until solution is light pink in colour
o Stop using once the pustules have scabbed
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UMBILICAL INFECTION
Home treatment
1. Wash hands
2. Gently wash off pus and
crusts with soap and water
3. Dry the area
4. Wash hands
• To do the treatment twice

daily for 5 days
DISCHARGE
• Before sending the patients home, need to check the mother's understanding by
using good checking questions.
Example:
• How much ointment you will put in the eyes. Show me.
• How often will you treat the eyes?
• When will you wash your hands?
• How many times per day will you dry the ear with a wick?
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ASSESSMENT OF YOUNG INFANTS
TRAINING MANUAL ON
APPROACH TO UNWELL
ASSESSMENT OF
YOUNG INFANTS
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Introduction
MODULE LEARNING OBJECTIVES
After you study this module, you will know how to:
• Assess a young infant for very severe disease and local bacterial
infection
• Recognize the clinical signs for assessing jaundice and diarrhoea.
• Check for a feeding problem or low weight
• Identify young infant that require urgent referral
• Provide pre-referral treatment to a young infant with very severe
disease
• Assess breastfeeding
WHY ARE YOUNG INFANTS SPECIAL?

• All young infants must be checked for very severe disease and local bacterial infection
• Young infants can become sick and die very quickly from bacterial infection. Therefore,
they require urgent referral.
WHY ARE YOUNG INFANTS SPECIAL?

• Young infants different from older infants and children in the ways they show signs of
infection.
• They become ill and die very quickly from serious bacterial infections. Severe infections
are the most common serious illness during first 2 months of life.
• Special risk for low birth weight infants: Infants under 2.5 kilograms at birth are low
weight. Infections are particularly dangerous in low birth weight infants. This means the
infant had low weight at birth, due either to poor growth in the womb or to prematurity
(being born early).
• Infants often show only general signs when seriously ill, such as difficulty in feeding,
reduced movements, fever or low body temperature.
• Newborn infants are often sick from conditions related to labour and delivery. Newborns
with any of these conditions require immediate attention. Some infants are premature, or
born before 37 weeks of pregnancy. They may have trouble in breathing due to immature
lungs. These conditions include birth asphyxia, birth trauma, preterm birth, and early-
onset infections such as sepsis from premature ruptured membranes.
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What To Do When Examining Young Infant?

Young Infant : Newborn To Age < 2 Months
• This lecture will emphasize on what should we do when examining young infant. Before start with the lecture-
to recap on age definition for child age 2 months up to 5 years. Start with age definition of young infant: < 2
months.
THE SICK YOUNG INFANT

(up to 2 months of age)
GREET THE CAREGIVER

ASK: chid's age (this chart is for sick young infant) ASK: number of visit?
ASK: what are the infant's problems? MEASURE: weight and temperature
ASSESS MAIN SYMPTOMS

ASSESS FOR GENERAL Even if •Jaundice
present •Diarrhoea
DANGER SIGNS
VERY SEVERE DISEASE AND •Feeding problem and growth
LOCAL BACTEAL INFECTION •HIV status or mother's HIV status
•Check Immunizations
•Assess other problems and mother’s health
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CHECK FOR VERY SEVERE DISEASE

• Not feeding well
• Greenish vomitus
• Convulsions
• Fast breathing 60 breath/min or more
• Severe chest indrawing
• Fever (37.5 C or above)
• Low body temperature (less than 35.5 C)
• Movement only when stimulated or no movement at all
• The first part of your assessment is checking for signs of severe illness. Every sick young infant
is checked for signs of very severe disease, especially a serious infection such as pneumonia,
sepsis, and meningitis. The signs of very severe disease also identify young infants who have
other serious conditions like severe birth asphyxia and complications of preterm birth.
• If one or more signs present

o Young infant requires urgent referral. Continue assessment quickly so referral is not
delayed.
• If no signs present
o CONTINUE ASSESSMENT: assess for jaundice, diarrhoea, check feeding problems and low
weight, check immunization status, and other problems
HISTORY (MUST ASK)

• Is the infant not feeding well?
• Does the infant vomits greenish vomitus?
• Has the infant had convulsions/fits/seizures?
• It is important to assess the signs in sequence.
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ASK: IS YOUR BABY HAVING DIFFICULTY IN FEEDING?

Infant not feeding well
• Poor suckling effort
• Reduce frequency of feeding whether breastfeeding/supplementary feeding
• Feeding less amount than usual
ASK: IS YOUR BABY HAVING DIFFICULTY IN FEEDING?

*history should be taken from mother or observation
• A young infant who was feeding well earlier but is not feeding well now may have a serious
infection. A newborn that has not been able to feed since birth may be premature or may have
complications such as birth asphyxia. These infants who are either not able to feed or are not
feeding well should be referred urgently to hospital.
• Poor suckling effort is assessed by asking duration of each suckling effort and the ability to
maintain suckling
ASK: ABOUT GREENISH VOMITUS

Greenish vomitus- Anak ada muntah hijau?
ASK: HAS YOUR BABY HAD CONVULSIONS [FITS]?

• spasms(kejang)
• arms & legs become stiff
• stop breathing & become blue (cyanosed)
• rhythmic movement any part of body
 eg: twitching of mouth or blinking of eyes
• loss of consciousness
• Greenish (bilious) vomiting is a sign of intestinal obstruction in a young infant. It is an urgent

condition that requires immediate referral to exclude conditions such as Duodenal Atresia,
midgut malrotation and volvulus, meconium ileus and necrotizing enterocolitis.
• For convulsions, use words the caregiver understands. For example, the caregiver may know
convulsions as “fits” or “spasms”.
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LOOK: DOES THE SICK INFANT HAVE FAST

BREATHING?
• Count Respiratory rate for 1 minute.
• Child must be calm and not feeding when counting the respiration rate.
• Healthy young infant : Resp. rate = 50-59/min.
• If Resp. rate ≥ 60/min, the respiration rate is counted for a second time because it is
normal for young infants to have irregular breathing.
• If the second respiration rate is also ≥ 60/ min, the young infant has FAST BREATHING.
• Remark: episodic breathing in young infant is usual
• If the first count is 60 breaths or more, repeat the count. This is important because the
breathing rate of a young infant is often irregular. The young infant will occasionally stop
breathing for a few seconds, followed by a period of faster breathing. If the second count is
also 60 breaths or more, the young infant has fast breathing.
• TO EMPHASIZE THE CHILD MUST BE CALM AND NOT FEEDING
LOOK: DOES THE SICK INFANT

HAVE FAST BREATHING
Exercise : Count the breath.mpg
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LOOK: DOES THE INFANT HAVE

SEVERE CHEST INDRAWING?
• The infant has chest indrawing if the lower chest wall (lower ribs)
goes IN when breath in
• Severe chest indrawing very deep and easy to see
• Present all the time when child is calm
The child breathing in WITHOUT The child breathing in WITH

chest indrawing chest indrawing
• Only severe chest indrawing is a serious sign in a young infant. Mild chest indrawing is normal
in a young infant because the chest wall is soft. Severe chest indrawing is very deep and easy
to see, and is a sign of pneumonia.
• TO EMPHASIZE THE CHILD MUST BE CALM AND NOT FEEDING
LOOK: DOES THE INFANT HAVE

SEVERE CHEST INDRAWING?
Exercise: Count the breath & severe chest indrawing.mpg
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MEASURE TEMPERATURE:
FEVER OR LOW BODY TEMPERATURE?
• Fever is defined as 37.5°C or above (axillary/ forehead)
• Low body temperature is below 35.5°C (axillary/ forehead)
•The thresholds for fever in the YOUNG INFANT chart are based on axillary temperature. Axillary
temperature is measured in the armpits.
•Fever is defined as 37.5 °C or above (axillary), 38.5°C (tympanic). Fever is uncommon in the
first two months of life. If a young infant has fever, this may mean the infant has very severe
disease. Fever may be the only sign of a serious bacterial infection.
•Low body temperature is below 35.5 °C (axillary), 36.5°C (tympanic). Young infants can also
respond to infection by dropping their body temperature. This is called hypothermia.
LOOK AT THE YOUNG INFANT'S MOVEMENTS

• Does the young infant move on his /her own?
• Does the young infant moves only when stimulated then stops? (by tapping the infant
soles with your 2 fingers)
• Infant does not move at all
○ no movement despite being stimulated
○ cannot be woken up even after stimulation
• Young infants often sleep most of the time, and this is not a sign of illness. Observe the
infant’s movements while you do the assessment. If a young infant does not wake up during
the assessment, ask the caregiver to wake him. An awake young infant will normally move his
arms or legs or turn his head several times in a minute if you watch him closely.
• If the infant is awake but has no spontaneous movements, gently stimulate the young infant.
If the infant moves only when stimulated and then stops moving, or does not move at all, it
is a sign of severe disease. An infant who cannot be waken up even after stimulation should
also be considered to have this sign.
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CHECK FOR LOCAL BACTERIAL INFECTION

LOOK AT THE UMBILICUS: IS IT RED OR DRAINING PUS
• Redness at the skin surrounding the umbilicus
• Pus draining from the umbilicus
• The umbilical cord usually separates one to two weeks after birth. The wound heals within 15
days. Redness of the end of the umbilicus, or pus draining from the umbilicus, is a sign of umbilical
infection. Recognizing and treating an infected umbilicus early are essential to prevent sepsis.
• Explain on technique on how to examine the umbilicus by using thumb and forefinger to separate
the umbilicus at 3 – 9 o’clock and 6 – 12 o’clock. If umbilicus is dirty, to clean it first.
LOOK FOR SKIN PUSTULES

• Examine whole body to look for skin pustules
• Skin pustules are red spots or blisters that contain pus.

• Examine the skin on the entire body. If you see pustules, is it just a
few pustules or are there many?
• A severe pustule is large or has redness extending beyond the
pustule. Many or severe pustules indicate a serious infection.
• Emphasize to expose child and look at hidden area; neck, axilla and
perineum
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LOOK FOR SKIN PUSTULES

• Young infant with redness of umbilicus/ pus at umbilicus skin pustules requires oral
antibiotic
• Refer to doctor for further assessment
• If child is unwell must refer urgently

• Convulsions
• Fever (37.5 Cor above )
Infant with any VERY SEVERE DISEASE signs needs urgent referral to hospital
ASSESSMENT OF THE SICK YOUNG INFANT

AGE UP TO 2 MONTHS
• Video on assessment of the sick young infant age up to 2 months
143
CHECK FOR JAUNDICE
if jaundice present ask:

•When did the jaundice first appear?
LOOK AND FEEL:

•Look for jaundice (yellow eyes or skin)
•Look at the young infant's palms and soles. Are
they yellow
CLASSIFY
JAUNDICE
• Any jaundice if age PINK: • Treat to prevent low

less than 24 hours SEVERE blood sugar
or JAUNDICE • Prefer URGENTY to
• Yellow palms and hospital
soles at any age • Advise mother how to
keep the infant warm on
the way to hospital
• Jaundice appearing YELLOW: • Advise the mother to
after 24 hours of JAUNDICE give home care in the
age and young infant
• Palms and soles not • Advise mother to return
yellow immedately if palms and
soles appear yellow
• If the young infant is
older than 14 days,
refer to a hospital for
assessment
Follow-up in 1 day
• No jaundice GREEN: • Advise the mother to
NO give home care in the
JAUNDICE young infant
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CHECK FOR JAUNDICE

• Look for jaundice under natural sunlight
• Press infant skin over the forehead with your fingers to blanch and look for yellow
discoloration
• If jaundice present: Ask did jaundice first appear before 24H of life or at Day 1 of life? If
jaundice is prolonged more than 14 days?
• Check level of jaundice:
 palms and soles
 below umbilicus
 above umbilicus
• To explain on the examination technique, show on the doll

• Explain examination of jaundice according to CPG for Neonatal Jaundice is done on the
anterior chest
CHECK FOR JAUNDICE
• To explain on the examination technique, show on the doll

• Using both thumb to stretch the skin
145
VIDEO BLANCHING TEST
KRAMER’S RULE
Range of Serum Bilirubin

Area of the Body Level
µmol/L Mg/dL
Head and neck 1 68-133 4-8
Upper Tunk (above

2 85-204 5-12
umbilicus)
Lower Tunk and thighs

(below umbilicus)
3 136-272 8-16
Arms and lower legs 4 187-306 11-18
Palms and soles 5 ≥306 ≥18
• Look for jaundice under natural light

• Press infant skin over the forehead with your fingers to blanch and look for yellow discoloration.
Jaundice is usually visible when bilirubin level =5-7mg/dL (86-120umol/L)
• Check level of jaundice
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CHECK FOR JAUNDICE

Refer urgently to hospital if jaundice:
• Appears at Day 1 of life or before 24H of life

OR
• Jaundice at palms and soles
JAUNDICE INFANT.MPG
• Video on jaundice infant
147
FOR JAUNDICE
• Refer to doctor
• Prolonged jaundice  jaundice > 14 days, inspect the stool and refer for assessment
• Refer to Integrated Manual on Detection and Management of Neonatal Jaundice and CPG on
Neonatal Jaundice
STOOL COLOUR CHART
1 2 3
Abnormal Colour Chart
4 5 6
Normal Stool Colours

• Abnormal colour: White, Grey, Light yellow (1,2,3)
• Normal stool colour: Yellowish, greenish (4,5,6)
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• Recap : Check for very severe disease
• Ask participant to list out criteria for very severe disease and explain each of them

• Convulsions
• Fever (37.5 C or above)
• Participants should be able to answer as in the picture above
149
DOES THE YOUNG INFANT

HAVE DIARRHOEA?
Diarrhoea in young infant:
• Change of stool pattern from usual stool pattern
• More frequent and watery (more water than faecal matter)
Normal frequent or semi-solid stool of a breastfed infant is NOT diarrhoea
• If the mother or caregiver says that the young infant has diarrhea, assess and classify for
diarrhoea.
• Diarrhoea in young infant:
- Change in pattern from usual stool pattern
- More frequent stool
- More watery stool (more water than faecal matter)
• It is normal for breastfed young infant to have frequent, loose or semi-solid stool.
NORMAL INFANT STOOL
• Examples of normal infant stool - can vary in colour, consistency and amount.
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YOUNG INFANT WITH DIARRHOEA

• Examine for hydration status
• Look for infant movements
 move on his/her own
 move only when stimulated then stops
 does not move at all
• Is the infant restless/irritable
• Look for sunken eyes
• Skin pinch : goes back very slowly (>2 sec)/slowly
• Look for infant movements

- Spontaneous movement
- Movement when stimulated and then stops
- No movement at all
- Is the infant restless / irritable?
• Look for sunken eyes
• Abdomen Skin pinch : goes back immediately or slowly
YOUNG INFANT WITH DIARRHOEA

Sign of dehydration in young infant
 Movement when stimulated and then stops
 No movement at all
 Restless/irritable?
 Sunken eyes
 Skin pinch : goes back slowly
If none of the above signs are present, treat with Plan A and follow up in 2 days. If not
improving, the infant may require admission.
Assess diarrhoea.mpg
• Sign of dehydration in young infant (add in slide above the point)

- Movement when stimulated and then stops
- No movement at all
- Restless / irritable?
- sunken eyes
- Skin pinch : goes back slowly
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ASSESS FEEDING PROBLEM &

CHECK FOR LOW WEIGHT
• Is the infant breastfeed? If yes how many times in 24 hours?
• Does the infant receive any other food or drinks? If yes, how often?
• What do you use to feed the infant?
• Determine weight for age (plot against chart)
• Look for ulcers or white patches (thrush) in mouth.
Check for feeding problem or low weight for age.mpg
• Adequate feeding is essential for growth and development.

• Poor feeding during infancy can have lifelong effects.
• In Infant growth is assessed by weight for age.
• Young infants should be breastfeed exclusively to provide the best nutrition and protection
against disease.
• Check for feeding or low weight for age ONLY if the infant does not have any indication for urgent
referral to hospital.
ASSESS BREASTFEEDING
Assess breastfeeding technique:
 Has the infant breastfeed in the previous hour?

• If not, observe breastfeeding for 4 minutes
 Check for signs of good positioning
 Check for signs of good attachment
 Check for effective suckling (slow deep sucks, sometimes pausing)
• It is important to observe breastfeeding technique and give corrective measures immediately.
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 Check for signs of good positioning:

• Baby's head and body in line
• Baby's held close to mother's body
• Baby's whole body supported
• Baby approaches breast, nose to nipple
 Check for signs of good attachment:

• More areola seen above baby's top lip
• Baby's mouth open wide
• Lower lip turn outwards
• Baby's chin touches breast
153
 Check for effective suckling

(slow deep sucks sometimes pausing)
• Slow deep sucks with pauses
• Cheeks round when suckling
• Baby releases breast when finished
• Mother notices signs of oxytocin reflex
BREASTFEEDING
Correct Positioning and Attachment
(Show video)
https://globalhealthmedia.org/videos
* Baby head must be in line with spine. Mother should support baby’s body adequately.
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ASSESSMENT OF SICK YOUNG INFANTS

Summary
• Young infant From birth to less than 2 months
• ALL young infant must check for very severe disease or local bacterial infection
• All young infant must check for Jaundice
• All young infant must ask if has diarrhoea
• Check for feeding problem or low weight
155
MOTHER’S CARD
TRAINING MANUAL ON
APPROACH TO UNWELL
MOTHER’S CARD
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APAKAH TANDA -TANDA BAHAYA ANAK ANDA PERLU

SERTA MERTA DIBAWA KE KLINIK?
157
MOTHER’S CARD
APAKAH TANDA -TANDA BAHAYA ANAK ANDA PERLU

SERTA MERTA DIBAWA KE KLINIK?
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APPENDIX 1
ROLE PLAY
(45 MINUTES)
STATION 1-PLAN B (CLINIC TREATMENT)

OBJECTIVE : Teaching Mother to take care for a diarrhoea
child with Some Dehydration at the clinic
PREPARATIONS
1. DOLL
2. ORS SOLUTION (ALREADY MIXED) 4 PACKETS
3. CUP, SPOON & 250mls bottle (AT LEAST 4)
4. FLIPCHART/MANJONG PAPER/MARKER
PLAN B (DEMO)
3 facilitators
1 Health worker
1 Mother
1 Moderator
Scenario: Baby Lura, 1 yr old ,10kg, diarrhoea with SOME DEHYDRATION

treat with Plan B at clinic
Health worker
- to explain on treatment of Plan B to mother-To determine amount of ORS first 4H
- to show mother how to give ORS solution, reassess after 4H for any signs of dehydration
- to emphasize no other fluids other than ORS & breastmilk within first 4H
Mother
- Should behave as a real concerned mother,
- To ask health worker about other fluids ie plain water,juices etc
- To ask about if child’s vomit
- To make up additional realistic information that fits the situation if necessary
Facilitator
-Introduction
-Emphasize on plan B at clinic
-Check mother’s understanding-APAC technique
-Summary
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MOTHER’S CARD
APPENDIX 2
ROLE PLAY
(45 MINUTES)
STATION 1-PLAN B (CLINIC TREATMENT)

Role play 1
1 facilitator – as moderator
2 participants :
1. Health worker
2. Mother
Case scenario:
Baby Lura, 1 yr old ,10kg, Diarrhoea with SOME DEHYDRATION. Baby needs to be given Plan B at
the clinic.
Mother (Facilitator to explain to participant earlier their role as Mother)

Encourage to act like normal concerned mother
To ask medicine to stop diarrhoea / vomiting
To become alarmed when the child vomits after giving ORS
To ask whether can give food / fluids to your child
Health worker (Facilitator to explain to participant earlier their role as Health Worker)
To explain to mother the reason for giving treatment plan B — is to replace the lost fluid with
ORS. This is very important in treating patient with some dehydration. (by explaining the reason,
the caretaker can coorperate better)
Steps for Plan B :

1. Determine the amount of fluids to be given in 4 hours
2. Show the mother how to give ORS solution
Facilitator
Inform all participants about the content of the scenario
-To emphasize on Plan B treatment at clinic
-To lead the discussion
-Key point of role play Plan B:
• What did the health worker do well?
• Did the health worker leave out anything important?
• Be sure to comment if the health worker told the mother the amount of ORS to give in the
next 4 hours, give ORS slowly, show her how to give fluid with spoon, the 3 basics steps
(Give information, Show example, Let Mother practise)
• Check the mother’s understanding
• To emphasize : APAC technique
A - Ask
P - Praise
A - Advice : give information, show example and practise
C - Check understanding : 5W (What, When, Where, Who, Which); 1H (How)
-Summary of role play and stress about the learning points from the role play
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STATION 2
(45 minutes)
PLAN A (Home treatment)

OBJECTIVE : Teaching Mother to take care for a diarrhoea
child with No Dehydration at home
PREPARATIONS
1.DOLL
2.ORS SOLUTION – 10 packets (1 for demo, 1 for mother to practice, 8 to be given to mother)
3.CUP, SPOON & 250MLS BOTTLE
4.FLIPCHART/MAHJONG PAPER/MARKER PEN
DEMO
3 facilitators
1 Health worker
1 Mother
1 Moderator
Scenario: Baby Lura, 1 yr old ,10kg, diarrhoea with SOME DEHYDRATION, treated with Plan B at
clinic. After 4 hours, reassessment by health worker shows Lura has improved and no
signs of dehydration. Health worker plan to discharge Lura and before discharge, the
health worker counselled mother on plan A
Health worker
- to explain on treatment of Plan A to mother (home care)
- to show mother how to mix ORS-expiry date, shake, colour of ORS, mix 250ml water
- to give extra fluid, amount of fluid given each diarrhoea
- to counsel when to return
Mother
- Should behave as a real concerned mother,
- To ask health worker about other fluids ie plain water, juices etc
- To ask what to do if child’s vomit
- To ask about the any medication to stop the diarrhoea or antibiotic
- To make up additional realistic information that fits the situation if necessary
Facilitator
- Introduction
- Emphasize on plan A at home – 4 steps
- Emphasize 3 basic steps-info, example, practise
- Check mother’s understanding-APAC
-Summary and stress about the learning points from the role play
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MOTHER’S CARD
STATION 2
(45 minutes)
Role play 2
Facilitator – as moderator
2 Participants
Health worker :
- To teach mother Plan A (take extra fluids, teach to mix and give ORS,
continue feeding)
- To show mother how much fluid to give
- To demonstrate how to give the fluid
- To counsel on when to return
- To check mother’s understanding
Mother
- To wait if health worker ask mother to practice on how to mix ORS
(pretend to miss some steps)
- To mix and give ORS to child
- Use 3 basic steps
- To ask no other medication needed eg anti-diarrhoeal or antibiotic
Facilitator
- To lead the discussion, introduction of scenario
- To comments whether the health worker do well or leave out anything important
Key point of role play

- If the health worker told the mother the amount of fluids to give and when to give?
- If the health worker said to continue giving normal fluids
- If he told to give fluids until diarrhoea stop
- If he discussed to continue feeding and when to return immediately
- How were the 3 basics steps (info, example and practice) demonstrated
- How did the health worker check the mother’s understanding?
- To emphasize APAC technique
Feeding Assessment and Mother’s Card
Objectives:
• To assess feeding and to identify feeding problems
• To give the correct feeding recommendation
• To introduce how to use mother’s card
Part 1 (demo) 10 min

Part 2 (role play) 15 min
Part 3 (role play) 15 min
Preparation
• Doll
• Mother’s card
• Checklist
• Mahjung paper/flip chart/marker pen
162
ATUCU5
APPENDIX 3
STATION 2
(45 minutes)
Part 1 ( demo case)

3 facilitators
1 Health worker
1 Mother
1 Moderator
To introduce role play on feeding advice and recommendation, use of checklist & mother’s card.
Using APAC technique during consultation
- To use scripted role play (Refer Appendix 1)
- Health worker to use the questions on the checklist to identify feeding problems
- Health worker to recommend the correct feeding practice
- Health worker to use mother’s card
- Mother to describe the child’s feeding
- Mother should behave as a real mother, to make up additional realistic information that fits the
situation if necessary
1 facilitator to lead the discussion
Key point:
• When to do feeding assessment :
o All child < 2 years old or
o Very low weight for age or
o Child with Anaemia
• Use checklist to assess feeding
o Do you breastfeed your child? How many time per day? Do you breastfeed at night?
o Does your child take any other food / fluids ? Types of food (variety)? Frequency ? Amount?
• Review the answers from mother
• List down on the flip chart the feeding problems and correct feeding practices
• Discuss whether all the necessary questions were asked of the mother
• Any additional questions should have been asked
• What might be the consequences of not asking these questions?
• To emphasize using of mother’s card when giving feeding advice & choices of food variety to
follow local food availability in the family / community
• To emphasize APAC technique
• Summary of the role play and stress about the learning points from the role play
Part 2 and 3 (role play)

2 participants
1 Health worker
1 Mother
Scenario: Baby Lura, 15 months old ,10kg. You are worried about Lura because you have very little
food available at home and you have other 3 children to feed. Lura no longer breastfeed. She takes
family diet 2 or 3 times per day. Drink condensed milk. She share her meal with her other siblings.
(The scenario is given to the mother)
Health worker to use checklist to identify feeding problems and use mother’s card for feeding
recommendation
Facilitator to lead the discussion
Key point – as above
163
MOTHER’S CARD
APPENDIX 4
Scripted Role Play Feeding Assessment & Feeding Advice
Aziz is 8 months old, weight 9.2 kg. He comes to clinic for URTI and his condition is stable.
Cues / Key points

Health Worker : Do you breastfeed Aziz ? Ask , Listen
Mother : Yes, I’m still breastfeeding
That’s very good.
Health Worker : Breastmilk is the best for your baby. Praise , Ask , Listen
How often do you breastfeed?
Mother : About 4-5 times in the day
Health Worker : Do you breastfeed at night ?
Mother : Yes if he wakes up at night 3-4 times.
Good. Continue breastfeeding as often as he wants.
Health Worker : Praise , Advice, Ask, Listen
Are you giving Aziz other foods or fluids?
Yes, I give him porridge and recently started giving him fruits eg
Mother :
banana
Those are good choices.
Health Worker : How often do you give porridge or fruits? Praise, Ask, Listen
Do you put anything in the porridge?
Just plain porridge about twice a day, sometimes I give fruits once
Mother :
a week
Let me show you on the mother’s card. For Aziz can give food 3
times per day. Can be porridge or fruits . You can either give him Advice, show on the
Health Worker :
porridge 3 times per day or twice a day porridge then fruits once mother's card
a day.
Mother : Oh ok
At his age he can eat any food listed in this picture. Eg You can
choose one or two of these food, such as meat /chicken /egg /fish Advice, show on the
Health Worker :
/ vegetables, cook together with the porridge. Can give potatoes mother's card
and other types of fruits too.
Mother : All right, I’ll add some food in the porridge
That's good mom. Now, during this illness has Aziz's feeding
Health Worker : Praise, Ask, Listen
changed?
Mother : Yes
Health Worker : How does his feeding changed when he is sick? Ask, Listen
When he is sick he eats & drinks less than usual. He has poor
Mother :
appetite
Health Worker : You must be very worried when Aziz is sick.
Mother : Yes. He will only breastfeed when he is not well.
164
ATUCU5
APPENDIX 5
Case Discussion Day 1:

Cough/Difficulty Breathing and Diarrhoea
(Refer slide Title: Case Discussion Day 1)
 This is an interactive session with participants
 To ensure to check for general danger signs
 Use clarifying questions during history taking
 Not to miss important points during general observation
 Use the checklist as a guideline
 To ensure participant are able to manage the case well
Case 1:
Salina, 15-month-old girl with weight of 8.5kg. Complaining of cough for 4 days and not eating
well. How would you manage this child?
Case 2:
Justin, 3-year-old bay with weight of 12 kg. Complaining of cough for 3 days and mom noticed
child looks weak. Temperature 37◦C
Case 3:
A 3-year-old child brought by mother to the clinic with history of loose watery stools for 3 days
Case 4:
1-year-old boy, presented with history of > 5 times diarrhoea and vomiting for 3 days. No blood
in stools. During examination, child was restless and irritable, no sunken eyes and skin pinch was
immediately. He take drinks eagerly.
How would you manage this child?
165
MOTHER’S CARD
APPENDIX 6
Case Discussion Day 2: (Refer slide Title: Case Discussion Day 2)
Fever, Cough/Difficulty Breathing and Diarrhoea
Assessment of the sick young infant
Case Discussion Day 2:

(Refer slide Title: Case Discussion Day 2)
Fever, Cough/Difficulty Breathing and Diarrhoea
Assessment of the sick young infant
Case 1:
Ali, 3 years 6 month old boy with weight of 14.5kg came to the clinic with history of fever for 2
days. How would you manage this child? What history do you ask and what are the important
general observation should be done?
Case 2:
Salina is a 15 months old girl with weight of 8.5kg. Mother complains child has been having
cough for 4 days and not eating well. How would you manage this child?
Case 3:
Raymond, a 2-year-old boy came to clinic with his mother. He has history of loose watery stools,
vomiting and fever for the past 3 days. He also has on and off abdominal pain. What are you
plans for Raymond?
Case 4:
A mother came to the clinic with her 1-month-old baby girl. She complains the baby is having
runny nose and notice baby was having difficulty to breath. The child’s weight is 2.8kg. What
would you do?
166
ATUCU5
APPENDIX 7
Report on suspected adverse drug reactions
(to be filled by healthcare worker)
167
APPENDIX 8
Checklist Approach to Unwell Children Under 5 years
The Sick Young Infant Age Up To 2 Month
FH/ATUCU5- checklist 1/2020

CHECKLIST
APPROACH TO UNWELL CHILDREN UNDER FIVE YEARS THE SICK YOUNG INFANT AGE UP TO 2 MONTH
Name: ……….………………………….. ……….…………………… Age:………………………... Weight: ……………. Temperature: ………….. ˚C
ASK:What are the child’s problems?........................................ Visit: 1st /2nd/3rd/4th/5th
ASK LOOK AND FEEL REFER FOR ADMISSION IF PRESENT
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
● Is the infant not feeding well? ● Count the breaths in one minute. ● Not able to feed
● Does the infant vomit greenish vomitus? ………… breath per minute. ● Feeding poorly
● Has the infant had convulsion? Repeat if 60 or more ………… Fast breathing? ● Greenish vomitus
● Look for severe chest indrawing. ● Convulsions
● Look at umbilicus. Is it red or draining pus? ● Fast breathing
● Look for skin pustule? ● severe chest indrawing
● Look at young infant’s movements ● Fever (> 37.5°C) or low body temperature (35.5°C)
Movement only when stimulated? ● Movement only when stimulated or no movement at all
No movement at all?
● Check temperature:
* Fever (> 37.5°C )
* Low body temperature (below 35.5°C )
CHECK FOR JAUNDICE ( Jaundice present / No Jaundice )
● When did the jaundice first appear? ● Look for level of jaundice ● Jaundice appearing before 24hrs of age
Before 24 hours of life / after 24 hours of life * Jaundice palms and sole ● Jaundice palm and sole at any age
● Is the infant more than 14 days old? * Jaundice below umbilicus ● TSB above photolevel
* Jaundice above umbilicus ● Pale stool
● Look at stool colour
● Check TSB if jaundice present
●For how long?................Days ● Look at the young infant’s general condition. ● 2 or more signs
●Is there blood in the stools? Move only when stimulated or not move at all? * movement only when stimulated or no movement
Restless or irritable? * restless or irritable
● Look for sunken eyes. * sunken eyes
● Pinch the skin of the abdomen. * skin pinch goes back slowly
Does it go back: Slowly OR Immediately
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS ( IMMUNIZATION SCHEDULE )
AGE VACCINE
Birth BCG Hep B 1 **Vit K
1 month Hep B 2
If the infant has no indications to refer urgently to hospital ● Determine weight for age. Low______ Not Low______
CHECK FOR FEEDING PROBLEM OR LOW WEIGHT ● Look for white patches in the mouth (thrush)
● Is the infant breastfed? Yes______ No_______
If Yes, how many times in 24 hours? _________ times
● Does the infant usually receive any
other foods or drinks? If Yes, please specify______
If Yes, how often?_____________
● Check feeding hygiene and preparation
ASSESS BREASTFEEDING If infant has not fed in the previous hour, ask the mother to
● Has the infant breastfed in the previous hour? put her infant to the breast. Observe the breastfeed for 4 minutes.
● Is the infant able to attach? To check attachment, look for :
- More areola seen above
infant’s top lip than below bottom lip Yes_____ No_____
- Mouth open wide open Yes_____ No_____
- Lower lip turned outwards Yes_____ No_____
- Chin touhing breast Yes_____ No_____
not well attached good attachment
● Is the infant suckling effectively ( that is, slow deep sucks, sometimes pausing)
not suckling effectively suckling effectively
● Clear a blocked nose if it interferes with breastfeeding.
Assess other problem
168
ATUCU5
APPENDIX 9
Checklist Approach to Unwell Children Under 5 years
The Unwell Child Age 2 Months Up to 5 Years
FH/ATUCU5- checklist 2/2020

CHECKLIST
APPROACH TO UNWELL CHILDREN UNDER FIVE YEARS THE UNWELL CHILD AGE 2 MONTHS UP TO 5 YEARS
Name: …………………………………………………………. Age: ……………………… Weight: ……………. Temperature: ………….. ˚C

.
ASK:What are the child’s problems?........................................................ Visit: 1st /2nd/3rd/4th/5th
ASK LOOK AND FEEL REFER FOR ADMISSION IF PRESENT
NOT ABLE TO DRINK OR BREASTFEED DROWSY OR UNCONSCIUS ●General danger sign
VOMIT EVERYTHING OR GREENISH VOMITUS CONVULSING NOW
CONVULSIONS DURING THIS ILLNESS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? ( YES / NO )
● For how long? …………… days ● Count the breaths in one minute. ●Chest indrawing
…………… breath per minute. Fast breathing? ●Stridor in calm child
● Check SPO2 (if available) ●Fast breathing
● Look for chest indrawing. ●SPO2 <96%
● Look and listen for stridor.
● Look and listen for wheeze.
● For how long? …………… days ● Look at the child’s general condition. Is the child: ● General danger sign
● Is there blood in the stool Drowsy or unconcious? ● Severe dehydration (2 or more signs)
Restless or irritable? ● Drowsy or unconcious
● Look for sunken eyes. ● Sunken eyes
● Offer the child fliuds. Is the child: ● Not able to drink or drink poorly
Not able to drink or drinking poorly? ● Skin pinch goes back very slowly
Drinking eagerly, thirsty?
● Pinch the skin of the abdomen. Does it go back:
very slowly (longer than 2 seconds)?
slowly?
DOES THE CHILD HAVE FEVER? (history/ temperature > 37.5°C (axillary/forehead) or > 38°C (ears)) ( YES / NO )
● For how long? …………… days ● Look and feel for stiff neck. ● General danger sign
● If more than 7 days, ● Look for petechial or purpuric rash ● Stiff neck
has fever been present every day? ● Look for maculopapular rash on palms or soles ●Petechial/purpuric rash
● Coming from Dengue Endemic area ● Look for other causes of fever ● Dengue
● Recent HFMD outbreak ● Check nose, ear and throat ● Malaria
● Check CCTVR (colour,capillary refill time, temperature, pulse volume and HR) ● HFMD with myoclonic jerk
* BFMP: Positive (Falciparum/Vivax)/ Negative/ Not done/pending ● Mastoiditis
● Unsure cause of fever (for further assessment
Does the child has measles now or within the last 3 months: ● Look for signs of MEASLES now: ● Measles with eyes and mouth complications
* Generalized measles rash and
* Triad : cough/ runny nose/ red eyes
● Look for mouth ulcers.
If Yes, are they deep or extensive?
● Look for pus draining from the eye.
● Look for clouding of the cornea.
CHECK FOR MALNUTRITION ● Determine weight for age (growth chart) ● Sign of severe wasting or edema both feet
Yellow zone____ Red zone____ Static /crossing zone
● Measure MUAC. 11.5 12.5 OR < 11.5
● Look for oedema of both feet
● Look for visible severe wasting
CHECK FOR ANAEMIA ● Look for palmar pallor
If present to check Hb
CHECK THE CHILD IMMUNIZATION STATUS ( IMMUNIZATION SCHEDULE )
AGE VACCINE
Birth
BCG Hep B 1 ** Vit K
1 month
(DTaP - IPV //Hib) 1
2 months Hep B 2
3 months
5 months
*Measles Hep B 3
6 months
MMR 1 * JE 1
9 months
MMR 2
12 months
18 months (DTaP - IPV //Hib) 4
21 months * JE 2
ASSESS CHILD’S FEEDING if child has ANAEMIA OR weigth for age in Yellow/Red zone OR child less than 2 years old.
● Do you breastfeed your child ? Yes______ No ______ ( If Yes, how many times in 24 hours ? ______ times. Do you beastfeed during the night ? Yes_______ No_______ )
● Does the child take any other food or fluids ? Yes _______ No ______ ( If Yes, what food or fluids ? _____________________________________________________________________________ How many times per day? ________times. What do you use to feed the child ? ________________________________ )
● If very low weight for age : How large are servings ? ________________________________________________________________ Does the child receive his own serving ? ______ Who feeds the child and how ?_______________________________
● During the illness, has the child’s feeding changed? Yes_________ No________ ( If Yes, How ? _____________________________________________________________________________________________________ )
Assess other problem
169
MEMBERS OF THE TECHNICAL
WORKING GROUP
Dr. Hii King Ching Pn. Noraliza Bt Mohd Ali
Consultant Paediatrician Health Matron
(General Paediatrics and Child Health) Nibong Tebal Health Clinic, Pulau Pinang
Kapit Hospital, Sarawak Pn. Siti Khatijah bt Mohd Zain
Dr. Aina Mariana Bt Abdul Manaf Health Matron
Consultant Paediatrician Nibong Tebal Health Clinic, Pulau Pinang
Port Dickson Hospital, Negeri Sembilan Pn. Mastura Bt Ahmad
Dr. George George Matthew Health Matron
Family Medicine Specialist Chini Health Clinic, Pahang
Tamparuli Health Clinic, Sabah Pn. Mahfuzah Mohd Nor
Dr. Juslina Omar Health Matron
Family Medicine Specialist Port Dickson Health Clinic, Negeri Sembilan
Petra Jaya Health Clinic, Sarawak Pn. Noorley Mamat
Dr. Anuradha Thiagarajan Health Matron
Family Medicine Specialist Lukut Health Clinic, Negeri Sembilan
Bukit Minyak Health Clinic, Pulau Pinang Pn. Rafidah Bt Mahamud
Dr. Yusnita Yusof Health Matron
Family Medicine Specialist Perlis State Health Department, Perlis
Penaga Health Clinic, Pulau Pinang Pn. Zaleha Sulaiman
Dr. Lim Jean-Li Health Matron
Family Medicine Specialist Sabah State Health Department, Sabah
Sikamat Health Clinic, Negeri Sembilan Pn. Zuraini bt Zainuddin
Dr. Nor Azam b. Kamaruzaman Health Matron
Associate Professor Family Medicine Specialist Kelantan State Health Department, Kelantan
International Islamic University Malaysia, Pn. Rohaidah Abdul Rahim
Pahang Health Matron
Dr. Rohaiza Binti Abd. Kadir Pahang State Health Department, Ipoh, Pahang
Family Medicine Specialist Pn. Norashikin Binti Mohamed
Seberang Takir Health Clinic, Terengganu Health Matron
Dr. Ziti Akhtar Bt Supian Manik Urai Health Clinic, Kelantan
Family Medicine Specialist En. Mohd Sukri Bin Zakaria
Seri Kembangan Health Clinic, Selangor Medical Assistant
Perlis State Health Department, Perlis
Dr. Nik Suhaila Zakaria
Family Medicine Specialist En Kalimuthu a/l Erulappan
Chiku 3 Health Clinic, Kelantan Medical Assistant
Pulau Pinang State Health Department,
Dr. Azainor Suzila Pulau Pinang
Family Medicine Specialist
Lukut Health Clinic, Negeri Sembilan En. Mohamad Hapizie Bin Din
Medical Assistant
Dr. Fazlina Mohd Yusof Jaya Gading Health Clinic, Pahang
Family Medicine Specialist
Seksyen 7 Health Clinic, Selangor En. Muthana Bin Ramlan
Medical Assistant
Pn. Zamzuriani Binti Abdullah Lukut Health Clinic, Negeri Sembilan
Health Matron
Gual Ipoh Health Clinic, Kelantan
170
ATUCU5
EDITOR
Dr. Aminah Bee Bt Mohd Kassim
Public Health Physician
Dr. Amy Nur Diyana Bt Mohamed Nasir

Medical Officer
ACKNOWLEDGEMENTS
We would like to acknowledge the committee members of IMCI, WHO for
the permission to adopt and adapt the programme. We are also grateful to
all those who gave feedback and suggestions during the development of this
document.
DISCLAIMER
This publication is supported by World Health Organization (WHO), however,
does not warrant that the information contained in this publication is complete
and correct and shall not be liable for any damages incurred as a result of its use
171
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MOH/K/ASA/97.

Family Health Development Division

WHO in collaboration with UNICEF, developed the Integrated Management of Childhood

Datuk Dr Noor Hisham bin Abdullah

The development of Training Manual on Approach to Unwell Children under 5 years

Dr. Hjh. Faridah binti Abu Bakar

FOREWORD BY DIRECTOR OF FAMILY HEALTH DEVELOPMENT DIVISION

1 INTRODUCTION 4 DIARRHOEA 7 IMMUNISATION

Quality of care, which is one of the modifiable medical factors for

Analysis of under 5 mortality data in 2017 shows that preventable

PREVENTABILITY BY AGE GROUP (2017)

PREVENTABLE deaths increasing with age

TOP CAUSES OF PREVENTABLE DEATHS

Condition From Condition From Injuries & External

Congenital Congenital Certain Infections &

Injuries & External Certain Infections &

1.2 Importance of Child Health Record Book in Management of Unwell

1.3 The elements of integrated case

THE ELEMENTS OF INTEGRATED CASE MANAGEMENT

Assess And Classify

Counsel The Caregiver

The elements of integrated case management in ATUCU-5 include:

1.4 Outline of management of unwell child

Age < 2 months Use Checklist <

Management of Unwell Child ( Age 2 Months - < 5 Years)

Ask the caregiver about the

Check for general danger

Management Of Age 2 months - Check for malnutrition and

Treat local infection

Counsel using the mother’s

Management of Unwell Child (Age <2 Months)

Ask the caregiver about the

Counsel using the mother’s

2. ASK THE MOTHER/CAREGIVER ABOUT THE CHILD’S

ASK THE MOTHER ABOUT THE CHILD’S PROBLEMS

• Great the mother appropriately

What Are Good Communication Skills?

GOOD COMMUNICATION SKILL

GIVE HER TIME

COUNSEL CAREGIVERS USING APAC

APAC (ASK, PRAISE, ADVICE, CHECK)

WHAT IS THE IMPORTANT INFORMATION YOU GATHER

Important information to ask the caregiver about the child:

6. Make sure the

4. Ask the caregiver 3. Find out the

YOU SHOULD ALWAYS:

2. CHECK FOR GENERAL

2.2 General Danger Signs

5. Child Is 1. Child Is Not

3. Child Has Had

• The following are general danger signs in young children:

General Danger Signs

Is the child able to drink

2.3 ASK: Is the child able to drink or breastfeed?

• Ask the caregiver if the child is able to drink or

• Ask the amount, frequency and duration of not able

GENERAL DANGER SIGNS

Video GDS Not able to drink or breastfeed.mpg

2.4 ASK: Does the child vomit everything or

GENERAL DANGER SIGNS

(If history is not clear - offer fluid to child and observe)

GENERAL DANGER SIGNS