CLASSIFICATION TABLES

COUGH AND DIFFICULT BREATHING

CLASSIFICATION TREATMENT
Any general danger Pink: Give first dose of an appropriate antibiotic
signs SEVERE PNEUMONIA Refer URGENTLY to hospital
Stridor in calm child or SEVERE DISEASE
Chest indrawing Yellow: Give oral Amoxicillin for 5 days
Fast breathing PNEUMONIA If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled
bronchodilator for 5 days
If chest indrawing in HIV exposed/infected child, give first dose of amoxicillin and refer.
Soothe the throat and relieve the cough with a remedy
If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma
assessment
Advise mother to return immediately
Follow-up in 3 days
No signs of pneumonia Green: If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled
or very severe disease COUGH or COLD bronchodilator for 5 days
Soothe the throat and relieve the cough with a remedy
If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma
assessment
Advise mother to return immediately
Follow-up in 5 days if not improving

DIARRHEA
CLASSIFICATION TREATMENT
Two of the following Pink: If child has no other classification:
signs: SEVERE DEHYDRATION - Give fluid for severe dehydration (Plan C)
Lethargic or OR
unconscious If child also has another severe classification:
Sunken eyes - Refer urgently to hospital with mother giving frequent sips of ORS on the way.
Not able to drink or - Advise the mother to continue breastfeeding
drinking poorly
Skin pinch goes back If child is 2 years or older and there is cholera in your area, give antibiotic for cholera.
slowly
Two of the ff: Yellow: Give fluid, zinc supplements and food for some dehydration (Plan B)
Restless, irritable SOME DEHYDRATION If child also has a sever classification:
Sunken eyes - Refer urgently to hospital with mother giving frequent sips of ORS on the way.
Drinks eagerly, thirsty - Advise the mother to continue breastfeeding
Skin pinch goes back Advise mother when to return immediately
slowly Follow up in 5 days if not improving

Not enough signs to Green: Give fluid, zinc supplements and food to treat diarrhea at home (Plan A)
classify as some or NO DEHYDRATION Advise mother when to return immediately
severe dehydration Follow up in 5 days if not improving

Dehydration Present SEVERE PERSISTENT Treat dehydration before referral unless the child has another severe classification
DIARRHEA
No dehydration PERSISTENT DIARRHEA Advise the mother on feeding a child has PERSISTENT DIARRHEA
Blood in stool DYSENTERY Give ciprofloxacin for 3 days
Follow-up in 2 days

KYZ | EXCELSUS
MALARIA RISK
CLASSIFICATION TREATMENT
Any general sign or Pink: Give first dose of artesunate or oral quinine for severe malaria (under
Stiff neck VERY SEVERE FEBRILE medical supervision
DISEASE Give first dose of an appropriate antibiotic
Treat the child to prevent low blood sugar
Give one dose of paracetamol in clinic for high fever (38.5°C or above)
Refer URGeNTLY to hospital
Malaria test POSITIVE Yellow: Give recommended first line oral antimalarial
MALARIA Give one dose of paracetamol in clinic for high fever (38.5°C or above)
Give appropriate antibiotic treatment for identified bacterial cause of
fever
Advise mother when to return immediately
Follow up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for assessment
Malaria test NEGATIVE Green: Give one dose of paracetamol in clinic for high fever (38.5°C or above)
Other cause of fever PRESENT FEVER NO MALARIA Give appropriate antibiotic treatment for identified bacterial cause of
fever
Advise mother when to return immediately
Follow up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for assessment

MEASLES
CLASSIFICATION TREATMENT
Any general danger sign or Pink Give Vitamin A
Clouding of cornea or SEVERE COMPLICATED Give first dose of an appropriate antibiotic
Deep or extensive mouth ulcers MEASLES If clouding of the cornea or pus draining from the eye, apply
tetracycline eye ointment
Refer URGENTLY to hospital
Pus draining from the eye or Yellow: Give Vitamin A
Mouth ulcers MEASLES WITH EYE OR If pus draining from the eye, apply tetracycline eye ointment
MOUTH COMPLICATION If mouth ulcers, teach the mother to treat with geitian violet
Follow-up in 2 days
Advise mother when to return immediately
Measles now or within the last 3 MEASLES Give Vitamin A
months

DENGUE HEMORRHAGIC FEVER

CLASSIFICATION TREATMENT
Bleeding from nose or gums or Pink: If persistent vomiting or persistent abdominal pain or skin
Bleeding in stools or vomitus or SEVERE DENGUE petechiae or positive tourniquet test are the only positive signs,
Black stools or vomitus or HEMORRHAGIC FEVER give ORS (Plan B)
Skin petechiae or If any other signs of bleeding are present, give fluids rapidly
Cold and clammy extremities or (Plan C).
Capillary refill more than 3 Treat the child to prevent low blood sugar
seconds or Refer all children URGENTLY to hospital
Persistent abdominal pain DO NOT GIVE ASPIRIN
Persistent vomiting or
Tourniquet test positive
No signs of severe dengue Green: Give ORS
hemorrhagic fever FEVER: DENGUE Advise the mother to return immediately
HEMORRHAGIC FEVER Follow-up in 2 days if fever persists or child shows signs of
UNLIKELY bleeding
DO NOT GIVE ASPIRIN

KYZ | EXCELSUS
EAR PROBLEM
CLASSIFICATION TREATMENT
Tender swelling behind the ear Pink: Give first dose of an appropriate antibiotic
MASTIODITIS Give first dose of paracetamol for pain
Refer URGENTLY to hospital
Pus is seen draining from the ear Yellow: Give antibiotic for 5 days
and discharge is reported for less ACUTE EAR INFECTION Give paracetamol for pain
than 14 days, or Dry the ear by wicking
Ear pain. Follow-up in 5 days
Pus is seen draining from the ear Yellow: Dry the ear by wicking
and discharge is reported for 14 CHRONIC EAR INFECTION Treat with topical quinolone eardrops for 14 days
days or more. Follow-up in 5 days
No ear pain and No pus seen Green: No treatment
draining from the ear. NO EAR INFECTION

MALNUTRITION
CLASSIFICATION TREATMENT
Edema of both feet, OR Pink: Give first dose appropriate antibiotic
WFH/L less than -3 z score, OR COMPLICATED SEVERE Treat the child to prevent low blood sugar
MUAC less than 115 mm (6 mos. ACUTE MALNUTRITION Keep the child warm
or older) Refer URGENTLY to hospital
And any one of the following:
Medical complication present,
OR
Breastfeeding problem (up to 6
mos), OR
Not able to finish the noted
amount of RUTF (6 mos. and
older)
MUAC less than 115 mm, OR Yellow: Give oral antibiotics for 5 days.
WFH/L less than -3 z score UNCOMPLICATED SEVERE Give ready-to-use therapeutic food for a child aged 6 months or more
ACUTE MALNUTRITION Re-establish effective breast feeding for a child less than 6 months
AND Counsel the mother on how to feed the child
No medical complication Assess for possible TB infection
No breastfeeding problem Advise mother when to return immediately
(under 6 mos.) Follow up in 7 days
Able to finish the noted amount
of RUTF (6 mos. and older)
MUAC between 115 up to 125 Yellow: A e he child feeding and co n el he mo her on he feeding
mm, OR MODERATE ACUTE recommendations
WFH/L between -3 and -2 z MALNUTRITION If feeding problem, follow up in 7 days.
scores and no edema of both Assess for possible TB infection
feet Advise mother when to return immediately
Follow up in 30 days
MUAC over 125 mm, OR Green: If child i le han ear old a e he child feeding and co n el
WFH/L z scores are -2 or more NO ACUTE MALNUTRITION the mother on feeding according to the feeding recommendations
and no edema of both feet. If feeding problem, follow-up in 7 days

ANEMIA
CLASSIFICATION TREATMENT
Severe palmar pallor Pink: Refer URGENTLY to hospital
SEVERE ANEMIA
Some pallor Yellow: Give Iron
ANEMIA Give mebendazole if the child is 1 year or older and has not had a dose
in the previous 6 months
Advise the mother to return immediately
Follow-up in 14 days
No palmar pallor Green: If he child i le han ear old a e he child feeding and co n el
NO ANEMIA the mother according to the feeding recommendations
If feeding problem, follow-up in 5 days

KYZ | EXCELSUS
IMCI part 1 In the past, the personnel in the health center
Dr. Charles Cabataña attend separate disease specific clinical guidelines
Mar. 8, 2021 and trainings:
o CARI (Control of Acute Respiratory
What is IMCI? Infection
IMCI is Integrated Management of Childhood Illness o CDD (Control of Diarrheal Diseases
What did WHO and UNICEF do to address the high M/M o Dengue fever/ Dengue hemorrhagic
among children <5 years of age? fever
o In 1990s it was found out that there was a high o Tuberculosis, etc
mortality and morbidity rate among children <5 yrs The integration of clinical guidelines is hard so the
old. poor health workers find it hart to integrate all the
o WHO and UNICEF conducted a study and identify disease specific clinical guidelines.
the common causes of the illnesses among WHO and UNICEF integrate ALL the disease specific
children <5 yrs old and the common cause of guideline into one clinical guideline- Integrated
death. Clinical Case Management (ICCM)
o The study able to identify 5 common causes of o Common symptoms are there:
illness and deaths among children: Cough or difficult breathing
1. Pneumonia Diarrhea
2. Diarrhea Fever
3. Measles Ear problem
4. Malaria o See the steps on how to assess in terms
5. Malnutrition of taking the history of the child s illness.
o Others: o Physical examination to identify the signs
1. Ear infections of the child s Illness, which will be
In what level of health facility is IMCI designed? utilized in determining the classification
o First level health facility of the child s illness hich also become
Province: Rural Health center/RHU the identification of the treatment.
City: Barangay Health centers
Hospital (public/private): Outpatient Rational for an integrated approach:
Department
o Started on 1990s
Training of IMCI
Participants were manning the 1st level
facility:
Doctor
Midwife
Rural health nurse
The midwife and nurses are included
because especially in the mountain
barangays, the doctors will just visit the
mountain health centers, once a month.
The certificate after finishing the training
is the License to Assess and Treat sick
children <5yrs old.
What is an integrated approach?

X-axis- no. of symptoms presented by a child when brought

to health facility in Bangladesh.
Y-axis- percentage of children presenting with these
different no. of symptoms.
It was found out that:
o Most children have 1 illness at a time
Ex. 20.5 % of the 1302 subjects of the
study had 3 symptoms when they are
brought to the clinic.

KYZ/GEUN | EXCELSUS
 o Often a single diagnosis may not be possible or o Importance of Nutritional rehabilitation:
appropriate If the malnourished child is left
More often the child present with more unattended, can increase risk of
than one problem infection.
Will have different diagnosis If given treatment and cure, the infection
In IMCI- we DO NOT make a diagnosis of will just be recurred.
the child s illness but simpl determine o Check Immunization status
the classification of the illness. IMCI Strategy:
The classification will tell the severity of o Promotes accurate identification of childhood
the child s illness so it will be the basis of illnesses
deciding whether the child can be By using few objective signs when doing
treated at home/OPD case or be physical examination.
admitted in the hospital. Not request Lab examination and
o Treatment may be complicated by the need to Imaging procedure (not available in all 1st
combine therapy for several conditions level facility).
Not use stethoscope. In pneumonia, the
What is a holistic approach? earliest sign is increase respiratory rate
before rales will develop.
o Ensures appropriate integrated treatment of all
major illnesses.
If the child has cough, diarrhea and
fever, integrate the treatment
o Strengthens counseling of caregivers
Counsel the mother on how to provide
the care at home.
Ex. John has pneumonia and Amoxicillin
is the drug used. Give instructions on
how to prepare the dose amoxicillin and
how often it is given. Demonstrate how
to pulverize, add water and sugar and
give it to the child.
o Identifies the need of and speeds up
Referral of severely ill children
1st thing to do:
Identify danger signs.
What are the key objectives of IMCI strategy?
o To reduce the global morbidity and mortality
o The main concerning in assessing a sick child is among sick children <5yrs old.
using the IMCI strategy is the illness of the sick child Reduce the occurrence or the frequency
(diarrhea, cough, ear problem, etc). of the illness
o Don t only focus on the illness of the sick child. You Reduce the severity and the disability
need to look into the other aspects of child health that comes with the illness if it s not
care: attended promptly.
Nutritional Status Attending to sick children as early as
To determine if there s an possible.
acute malnutrition (severe or Institute the appropriate treatment.
moderate). o Ensure the growth and development among
Immunization Status children.
If there s missed opportunities Looking the other aspects of child
of immunization. health care.
Other Preventive and Promotive Aspects Nutritional status
Give vitamin A Immunization
Deworming- prevent Other preventive and
hookworm infection promotive aspects
Iron
Breastfeeding

o Ex. Child with cough with fast breathing. You

classified it as Pneumonia. You looked into the
nutritional status; the child is moderately
malnourished. You also need to address the
malnutrition. Rehabilitate the child so that the
nutritional status will become normal.

KYZ/GEUN | EXCELSUS
 o Includes both preventive and curative 4. Identify the treatment needed
treatments. o Needs urgent referral (RED)
o Treat in clinic (YELLOW)
o Treat at home (GREEN)

Using IMCI: 2 groups

o Birth up to 2 months
o 2 mos.- 5 yrs. Old (exactly 2 mos.- 4yrs 11months
and 29 days)
o If exactly 5 yrs. old, do not use the IMCI strategy-
the cut off the signs might be different for a child
who is exactly 5 yrs and above.
o Ex. When assessing a child with cough and the age
is between 2 mos and 5 yrs, theirs is a cut off to
say that there is fast breathing. (40 breaths/min).
o >5 yrs (35 breaths/min).

Principles of the Integrated Clinical Case Management

Guidelines:

Curative Treatments
o If the child has pneumonia, give antibiotic
o Anemia- give iron
o Diarrhea- oral rehydrating solution
o Dysentery- give ciprofloxacin
Preventive
o Advising and counseling the mother in
breastfeeding and immunization, etc. (see table).

What are case management guidelines?

o What are utilized in the assessment of sick

children?
Utilized few objective signs
Examples: (check the pic above)
To classify cough or difficulty in breathing:
Count the breaths in 1 min.
Signs of chest indrawing
Signs of stridor
Look and listen for wheezing
o What are the bases in selecting them?
Based on sensitivity and specificity
Sensitivity
Steps that will describe how to provide the care to a sick
Ability of the sign to label a child
child.
with cough or difficult breathing as
1. Check first for the presence of a general danger sign.
having pneumonia.
2. Assess the main symptoms
Specificity
o By taking the history of the illness of the cough,
The ability of the sign to label a
fever, etc.
child with cough or difficult
o Do physical examination
breathing as having NO
3. Make classification based on the physical examination
pneumonia.
Example:

KYZ/GEUN | EXCELSUS
 The age of the child is between 2 mos. to o Do we make a diagnosis of the child’s illness in
12 mos. old. John is 10 mos. old. IMCI? (not answered in this slide but already
We get the respiratory rate- 55 mentioned before)
breaths/min. There is fast breathing (cut In IMCI- we DO NOT make a diagnosis of
off- 50 breaths/min) {refer to pic above}. the child s illness but simpl determine
John, due to his coughs has pneumonia. the classification of the illness
If getting the RR of John, it s 40 Classification of illness is based on a color-coded triage
breaths/min, it doesn t reach the cut off, system:
so John doesn t ha e pneumonia o What is the basis of the classification of the
o How is a classification of a child’s illness child’s illness?
determined? Based on a color-coded triad system
CLASSIFICATION TABLE o What does pink , yellow and green
(MEMORIZE! Part of 3rd Bimonthly) classification mean?
Any general Pink: Give first dose of an Importance of classifying the child s
danger signs SEVERE appropriate antibiotic illness is to be able to decide where to
Stridor in PNEUMONIA or Refer URGENTLY to hospital treat the child.
calm child SEVERE DISEASE PINK- severe disease, needs urgent
Chest Yellow: Give oral Amoxicillin for 5 referral
indrawing PNEUMONIA days YELLOW- as an Outpatient case. Give a
Fast If wheezing (or specific medical treatment (giving an
breathing disappeared after rapidly antibiotic)
acting bronchodilator) GREEN- can be treated as an outpatient
give an inhaled case. No specific medical treatment
bronchodilator for 5 days given. Give supportive tx. If there s
If chest indrawing in HIV cough, soothe the throat and relieve the
exposed/infected child, cough with a safe remedy (Calamansi
give first dose of juice). The best mucolytic is WATER.
amoxicillin and refer. What are case management charts?
Soothe the throat and
relieve the cough with a
remedy
If coughing for more than
14 days or recurrent
wheeze, refer for possible
TB or asthma assessment
Advise mother to return
immediately
Follow-up in 3 days
No signs of Green: If wheezing (or
pneumonia or COUGH or COLD disappeared after rapidly
very severe acting bronchodilator)
disease give an inhaled
bronchodilator for 5 days
Soothe the throat and
relieve the cough with a
remedy
If coughing for more than
14 days or recurrent
wheeze, refer for
possible TB or asthma
assessment
Advise mother to return
immediately
Follow-up in 5 days if not
improving
When making the classification for
cough or difficult breathing, the rule is
that to start at the pink row and look at o Show sequence of steps
the signs. When assessing and treating a sick child,
In making a classification of cough, it follow six (6) steps:
will require 1 sign only. Assess the sick child
Assessment box in the chart

KYZ/GEUN | EXCELSUS
 Check general danger signs Parts of the IMCI cases management charts:
and ask 3 questions (refer to
pic above).
o Provide info on how to perform the different
steps
1. Assess
2. Classify
3. Identify treatment
4. Treat the sick child
5. Counsel the mother
6. Provide follow-up care
o WHO has assembled this series of charts into the
IMCI chart booklet.
2 case management charts:
Birth- 2 mos.
2mos- 5yrs old

o What is the basis in the selection of appropriate

case management chart for sick children?
Based on the AGE of the child.

1. ASSESS column
o It is utilized to take history of the child’s illness,
identify the signs and make the classification of
the cough or difficult breathing or the
classification of the four main symptoms which
are cough, difficult breathing, diarrhea, fever and
ear problem.
o Ask only 1 to 2 question to not delay assessment.
o Do physical examination

2. CLASSIFY column (check the CLASSIFICATION TABLE)

o Lists Signs & classification of the child’s illness.
o Classify means help to determine the severity
of the illness so that you will know where to
treat the child.
o State the importance of classifying a child’s
illness.
o To determine on where and how to
treat the child.
What is IMCI Integrated Case Management Process?
o What are the 6 steps involved? 3. IDENTIFY TREATMENT column
1. Assess o Helps you to identify the relevant treatment.
2. Classify o Pneumonia- you chose in the classification table
3. Identify treatment which considered relevant for the classification
4. Treat the sick child and the signs that you were able to identify.
5. Counsel the mother 4. TREAT chart
6. Provide follow-up care
o What is its importance? Step by step basis
Ensure correct assessment of the child s
illness and the institution of an
appropriate treatment plan.

o Shows on how to administer or institute the Tx.

KYZ/GEUN | EXCELSUS
 5. COUNSEL the Mother Chart:
o Who are their clients?
Birth-2 mos. old
2 mos.- 5yrs old
o It is intended for a first-level facility, such as:
Province: Rural Health center/RHU
City: Barangay Health centers
Hospital (public/private): Outpatient
Department
Private clinics: Outpatient
Case recording forms:

o Assesses and gives recommendations on

o Home treatments
o Feeding and fluids- diarrhea
o When to return for follow up or return
immediately
o Counsel the mother on her on health

6. Give FOLLOW-UP Care chart

o Designed to help you systematically

1. Record information on: History of the illness
& the signs that you have determine during
the physical examination.
If the signs and symptoms is on the
list, encircle. If not, leave as it is.
After assessing, always make a
classification.
2. Write treatments needed for its
classifications & the treatment procedure.
At the back, write treatment across
its classification.
Ex. Ear infection- teach the mother
how to dry the ear by wicking.
o Select a case recording form appropriate to the
AGE of the child.
You have to teach the mother in drying the air by wicking or wicking
the ear dry
Pls. refer to page 7 of module 2 (recording form for the management
o Describes steps for _____.
of the sick young infant aged up to 2 months/ management of te sick
o There will be follow-up boxes depending
child aged 2months up to 5 years)
on the classifications made in the initial
** What is the basis of selecting a case recording form? It is based on
visit.
the age of the child.
o At a follow-up visit, you determine whether the
child’s condition is improving, responding to the
treatment or the child’s condition has worsened
so that you can refer the child to the hospital
Who can use the IMCI case management process?
o Doctors, midwives and nurses manning the 1st
level health facility.
o Should have attended the training in IMCI.

KYZ/GEUN | EXCELSUS
IMCI: ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5
YEARS

Ask mother about the child’s problems:

First step after determining child s problems or complaints is to

CHECK ALL SICK CHILDREN FOR GENERAL DANGER SIGNS:

ASSESMENT BOX FOR CHECKING GENERAL DANGER SIGNS:

When asking, you should always:

1. Greet the mother appropriately

E.g. Welcome Jean, good morning. Then offer a seat to make both
mother and child comfortable. So the client will feel that you are
responsive to the needs of her sick child.
2. Use good communication skills
Use the dialect for the mother to be able to understand you and when General danger signs if:
you start asking questions, ask in a manner that the mother can - Child is not able to drink or breastfeed
understand Don t use medical terms not understood b the mother If How to determine? E.g. jean have you given john a drink at home?
she can t gi e ou the ans er right a a be patient or rephrase the Describe to what happens after giving a cup of water? (If child is old
question so that the mother can understand it and give you the enough Then she tells ou john doesn t drink asn t able to drink
information required to be able to make a good assessment of the the water I gave him. Then this could mean that he is not able to
child s illness condition drink and thus a danger sign.
3. Find out the child’s age
Because this will be the basis in selecting the appropriate case When will a child not be able to drink? When he/she has a severe
management chart and the case recording form. disease that the child becomes very weak and is unable to hold a cup
4. Look to see if the child’s weight and temperature have or glass of water, put it to his mouth and swallow the water.
been measured and recorded
If not determine the child s eight because it ill be the better basis E.g. John has been coughing for 5 days and you notice that is he is
in determining the dose of the drug Take the child s temperature to lethargic?
know if he/she has fever. What makes a child with cough have changes in their level of
5. Ask the mother what the child’s problems are consciousness If a pneumonia is se ere enough there ll be an
E g Jean h ha e ou brought John toda Then she ll tell ou that impairment in gas exchange and therefore affect the oxygenation of
he has been coughing for 5 days etc. tissues in the body. One effect is hypoxia, and the muscles will not get
6. Find out if this is an initial or follow-up visit for this the required O2 required which will be utilized as the final acceptor of
problem. the protons and electrons moving in the diff. components of the ETC.
Initial visit: the first time mother brought her sick child for a Thus, insufficient oxygen will lead to insufficient ATP synthesized
consultation. thereby making the child very weak. Also the energy needed for
Follow-up visit: visit made after having made an initial visit where the muscles to contract is insufficient for the child as he holds a cup and
child had already been given treatment and where the mother returns put it into his mouth to drink and swallow.
for follow-up care. Then you provide the care needed to determine if
the child s condition is improving, not improving, or is worsening. Or Jean, is john able to suckle from your breast? The danger is present
if he is unable to attach to his mother s breast or he is unable to suckle
and swallow breast milk.

KYZ/GEUN | EXCELSUS
 - Vomiting everything means that anything taken in (whether
drug, food or fluid) cannot be held/kept in the stomach, and
all vomited out.

E.g. If there are 3 episodes of vomiting, all that had been taken in
should e been omited out in all 3 episodes to say that he is vomiting
everything. If only 1 out of the 3 episodes where all that has been taken
in has been omited out then e don t sa that the child is omiting
everything.
After asking the 3 questions, look to see if the child is lethargic or
unconscious Do PE A child is lethargic if he she is dro s doesn t to
seem to show interest in what is going on in the environment /
unresponsive when you clap or snap your finger. E.g. Fatima has been having cough and trouble breathing, and on
A child is unconscious when he/she cannot be wakened whether you checking for general danger sign, she is unconscious. Therefore, in the
touch, handle or shake the child. classification for the general danger sign ou ll rite er se ere
disease. If there is presence of any one of the general danger signs in
Determine if the child is convulsing now. the table, you make the classification as very severe disease.

In IMCI, it is not specific in determining the level of consciousness. We What is the classification of a child who has coughs or
just determine if child is lethargic or unconscious. difficulty breathing and has any of the 4 general danger
(Conscious- if awake, alert or responsive to any form of stimulus signs? VERY SEVERE DISEASE
whether applied or present in the environment. State the 3 actions to be taken if during assessment you
Lethargic- child is sleepy and the way for him to respond is by calling found presence of a general danger sign.
his name or wakes up by stimulus of name calling then upon stopping,
he becomes drowsy/sleepy again. 1. Quickly complete the physical examination.
Obtunded- doesn t respond after name is called ou ha e to tap his 2. Identify the urgent pre-referral treatment that would be
shoulder as well for him to respond and wake up but after withdrawal needed and administer this prior to referral because they
of stimulus, he will be drowsy again. can be life-saving.
Stupor- requires application of pain to elicit response. 3. Refer/send the child to the hospital
Unconscious- child doesn t ake up no matter ho painful the
stimulus is.) E.g. there is cough and very severe disease, then you move to the 1st
After asking the 3 question and looking for the 2 signs, we are now main symptom and found out that there is a sign of pneumonia. Due
ready to make a classification for general danger signs. to the presence of a danger sign, then the classification for
pneumonia would be severe pneumonia or very severe disease. Then
What are these convulsions that are convulsions that are you are going to identify urgent pre-referral treatment for a severe
considered a life threatening danger sign? pneumonia, one of it would be the 1st dose of an antibiotic. However,
o In children aged <6 months: since the child is unconscious ou don t gi e the first dose as an oral
- Any convulsion regardless of duration (whether it has preparation like first dose of amoxicillin which can be aspirated by the
reached > or < 15 mins) and regardless of frequency child and lead to death by asphyxiation. Thus the 1 st dose of the drug
(whether > or < 1 episode) will always be considered life- is an injectable gentamycin and ampicillin. Be careful in giving the
threatening. urgent pre-referral treatment so as not to add insult to the injury that
In IMCI, we consider our clients as a child regardless of their age. is already present.
It is not specific like at birth (newborn), bet. 0-28 days (neonate),
day 29 onwards (infant), 1 year & above (young child) then older HOW TO ASSESS A CHILD WITH COUGH OR DIFFICULTY BREATHING
child. Assess cough/difficult breathing
o In children aged >6 months:
No. of episode: more than 1
Duration: >15mins per episode

When is convulsion not considered a general danger sign?

o Age of child: > 6months
o No. of occurrence: only once
o Duration: <15 minutes and especially when it
occurs at the height of fever. This type of
convulsion is termed BFS/Benign Febrile Seizure
w/c is triggered by fever occurring in the child.

First, ask the mother, does the child have cough or difficult breathing?
Take note that ou don t ha e a question to be asked hether the child
has a general danger sign. Ask these questions right away. Is the child
able to drink/ breastfeed? Unlike in the cough assessment box, you
have to ask the mother for the presence of the main symptom. If jean

KYZ/GEUN | EXCELSUS
tells ou no he doesn t ha e cough or difficult breathing then skip the o Similar to what is done in detecting stridor. If
assessment box for cough. But if she tells you that John has been sound is heard when upper chest wall is moving in/
coughing for 3 days, then you assess by getting inside the assessment expiration, then sound heard is wheezing.
box. If she tells you no but john is coughing in front of you, assess him o Wheezing is a musical sound heard due to the
for cough and difficult breathing and do not reprimand the mother. entry of air into a narrowed lumen of an airway. In
Don t make an unnecessar or negati e comments asthma this is due to bronchoconstriction and
inflammation of the epithelial lining of the airway
Ask for how long the child is coughing to determine if it is acute or and accumulation of mucus.
chronic since the management for each is different. o A stethoscope is not used to auscultate for
o Acute if <14 days/2 weeks wheezing in the lungs. Do it as previously stated.
o Chronic if > 14days/2 weeks
After doing all 4, make a classification for cough/difficult breathing.
Then determine the signs related to cough or difficult breathing. However, if child has wheezing and either fast breathing/chest
Look listen feel indrawing, give a trial of rapid acting inhaled bronchodilator for up to
- In counting the breaths in one full minute the child must be 3x 15-20 minutes apart. Count the breaths and look for chest indrawing
calm, not crying/eating/breastfeeding because this can again, and then classify.
increase the RR. Inhaled bronchodilator used: salbutamol w/c may be given
o Just check for the presence of breathing by nebulization (immediate effect) or via a metered dose
movements on the chest/abdomen. Do not inhaler (if <5 y.o. give this via a metered dose inhaler using a
undress the child onl do so if ou can t see an spacer)
breathing movements on the chest/abdomen.
o Why in 1 full minute? Breathing in children can be E.g. after 1st dose there is no more fast breathing/chest indrawing, this
irregular, counting w/in 15secs and multiplying by tells you that the cause for wheezing is asthma and not pneumonia.
4 gives an inaccurate count. Use a wristwatch. However, if after the 1st dose, fast breathing/ chest indrawing persists
Then refer to the table to determine if the cut-off then give the 2nd dose If it s still present after the nd and/or 3rd dose,
for fast breathing has been reached. then this means that wheezing is due to pneumonia.
E.g. cut-off for child who is between 2months-11months and 29 days
is breaths min If it s then there is fast breathing Then record RULES IN MAKING A CLASSIFICATION
this info in the recording form. Write the number of breaths and
encircle fast breathing If it s onl rite the number of breaths/min
and do not encircle fast breathing.
If child is exactly 12mos. Up to 5 years, cut off is 40.
- Look for chest indrawing. Child must be calm and let mother
undress the child to see the entire chest wall and recognized
the presence of mild chest indrawing w/c is a also a sign of
pneumonia.
o This is the inward movement of the lower chest
wall when child breaths in (inspiratory part of the
respiratory cycle). This is not equivalent to
intercostal space retraction w/c is the moving in of
the intercostal spaces during inspiration nor is it
equivalent to subcostal retraction. This refers to
the drawing in of the subcostal space.
o Normal pattern of breathing: during inspiration,
the upper chest wall moves out because the chest
expands and the lower chest wall also moves out.
o It is present when lower chest wall is moving in at
1st rule: Start in the pink row. Requires only 1 sign to classify cough as
all times and not only when child is crying/eating.
sever pneumonia or very severe disease.
2nd rule: if no sign in pink row, move down to yellow row.
- Look and listen for stridor.
3rd rule: if no sign on the yellow row. Move down to green row.
o Stridor is a harsh sound made during inspiration.
This is due to swelling in the epiglottic area or
If there is one sign on the pink ro and ello ro ou re decision is
trachea in a disease called croup. As air moves
to choose the severe classification. If there is danger sign or stridor,
inside, a harsh sound is created.
then it means that the child has a very severe disease. If you chose
o This is determined by letting the child lie down and
pneumonia, there is the risk that the child can die from a very severe
put our ear near the child s nose or mouth to
pneumonia/disease when treated at home.
listen for stridor while at the same time looking at
the upper chest wall/abdomen when they are
Acute asthmatic attack classification falls under cough or cold.
expanding to determine when the sound occurs. If
Common cause for chronic cough is TB or asthma.
it is during inspiration or expiration. If it occurs
during inspiration, then the sound heard is stridor.

- Look and listen for wheezing.

KYZ/GEUN | EXCELSUS
HOW TO ASSESS A CHILD WITH DIARRHOEA because he is thirsty due to dehydration. (Sign: drinking eagerly,
thirsty).

Drinking poorly: child is weak but when offered assistance in giving a

drink of water, the child is still able to swallow it.
Drinking normally: if you offer water then withdraw it, the child will
not be asking for some more water/expressed breast milk because he
is not dehydrated.

Best site to determine skin turgor: pinch the skin between the
umbilicus and the lateral side of the abdomen. Use the ball of your
thumb and knuckle of index finger in grasping the skin and making fold
of skin Don t use tip of fingertips as it ill be painful After making a
vertical fold of skin along the vertical axis of the body, release it and
observe how the skin fold returns back to its original state.

If the return is >2seconds, skin pinch goes back very slowly.

Ask mother if the child has diarrhea and assess for signs related to it. This is a sign of severe dehydration.
First ask the 2 questions. Asking the duration is important in Skin pinch goes back w/in 2 seconds, skin pinch goes back
determining if diarrhea is acute or chronic. (Remember the cut-offs!) slowly. This is a sign of some dehydration.
Acute: having loose bowel movements for <14 days Skin turgor is normal, if skin fold returns immediately to its
Chronic: having loose bowel movements for > 14 days original state.

Chronic diarrhea is termed as persistent diarrhea in IMCI. Treatment

for acute and persistent diarrhea is the similar but there are
differences.
(Write this info in the space provided on the recording form under
duration)
Ask for presence of blood in the stool to know if there is dysentery. This
is a type of diarrhea w/ blood in stool which is commonly caused by
Shigella.
(Encircle this info in the recording form)

If patient is not lethargic/unconscious, determine if child is restless &

irritable. Child is restless & irritable if when touched or handled,
becomes restless and irritable or is not pacified by giving food/water
or drink/ letting the mother handle or cuddle the child. Meaning all the
time, the child is restless & irritable. The continuous restlessness &
irritability is due to dehydration. Unless dehydration is corrected in a
child with diarrhea, then he will stay restless & irritable. However, this 3 possible classifications in a child w/ diarrhea:
sign is considered absent if child is pacified by either of those 1. Dehydration
previously mentioned. 2. Persistent diarrhea
3. Dysentery
Sunken e es ask mother to describe child s eyes before an episode of
diarrhea and during an episode of diarrhea Don t ask a leading A classification which should always be present is the classification for
question like is the child s e e sunken dehydration. Additional classification of persistent diarrhea is only
added if duration is >14days or more and dysentery is only added when
Thirst. Best fluid to offer in checking for thirst is: there is blood in the stool.
- Water: for infants not exclusively breastfed (starting at 7
months old onward) So, start in the pink row. 2 or more signs needed to classify as severe.
- If child is <6months (still in exclusive breastfeeding), fluid If onl one then ou don t ha e enough signs to make the classification
used is expressed breast milk. (2-6 months of age) severe dehydration, and must move down to the yellow row. If 2 or
more signs present, classified as some dehydration. But if only 1 sign
Why not a sweetened beverage like juice/cola? Anything that tastes present, move down to green row and classification would be no
sweet, children will love to take it and you might label the child as dehydration.
drinking eagerly because he is thirsty. ORS is also not used because
child might not find it palatable and refuse to drink, thus making you To make classification of persistent diarrhea, duration must be >14days
consider the child as not being able to drink/drinking poorly. Thus, and start at pink row. If dehydration present whether some/severe,
water/expressed breast milk is used. If child is young/newborn/infant, classify as severe persistent diarrhea. If no dehydration present, then
fluid is offered to the mouth by using a teaspoon or dropper and let the additional classification would be persistent diarrhea. If duration is
mother place infant in an upright or semi-upright position. If child da s don t make an additional classification of persistent diarrhea.
cries/grabs the spoon or cup, this tells you that the child wants to drink

KYZ/GEUN | EXCELSUS
IMCI Part 2.1 could be lesser or low risk of malaria
Doc Cabataña being the cause of fever.
March 22, 2021 2. Ak F h l g ha he child bee ha i g fe e
texts on black font color: side notes (from lecture) If the mother will say more than 7 days, proceed
texts on red font color: notes from the ppt to (number 3).

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) 3. If more than 7 days, ask: Has fever been present
ASSESS FEVER e e da
HOW TO ASSESS A CHILD WITH FEVER If there is fever for more than 7 days, and usually
if it will last for more than 2 weeks or more, then
you will now be entertaining typhoid fever as the
cause of the fever of the child.

4. A k Ha he child had ea le i hi he la
h
If the answer to this question is yes, then you
don proceed immedia el o making a ph sical
examination to look for signs related to fever. But,
what you do if the answer of the mother is yes, is
first to check for complication of measles.

Figure 1. D e he chi d ha e fe e .
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014)

DOES THE CHILD HAVE FEVER?

-Assess if the child has fever through:
1. Fever based on History
Ask he mo her if he child has fe er a home Does John
had fe er a home
If the mother says yes, then the child is having
fever at home based on history.
.2. Upon the visit, feel for the body temperature
When the mother brings the child to the health facility, feel
for hotness or body temperature of the child through: Figure 2. Assessment for Complications of Measles.
Placing the palm on the stomach or insert your (Image lifted from: IMCI, Chart Booklet, WHO, March 2014; ICATT,
hand into the axilla of the child. WHO, Swiss Tropical, & PHI, Novartis Foundation)
If it feels hot on the stomach or axilla,
then you say that the child has fever Assess for Complications of Measles:
also. What are the complications of Measles?
If you have thermometer, then you measure the Mouth Ulcers
body temperature Look for mouth ulcers in the oral cavity:
If it reaches 37.5°C and above, then you lips, tongue, buccal mucosa
will say that the child has fever. Mouth ulcers are open sores that are
painful and can make the child difficult
-If yes, to eat because these lesions are painful
1. Decide if there is malaria risk, meaning it would be Check if these ulcers are deep and
possible that the cause of the fever could be malaria. extensive (if there are many lesions in
When do we decide that there is risk for malaria? the oral cavity)
Ask if they/ if the child has visited malarial- Pus Draining from the Eye
infested area in the past 2 or 3 weeks. Because measles can also cause
in that place also, malaria is endemic, conjunctivitis
meaning the cases are there all year Clouding of the Cornea
round. Look at the cornea, the transparent
and sometimes, it could not be all year material in the eye.
round because it is the mosquitoes that Presence of haziness in any portion of
will transmit the cause of the malaria. If the cornea is an indication of clouding
it is not during the rainy season, there of the cornea. Whitish material (seen

1|MJ CR
 in the picture below) is the cornea 1. Let the mother lie the child
being affected by measles. flat supine on a bed.
2. Insert the hand and support
the shoulder with one arm
and use the other arm with
the hand bending the head
forward.

If there is no stiffness of the neck when

bending he child s head for ard
o ards he ches sa or label as no
s iffness .
If there is stiffness of the neck when
bending the child s head for ard
o ards he ches sa or label as here
Other Complications of Measles is a s iff neck .
Pneumonia Other sign of stiff neck will be: the child
will resist his head being bent forward.
But you do not check
-Why will a child resist on bending his
Pneumonia under this part
head forward? Reason: if a child has a
because when you will be
neurological problem like the
assessing the child for cough
meningitis or encephalitis, bending the
and difficulty of breathing,
head forward will increase the
then you will be able to pick
intracranial pressure. If there is an
up that complication of
increase of the intracranial pressure, it
measles.
will now stimulate pain receptors and
Encephalitis
cause pain on the part of the child.
You will be able to check it
Tha s h child would resist on
when you look and feel for
bending his head forward.
stiff neck.
Diarrhea
Look for runny nose
A child with measles can have
Runny nose- common cause of fever
diarrhea. Same with
Common colds and rhinitis (rhinitis is in
pneumonia, not under the
infectious form, not the allergic rhinitis)
assessment for complications
of measles because when you
Look for any bacterial cause of fever
assess the child for diarrhea,
SIGNS OF BACTERIAL INFECTION
then you can pick it up if the
may be:
diarrhea is a complication of
1. A local tenderness
measles.
2. Refusal to use a limb
3. Hot tender swelling
(continuation for Figure 1)…
4. Red tender skin or boils
5. Look and feel for:
5. Lower abdominal pain
Look or feel for stiff neck
-this could be due to acute
A. LOOK FOR STIFF NECK
appendicitis when it is in the right
Look first. Observe the child. If the child
lower quadrant area.
will move his head to the right & left or
6. Pain on passing urine in older
up and down, then you will not say that
children
the child has stiff neck.
-this could be due to urinary tract
If the child will not be moving his neck,
infection (UTI).
stimulate the child. Use a pen light then
Look for signs of measles
move the light from the head to toes
Generalized rash
and check if the child follows the light
Described as maculopapular
you are flashing from up to down or to
rashes that starts from the
the sides by moving his head.
head and moves down to
B. FEEL FOR STIFF NECK
lower extremities.
If you are not able to observe that the
Sho ld be generali ed
child is still not moving his head, you
Could also be associated with either of
can now feel for the stiff neck.
the three/ one of these: cough, runny
How to feel for the stiff neck?

2|MJ CR
 nose (coryza), or red eyes (or Malaria test Give recommended first line
conjunctivitis) POSITIVE oral antimalarial
If here s measle d ring he Give one dose of paracetamol
examination, then check for in clinic for high fever (38.5°C or
complications of measles (back to above)
Figure 2). Give appropriate antibiotic
treatment for an identified
bacterial cause of fever
Follow-up in 3 days if fever
CLASSIFICATION OF FEVER
persists
If fever is present everyday for
more than 7 days, refer for
assessment.

Yellow:
MALARIA
Malaria test Give one dose of paracetamol
NEGATIVE in clinic for high fever (38.5°C or
Other cause of above)
fever PRESENT Give appropriate antibiotic
treatment for an identified
bacterial cause of fever
Advise mother when to return
immediately
Follow-up in 3 days if fever
persists
Figure 3. Classification of Fever with Malaria Risk.
If fever is present everyday for
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014) Green: more than 7 days, refer for
FEVER assessment
NO
MALARIA

Table 2. Classification of fever without Malaria risk and no history of

travel to Malaria risk area.
Any general Give first dose of
danger signs artesunate or oral
or quinine for severe
Stiff neck malaria (under medical
supervision)
Give first dose of an
appropriate antibiotic
Treat the child to
prevent low blood sugar
Figure 4. Classification of Fever without Malaria Risk. Give one dose of
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014) Pink: paracetamol in clinic for
VERY high fever (38.5°C or
SEVERE above)
Table 1. Classification of fever with Malaria risk. FEBRILE Refer URGENTLY to
DISEASE hospital
Any general Give first dose of artesunate or
danger signs or oral quinine for severe malaria No general Give one dose of
Stiff neck (under medical supervision) danger signs paracetamol in clinic for
Give first dose of an No stiff neck high fever (38.5°C or
appropriate antibiotic above)
Treat the child to prevent low Give appropriate
blood sugar antibiotic treatment for
Give one dose of paracetamol any identified bacterial
in clinic for high fever (38.5°C or cause of fever
above) Advise mother when to
Pink: Refer URGENTLY to hospital return immediately
VERY Follow-up in 2 days if
SEVERE fever persists
FEBRILE If fever is present every
DISEASE day for more than 7

3|MJ CR
 Green: days, refer for If mouth ulcers, teach
FEVER assessment the mother to treat
Yellow: with geitian violet.
There are 2 classification tables for fever: MEASLES WITH EYE Follow-up in 2 days.
-for with Malaria risk OR MOUTH Advise mother when to
-for no Malaria risk and no history of travel to Malaria risk COMPLICATIONS**** return immediately.
area Measles Give Vitamin A
now or
Check signs from pink row to the green row. within the
last 3 Green:
months MEASLES
For Table 1, yellow row (malaria):
-What will be the Malaria test that you will do after noting
When you classify for measles, you start with the pink row
that there is Malaria risk?
and need 1 sign only (or maybe all of them. But, the
you can do a Peripheral Blood Smear so
requirement is only 1 sign to be classified as severe
that the causative microorganisms can
complica ed measles an general danger sign or
be identified, the Plasmodium
clo ding of he cornea or deep or e ensi e mo h
falciparum or the Plasmodium vivax.
lcers .
Rapid Antigen Test
If there are no signs in the pink row, proceed to yellow row
I is an and and or classifica ion
If Malaria test is negative, proceed to green row (fever: no malaria):
-Note also if there are other causes of fever (as mentioned If the sign is only the pus draining from
above): pneumonia, diarrhea, and so on. he e e i is classified as Measles i h
e e complica ions .
If the sign is only the mouth ulcers, it is
CLASSIFICATION OF MEASLES classified as Measles i h mo h
complica ions .
If bo h signs Measles i h e e and
mo h complica ions .
If there are no signs in the yellow row, move down to the
green row.

ASSESS DENGUE HEMORRHAGIC FEVER (DHF)

ASK:
Has the child had any bleeding from the nose or
gums or in the vomitus or stools?
In the vomitus, there could be blood if
there is GIT bleeding esp. in the
stomach or upper intestine areas.
Black stool- bleeding in the stomach or
Figure 5. Classification of Measles. upper intestine
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014) Has the child had black vomitus?
Has the child had black stools?
Table 3. Classification of Measles. Has the child had persistent abdominal pain?
Any general Give Vitamin A Pain is due to GIT bleeding
danger signs Give first dose of an Pain is not related to fluid or food intake
or appropriate antibiotic
problem
Clouding of If clouding of the
Has the child had persistent vomiting?
cornea or cornea or pus draining
Deep or from the eye, apply
extensive Pink: tetracycline eye
mouth SEVERE ointment
ulcers. COMPLICATED Refer URGENTLY to
MEASLES**** hospital
Pus draining Give Vitamin A.
from the eye If pus draining from
Bleeding from nose
or the eye, apply
Mouth tetracycline eye
ulcers ointment.

Bleeding from gums Skin petechiae

4|MJ CR
LOOK AND FEEL: If pressure midway is 100
Look for the bleeding from nose or gums. mmHg, raise the pressure of
Presence of blood clot in the nose- sign the child to 100 mmHg and
of bleeding keep pressure for 5 minutes
Look for the skin petechiae After 5 minutes, deflate the
Skin petechiae- red patches or spots cuff
found on the skin of the child Make an imaginary one-
How do you check/ ensure that these square inch on the arm below
are skin petechiae? Stretch the portion the lowest portion of the cuff
of the skin at site where there is placed
suspected petechiae. Check if the red Count how many petechiae
color persists after stretching, then are inside this one-square
those lesions are petechiae. inch
Most likely to occur/form when the If more than 20 petechiae
platelet count drops to less than 50,000 noted, tourniquet test is
Feel for cold and clammy extremities positive and a sign of DHF
Touch the arm or lower extremities if
cold or clammy (moist) at the same CLASSIFICATION OF DENGUE HEMORRHAGIC FEVER (DHF)
time, this could be a sign of shock.
If cold and clammy, check for slow
capillary refill. (test is called: Capillary
Refill Test or CIT)
How to perform CIT?
o Apply enough or minimum
pressure on the thumb or big
toe of child to make pink nail
bed disappear, then release it
o Take note the seconds when
the pink nail bed return.
o If more than 3 seconds, CIT is
positive.

If none above ASK or LOOK and FEEL signs are present and
Figure 6. Classification of Dengue Hemorrhagic Fever (DHF).
the child is 6 months or older and fever is present for more
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014)
than 3 days
Perform the tourniquet test Table 4. Classification of Dengue Hemorrhagic Fever (DHF).
Do not perform this test to all children Bleeding from If persistent vomiting or
with fever. You have to satisfy the 3 nose or gums persistent abdominal pain
criteria: or or skin petechiae or
1. No signs for the ASK and Bleeding in positive tourniquet tests
LOOK and FEEL present stools or are the only positive signs,
2. Child s age mon hs or older vomits or give ORS (Plan B)
3. Fever for more than 3 days Black stools or If any other signs of
How to perform tourniquet test? vomitus or bleeding are present, give
Skin petechiae fluids rapidly (Plan C)
Get the systolic and diastolic
or Treat the child to prevent
blood pressure, then raise the
Cold and low blood sugar
bp midway using the
clammy Refer all children
sphygmomanometer
extremities or URGENTLY to hospital
between systolic and diastolic DO NOT GIVE ASPIRIN
Capillary refill
pressure. more than 3
What is a bp midway between seconds or
systolic and diastolic? Persistent
Add sys and dia bp abdominal
(Ex. 120 + 80= 200) pain
Get the average or Persistent Pink:
vomiting or SEVERE
divide by 2
Tourniquet DENGUE
(200 ÷ 2= 100)
test positive HEMORRHAGIC
Pressure Midway:
FEVER
100 mmHg

5|MJ CR
 No signs of Give ORS -► Importance of still checking the pus draining and the
severe dengue Green: Advise mother when to swollen & tender bone: since acute or chronic ear problem
hemorrhagic FEVER: return immediately (Otitis media) is common in the Philippines.
fever DENGUE Follow-up in 2 days if fever o Otitis media is of concern because once the
HEMORRHAGIC persists or child shows tympanic membrane will rupture, it becomes
FEVER signs of bleeding infectious.
UNLIKELY DO NOT GIVE ASPIRIN o The microorganisms present in the middle ear
cavity will cause pus to collect and pressure
In the pink row, need only one sign. So, if you have one sign
increases
or more of the DHF, then the classification is Severe DHF.
o Increased pressure can cause the tympanic
If here s no sign of he pink ro mo e do n o he green
membrane to rupture and may impair the hearing
row. So, the classification is Fever: DHF Unlikely. But, even
of the child
if it is unlikely, you have to continue monitoring the child for
o Impairment of hearing can affect the growth and
signs of DHF.
development of the child. It can affect:
Do not give aspirin to children with fever. Aspirin can speech development
destroy or impair platelet function and may lead to
performance in school
bleeding.
Intelligence quotient (IQ)
The best antipyretic for children is the paracetamol.
CLASSIFICATION OF EAR PROBLEM
ASSESSING THE EAR PROBLEM Table 5. Classification of Ear Problem.
Tender Give first dose of an
swelling appropriate antibiotic
behind the Give first dose of
ear. Pink: paracetamol for pain
MASTOIDITIS Refer URGENTLY to hospital
Pus is seen Give an antibiotic for 5 days
draining from Give paracetamol for pain
the ear and Dry the ear by wicking
discharge is Follow-up in 5 days
reported for
less than 14 Yellow:
days, or ACUTE EAR
Ear pain. INFECTION
Pus is seen Dry the ear by wicking
Figure 7. Assessment of ear problem. draining from Treat with topical quinolone
(Image lifted from: IMCI, Chart Booklet, WHO, March 2014; ICATT, the ear and eardrops for 14 days
WHO, Swiss Tropical, & PHI; Norvatis Foundation) discharge is Yellow: Follow-up in 5 days
reported for CHRONIC
14 days or EAR
DOES THE CHILD HAVE AN EAR PROBLEM? more. INFECTION
If YES, No ear pain No treatment
-► Ask: and NO pus Green:
o Is there ear pain? seen draining NO EAR
o Is there ear discharge? from the ear. INFECTION
If yes, for how long?
Acute Ear Problem: if the ear discharge is To dry the ear by wicking
present for less than 14 days. Use a thick tissue paper, roll and make a wick
Chronic Ear Problem: if the ear discharge is Insert the wick inside the ear of the child to
present for more than 14 days. absorb pus
-► Look and Feel: Continue wicking until no more pus in the ear
o Look for pus draining from the ear Importance of wicking: for the ear to be clean
o Feel for tender swelling behind the ear from pus and the quinolone drop will be instill
-► Classify Ear Problem properly to promote healing.
If NO, Cotton buds is not recommended to be used for
-► Still have to look into the ears of the child to check for wicking since the cotton may fall off from the
pus draining. (this practice is adapted/implemented in Phil.) stem and be retained in the ear cavity of the child
-► Check also the bone behind the ears, the mastoid bone, and have another ear problem.
if it is swollen. If swollen, you have: Thin tissue paper is not recommended because it
o to feel if it is tender or painful migh be lef also in he child s ear
o press it, check if it will be depressed

6|MJ CR
 CHECK FOR ACUTE MALNUTRITION AND ANEMIA o State the importance of plotting the weight of
the child against his length or height.
Weight-for-height
Used if child is 2 years or older
Plot the weight of the child in
kilos against the height of the
child in centimeters
One way of monitoring the
growth of the child (if normal
or has problems related to
growth- malnourished)
Used this to determine the
thinness of the child
Weight-for-length
Used if child is less than 2
years old

Figure 8. Assessment of Acute Malnutrition.

(Image lifted from: IMCI, Chart Booklet, WHO, March 2014)

To Check Acute Malnutrition

No need to ask questions, proceed to look and feel
LOOK AND FEEL
o Look for edema of both feet (+) (++) (+++)
Edema is +1
Limited on the foot, does not
go up beyond the ankle
Edema is +2
Moves up to lower leg
Edema is +3
Moves up to the knee into the
thigh
o Determine the weight for height or length
(WFH/L) * _______ z-score Figure 9. Weight-for-height Boys (2 to 5 years).
o Measure mid-upper arm circumference (Image lifted from: ICATT, WHO, Swiss Tropical, & PHI, Novartis
(MUAC)** _______mm in 6 months or older Foundation)

ASSESS WEIGHT FOR HEIGHT OR LENGTH (WFH/L):

CLINICAL ASSESSMENT
o Line labelled 0
ASSESS ALL CHILDREN FOR:
Median or average
o Signs of Acute Malnutrition
WFH/L
Edema of both feet
Most healthy children
WFH/L below -3 z score
Near the median curve
Weight for height:
A little either:
2 years or older
o Above or
Weight for length:
o Below it
< 2 years of age
On the line labeled zero (0)
Measure the length by
If the weight of child is
asking the child to lie flat on
plotted, and if it falls exactly
height scale called
on line zero, or a little above
infantometer.
or a little below zero= child is
Mid-upper circumference (MUAC) not malnourished.
Children aged 6 months o The other lines, called z-score or standard
(< 155 mm) deviations (SD) lines
Indicate distance from the average
7|MJ CR
 So, the concern will be when the z-score
will be between minus 1 or 2 or 3 z- Window
score. (with arrows)
POINT OF INTERSECTION BETWEEN WEIGHT AND LENGTH Slit
OR HEIGHT: (recheck this- in module 6)

Tip
Figure 11. Measuring of MUAC.
(Image lifted from: ICATT, WHO, Swiss Tropical, & PHI,
Novartis Foundation)

How to measure MUAC

Bring the forearm of the child
upward across the abdomen
Figure 10. Point of Intersection Between WH/L. or chest so that it will align
(Image lifted from: IMCI, DCL, Mod. 9, Care of a Well Child, the upper arm.
WHO, Mar. 2014) Locate the middle portion
between shoulder joint and
o If the point is at 0 or a little above or below it
elbow joint, then wrap
No acute malnutrition or wasting, thus,
around the measuring tape.
normal
Insert the tip into the
o If the point is below -2 and above or on -3 z-score
window. Then, insert further
curve (between < -2 and -3 z-score)
the tip that comes out from
Child has moderate acute malnutrition
the window into the slit. Look
o If the point is below the bottom curve (-3 z-
out/ measure now the MUAC
score)
by taking note of what
Child has severe acute malnutrition
n mber o ll see in he
window, pointed by the
MEASURE MID-UPPER ARM CIRCUMFERENCE (MUAC) arrows.
o What is the value of measuring MUAC in children
o If the reading in the
6 months? window is 11, you
Do not get MUAC in infants < 6 months multiply it by 10.
of age. Therefore, the final
Why? - it is expected that no reading is 110 mm.
infants are malnourished in This is also a color-coded
the first 6 months of life measuring tape:
because if the mother is o If what will come
exclusively breastfeeding the out on the window
child and breast milk contains after inserting the
all the nutrients that will tip is the red one,
sustain the normal growth the child has severe
and development in the first 6 acute malnutrition.
months of life. o If yellow, child has
Th s e don e pec moderate acute
malnutrition to be occurring malnutrition
in children less than 6 months o If green, child does
of age. not have severe

8|MJ CR
 acute or moderate nutritionally rehabilitated at
acute malnutrition home by feeding the child a
But it would be best to get the ready-to-use therapeutic
actual reading (number/ food (RUTF).
measurement shown on the
window in the measuring
tape).
MUAC interpretation
If MUAC is < 115 mm
o E.g. come out in
the window 11.5
(then multiply by
10= 115 mm)
o Severe acute
malnutrition and
o Threat of death
If MUAC is between 115 to <
125 mm
o Moderate acute Figure 12. H D e a Chi d Pa he A e i e Te .
malnutrition (Image lifted from: IMCI, DCL, Mod. 6, Malnutrition & Anemia, WHO,
If MUAC is < 125 mm or more Mar 2014)
o No malnutrition
Appetite test is positive if:
For example, to a child with <
CHECK FOR MEDICAL COMPLICATIONS IN A CHILD
4 kg, the child was able to eat
o If WFH/L is < -3 z-score or
a minimum of 1/8 sachet
o MUAC < 115 mm or
content to a maximum of ¼
o Edema of both feet either +1 or +2
sachet content (depending of
o Medical complications to check in a child
the weight of the child- check
Any danger signs
figure 12).
Any sever classification
Appetite test is negative if:
Pneumonia
For example, to a child with <
Fever: T > 38.5°C
kg he child asn able o
Hypothermia: T < 35°C eat less than 1/8 sachet
Extensive skin infection content.
Diarrhea with recent sunken eyes This child must be sent to the
o Additional medical complications for < 6 months hospital for the rehabilitation
old child of the severe acute
Recent weight loss or inability to gain malnutrition.
weight
Any medical issue for further o When not to conduct an appetite test for a child
assessment or support aged 6 months who shows signs of severe
Maternal depression or adverse social malnutrition:
circumstances If a child has any general danger signs
o Conduct an appetite test for a child aged 6 Among children who have pneumonia,
months who: persistent diarrhea, dysentery,
Has MUAC < 115 mm or measles, or malaria
Has WFH/L < -3 z-score or
Has edema of both feet AND ASSESS BREASTFEEDING
Does not have medical complications o Assess breastfeeding in infants aged < 6 months
having:
Purpose of conducting an appetite test Edema of both feet or
If the child with acute severe WFL < -3 z-scores and
malnutrition, child can be Who do not have medical complications
rehabilitated by giving a Child is < 6 months old: assess BF
ready-to-use therapeutic Position, attachment,
food (RUTF). suckling
To determine who are those o Signs of effective
children with no medical attachment:
complications that can be

9|MJ CR
 upper lip turned Complicated
upward Severe Acute
mouth wide open Malnutrition
chin nearly Edema both feet + Give oral antibiotic for
touches breast of or ++, OR 5 days
the mother WFH/L < -3 z score, Continue
more areola seen OR breastfeeding
abo e he bab s MUAC < 115 mm Give RUTF if available
top lip than below AND for a child 6 months
Able to finish RUTF Counsel mother on
o Signs of effective
how to feed the child
suckling: child will
Assess for possible TB
make deep slow Yellow: infection
suck. In between Uncomplicated Advise mother when to
deep slow sucks, Severe Acute return immediately
the child will pause Malnutrition Follow up in 7 days
to swallow the WFH/L between -3 Assess he child s
breastmilk and -2 z scores, OR feeding and counsel
BF frequency and night feeds MUAC 115 up to the mother on feeding
o The mother should 125 mm If feeding problem,
BF 8 times or more follow up in 5 days
in a day. Assess for possible TB
o The mother should Yellow: infection
BF at night also Moderate Advise mother when to
Acute return immediately
since more
Malnutrition Follow up in 30 days
prolactin is
secreted at night. WFH/L -2 z score or If the child is < 2 yrs.
o Prolactin is the more old assess he child s
MUAC 125 feeding and counsel
hormone that will
the mother on feeding
stimulate the
according to the
breast tissue to feeding
secrete/ synthesize recommendations
breastmilk. Give micronutrient
Types of complementary Green: powder supplement
foods or fluids, frequency of No Acute If feeding problem,
feeding and whether feeding Malnutrition follow-up in 5 days
is active, and
Feeding patterns during the OR Need onl sign
current illness AND sign incl ded
Does the child have a BF problem?
CHECK FOR ANEMIA
CLASSIFICATION OF NUTRITIONAL STATUS o Look for palmar pallor. Is it:
Severe palmar pallor?
Table 6. Classification of Nutritional Status.
Some palmar pallor?
Edema of both Give first dose of an
feet +++ OR appropriate antibiotic
Palmar pallor
Any edema and Treat the child to
MUAC < 115 mm prevent low blood Unusual paleness of the skin/
or WFH/L < -3 z sugar. palms when checking child for
score OR Keep the child warm palmar pallor
Edema + and ++, or Refer URGENTLY to How to check for palmar pallor?
WFH/L < -3 z score, hospital. Compare palm with the
or MUAC < 115 child s palm
mm and any of the Bend child s finger do no
ff: extend
Medical Sign of Some Palmar Pallor
complication
If he skin of he child s palm
present, OR
looks paler than the
Not able to finish
e aminer s palm
RUTF, OR
Breastfeeding Pink: Sign of Severe Palmar Pallor
problem

10 | M J C R
 If he skin of he child s palm CHECK CHILD S IMMUNIZATION VITAMIN A DEWORMING STATUS
is so white in comparison to AND ORAL HEALTH
he e aminer s palm
Table 8. Early Childhood Care and Development (ECCD) Card.

AGE VACCINE
Birth BCG + Hepatitis B- 0
6 weeks DPT + HIB + OPV- 1
Hepatitis B- 1
10 weeks DPT + HIB + OPV- 2
Hepatitis B- 2
14 weeks DPT + HIB + OPV- 3
Hepatitis B- 3
A. B. 9 months Measles (MV1)
12 months Measles, Mumps, Rubella (MMR)
Figure 13. Child & Examiner s hands on assessment for anemia.

For fig re ha s rong i h he pic res -the fingers Ask the mother for the Early Childhood Care and
of the child and the examiner must be bent, not extended. Development (ECCD) card
Figure 13A shows a sample of some palmar pallor where the Before, we used to have a yellow card
skin of he child s palm looks paler han he e aminer s palm Now, white card is used
Figure 13B shows a sample of severe palmar pallor where Immunization record of the child
he skin of he child s palm looks so hi e han he If the mother is not able to bring the ECCD card,
e aminer s palm. you just have to ask the mother the information
written in the card.
CLASSIFICATION OF ANEMIA Ho o check he child s imm ni a ion s a s
Check the missed opportunities
Table 7. Classification of Anemia immunizations so that you can give the
Severe palmar Pink: Refer URGENTLY to hospital missed vaccines.
pallor SEVERE Ex: The child is 8 weeks old and the child
ANAEMIA is sick. Ask the mother: Was the child
Some pallor Yellow: Give iron** given DPT or pentavalent vaccine
ANAEMIA Give mebendazole if child is composed of DPT, HIB and Hep B-1
1 year or older and has not
(check 6 weeks). If the mother says no,
had a dose in the previous 6
m child asn able o recei e his
months
pentavalent vaccine , then you can give
Advise mother when to
return immediately this vaccine as long as the child has no
Follow-up in 14 days pink classification or danger sign for
No palmar Green: If child is less than 2 years immediate referral is needed.
pallor NO ANAEMIA old, assess the child s
feeding and counsel the Vitamin A Prophylaxis
mother according to the Vitamin A Supplementation Schedule:
feeding recommendations The first dose at 6 months or above. Subsequently
if feeding problem, follow- dose every 6 months.
up in 5 days It is not given to children < 6 months of age
Routine Worm Treatment
Give every child Mebendazole or Albendazole
every 6 months starting at 1 year of age. Record
he dose on he child s card
Dental Check-up
Advise mothers and caregivers to bring their
children for regular dental check-up every 6
months (twice a year).

11 | M J C R
 Since here s more
production of prolactin at
night, thus the mother must
do the breastfeeding at night
as well.
Does he child ake an o her foods or fl ids
if yes esp. on <6 months of age, it is another
feeding problem.
Figure 14. Recording form.
if the child is 6 months or older and no
(Image lifted from: IMCI, Chart Booklet, WHO, Mar 2014)
complimentary foods or fluids given, then it is
Encircle the missed vaccines. another feeding problem.
If the child has no danger sign, you can encircle one. Does he child recei e his o n ser ing
All children of the family should have his or her
own serving.
ASSESS THE CHILD S FEEDING The children must not be sharing food because
they might not get the adequate amount of food
to sustain normal growth and development.
After checking/ assessing feeding, you also assess other
problems of the child because in IMCI, this will address only
70% of the illnesses during childhood. The remaining 30%
illnesses, there are no guidelines shown in IMCI strategy on
how to assess and treat the child.
For other problems esp. when severe, you must refer the
child to the hospital.
Also ask he mo her s o n heal h and attend the health
needs of the mother
Thus, you have 2 clients, aside from the child since
some infections can be transmitted from the
Figure 15. I dica i f A e i g he Chi d Feeding. mother to the child.
(Image lifted from: IMCI, Chart Booklet, WHO, Mar 2014)

It is important to assess how the mother feeds the child

when the child is less than 2 years of age, because it is a
very critical period for the brain development.
If there is chronic malnutrition in the first 2 years
of life, it will impair brain development.
A child will have a low IQ
Assess feeding only if there are indications
Age < 2 years old
Moderate acute malnutrition
Anemia
HIV exposed or infected
but we are not assessing this,
we refer it to the hospital for
this problem
No danger sign/ pink classification
If here s danger sign/ pink
classification, it will delay
referral.

THEN ASK:

Do o breas feed o r child

If es ask ho man imes in ho rs
Feeding should be 8 or more times
If imes means here s no eno gh
feeding.
Ask also Do o breas feed d ring he nigh
If yes, no problem
If no, another feeding problem

12 | M J C R
IMCI Part 2.2 your area, give antibiotic
Dr. Charles Cabataña for cholera
Dehydration Pink: Treat dehydration before
IDENTIFY TREATMENT present SEVERE referral unless the child has
PERSISTENT another severe
DIARRHEA classification
IDENTIFY TREATMENT FOR THE CHILD Refer to hospital
No dehydration Yellow: Advise the mother on
Any general Pink: Give the first dose of an PERSISTENT feeding a child who has
danger sign SEVERE appropriate antibiotic DIARRHEA persistent diarrhea
or PNEUMONIA Refer urgently to Give multivitamins and
Stridor in OR VERY hospital** minerals (including zinc) for
calm child SEVERE 14 days
DISEASE Follow-up in 5 days
Two of the Yellow: Give fluid, zinc, State 3 indications for referral to the hospital
following signs: SOME supplements, and food
Restless, DEHYDRATION for some dehydration 1. Any pink/severe classification.
irritable (PLAN B) 2. Any general danger sign.
Sunken eyes If child also has a severe 3. Presence of other severe problem where there is no
Drinks classification: guideline in IMCI on how to assess and treat this other
eagerly, **Refer URGENTLY to severe problem (e.g. a history of fall w/ loss of
thirsty hospital with mother giving consciousness)
Skin pinch frequent sips of ORS on the
goes back way State 2 EXCEPTIONS for urgent referral to the hospital
slowly ** Advise the mother to 1. SEVERE DEHYDRATION is the only pink/severe
continue breastfeeding
classification. Another condition is if:
Advise mother when to
a. You can give fluid for rehydration, meaning
return immediately
you have an IVF/ IV line/catheter and a health
Follow-up in 5days if not
personnel who can monitor the rehydration.
improving
So you can give fluid for severe dehydration
Malaria test Yellow: Give recommended first
POSITIVE MALARIA using plan C.
line oral antimalarial
Give one dose of
b. However, even if there is no other severe
paracetamol in clinic for a a a IVF
high fever 38.5oC or someone trained to insert the catheter and
above run the IVF, STILL REFER THE CHILD.
Give appropriate WITHOUT THIS, REFER CHILD IMMEDIATELY TO HOSPITAL
antibiotic treatment for
2. If SEVERE PERSISTENT DIARRHEA is the only pink/severe
an identified bacterial
classification. However, only if you have the capability
cause of fever
to rehydrate the child similar to that in number 1.
Advise mother when to
return immediately How to identify treatment after you have assessed and classified the
Follow-up in 3 days if USE THE FLOWCHART
fever persists
If fever is present every FLOWCHART IN IDENTIFYING TREATMENT
day for more than 7
days, refer for
assessment
Measles now or Green: Give vitamin A treatment
within the last 3 MEASLES
months.
Two of the Pink: If child has no other
following signs: SEVERE classification:
Lethargic or DEHYDRATION ♦ Give fluid for severe
unconscious dehydration (Plan C)
Sunken eyes OR
Not able to If child also has another
drink or severe classification:
drinking ♦ Refer URGENTLY to
poorly hospital w/ mother giving
Skin pinch frequent sips of ORS on
goes back the way When do we say that there is no urgent referral needed?
very slowly ♦ Advise the mother to - W a a a a
continue breastfeeding yellow/green or both.
If child is 2 years or older
and there is cholera in
Where do you refer to make a decision on which treatment - For malaria: give recommended 1st line of an oral
is needed for the sick child? antimalarial. Similar rule to that in pneumonia, however
- Refer the IDENTIFY TREATMENT column beside each if no IV drug available, do not give the oral drug. Give a
classification. However in yellow & green classifications, suppository instead.
o Give one dose of paracetamol in clinic for high
Identify which among them is RELEVANT to the fever (> 38.5oC).
based on the signs - For measles: give 1st dose of vitamin A.
noted during physical examination.
URGENT REFERRAL:
To identify treatments needed, what will you do when a
child has more than one classification? o What will you do if an infant or child must be
o For classifications w/ the same treatment, list referred urgently?
them ONCE on the back portion of the - Identify and give 1st the urgent prereferral treatment.
recording form where the treatment portion o Which treatments will you give?
is. - Those written in bold but assess first which of them
o For classifications requiring different are relevant.
treatments, WRITE THEM SEPARATELY.
IDENTIFY AND GIVE URGENT PRE-REFERRAL TREATMENT NEEDED:
o F is pneumonia,
acute ear infection, malaria and dysentery. IDENTIFY URGENT PRE-REFERRAL TREATMENT:
Treatment for both pneumonia and acute ear
infection is amoxicillin. LIST AMOXICILLIN ONCE 1. Give an appropriate antibiotic
because if you list it twice you might be mistaken 2. Give quinine for severe malaria
and give the drug twice as well. 3. Give an oral antimalarial
4. Give Paracetamol for Temp. > 38.5oC or pain from
mastoiditis
5. Give vitamin A (for measles)
6. Treat the child to prevent low blood sugar.
- Esp. if you have a young infant w/c can easily be
hypoglycemic. Ask mother to breastfeed to prevent
hypoglycemia.
7. Start IVF according to plan C (DHF w/ **bleeding or cold
clammy skin or CRT > 3 secs)
** Signs of shock in a child w/ DHF
8. Give ORS according to Plan B (DHF w/ only petechiae or a +
Tourniquet Test (TT) or persistent abdominal pain or
persistent vomiting but w/o cold clammy skin and with
normal CRT)
- Take note of the level of consciousness
9. Provide ORS solution so mother can give frequent sips on
the way to the hospital
IDENTIFY AND GIVE URGENT PRE-REFERRAL TREATMENT ALGORITHM ON HOW TO TREAT FOR SEVERE DEHYDRATION:
NEEDED: How do you identify urgent treatments on the
ASSESS AND CLASSIFY chart?
- E.g. you have the 3 classifications: severe pneumonia,
malaria and measles for a child who has been coughing
and has fever. Thus, there is 1 pink classification that
requires urgent hospital referral. How do you identify
urgent prereferral treatment? Identify urgent
prereferral treatment for all the classifications. THOSE
WRITTEN IN BOLD. (Check also if they are relevant or
appropriate based on the classification, vials signs and
findings during physical examination).
- For severe pneumonia/very severe disease: give 1 st
dose of an appropriate antibiotic. E.g. If can tolerate an
oral dose, can be AMOXICILLIN. But if w/ changes in the

it may be aspirated and the child might die of asphyxia.

Thus always check level of consciousness before giving
an oral drug. If there is, then the 1st dose for this should
be an injectable antibiotic (GENTAMICIN/ AMPICILLIN).
 Mambaling, Cebu City
IDENTIFY TREATMENT FOR THE CHILD: for severe dehydration
Weight is very important because if ever child undergoes
If you are trained to treat the child according to plan C, you cardiopulmonary arrest upon arrival at the hospital, then the referral
may decide to use plan C to decide whether to refer the hospital will have a basis in the computation of the dose of the
child emergency treatment.
What will you do if the child has another severe
IDENTIFY TREATMENTS FOR CHILDREN WHO DO NOT NEED URGENT
classification in addition to severe dehydration?
REFERRAL
IDENTIFY AND GIVE URGENT PRE-REFERRAL TREATMENT NEEDED: Components of treatment plan for children who do not need urgent
referral:
How much of the identified pre-referral drugs are you going
to give? 1. Relevant treatment
- The FIRST DOSE ONLY 2. Non-urgent referrals
3. Follow-up schedule
What is the importance of giving urgent treatments prior to
4. Signs when to return immediately
referral?
5. Immunization needed
1. Prevent serious consequences of PINK classification.
6. Vitamin A supplementation
P
7. Deworming
condition.
8. Advice on feeding
REFER A CHILD TO THE HOSPITAL
What will you check among children who do not need
What will you explain to the mother when referring her
urgent referral?
child to the hospital?
What will you do if the child has more than one
- Tell the mother that it will be risky and that the child
classification?
might die from the illness.
What will you secure?
QUESTIONS THAT CAME OUT OF THE 3rd BIMONTHLY EXAMS:
- MO HER S CONSEN
What will you do if you suspect that she does not want to
Case 1: Jeffrey is 8 months old, his mother tells you that he has been
take the child to the hospital?
coughing for 10days. He is very weak and could not drink water nor
- Find out the reasons why and it depends on the
eat food.
answer B
1. J
sign a waiver. Just explain the consequences of their
illness?
refusal, so they would at least know and make them
a. Very severe disease
stay near the facility so you can visit and offer your
b. Pneumonia
assistance in giving the required treatments. If they
c. Cough or cold
hem at home several times a day just to be
ANSWER: D (Very severe disease)
Basis: the child could not drink water (a general danger sign)
IDENTIFY TREATMENT FOR THE CHILD
2. Which of the following is the appropriate intervention for
When urgent referral is not possible:
J
o What will you do if referral is not possible, or if
a. Refer him to a specialist
the parents refuse to take the child to the
b. Refer him to the hospital immediately
hospital? See previous answer.
c. Give him a trial of an injectable antibiotic first and
observe if his condition will improve.
SAMPLE REFERRAL NOTE:
d. Refer him to the hospital after the urgent
prereferral treatment has been given.
February 20, 2007 9:30AM
Urgent referral to Cebu City Medical Center ANSWER: D
John Dela Cruz, age 18 months, 12kg.
3. If Jeffrey had convulsions at home, which of the following is
considered a life-threatening convulsion?
Referred for: Severe dehydration (drinking poorly, skin pinch going
a. 1 episode of generalized convulsion.
back very slowly), Severe Malnutrition (visible severe wasting). Also
b. 1 episode of convulsion <15minutes
has cough- no fast breathing, no chest indrawing).
c. 1 episode of convulsion w/ loss of consciousness
d. >1 episode of convulsion
Treatment given at Barangay Health Station:
** consider the MON HS
Vitamin A 200,000 IU
ANSWER: D
ORS- mother instructed to give sips on the way to the
Basis: Convulsion is considered a life threatening danger sign if the
hospital
child >6 months old have: >1 episode of convulsion or seizure lasting
Needs measles immunization- not given
for >15 mins.
Pedro dela Cruz, PHN A-C applies to those <6months old
Mambaling Health Center
Tel. no. 2323939
 4. Which of the following is the general danger sign that A B
Jeffrey has?
5. Which of the following statements is true regarding signs
a. Coughing for 10days
related to cough/difficult breathing?
b. Being very weak
a. Stridor is a musical sound heard when the child
c. Not able to drink
breathes OUT
d. Not able to eat
b. Wheezing is a harsh noise heard when the child
ANSWER: C
breathes IN
D is not a danger sign because anyone who gets sick will have no
c. Wheezing is a sign of pneumonia
appetite. B can be correct, but it is not included in the assessment
d. For chest indrawing to be present it must be
box. E.g. not being able to breastfeed, vomiting everything,
visible and present all the time.
convulsion.
6. ANSWER: D
5. Which of the following will tell you that a child is lethargic. A incorrect, stridor is a harsh sound.
When he is? B Wheezing is a musical sound heard when the child breathes OUT
a. Unusually sleepy
b. D CASE 3: Edwin is 3 years old. He has loose watery stools for 2 weeks.
c. D His mother says that there is blood in his stools. PE findings: sunken
to. eyes, skin pinch going back slowly.
d. Cannot be wakened.
1. What is the classification of E s illness regarding
ANSWER: B
dehydration?
A, C & D are signs of an unconscious child. A would be correct if
a. Severe dehydration
sleepy or drowsy.
b. Some dehydration
Case 2. Diana is 15 months old. She has been coughing for 5 days c. No dehydration
and is not eating well. PE findings: RR 45breaths/min with no chest ANSWER: B (basis: sunken eyes, skin pinch going back slowly)
indrawing.
2. Which of the following are the other classifications of
1. What is the classification of D s illness? E s illness?
a. Severe pneumonia or very severe disease a. Severe persistent diarrhea
b. Pneumonia b. Dysentery
c. Cough or cold c. Persistent diarrhea and dysentery
d. Severe persistent diarrhea and dysentery
ANSWER: B, because of RR. FAST BREATHING (cut off for children ANSWER: D (severe persistent if w/ dehydration, whether some or
>12months old: >40 breaths/min) severe)
2. What is the cut-off for FAST BREATHING among children
2months up to 12 months of age? 3. Where is the best site to check for skin turgor?
a. 35 a. Halfway bet. the umbilicus and the side of the
b. 40 abdomen
c. 50 b. Halfway bet. the umbilicus and the epigastric area
d. 60 c. Halfway bet. the umbilicus and hypogastric area
ANSWER: C d. Anywhere on the abdomen
60 from birth up to <2months ANSWER: A
35 for 5 years or older
4. When is the sign sunken eyes present in a child w/
3. If you will assess a child who is coughing, which of the diarrhea?
following will be your basis in saying the child has a. I
pneumonia? b. When on observation, you notice the eyes of the
a. Not able to drink child are sunken.
b. Wheezing c. If the mother
c. Stridor d. I
d. Fast breathing

ANSWER: D ANSWER: D
Wheezing is a musical sound heard in a child w/ bronchial asthma. eyes)
A & C are general danger signs/ signs of very severe disease 5. In which of the following will you say the skin pinch goes
4.Which of the following findings on physical examination will back slowly?
tell you a child who has been coughing has chest indrawing? a. If the skin stays up for >3secs.
a. Subcostal retractions b. If the skin stays up for >2secs.
b. Intercostal space retractions c. If the skin stays up for even a brief time after you
c. Lower chest wall goes in when the child breathes release it.
IN d. If the skin pinch goes back immediately.
d. Lower chest wall goes in when the child breathes ANSWER: C (anytime bet. 2secs or less than 2 secs)
OUT A- Very slowly
ANSWER: C B- Not in the category
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS What will you do if the child has more than one
PART 3.1 classification?
DR. CHARLES CABATAÑA • If there are several classifications, you will
MAR 31, 2021 identify many treatments
• For example, the child has Pneumonia, acute
IDENTIFY TREATMENT ear infection, fever, and measles. So,
Pneumonia and acute ear infection has the
Identify Treatments for Children Who Do Not Need same treatment which is oral antibiotic. First
Urgent Referral line for both is Amoxicillin. So, list the antibiotic
• When one classifies the children illness, they once only at the back of the recording form to
are yellow and green classifications prevent double doses and overdose of the
treatment. For different illness with different
treatments, list their treatments separately. In
fever, if 38.5 degrees Celsius, write “For high
fever (38.5C)”. For measles, write “Give Vitamin
A treatment”.
• So, take note if the illnesses have the same
treatment

Relevant Treatment
• The treatment appropriate treatment of the
child based on the classifications of the child’s
illness, signs noted during physical examination,
and the vital signs
• SCENARIO: the patient has pneumonia and the
duration of the condition is 5 days. During the
first PE, you haven’t noticed the wheezing. So
how will you know the treatments that relevant
to the classification, pneumonia?

Components of Treatment Plan for Children Who Do • First, you look the box and check each bullet if
Not Need Urgent Referral: these are relevant to the patient. Example, the
1. Relevant Treatment first bullet, giving Amoxicillin is relevant to
2. Non-Urgent referral pneumonia. The second bullet is not relevant to
3. Follow-up schedule the patient because the PE didn’t detect
4. Signs when to return immediately wheezing. Delete this component of the
5. Immunization needed treatment plan. Then, you check each bullet
6. Vitamin A supplementation after if it is relevant or not.
7. Deworming • Children with less than 5 years old, we don’t
8. Advice on feeding give antitussives (Tuseran) and mucolytics
(Carbocisteine). Expectorant (Ambroxol) is not
What will you check among children who do not need also needed by the child since children cannot
urgent referral? expectorate yet.
• You will review or check if there is one or more • Safe remedy: best mucolytic is WATER. Also,
classifications of the child’s illness giving Calamansi juice is enough.
• The important treatment is the antibiotic since Non-urgent Referrals
it will kill the causative microorganism and help
loosen the phlegm.
• The fifth bullet is not relevant to the case since
the duration is only 5 days but if goes beyond
14 days, you should refer the patient to a TB
Center.
• The sixth bullet is relevant because you will
advise the mother what she needs to watch at
when at home. If she sees this, she needs to • The patient has more than 14 days of cough so
bring the child to the hospital immediately. you need to refer the child to a TB or asthma
assessment but it is not immediately needed
but you need to the instruct the parents that
you still need a referral in order to proceed.
• Common causes of chronic cough in children
are TB and asthma.
• Asterisk: Non-urgent referral

• Example fever, if the patient’s temperature

doesn’t reach 38.5C, you will not give the one
dose of paracetamol.
• In the same scenario, if the patient has
• Asterisk: Non-urgent referral
pneumonia and fever, write the antibiotic once.
You can give a different antibiotic if you can find
Follow-up Schedule
a different cause of the fever.
• So, the patient has 5 days pneumonia and fever, Differentiate between definite and conditional follow-
so follow-up in 2 days will be relevant and the up schedule
last bullet will not. Unless stated in case that
the fever has been more than 7 days, refer to a
referral hospital in order to assessment the
child.

• In Pneumonia, the follow-up is 3 days while in

fever (definite), the follow is 2 days but the
patient does not go if it does not persist
(conditional).
 Signs When to Return Immediately

Check Immunization Needed

What will you do if several different times are specified

for follow-up?

• Ask for Childhood Care Development Card and

check which immunizations were received
• SCENARIO: If the child is 10 weeks old and sick
but no yellow or pink signs so you will ask the
parents whether the child is immunized PV1
AND OPV1 on the 6th week and the child was
not according to the parents so you will
immunized the child with PV1 and OPV1.
• You have a well-child visit (every month) or sick
• If you have different follow-up dates for
child visit (within the week)
different illnesses like pneumonia, acute ear
infection, and fever. You will write the follow up
Check The Child’s Vitamin A and Deworming Status
in (A) 3 days for pneumonia (It is during third
day, you will write follow-up in 2 days for acute
ear infection). Next, you will write (B) follow up
in 2 days if fever persists because the date is
earlier than the 3 days (But remember, that if
the fever persists (conditional)).
 • You ask the parents if the child received Vitamin • Write relevant treatments, example in the
A supplementation, if none, you give it during photo, Amoxicillin was written twice but
the visit. because it is both a treatment for Pneumonia
• For deworming treatment, you ask if the patient and Acute Ear Infection so it should be written
is already 1 year old and if the child was once. In the photo, there is a line connected the
dewormed, if not, you also give the treatment two Amoxicillin written but the 2nd word written
during the visit. was crushed out.

Assess The Child’s Feeding and Counsel the Mother on

Feeding

• 1st line: Return for follow-up – example,

pneumonia, 3 days
• 2nd line: Return immediately – write what you
taught the parents
• 3rd line: write immunizations given

• Only when the child does not need to be

referred for a pink classification or there is a
danger sign.

Fill in the treat portion of a Case Recording Form:

• List treatments needed

o On the back of the form
o Across from classification
• Write down only
o Relevant treatments
• Shorten wording of treatments
o If desired

What will you do if same treatment is needed for > 1

classification?
• Write it once
What if different treatments may be needed for
different classifications?
• Example, there is Dysentery, write it separately
and it its treatments like ciprofloxacin
What will you do if a child requires urgent referral?

Treat the Child Chart:

• What appears in the recording form is just the State the importance of the treat the child chart
antibiotic needed then referred urgently to • Describe how to give the treatment
hospital.
• Prior to referral, give first the first dose of the State the things that a drug table shows
antibiotic. • Table above describes how Amoxicillin is given.
• The topmost portion lists the indications of
What will you do if a child does not require urgent Amoxicillin as 1st line drug, 1st column is the
referral? age/weight, 2nd column is the antibiotic
treatment
o If the drug formulation available is only
tablet, instruct the parents on how to
make it easier to administer by
pulverizing the drug, add the desired
water needed. You can also add sugar
to make it palatable.
o You should also demonstrate on how to
give the first dose of the drug during
the visit in order for the parents to
know how to administer it at home. Ask
them to position the child in a semi
upright or upright position in order for
the child not to aspirate the drug and
prevent asphyxiation.
• Which is the best in using as a basis to
determine the dose of the drug? Weight
• List down each treatment needed for each because there are children that are heavier or
classification, date of follow-up and the signs less than their age. You might give overdose in
that would need an immediate follow-up malnourished child or underdose in obese child.
• Why are tablets recommended than syrups? In
pharmacology, when you reconstitute the
TREAT THE CHILD
syrup, it is difficult to maintain the potency of
the drug.
Select and Give Oral Drugs
What does a schedule tell you?
• The 2nd column tells you the dosing frequency
and duration, example in the table, Amoxicillin
– give two times daily for 5 days.
o Though Amoxicillin 2x day is effective
already in killing the microorganism but
giving 3x a day can kill at a higher range.
There is what we called recommended
basis computing Amoxicillin 50-100
mg/kg/d. Higher rate is 75-100 mg. In
children, we use the higher limit to
ensure response • There is no written 1st and 2nd line drugs, so you
check which antibiotic responds to your
community. Either Erythromycin or Tetracycline
o You can’t give Tetracycline in children
below 8 years old due to discoloration
of teeth

Intramuscular Drugs
How will you determine the correct dose of a drug you
IM Antibiotics:
will give the child using the drug table?
When are IM antibiotics given to a sick child?
Oral Antibiotics:

What is the basis in selecting the most appropriate

treatment for the child’s illness?
• Classification

State the reasons why first-line oral antibiotic is given if

it is available
• Like Amoxicillin, it affordable, easy to
administer, and effective
o Before, Co-trimoxazole was the 1st line
drug for Pneumonia but due to
resistance, it was replaced by
Amoxicillin

State the 2 conditions when a second-line is antibiotic

given
• When the 1st line is not available. But in
Pneumonia, there is not 2nd line already. You
can ask the mother to buy it and come back so
that you can demonstrate how to administer it
at home Example the child has pneumonia, very severe disease,
• Example there a 1st line and 2nd line drugs for a change in consciousness, could not eat, so you can’t
classification, the 2nd line frug can be given if give oral Amoxicillin therefore you can give Ampicillin
there is no response to the 1st line drug. and Gentamicin intramuscularly.
Oral Antimalarial: • In cough, you can give it when there is wheezing
ACTs: • It is given by a spacer with children under 5
• In the Philippine Malarial Treatment Protocol, years of age if you don’t have a nebulizer.
Artemether-Lumefantrine (AL) o The other tip is the mouthpiece which is
o First line drug in the treatment of placed into the mouth and nose of the
Malaria child. In the other, you will put the MDI.
You press on the canister and it will be
delivered into the space. When the
child will inhale or cry, the drug will be
deposited into the lungs.
o In nebulizer, use a face mask so more
drugs will be inhaled.

For how many times should it be given?

• 2 puffs or press twice, repeat up to 3 times
every 15 minutes before classifying pneumonia
• For wheezing, give it for 5 days

What preparation will you give?

• MDI

Among which group of children is the use of spacer

recommended when giving a rapid acting
bronchodilator and why?
• For infants, they don’t have the ability to press
the canister and inhale the drug. In older
children, even though they can press the
canister, they find it hard in pressing the
canister and inhaling at the same time.
•
When is a rapid acting bronchodilator given to a child
with cough or difficulty breathing? How?
When is antibiotic treatment not indicated among Until what age is it given?
children with cough or difficult breathing who have • Until 72 months and 6 years of age
wheezing and either fast breathing or chest indrawing?
• After giving a rapid acting bronchodilator, the How is it given?
fast breathing or cheat indrawing will be gone
so the classification will be cough and cold not
pneumonia, it is due to asthma

Paracetamol:

What are the indications when giving Paracetamol?

• High fever or ear pain

How often are you going to give it if a child has fever or

ear pain?
• You will not give Paracetamol every 6 hours but
check the temperature or if there is an ear pain
every 6 hours then give only when there is high
fever and ear pain
• We don’t give every 4 hours and round the • Based on the age
clock because of hepatotoxicity and since fever • Ask the child if he or she can shallow
is part of inflammatory process unless the child • For an infant who cannot swallow, cut the neck
has a history of Febrile Benign seizures of the pearl and squeeze the whole contents
and squirt it while the child is in an upright
Vitamin A Supplementation: position not lying flat supine.
• If 100 T IU is not available, use the 200 T IU and
squirt 3 drops. But if you to be accurate,
aspirate the whole content, and you get 3 ml for
example, then give ½ which 1.5 ml.

When is it started?
• 6 months and above
How often is it given?
• Every 6 months
Iron:

What is the indication when giving iron?

• When there is some palmar pallor

What preparation is given for children under 12 months

of age and when the child is aged 12 months or older?
• Under 12 months – syrup or drops
• 12 months and older – Both tablet or syrup
o Based on weight

For how long is it given

• Given one dose daily for 14 days
IMCI . :00 onward ■ Add sugar and water onto a spoon and put the
child in an upright/semi-upright position and
Select and Give Oral Drugs show how to give the dose along the sides of the
mouth and ot the center
Micronutrient Powder: . Third, let the mother practice.
● Which age group is supposed to receive micronutrient ● Ask the mother to do the task while you watch.
supplement?
■ Started at to months.
● When is it started among children?
■ At moths of age when children are to receive
complementary foods.
● What is its content?
■ Contains minerals and vitamins.
● What is its preparation?
■ Comes in sachet form.
● How is it given?
■ Mix the contents of the sachet with ready-to-eat food.
● What are you going to do to observe when giving it?
■ Do not mix it when cooking the food because heat can
destroy vitamins and minerals.

Mebendazole/Albendazole:
● What is its indication?
When teaching the mother:
■ If the area where the child lives, there is a high
. Limit your advice to what is relevant to the mother at
incidence of infestation by worms.
this time.
◆ Especially hookworms, roundworms and . Use words that the mother understands.
whipworms. ● Speak in the dialect not medical terms.
● How is it given? . If possible, use pictures or real objects to help explain.
● When is it started among children? ● Show amounts of fluid in a cup or container.
Medicine Give as a single dose every months . Give feedback when the mother practices.
0- Year - Years - Years ● Praise what she does well and correct any mistakes.
Albendazole None / tablet tablet ● Allow for more practice if needed.
( 00mg tablets) ( 00mg) ( 00mg) . Encourage the mother to ask questions.
Mebendazole None / tablet tablet ● Answer all questions.
( 00mg tablet) ( 0mg) ( 00mg) . Advise against any harmful practices that the mother
may have used.
*Why mebendazole and albendazole over pyrantel palmoate? ● When correcting a harmful practice, be clear.
Mebendazole and Albendazole are broad spectrum ● Be careful not to make the mother feel guilty or
anti-helminthics incompetent.
● Explain why the practice is harmful.
Teach the Mother to Give Treatment at Home . Check the Mother’s Understanding
● After you teach a mother how to treat her child
Use Good Communication Skill ■ You want to be sure that she understands how to
● Ask questions to find out what the mother is already doing give the treatment correctly.
for her child. ● Use checking questions
■ Example: Child has pneumonia, before advising the ■ To find out what the mother has learned.
mother ask if they have tried the treatment. If they say
yes then ask the mother to demonstrate how to Teach The Mother How To Give Oral Drugs At Home
prepare a dose. ● Determine the appropriate drugs and dosage for the child’s
● raise the mother for what she has done well. age and weight.
■ Builds the confidence of the mother ● Tell the mother the reason for giving the drug to the child.
● Advise her how to treat her child at home. ● Demonstrate how to measure a dose.
● Check the mother’s understanding. ● Watch the mother practice measuring a dose.
■ Use open ended questions ● Ask the mother to give the first dose.

Use Three Basic Teaching Steps: Teach Mother How To Give Treatment at Home
. First, give information. . Teach the mother how to give inhaled salbutamol for
● Explain to the mother how to do the task. wheezing.
● Give the reason why to use the drug/treatment . Local Infections that mother can treat at home:
● Provide dosages and duration a) Eye Infection with Tetracycline eye ointment.
. Second, show an example. b) Dry the ear by wicking for acute ear infection and instill
● Show how to do the task. qinolon eardrops for chronic ear infection.
● Show how to prepare the medication c) Treat mouth ulcers with gentian violet.
● Cutting the medication and pulverizing d) Soothe the throat, relieve the cough with safe remedy.
■ Pulverize by putting in an envelope and crushing
Teach The Mother To Give RUTF ● If the child cannot swallow and you know how to use a
nasogastric (NG) tube, give the child 0mL of milk (expressed
How to Give Ready-to-use Therapeutic Food (RUTF) breast milk or breast-milk substitute) or sugar water by NG
● Give small, regular meals of the RUTF and encourage the tube.
child to eat often - meals per day every to hours. ● To make sugar water:
● If the mother is breastfeeding, tell her: ■ Dissolve level tsp ( 0mg) of sugar in a 00mL cup of
■ You should continue breast feeding as any times a day clean water.
as the child wants.
■ Offer the breast to the child before each RUTF feed. Give Extra Fluid For Diarrhea & Continue Feeding

Determine Priority of Advice Treatment Plans For Diarrhea Management

● Do not overload the mother with too much information ● Plan A - Treat Diarrhea at home
● Limit the Instructions to what is mots important. ● Plan B - Treat some dehydration with ORS
● When a child has only one problem to be treated ● Plan C - Treat severe dehydration quickly
■ Give all of the relevant treatment instructions & advice COMPOSITION OF WORLD HEALTH ORGANIZATION
listed on the charts REDUCED-OSMOLARITY ORAL REHYDRATION SOLUTIONS (ORS)
● Essential Treatments: Constituent Concentration, mmol/L
■ Giving antibiotic or antimalarial drugs (where malaria is Na
present) and K 0
■ Giving fluids to a child with diarrhea Cl-
● Teach the few treatments well and check that the mother Citrate 0
remembers them
Glucose
● If necessary, omit or delay the following:
Total Osmolarity
■ Feeding assessment and feeding counseling
*when Citrate is metabolized it will provide bicarbonate ions
◆ Do when mother return for follow-up and the *ORS needs to contain Glucose to be more effective for
child has improved transportation of Na by SGLT in the intestine
■ Soothing remedy for cough and cold *Reduced because high content caused osmotic diarrhea
◆ If you give the antibiotic it will kill the causative
microbe/microorganism
■ Paracetamol
◆ If you give the antibiotic it will kill the causative
microbe/microorganism and the fever can be
resolved
■ Iron treatment
◆ Not very necessary
◆ After follow-up to treat anemia or subpalmar
palor
■ Wicking an ear
◆ Can be taught later in case of information
overload
◆ Unless it is an ear infection
● You can give the other treatment instructions when the
mother returns for follow-up visit.

Give Treatment And Immunize The Child At The Clinic

● You may have to give one or more of the following
treatments in the clinic before the child leaves for the
hospital:
*You can immunize the child as long as there is no danger
sign
■ Intramuscular antibiotics
■ Quinine or artesunate for severe malaria
■ Breast milk or sugar water to prevent low blood sugar
● You should also check the immunization status of every child
you treat in your clinic and
■ Immunize him or her as needed

Treat The Child To Prevent Low Blood Sugar

● Preventing low blood sugar is an urgent pre-referral
treatment for children with the following classifications:
■ Very Severe Disease
■ Very Severe Febrile Disease
■ Complicated Severe Acute Malnutrition
IMCI .
Dr. Charles Cabataña

PLAN A: Treat For Diarrhea at Home

Counsel the mother on the Rules of Home Treatment
. Give Extra Fluid
. Give Zinc Supplement ( months to years)
. Continue Feeding
. When To Return

. Give Extra Fluid (as much as the child will take)

● Tell the Mother
■ Breastfeed frequently and for longer at each feed
■ If the child is exclusively breastfed, give ORS or
clean water in addition to breast milk
■ If the child is not exclusively breastfed, give one
or more of the following: food-based fluids (soup,
rice water, yoghurt drinks) or ORS
● It is especially important to give ORS at home when:
■ The child has been treated with Plan B or Plan C
during this visit
■ The child cannot return to a clinic if the diarrhea
gets worse
● Teach the mother how how to mix and give ORS. Give
the mother Packets of ORS to use at home
*Contents must not be yellow
● Show the mother how much fluid to give in addition to
the usual fluid intake:
■ Up to Years: 0 to 00mL after each loose stool
■ Years or more: 00 to 00mL after each loose
stool
*use cups of estimated volume if specific
measurements are not available
● Tell the mother to:
■ Give frequent small sips from a cup
*Young given by teaspoon or for infants a dropper
■ If the child vomits, wait 0 minutes then continue
- but more slowly
■ Continue giving extra fluid until diarrhea stops
. Give Zinc ( age months up to months)
● Tell the mother How much Zinc to give ( 0mg tab):
■ months to moths - / tablet daily for days
■ months or more - tablet daily for days
● Show The Mother How To Give Zinc Supplements
■ Infants - dissolve tablet in a small amount of
expressed breast milk, ORS or clean cup of water
■ Older children - tablets can be chewed up or
dissolved in a small amount of clean water in a
cup
*Zinc can shorten the duration or reduce the severity of diarrhea
*Zinc can prevent recurrence of diarrhea in the next to months
if the full course of days is followed
*Zinc can help in re-epithelialization of the damage of the
epithelial lining of the gastrointestinal tract. Especially damage of
Rotaviruses
. Continue Feeding (exclusive breastfeeding if age less
than months)
* months or older - complementary foods
*can give fatty foods - more calories /g
. When to Return
*Drinking poorly
*Bloody Stool
*Unable to drink or breastfeed
*Becoming sicker
*Develops fever
1
IMCI Part Why is it that feeding is not recommended in the first hours of
Dr. Charles Cabataña rehydration?
April 0 , 0 1 - Because if the child’s stomach will be full with food, the
child will no longer drink the ORS
PLAN B: TREAT FOR SOME DEHYDRATION WITH ORS - Delay feeding with food but you can ask the mother to
continue breastfeeding
If the mother must leave before completing treatment:
- For example, after hours, the mother requests to go
home, show her the remaining amount to give in the next
hours
- After the next hours, if the child will still be having some
bouts of diarrhea, tell the mother how to prepare the ORS
and treat the diarrhea at home using Plan A
- We don’t want the mothers to prepare salt and sugar
solution at home because they might have accurate
measuring devices and commit mistakes
- Give them ORS sachet recommended by WHO or can buy it
When to Return
- Blood in the stool (if initially there was no blood in the
stool)
- Drinking poorly
- Becoming sicker
- Developing fever
PLAN C: TREAT FOR SEVERE DEHYDRATION QUICKLY

Notes:
- Plan B: rehydrate the child in the clinic or in the barangay
health center
- Rehydrate using ORS for hours in the health center
- Don’t teach the mother how to prepare the ORS, but
prepare it yourself
- After preparing the ORS, determine the amount of ORS to
give during the first hours of rehydration - based on the
actual weight and age of the child or multiplying the child’s
weight (in kg) times
For example the child is between kg ou are
allowed to give mL or ou can give up to mL
So around mL of ORS given ever hour
during the first hours of reh dration
Go back to the child ever hour to check whether the
mother has been giving the volume to be delivered to the
child
Check for vomiting or abdominal distention
For example if before reaching hours the child has
alread consumed the ORS and the child is asking for
more ou can give more if the child still has signs for
deh dration
After hours
- If the classification now is no dehydration, teach the Notes:
mother about Plan A Classification of the child’s illness is diarrhea with severe
- If the child still has some dehydration, give another round dehydration, can you give an IVF immediately? If yes, go ahead
and begin feeding the child - If the child can drink, give ORS while stepping the drip
- Rehydrating a child under months old is hours

f m
2
- If the child is months old and weighs kg, first IMCI: COUNSEL THE MOTHER
give 0 mL per kilo in the first hour of Feeding Recommendations:
rehydration ( 0mL x 0 ) 0 mL of the IVF Newborn, Birth up to 1 week
in hour - moderate fast drip
- In the next hours, give 0 mL per kilo ( 0 x
0 mL)
- Rehydrating a child months up to years is hours
- 0 mins - fast drip
- hours (compute for infusion rate)
- Reassess the child every - hours
- Give ORS if hydration status is improving
- What is the importance of giving ORS when you have
already hooked an IVF?
- This volume of the IVF is given to replenish what
has been lost but not intended to replace
ongoing losses
- Ongoing losses - if the child has diarrhea with
severe dehydration, the child can continue to
have loose stools
- Replace what has been lost (IVF) and ongoing
losses (using ORS)
- Rate of giving ORS is about mL/kg/h
- For example, weight of child is 0kg x
0 mL per hour is given PO
- Instruct the mother to bring the child in a
semi-upright or upright position, so that the child
will not aspirate and not become asphyxiated
- Reassess an infant after hours and a child after hours
- Severe dehydration: repeat giving IVF
- Some dehydration: use plan B
- No dehydration: use plan A
If you cannot give IVF, is the IV treatment available nearby (within 0
mins)? If yes, refer the child urgently.
- Please follow the chart for more deets Notes:
If trained to use NGT for rehydration, - Skin to skin contact of newborn baby with the mother
- Rate of rehydration 0 ml/kg/h for hours (total of 0 after drying the baby at DR
ml/kg) - Colostrum - contains IgA antibodies and first form if
- For example, child’s weight is 0 ( 0x 0) immunization to the baby as it contains preformed
- 00 mL every hour for hours antibodies
- Total of 00 mL in hours - The baby should breastfeed within the st hour to prevent
- Please follow the chart for more deets hypoglycemia
GIVE EXTRA FLUID FOR DIARRHEA & CONTINUE FEEDING - Breastfeed the baby if the mother can see hunger cues
Treat Persistent Diarrhea - Opening of the mouth
- Requires special feeding - Sticking out of the tongue
- Advise the mother about feeding her child - Sucking the fingers or anything
- Refer to feeding recommendations for a child with - Crying - late sign of hunger
persistent diarrhea on the Counsel The Mother chart - Baby should lie on the same bed with the mother so she
Treat Dysentery can see the hunger cues of her baby
- Give an oral antibiotic recommended for Shigella in your
area
- Ciprofloxacin
- Tell your mother to return in days for follow-up to be
sure that the child is improving

f m
1 Week up to months -1 months
Notes:
Notes: - Breastfeed the baby for years
- For example the child got sick and beyond, as long as the mother has
at mos old and the mother breast milk
visits the clinic, do
anticipatory guidance
- Anticipatory guidance: in
month’s time, the child will
now become months old,
so tell the mother how to
feed the baby at mos old

- months
1 months to years old
Notes:
- Complementary feeding begins Notes:
- Instruct the mother to - At months of age, they have to
breastfeed the child first before giving share with family food
complementary food because if the
stomach becomes full with food already,
the baby will not suckle anymore

What will happen if the baby will not

suckle anymore?
- No constant stimulation of the
breast to continue secreting breast milk
- Stimulus for PRL to be released
is suckling of the baby

f m
 years and older FEEDING ASSESSMENT
Notes:
- All children must receive their own
food and not share food with other siblings or
with the parents to ensure they will be getting
the adequate amount of food to sustain normal
growth and development
How do we identify feeding problems?
- Balanced diet: CHO, CHON, Lipids, &
- Based on the answers of the mother to the questions
veggies and fruits to provide the vitamins and
above
minerals needed in the metabolism of CHO,
- Frequency of breastfeeding should be x or more
CHON, and Lipids
Identifying Feeding Problems
- What is the basis in identifying feeding problems?
- The recommendations and actual responses of
the mother
- If there are deviations from the
recommendations to the answers of the mother,
then that will be the basis/guide in ID of feeding
problems
- What should be done to be able to identify feeding
problems?
- Know the recommendations based on the child’s
age
- The child should be breastfeed up to years or

Special Recommendations For Children With Persistent Diarrhea

- Children with persistent diarrhea may have difficulty
digesting milk other than breast milk
beyond as long as she has breast milk
Lactose intolerance
- Mixed feeding can cause nipple confusion
- They need to temporarily reduce the amount of other milk
- In addition to differences from feeding recommendations,
in their diet
what are some other feeding problems that may become
- Relactation: ask the baby to suckle from the
apparent from the mother’s answers?
breast but since there is no more breast milk, the
- Difficulty or wrong positioning of the baby during
mother can prepare a milk formula and put this
breastfeeding
in a dropper, simulating as if the baby is getting
- Attachment problems
something. With continuous suckling, the breast
- Use of a feeding bottle
will now be stimulated to form breast milk
USE GOOD COMMUNICATION SKILLS
through the release of PRL from the PG
When counseling mothers, it is important to use the following
- They must take more breast milk or other foods to make
skills:
up for this reduction
. Ask and Listen
- If the child is still breastfed, give more frequent, longer
. Praise
beastfeeds, day and night
. Advice
- If taking other milk:
. Check understanding
- Replace with increased BF or
Giving Relevant Advice on Feeding
- Replace with fermented milk products, such as
When Giving Relevant Advice on Feeding
yogurt or
- First you need to assess the child’s feeding and find out if
- Replace half the milk with nutrient-rich
there are feeding problems
semi-solid foods
- Then you will be able to limit your advice to what is most
- Thick cereal gruel with added oil
relevant to the mother
- Meat, fish, eggs, pulses
- Fruits & veggies

f m
 sinuses towards the palate, squeezed,
Child’s Actual Feeding Problem Recommendation
Feeding Feeding and milk will come out from here,
initiating swallowing reflex in the baby
A -month-old Giving sugar water A -month old - If you offer a feeding bottle, the nipple is already
infant is given sugar in addition to infant should be elongated there and the baby does not need
water as well as breastmilk given only stretch it; the baby will just suck it so the milk
breast milk breastmilk and no will come out from the pores, which is entirely
other food and fluid
different from breastfeeding
An -month old Baby has not been A breastfed - Therefore, the baby will find it easier to feed on
infant is still started on month-old infant a feeding bottle than on the breast - nipple
exclusively complementary should also be confusion
breastfed foods yet given adequate Describe active feeding
servings of a - The mother encouraging the child to eat and not sharing
nutritious food with the siblings or the parents
complementary
What will you do if the child is not being fed actively?
food x a day
- Tell the mother to provide each children their own serving
A -year old child is Child is fed only x A -year old child and encourage them to eat
fed only x each a day should receive What will you do if the child is not feeding well during illness?
day extra feedings - Continue feeding the ill child with foods preferred by the
between meals, as child (nutritious foods)
well as - meals a ADVISE MOTHER TO INCREASE FLUIDS DURING ILLNESS
day
For any sick child:
- What will be your advice on breastfeeding?
What will you do if feeding recommendations for the child’s age: - Breastfeed frequently, longer in duration
- Are being followed and there are no problems? - If the child is taking breast milk substitutes, what will you
- Praise the mother do?
- Are not being followed? - Decrease the amount of breastmilk substitutes,
- Do not make negative comments and increase breastfeeding
- Advice the mother, offer the info again - Increase intake of which fluids will you recommend?
- What will you counsel the mother on? - Food based fluids (Soup, rice, water, yogurt)
- On other feeding probs you might have For a child with diarrhea, what will be your advice on:
encountered like - Fluid and electrolyte losses during episodes of diarrhea
- Difficulty or wrong positioning of the - Give extra fluid such as ORS
baby during breastfeeding - Food based fluids
- Attachment problems - Clean water
- Use of a feeding bottle - Feeding
What will you do if the child is about to enter a new age group with - Breastfeed more frequently
different feeding recommendations? - Continue giving extra fluids until diarrhea stops
- Anticipatory guidance ADVISE MOTHER ON FOLLOW-UP VISIT & WHEN TO RETURN
What will you do if the mother reports difficulties with IMMEDIATELY
breastfeeding?
- Ask the mother to breastfeed the child and check the
positioning and signs of attachment
- Take note if the child is suckling effectively
What will you do if the mother is using a bottle to feed the child?
- If the mother is mixed-feeding, the child will have “nipple
confusion”
- Instruct the mother:
- Areola should go into the mouth of the baby
during attachment, where the lactiferous sinuses
are found and where the breastmilk is stored
- During suckling, the baby will elongate
the areola, making a “teat”
- When this is elongated, the baby will
press his tongue on these lactiferous
f m
 IMCI: CARE OF YOUNG INFANT AGED UP TO MONTHS
Check for Very Severe Disease and Local Bacterial Infection

What things will you advise every mother who brought her child
for consultation and is taking her child home?
- Follow-up schedule based on the classification
- Signs when to return immediately
NEXT WELL-CHILD VISIT
What needs will you remind the mother on her child’s next well
visit?
- Immunizations
- Vitamin A prophylaxis
- st dose at months or above
- Subsequent dose every months
- Routine worm treatment
- Give every child Mebendazole or ALbendazole
every months starting at year of age
- Record the dose on the child’s card
- Dental check-up
- Advice mothers and caregivers to bring their
children for regular dental check-up every
months ( x a year)
COUNSEL THE MOTHER ABOUT HER OWN HEALTH
- During a sick child visit, listen for problems that the
mother may also have Notes:
- Mother may need treatment for these problems or referral - What is the difference in assessing young infants from
to a specialist children months to years of age?
- Do not force mothers to cue twice (first for the baby, then - there’s no assessment box for general danger
for her own problems) and be sent to another department. sign (cough or difficulty in breathing)
If you know how to address the problem of the mother, - Difficulty in feeding
provide it yourself. If you don’t know, refer her to an - Positioning or attachment problems
appropriate department where her needs can be attended - Convulsions - may not necessarily be part of the current
to. illness of the infant; could be a history of convulsion
Question regarding a mother with lots of milk - If the first count of RR yields 0 or more breaths per min,
- It is not recommended to use a breast pump do not report it immediately, but repeat the count. If you
- Manual expression of the breast is recommended get the same results from the nd counting, then the
- Milk stored in plastic containers then placed in the infant has fast breathing
freezer/ref - Fast breathing in a young infant is not a sign of
- In giving the expressed breastmilk, it is not recommended pneumonia, but a sign of very severe disease
to use a feeding bottle, (to avoid nipple confusion) but to - Chest indrawing - lower chest wall moves in when the
let the baby have small sips on a small cup in an upright or child breaths in
semi-upright position - Must be severe or deep to consider very severe
disease
- Mild is considered normal because the chest wall
is soft among young infants
- Umbilicus
- Red or draining pus: infection of the umbilicus
- Skin Pustules
- Red spots with pus on top of it which is a sign of
a local bacterial infection

f m
 - General condition of the child Asses Young Infant’s Diarrhea
- Check for infant’s movement Ask: Does the young infant have diarrhea?
- We don’t assess the level of consciousness
because infants sleep most of the time

Classify
Diarrhea
for

Dehydration

Check Young Infant for Jaundice

Describe how to check for jaundice and assess its severity

- Yellowish discoloration in the infant’s eyes or skin
- Ask the mother when the jaundice started to appear
- Feel for jaundice by putting fingers on or running fingers
Check Young Infant for Feeding Problem or Low Weight
across the forehead. Remove fingers and take note for
yellowish discoloration
- Assess severity by checking yellow discoloration at the
palms and soles
Classification of Jaundice
When will you counsel a mother/caregiver about feeding
problems?
- If there are feeding problems like positioning or
attachment
- Or if the mother is not breastfeeding at all
- Or breastfeeding less than x a day
- Or the mother is giving complementary foods when the
infant is less than months of age
Check if Young Infant has Low Weight for Age IMCI Module
When does physiologic jaundice occur
- On the th hours of life or beyond

f m
What will you plot when checking if a young infant is low weight - No more because it is useless
for age? - Give when the baby is weeks old
- Determine weight of infant on y-axis When are you going to give an infant Hep B if he has not received it
- Infant’s age in weeks plotted at the x-axis by the time he is days old?
Look for Ulcers or White Patches in the Mouth (Thrush) - weeks old
- Due to candidiasis What other vaccines will you give?
- Where do we check for oral thrush? - DPT, Influenza, Hep B
- In the oral mucosa, cavity, lips Will you immunize a young infant who is going to be referred?
Assess Breastfeeding: Look at the infant’s attachment - No. it is a relative contraindication
What are the signs of good attachment? - Just write what immunization is to be received
. Mouth is wide open - Prior to discharge, patient receive antigens missed at OPD
. Lower lip torn outward of hospital
. Chin touches or nearly touches the breast of the mother What other problems are you going to assess in a sick young infant?
. More areola is seen above the baby’s top lip than below - The mother will tell you or
When do you say the infant is not well-attached? - You will notice it
- Please refer to the signs of good attachment How will you treat these other problems?
When do you say that an infant is suckling effectively? - Depending on your experience and knowledge
- When the infant makes slow, deep sucks Example:
- In between slow, deep sucks, the child will pause to Diaper rash - if you know, treat. If not, refer
swallow the breastmilk How will you identify treatment, treat the sick young infant, counsel
the mother, provide ff-up care?
- Use the algorithm

Check Young Infant’s Immunization Status

Birth - BCG, Hep B0
weeks - PVV , OPV
10 weeks - PVV , OPV
Give all missed doses on this visit
Vitamin A - 00,000 IU to the mother within weeks of delivery
- To cause re-epithelization of the uterine lining
When are you going to give the recommended vaccine?
- Birth - BCG, Hep B0
- weeks - PVV , OPV
- 10 weeks - PVV , OPV
What contraindication to immunization are you going to observe?
- Don’t give BCG to a baby born from a mother with HIV, bc
the baby might develop TB
- Don’t give a nd dose of pentavalent vaccine, if within
days of giving PVV → seizure due to Pertussis component
of PVV
- Don’t give PVV or DPT to a baby with neuro disorder
Are you going to give Hep B0 to an infant days old?
f m
IMCI Part 4 child is full, he/she will not take the ORS
Dr. Charles Cabataña anymore.

PLAN B: TREAT SOME DEHYDRATION WITH ORS IF THE MOTHER MUST LEAVE BEFORE
• In the clinic, give recommended amount of ORS COMPLETING TREATMENT:
over 4-hour period (in the health center) • Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 4-hour
DETERMINE AMOUNT OF ORS TO GIVE DURING treatment at home.
FIRST 4 HOURS • Give her enough ORS packets to complete
Weight <6 kg 6- <10kg 10- <12kg 12-19 kg rehydration. Also give her 2 packets as
Age Up to 4mos – 12mos- 2 yrs-5yrs recommended in Plan A.
4mos 12mos 2yrs • Explain the 4 Rules of Home Treatment:
In (ml) 200 - 450 450 - 800 800 - 960 960 - 1600 1. GIVE EXTRA FLUID
The amount of ORS given to the child in the first 4hours 2. GIVE ZINC (age 2 months up to 5
will be based on the weight and age, but it is better to years)
based it from the exact age of the child. 3. CONTINUE FEEDING (exclusive
breastfeeding if age less than 6 months)
* Use the child's age only when you do not know the 4. WHEN TO RETURN
weight. The approximate amount of ORS required (in ml) Signs
can also be calculated by multiplying the child's weight - Blood in the stool
(in kg) times 75. - Drinking poorly
• If the child wants more ORS than shown, give - Signs of any sick child
more. (Basis: signs of dehydrationà can give • Not able to drink or
more than what is required) breastfeed
• For infants under 6 months who are not • Becomes sicker
breastfed, also give 100 - 200 ml clean water • Develops a fever
during this period if you use standard ORS. This
is not needed if you use new low osmolarity PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
ORS. Start Here
Example:
Can you give • Start IV fluid immediately.
Child’s Weight; 10- <12kgs • If the child can drink, give ORS by mouth
intravenous YES
• Amount of ORS that should be given during the (IV) fluid while the drip is set up.
first 4H- 800-960ml (According to Dr. Cabataña, immediately? • Give 100 ml/kg Ringer's Lactate Solution
it’s okay to give 1000ml- in this case you can (or, if not available, normal saline), divided
NO as follows
instruct the mother to give, 250ml of ORS every Age First give Then give
hour) 30ml/kg in: 70ml/kg in:
Infants 1 hour* 5 hours
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. (under 12
months)
• Give frequent small sips from a cup. (Dropper for Children 30 2 1/2 hours
infants) (12 months minutes*
• If the child vomits, wait 10 minutes. Then up
to 5 years)
continue, but more slowly.
* Repeat once if radial pulse is still very
• Continue breastfeeding whenever the child weak or not detectable.
wants. Example 1:
* Check the child every hour. Child’s Age- 6mos old
!"# %& '(&)*+
Child’s Wg- approx. ( + 3 = 6kgs
,
AFTER 4 HOURS: • In the first hour: Give 30ml.kg- 30ml x
6kgs = 180ml of IVF in 1hr (Moderate
• Reassess the child and classify the child for fast drip)
dehydration. • In the next 5 hours: : Give 70ml.kg-
• Select the appropriate plan to continue 70ml x 6kgs = 420ml of IVF for 5hours
treatment. (Compute for Infusion rate)
• Duration of hydration of a younger
* If reassessment of the child after 4 hours, and child is 6hrs (1 + 3hours)
classification still falls on “Some Dehydration”, Example 2:
give more ORS to be consumed in the next 4 Child’s Age- 5yrs old
hours. Child’s Wg- approx. (age in yrsx2)+7=
17kgs~20kg
* If reassessment of the child after 4 hours, and • In the first hour: Give 30ml.kg- 30ml x
classification is “No Dehydration”, teach the 20kgs = 600ml of IVF in 30min (fast
mother of Plan A. drip)
• Begin feeding the child in clinic. • In the next 2.5 hours: : Give 70ml.kg-
70ml x 20kgs = 1400ml of IVF for
* Feeding is not recommended during the first 4 2.5hours (Compute for Infusion rate)
hours of initial dehydration, because when the • Duration of hydration of an older child
is 3hrs (30mins + 2.5hours)
mgedano
 • Reassess the child every 1-2 hours. If GIVE EXTRA FOOD FOR DIARRHEA & CONTINUE
hydration status is not improving, give the FEEDING
IV drip more rapidly.
• Also give ORS (about 5 ml/kg/hour) as Treat Persistent Diarrhea
soon as the child can drink: usually after • Require special feeding
3-4 hours (infants) or 1-2 hours (children). • Advise the mother about feeding her child
• What is the importance of giving ORS in
the presence of IV in a child with severe • Refer to the feeding recommendations for a child
dehydration? with persistent diarrhea on the counsel the
o The volume given during the first 6hrs mother chart
is to replace what has been lost, not
intended to replace on going losses.
o Ongoing fluid losses in a child with Treat Dysentery
diarrhea with severe dehydration, the • Give an oral antibiotics recommended for
child can continue to have loose Shigella in your area
stools. Therefore, when fluids and
electrolytes are not replaced after • Tell the mother to return in 2 days for follow-up
each bowel movement, the child will to be sure that the child is improving
still be dehydrated.
o Instruct the mother to bring the child in
a semi upright/upright position, so that
the child will not aspirate. COUNSEL THE MOTHER
Example: FEEDING RECOMMENDATIONS
Child’s Age- 5yrs old Newborn, Birth up to 1 week
Child’s Wg- approx. (age in yrsx2)+7=
17kgs~20kg • Immediately after birth, put your baby in skin to
• 20kgs x 5ml=100ml/hour PO skin contact with you. (Review essential
• Reassess an infant after 6 hours and a newborn care: Dry the babyà skin to skin
child after 3 hours. contact with the motherà timely cut the cord)
• Classify dehydration. Then choose the
appropriate plan (A, B, or C) to continue • Allow your baby to take the breast within the first
treatment. hour. Give your baby colostrum, the first
o Severe Dehydration- Repeat giving IV yellowish, thick milk. It protects the baby from
Fluid (Plan C) many Illnesses. (Colostrum is the first form of
o Some Dehydration- Follow Plan B
o No dehydration- Follow Plan A immunization because it contains preformed
antibodies. Feeding the baby will prevent
hypoglycemia)
Is IV • Refer URGENTLY to hospital for IV • Breastfeed day and night, as often as your baby
Treatment treatment. wants, at least 8 times in 24 hours. Frequent
available YES • If the child can drink, provide the mother feeding produces more milk.
nearby with ORS solution and show her how to
(within 30 give frequent sips during the trip or give • If your baby is small (low birth weight), feed at
mins) ORS least every 2 to 3 hours. Wake the baby for
• NO by naso-gastric tube. feeding after 3 hours, if baby does not wake self.
NO
(It is important to feed the baby when there is
presence of hunger cues, such as, opening of
• Start rehydration by tube (or mouth) with
Are you ORS solution: give 20 ml/kg/hour for 6 the mouth, sticking out of the tongue, sucking of
trained to hours (total of 120 ml/kg). finger. Crying is a late sign of hunger)
use Naso- YES Example: • DO NOT give other foods
gastric (NG) Child’s Wg- 10
or fluids. Breast milk is all
tube for • 10kgs x 20ml=200ml/hour for
rehydration 6hours your baby needs. This is
• Total of 1200ml especially important for
NO • Reassess the child every 1-2 hours while infants of HIV positive
waiting for transfer: mothers. Mixed feeding
o If there is repeated vomiting or
YES increasing abdominal distension, give
increases the risk of HIV
Can the child mother-to-child
the fluid more slowly.
drink
o If hydration status is not improving transmission when
NO after 3 hours, send the child for IV compared to exclusive
therapy.
o After 6 hours, reassess the child.
breastfeeding
Classify dehydration. Then
Refer • choose the appropriate plan (A, B or C) to 1 week up to 6 months
urgently to continue treatment
hospital for • Breastfeed as often as your child wants. Look for
IV or NG signs of hunger, such as beginning to fuss,
treatment Note: sucking fingers, or moving lips.
• If the child is not referred to hospital,
observe the child at least 6 hours after
• Breastfeed day and night whenever your baby
rehydration to be sure the mother can wants, at least 8 times in 24 hours. Frequent
maintain hydration giving the child ORS feeding produces more milk.
solution by mouth.
• In the hospital, when the child’s condition
mgedano become stable it is emphasize to give zinc
 • Do not give other foods or fluids. Breast milk is • If your child refuses a new food, offer "tastes"
all your baby needs. several times. Show that you like the food. Be
patient.
6 up to 9 months • Talk with your child during a meal and keep eye
• Breastfeed as often as your child wants. (start contact.
giving complimentary food) • Children at this stage must receive their own
• Also give thick porridge or well-mashed foods, food, they should not
including animal source foods and vitamin A-rich be sharing with their
fruits and vegetables. (Instruct the mother to siblings or parents, in
breast feed the child first order to ensure they
before giving the get the proper
complimentary food) nutrients to sustain
• Start by giving 2 to 3 normal growth and
tablespoons of food. development. Always
Gradually increase to ½ observe balance diet.
cups (1 cup = 250ml).
• Give 2 to 3 meals each day. SPECIAL FEEDING RECOMMENDATIONS
• Offer 1 or 2 snacks each day For Children with severe diarrhea
between meals when the • Children with persistent diarrhea may have
child seems hungry. difficulty digesting milk other than breast milk
• They need to temporarily reduce the amount of
9 up to 12 months other milk in their diet
• Breastfeed as often as your child wants. • They must take more breast milk or other foods
• Also give a variety of mashed or finely chopped to make up for this reduction. Perform re-
family food, including animal source foods and lactation.
vitamin A-rich fruits and vegetables. • If the child is still breastfed, give more frequent,
• Give 1/2 cup at each meal (1 cup = 250 ml). longer breastfeeds, day and night
• Give 3 to 4 meals each day. • If taking other milk:
• Offer 1 or 2 snacks between meals. The child o Replace with increased BF OR
will eat if hungry. o Replace with fermented milk products,
• For snacks, give small chewable items that the such as yoghurt OR
child can hold. Let your child try to eat the snack, o Replace half the milk with nutrient-rich
but provide help if needed. semi-solid foods (for example thick
cereal gruel with added oil, meat, fish,
12 months up to 2 years eggs, pulses and fruits and vegetables)
• Breastfeed as often as your child wants.
• Also give a variety of mashed or finely chopped FEEDING ASSESMENT
family food, including animal source foods and
• Use the table below to assess any feeding
vitamin A-rich fruits and vegetables.
problems of the child
• Give 3/4 cup at each meal (1 cup = 250ml).
• Give 3 to 4 meals
each day. (Child
starts to share family
food)
• Offer 1 to 2 snacks
between meals.
• Continue to feed
your child slowly,
patiently. Encourage
-but do not force -
your child to eat.

2 years and older • Mixed feeding can cause nipple confusion.

• Give a variety of family foods to your child,
including animal source foods and vitamin A-rich Identifying feeding problems
fruits and vegetables. • What is the basis in identifying feeding
• Give at least 1 full cup (250 ml) at each meal. problems?
• Give 3 to 4 meals each day. o The basis will be the IMCI
• Offer 1 or 2 snacks between meals. recommendations based on the actual
answers of the mothers.
mgedano
 • What should be done to be able to identify between meals, as well as
feeding problems? 3-4 meals a day.
o Know the recommendations based on • What will you do if feeding recommendation for
the age of the child. Identify any the child’s age
difference or deviation from the o Are being followed and there are no
recommendation that becomes a problems? Praise the mother, give
feeding problem. compliments
• In addition to difference from the feeding o Are not being followed? DO NOT make
recommendations, what are some other feeding negative comments. Advise the mother,
problems that may become apparent from the offer the information again.
mother’s answers? o What will you also counsel the mother
o Difficulty or wrong positioning of the on? Counsel the mother on other
baby during breast feeding feeding problems you may have
o Attachment problems encountered (Use of feeding bottle,
o Use of a feeding bottle attachment, positioning)

USE GOOD COMMUNICATION SKILLS • What will you do if the child is about to enter a
When counseling mothers, it is important to use the new age group with different feeding
following skills recommendations? Give the mother anticipatory
• Ask and listen- guidance
• Praise o 1 week up to 6 months
• Advise § Breastfeed as often as your
• Check understanding child wants. Look for signs of
o Ask the mother how she feeds the child. hunger, such as beginning to
If it is within the recommended age fuss, sucking fingers, or moving
group, praise the mother. If not, DO lips.
NOT scold or give negative comments § Breastfeed day and night
at the mother. Instead, give advice on whenever your baby wants, at
how to properly feed the child. Lastly, least 8 times in 24 hours.
check the mother’s understanding by Frequent feeding produces
asking good questions. more milk.
§ Do not give other foods or fluids.
When giving relevant advice on feeding Breast milk is all your baby
needs.
• First you need to assess the child’s feeding and
o 6 up to 9 months
find out if there are feeding problems
§ Breastfeed as often as your
• Then you will able to limit your advice to what is
child wants. (start giving
most relevant to the mother.
complimentary food)
§ Also give thick porridge or well-
Child’s actual feeding Feeding problem mashed foods, including animal
A 3 month old infant is Giving sugar water in source foods and vitamin A-rich
given sugar, water as addition to breast milk fruits and vegetables. (Instruct
well as breast milk. the mother to breast feed the
An 8 month old infant is Baby has not been started child first before giving the
still exclusively breast on complimentary foods complimentary food)
feed. yet § Start by giving 2 to 3
A 2 year old child is feed Child is feed only 3x a day tablespoons of food. Gradually
only 3x each day increase to ½ cups (1 cup =
250ml).
Child’s actual feeding Recommended feeding § Give 2 to 3 meals each day.
A 3 month old infant is A 3 month old infant § Offer 1 or 2 snacks each day
given sugar, water as should be given only between meals when the child
well as breast milk. breast milk and no other seems hungry.
food and fluid
An 8 month old infant is A breast feed 8month old • What will you do if the mother reports difficulty
still exclusively breast infant should also be with breastfeeding? Ask the mother to
feed. given adequate servings breastfeed the child and check the positioning
of the nutritious and the signs of attachment. Take note if the
complimentary food 3x a child is suckling properly.
day • What will you do if the mother is using a bottle to
A 2 year old child is feed A 2 year old child should feed the child? The child will have nipple
only 3x each day receive 2 extra feedings confusion.
mgedano
 • Describe active feeding. Simply means, the
mother encouraging the child to eat
• What will you do if the child is not being feed
actively? Tell the mother to provide her child
his/her own serving.
• What will you if the child is not feeding well
during illness? Tell the mother to continue
feeding the ill child.

Advise mother to increase fluids during illness

• For any sick child
o What will be your advice on BF?
Breastfeed more frequently and for
longer at each feed. If child is taking
breast-milk substitutes, increase the
amount of milk given.
o If the child is taking breastmilk COUNSEL THE MOTHER ABOUT HER OWN HEALTH
substitute, what will you do? • During a sick child visit
Increase other fluids. For example, give o Listen for problems that the mother may
soup, rice water, yoghurt drinks or clean have.
water. • Mother may need treatment for her problems or
referral to a specialist.
o Increase intake of which fluids will you
• Do not force mothers to:
recommend o Cue twice, attend to the needs of the
• For child with diarrhea: mother
o Giving extra fluid can be lifesaving.
o Give fluid according to Plan A or Plan B
on TREAT THE CHILD chart.
o Breastfeed more frequently and longer
at each feeding
o Continue giving extra fluids until
diarrhea stops

NEXT WELL-CHILD VISIT

• What needs will you remind the mother on her
child’s next well visit? Immunization

mgedano
 CARE OF THE YOUNG INFANT (BIRTH-2 MONTHS) o For the chest indrawing to considered
Check for very severe disease and local bacterial present in young infants it must be
infection severe or deep and most be present at
• The difference between assessment of young all times
infants from children 2mos- 5years is that, there
o If it is mild, it is considered normal.
is no assessment box for danger sign.
Because the chest wall is soft among
young infants
• Measure axillary temperature
o Fever or hypothermia are considered
sign of very severe disease
• Look at the umbilicus
o Red or draining pus- signs of local
infection
• Look for Skin Pustules
o Red spots with pus on top of it which is
a sign of a local bacterial infection
• Check general condition
o Infant does not move at all- sign of very
severe disease

• Ask the mother is the infant having difficulty in

feeding?
o Positioning or attachment problems
• Has the infant had Convulsions (Fits)
o may not necessarily be part of the
current illness of the infant. This could
be a history of convulsion
• One sign on the pink row à Classification: Very
• Look listen and feel
severe disease
o Do it again when the infant is calm and
• No signs on the pink row, move down the yellow
not eating
row. Any of the three signs on the yellow rowà
o Take the RR in 1 full minute.
Classification: Local bacterial infection
o If the first count of RR yields 60 or more
breaths per min, do not report it • No signs on the yellow row, move down the
immediately, but repeat the count. If you green rowà Classification: Severe disease or
get the same results from the 2nd local infection unlikely.
counting, then the infant has fast
breathing CHECK FOR JAUNDICE
o Fast breathing in a young infant (birth - • If jaundice is present, ask: When did the
2mos) is not a sign of pneumonia, but a jaundice appear first?
sign of very severe disease • How to assess the severity of Jaundice if
• Look for severe Chest indrawing present?
o lower chest wall moves in when the o Look at the young infant's palms and
child breaths in soles. Are they yellow?
o If it does not appear yellowish, place
your hands on the forehead, remove
mgedano
 fingers from the forehead. Take note of § Very slowly (longer than 2
yellowish discoloration in the forehead. seconds)
§ or slowly
§ Make a vertical fold of the skin
using the ball of the thumb and
knuckle of the index finger (DO
NOT use your fingers to make a
vertical fold).

• One sign on the pink row à Classification:

Severe Jaundice
• No signs on the pink row, move down the yellow
row. BOTH signs should be present in the yellow
rowà Classification: Jaundice
• No signs on the yellow row, move down the
green rowà Classification: No jaundice

• When does physiologic jaundice occur?

o Appears on the first 48 hours of life
• Two or more signs on the pink row à
Classification: Severe dehydration
• 1 or No signs on the pink row, move down the
ASSESS YOUNG INFANT’S DIARRHEA
Does the young infant have diarrhea? yellow row. 2 or more signs in the yellow rowà
Classification: Some dehydration
• IF YES, LOOK AND FEEL:
o Look at the young infant's general • 1 or No signs on the yellow row, move down the
condition: green rowà Classification: No dehydration
o Infant's movements
§ Does the infant move on his/her CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
own?
§ Does the infant not move even
when stimulated but then stops?
§ Does the infant not move at all?
§ Is the infant restless and
irritable? The infant cannot be
pacified in any manner.
Restless and irritability is due to
dehydration.
o Look for sunken eyes. • When will you counsel a mother /caregiver about
§ Ask the mother, confirm for feeding problems? If there are feeding problems
changes in the eyes of the child like positioning and attachment; mother is not
§ Thirst is not assess in young breast feeding at all; the infant is breast feed
infants but this criteria is assess <3x/day; mother is giving complementary food
in children 2mos-5years old. even if the infant is <6mos.
Because it is difficult to • What will you plot when checking if a young
differentiate thirst from hunger. infant is low weight for age?
o Pinch the skin of the abdomen. Does it o Determine weight of infant on y-axis
go back: o Infant’s age in weeks plotted at the x-
axis
mgedano
 • one sign on the yellow rowà Classification:
feeding problem
• No signs on the yellow row, move down the
green rowà Classification: no feeding problem
• Feeding problem
o Not well attached to breast or
o Not suckling effectively or
o Less than 8 breastfeeds in 24 hours or
o Receives other foods or drinks or
o Thrush (ulcers or white patches in
mouth).
• Low weight problem
• Look for Ulcers or White Patches in the Mouth o Low weight for age
(Thrush)
o White patches are due to candidiasis or • Example:
moniliasis o Sign: Not well attached to breast à
• Where do we check for oral thrush? Classification: Feeding Problem
o In the oral mucosa, cavity, lips
o Sign: Less than 8 breastfeeds in 24
ASSESS BREASTFEEDING hours + Low weight for ageà
• Look at the infant’s attachment Classification: Feeding Problem & Low
o What are the 4 signs of good weight problem
attachment? (when one sign is absentà
the baby is not properly attached, all CHECK YOUNG INFANT’S IMMUNIZATION STATUS
signs should be there for the suckling to
be effective)
§ Mouth is wide open
§ Lower lip torn outward
§ Chin touches or nearly touches
the breast of the mother
§ More areola is seen above the
baby’s top lip than below
• When do you say the infant is not well-attached?
• When do you say that an infant is suckling
effectively?
o When the infant makes slow, deep • Vitamin A - 200,000 IU to the mother within 4
sucks weeks of delivery. To cause re-epithelization of
o In between slow, deep sucks, the child the uterine lining
will pause to swallow the breastmilk • When are you going to give the recommended
vaccine? At the age when they are
recommended to be given.
o Birth - BCG, Hep B0
o 6 weeks - PVV1, OPV1
o 10 weeks - PVV2, OPV2
• What contraindication to immunization are you
going to observe?
o Don’t give BCG to a baby born from a
mother with HIV, because the baby
might develop TB
o Don’t give a 2nd dose of pentavalent
vaccine, if within 3 days of giving PVV1
à seizure due to Pertussis component
of PVV
o Don’t give PVV or DPT to a baby with
neuro disorder
• Are you going to give Hep B0 to an infant >14
days old?
o No more because it is useless. It could
not protect anymore against hepatitis B
via vertical transmission.

mgedano
 o Give when the baby is 6 weeks old
• When are you going to give an infant Hep B if he
has not received it by the time he is 15 days
old?
o 6 weeks old
• What other vaccines will you give?
o DPT, Influenza, Hep B
• Will you immunize a young infant who is going
to be referred?
o No. it is a relative contraindication, just
write what immunization is to be
receive. Prior to discharge, patient
receive antigens missed at OPD of
hospital
• What other problems are you going to assess in
a sick young infant?
o The mother will tell you or you as a
physician will notice it
• How will you treat these other problems?
o Depending on your experience and
knowledge
o Example: Diaper rash (no guidelines in
IMCI to treat diaper rash) - if you know,
treat. If not, refer
• How will you identify treatment, treat the sick
young infant, counsel the mother, provide follow-
up care?
o The same with the sick child. Use the
algorithm

mgedano
IMCI Par
D c Caba a a
A il

INTEGRATED MANAGEMENT OF CHILDHOOD CARE

FOLLOW UP
Wha i a f ll ca e
● A ca e gi e a child h e f a f ll
● T de e i e if he ea e ided i
i i g effec i e
E P e ia gi e a icilli
Wha a e ili ed ide he ca e eeded
● U ili ed f ll b e

H a age a child h c e f f ll
● A k he he ab he child ble
● I hi a f ll i i ial i i f hi ill e
A e he child acc di g he i ci i he
● If f ll f a ill e
f ll b i he IMCI cha
● A k he he if he child ha i addi i
● The i ci a ell a e a
de el ed a e ble
aj a he ASSESS CLASSIFY
● If he child ha a ne problem
cha
● A f ll a e e i e i ed
● The a al ell a e addi i al
▪ A a a i i ial i i
ig
● Check f ge e al da ge ig a e all he
Ski he CLASSIFY a d ide if ea e c l f
ai child i i al a
he A e a d Cla if cha
▪ Cla if a d ea he child f he e
● A id gi i g he child e ea ed
ble a ld a a i i ial
ea e ha d ake e e
ii
▪ E A child c e f a f ll a d
Whe h ld he he b i g a child h eed f ll f e
cla ifica i i e ia
ha e c di i cla ifica i
d a e c gh diffic l
● If he e a e e e al cla ifica i he he h ld b i g
b ea hi g a e beca e he child
he child f f ll i g he ea lie defi i i e i e
had bee ea ed i i iall d i g he
● E If he child had e ia ac e ea i fec i a d
e i ii
fe e he ha e f ll ched le
▪ Y l a e he e f he ai
a d i i al a Che i d a i g Yell ● Gi e al A icilli f
Fa b ea hi g PNEUMONIA da
● Rea e ea he e ia acc di g he
f ll b i he IMCI cha ● If hee i g
▪ D e he a e e b f di a ea ed af e
c gh diffic l b ea hi g a idl ac i g
b ch dila gi e a
L ca e he f ll b ha a che he child i haled b ch dila
e i cla ifica i i he IMCI cha f da
▪ The f ll he i ci i ha ● If che i d a i g i HIV
b e ed i fec ed child
gi e fi d e f
a icilli a d efe
● S he he h a a d
elie e he c gh i h a
e ed
● If c ghi g f e
ha da
ec e hee e efe
f ible TB
a h aa e e
● Ad i e he e
i edia el

F ll i da
P i ee d ai i g Yell ● Gi e a a ibi ic f
f he ea a d da

K /KJM E CEL
d c a ge ACUTE EAR ● G e a ace a f a ● Re e a d ab e
e ed f e INFECTION ● D e ea b c g ● L f e e e
a da ● F da ● Offe e c d f d e
Ea fec c d
N ge e a da ge G ee ● G e e d e f ● N ab e d
g FEVER a ace a c c f d g
N ff ec g fe e C ● D g ea
ab e ● P c e f e
● G e a ae abd e D e g bac
a b c ea e f ● Ve ge a
a de f ed bac e a ec
ca e f fe e ● S
● Ad e e e
e ed a e
● F da f
fe e e
● If fe e f e e e e
da f e a da
efe f a e e

● T e f c ega d g f f f fe e
e da f e efe e ab e ab e
● d
c d be da e a CLASSIFY DIARRHEA
● Ta e e F fe e c d a O e f e T f e SEVERE If c d a e
fe e e f g g DEHYDRATION c a f ca
● If e fe e d d e ec d e da ● Le a g c G e f d f e ee
f ef f e a T e e da ae c c de d a Pa C
f ef f e ac e ea fec ● S e e e
● J e e ea e def e f e a d e ● N ab e OR
ea e c d a f e If child also has another
d
● F b f e a severe classification:
d g
- Refer urgently to
● S c
hospital with mother
g e bac
giving frequent sips of
ORS on the way.
- Advise the mother to
continue
breastfeeding

If child is 2 years or older

and there is cholera in
your area, give antibiotic
for cholera.
● T e ea e de e d a e e T f e ff SOME G e f d c
● T ee ec d e a b c f e a f Re e ab e DEHYDRATION e e a df df
ee e e ec d be efe ed e S e e e e de d a Pa B
D eage If c d a a a e e
a e ec a f ee e e ce f da ge g
c a f ca
d
S c g e - Refer urgently to
● If the child has any kind of diarrhea: bac hospital with mother
o Ue e c d g e ec ea a e
giving frequent sips of
ea e
ORS on the way.
o C a f a d ea e de d a a d
- Advise the mother to
a eI a A e e
continue
o G e ea e
breastfeeding
IF YES, ASK LOOK AND FEEL:
● F g ● L a e c d ge e a Ad e e e
● I eeb d e c d I ec d e ed a e
● Le a g c F da f
c c g

K /KJM E CEL
N e g g NO G e f d c
ca f a DEHYDRATION e e a d f d
e e ee ea d a ea a e
de d a Pa A
Ad e e e
e ed a e
F da f
g

● Refer the child who comes for follow-up to the hospital:

o If e c d a e e a be a d ge g
e
o If a ec d e d g a a ab e
If ae ed ab e c d d
a d f ec d

K /KJM E CEL
 MALARIA

Please refer to Part 1 for clear tables.

PERSISTENT DIARRHEA

● If e c a f ca e g d fe e d a FULL
ea e e f ec d

DYSENTERY

MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR MOUTH

ULCERS OR THRUSH

K /KJM E CEL
 MODERATE ACUTE MALNUTRITION

EAR INFECTION

FEEDING PROBLEM AND ANEMIA

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

K /KJM E CEL
 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
CASE: DOES REQUIRE URGENT REFERRAL CLASSIFY COUGH
CASE ● A ge e a P ●G e f d e fa
J O d He e g g H ec be e g da ge g SEVERE a a ea b c
c H e ea e C He e Pa a a T e ea ● S d PNEUMONIA ●Refe URGENTLY a
e a ed W a a e e c d be T e e ad ca c d SEVERE
J a bee c g g f da a d e ea g e He DISEASE
a bee feb e f da a ead He a d a ea f da He ● C e Ye ● G e a A c f
a a e He e a bee d c a ge c gf J ea da g PNEUMONIA da
a d ff f ab a ea T J a f be ● Fa ● If ee g
b ea g d a ea ed af e a d
A e e Ca f ca ac g b c d a
g ea a ed
b c d a f da
● If c e d a g HIV
e ed fec ed c d
g ef d e f
a c a d efe
General Danger Signs ● S e e a a d
e e e ec g a
e ed
● If c g g f e a
da ec e
ee e efe f
b e TB a a
a e e
● Ad e e e
ed a e
● F da

N fg G ee ● If ee g
e a COUGH d a ea ed af e a d
e e ee COLD ac g b c d a
Classification: No classification for danger sign. d ea e g ea a ed
b c d a f da
● S e e a a d
e e e ec g a
e ed
● If c g g f e
a da ec e
ee e efe f
N da ge g ee Lea e eca f c ba ab e
b e TB a a
a e e
COUGH OR DIFFICULT BREATHING
● Ad e e e
ed a e
● F da f
g

DIARRHEA

Classification: Pneumonia (check the classification table)

● W e ed a f ec g da a d b ea

● J a fa b ea g Od Tc e e

K /KJM E CEL
Classification: SOME DEHYDRATION efe eDa ea
c a f ca ab e

● W e ed a fda ea da
● E c ce e f e a e ab e e
e e d g eage P c

● Tc e E c ce aa a d c g
● W e g e fe e da
● Ca e f a a a f e e a a ab e e e fac
● E c ce e ge e a ed a c g e
● Ca a ea e ca f ca beca e e e ed e e e ea e
b d e e e d a ea d a ● If e c d a ea e W a
da da c a f ca MEASLES efe e ab e be
● W e c a f ca e ace ded e
FEVER ec d
MEASLES Classification

Classification: FEVER, NO MALARIA

● U e aa a ab e f c a f ca f fe e
● Re e be J c e f Pa a a E de c
● P b e ca e f fe e R e e a da ea
● N da ge g a d ce

K /KJM E CEL
DENGUE Classification

● Tc e F g Ab a ea
Classification: FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
● E c ce da gf e ea
● P e c a f ca e ace be e Ye

MALNUTRITION AND ANEMIA

Classification: MODERATE ACUTE MALNUTRITION ab e be

● W a ae e g f a N ede a W d f
e g Z c e MUAC
● S g f a e a Pa a a
MALNUTRITION Classification
● Refe ab e T c e a e e f e ag c
fe e D e a g beca e f ega e
e e P e c a f ca e ace
ded e d

EAR PROBLEM

Classification: CHRONIC EAR INFECTION efe e ab e be

EAR PROBLEM CLASSIFICATION

K /KJM E CEL
 ● C ec e a a d a e a E c c e be ee
a d T e e MUAC E c ce e a a
a P e c a f ca e e
ANEMIA CLASSIFICATION

ASSESSING FEEDING

Classification: ANEMIA ab e ab e

IMMUNIZATION, VIT A & DEWORMING STATUS

Feeding Problems:
● Sharing of food
o C de d ece e e e g f
f d
● Do not breastfeed at night
Vaccines: need MMR o P ac ec e ed a g T e e ca
Vitamin A: needs vitamin A c e b ea feed g ea
Deworming: needs deworming o Ma a b ea b c a
b ea feed g g g ec e e a
f d
● Breastfeed x a day
o S d be a da e ec a a e
f fe
● Beca e J ed a a d MMR ● 2 meals and 1 snack a day (not enough)
ca be g e be ee d e c c e Mea e
E c ceV a A a d Mebe da e
● I a g e MMR beca e d e ec
f R be a b a f R be a Ge a ea e a d
M
● N e c ed e f a e a J
a ead ece ed a a e ce f MMR O ce
e ece ed e acc e e e f e e
a
o F e a de f ed feed g be
● U e e e a f a e e f acc e e g
R a C c e C e a de e d g e
Feeding Recommendations 12 months up to 2 years
a a ab e fac Y ca efe e a
o B ea feed a f e a c d a
ed a c a
A g e a a e f a ed f e c ed fa
Schedule for the Vaccines and Doses
f d c d g a a ce f d a d a A c
f a d ege ab e
G e c a eac ea c
G e ea eac da
Offe ac be ee ea
C e feed c d a e E c age d
f ce c d ea

Classifications and Signs of the Case (Summary)

● P e a
o Fa b ea g b ea
o C e da g

K /KJM E CEL
● S e de d a
o I ab e e e e d eage
c g e bac
● Fe e N Ma a a
● Mea e
o Ge e a ed a c g e ed e e
● Fe e DHF U e
o T e e ega e
● C c Ea fec
o D c a ge c gf J ea a d ff f
ab a ea
● M de a e Ac e Ma
o c e MUAC
● A e a
o S e a a a
● I a Sa
o Rece ed e ff acc e BCG He B PV PV
PV OPV OPV OPV
o M ed acc e MMR
● V a A a d De gS a
Dd ece e a d e f V a A a d
Mebe da e e a

K /KJM E CEL
 FLOWCHART in IDENTIFYING TREATMENT ● Fever: No Malaria
We g g
Te e a e C
T ea e efe e c a f ca ab e f
aa a
▪ Give recommended 1st oral
antimalarial
▪ Give the 1st dose of paracetamol
▪ D a b c a
beca e a ead ga e A c
f e ea e f e a
b e ca e f fe e
▪ Advise the mother to return
immediately
▪ Follow-up in 3 days if fever persists.
● Re e a c a f ca a d de e e f U ge
● Measles
efe a eeded
o Ge e a ed a c g e ed e e
● D e ec d e e ge efe a NO.
T ea e
● If
▪ Give Vitamin A (200,000 IU)
IDENTIFY a e ea e eeded f a e
● Fever: DHF Unlikely
c a f ca
o T e e ega e
TREAT e c c d
o T ea e
TEACH e e d e ea e
▪ Give ORS
a e
▪ Advise the mother to return
COUNSEL e e ab feed g f d a d
immediately
e e
▪ Follow- up in 2 days if fever persists or
child shows signs of bleeding
IDENTIFY TREATMENTS NEEDED
▪ DO NOT GIVE ASPIRIN.
● Refe e c a f ca ab e Ide f a ae e
● I a a ee f c
ee a ea e ba ed e g f e a e
● Chronic Ear infection
● Pneumonia
o D c a ge c gf J ea a d ff f
o C e da g
ab a ea
o Fa b ea g b ea
o T ea e
o We g g
▪ Dry the ear by wicking.
o T ea e
● Teac e e
▪ Amoxicillin
c a da e ea
▪ Soothe the throat and relieve the
bec e d f
cough with a safe remedy.
▪ Treat with topical quinolone eardrops
▪ Advise the mother to return
for 1 days.
immediately
▪ Follow-up for days.
▪ Follow-up in 3 days.
● M de a e Ac e Ma
● Some Dehydration
o c e MUAC
D a ea f da b d
o T ea e
I ab e e e e d eage
▪ Assess the child’s feeding and counsel
c g e bac
the mother on the feeding
We g g
recommendations.
T ea e efe e c a f ca ab e f
▪ If feeding problem, follow up in
d a ea Ide f a a e e ee a
days.
ea e ba ed e g f e a e
▪ Assess for possible TB infection
▪ Give fluid, zinc supplements and food
▪ Advise the mother to return
for some dehydration (Plan B). T ea a
immediately
e ea ce e
▪ Follow-up in 30 days
▪ G e c e e
● A e a
c ORS g e
o S e a a a
● We g g a
o T ea e
f ORS
▪ G e
▪ Advise the mother to return
▪ G e ebe da e f e c d ea
immediately
de a d a ad a d e e
▪ Follow-up in days if not improving.
e

K /KJM E CEL
 ● G e beca e e c d d d a d
ece e e d e e de
a a d MUAC e a Ye G e a a b c
a c OR UNCOMPLICATED f da
ca e f a e a WFH L e SEVERE ACUTE G e ead e
▪ Advise the mother to return a Z c e MALNUTRITION e a e cf df a
immediately AND c d aged
N ed ca e
▪ Follow-up in 1 days
c ca Re e ab effec e
● I a Sa
N b ea feed g f a
o Rece ed e ff acc e BCG He B PV PV
b ea feed g c d aged e a
PV OPV OPV OPV be de
o M ed acc e MMR C e e e
o Vacc e eeded MMR Ab e f feed e
● V a A a d De gS a e ed c d
Dd ece e a d e f V a A a d a f RUTF A e f be
Mebe da e e a a d TB fec
o Needed Vitamin A and Mebendazole de Ad e e e
e ed a e
COUNSEL ON FEEDING F da
T e ea e a e ed J feed g H e ad I MUAC be ee Ye A e ec d
b ea feed J a da I d b ea feed a g I e e MODERATE ACUTE feed g a d c e
OR MALNUTRITION e e e
ea a d ac a da He a e f d e a d ea
WFH L feed g
W e e ge c e ef e ea
be ee Z ec e da
Feed g C e g C e e e ef g feed g a d Z c e If feed g be
ec e da a d ede a f da
E c age e c d ea e e f e c d fac a e ec e fb fee A e f be
f e e TB fec
Ad e e e
Feeding Recommendations e ed a e
ea F da
● B ea feed a f e a c d a
● A g ea a e fc ed fa f d c d g MUAC e G ee If c d e a
a a ce f d a d V a A c f a d OR NO ACUTE ea d a e e
ege ab e WFHL Z c e MALNUTRITION c d feed g a d
ae e c e e e
● G e c a eac ea c L
a d ede a feed g acc d g
● G e ea eac da
b fee e feed g
● Offe ac be ee ea
ec e da
● C e feed c d a e E c age If feed g be
b d f ce c d ea f da

Oede a f P G ef d e Follow-up Schedule

b fee COMPLICATED a a ea b c FOLLOW UP VISIT Ad e e e c ef f a e
OR SEVERE ACUTE T ea e c d ea e e ed f ec d be
WFH L e MALNUTRITION e e b d
If e c d a Re f f
a Z c e ga
● P e a da
OR Kee ec d a
MUAC e a Refe URGENTLY ● D e e
a ● Ma a a f fe e e
● Fe e aa a f
de fe e e
AND a e f ● Mea e e e
ef g c ca
Med ca ● M g ce
c ca
e e OR
B ea feed g ● Pe e d a ea da
be ● Ac e ea fec
OR ● C c ea fec
N ab e ● C g c d f
f e ed g
a f RUTF

K /KJM E CEL
 ● U c ca ed e e e da N g
f G ee If ee g
ac e a e a COUGH OR COLD d a ea ed af e
● Feed g be e e ee a d ac g
d ea e b c d a g e
● A e a da a a ed
b c d a f
● M de a e ac e da da
a S e e a
a d e e e ec g
● C f ed HIV fec Acc d g a a a afe e ed
● HIV e ed ec e da If c g g f e
a da
ec e ee g
Classifications & Signs efe f b e TB
C a f ca a aa e e
● P e a Ad e e e
Fa b ea g b ea e ed a e
C e da g F da f
● S e de d a g
I ab e e e e d eage
c g e bac
● Fe e aa a T f e SEVERE If c d a
● Mea e f g g DEHYDRATION e e ee
Ge e a ed a c g e ed e e c a f ca
Le a gc G ef df
● Fe e DHF U e
c c e e e de d a
T e e ega e
S e e e Pa C
● C c ea fec N ab e d OR
D c a ge c gf J ea a d ff d g If c d a a e
ab a ea S c g e e ee
● M de a e ac e a bac e c a f ca
c e MUAC Refe URGENTLY
● A e a a
S e a a a e g g
fe e f ORS
A ge e a P G ef d e fa e a
da ge g SEVERE a a ea b c Ad e e e
OR PNEUMONIA OR Refe URGENTLY c e
S d ca VERY SEVERE a b ea feed g
c d DISEASE
C e da g Ye G e a A c If c d ea
PNEUMONIA f da de a d e e
Fa b ea g If ee g c ea
d a ea ed af e a ea g e a b c
a d ac g f c ea
b c d a g e T f e SOME G ef d c
a a ed f g g DEHYDRATION e e a d
b c d a f f df e
da Re e ab e de d a Pa
If c e da g S e e e B
HIV e ed fec ed D eage If c d a a a
c d g ef d e f e ee
a c a d efe S c g e c a f ca
e e a bac Refe URGENTLY
a d e e e ec g a
afe e ed e g g
fc g gf e fe e f ORS
a da e a
ec e ee e Ad e e
efe b e TB e c e
a aa e e b ea feed g
Ad e e e Ad e e
e ed a e e e
F da ed a e
F da

K /KJM E CEL
N e g g NO DEHYDRATION G ef d c When to return Immediately
ca f e e e a d Ad e e e ed a e f e c d a a f ee
e ee f d ea g
de d a d a ea P a A A c c d N ab e d b ea feed
Ad e e Bec e c e
e e De e a fe e
ed a e If c d a COUGH OR COLD Fa b ea g
F da a e f D ff c b ea g
f g If c d a d a ea a B d
e f D g

Sg e e ed a e T e g fa c c d
ab e d b ea feed bec e c e de e fe e

Ca e U ge Refe a Needed
● J d He e g g H ec be
e g c H e ea e C He e
Pa a a
● T e ea e a ed W a a e e c d be
T e e ad J a bee c g g f da a d
e ea g e He a bee feb e f da
a ead He a d a ea f da He a a e
T e e a bee d c a ge c gf J ea a d
ff f ab a ea T J a f
be
A e e C a f ca
Ma age e f e c c d aged ea
Na e Age We g He g Le g Te e a e
g c C
A W a I a F
ae e V
c d
be

General Danger Signs

T e ea e c ec ed J f ge e a da ge g He
a ed I J ab e d b ea feed T e e ad N
J d e a b ea feed T e ea e ga e J
e a e He a ea f ead He a ab e
d f ac
Ne e a ed e e Dd e ed a e T e e
a d N T e e a ed Ha e ad c T e e
ad N
T e ea e ed ee f J a e a gc
c c J a d
C a f ca Very Severe Disease
A e C cea g ee Ca f
CHECK FOR GENERAL DANGER Ge e a da ge g ee
SIGN Ye N
N ab e d Re e be e da ge g
b ea feed e e ec g c a f ca
V e e g
C
Le a g c c c
C g

Cough or Difficult Breathing

T e ea e c ed e be f b ea J ad
f e He c ed b ea e e T e ea e
a c e d a g He d d ea d ee g
C a f ca Severe pneumonia or very severe disease

K /KJM E CEL
D e e c d a e c g d d ff c b ea g Ye N
F g da
C e b ea e e b ea e
e Fa b ea g
L f c e da g
L a d e f d
L a d e f ee g

Diarrhea
He a b d e H e e ae e H fa e a d
e a a J e e ae e T e ea e
ffe J e a e a d ec d a ab e d W e
e ea e c ed e e c d abd e e
bac e
Classification/s: Severe dehydration
DOES THE CHILD HAVE DIARRHEA Ye N
F g da
Ear problem
I e eb d e
T e e a bee d c a ge c gf J ea He d d fee
L a e c d ge e a c d I ec d
Le a g c c c a e de e g be d e e ea
Re e a d ab e C a f ca Chronic ear infection
L f e e e
ffe e c d f d I e c d Malnutrition and Anemia
N ab e d d g T e ea e c ec ed J f a a d a e a He
D g eage a e a a a T ee a ede a f b fee T e
P c e f e abd e D e g bac ea e de e ed J eg f e g a d d e
Ve ge a ec d a c c fe e ce H c e a be ee H MUAC a
S
C a f ca Moderate acute malnutrition
Fever F a e a ANEMIA
Ne e ea e a ed ab J fe e T e e ad
J a fe f da J dd a e a ff ec He a
ad a e e e ad
O PE J a a a c e g eb d J e e ee
ed T e e e e ce T e e a da gf
ee e a d c d g f e c ea N e ec ae e e ed
T e e a ega e
C a f ca Very severe febrile disease (because of the danger
signs)
F e ea e severe complicated measles
F e de g e fever dengue hemorrhagic fever unlikely

A e Feed g N beca e a ea c a f ca S
a e g feed g beca e e de a g e efe a

Classifications and Signs of the Case (Summary)

● Ve Se e e D ea e
N ab e d
● P e a
N ab e d
o Fa b ea g b ea
● S e de d a
o I ab e e e e d eage
c g e bac
● Ve Se e e Feb e D ea e
N ab e d
● Se e e C ca ed Mea e
N ab e d
o Ge e a ed a c g e ed e e
● Fe e DHF U e

K /KJM E CEL
 o T e e ega e U ge e efe a ea e
● C c Ea fec ▪ If child also has another severe
o D c a ge c gf J ea a d ff f classification:
ab a ea ● Refer urgently to hospital
● M de a e Ac e Ma with mother.
o c e MUAC o Omit giving ORS (the
● A e a child is not able to
o S e a a a drink).
● I a Sa ● Stop the mother to continue
o Rece ed e ff acc e BCG He B PV PV breastfeeding (not able to
PV OPV OPV OPV drink).
o M ed acc e MMR
● V a A a d De gS a
Dd ece e a d e f V a A a d
Mebe da e e a

PLAN C: Treat for Severe Dehydration Quickly

● If e e a ea efe ec d ed a e Ye
beca e f e da ge g a d c a f ca W a
ea e de f P e efe a ea e f a
c a f ca f ge efe a

● T e a e da d eg g
● f e be f f d a d e efe
ed a e

● Very Severe Febrile Disease

IDENTIFY URGENT PRE-REFERRAL TREATMENT ● N ab e d
● We g g
● Severe Dehydration ● Te e a e C
D a ea f da b d e ● U ge e efe a ea e
I ab e e e e ab e d D g e d e f a e a e beca e e
c g e bac e ca e f e e e e feb e d ea e e
We g g e ee e a

K /KJM E CEL
 D e g e f d e f a
a a e a b c a ead g e de
e ee e a c a f ca
D g e a ace a e c d ca
d e f a ace a
ca be g e
o Refer URGENTLY to hospital e e
c ded

● Chronic Ear Infection

D c a ge c gf J ea a d ff f
ab a ea
U ge e efe a ea e
▪ D d ea c g de a efe a
▪ Refer to the hospital

● Severe Complicated Measles

N ab e d
Ge e a ed a c g e ed e e
U ge e efe a ea e
▪ Refer URGENTLY to hospital

● Moderate acute malnutrition

c e MUAC
U ge e efe a ea e
▪ D a e e c d feed g f
efe a
▪ Refer URGENTLY to the hospital

● Fever: DHF unlikely

T e e ega e
U ge e efe a ea e
▪ Cannot give ORS (child isn’t able to
drink)
▪ Refer URGENTLY to hospital
▪ DO NOT GIVE ASPIRIN

K /KJM E CEL
 ● Anemia ● D g e c e e ed a e
o S e a beca e f efe a
U ge e efe a ea e
▪ Refer URGENTLY to hospital SAMPLE REFERRAL NOTE

● Immunization Status
o Rece ed e ff acc e BCG He B PV PV
PV OPV OPV OPV Classifications and Signs of the Case (Summary)
o M ed acc e MMR
o Vacc e eeded acc a e e c d ● Ve Se e e D ea e
NO. It will delay the referral. N ab e d
o I be g e e a e ec d ● P e a
c d bec e ab e d c a ge N ab e d
o Fa b ea g b ea
● S e de d a
o I ab e e e e d eage
c g e bac
● Ve Se e e Feb e D ea e
N ab e d
● Ca e c c e Mea e V a A a d Mebe da eb
● Se e e C ca ed Mea e
e efe a e a a g e
N ab e d
o Ge e a ed a c g e ed e e
FOLLOW-UP SCHEDULE? Not needed. This is for referral.
● Fe e DHF U e
o T e e ega e
● C c Ea fec
o D c a ge c gf J ea a d ff f
ab a ea
● M de a e Ac e Ma
o c e MUAC
● A e a
o S e a a a
● I a Sa
o Rece ed e ff acc e BCG He B PV PV
PV OPV OPV OPV
o M ed acc e MMR
● V a A a d De gS a
Dd ece e a d e f V a A a d
Signs when to return Immediately? Mebe da e e a

K /KJM E CEL