Integrated Management of newborn and

Childhood Illness
(IMNCI)
 Learning Objectives

By the end of the session, the students will be able to:

• Explain the rationale for integrated management of
childhood illnesses;
• Specify the objectives of IMNCI;
• Describe the different components of IMNCI;
• Enumerate the benefits of IMNCI
 What is IMNCI?

• IMNCI is an integrated approach to child health that

focuses on the well being of the whole child by
providing comprehensive & continuous care to under
five children.
• Is a strategy for reducing the mortality and morbidity
associated with major cause of childhood illness.
• Includes both preventive and curative elements that are
implemented by families, communities, and health
facilities.
 Objectives

• To reduce mortality and morbidity associated with the

major causes of disease in children less than five
years of age.
• To contribute to healthy growth and development of
children
 Mortality and Morbidity

• Under fives in low to middle income countries are 10

times more likely to die than those in industrialized
countries.
• Over 10 million under fives die yearly in most
developing countries.
• Over 70% of these are due to completely treatable or
preventable conditions acting singly or in combination,
namely acute respiratory infections (esp. pneumonia),
diarrhea, measles, malaria and malnutrition.
5 major killers of children:

1. Diarrhea

2. Acute Respiratory Infections

(Pneumonia)

3. Measles

4. Malaria

5. Malnutrition
 What are neonates dying of?

}
• Preterm births
• Severe infection
• Asphyxia ~ 75%
• Congenital anomalies
• Tetanus
 U5 Mortality - Ethiopia

• IMR ~ 97/1000 Live Births

• U5 MR ~ 140/1000 Live Births

• 472,000 Deaths Annually (rank 6th globally in terms

of absolute No of deaths)

• Number of under-5 deaths preventable:

~ approx. 72% or 340,000
 Components of IMNCI

• Improvement of the skills of the health worker.

• Improvement of the Health Systems.
• Improvement of Family Practice.
 1. Improving Health worker’s skills

• Standards guidelines
• Training of facility-based public health providers
(pre-service /in-service)
• Maintenance of competence among trained health
workers (follow-up after training)
 2. Improving of Health Systems

• Improving drug and other supplies.

• Improving the organization and the function of the
health facility.
• Improving the facilities:
– management and supervision
– referral system
 3. Improving family and community practices

• For physical growth and mental development

• For disease prevention
• For appropriate home care
• For seeking care
3. Improving family and community practices

• For physical growth and mental development

– Promoting breastfeeding.
– Training on appropriate weaning foods.
– Promoting and providing micronutrients, for
example vitamin A, iron and iodine.
 3. Improving family and community practices

• For disease prevention

– Promoting safe disposal of waste and also
promoting hygiene/Hand washing
– Promoting complete immunization.
– Promoting the use of insect-treated bed-
nets in affected areas for malaria
prevention.
 3. Improving family and community practices
• For appropriate home care

– Promoting continuing to feed and offer

fluids to children and breastfeeding them
when sick.
– Giving children appropriate home
treatment for infections.
 3. Improving family and community practices
• For seeking care
• Promoting recognition of when to seek
treatment outside the home.
• Promoting compliance, follow up and referral.
• Promoting adequate antenatal care for
pregnant women.
• Postnatal (postpartum) consultation
The 3 Components of IMCI
 Features of IMNCI

• Not necessarily dependent on the use of sophisticated

and expensive technologies
• A more integrated approach to managing sick
children
• Move beyond addressing single diseases to
addressing the overall health and well-being of the
child
 Features of IMCI…

• Careful and systematic assessment of common

symptoms and specific clinical signs to guide rational
and effective actions
• Integrates management of most common childhood
problems (pneumonia, diarrhea, measles, malaria,
malnutrition and anemia, ear problems)
• Includes preventive interventions
 Features of IMCI…

• Adjusts curative interventions to the capacity and

functions of the health system
• Involves family members and the community in the
health care process
 Advantages of IMNCI

• Accurate identification of illness

• Focuses on care of the child as a whole and not on the

reason for the visit.

• Ensures integrated management of all prevalent

illnesses that the child may present.

• Ensures the early identification and prompt referral of

all seriously ill children

• More appropriate & combined treatment

 Advantages of IMCI

• Promotes Rational use of drugs

• Attention to the health needs of the mother

• Strengthening of preventive services

• Includes actions to improve parental practices

in caring for the child at home
 The integrated case management process

• Integrated case management relies on case detection

using simple clinical signs and empirical treatment.
• The IMNCI process can be used by doctors, nurses
and other health professionals who see sick infants
and children aged from birth up to five years.
• It is a case management process for a first-level
facility such as a clinic, a health centre or an
outpatient department of a hospital.
 Cont’d…
• The IMNCI guidelines describe how to care for a child
who is brought to a clinic with an illness, or for a
scheduled follow up visit to check the child’s progress.
• The guidelines give instructions for how to routinely
assess a child for general danger signs (or possible
bacterial infection in a young infant), common illnesses,
malnutrition and anaemia, and to look for other problems.
• In addition to treatment, the guidelines incorporate basic
activities for illness prevention.
IMNCI case management process
1. Assess the child or young infant

2. Classify the illness

3. Identify treatment

4. Treat the child or refer

5. Counsel the mother

6. Give follow-up Care

 Case Management Process
1. Assess a child
• All sick children must be examined for general
danger sign.
• All sick children must be routinely assessed for
major/main symptoms.
• All sick children must be assessed for nutrition and
immunization status, feeding problems, HIV infection
and exposure and other potential problems.
 Assessing the Sick Child

• General Danger Sign

• Lethargy or unconsciousness
• Inability to drink or breastfeed
• Vomit everything
• Convulsions history
• Convulsing know
 Checking the Main Symptoms
• Cough and difficult breathing-
• Diarrhea
• Fever
• Ear problem
 Checking the Main Symptoms

1. Cough or difficult breathing

• 3 clinical sign
– Respiratory rate
– Lower chest wall in drawing
– Stridor
 Checking the Main Symptoms
2. Diarrhea
– Acute watery diarrhea (Dehydration)
• General condition–
• Sunken eyes
• Thirst
• Skin elasticity
– Persistent diarrhea
– Dysentery

• –
• –
• –
 Checking the Main Symptoms

3. Fever
– Stiff neck
– Risk of malaria
– Runny nose
– Measles
– Duration of fever (e.g. typhoid fever)
 Checking the Main Symptoms

4. Ear problems
– Tender swelling behind the ear
– Ear pain
– Ear discharge or pus (acute or chronic)
Checking Nutritional Status, Feeding, HIV infection
and exposure, and Immunization Status

• Malnutrition
– Visible severe wasting
– Edema of both feet
– Weight for age, weight for height/length
• Anemia
– Palmar pallor
• Feeding and breastfeeding
• Immunization status
• HIV infection and exposure
 Assessing Other Problems

• Meningitis
• Sepsis
• Tuberculosis
• Conjunctivitis
• Others:
• also mother’s (caretaker’s) own health
 Case mgt…
2. Classify a child’s illnesses
• Only a limited number of carefully-selected clinical signs
are used,
• A combination of individual signs leads to a child’s
classification rather than diagnosis.
• Classifications are color coded.
– Pink/Red suggests hospital referral or
admission.
–Yellow indicates initiation of treatment
–Green calls for home treatment.
• IMCI guidelines address most, but not all, the major
reasons a sick is brought to the clinic.
 IMNCI
Colour Coded Case Management Strategy
• PINK/RED CLASSIFICATION: Child needs Drugs &
inpatient care –Mostly serious infections

• YELLOW CLASSIFICATION: Child needs specific

treatment, (e.g. antibiotics, anti-malarial, ORT) for Mild
infections can be Provided at home / community level

• GREEN CLASSIFICATION: Child needs no

medicine, advise home care
 Case mgt…

3. Identify specific treatments for the child.

• If a child requires urgent referral, give essential
treatment before the patient is transferred.
• Pink Urgent Referral (Outpatient)
– Pre-referral treatment
– Advise parents
– Refer
 Case mgt…

• If a child needs treatment at home, develop an

integrated treatment plan for the child and give the
first dose of drugs in the clinic.
• Yellow (Treatment at Outpatient Facility)
• Treat local infection
• Give oral drugs
• Advise and teach caretaker
• Follow-up
• If a child should be immunized, give immunizations
 Case mgt…
• Green (Home Treatment)
• Caretaker is counseled on:
–Home treatments.
–Feeding and fluids.
–When to return immediately.
–Follow-up
 Case mgt…
• 4. Provide practical treatment
instructions, including
• teaching the caretaker how to give oral drugs,
• how to feed and give fluids during illness, and
• how to treat local infections at home.
• Ask the caretaker to return for follow-up on a
specific date, and
• teach her how to recognize signs that indicate the
child should return immediately to the health
facility.
 Case mgt…
5. Counseling the mother
– Use words that he/she understands
– Use teaching aids that are familiar
– Give feedback when he/she practices,
praise what is done well and make
corrections
– Allow more practice if needed
– Allow the caretaker to ask questions
– Check caretaker’s understanding
 Case mgt…

• Assess feeding, including assessment of

breastfeeding practices, and counsel to solve
any feeding problems found. Then counsel the
mother about her own health.

6. When a child is brought back to the clinic as

requested, give follow-up care and, if necessary,
reassess the child for new problems.
 Case mgt…
• The case management process is
presented on two different sets of charts:

– one for children age 2 months up to five

years, and

– one for children age from birth up to 2

months.
 Selecting the appropriate case
management charts
FOR ALL SICK CHILDREN age from birth up to 5 years who are brought to the
clinic

ASK THE CHILD’S AGE

IF the child is from birth up to 2 IF the child is from 2 months up to 5

months years

USE THE CHART: USE THE CHARTS:

● ASSESS, CLASSIFY AND TREAT THE SICK ● ASSESS AND CLASSIFY THE SICK CHILD ●
YOUNG INFANT TREAT THE CHILD
● COUNSEL THE MOTHER
The steps on the ASSESS AND CLASSIFY THE SICK CHILD
chart
• describe what you should do when a mother brings her child
to the clinic because her child is sick.

• The chart should not be used for a well child brought for
immunization or for a child with an injury or burn.

• When patients arrive at most clinics, clinic staff identify the

reason for the child’s visit.

• Clinic staff obtain the child’s weight and temperature and

record them on a patient chart, another written record, or on
a small piece of paper. Then the mother and child see a health
worker.
When you see the mother, or the child’s caretaker, with the sick child:

▼ GREET THE MOTHER APPROPRIATELY AND ASK

ABOUT THE CHILD

▼ LOOK TO SEE IF THE CHILD’S WEIGHT AND

TEMPERATURE HAVE BEEN RECORDED

▼ ASK THE MOTHER WHAT THE CHILD’S PROBLEMS

ARE
 Cont’d…
• Listen carefully to what the mother tells you. This will show her
that you are taking her concerns seriously.

• Use words the mother understands. If she does not understand

the questions you ask her, she cannot give the information you
need to assess and classify the child correctly.

• Give the mother time to answer the questions. For example, she
may need time to decide if the sign you asked about is present.

• Ask additional questions when the mother is not sure about her
answer. When you ask about a main symptom or related sign, the
mother may not be sure if it is present. Ask her additional
questions to help her give clearer answers.
 Cont’d…
▼ DETERMINE IF THIS IS AN INITIAL OR FOLLOW-UP
VISIT FOR THIS PROBLEM

• If this is the child’s first visit for this episode of an illness or problem,
then this is an initial visit.

• If the child was seen a few days before for the same illness, this is a
follow-up visit.

• A follow-up visit has a different purpose than an initial visit.

• During a follow-up visit, you find out if the treatment given during
the initial visit has helped the child. If the child is not improving or is
getting worse after a few days, refer the child to a hospital or change
the child’s treatment.
 When a child is brought to the clinic

FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC

Use Good Communication Skills:

GREET the mother appropriately ● Listen carefully to what the mother tells you
and ask about her child. LOOK to ● Use words the mother understands
see if the child’s weight and ● Give the mother time to answer the questions
temperature have been recorded ● Ask additional questions when the mother is not
sure about her answer
Record Important Information

DETERMINE if this is an initial visit or a follow-up visit for this problem

IF this is an INITIAL VISIT for the problem IF this is a FOLLOW-UP VISIT for the
problem

ASSESS and CLASSIFY the child

following the guidelines GIVE FOLLOW-UP CARE according to the
guidelines
 Management of the sick young
infants from birth up to 2 months
 Learning objectives
At the end of this session you will be able to
• Giving essential newborn care
• Assessing and classifying a young infant for birth
asphyxia
• Assessing and classifying a young infant for birth
weight and gestational age
• Assessing and classifying a young infant for very
severe disease or local bacterial infection
• Assessing and classifying for jaundice
 Learning objectives

• Assessing and classifying for diarrhea

• Assessing and classifying a young infant for HIV
exposure and infection
• Checking for feeding problem or underweight,
assessing breast feeding and classifying feeding
• Check immunization status
• Assessing other problems
For all sick young infants:
• Check for and classify sign of very severe disease and
local bacterial infection
• Check for and classify sign of jaundice
• Assess for diarrhoea, and classify for dehydration
and/or persistent diarrhoea and or dysentery if
present
• Check for HIV exposure and infection
• Check for feeding problem or underweight.
• This may include assessing breast feeding.
• Then classify feeding
• Check the young infants immunization status
• Assess any other problems
 Assess for Birth Asphxia

• If you are attending delivery or baby is brought to you

immediately after birth; assess for birth asphyxia.
• Assess the baby while drying and wrapping with dry
cloth.
• To assess for birth asphyxia, look and listen for
breathing pattern.
 Assess
• Is baby not breathing: has no cried or no spontaneous
movement of the chest
• Is baby Gasping: The attempt to make some effort to
breath with irregular and slow breathing movement
• Count breathing in one minute: The normal breathing
rate of the newborn baby is from 30-60 per minute.
• If the breathing rate is less than 30 per minute it is a sign
of asphyxia
 Check for birth asphyxia

Assess Look, Listen

Classify
- Is baby not breathing? ALL
- Is baby gasping ?
- Count breaths in one minute
Newborns
 Classification of birth asphyxia
SIGNS CLASSIFY AS TREATMENT:
(Urgent pre-treatments are in bold print)

If any of the following sign Start Resuscitation

 Not breathing Birth  Clamp/tie and cut the cord immediatlely
 Gasping ASPHYIXIA  Position the newborn supine with neck slightly extended
 Is breathing poorly (less than  Clear the mouth and nose with bulb syringe
30 per minute)
 Ventilate with appropriate size mask and bag
 If the resuscitation is successful continue giving essential newborn
care
 If the baby remains weak or is having irregular breathing after 20
minutes of resuscitation refer urgently to hospital while continuing to
resuscitate on the way
 Stop resuscitation after 20 minutes if no response (no spontaneous
breathing)
 Monitor continuously for 6 hours
 Follow after, 12 hrs, 24 hrs, 3 days, 7 days and 6 weeks

• Breath normally (Crying or > 30  Give Cord care

breath/minutes and No Birth ASPHYXIA  Eye care
• Pink tongue and lips  Vitamin K
 Initiate skin-to-skin contact
 Initiate exclusive breastfeeding
 Give BCG, and OPV 0
 Advise mother when to return immediately
 Follow after, 6 hrs, 3 days, 7 days and 6 weeks
Opening the Airway
Ventilation with bag and mask
 Some maternal and fetal risk factors for birth
asphyxia are:
• Maternal illnesses such as • Prolonged labour
sexually transmitted diseases
• Malaria • Difficult or traumatic
• Eclampsia (including the delivery
treatment) • Prolapsed cord
• Bleeding before or during labour
• Fever during labour
• Meconium-stained
• Maternal sedation, analgesia or amniotic fluid
anaesthesia • Preterm birth
• Prolonged rupture of membranes
• Post-term birth
• Breech or other abnormal
presentation • Multiple birth
• Congenital anomaly.
 Assess and classify for birth weight and
gestation age
• If you are attending delivery or baby brought to you with in 7
days after birth; assess for birth weight and gestational age.
• Assess:
• Ask the gestational age; duration of pregnancy in weeks. Use
the mother’s word or LMP to estimate GA. If this is not
possible use the weight to classify the newborn
• Weigh the baby; if you do not have the birth weight (weight
taken within 24 hours of life, the weight taken in the first 7
days of life may be used for the classification of birth weight
 Classification for birth weight and gestational age
SIGNS CLASSIFY AS TREATMENT

VERY LOW BIRTH  Continue breast feeding (if not sucking feed with expressed
WEIGHT breastmilk by cup
Weight < 1500gm or  Start Kangaroo Mother Care
Gestational Age < 32 AND/OR
 Give Vitamin K 1mg IM on anterior mid thigh, if not already
VERY PRETERM
weeks given
 Refer URGENTLY with mother to hospital with KMC position

Weight 1500 - 2500 gm or  Kangaroo Mother Care (KMC) if < 2,000gm

Gestational age 32-37weeks LOW BIRTH  Counsel on optimal breastfeeding
WEIGHT  Counsel mother/family on prevention of infection
AND/OR  Give Vitamin K 1mg IM on anterior mid thigh
PRETERM  Provide follow-up visits for KMC
 If baby > 2,000gms follow up visit at age 6-24 hrs, 3
days, 7 days & 6 weeks
 Advise mother when to return immediately
Weight ≥ 2500 gm or  Counsel on optimal breastfeeding
Gestational age ≥ 37 weeks NORMAL WEIGHT  Counsel mother/family on prevention of infection
AND/OR  Provide follow-up visits at age 6-24 hrs, 3 days, 7 days
TERM & 6 weeks
 Give 1st dose of vaccine
 Give Vitamin K 1mg IM on anterior mid thigh
 Advice mother when to return immediately
 Jaundice
• Jaundice is a yellow discoloration of the skin and
mucus membrane
• Most of baby may have physiologic jaundice in the
first week of birth
• Physiologic jaundice usually appears
– B/n 48 -72 hours of age
– Maximum intensity seen on 4-5th day in term and
– 7th in preterm neonates
– Disappears by 14 days
 Cont’d…

• Physiological jaundice does not extend to palms and

soles, and does not need any treatment.
• If the jaundice appears on the first day, persist
beyond 14 days and extend to palms and soles it is
severe jaundice and require urgent attention
 Cont’d…
• Look for jaundice:
– Is the skin on the face or eyes yellow?
– Are the palms and soles yellow?

• To look for jaundice:

• Press the infant’s skin over the forehead with your fingers
to blanch, remove your fingers and look for yellow
discoloration under natural light

• If there is yellow discoloration, the infant has jaundice

• Look also in to the eyes and palms and soles of the infant
for yellowish discoloration
 Assess the young infants for diarrhea
• If the mother says that the young infant has diarrhoea,
assess and classify for diarrhea.
• Babies who are exclusively breastfed often have stool that
are soft; this is not diarrhea.
• The assessment is similar to the assessment of diarrhoea
for an older infant or young child, but fewer signs are
checked.
– Thirst is not assessed.

• This is because it is not possible to distinguish thirst from

hunger in a young infant.
 Cont’d…

• General condition is assessed by observing movement

and whether the young infant is restless and irritable
• A young infant with diarrhea is assessed for

– How long the child has had diarrhea

– Blood in the stool to determine if the young infant

has dysentery
– Sign of dehydration
 ASK: Does the young infant have diarrhea?

for
DEHYDRATION
IF YES ASK: LOOK AND FEEL:
• Look at the young infant’s
general condition.
• For how long?
- Infant move only when
stimulated
• Is there blood - Infant does not move even classify
in the stool? when stimulated DIARRH
EA
- Restless and irritable?
and if diarrhea
• Look for sunken eyes 14 days or more
• Pinch the skin of the abdomen.
Does it go back:
- Very slowly (> 2 sec.)? and if blood
in stool
- Slowly?
Check the young infants for HIV exposure and
infection
• The exact prevalence of HIV in children is not
known, however,
• There were nearly 80,000 children under 14 years
living with HIV/AIDS in Ethiopia at the end of
2010.
• Mother to child transmission of HIV (MTCT) is the
main way (90%) through which children are infected
with HIV.
• The average risk of HIV transmission from mother
to child is about one-third and transmission can
occur during pregnancy, labor and delivery and
postnatally through breast feeding.
 Cont’d…
• There is a 15-20 % risk of HIV transmission through
breast feeding only if an HIV positive mother feed
her infant breast milk for 24 months
• If HIV positive women feed their infant breast milk
exclusive for 6 months only, the risk of transmission
of HIV through breast feeding get less.
• Studies have shown that exclusive breast feeding
carries a smaller risk of HIV transmission when
compared with mixed feeding
 Cont’d…

• Early diagnosis of HIV infection and treatment in

infants and children is important since the disease
progress rapidly in children with 50% and 75 %
mortality by age two and five respectively.
• Passively transfer maternal HIV antibodies make
interpretation of positive antibody tests difficult in
children less than 18 months of age.
 Cont’d…

• In order to diagnose HIV infection definitively in

these group of children, assays that detect the virus
or its component (i.e., virologic tests) are required.
• DNA PCR is the preferred method of choice for HIV
diagnosis in infant and children under 18 months.
• In children 18 months and older, rapid antibody
tests reliably diagnose HIV infection.
Assessing the sick young infants for HIV infection

• Ask:

• What is the HIV status of the mother?

• Positive,

• negative,

• Unknow

• What is the HIV status of the young infant?

- HIV antibody test: Positive, negative, unknown

- DNA PCR test: Positive, negative, unknown
 Check for feeding problems or under weight

• It is important to assess a young infant’s feeding and

weight so that feeding can be improve if necessary.
• The best way to feed a young infant is to breast feed
exclusively.
• Exclusive breast feeding means that the infant takes
only breast milk, and no additional food, water and
other fluid except medicine and vitamins
 Cont’d…

• The assessment has two parts.

• The first part, you ask the mother questions.
• You determine
– if she is having difficulty of feeding the infant
– What the young infant is fed and how often
– Weight for age and
– Check mouth ulcer or white patch
 Cont’d…

• In the second part, if the infant is breast feeding and

has no urgent referral problem, then assess breast
feeding.
• How to assess the young infant for feeding problem
or under weight
 Cont’d…
• ASK: Is there any difficulties of feeding?
• Breast feeding difficulties mentioned by a mother
may include:
• Her infant feeds too frequently, or
• Not frequently enough because of:
– She does not have enough milk
– Her nipples are sore
– She has flat or inverted nipples
– The infant does not want to take the breast
• If the mother say that the infant is not able to feed,
assess breast feeding or watch her try to feed the
infant with a cup to see what she means by this.
 Cont’d…
▼ ASK: Is the infant breastfed? If yes, how many
times in 24 hours?
• The recommendation is that the young infant be
breastfed as often and for as long as the infant wants,
day and night. This should be 8 or more times in 24
hours.
▼ ASK: Do you empty one breast before switching to
the other?
• One breast has to be emptied before switching to the
other for maximal production of milk and maximal
delivery of protein, calories and water to the infant
 Cont’d…

▼ ASK: Do you increase frequency of breast feeding

during illness?
• Frequency of feeding has to be increased during
illness because of an increased demand of an infant’s
body during illness
 Cont’d…
▼ASK: Does the infant usually receive any
other foods or drinks? If yes, how often?
• A young infant should be exclusively breastfed.
• Find out if the young infant is receiving any other
foods or drinks such as other milk, juice, tea, thin
porridge, dilute cereal, or even water.
• Ask how often he receives it and the amount.
• You need to know if the infant is mostly breastfed, or
mostly fed on other foods.
 Cont’d…

▼ASK: What do you use to feed the infant?

• If an infant takes other foods or drinks, find out if the
mother uses a feeding bottle, cup or others.
▼ LOOK: Determine weight for age
• Use appropriate weight for age chart (for boys and
girls) to determine if the young infant is under
weight.
 Cont’d…

• Young infant whose weight for age lies below -2 Z-

score are under weight, while those whose weight for
age is at -2 Z-score and above are not under weight.
 Cont’d…

▼LOOK for ulcer or white

patches in the mouth
(thrush)

• Look inside the mouth at the

tongue and inside the cheek.
• Thrush look like milk curds
on the inside of the cheek, or
a thick white coating of the
tongue
• Try to wipe the white off.
The white patches of thrush
will remain
 How to assess breastfeeding
• This is the second part of feeding assessment.
• First decide whether to assess the infant’s
breastfeeding:
■ If the infant is not breastfed at all, do not assess
breastfeeding.
■ If the infant has a serious problem requiring urgent
referral to a hospital, do not assess breastfeeding.
• Otherwise, assess breast feeding in all young
infants
 Cont’d…

▼ ASK: HAS THE INFANT BREASTFED IN THE

PREVIOUS HOUR?
• If yes, ask the mother to wait and tell you when the
infant is willing to feed again.

• In the meantime, complete the assessment by

assessing the infant’s immunization status.

• You may also decide to begin any treatment that the

infant needs, such as giving an antibiotic for LOCAL
BACTERIAL INFECTION or ORS solution for SOME
DEHYDRATION.
 Cont’d…
• If the infant has not fed in the previous hour,
he may be willing to breastfeed.
• Ask the mother to put her infant to the breast.
• Observe a whole breastfeed if possible, or
observe for at least 4 minutes.
• Sit quietly and watch the infant breastfeed.
 Cont’d…
▼ LOOK: IS THE INFANT WELL
POSITIONED Example of good and poor positioning
• The four sign of good
positioning are:
– Infant’s body straight
– Head and body facing breast
– Infant’s body close to
mother’s body
– Supporting infant’s whole
body

• If all the above are present,

the infant has good
positioning
 Cont’d…

▼ LOOK: IS THE INFANT ABLE TO

ATTACH?
• The four signs of good
attachment are:
— chin touching breast (or very
close)
— mouth wide open
—lower lip turned outward
—more areola visible above than
below the mouth

• If all of these four signs are

present, the infant has good
attachment):
How can see differences in good and bad attachment :
observing a mother to breast feed
 Cont’d…
• If attachment is not
good, you may see
the infant is not well
attached):
— chin not touching breast
— mouth not wide open,
lips pushed forward
— lower lip turned in, or
— more areola (or equal
amount) visible below
infant’s mouth than
above it
 Cont’d…
▼ LOOK: IS THE INFANT SUCKLING EFFECTIVELY?

• The infant is suckling effectively

– if he suckles with slow deep sucks and sometimes
pauses.
– You may see or hear the infant swallowing.
– If you can observe how the breastfeed finishes, look for
signs that the infant is satisfied.
– If satisfied, the infant releases the breast spontaneously
(that is, the mother does not cause the infant to stop
breastfeeding in any way).
– The infant appears relaxed, sleepy, and loses interest in
the breast.
 Cont’d…

• An infant is not suckling effectively

– if he is taking only rapid, shallow sucks.
– You may also see in drawing of the cheeks.
– You do not see or hear swallowing.
– The infant is not satisfied at the end of the
feed, and may be restless.
– He may cry or try to suckle again, or
continue to breastfeed for a long time.
 Cont’d…

• An infant who is not suckling at all

– is not able to suck breast milk into his mouth and

swallow.
– Therefore he is not able to breastfeed at all.
– If a blocked nose seems to interfere with
breastfeeding, clear the infant’s nose.
– Then check whether the infant can suckle more
effectively.
x
 Check the young infant’s immunization status

Immunization

AGE VACCINE

Birth BCG OPV- 0

Hep. B BD
6 weeks DPT1-HepB1-Hib 1 OPV-1 PCV-1

* Do not give OPV-0 to an infant who is more than 14 days old. Keep an interval of at least
4 weeks between OPV-0 and OPV-1.
 Cont’d…

• Remember that you should not give OPV 0 to

an infant who is more than 14 days old.

• Therefore, if an infant has not received OPV 0

by the time he is 15 days old, you should wait
to give OPV until he or she is 6 weeks old.
Then give OPV 1.
 Assess other problem
• Assess any other problem mentioned by the
mother or observed by you.

• If you think the infant has a serious problem,

or you do not know how to help the infant,
refer the infant to a hospital
THE SICK CHILD AGE 2 MONTHS
UP TO 5 YEARS:
ASSESS AND CLASSIFY
 General danger signs
For ALL sick children ask the mother about the child’s problem, then CHECK FOR GENERAL
DANGER SIGNS

CHECK FOR GENERAL DANGER SIGNS Make sure

that a child
ASK: LOOK:
with any
● Is the child able to drink or breastfeed? ● See if the child is
danger sign
lethargic or unconscious.
is referred
● Does the child vomit everything?
after
● Has the child had convulsions?
receiving
urgent pre
Child with any general danger sign needs URGENT attention; complete the referral
assessment and any pre-referral treatment immediately so referral is not treatment.
delayed

Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear
problems. CHECK for malnutrition and anaemia, immunization status and for other
problems.
Main symptoms
 Main symptoms
• Cough and difficult breathing
• Diarrhea
• Fever
• Ear problem

06/17/2024 109
 Session 4a

• Cough or difficult breathing

06/17/2024 110
 Cough or difficult breathing
• A child with cough or difficult breathing may have
pneumonia or another severe respiratory infection.

• Pneumonia is an infection of the lungs. Both bacteria and

viruses can cause pneumonia.

• In developing countries, pneumonia is often due to bacteria.

• The most common are Streptococcus pneumoniae and
Hemophilus influenzae.

• Children with bacterial pneumonia may die from hypoxia

(too little oxygen) or sepsis (generalized infection).

06/17/2024 111
 How to assess a child with cough or difficult breathing

ASK: Does the child have cough or difficult breathing?

IF NO IF YES,

IF YES, ASK: LOOK, LISTEN, FEEL:

• Count the breaths in one
For how long?
minute:
• Look for chest indrawing
• Look and listen for stridor

If the child is: Fast breathing is:

2 months up to 12 months 50 breaths per minute or more
ASK: About main
Symptoms: 12 months up to 5 years 40 breaths per minute or more
Diarrhea, fever,
ear problems
Classify child’s illness using color coded classification table
06/17/2024
for cough or difficult breathing 112
 Ask: For how long
• A child who has had cough or difficult
breathing for more than 14 days has a chronic
cough.
• This may be a sign of tuberculosis, asthma,
whooping cough or another problem.

06/17/2024 113
 LOOK FOR CHEST INDRAWING
Look for chest indrawing
when the child breathes
IN. Look at the lower
chest wall (lower ribs).

The child has chest

indrawing if the lower
chest wall goes IN when
the child breathes IN.

In normal breathing, the whole

chest wall (upper and lower)
and the abdomen move OUT
when the child breathes IN.

06/17/2024 114
 Cont’d…
• For chest in drawing to be present, it must be clearly visible
and present all the time.

• If you only see chest indrawing when the child is crying or

feeding, the child does not have chest indrawing.
• If only the soft tissue between the ribs goes in when the child
breathes in (also called intercostal indrawing or intercostal
retractions), the child does not have chest indrawing.
• In this assessment, chest indrawing is lower chest wall
indrawing. This is the same as
• “subcostal indrawing” or “subcostal retractions.” It does not
include “intercostal indrawing.”

06/17/2024 115
 LOOK AND LISTEN FOR STRIDOR

• Stridor is a harsh noise

made when the child
breathes IN.

• Stridor happens when

there is a swelling of the
larynx, trachea or epiglottis.
These conditions are often
called croup.

• This swelling interferes

with air entering the lungs.
It can be life-threatening
when the swelling causes
the child’s airway to be
06/17/2024 blocked. 116
 Cont’d…
To look and listen for stridor :
• look to see when the child breathes IN.

• Then listen for stridor. Put your ear near the

child’s mouth because stridor can be difficult
to hear.

• You may hear a wheezing noise when the

child breathes OUT. This is not stridor.
06/17/2024 117
 Treatment

• Soothe the throat and relieve the cough with a

safe remedy.
• Safe remedies to recommend:
- Breast milk for exclusively breastfed infant.
- Home fluids such as tea with honey, fruit juices

• Harmful remedies to discourage:

– Cough syrups containing diphenyl hydramine and/or
Codeine.
Examples: Benylin with and without codeine, Berantin

06/17/2024 119
 Session 4b

Diarrhea

06/17/2024 121
 Diarrhea

• In many regions diarrhea is defined as three or

more loose or watery stools in a 24-hour period.

• It is common in children, especially those between

6 months and 2 years of age.

• It is more common in babies under 6 months who

are drinking cow’s milk or infant formulas.
• Frequent passing of normal stools is not diarrhea.
• The number of stools normally passed in a day
varies with the diet and age of the child.
06/17/2024 122
 What are the types of diarrhea?

• If an episode of diarrhea lasts less than 14

days, it is acute diarrhea.

• Acute watery diarrhea causes dehydration and

contributes to malnutrition.

• The death of a child with acute diarrhea is usually due

to dehydration.

• Cholera is one example, of loose or watery diarrhea.

• Only a small proportion of all loose or watery diarrheas
are due to cholera.
06/17/2024 123
 What are the types of diarrhea?
• Diarrhea with blood in the stool, with or without
mucus, is called dysentery.

• The most common cause of dysentery is Shigella

bacteria.

• Amoebic dysentery is not common in young

children.

• A child may have both watery diarrhea and

dysentery.
06/17/2024 124
 Cont’d…
▼ ASK: FOR HOW LONG?
• Diarrhea which lasts 14 days or more is
persistent diarrhea. Give the mother time to
answer the question. She may need time to
recall the exact number of days.

▼ ASK: IS THERE BLOOD IN THE STOOL?

• Ask the mother if she has seen blood in the
stools at any time during this episode of
diarrhea.
06/17/2024 125
 Cont’d…
▼ LOOK AT THE CHILD’S GENERAL CONDITION
• When you checked for general danger signs,
you checked to see if the child was lethargic
or unconscious.

• If the child is lethargic or unconscious, he has

a general danger sign.

• Remember to use this general danger sign

when you classify the child’s diarrhea
06/17/2024 126
 Cont’d…
• A child has the sign restless and irritable if the
child is restless and irritable all the time or
every time he is touched or handled.

• If an infant or child is calm when breastfeeding

but again restless and irritable when he stops
breastfeeding, he has the sign “restless and
irritable”.

06/17/2024 127
Child with sunken eyes ▼ LOOK FOR
SUNKEN EYES
•The eyes of a child
who is dehydrated may
look sunken.

• Decide if you think

the eyes are sunken.

• Then ask the mother

if she thinks her child’s
eyes look unusual.

06/17/2024 128
 Child with sunken eyes

06/17/2024 129
• Note: In a severely malnourished child who
is visibly wasted (that is, who has marasmus),
the eyes may always look sunken, even if the
child is not dehydrated.
• Even though the sign sunken eyes is less
reliable in a visibly wasted child, you should
still use the sign to classify the child’s
dehydration.

06/17/2024 130
 Cont’d…

▼ OFFER THE CHILD FLUID

• Ask the mother to offer the child some water in a cup or
spoon. Watch the child drink.

• A child is not able to drink if he is not able to take fluid in

his mouth and swallow it.
For example, a child may not be able to drink because he is
lethargic or unconscious. Or the child may not be able to
suck or swallow.

• A child is drinking poorly if the child is weak and cannot

drink without help.
•06/17/2024
He may be able to swallow only if fluid is put in his mouth.131
 Cont’d…

• A child has the sign drinking eagerly, thirsty if

it is clear that the child wants to drink.

• Look to see if the child reaches out for the cup

or spoon when you offer him water.

• When the water is taken away, see if the child

is unhappy because he wants to drink more
06/17/2024 132
 Cont’d…
▼ PINCH THE SKIN OF THE ABDOMEN
• Ask the mother to place the child on the
examining table so that the child is flat on his
back with his arms at his sides (not over his
head) and his legs straight. Or,

• Ask the mother to hold the child so he is lying

flat in her lap.

06/17/2024 133
Skin pinching •Locate the area on the child’s
abdomen halfway between the
umbilicus and the side of the
abdomen.

•To do the skin pinch, use your

thumb and first finger.

•Do not use your fingertips

because this will cause pain.

•Firmly pick up all of the layers of

skin and the tissue under them.

•Pinch the skin for one second and

then release it.
134
06/17/2024
 Cont’d…
• When you release
the skin, look to see
if the skin pinch goes
back:
— very slowly (longer
than 2 seconds)
— slowly (skin stays up
even for a brief
instant)
— immediately
06/17/2024 135
• Note: In a child with marasmus (severe
malnutrition), the skin may go back slowly even if
the child is not dehydrated.

• In an overweight child, or a child with oedema,

the skin may go back immediately even if the
child is dehydrated.

• Even though skin pinch is less reliable in these

children, still use it to classify the child’s
dehydration.
06/17/2024 136
 Classification for dehydration
If child has no other severe classification:
Two of the following signs: SEVRE - Give fluid for severe dehydration (plan C). OR
DEHYDRATION
 Lethargic or unconscious
If child also has another severe classification:
 Sunken eyes
 Not able to drink or drinking Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way. Advise the mother to continue
Poorly breastfeeding.
 Skin pinch goes back very If child is 2 years or older, and there is cholera in your area, give
slowly. antibiotic for cholera.

Two of the following signs: SOME Give fluid, Zinc supplements and food for some
DEHYDRATION dehydration (plan B)
• Restless, irritable
If Child also has a severe classification:
• Sunken eyes
• Drinks eagerly, thirsty - Refer URGENTLY to hospital with mother Giving frequent slips of
• Skin pinch goes back ORS on the way.
slowly. - Advise the mother to continue breastfeeding .
Advise mother when to return immediately.
Follow-up in 5 days if not improving
Not enough signs to classify NO Give fluid, Zinc supplements and food to treat diarrhoea at home
as some or severe DEHYDRATION (Plan A)
dehydration Advise mother when to return immediately.
06/17/2024 137
Follow-up in 5 days if not improving.
 Classification for diarrhea 14 days or more
SEVERE Treat dehydration before referral unless the
• Dehydration present. PERRSISTENT child has another severe classification.
DIARRHOEA Give Vitamin A
Refer to hospital.
PERSISENT Advise the mother on feeding a child who has
• No dehydration DIARRHOEA PERSISTENT DIARRHOEA
Give Vitamin A, therapeutic dose
Advise the mother when to return immediately
Follow-up in 5 days.

Classification if blood In stool

Treat for 5 days with Cotrimoxazole

• Blood in the stool DYSENTERY Advise the mother when to return
immediately
Follow-up in 2 days.
06/17/2024 138
Child with no dehydration

• The child need extra

fluid to prevent
dehydration

• A child with NO
DEHYDRATION needs
home treatment

06/17/2024 139
 Plan A: Treat Diarrhea at Home

• Counsel the mother on the 4 Rules of Home

Treatment:
• Give Extra Fluids,
• Continue Feeding,
• Give supplemental zinc, and
• When to Return

06/17/2024 140
 The 4 rules of home treatment
1. GIVE EXTRA FLUIDS (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 in addition

to breast milk.

• If the child is not exclusively breastfed, give one or

more of the following:
– ORS solution, food-based fluids (such as soup, rice
water and yoghurt drinks), or clean water.
06/17/2024 141
 The 4 rules of home…

• TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE
MOTHER 2 PACKETS OF ORS TO USE AT HOME.

• SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO

THE USUAL FLUID INTAKE:

UP to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Tell the mother to:

- Give frequent small sips from a cup.
- If the child vomits, wait 10 minutes. Then continue, but
more slowly.
- Continue giving extra fluid until the diarrhea stops.
06/17/2024 142
 The 4 rules of home treatment

2. GIVE ZINC SUPPLEMENTS

• TELL THE MOTHER HOW MUCH ZINC TO GIVE:

Up to 6 months - 1/2 tablet for 10 days
6 months or more -1 tablet for 10 days

• SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS

• For Infants- dissolve tablet in a small amount of expressed breast milk, ORS
or clean water in a cup
• Older children - tablets can be chewed or dissolved in a small amount of
clean water in a cup

3. CONTINUE FEEDING

4. WHEN TO RETURN: Blood in stool, Drinking poorly

06/17/2024 143
Child with some dehydration

• Child with SOME

DEHYDRATION needs
fluid and food.

• Treat the child with

ORS solution.

06/17/2024 144
Plan B: Treat Some Dehydration with ORS

• Give in clinic recommended amount of ORS over 4-

hour period
• DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST
4 HOURS
AGE Up to 4 4 months up to 12 months up to 2 years up to
Months 12 months 2 years 5 years
WEIGHT < 6 kg 6 – 10 kg 10 – 12 kg 12 – 19 kg
In ml 200 - 400 400 - 700 700 - 900 900 - 1400

Use the child’s age only when you do not know the weight. The
approximate amount of ORS required (in ml) can also be
calculated by multiplying the child’s weight (in kg) times 75
06/17/2024 145
 Plan B: Treat Some Dehydration with ORS
• If the child wants more ORS than shown, give more.
• For infants under 6 months who are not breastfed,
also give 100-200 ml clean water during this period.

• SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then continue,
but more slowly.
• Continue breastfeeding whenever the child wants.

06/17/2024 146
 Plan B: Treat Some Dehydration with ORS

AFTER 4 HOURS:
• Reassess the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING

TREATMENT:
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 4-hour treatment
at home
• Give her enough ORS packets to complete rehydration.
• Also give her 2 packets as recommended in plan A
• Explain the 4 Rules of Home Treatment:
06/17/2024 147
Child with sever dehydration

• Child with severe

DEHYDRATION needs
fluid quickly.

• Treat the child with

IV fluids

06/17/2024 148
 Plan C: Treat Severe Dehydration Quickly
Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is
Can you give set up. Give 100ml/kg Ringer’s Lactate Solution (or, if not available, normal saline),
Intravenous (IV) divided as follows:
Fluid immediately?
AGE First give Then give
30 ml/kg in: 70 ml/kg in:
Infants (under 12 months) 1 hour* 5 hours
Children (12 months up to 5 years) 30 minutes* 2 ½ hours
 Repeat once if radial pulses still very weak or not detectable
 Reassess the child every 1-2 hours. If hydration status is not improving,
give the IV drip more rapidly.
 Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually
after 3-4 hours (infants) or 1-2 hours (children).
 Reassess an infant after 6 hours and a child after 3 hours. Classify
dehydration. Then choose the appropriate plan (A,B, or C) to continue
treatment.
Is IV treatment
Available nearby  Refer URGENTLY to hospital for IV treatment.
(within 30 minutes)?  If the child can drink, provide the mother with ORS solution and show her how to give frequent
sips during the trip
Are you trained to  Start rehydration by tube (or mouth) with ORS solution give 20 ml/kg/ hour for 6 hours (total of 120 ml/kg)
Use a naso-gastric  Reassess the child every 1-2 hours:
(NG) tube for
Rehydration? - If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly.
- If hydration status is not improving after 3 hours, send the child for IV therapy
 After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to
Can the child continue treatment.
drink?
NOTE:
Refer URGENTLY  If possible, observe the child at least 6 hours after rehydration to be sure the mother can
To hospital for IV 149
06/17/2024
or NG treatment maintain hydration giving the child ORS solution by mouth.
 SEVERE PERSISTENT DIARRHEA
TREATMENT
• Need referral to hospital
• Need special attention to help prevent loss of
fluid
• Need a change in diet
• Need laboratory tests of stool samples to identify
the cause of diarrhea
• Need zinc supplement
• Treat the child’s dehydration before referral
unless the child has another severe classification
06/17/2024 150
 PERSISTENT DIARRHEA
• TREATMENT
• Special feeding is the most important
treatment
• Vitamin A is given as recommended
• Also give zinc supplementation

06/17/2024 151
 Feeding Recommendations for a child who has PERSISTENT DIARRHOEA

• If still breastfeeding, give more frequent, longer

breastfeeds, day and night.

• If taking other milk:

- replace with increased breastfeeding OR
- replace with fermented milk products, such as
yoghurt OR
- replace half the milk with nutrient-rich
semisolid food.

• For other foods, follow feeding recommendations for

the child’s age.
06/17/2024 152
 FOR DYSENTERY:
Give antibiotic recommended for Shigella in your area for 3 - 5 days.

FIRST-LINE ANTIBIOTIC: Ciprofiloxacine

CIPROFLOXACIN
Give two times daily for 3 days

AGE or WEIGHT TABLET

250 mg
2 months up to 4 months (4-6 kg) ¼
4 months up to 12 months (6-10kg) ½
12 months up to 5 years (10-19kg) 1

06/17/2024 153
 Fever
• A child with fever may have malaria, measles
or another severe disease. Or,

• A child with fever may have a simple cough or

cold or other viral infection.

06/17/2024 156
 Malaria
• Malaria is caused by parasites in the blood
called “plasmodia.”

• They are transmitted through the bite of

anopheline mosquitoes.

• Four species of plasmodia can cause malaria,

but the most dangerous one is Plasmodium
falciparum.
06/17/2024 157
 Sign and symptom of malaria
• Fever: the main symptom
• Shivering, sweating and vomiting
• A child with malaria may have chronic
anaemia (with no fever) as the only sign of
illness.
• Signs of malaria can overlap with signs of
other illnesses.
• In areas with very high malaria transmission,
malaria is a major cause of death in children.
06/17/2024 158
 Measles
• Measles is highly infectious and it is caused by a virus.

• Most cases occur in children between 6 months and 2 years

of age.

• Maternal antibody protects young infants against measles

for about 6 months. Then the protection gradually
disappears.

• Overcrowding and poor housing increase the risk of

measles occurring early.

• Fever and a generalized rash are the main signs of measles.

06/17/2024 159
 Measles

• It infects the skin and the layer of cells that

line the lung, gut, eye, mouth and throat.

• The measles virus damages the immune

system for many weeks after the onset of
measles.
• This leaves the child at risk for other
infections.
06/17/2024 160
 Measles

• Complications of measles occur in about 30%

of all cases. The most important are:
— diarrhoea (including dysentery and
persistent diarrhoea)
— pneumonia
— stridor
— mouth ulcers
— ear infection and
— severe eye infection (which may lead to
corneal ulceration and blindness).
06/17/2024 161
 Measles
• Encephalitis (a brain infection) occurs in about
one in one thousand cases.

• A child with encephalitis may have a general

danger sign such as convulsions or lethargic or
unconscious.

06/17/2024 162
 Measles
• Measles contributes to malnutrition because it causes
diarrhea, high fever and mouth ulcers. These problems
interfere with feeding.

• Malnourished children are more likely to have severe

complications due to measles. This is especially true for
children who are deficient in vitamin A.
• One in ten severely malnourished children with
measles may die.

• For this reason, it is very important to help the mother

to continue to feed her child during measles.
06/17/2024 163
 Assess fever
• A child has main symptom of fever
if:
– The child has history of fever
– The child feel hot
– The child has an axillary temperature
of 37.5 or above

06/17/2024 164
Does the child has fever?
(by history or feels hot or temperature of 37.5oC or above)**
• If malaria risk is high or low or High
IF YES: travel to a malarious area, then Malaria Risk
•Decide Malaria Risk: high, low or no do a blood film or RDT (Rapid
If “low or no” malaria risk, then ask: Diagnostic Test), if possible
• Has the child traveled outside this
area During the previous 15 days? LOOK AND FEEL:
• If yes, has he been to a malarious • Look or feel for stiff neck.
area? • Look or feel for bulging
THEN ASK: fontanels (<1 year old) Classify Low
FEVER Malaria Risk
For how long has the child had fever? • Look for runny nose.
• If more than 7 days, has fever been
Look for signs of MEASLES
present every day? • Generalized rash and
• Has the child had measles within
• One of these: cough,
the last 3 months?
runny nose, or red eyes.

No
If the child has measles now
06/17/2024 Malaria165Risk
or within the last 3 months:
 Does the child have fever?
(by history or feels hot or temperature of 37.5oC or above)**

Look for mouth

If the child has
ulcers.
measles now Are they deep or
or within the last extensive?
IF MEASLES
3 months: Look for pus draining
now or
from the eye:
Within the
Look for clouding of
last 3
the cornea
months,
Classify

06/17/2024 166
 Cont’d…

▼ ASK: DOES THE CHILD HAVE FEVER?

• Check to see if the child has a history of fever,
feels hot or has a temperature of 37.5°C or above.

• Feel the child’s stomach or axilla (underarm) and

determine if the child feels hot.

• Look to see if the child’s temperature was

measured today and recorded on the child’s chart.

06/17/2024 167
 Cont’d…

• If the child has NO fever (by history, feel, or measured

temperature of 37.5°C or above), ask about the next main
symptom, ear problem. Do not assess the child for signs
related to fever.

• If the child HAS fever (by history, feel, or measured

temperature of 37.5°C or above), assess the child for
additional signs related to fever.

• History of fever is enough to assess the child for fever.

Assess the child’s fever even if the child does not have a
temperature of 37.5°C or above or does not feel hot now.
06/17/2024 168
 Cont’d…

▼ DECIDE THE MALARIA RISK

• To classify and treat children with fever, you must
know the malaria risk in your area.
■ There is a high malaria risk in areas where more than
5% of the fever cases in children are due to malaria.

■ There is a low malaria risk in areas where 5% or less

of the fever cases in children are due to malaria.

■ There is no malaria risk in areas where no

transmission of malaria occurs.
06/17/2024 169
 Cont’d…
• Malaria risk can vary by season. The breeding
conditions for mosquitoes are limited or absent
during the dry season.

• As a result, during the dry season, the risk of malaria

is usually low. Areas where malaria occurs, but only
rarely, are also identified as low malaria risk.

• The malaria risk during rainy season is high. Many

children develop malaria.
• They present with fever, anaemia, and signs of
cerebral malaria.
06/17/2024 170
 Cont’d…

• Find out the risk of malaria for your area. If

the risk changes according to season, be sure
you know when the malaria risk is high and
when the risk is low.

• If you do not have information telling you that

the malaria risk is low in your area, always
assume that children under 5 who have fever
are at high risk for malaria.

06/17/2024 171
 Cont’d…
• If a child lives in a low or no malaria risk area, you may need
to ask an additional question—Has the child travelled
outside this area within the last 2 weeks?

• If yes, has the child been to a high or low malaria risk

area?

• If the child has travelled to a high or low malaria risk area,

you should assess the child as though he lived in the area to
which he travelled.

• Decide if the malaria risk is high, low or no.

06/17/2024 172
 Cont’d…

▼ ASK: FOR HOW LONG? IF MORE THAN 7

DAYS, HAS FEVER BEEN PRESENT EVERY DAY?
• Most fevers due to viral illnesses go away
within a few days.

• A fever which has been present every day for

more than 7 days can mean that the child has
a more severe disease such as typhoid fever.

06/17/2024 173
 Cont’d…
▼ LOOK OR FEEL FOR STIFF NECK
• A child with fever and stiff neck may have
meningitis.

• A child with meningitis needs urgent treatment

with injectable antibiotics and referral to
hospital.

• While you talk with the mother during the

assessment, look to see if the child moves and
bends his neck easily as he looks around.

• If the child is moving and bending his neck, he

does not have a stiff neck.

• If you did not see any movement, or if you are

not sure, draw the child’s attention to his
06/17/2024 174
umbilicus or toes.
 Look or feel for bulging fontanels (<1 year old)

06/17/2024 175
 Cont’d…

▼ LOOK FOR RUNNY NOSE

• A runny nose in a child with fever may mean that the
child has a common cold.

• If the child has a runny nose, ask the mother if the child
has had a runny nose only with this illness.

• If she is not sure, ask questions to find out if it is an acute

or chronic runny nose.

• When malaria risk is low or no, a child with fever and a

runny nose does not need an antimalarial. This child’s
fever is probably due to a common cold.
06/17/2024 176
 Cont’d…
▼ LOOK FOR SIGNS SUGGESTING MEASLES
• Assess a child with fever to see if there are
signs suggesting measles.

• Look for a generalized rash and for one of the

following signs: cough, runny nose, or red
eyes.

06/17/2024 177
 Cont’d…
• Generalized rash
• In measles, a red rash begins behind the ears and on the neck.
It spreads to the face.

• During the next day, the rash spreads to the rest of the body,
arms and legs.

• After 4 to 5 days, the rash starts to fade and the skin may peel.

• Some children with severe infection may have more rash

spread over more of the body. The rash becomes more
discolored (dark brown or blackish), and there is more
peeling of the skin.
06/17/2024 178
 Children with measles

06/17/2024 179
 Child with measles

06/17/2024 180
 Cont’d…

• A measles rash does not have vesicles (blisters) or

pustules. The rash does not itch.

• Do not confuse measles with other common childhood

rashes such as chicken pox, scabies or heat rash.

• The chicken pox rash is a generalized rash with vesicles.

• Scabies occurs on the hands, feet, ankles, elbows, buttocks

and axilla. It also itches.

• Heat rash can be a generalized rash with small bumps and

vesicles which itch. A child with heat rash is not sick.)
06/17/2024 181
 Cont’d…
• Cough, runny nose, or red eyes

• To classify a child as having

measles, the child with fever must
have a generalized rash AND one
of the following signs: cough,
runny nose, or red eyes.

• The child has “red eyes” if there is

redness in the white part of the
eye. In a healthy eye, the white
part of the eye is clearly white
and not discolored.
06/17/2024 182
 Cont’d…

• IF THE CHILD HAS MEASLES NOW OR WITHIN

THE LAST 3 MONTHS:

• Look to see if the child has mouth or eye

complications.
• Other complications of measles such as stridor
in a calm child, pneumonia, and diarrhea are
assessed earlier. Malnutrition and ear
infection are assessed later.
06/17/2024 183
 Cont’d…

▼ LOOK FOR MOUTH ULCERS. ARE

THEY DEEP AND EXTENSIVE?
• Look inside the child’s mouth for mouth
ulcers.

• Ulcers are painful open sores on the inside of

the mouth and lips or the tongue.

• They may be red or have white coating on

them.

• In severe cases, they are deep and extensive.

• When present, mouth ulcers make it difficult

for the child with measles to drink or eat.
06/17/2024 184
 Cont’d…
• Mouth ulcers are different than the small spots called
Koplik spots.

• Koplik spots occur in the mouth inside the cheek

during early stages of the measles infection.

• Koplik spots are small, irregular, bright red spots with a

white spot in the center.

• They do not interfere with drinking or eating.

•06/17/2024
They do not need treatment. 185
 Koplic’s spots

06/17/2024 186
 Cont’d…

▼ LOOK FOR PUS DRAINING FROM THE EYE

• Pus draining from the eye is a sign of
conjunctivitis.

• Conjunctivitis is an infection of the conjunctiva,

the inside surface of the eyelid and the white
part of the eye.

• Often the pus forms a crust when the child is

sleeping and seals the eye shut.
06/17/2024 187
 Cont’d…

▼ LOOK FOR CLOUDING OF THE

CORNEA
• The normal cornea (the clear window
of the eye) is bright and transparent.

• Look carefully at the cornea for

clouding.

• The cornea may appear clouded or

hazy, such as how a glass of water
looks when you add a small amount
of milk.

• The clouding may occur in one or

both eyes.
06/17/2024 188
 Cont’d…

• Corneal clouding is a dangerous condition.

• The corneal clouding may be due to vitamin A

deficiency which has been made worse by
measles.

• If the corneal clouding is not treated, the cornea

can ulcerate and cause blindness.

• A child with clouding of the cornea needs urgent

treatment with vitamin A.
06/17/2024 189
 How to classify fever
• If the child has fever and no signs of measles,
classify the child for fever only.

• If the child has signs of both fever and

measles, classify the child for fever and for
measles.

06/17/2024 190
Malaria Risk (High/Low)
No malaria risk and no travel to malarias area
 Treat the Child to Prevent Low Blood Sugar
• If the child is able to breastfeed:

– Ask the mother to breastfeed the child.

• If the child is not able to breastfeed but is able

to swallow
– Give expressed breast milk or a breast milk
substitute.
– If neither of these is available, give sugar water.
– Give 30-50 ml of milk or sugar water before
departure.
06/17/2024 195
 Treat the Child to Prevent Low Blood
Sugar
• To make sugar water:
• Dissolve 4 level teaspoons of sugar (20 grams)
in a 200-ml cup of clean water.

• If the child is not able to swallow:

• Give 50 ml of milk or sugar water by nasogastric

tube.

06/17/2024 196
 Treat the child: Paracetamole for high fever: (≥38.5oc) or ear pain

• Give Paracetamol for High Fever

• Give paracetamol every 6 hours until high fever or ear pain is
gone.

06/17/2024 197
 Treat the child: Give Vitamin A
Treatment:
• For MEASLES, MEASLES with EYE/MOUTH
Complications and PERSISTENT DIARRHEA give
three doses
• Give first dose in clinic
• Give two doses in the clinic on days 2 and 15
• Supplementation: give one dose in clinic if
• Children 6 months up to 5 years
• The child has not received a dose within the last 6
months.
06/17/2024 198
 Treat the child: Give Vitamin A

• 200,000 IU = 6 drops
• 100,000IU = 3 drops
06/17/2024 199
 Session 4d
Ear problem

06/17/2024 200
 Ear problem

• A child with an ear problem may have an ear infection.

• When a child has an ear infection, pus collects behind the

ear drum and causes pain and often fever.

• If the infection is not treated, the ear drum may burst. The
pus discharges, and the child feels less pain. The fever and
other symptoms may stop, but the child suffers from poor
hearing because the ear drum has a hole in it.

• Usually the ear drum heals by itself. At other times the

discharge continues, the ear drum does not heal and the
child becomes deaf in that ear.
06/17/2024 201
 Ear problem

• Sometimes the infection can spread from the ear to the

bone behind the ear (the mastoid) causing mastoiditis.
• Infection can also spread from the ear to the brain
causing meningitis. These are severe diseases. They
need urgent attention and referral.

• Ear infections rarely cause death. However, they cause

many days of illness in children.

• Ear infections are the main cause of deafness in

developing countries, and deafness causes learning
problems in school.
06/17/2024 202
How to assess a child with an ear problem

IF YES, ASK:
LOOK, AND FEEL:
Does the • Is there ear • Look for pus Classify
child has pain? draining from the EAR
an ear • Is there ear ear PROBLEM
problem? discharge? • Feel for tender
• If yes, for how swelling behind the
long?
ear.

06/17/2024 203
 Clean the Ear by Dry Wicking and Give Quinolone Eardrops

• Ciprofloxacin, Norfloxacin, or Ofloxacin ear drops

• Dry the ear at least 3 times daily
• Roll clean absorbent cloth or soft, strong tissue paper
into a wick
• Place the wick in the child’s ear
• Remove the wick when wet
• Replace the wick with a clean one and repeat these
steps until the ear is dry
• Instil Ciprofloxacin eardrops (2-3 drops) after dry
06/17/2024 wicking three times daily for two weeks 205
 SESSION 5

Malnutrition and anemia

 Anemia
Anemia is
• a reduced number of red
cells or
• a reduced amount of
hemoglobin in each red
cell.

• Not eating foods rich in

iron can lead to iron
deficiency and anemia.
 Condition predisposing anemia

A child can also develop anemia as a result of:

Infections:
✔ Parasites such as hookworm or whipworm
that can cause blood loss from the gut and lead
to anemia.
✔ Malaria, which can destroy red cells rapidly.
 How to check /assess a child for anemia

▼ LOOK FOR PALMAR PALLOR

• Pallor is unusual paleness of the skin.
• It is a sign of anemia.
• To see if the child has palmar pallor, look at
the skin of the child’s palm.
Children with anemia and malnutrition
 Cont’d…
• Hold the child’s palm open by grasping it gently from the
side. Do not stretch the fingers backwards. This may
cause pallor by blocking the blood supply.

• Compare the color of the child’s palm with your own

palm and with the palms of other children.

• If the skin of the child’s palm is pale, but has some pink
areas, the child has some palmar pallor.

• If the skin of the palm is very pale or so pale that it

looks white, the child has severe palmar pallor.
 Give Iron
 Give one dose daily for 14 days

AGE or WEIGHT IRON TABLET IRON SYRUP

Ferrous sulfate 300 mg Ferrous Fumarate 100 mg
(60 mg elemental iron) per 5 ml (20 gm elemental
iron per ml
2 months up to 4 months (4-6 kg) 1.00 ml (15 drops)
4 months up to 12 months (6-10 1.25 ml (20 drops)
kg)
12 months up to 3 years (10-14 ½ tablet 2.00 ml (30 drops)
kg)
3 years up to 5 years (14-19 kg) ½ tablet 2.5 ml (35 drops)
 Give Mebendazole or Albendazole

Give as a single dose if child has not got

Drug within the previous 6 months to these age
groups
0 - 1 year 1 - 2 years 2 - 5 years

Albendazole 400mg None 1/2 tablet 1 tablet

tablet
Mebendazole 500 mg None 1/2 tablet 1 tablet
tablet or 5 tablets of 100 ( 250 mg) ( 500mg)
mg
Malnutrition
 Malnutrition
• A pathological state secondary to relative or
absolute deficiency or excess of one or more
essential nutrients

• It can also developed in children with diet

lacking in the recommended amount of
essential vitamins and minerals (Iron)
 Causes of malnutrition

• There are several causes of malnutrition. They

may vary from country to country.

• Not getting enough energy or protein from his

food to meet his nutritional needs.

• A child who has had frequent illnesses can also

develop protein energy malnutrition.
 Forms of malnutrition

1. Severe acute malnutrition is a deficiency of

calories and or protein in a child’s diet.
FORMS OF SAM :
A. Marasmus
B. kwashiorkor
C. Marasmic-kwashiorkor
• SAM is present if,
– The child is severely wasted
– The child develop edema
– The child do not grow well and become stunted
 Forms of malnutrition

2. Nutrient deficiencies
• Anemia (Lack of iron)
• Vitamin A deficiency
• A child whose diet lacks recommended amounts of essential
vitamins and minerals can develop malnutrition.

• Not eating foods that contain vitamin A can result in vitamin

A deficiency.
• A child with vitamin A deficiency is at risk of death from
measles and diarrhea. The child is also at risk of blindness.

• Not eating foods rich in iron can lead to iron deficiency and
anemia.
 Marasmus

• Occur at all ages, more common less than 1

year old
• Child is not getting enough energy from his
regular diet
• Balanced nutrition
• Result of unsuccessful breast feeding or
insufficient breast supply
• Severely wasted
• Gross loss of subcutaneous fat; all skin and
bone; loose skin folds in buttocks
 Marasmus
• Potbelly and winged scapulae
• Good appetite
• Apathetic
• “Little old man face” appearance
Severely malnourished child
 kwashiorkor

• Usually 2-4 years old

• Result from a low protein diet
• Presence of bipedal edema is a cardinal sign
• Common sign:
– Thin, sparse and pale (reddish to white) hair that
easily falls out;
– Dry, scaly skin especially on the arms and legs; and
– A puffy or “moon” face.
Edema of both feet
Severely malnourished children
 How to check /assess a child for acute
malnutrition
• Children are classified for acute malnutrition
based on the
– presence and absence of edema and wasting.
• Wasting is assessed by determining
– weight for length/height in all children and
– Mid Upper Arm circumference (MUAC) in those
aged 6 to 59 months.
• Visible severe wasting can be determined in
infant below the age 6 months by inspection
 Cont’d…
▼ LOOK FOR VISIBLE SEVERE WASTING
• A child with visible severe wasting has marasmus, a
form of severe malnutrition.

• A child has this sign if he is very thin, has no fat, and

looks like skin and bones.
• Some children are thin but do not have visible severe
wasting.

• This assessment step helps you identify children with

visible severe wasting who need urgent treatment
and referral to a hospital.
 To look for visible severe wasting
• Remove the child’s clothes.
• Look for severe wasting of the muscles of the
shoulders, arms, buttocks and legs.

• Look to see if the outline of the child’s ribs is easily

seen.
• Look at the child’s hips. They may look small when
you compare them with the chest and abdomen.

• Look at the child from the side to see if the fat of the
buttocks is missing.
 Cont’d…
• When wasting is extreme, there are many
folds of skins on the buttocks and thigh. It
looks as if the child is wearing baggy pants.

• The face of a child with visible severe wasting

may still look normal.

• The child’s abdomen may be large or

distended.
Visible sever wasting
Visible sever wasting
 Cont’d…
• For children aged 6 month or
more, the best way to determine
wasting is
• Weight For Length or Weight For
Height (WFL/WFH) Z– score or
• Percent of median and measuring
MUAC
 Cont’d…

▼ LOOK AND FEEL FOR OEDEMA OF BOTH FEET

• A child with edema of both feet may have
kwashiorkor, another form of severe
malnutrition.

• Look and feel to determine if the child has

oedema of both feet.

• Use your thumb to press gently for a few

seconds (at least three second) on the top side
of each foot.
Edema of both feet
 Cont’d…
• The child has oedema if a dent remains in the child’s
foot when you lift your thumb.
• Grade the degree of edema depending on the extent
of the involvement of the upper part of the child’s
body.
• Grade of edema:
Grade description
+ Mild Edema of both feet and below the ankel
++ Moderate Edema of both feet plus lower legs (below
knees) and lower arms (below the elbow)

+++ severe Generalized edema including both feet ,

legs, hands, arms and the face
 Cont’d…

▼ LOOK AND CHECK FOR DERMATOSIS

• Dermatosis is a skin condition

• In sever malnutrition, it is more common in children

who have edema than in wasted children.

• A child with dermatosis may have patches of skin

that is abnormally light or dark in color, shedding of
skin in scales or sheets, and ulceration of the skin of
perineum, groin, limbs, behind the ears, and in the
armpits.
 Cont’d…

• The extent of dermatosis can be described in

in the following way:
Grade description

+ Mild Discoloration or a few rough patches of

skin
++ Moderate Multiple patches on arms and/or legs

+++ severe Flaking skin, raw skin, fissures (opening in

the skin)
 Cont’d…

• There are a separate assessment and

classification boxes for children
– below 6 months of age and
– 6 months and above those age
 Cont’d…

Appetite test
• It is done only for children above the age of 6
months or older with severe acute
malnutrition (WFL/WFH less -3 Z-score or <
70% of median or MUAC less the 11 cm or if
edema of both feet)
• do appetite test if the child fulfill the
following criteria
 Cont’d…
• Has no general danger sign
• No medical complications (any sever
classification, pneumonia, watery diarrhea
with dehydration, persistent diarrhea,
dysentry, fever >38.50 c, measles now or
measles with eye or mouth complications, low
body temperature <350 c.
• NO +++ edema, and
• NO marasmic-kwashiorkor
 How to do the appetite test

1. The appetite test should be conducted in a separate

quite place
2. Explain to the care taker, the purpose of the appetite
test and how it will be carried out.
3. The care taker, where possible, should wash his/her
hands
4. The care taker should sit comfortably with the child
on her/his lap and either offers the Ready to Use
Therapeutic Food (RUTF) from the packet or put a
small amount on her/his finger and give it to the
child
 Cont’d…
5. The care taker should offer the child the RUTF
gently, encouraging the child all the time.
• If the child refuses then the care taker should
continue to quietly encourage the child and
take time over the test.
• The test usually takes 15 -30 minutes.
• The child must not be forced to take the
RUTF.
6. The child need to be offered plenty of water
to drink from a cup as he/she is taking the
RUTF
 The result of the appetite test
• Appetite test pass:
1. A child who takes at least the amount shown
in the appetite test table passes the appetite
test
2. Explain to the care taker the choice of
treatment is Outpatient Treatment Program
(OTP)
3. Record the child on IMNCI register and admit
to the OTP for registration and initiation of
treatment.
 Appetite test table
Appetite test for RUTF
This is the minimum amount that malnourished patient should take to pass
the appetite test

Plumpy Nut (500Kcal/sachet of 92 gms BP 100 (1 BP bar=

56.7 gms= 300 Kcal)
Body weight (Kg) Sachet Bars

< 4kg 1/8 ¼

4 up to 10kg
¼ ½
10 up to 15 kg
½ ¾
> 15 kg
¾ 1
 The result of the appetite test

• Appetite test Failed:

1. A child who does not take at least the
amount of RUTF shown in the table should
be referred for in-patient care
2. Explain to the care taker the choice of
treatment is in-patient care and the reason
for recommending in-patient care
3. Refer the patient to the nearest Therapeutic
Feeding Unit (TFU) or hospital for in-patient
management
 SESSION 6

HIV EXPOSURE AND INFECTION

 CHECK THE CHILD FOR HIV EXPOSURE AND
INFECTION
• The exact prevalence of HIV in children is not known,
however,
• There were nearly 80,000 children under 14 years living
with HIV/AIDS in Ethiopia at the end of 2010.

• Mother to child transmission of HIV (MTCT) is the main

way (90%) through which children are infected with HIV.

• The average risk of HIV transmission from mother to

child is about one-third and transmission can occur
during pregnancy, labor and delivery and postnatally
through breast feeding.
 Cont’d…
• There is a 15-20 % risk of HIV transmission through
breast feeding only if an HIV positive mother feed
her infant breast milk for 24 months

• If HIV positive women feed their infant breast milk

exclusive for 6 months only, the risk of transmission
of HIV through breast feeding get less.

• Studies have shown that exclusive breast feeding

carries a smaller risk of HIV transmission when
compared with mixed feeding
 Cont’d…

• Early diagnosis of HIV infection and

treatment in infants and children is
important since the disease progress rapidly
in children with 50% and 75 % mortality by
age two and five respectively.

• Passively transfer maternal HIV antibodies

make interpretation of positive antibody tests
difficult in children less than 18 months of age.
 Assess for HIV exposure and Infection
• All sick children (and their mother) should be
tested and assessed for HIV exposure and
infection.

• During assessing the HIV status of the mother

and child, present the question wisely and
maintain confidentiality as much as possible
since it is sensitive.
 HIV status of the mother
• HIV antibody (serological) test or rapid tests are
used for knowing the maternal HIV status.

• A mother with positive antibody test result is taken

as HIV infected mother, and the one with negative
test result is considered to be uninfected.

• If mother is not tested for HIV , she is considered to

be “unknown status”.

• If mother is not tested and is unknown, health

worker should encourage her for HIV screening.
 HIV status of the child
• Different test are available to diagnose HIV infection in
children (serological and virological test).

• Serological or antibody test, including rapid test detect

only antibodies, but they do not detect the virus itself.

• Antibody from the mother pass on to the child and in

some instance do not disappear until the child is 18
months of age.
• This means that a positive antibody test in children
under the age of 18 months does not confirm that the
child is truly HIV infected.
 Cont’d…

• Virological test such as DNA PCR test directly

detect HIV in the blood.

• These tests HIV infection in the child as early

as 6 weeks old (before 18 months)
 Is the child breast feeding

• If a child is on breast feeding, he/she is on

continuous exposure for HIV transmission.

• A negative PCR or antibody test in a breast feeding

child at any age should be repeated 6 weeks after
breast feeding stopped to confirm HIV infection
status.
 Classify for HIV infection

• Based on the age of the child, the

classification for HIV is divided into two:

• For children below 18 months and for children

aged 18 months and above
 Check for HIV exposure and infection, in children 2- < 18 months

ASK:
Classify for HIV
• What is the HIV status of the mother?
exposure and
Positive negative unknown
infection
•What is the HIV antibody test result of the
sick child?
Positive negative unknown
• What is the DNA PCR test result of the
sick child?
Positive negative unknown
•Is the child on breast feeding? Note:
Yes No • If DNA/PCR is not available, AND child
•If No, was the child breast fed in the last 6 antibody is positive, AND two of the following are
weeks present (oral thrush, sever pneumonia, or very
Yes No sever disease); consider this child to have
“presumptive HIV disease” . And this child should
be referred and treated as “HIV infected” child
 Recommended Co-trimoxazole dosage for infants and children

Give Co-trimoxazole Prophylaxis for HIV infected/exposed

child
 For HIV exposed, give Co-trimoxazole once daily from the
age of 6 weeks until HIV infection has been definitely ruled
out and the mother is no longer breastfeeding.

 For HIV INFECTED give Co- trimoxazole once daily.

 DO NOT GIVE CO-TRIMOXAZOLE TO INFANTS UNDER

6 WEEKS OF AGE
 Recommended Co-trimoxazole dosage for infants and
children

Recommended Co-trimoxazole dosage for infants and children

Recommended Suspension Paediatric tablet Single strength tablet

daily dosage (40mg (20 mg (80mg
Trimethoprim/200mg Trimethoprim/100 Trimethoprim/400mg
Sulphamethoxazole in mg Sulphamethoxazole)
Sulphamethoxaz
5 mls) ole)
< 6 months 2.5 ml One tablet ¼ tablet

6 months – 5 5 ml Two tablets ½ talet

years
> 6 – 14 years 10 ml Four tablets One tablet

> 14 years - - Two tablets

 SESSION 7

IMMUNIZATION STATUS
 IMMUNIZATION

• Disease prevention means immunizing infants and

young children against preventable viral and bacterial
diseases
• Goal of immunization: to confer long lasting
immunity against infectious diseases

• Immediate goal is prevention of disease in

individuals or groups

• Ultimate goal is eradication of disease .

 Immunization status

• All children should receive all the recommended

immunizations before their first birthday.

• If the child does not come for an immunization at the

recommended age, give the necessary
immunizations any time after the child reaches that
age.
• For each vaccine, give the remaining doses at least 4
weeks apart.
 Cont’d…

▼ OBSERVE CONTRAINDICATIONS TO IMMUNIZATION

• There are only three situations at present that are
contraindications to immunization:
■ Do not give BCG to a child known to have AIDS.
■ Do not give DPT 2 or DPT 3 to a child who has had convulsions
or shock within 3 days of the most recent dose.
■ Do not give DPT to a child with recurrent convulsions or
another active neurological disease of the central nervous
system.

• In all other situations, here is a good rule to follow: There are

no contraindications to immunization of a sick child if the
child is well enough to go home.
 Cont’d…

• Minor illness is not a contraindication to

immunization, should not delay immunization

• It is very important to immunize sick and

malnourished children against tuberculosis,
Hepatitis B, Measles, Polio, Diphtheria,
Pertussis & Tetanus
 Cont’d…

• If a child is going to be referred, do not immunize the

child before referral.

• The hospital staff at the referral site should make the

decision about immunizing the child when the child
is admitted. This will avoid delaying referral.

• Children with diarrhea who are due for OPV should

receive a dose of OPV (oral polio vaccine) during this
visit. However, do not count the dose.
 Cont’d…
• The child should return in 4 weeks for the
missing dose of OPV.

• Advise the mother to be sure that the other

children in the family are immunized. Give the
mother tetanus toxoid, if required.
 How to decide if a child needs immunization
today

▼ LOOK AT THE CHILD’S AGE ON THE CLINICAL

RECORD
• If you do not already know the child’s age, ask
about the child’s age.
▼ ASK THE MOTHER IF THE CHILD HAS AN
IMMUNIZATION CARD
• If the mother answers YES, ask her if she
brought the card to the clinic today.
• If she brought the card with her, ask to see the
card:
THEN CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A STATUS
 Follow the recommended schedule

1. Give the recommended vaccine when the child is at the

appropriate age for each dose.
2. If the child do not come for an immunization at the
recommended age. Give necessary immunization any time after
the child reaches that age.

3. No need to repeat the whole schedule

 THANK YOU!
06/17/2024 GB 280