MODULE 3: Integrated Management of Childhood Illness (IMCI) Flashcards
Over the past 25 years
Child mortality has dropped from 91 to 43 deaths per 1000 live births between 1990 and 2015
Yet in 2015
An estimated 5-9 million still died before reaching their 5th birthday, most from conditions that are ready preventable or treatable with proven cost-effective interventions
How much is the global under five deaths are among neonates
45%
Highest cause of death among neonates and children under five years of age
Prematurity 18%
Second highest cause of death among neonates and children under five years of age
Pneumonia
Issues affecting quality of care
a. health worker skills
b. health systems support
c. community and family practices
Who developed IMCI
WHO and UNICEF
Why IMCI was developed
to promote health and provide preventive and curative services for children under five in countries with greater than 40 deaths per 1000 live births
Achieving the SDG’s for child health
a. promote health, growth, and development
b. prevent illness
c. treat sick newborns and children
Why IMCI changed to IMNCI in 2003
Added newborns
What is IMCI
Strategy for reducing mortality and morbidity associated with major causes of childhood illness form birth up to five years old
Conditions associated with IMCI
a. respiratory
b. diarrhea
c. fever
d. ear problems
e. nutritional
Respiratory
a. pneumonia
b. cold / cough
Diarrhea
a. acute watery
b. dysentery
c. persistent
Fever
a. malaria
b. measles
c. meningitis
d. encephalitis
Ear problems
a. mastoditis
b. acute and chronic conditions
Nutritional
a. kwashiorkor / maramus
b. anemia
c. feeding problems
d. breast feeding
e. counseling
f. neonatal sepsis
g. local infections
h. hypoglycemia
i. hypothermia
j. oral thrush
k. immunization
l. Vit. A supplementation
m. deworming
WHO and UNICEF adapted IMCI to what
to each country
Why is IMCI better than single condition approaches
a. To go beyond single diseases and address the overall health of the child
b. Looking to the Child as a Whole
Growth promotion at home
a. Community/home- based interventions to improve nutrition
b. Insecticide- impregnated bed nets
Response to sickness at home
a. Early case management
b. Appropriate care seeking
c. Compliance with treatment
Growth promotion at health facility
a. Vaccination
b. Complementary feeding
c. Breastfeeding counselling
d. Micronutrient supplementation
Response to sickness at health facility
a. Case management of: ARI, diarrhea,measles, malaria, malnutrition, other serious infection
b. Iron treatment
c. Anthelmintic treatment
Ways to improve child health
a. Improve case management of children
b. Improve nutrition
c. Ensure immunization
d. Prevent injuries
e. Prevent other disease
f. Improve psychosocial support and stimulation
g. Integration of care
Overall IMCI strategy
a. to reduce childhood death - improve child survival
Specific IMCI strategy
a. To reduce the frequency and severity of sickness and disability
b. To continue to improved growth and development
Preventive interventions
a. Vaccination
b. Nutrition counseling
c. Breastfeeding
d. Vitamin A supplements
e. Iron supplements f. Deworming , personal hygiene and sanitation
Integration of approaches: the essence of IMCI
a. community and family practices
b. primary care
c. referral care
Where is it implemented
a. usually in asia and Africa
b. coverage for preventive interventions are low
c. managing sick children is not standardized - EB interventions are missed
Community and family practices
a. Community IMCI
b. BHWs
Primary care
a. IMCI at primary level
b. RHM PHN MDs
Referral care
a. Hospital IMCI
b. Hospital staff
GOLD pediatric standard
a. Complete medical history
b. Physical examination
c. Primary diagnosis and differential diagnoses
d. Ancillary procedure (if required)
e. Initial therapeutic plan
f. Monitor progress of the patient (revisit #3, #4, #5)
g. Final Diagnosis
h. Revise therapeutic plan
I. Counsel and Follow Up
IMCI approach
a. assess
b. classify
c. treatment
d. counsel
e. follow up care
assess
a. what is the age of the child
b. is this an initial visit? follow up visit?
c. focused assessment of danger signs and symptoms
classify
not a diagnosis, but guides the HW to know that definitive action is needed based on the severity of the illness
treatment
outlines the actions to be taken. Urgent referral vs home management
treatment
guidelines on dosages of drugs, and home care interventions
Most common causes of child deaths
a. pneumonia
b. diarrhea
c. measles
d. malnutrition
How is started: Phase 1
the first model course of staff selected at the national DOH, regions IX and XI was thereafter conducted at the davao regional hospital
Subsequent courses in pilot provinces
a. saranggani
b. Zamboanga del norte
When was IMCI introduced in Philippines
1995
When was the early implementation phase conducted
May 1999
Review of the early implementation phase
served as the basis for expansion IMCI to other regions in the country (phase III)
Enhancing the nursing and midwifery curriculum through the IMCI strategy
2002: the enhancement of the nursing and midwifery curriculum
Community IMCI
a. care of the newborn
b. care for growth and development
Care of the newborn
Capacitates the BHW to make prenatal visits to the mother and postnatal visits to the mother and child
Care for growth and development
Enhance BHW skills to promote G&D interventions: nutrition, immunization, injury prevention, hygiene, early care seeking
Improves health worker skills
a. case management guideline
b. training of health providers who look after sick infants and children up to 5 years (pre-service and in-service)
3 main component of IMCI
a. improvement of health worker skills
b. improvement of health systems
c. improvement of family and community practices in relation to child health
Training of health providers who look after sick infants and children up to 5 years (pre-service and in-service)
a. pre-service: before admission
b. in-service: admitted already
Improves health system
a. Targets first level health facilities
b. Organization of work
c. Availability of drugs and supplies
d. Monitoring and supervision
e. Referral pathways and systems
f. Health information systems
Improves family and community practices
a. Exclusive Breastfeeding
b. Complementary feeding
c. Cont. feeding during illness
d. using of iodized salt e. Routine vaccination f. Irregular growth monitoring
g. Early care-seeking
h. Compliance to provider advice
i. Home care of sick children
j. Recognition of severe illness
k. Proper waste disposal
l. Use of long lasting treated nets (LLTN)
m. Antenatal care
n. Tetanus toxoid for pregnant women
o. Proper nutrition for pregnant women
Benefits of IMCI
a. addresses major child health problems
b. promotes prevention as well as cure
c. improves health worker performance
d. reduce under five mortality
e. cost effective inappropriate management of childhood illness wastes scarce resources
f. improves equity
Diseases covered by the IMCI
a. diarrhoeal diseases
b. acute respiratory infections
c. malaria
d. measles
e. malnutrition
Age groups covered by IMCI
a. children age 2 months up to 5 years
b young infants age up to 2 months
why not use the process for 5 years old or more
assessment and classification of older children would differ
Cut off rate for fast breathing would be different because
normal breathing rates are slower in children
Classification of illness
a. red
b. yellow
c. green
red
urgent pre-referral treatments and referral
yellow
specific medical treatment and advice
green
simple advice on home management
IMCI case management
a. focused assessment
b. classification
c. treatment
d. counsel & follow up
Focused assessment
a. danger signs
b. main symptoms
c. nutritional status
d. immunization status
e. other problems
Classification
a. need to refer (pink)
b. specific treatment
c. home management
Treatment
identify, treatment, treat
Counsel & Follow up
a. counsel caretakers
b. follow - up
What do the IMCI guidelines explain
a. assess
b. classify
c. treatment
d. counsel
e. follow-up care
Assess sick infants and children for
a. serious illness
b. common health conditions
c. nutrition status, immunization status and other problems
Classify sick infants and children for
a. classify each heath condition using color - coded IMCI charts
Red
very serious condition requires urgent pre-referral treatment and referral
Yellow
serious condition needs treatment and advice in the clinic
Green
less serious condition needs home treatment and advice
Treat
a. develop an integrated treatment plan
b. if a child requires urgent referral, give essential treatment before the patient is transferred
c. if a child needs treatment at the clinic, you will often give the first dose in the clinic
Counsel
a. counsel the caregiver about her own health
b. advise the caregiver to return for follow up on a specific date
c. teach caregivers when to return immediately if child shows signs of severe illness
Follow-up care
reexamine conditions to see if the issues are improving
Young infant
birth up to 2 months
For all sick children unto 5 years of age who are brought to the clinic
a. greet the caregiver and ask the child’s age
If the child is up to 2 months old
Use the charts
a. assess & classify sick young infant
b. treat the sick young infant
If child is 2 months up to 5 years old
Use the chart
a. assess & classify sick child
b. treat the child
What does up to 5 years mean
child has not yet had his or her 5th birthday
What does up to 2 months mean
child has not yet reached 2 months old
Management of sick young infant aged up to 2 months old
a. check for severe disease and local bacterial infection
b. then check for jaundice
c. does the young infant have diarrhea
d. then check for feeding problem or low weight
e. then check for HIV infection
f. then assess breastfeeding
g. then check the child’s immunization status (circle immunization needed today
h. then assess other problems
Check for severe disease and local bacterial infection
a. is the infant having difficulty in feeding
b. has the infant had convulsions
Then check for jaundice
a. when did the jaundice appear first
Then check for feeding problem or low weight infection
a. is there any difficulty in breathing
b. is the infant breastfeed
c. does the infant usually receive any other foods or drinks
d. what do you use to feed the child
Then check for HIV
a. mother’s hiv test
b. child’s virological test
c. child’s serological test
If mother is HIV positive and no positive virological test in young infant
a. is the infant breastfeeding now
b. was the infant breastfeeding at the time of test or 6 weeks before it
c. if breastfeeding, is the mother and infant on ARV prophylaxis
Then assess breastfeeding
Has the infant breastfeed in the previous hour
Management of the sick child aged 2 months up to 5 years old
a. check for general danger sign
b. does the child have cough or difficult breathing
c. does the child have diarrhea
d. does the child have fever (by history)
e. if the child has measles now or within the last 3 months
f. does the child have an ear problem
g. then check for acute malnutrition and anemia
h. if the child has MUAC less than 115 or WFH/L less than -3 Z scores or edema of both feet
h. check for HIV infection
i. check the child’s immunization status (circle immunizations needed today)
j. assess for feeding if the child is less than 2 years old, has moderate acute malnutrition, aneamia, or is HIV exposed or infected
Assess the sick young infant, age up to 2 months
a. greet the caregiver
b. ask child’s age
c. initial or follow-up visit for problems
c. what are the infant’s problems
d. measure weight and temperature
e. assess for general danger signs for very severe disease
f. assess main symptoms
g. classify color coding
Assess main symptoms for age up to 2 months
a. jaundice
b. diarrhoea
c. HIV status or mother’s HIV status
d. Feeding problem and growth
e. check immunization
f. assess other problems and mother’s health
Check for general danger signs
a. unable to drink or breastfeed
b. vomits everything
c. convulsions
d. lethargic or unconscious
Assess the sick child, age 2 months up to 5 years old
a. greet the caregiver
b. ask the child’s age
c. initial or follow-up visit for problems
d. what are the child’s problems
e. measure the child’s weight and temperature
f. check for general danger signs
g. assess main symptoms
h. classify color coding
Assess main symptoms for age 2 months up to 5 years old
a. cough or difficult breathing
b. fever
c. malnutrition
d. check immunizations
e. diarrhoa
f. ear problems
g. HIV status
h. others
What to do when danger signs are present
Urgent referral
What to also consider to do when there are general danger signs
Even present, assess main symptoms
Assess major 4 symptoms
a. cough or difficult breathing
b. diarrhoea
c. fever
d. ear problems
Objectives of the global child health program
a. to reduce significantly global mortality and morbidity associated with the major causes of disease in children
b. to contribute to healthy growth and development of children
IMCI case management process
a. assess
b. classify
c. identify specific treatment
d. provide practical treatment instructions
e. counsel
f. follow - up care
After checking for other problems
a. classify conditions / color coding
b. identify treatment actions
green (home)
a. home treatment
b. feeding & fluids
c. when to return immediately
d. follow - up
yellow (outpatient health facility)
a. treatment
b. treat local infection
c. give oral drugs
d. advise and teach caretaker
e. follow - up
Pink
a. outpatient health facility
b. referral facility
Pink (outpatient health facility )
a. urgent referral
b. pre - referral treatment
c. advise parents
d. refer child
Pink (referral facility)
a. emergency triage & treatment
b. diagnosis & treatment
c. monitoring & follow - up
If the child is from 1 week up to 2 months
Asses, classify, and treat the sick young infant
If the child is from 2 months up to 5 years
Assess and classify the sick child, treat the child, counsel the mother
If this is an initial visit
a. check for general danger signs
b. ask about 4 main symptoms
c. when a main symptom is present
c.1. asses the child further for signs related to the main symptom
c.2. classify the illness according to the signs which are present or absent
What to do when there is a problem or there is no problem
Proceed to the next management of possible symptoms
General danger signs
a. lethargy or unconscious
b. inability to drink or breastfeed
c. vomiting
d. convulsions
Clinical signs of cough or difficulty breathing
a. respiratory rate
b. lower chest wall indrawing
c. stridor
Clinical signs of diarrhoea
a. dehydration
b. sunken eyes, thirst, skin elasticity
c. persistent diarrhea
d. dysentery
Clinical signs of fever
a. stiff neck
b. risk of malaria and other endemic infections, e.g., dengue hemorrhagic fever
c. runny nose
d. measles
e. duration of fever (e.g., typhoid fever)
Clinical signs of ear problems
a. tender swelling behind the ear
b. ear pain
c. ear discharge or pus (acute or chronic)
Checking of nutritional status, feeding, immunization status
a. malnutrition
b. anemia
c. feeding and breastfeeding
d. immunization status
Assessment of other problems
a. meningitis
b. sepsis
c. tuberculosis
d. conjunctivitis
e. others: also mother’s (caretakers) own health
Treatment for cough or difficulty breathing
a. breastmilk
b. tamarind
c. calamansi
d. ginger
Harmful remedies to discourage
a. codeine cough syrup
b. other cough syrups
c. oral and nasal decongestants
If the child does not have cough or difficult breathing
ask about the next main symptoms: diarrhoea, fever, ear problems
If the child does have cough or difficult breathing
a. ask for how long
b. look, listen, feel (child must be calm)
Look, listen, feel
a. count the breaths in one minute
b. look for chest indrawing
c. look and listen for stridor
If the child is fast breathing
a. 2 months - 12 months = 50 breaths / min or more
b. 12 months - 5 years = 40 breaths / min or more
After flashcard #121
classify child’s illness for cough or difficult breathing
Cough or difficulty breathing : PINK
a. any general danger sign
b. chest indrawing
c. stridor in a calm child
d. severe pneumonia or very severe disease
e. give first dose of an appropriate antibiotic
f. refer urgently to hospital
Cough or difficult breathing: Yellow
a. fast breathing
b. pneumonia
c. give an appropriate oral antibiotic for 5 days
d. soothe the throat and relive the cough with a safe remedy
e. advise the mother when to return immediately
f. follow - up in 2 days
Cough or difficult breathing: Green
a. no signs of pneumonia or very severe disease
b. no pneumonia: cough or cold
c. if coughing > 30 days, refer to cough with a dafe remedy
d. advise mother when to return immediately
e. follow - up in 5 days if not improving
Treatment for pneumonia or very severe disease
a. cotrimozaxole
b. amoxycillin
Vit A capsule supplementation for severe pneumonia or very severe disease
a. 100,000 IU / 1 capsule for 6-12 months of age
b. 200,000 IU / 2 capsules for 12 months - 5 yrs of age
If the child does not have Diarrhoea
a. Classify the child’s illness using the color-coded classification tables for diarrhea
b. Then ask about the next main symptoms: fever, ear problem, and check for malnutrition and anemia, immunization status, and other problems
If the child does have Diarrhoea
a. ask for how long and if there is blood in the stool
b. Look, listen, feel
c. look for sunken eyes
d. offer the child fluid
e. pinch the skin of the abdomen, does it go back?
f. classify the child’s illness
g. then ask about the next main symptoms
Look, listen, feel
a. look at the child’s general condition, is the child lethargic or unconscious, restless or irritable
Offer the child fluid
a. not able to drink or drink poorly?
b. drinking eagerly, thirsty?
Pinch the skin of the adbomen
a. very slowly (longer than 2 seconds)
b. slowly
Two of the following signs of Severe Dehydration: PINK
a. Abnormally sleepy or difficult to awaken
b. Sunken eyes
c. Not able to drink or drinking poorly
d. Skin pinch goes back very slowly
After assessing that the child has diarrhoea
Classify the diarrhoea for dehydration
Treatment for severe dehydration
a. If child has no other severe classification:
- Give fluid for severe dehydration ( Plan C ) OR
b. If child has another severe classification :
- Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
- Advise the mother to continue breastfeeding
c. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera
Two of the following signs of Some Dehydration: YELLOW
a. Restless, irritable
b. Sunken eyes
c. Drinks eagerly, thirsty
d. Skin pinch goes back slowly
Treatment for some dehydration
a. Give fluid and food for some dehydration ( Plan B )
b. If child also has a severe classification :
- Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
- advise the mother to continue breastfeeding
c. Advise mother when to return immediately
d. Follow up in 5 days if not improving
Two of the following signs of No Dehydration: GREEN
Not enough signs to classify as some or severe dehydration
Treatment for No Dehydration
a. Give fluid and food to treat diarrhea at home ( Plan A )
b. Advise mother when to return immediately
c. Follow up in 5 days if not improving
Then classify diarrhoea if it last 14 days or more
a. dehydration present
b. no dehydration
c. blood in stool
Sign of severe persistent diarrhea: PINK
dehydration present
treatment for severe persistent diarrhea
a. Treat dehydration before referral unless the child has another severe classification
b. Refer to hospital
Sign of Persistent diarrhoea: YELLOW
No dehydration
Treatment for No dehydration
a. Advise the mother on feeding a child who has persistent diarrhea
b. give multivitamins and minerals (including zinc) for 14 days
c. Follow up in 5 days
Signs of Dysentery: YELLOW
blood in stool
Then classify diarrhoea if blood is present in stool
a. blood in stool
Treatment for Dysentery
a. Give ciprofloxacin for 3 days
b. follow - up in 3 days
What to ask in assessing measles to a child
a. does the child have fever
b. travel history to malaria prone places
If there is measles
a. ask for how long
b. look and feel
c. look for signs of measles
d. if the child has measles now or within the last 3 months
Ask for how long
a. If more than 7 days, has fever been present every day?
b. Has the child had measles within the last 3 months?
Look and feel
a. Look or feel for stiff neck b. Look for runny nose
Look for signs of measles
a. Generalized rash
b. Cough
c. Runny nose
d. Red eyes
Then classify fever as high or low malaria risk
a. very severe febrile disease
b. malaria
c. fever: no malaria
If the child has measles now or within the last 3 months
a. Look for mouth ulcers. Are they deep and extensive?
b. Look for pus draining from the eye
c. Look for clouding of the cornea
Signs of very severe febrile disease: PINK
a. Any general danger sign
b. Stiff neck
Treatment for very severe febrile disease
a. Give first dose of quinine ( under medical supervision or if a hospital is not accessible within 4hrs )
b. Give first dose of an appropriate antibiotic
c. Treat the child to prevent low blood sugar
d. Give one dose of paracetamol in health center for high fever (38.5oC) or above
e. Send a blood smear with the patient
f. Refer URGENTLY to hospital
Signs of malaria: YELLOW
malaria test positive
Treatment for malaria : YELLOW
a. Treat the child with first line oral antimalarial
b. Give one dose of paracetamol in health center for high fever (38.5oC) or above
c. Give appropriate antibiotic treatment for an identified bacterial case of fever
d. Advise mother when to return immediately
e. Follow up in 3 days if fever persists
e. If fever is present everyday for more than 7 days, refer for assessment
Signs of No malaria: Green
a. malaria test: negative
b. other cause of fever present
Treatment for no malaria: GREEN
a. Give one dose of paracetamol in health center for high fever (38.5oC) or above
b. Give appropriate antibiotic treatment for an identified bacterial case of fever
c. Advise mother when to return immediately
d. Follow up in 3 days if fever persists
d. If fever is present everyday for more than 7 days, refer for assessment
Signs of very severe febrile disease: PINK
a. any general danger sign
b. stiff neck
Then classify fever on when no malaria risk and no travel to malaria risk area
a. very severe febrile disease
b. fever
Treatment for very severe febrile disease
a. Give first dose of an appropriate antibiotic
b. Treat the child to prevent low blood sugar
c. Give one dose of paracetamol in health center for high fever (38.5oC) or above
d. Refer URGENTLY to hospital
Signs of fever: GREEN
a. no general danger signs
b. no stiff neck
Treatment for fever: GREEN
a. Give one dose of paracetamol in health center for high fever (38.5oC) or above
b. Give appropriate antibiotic treatment for an identified bacterial case of fever
c. Advise mother when to return immediately
d. Follow up in 2 days if fever persists
e. If fever is present everyday for more than 7 days, refer for assessment
Then classify fever is child has measles now or within the last 3 months
a. severe complicated measles
b. measles with eye or mouth complications
c. measles
Treatment for Severe complicated measles
a. Give Vitamin A
b. Give first dose of an appropriate antibiotic
c. If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment
d. Refer URGENTLY to hospital
Signs for severe complicated measles: PINK
a. any general danger sign
b. Clouding of cornea
c. Deep or extensive mouth ulcers
Treatment for measles with eye or mouth complications
a. Give Vitamin A
b. If pus draining from the eye, apply tetracycline eye ointment
c. If mouth ulcers, teach the mother to treat with gentian violet
d. follow - up in 3 days
Signs of measles with eye or mouth complications
a. Pus draining from the eye
b. Mouth ulcers
Signs for measles: GREEN
child has measles now or within the last 3 months
Treatment for measles: GREEN
Give vitamin A treatment
What to ask when assessing ear problem
a. does the child have an ear infection
If there is ear problem
a. ask if there is ear pain
b. is there ear discharge, if yes, for how long?
c. look and feel
c.1. look for pus draining from the ear
c.2. feel for tender swelling behind the ear
Signs for Mastoiditis: PINK
a. tender swelling behind the ear
Treatment for Mastoiditis: PINK
a. give first dose of an appropriate antibiotic
b. give first dose of paracetamol for pain
c. refer urgently to hospital
Signs for acute ear infection: YELLOW
a. pus is seen draining from the ear and discharge is reported for less than 14 days
b. ear pain
Treatment for acute ear infection: YELLOW
a. give an antibiotic for 5 days
b. give paracetamol for pain
c. dry the ear by wicking
d. follow - up in 5 days
Signs for chronic ear infection: YELLOW
a. pus is seen draining from the ear and discharge is reported for less than 14 days
Signs for no ear infection: GREEN
a. no ear pain
b. no pus seen draining from the ear
Treatment for chronic ear infection: YELLOW
a. dry the ear by wicking
b. treat with topical quinolone ear drops for 14 days
c. follow up in 5 days
Treatment for no ear infection: GREEN
no treatment
Then check for anemia
a. look for Palmar pallor
a.1. severe palmar pallor?
a.2. some palmar pallor?
Signs for severe anemia: PINK
a. sever palmar pallor
Treatment for severe anemia: PINK
Refer urgently to hospital
Signs for anemia: YELLOW
a. some pallor
Treatment for anemia: YELLOW
a. give iron
b. give mebendazole if child is 1 year or older and has not had a dose in the previous 6 months
c. advise the mother when to return immediately
d. follow - up in 14 days
Signs for no anemia: GREEN
no palmar pallor
Treatment for no anemia: GREEN
a. if the child is less than 2 years old, asses the child’s feeding and counsel the mother according to the feeding recommendations
b. if feeding problem, follow - up in 5 days
Then check for acute malnutrition
a. look and feel
b. If WFH/L less than -3 z-scores or MUAC less than 115 mm
c. if no medical complications present
Look and feel
a. Look for edema of both feet
b. Determine WFH/L*____ z-score
c. Measure MUAC**____ mm
If WFH/L less than -3 z-scores or MUAC less than 115 mm, then
a. Check for any medical complication present:
b. Any general danger signs c. Any severe classification
d. pneumonia with chest indrawing
If not medical complications present
a. Child is 6 months or older, offer RUTF*** to eat is the child:
b. Child is less than 6 months, assess breastfeeding
Child is 6 months or older, offer RUTF*** to eat is the child:
a. not able to finish the RUTH portion?
b. able to finish the RUTF portion?
Child is less than 6 months, assess breastfeeding
does the child have a breast feeding program
Signs for complicated severe acute malnutrition: PINK
a. oedema of both feet
b. WFH/L less than -3 z scores or MUAC less than 115 mm and any of the following
b.1. medical complication present
b.2. not able to finish RUTF
b.3. breastfeeding problem
Treatment for complicated severe acute malnutrition: PINK
a. give first dose appropriate antibiotic
b. treat the child to prevent low blood sugar
c. keep the child warm
d. refer urgently to the hospital
Signs for uncomplicated severe acute malnutrition: YELLOW
a. WFH/L less than -3 z scores
b. MUAC less than 115 mm
c. able to finish RUTF
Treatment for uncomplicated severe acute malnutrition: YELLOW
a. give oral antibiotics for 5 days
b. give ready-to-use therapeutic food for a child aged 6 month or more
c. counsel the mother on how to feed the child
d. assess for possible TB infection
e. advise mother when to return immediately
f. follow - up in 7 days
Signs for moderately acute malnutrition: YELLOW
a. WFH/L between -3 z and -2 z scores
b. MUAC 115 up to 125 mm
Treatment for moderately acute malnutrition: YELLOW
a. assess the child’s feeding and counsel the mother on the feeding recommendations
b. if feeding problem, follow - up in 7 days
c. assess for possible TB infection
d. advise mother when to return immediately
e. follow - up in 30 days
Signs for no acute malnutrition: GREEN
a. WFH/L -2 z scores or more
b. MUAC 124 mm or more
Treatment for no acute malnutrition: GREEN
a. if child is less than 2 years old, assess the child’s feeding and consult the mother on feeding according to the feeding recommendations
b. if feeding problem, follow - up in 7 days
Less than 115 mm
severe acute malnutrition and threat of death
115 - 125 mm
moderate acute malnutrition
115 mm or more
no malnutrition
Then assess for HIV infection
a. has the mother and / or young infant had an HIV test?
If the mother or infant had an HIV test
a. decide HIV status
b. If the mother is HIV positive and child is negative of unknown
Decide HIV status
a. Mother: POSITIVE or NEGATIVE
b. Child
b.1. Virological test POSITIVE or NEGATIVE
b.2. Serological test POSITIVE or NEGATIVE
If the mother is HIV positive and child is negative of unknown, ASK;
a. Was the child breastfeeding at the time or 6 weeks before the test
b. Is the child breastfeeding now
c. If breastfeeding, ASK: is the mother and child on ARV prophylaxis
If the mother / young did not had an HIV test, then test;
a. mother and young infant status unknown: test mother
b. mother HIV positive and child unknown: test child
Signs for confirmed HIV infection: YELLOW
a. positive virological test in child
b. positive serological test in child 18 months or older
Treatment for confirmed HIV infection: YELLOW
a. initiate ART treatment and HIV care
b. give cotrimoxazole prophylaxis
c. assess the child’s feeding and provide appropriate counseling to the mother
d. advise the mother on home care
e. asses or refer for TB assessment and INH preventive therapy
f. follow - up regularly as per national guidelines
Signs for HIV exposed: YELLOW
a. mother-HIV positive and negative virological test in a breastfeeding child or only stopped less than 6 weeks
b. mother hiv positive, child not yet tested
c. positive serological test in a child less than 18 months
Treatment for HIV exposed: YELLOW
a. give cotrimoxazole prophylaxis
b. start or continue ARV prophylaxis as recommended
c. do virological test to confirm HIV status of child
d. assess the child’s feeding and provide appropriate counseling to the mother
e. advise the mother on home care
f. follow - up regularly as per national guidelines
Signs for HIV infection unlikely: GREEN
negative HIV test in mother or child
Treatment for HIV infection unlikely: GREEN
Treat, counsel and follow - up existing infections
After assessing HIV infection
Check child’s immunization, vitamin A, and deworming status
After first dose of an appropriate antibiotic and other urgent treatments
treat all children with a general danger sign to prevent low blood sugar
One year and older
200,000 IU
6-12 months of age Vit. A supplementation
100,000 IU
Give intramuscular antibiotics to
Children being referred urgently
Medication to stop convulsions
Diazepam
Medication for severe malaria
Artesunate suppositories or intramuscular artesunate or quinine
If the child is not able to breastfeed
a. give expressed breast milk or a breast milk subtitute
b. if neither of these is available, give sugar
c. give 30-50 ml of milk or sugar before departure
If the child is able to breastfeed
ask the mother to breastfeed the child
If the child is not able to swallow
a. give 50 ml of milk or sugar water by nasogastric tube
b. if no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water sublingually and repeat doses every 20 minutes to prevent relapse
c. to make sugar water: dissolve 4 levels teaspoon of sugar (20 grams) in a 200 ml cup of clean water
When to give extra fluid
a. diarrhoea
b. continue feeding
Give extra fluid (as much as the child will take)
a. tell the mother
b. it is especially important to give ORS at home
c. teach the mother how to mix and give ORS
d. give the mother 2 packets of ORS to use at home
d. show the mother how much fluid to give in addition to the usual fluid intake
d.1. up to 2 years old - 50 to 100 ml after each loose stool
d.2. 2 years or more - 100 to 200 ml after each loose stool
PLAN A : treat diarrhoea at home
a. give extra fluid (as much as the child will take)
b. give zinc (age 2 months up to 5 years)
c. continue feeding (exclusive breastfeed if age less than 6 months)
d. when to return
Give zinc (age 2 months up to 5 years)
a. 2 months up to 6 months - 1/2 tablet daily for 14 days
b. 6 months or more - 1 tablet daily for 14 days
PLAN B: TREAT SOME DEHYDRATION WITH ORS
Give recommended amount of ORS over a 4-hour period
a. show how to give ORS solution
b. after 4 hours
c. if the mother must leave before completing treatment
4 Rules of home treatment
a. give extra fluid
b. give zing (age 2 months up to 5 years)
c. continue feeding (exclusive breastfeeding if age less than 6 months)
d. when to return
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
a. start IV fluid immediately
b. reassess the child every 1-2 hours
c. refer urgently to hospital for IV treatment
d. start rehydration by tube with ORS solution if you are trained
e. reassessment the child every 1-2 hours while waiting for transfer
Counsel the mother
a. assess child’s appetite
Give follow up care for acute conditions
a. pneumonia
b. persistent diarrhoea
c. dysentery
d. malaria
Return for follow-up in 3 days
a. pneumonia
b. dysentery
c. malaria, if fever persist
d. fever: no malaria, if fever persist
e. measles with eye or mouth complications
f. mouth or gum ulcers or thrush
Return for follow - up in 5 days
a. persistent diarrhoea
b. acute ear infection
c. chronic ear infection
d. cough or cold, if not improving
Return for follow - up in 14 days
a. uncomplicated severe acute malnutrition
b. feeding problem
c. anaemia
Return for follow - up in 30 days
a. moderate acute malnutrition
Return for follow - up in accordance to national recommendations
a. confirmed HIV infection
b. HIV exposed
