2018 IMNCI Chart PDF

MINISTRY OF HEALTH Newborn, Child and Adolescent Health Unit (NCAHU) INTEGRATED MANAGEMENT OF NEWBORN & CHILDHOOD ILLNESSES (IMNCI) A guide for healthcare workers...

MINISTRY OF HEALTH Newborn, Child and Adolescent Health Unit (NCAHU) INTEGRATED MANAGEMENT OF NEWBORN & CHILDHOOD ILLNESSES (IMNCI) A guide for healthcare workers 2018 EDITION TABLE OF CONTENTS SICK CHILD AGE 2 MONTHS UP TO 5 YEARS SICK YOUNG INFANT AGE UP TO 2 MONTHS Acknowledgements..................................................................... 1 Treatment of Severe Malaria............................................... 16 ASSESS AND CLASSIFY THE SICK YOUNG INFANT Foreword..................................................................................... 2 Treat the Child for Low Blood Sugar................................... 17 Assess, Classify and Identify Treatment Treat for Possible Asthma................................................... 17 Check for Very Severe Disease......................................... 32 Introduction to Integrated Management of Newborn & Check for Jaundice, Eye Infection..................................... 33 Childhood Illnesses (IMNCI) Chart Booklet..........................3 Rehydration Therapy & Feeding for Diarrhoea Does the Young Infant Have Signs of Dehydration?........... 34 Plan A: Treat Diarrhoea With No Dehydration.................... 18 Check For HIV Exposure And Infection............................. 35 ASSESS AND CLASSIFY THE SICK CHILD Plan B: Treat Diarrhoea at Facility with ORS Check For Feeding Problem, Low Weight or (Some Dehydration)............................................................ 18 Low Birth Weight:................................................................ 36 Assess, Classify and Identify Treatment Treat Shock......................................................................... 19 Where Referral is Refused or Not Feasible....................... 37 Plan C: Treat Severe Dehydration Quickly......................... 19 Check For Special Treatment Needs................................. 38 Check for General Danger Signs............................................... 4 Rehydration Therapy for Diarrhoea in Children With Check The Young Infant’s Immunization Status................ 38 Then Ask About Main Symptoms: Acute Malnutrition................................................................ 19 Assess Other Problems That The Infant May Have............ 38 Does The Child Have Cough Or Difficult Breathing?............ 4 Give Multivitamin/Mineral supplement for Assess the Mother's /Caregiver's Health Needs................. 38 Does The Child Have Diarrhoea?........................................ 5 Persistent Diarrhoea............................................................ 19 Routine Care For All Newborns After Delivery................... 40 Does The Child Have Fever?............................................... 6 Keep The Young Infant Warm............................................ 40 Classify Malaria........................................................... 6 HIV Care For Children Classify Measles.......................................................... 6 TREAT THE YOUNG INFANT What To Start: Children....................................................... 20 Does The Child Have An Ear Problem?.............................. 7 Resuscitation, IV/IM/Oral Antibiotics, Low Blood Sugar...... 41 ART Treatment in Children With TB.................................... 20 Check For Acute Malnutrition & Anaemia.................................. 8 Convulsions, Where Referral is Refused or Not Feasible, Dosage For Cotrimoxazole Prophylaxis............................. 20 Check For HIV Exposure & Infection.......................................... 9 Zinc Sulphate...................................................................... 42 Paediatric ARVs Dosages................................................... 21 Check for Child’s Developmental Milestones............................ 10 Teach The Caregiver To Treat Local Infections, Give Oral Simplified Weight Band Dosing Schedule for LPV/r.......... 21 Assess for Interaction, Communication and Responsiveness. 11 Drugs At Home Skin Pustules or Umbilical Infections, Check Immunization, Vitamin A & Deworming Status............... 12 Thrush or Mouth Ulcers, Eye Infection................................ 43 GIVE FOLLOW - UP CARE Assess For Other Problems That The Child May Have............. 12 COUNSEL THE MOTHER Assess The Mother’s / Caregiver's Health Needs..................... 12 Pneumonia.......................................................................... 22 Teach Correct Positioning And Attachment Wheezing............................................................................ 22 For Breast Feeding............................................................. 44 Persistent Diarrhoea........................................................... 22 Teach The Mother To Treat Breast or Nipple Problems...... 44 TREAT THE CHILD Dysentery............................................................................ 22 Teach The Mother How To Keep The Young Infant With Low Teach the Mother to Give Oral Drugs at Home Uncomplicated Malaria....................................................... 23 Weight Or Low Body Temperature Warm At Home............. 44 Give Metronidazole........................................................... 13 Fever - No Malaria.............................................................. 23 Advise Mother To Give Home Care For The Young Infant.. 45 Give an Appropriate Oral Antibiotic..................................... 13 Eye or Mouth Complications of Measles............................ 23 When To Return To A Health Worker Or Health Facility...... 45 Give an Oral Antimalarial................................................... 14 Ear Infection........................................................................ 23 Counsel The Mother or Caregiver on Management Feeding Problem................................................................ 24 GIVE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT of Malaria For a Sick Child:................................................ 14 Pallor................................................................................... 24 Local Bacterial Infection..................................................... 46 Give Vitamin A.................................................................... 14 Malnutrition......................................................................... 24 Jaundice, Eye Infection, Diarrhoea.................................... 46 Give Iron and Folate.......................................................... 14 HIV Exposed & Infected Children....................................... 24 Where Referral is Refused or Not Feasible....................... 46 Give Zinc Sulphate............................................................. 14 Feeding Problem, Low Weight or Low Birth Weight........... 47 Give Paracetamol for Fever or Ear Pain............................ 14 COUNSEL THE MOTHER/CAREGIVER Thrush or Mouth Ulcers...................................................... 47 Assess Child’s Feeding....................................................... 25 Teach The Mother to Treat Local Infections at Home Conduct The Appetite Test.................................................. 25 Recording Forms Treat Eye Infection with Tetracycline Eye Ointment............ 15 About Feeding Problems.................................................... 26 The Sick Child age 2 Months up to 5 Years............................. 48 Dry the Ear by Wicking...................................................... 15 About Feeding Options: HIV Exposed & Infected............... 26 Sick Young Infant age up to 2 Months....................................... 51 Treat Mouth Ulcers with Gentian Violet.............................. 15 Feeding Recommendations................................................ 27 Weight-for-Age BOYS............................................................. 54 Treat for Thrush with Nystatin............................................ 15 Recommendations for Care for Child’s Development......... 28 Length/Height-for-Age BOYS................................................. 54 Soothe the Throat, Relieve the Cough with a Safe Remedy...... 15 About Care for Development Problems.............................. 29 Weight-for-Age GIRLS............................................................. 55 When To Return Immediately.............................................. 30 Length/Height-for-Age GIRLS................................................ 55 Give These Treatments In Health Facility Only Give Good Home Care For Your Child............................... 30 Weight For Length From Birth To 2 Years: Boys.................. 56 Treatment of Very Severe Disease or Severe Pnuemonia.16 When To Return for Scheduled Visits................................. 31 Weight For Length From Birth To 2 Years: Girls.................. 56 Give an Intravenous/ Intramuscular Antibiotic..................... 16 About Her Own Health........................................................ 31 Weight For Height From 2 - 5 Years: Boys............................ 57 Treat for Convulsing Now.................................................... 16 Weight For Height From 2 - 5 Years: Girls............................ 57 Algorithm for Pulmonary TB Diagnosis in Children............ 58 Regimen For Treatment Of TB In Children............................ 59 HIV Care For Children: EID & Dual Prophylaxis................... 60 Intergrated MCH Flow Chart................................................... 61 Acknowledgements The Ministry of Health (MOH) is indebted to many institutions and individuals whose unwavering support and collaborative contribution made it possible the updating of the 2018 Edition of Integrated Management of Newborn & Childhood Illnesses (IMNCI) guidelines. The review and revision was done through extensive consultations led by the Ministry of Health. I acknowledge with much appreciation the institutions that participated in the rigorous review of these guidelines. Special compliments to the Department of Preventive and Promotive Health Services, Division of Family Health, Neonatal Child and Adolescent Health Unit (NCAHU), Child Health ICC members, County Level Child Health Focal Persons, WHO – Kenya Country Office, UNICEF – Kenya Country Office, Clinton Health Access Initiative (CHAI), Nutrition International (NI), Kenya Medical Training College (KMTC), Program for Appropriate Technology in Health (PATH), Population Services Kenya (PSK), USAID Maternal Child Health Survival (MCSP), Kenya Medical Research Institute (KEMRI) and Kenya Paediatric Association (KPA). In addition, I thank every member of the core team that worked diligently to provide technical and financial support towards the development of this document. Special gratitude to the Ministry of Health officials at NCAHU who coordinated and provided leadership to the whole process namely; Dr. Osman Warfa, Dr. Rachel Nyamai, Dr. Stewart Kabaka and Dr. Silas Agutu, Andolo Miheso, Elsa Odira, Allan Govoga, Martin Matingi, Lydia Karimurio, Benard Wambu, Grace Wasike, Charles Matanda, Jedida Obure and Hellen Karimi. I also take this opportunity to appreciate the efforts of Pamela Ochieng (NCK), Joyce Atandi (NU), Dr. Laura Oyiengo, Ruth Musyoki and Eunice Ambani (NASCOP), Dr. Immaculate Kathure (NLTD-P) and Mr. Samuel Kigen (NMCP). Special compliments to county child health focal persons namely, Jackson Cheruiyot and George Ndichu (Nakuru), Immaculate Njoroge and Gerald Mutiso (Kiambu), Eunice Kiilu (Machakos), Muritu Mbogo, Mildred Indeje and Agnes Obanda (Nairobi), Lillian Angwenyi (Kajiado), Elizabeth Chomba (Kwale), Enoch Koti Kot (Narok), Christine Kalema (Taita Taveta) and Absaloam Ingabo (Kakamega). Additionally, I greatly acknowledge members of organizations that provided significant support and contribution in the review process namely; Dr. Ambrose Agweyu (KEMRI), Jason Kiruja (KPA) Dr. Khadija Abdalla and Dr. Peter Okoth, Judith Raburu (UNICEF), Dr. Martin Chabi (WHO), Rosemary Kihoto and Betty Wariari (CHAI), Elijah Mbiti and Mary Kihara (NI), Dr. Angela Muriuki (Save The Children), Wanjiku Manguyu, Immaculate Salaon and Dr. Samwel Onditi (PATH), Francis Njuguna (KMTC), Diana Anyole (CoG), Dr. Nicholas Odero, Dr. Angeline Ithondeka , Dr. Catherine Mutinda (KPA), Dr. Ann Mburu (Aga Khan University). Thank you all for the commendable efforts in making the updating of these guidelines possible. There is no doubt that by implementing IMNCI, we shall accelerate the reduction of child mortality using scalable, high impact and affordable interventions. Dr. Mohamed A. Sheikh Head, Division of Family Health Ministry of Health 1  INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES Foreword Child deaths in Kenya remain unacceptably high with 52 out of 1,000 children born dying every year. Unfortunately, 70% of these deaths are attributed to preventable and treatable childhood illnesses such as diarrhoea, pneumonia (acute respiratory infections), malnutrition & anaemia, malaria, measles, HIV and tuberculosis. Additionally, a significant proportion of deaths in children under-five occur in the neonatal period due to infections such as sepsis, complications of pregnancy and childbirth such as birth asphyxia prematurity low birth weight and other congenital anomalies. The Integrated Management of Newborn & Childhood Illnesses (IMNCI) strategy for delivering interventions that prevent and treat common causes of mortality in children was first introduced in the mid 1990s by WHO/UNICEF as part of Child Survival Strategy. IMNCI has demonstrated improved efficiency and quality of child health services. It recognizes that sick children often present more than one symptom at the same time. These symptoms contribute to many childhood deaths if not comprehensively assessed, classified and treated. As a result, all sick children should be managed using an integrated approach in order to tackle the major drivers of child mortality and thereby save lives. The IMNCI strategy incorporates standard case management guidelines meant to improve skills of health care workers, as well as approaches for improving family and community health practices that ensure child survival, growth and development. IMNCI calls for better integration of child health programming across different ministries and sectors at the national and county level. As such its implementation requires continuous strengthening of a number of elements of child health programs in planning and policy development, financing, health systems strengthening, skilled human resources at all levels of care, health promotion and community-based care. Importantly, IMNCI guidelines remain responsive to current research and recommendations; hence it is an important tool for health care professionals. The information is presented in a simplified manner using the IMNCI 6 major steps namely; assessment, classification, identification of treatment, treating the sick child or young infant, counseling the mother and providing follow up care. Through the dissemination of IMNCI 2018 updated guidelines, it is envisaged that the technical information herein will provide impetus towards county level implementation and compliance at all levels of care in Kenya. Dr. Kioko Jackson K., MBS DIRECTOR OF MEDICAL SERVICES Ministry of Health 2  INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES (IMNCI) CHART BOOKLET Background Classification In Kenya , 52 out of every 1000 children born do not live to be five years of age (KDHS 2014) Of note, 70% of The classify (signs and classify) column of the chart lists clinical signs of illnesses and their classification. all deaths in children can be attributed to easily preventable and treatable diseases namely: Acute respiratory “Classify” in the chart means the health worker has to make a decision on the severity of the illness. infections (mostly pneumonia), Diarrhoea, Measles, Malaria, Malnutrition & Anaemia, HIV and Tuberculosis. Often Healthcare workers will be able to classify children or young infants illnesses using the colour- coded triage children succumb to a combination of these conditions - with most children presenting in health facilities with system. The classifications contained in the booklet are based on whether the diagnosed illness are: the combined signs and symptoms of more than one of theses diseases. Evidence for various assessments has Colour shown that many of these children are not comprehensively assessed, treated and given the appropriate advice. Pink ment and referral Recognizing the need to improve on the care of these children, WHO and UNICEF developed the Integrated Yellow Management of Newborn and Childhood Illnesses (IMNCI) strategy which emphasizes on integrated case management of the most common childhood diseases. Kenya in the year 2000 adopted the IMNCI strategy which Green given forms a critical part of the Kenya Essential Package for Health (KEPH). Identify Treatment What is IMNCI? The identify treatment column helps the healthcare workers to quickly and accurately identify treatments for the The Integrated Management of Newborn and Childhood Illnesses (IMNCI) case management approach offers classifications selected. If a child or young infant has more than one classification, the healthcare worker must look simple and effective methods to comprehensively prevent and manage the leading causes of serious illnesses and at more than one table to find the appropriate treatments. mortality in children below five years. With IMNCI, sick children or young infants are not only treated for the signs and symptoms they present within a health facility, but are also assessed for the other disease conditions they may Treat be suffering from. The treat column shows how to administer the treatment identified for the classifications. Treat means giving the treatment in the facility, prescribing drugs or other treatments to be given at home and also teaching the mother/ IMNCI is based on the following principles: caregiver how to administer treatment at home. All sick children aged up to 5 years are examined for general danger signs and all young infants are The following rules should be adhered to. examined for signs of very severe disease. These signs indicate the need for immediate referral or admission to hospital. If a child or young infant requires admission or referral (pink classification), it is important the essential Children and infants are then assessed for main symptoms. For the older children, the symptoms include treatment is offered to the child or young infant before admission or referral. cough, difficulty breathing, diarrhoea, fever, TB, HIV, ear infections, anaemia, measles and malnutrition. If the child or young infant requires specific treatment (yellow classification), develop a treatment plan, A combination of individual signs then lead to the child’s or young infant’s classification within one or more administer drugs to be given at the facility and advise on treatment at home and counsel the mother/ symptom groups. caregiver accordingly. Essential drugs are then used to treat the children or young infants. Lastly counseling of caregivers regarding If no serious conditions have been found (green classification), advise the mother/caregiver on care of child home care, appropriate feeding and fluids and when to return to facility - immediately or follow-up, is done. at home. IMNCI 6 major steps Counsel If follow up care is indicated, teach the mother/caregiver when to return to the clinic. Also teach the mother/ caregiver how to recognize signs indicating that the child or young infant should be brought back to the facility immediately. Follow up Some children or young infants need to be seen more than once for a current episode of illness. Identify such Where can IMNCI be applied? children or young infants and when they are brought back, offer appropriate follow up care as indicated in the The IMNCI approach is designed for use in clinical settings at all levels of health care in Kenya where children IMNCI guidelines and also reassess the child or young infant for any new problems. under 5 years are managed. These are dispensaries, health centres, sub-county hospitals, county hospitals and The guidelines also aim to empower healthcare workers to: national referral hospitals including, faith based and private health facilities. Correctly interview caregivers. Provide counseling for appropriate preventative and treatment measures. What is the IMNCI Chart booklet? Correctly counsel the mother about her own health. Kenya’s IMNCI guidelines are packaged in this chart booklet. The chart booklet provides a simplified step-by-step guide to a healthcare worker on case management of children below 5 years of age visiting health facilities. The Who can apply the IMNCI approach? chart booklet summarizes and describes the 6 step IMNCI process illustrated above. The IMNCI process can be applied to any healthcare worker working in settings where children or young infants below five years are managed. These should include: Doctors, Clinical Officers and Nurses. Benefits of Using the IMNCI Approach By using the IMNCI chart booklet and implementing the guidelines the health workers will be able to implement on What should you do when you receive the IMNCI chart booklet at your facility? the key elements of IMNCI: The Ministry of Health has distributed the IMNCI chart booklet to all health facilities in Kenya. Upon receiving a copy at your facility, all health workers should familiarize themselves with the guidelines and begin Assessment immediate implementation/use. NB: the hard copy of the chart booklet should remain at the health The assess column in the chart booklet describes how to take history and do a physical exam facility at all times. Routinely assess for general danger signs (or possible bacterial infection in a young infant) - a general A mobile application of the IMNCI guidelines has been developed by the Ministry of Health (MOH) and is danger sign indicates that a child has a serious and life threatening condition that requires urgent attention available for free to all healthcare workers. For instructions on how to download, please visit www.health.go.ke or Assess for common illnesses in children or young infant’s by asking questions about common conditions, contact the Newborn Child and Adolescent Health Unit (NCAHU) at the MOH. examining the child or young infant and checking the need for other routine services such as immunization and nutrition. Look for other health problems. 3  INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES ASSESS AND CLASSIFY THE SICK CHILD (AGE 2 MONTHS UP TO 5 YEARS) ASSESS CLASSIFY IDENTIFY TREATMENT ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE USE ALL BOXES THAT MATCH THE CHILD’S SYMPTOMS AND PROBLEMS Determine if this is an initial or follow-up visit for this problem. TO CLASSIFY THE ILLNESS. -- If follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. -- If initial visit, assess the child as follows: TREATMENT SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.) CHECK FOR GENERAL DANGER SIGNS LOOK: Any general danger sign. VERY Give diazepam if convulsing now (see pg 16) ASK: See if the child is lethargic or SEVERE Quickly complete the assessment Is the child able to drink or unconscious. DISEASE Give any pre-referral treatment immediately breastfeed? URGENT Treat to prevent low blood sugar (see pg 17) Does the child vomit everything? Is the child convulsing now? If yes treat immediately. (see pg.16) ATTENTION Keep the child warm. Has the child had convulsions in Refer URGENTLY. this illness? Screen for possible TB disease and check for HIV A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed. Any general danger sign If oxygen saturation is less than 90%, start oxygen therapy and refer THEN ASK ABOUT MAIN SYMPTOMS: OR SEVERE or admit. Oxygen saturation PNEUMONIA Give first dose of Benzyl Penicillin & Gentamicin (see pg 16) Does the child have cough or difficult breathing? less than 90% OR VERY Treat for and to prevent low blood sugar. (see pg 17) Stridor in calm child. SEVERE Keep the child warm. IF YES, ASK LOOK, LISTEN, FEEL Central Cyanosis Treat wheeze if present, admit or refer urgently to hospital (see pg 17). CHILD Classify DISEASE For how long? Count the breaths in one minute. AVPU = V, P or U Screen for possible TB disease and check for HIV MUST BE COUGH or Use respiratory rate timers where DIFFICULT available CALM BREATHING Chest indrawing in PNEUMONIA Give Amoxicillin Dispersible Tablet. (see pg 13) Look for chest in-drawing* calm child Give Vitamin A. (see pg 14) Look and listen for stridor** OR Treat wheeze if present (see pg 17). Look and listen for wheeze*** Fast breathing If wheezing, follow-up in 2 days (see pg 22) Check for central cyanosis AND Soothe the throat and relieve the cough with a safe remedy. Check for oxygen saturation using No signs of severe Screen for possible TB disease and check for HIV. pulse oximetry where available. pneumonia Review in 2 days, if not possible, admit OR refer children with chest Check AVPU**** indrawing (see pg 22) If wheezing with either chest in- If the child is: Fast breathing is: Advise mother when to return immediately. drawing or fast breathing: Assess 2 months up 50 breaths per No signs of pneumonia NO Treat wheeze if present ( see pg 17) for possible Asthma (see pg17) to 12 months minute or more or very severe disease. PNEUMONIA: If wheezing, follow-up in 2 days (see pg 22) If wheezing assess for possible COUGH OR Soothe the throat and relieve the cough with a safe remedy (see pg 15). 12 months up 40 breaths per TB disease Follow-up in 5 days if not improving. to 5 years minute or more COLD Screen for possible TB disease and check for HIV. Advise mother when to return immediately. TA B L E : 1 Note: *Chest in-drawing is present if the lower chest wall moves in during inspiration. **Stridor - a harsh sound heard during inspiration. 4 ***Wheeze - a musical sound heard during expiration. ****AVPU - Alert, responsive to Voice, responsive to Pain, Unresponsive ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES CLASSIFY IDENTIFY TREATMENT ASSESS All four of: Weak/absent pulse TREAT FOR SHOCK. Give Ringer's Lactate 20mls/kg (see pg 19) AVPU* < A - A second bolus may be given if required before proceeding to step 2 of PLAN C (see pg 19) Cold hands + Temp HYPOVOLAEMIC Treat for and to prevent low blood sugar (see pg 17) Does the child have diarrhoea? gradient SHOCK Assess for severe acute malnutrition (see pg 8) FROM Capillary refill > 3 sec Assess for severe anaemia (see pg 8) DIARRHOEA/ PLUS DEHYDRATION NB: If HB 7 days assess further or refer Look for any other cause of RISK Screen for possible TB disease and check for HIV fever Advise when to return immediately. High Malaria risk: Malaria test NEGATIVE FEVER: Give one dose of paracetamol in clinic for high fever (≥38.5 °C) Do a malaria test TEST POSITIVE NO MALARIA Assess for other possible causes of fever ○ Endemic Zone P.falciparum PRESENT Follow up in 3 days if fever persists (see pg 23) ○ Seasonal Transmission Zone P.vivax PRESENT If fever is present every day for more than 7 days assess further or refer (see pg 23) ○ Epidemic prone areas Screen for possible TB disease and check for HIV Low malaria risk: TEST NEGATIVE Advise mother when to return immediately. ○ Do a malaria test if no P.falciparum or P.vivax obvious cause of fever absent NOTE: If you can’t test, don’t withhold treatment Generalized rash of measles and SUSPECTED Give Vitamin A (See page 14) One of: cough, runny nose or MEASLES Notify, take blood sample for confirmation red eyes Screen for possible TB disease and check for HIV Advise mother when to return immediately. Any general danger sign or SEVERE Give Vitamin A (see pg 14) Clouding of cornea or COMPLICATIONS Give first dose of Ceftriaxone Antibiotic (See page 16) CLASSIFY Deep or extensive mouth OF MEASLES If clouding of the cornea or pus draining from the eye, apply tetracycline MEASLES ulcers. eye ointment. (See page 15) Notify, take blood sample for confirmation OR refer Admit or refer URGENTLY to hospital Screen for possible TB disease and check for HIV. Pus draining from the eye or EYE OR MOUTH Give Vitamin A (See page 14) Mouth ulcers. COMPLICATIONS If pus draining from the eye, treat eye infection with tetracycline eye OF ointment. (See page 15) MEASLES**** If mouth ulcers, treat with nystatin (see pg 15) Check for Complications of MEASLES Follow-up in 2 days (see pg 23) If child has no indication for referral, notify and draw blood sample for confir- If the child has signs of measles now or within the If MEASLES mation of measles last 3 months Look for mouth ulcers, are they deep now or within the last Screen for possible TB disease and check for HIV. or extensive? 3 months, Classify No pus draining from the eye or NO EYE Give Vitamin A if not received in the last 1 month (see pg 14) Look for pus draining from the eye mouth ulcers. OR MOUTH If child has no indication for referral, draw blood and send for confirmation Look for clouding of the cornea COMPLICATIONS Screen for possible TB disease immediately after the measles infection and OF MEASLES check for HIV. TA B L E : 3 * These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C higher. ** If no malaria test available: High risk-classify as MALARIA; Low malaria risk AND NO obvious cause of fever– classify as MALARIA *** Look for local tenderness, refusal to use a limb, hot tender swelling, red tender skin or boils, lower abdominal pain or pain on passing urine 6 **** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables. ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES ASSESS CLASSIFY IDENTIFY TREATMENT Does the child have an ear problem? Give first dose of Ceftriaxone Antibiotic. (See pg 16) Give first dose of paracetamol for pain (see pg 14) Tender swelling behind the ear. MASTOIDITIS Refer URGENTLY to hospital or admit IF YES: LOOK AND FEEL: Check for HIV. Look for pus draining from Is there ear pain? the ear. Is there ear discharge? If Feel for tender swelling Pus is seen draining from the ear or Give Amoxicillin dispersible tablet for 5 days. (See pg 13) yes, for how long? Classify Discharge is reported for less than 14 Give paracetamol for pain (see page 14) behind the ear. ACUTE EAR EAR PROBLEM days,or Dry the ear by wicking (See pg 15) INFECTION Ear pain. Check for HIV infection Follow-up in 5 days (see pg 23) Pus is seen draining from the ear or Dry the ear by wicking (See pg 15) CHRONIC EAR discharge is reported for 14 days or Check for HIV infection INFECTION more. Follow-up in 5 days (see pg 23) No ear pain and No treatment. No pus seen or reported NO EAR draining from the ear. INFECTION TA B L E : 4 7 ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES ASSESS CLASSIFY IDENTIFY TREATMENT Oedema of both feet, Treat the child to prevent low blood sugar (see pg 17) OR Keep the child warm CHECK FOR ACUTE MALNUTRITION WFH/L less than -3 z scores OR SEVERE Give first dose of Benzyl Penicillin + Gentamicin (see pg 13) Give Vitamin A (see pg 14) AND ANAEMIA MUAC Less than 11.5 cm and ANY one of the following: ACUTE MALNUTRITION Refer URGENTLY to hospital Admit or refer urgently to hospital if child has any other complications (Danger signs: Diar- WITH - medical complication present rhoea, Pneumonia, Fever, No appetite, etc) COMPLICATIONS or Immunize as per schedule (see pg 12) FOR CHILDREN ASK: Is there history of TB contact? - not able to finish RUTF***or Screen for possible TB disease and check for HIV (see pg 13) - Breast feeding problem LOOK AND FEEL: ( -3 to < -2 z scores ACUTE Assess the child’s feeding and counsel the mother on the feeding recommendations (see pg 25 & 26) consecutive months?) OR MALNUTRITION Give Albendazole if child is 1 year or older and has not had a dose in the previous 6 months (See pg 12) Measure MUAC**mm in a child 6 months or older MUAC 11.5 to 12.4cm If feeding problems, follow up in 14 days (see pg 24) Screen for possible TB disease and check for HIV Immunize as per schedule (see pg 12) IF WFH/L less than -3 z-score or MUAC less than 115mm Advise mother when to return immediately. then: For all age groups: AT RISK OF If child is less than 2 years old, and has growth faltering, assess the child’s feeding and counsel the Check for any medical complication present: Static weight or losing weight ACUTE mother on feeding according to the feeding recommendations Any general danger signs. -2 to - 1 z - scores NO ACUTE If child is less than 2 years old, assess the child’s feeding and counsel the mother on feeding according > Not able to finish RUTF portion OR MALNUTRITION to the feeding recommendations (see pg 25 & 27) > Able to finish RUTF portion MUAC > 13.5 cm If feeding problem, follow-up in 5 days (see pg 24) Give Albendazole if child is 12 months and has not had a dose in the previous 6 months (see pg 12) Immunize as per schedule (see pg 12) Child is less than 6 months, assess breast feeding Screen for possible TB disease and check for HIV (see pg 43) > does the child have breast feeding problems? Treat to prevent low blood sugar (see pg 17) Severe palmar pallor SEVERE Keep the child warm If child has acute Malnutrition and is receiving RUTF, If HB