At the start of a sick child (2 months to 5 years) consultation

1. At the start of a sick child (2 months to 5 years) consultation • Ask the mother what the child’s problems are. • Determine if this is an initial or follow-up visit for this problem.

2. IMCI Case Management Classification Focused Assessment Need to Refer Danger signs Main Symptoms Nutritional status Immunization status Other problems Specific treatment Home management Counsel & Follow-up Treatment Counsel caretakers Follow-up Identify treatment Treat

3. Check for general danger signs Ask: • Not able to drink or breastfeed, • Vomits everything, • Convulsions, or Look: • Abnormally sleepy or difficult to awaken Need to Refer (except in severe dehydration)

4. Ask about the main symptoms • Cough or difficulty in breathing • Diarrhea • Fever • Ear problem

5. Cough or difficulty in breathing Ask: • For how long? Look: • Count RR • Chest indrawing • Stridor The child must be calm.

6. Any general danger sign or • Chest indrawing or • Stridor SEVERE PNEUMONIA OR VERY SEVERE DISEASE • 1st dose of antibiotic • Vitamin A • Breastfeeding/sugar water • URGENT REFERRAL

8. Fast breathing • 2 – 12 months old: ≥ 50/minute • 1 year or older: ≥ 40/minute PNEUMONIA • Antibiotic for 5 days • Relieve cough with safe remedy • Advise mother on danger signs • Follow up in 2 days

9. No signs of pneumonia or a very severe disease NO PNEUMONIA: COUGH OR COLD • If cough ≥ 30 days  refer to hospital for assessment • Relieve cough with safe remedy • Advise mother on danger signs • Follow up in 5 days if no improvement

10. Diarrhea: Classify For dehydration Persistent diarrhea Blood in the stool

11. Classify for dehydration • 2 or more of the following: • Abnormally sleepy/difficult to wake • Sunken eyes • Not able to feed/drinking poorly • Skin pinch goes back very slowly SEVERE DEHYDRATION Plan C

13. Plan C: To treat dehydration quickly IV fluid: LRS 100 ml/kg body weight (in 6 hrs for infants; 3 hrs for children) NO IV treatment within 30 minutes NO Oresol/NGT

14. Plan C: To treat dehydration quickly Oresol/NGT NO Oresol p.o. NO URGENT REFERRAL

15. Classify for dehydration • 2 of the following: • Restless, irritable • Sunken eyes • Drinks eagerly, very thirsty • Skin pinch goes back slowly SOME DEHYDRATION Plan B

16. Plan B: Treat some dehydration with ORS Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.

17. Plan B: Treat some dehydration with ORS Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.

18. Plan B: Treat some dehydration with ORS • Show the mother how to give Oresol to the child: frequent sips from a cup • If the child vomits, wait for 10 minutes. Then continue, but more slowly. • Continue breastfeeding if the child wants to breastfeed. • If the child develops puffy eyelids, stop ORS.

19. Plan B: Treat some dehydration with ORS After 4 hours: • Reassess the child & classify for dehydration. • Select appropriate plan. • Begin feeding the child in the health center.

20. Classify for dehydration Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION NO DEHYDRATION Plan A

21. Plan A: Treat diarrhea at home • Give extra fluid. • Continue feeding. • Know when to return.

22. Persistent diarrhea: 14 days or more + Dehydration=severe persistent diarrhea • Treat dehydration • Give Vitamin A • Refer to hospital

23. Persistent diarrhea: 14 days or more No dehydration=persistent diarrhea • Advise regarding feeding • Give Vitamin A • Follow up in 5 days

24. Blood in the stool = dysentery • Oral antibiotic for shigella for 5 days • Follow up in 2 days

25. Fever: (history/temperature 37.5°C or above) Malaria risk? Measles now or w/in last 3 mos Dengue risk?

26. Fever: Ask about malaria risk • Residing in endemic area? OR: • Travel & overnight stay in endemic area, or • Blood transfusion w/in past 6 mos

27. Malaria risk + • Blood smear • Ask: Duration of fever? • Present everyday? • Look: Stiff neck • Runny nose • Other signs of measles

28. Malaria risk + any general danger sign or stiff neck Very severe febrile disease/malaria • Quinine (under med. supervision) • 1st dose of antibiotic, Paracetamol • Urgent referral

29. Malaria risk +, blood smear +No runny nose, no measles Malaria • Oral antimalarial • Paracetamol • Follow up in 2 days • > 7 days fever  hospital for assessment

30. No malaria riskAny general danger sign or stiff neck Very severe febrile disease • 1st dose of antibiotic, Paracetamol • Urgent referral

31. Measles now or w/in last 3 mosClouding of cornea orDeep or extensive mouth ulcers Severe complicated measles • 1st dose of antibiotic, Vitamin A • Urgent referral

32. Measles now or w/in last 3 mosPus draining from the eye orMouth ulcers Measles with eye or Mouth complications • Vitamin A • Tetracycline eye ointment • Gentian violet • Follow up in 2 days

33. Measles now or w/in last 3 mosNo other signs Measles Vitamin A

34. If there is Dengue risk Bleeding gums, nose, in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs, but fever > 3 days  Tourniquet test

35. Slow capillary refill • Indicates poor skin perfusion • Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

36. Any of the danger signsor + tourniquet test Severe Dengue hemorrhagic fever • If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS • Any other signs of bleeding  Plan C • Urgent referral • Do not give aspirin

37. Ear problem:tender swelling behind ear Mastoiditis • 1st dose of antibiotic • Paracetamol for pain • Urgent referral

39. Ear discharge < 14 days orEar pain Acute ear infection • Antibiotic for 5 days • Paracetamol for pain • Wicking • Follow up in 5 days

40. Ear discharge for 14 days or more Chronic ear infection • Wicking • Follow up in 5 days

42. Visible severe wasting or Edema on both feet orSevere palmar pallor Severe malnutrition or severe anemia • Vitamin A • Urgent referral

43. Some palmar pallor orVery low weight for age Anemia or very low weight for age • Assess for feeding problem • Pallor: iron & Mebendazole in children > 2 yrs • Wt for age very low: Vitamin A