INTEGRATED MANAGEMENT OF

CHILDHOOD ILLNESS
Jenell Y. Oczon-Naldo, MD, MPH, DFM, FPAFP
Assistant Professor
FEU-NRMF Department of Community and Family Medicine
LEARNING OBJECTIVES

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

1. describe the IMCI process;
2. classify severity of patient’s disease;
3. identify patients needing referral or early
treatment.
INTRODUCTION
Every year…
• 12 million children die before their 5th birthday
• many during the first year of life.
• Seven in ten of these deaths are due to acute
respiratory infections (mostly pneumonia), diarrhea,
malnutrition, measles and malaria- and often to a
combination of these conditions.
• In addition to deaths, three in four of the episodes of
childhood illness presenting to primary health facilities
are due to these five conditions, singly or in
combination.
• This overlap means that:
• A single diagnosis may not be appropriate.
• Treatment needs to combine therapy for several
conditions.
• So, an integrated approach to managing sick children is
more useful in order to go beyond single diseases and
to focus on the overall health of the child.
• Pneumonia, diarrhea, dengue hemorrhagic fever,
malaria, measles and malnutrition cause more than
70% of the deaths in children under 5 years of age.
• All these are preventable diseases in which when
managed and treated early could have prevented these
deaths.
• WHO and UNICEF used updated technical findings to
describe management of these illnesses in a set of
integrated guidelines for each illness.
• They developed this protocol to teach the integrated
case management process to health workers who see
sick children and know which problems are most
important to treat.
THE IMCI PROCESS

• The integrated case management relies on:

• Case detection using few simple clinical signs.
These signs are based on expert clinical opinion and
research results.
• Empirical treatment developed according to action-
oriented classifications rather than exact diagnosis and
covering the most likely diseases covered by each
classification.
• The IMCI process can be used by doctors or nurses
who see sick children aged from 1 week up to 5 years
at 1st level health facilities.
THE IMCI PROCESS
The charts describes the following steps:

1. assess the child or young infant

2. classify the illness
3. identify the treatment
4. treat the child
5. counsel the mother
6. give follow up care
• For children who can be treated at home, caregivers are
taught how to provide treatment and when to seek care
for their children.
• The guidelines also identify actions to prevent illness
through the immunization of sick children,
supplementation of micronutrients, promotion of
breastfeeding, and counseling of mothers to solve feeding
problems.
• It is also an important factor to teach families when to
seek care for a sick child as part of the case management
process.
• This approach, which combines steps to manage and
prevent several different conditions, is comprehensive
and systematic.
 THE IMCI CHART
COLOR of the row helps to IDENTIFY RAPIDLY whether the child has a SERIOUS
DISEASE requiring URGENT ATTENTION. Each row is colored either –

PINK – means the child has a severe classification and needs urgent attention and
referral or admission for inpatient care.
YELLOW – means the child needs a specific medical treatment such as an
appropriate antibiotic, an oral anti-malarial or other treatment; also
teaches the mother how to give oral drugs or to treat local infections at
home. The health worker teaches the mother how to care for her child
at home and when she should return.
GREEN – not given a specific medical treatment such as antibiotics or other
treatments. The health worker teaches the mother how to care for her
child at home.

Always start at the top of the classification table. If the child has signs from more than 1 row
always select the more serious classification.
OBJECTIVES OF IMCI

• To reduce significantly global morbidity and mortality

associated with the major causes of illnesses in
children

• To contribute to healthy growth and development of

children
 WHY NOT USE THE PROCESS FOR CHILDREN AGE 5
YEARS OR MORE?
• ASSESSMENT AND CLASSIFICATION of older children
would differ. For example, the cut off rate for determining
fast breathing would be different because normal
breathing rates are slower in older children.
• Chest indrawing is not a reliable sign of severe
pneumonia as children get older and the bones of the
chest become more firm.
• In addition, certain treatment recommendations or advice
to mothers on feeding would differ for >5yrs old.
• The drug dosing tables only apply to children up to 5yrs
old. The feeding advice for older children may differ and
they may have different feeding problems.
 WHY NOT USE THIS PROCESS FOR YOUNG
INFANTS AGE < 1 WEEK OLD?

• It greatly differs from older infants and young children.

• In the first week of life, newborn infants are often sick

from conditions related to labor and delivery. Their
conditions require special treatment.
 SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESS
For all sick children age 1 week up to 5 years who are brought to a first-level health facility

ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a
main symptom is reported, assess further. Check nutrition and immunization status. Check for other
problems.

CLASSIFY the child’s illnesses: Use a colour-coded triage system to classify the child’s main symptoms
and his or her nutrition or feeding status.

IF URGENT REFERRAL is needed and possible IF NO URGENT REFERRAL isneeded or possible

IDENTIFY URGENT IDENTIFY TREATMENT needed for the child’s classifications:

PRE-REFERRAL TREATMENT(S) Identify specific medical treatments and/or advice.
needed for the child’s classifications.
. TREAT THE CHILD: Give the first dose of oral drugs in the clinic
and/or advise the child’s caretaker. Teach the caretaker how to
TREAT THE CHILD: Give urgent pre- give oral drugs and how to treat local infections at home. If needed,
referral treatment (s) needed. give immunizations.

REFER THE CHILD: Explain to the
child’s caretaker the need for referral.
Calm the caretaker’s fears and help
resolve any problems. Write a
referral note. Give instructions and
supplies needed to care for the child
on the way to the hospital.
COUNSEL THE MOTHER: Assess the child’s feeding, including
breastfeeding practices, and solve feeding problems, if present.
Advise about feeding and fluids during illness and about when to
return to a health facility. Counsel the mother about her own
health.
FOLLOW-UP care: Give follow-up care when the child returns to the
clinic and,if necessary, reassess the child for new problems.
For ALL sick children ask the mother about the child’s problem,
then CHECK FOR GENERAL DANGER SIGNS

Make
CHECK FOR GENERAL DANGER SIGNS
sure that
a child
ASK: LOOK:
with any
Is the child able to drink or breastfeed? •
• See if the child is lethargic or
danger
Does the child vomit everything? unconscious
sign is
Is the child convulsing or had had convulsions?
•
referred
after
A child with any general danger sign needs URGENT attention;
receiving
complete the assessment and any pre-referral treatment
urgent
immediately so referral is not delayed
pre-
referral
treatment
Then ASK about MAIN SYMPTOMS: cough and difficult .
breathing, diarrhoea, fever, sorethroat, ear problems. CHECK for
malnutrition and anaemia, immunization status and for other
problems.
 THE SICK CHILD AGE
2 MONTHS TO 5 YEARS:

ASSESS AND CLASSIFY

 SUMMARY OF ASSESS AND CLASSIFY
Ask the mother or caretaker about the child’s problem.
If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a
follow-up visit for the problem, give follow-up care according to PART VII)

Check for general danger signs.

Ask the mother or caretaker about the When a main symptom is present:
five main symptoms: • œ assess the child further for
œ cough or difficult breathing, signs related to the main
œ diarrhoea symptom and œ classify the
œ
 fever, œ sorethroat illness according to the signs
œ
 ear problem which are present or absent.

Check for signs of malnutrition and anaemia and classify the child’s nutritional status

Check the child’s immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child

(PART V), and Counsel the Mother (PART VI)
 WHEN THE CHILD IS BROUGHT TO
THE CLINIC
Use Good Communication Skills:

• Listen carefully to what the mother

tells you
• Use words the mother understands
• Give mother time to answer
questions
• Ask additional questions when
mother not sure of answer
Record important information
 Cough or Difficult Breathing
For ALL sick children ask the mother about the child’s problem, check for
general danger signs,
Ask about cough or difficult breathing and then
ASK : DOES THE CHILD HAVE COUGH?

If NO If YES

Classify COUGH or DIFFICULT

BREATHING in a calm child
IF YES, ASK: LOOK, LISTEN, FEEL:

œ For how long?

 œ Count the breaths in one
• If the child is: Fast breathing is:
minute. 2 months up 50 breaths per
to 12 months minute or more
œ Look for chest indrawing
•
œ Look and listen for stridor 12 months up 40 breaths per
to 5 years minute or more

CLASSIFY the child’s illness using the colour-coded classification table for cough or difficult breathing.

Then ASK about the main symptoms : fever, ear problem, and CHECK for malnutrition
and anaemia, immunization status and for other problems
CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING
SIGNS CLASSIFY IDENTIFY TREATMENT
•Any general danger •Give first dose of an appropriate
sign or SEVERE antibiotic.
•Chest indrawing or PNEUMONIA •Refer URGENTLY to hospital.
•Stridor in calm
OR VERY
child.
SEVERE DISEASE

•Fast breathing •Give an appropriate oral

PNEUMONIA antibiotic for 5 days.
•Soothe the throat and relieve the
cough with a safe remedy.
•Advise mother when to return
immediately.
•Follow-up in 2 days.

No signs of NO PNEUMONIA: •If coughing more than 30 days,

pneumonia COUCH OR COLD refer for assessment.
or very severe •Soothe the throat and relieve the
disease. cough with a safe remedy.
•Advise mother when to return
immediately.
•Follow-up in 5 days if not
improving.
 Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs,
ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHEA?

If YES
If NO

IF YES, ASK: LOOK, LISTEN, FEEL:

œ For how long?
 œ Look at the child’s general condition.
Is the child:
œ Is there blood in the stool? Lethargic or unconscious?
Restless or irritable?
œ Look for sunken eyeballs

œ Offer the child fluid.

Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
œ Pinch the skin of the abdomen.

Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and
anaemia, immunization status and for other problems.
CHILD WITH DEHYDRATION
 CLASSIFICATION TABLE FOR DEHYDRATION
SIGNS
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking
poorly
Skin pinch goes back very
slowly
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
Not enough signs to
classify as some or
severe dehydration.
CLASSIFY IDENTIFY TREATMENT
If child has no other severe classification:
— Give fluid for severe dehydration (Plan C).
OR
SEVERE If child also has another severe
classification:
DEHYDRA — Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
TION
Advise the mother to continue breastfeeding
If child is 2 years or older and there is
cholera in your area, give antibiotic for
cholera.
Give fluid and food for some dehydration (Plan B).
If child also has a severe classification:
— Refer URGENTLY to hospital with mother
SOME giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
DEHYDRA Advise mother when to return immediately.
TION Follow-up in 5 days if not improving.
Give fluid and food to treat diarrhoea
at home (Plan A).
NO
DEHYDRA Advise mother when to return
immediately.
TION
Follow-up in 5 days if not improving.
 CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

SIGNS CLASSIFY IDENTIFY TREATMENT

Treat dehydration before
Dehydration SEVERE referral unless the child has
present PERSISTENT another severe classification.
DIARRHEA Refer to hospital.

Advise the mother on feeding a child

No dehydration PERSISTENT who has PERSISTENT DIARRHOEA.
DIARRHEA Follow-up in 5 days.
 CLASSIFICATION TABLE FOR DYSENTERY

SIGNS CLASSIFY IDENTIFY TREATMENT

Treat for 5 days with an

oral antibiotic
Blood in the DYSENTERY recommended for
Shigella in your area.
stool
Follow-up in 2 days.
 Fever
For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask
about cough or difficult breathing, diarrhoea and then

ASK: DOES THE CHILD HAVE FEVER?

If NO If YES

IF YES:
Decide the Malaria Risk: high or low

THEN ASK: LOOK AND FEEL:

œ For how long?
 • œ Look or feel for stiff neck.
œ If more than 7 days, has
 • œ Look for runny nose.
fever been present every day?
Look for signs of MEASLES
 Has the child had measles within
œ
the last 3 months? • œ Generalized rash and
œ One of these: cough, runny nose or red eyes.


If the child has measles now or  Look for mouth ulcers. Are they deep and extensive?
œ
within the last 3 months: œ Look for pus draining from the eye.

œ Look for clouding of the cornea.
•

CLASSIFY the child’s illness using the colour-coded classification tables for fever.

Then ASK about the next main symptom: ear problem, and CHECK for malnutrition and anaemia,
immunization status and for other problems.
 Fever

LOOK FOR SIGNS OF LOOK FOR SIGNS OF

MEASLES DENGUE/DHF
has measles now or within -bleeding tendencies
the last 3 months -flushing
-Rash -(+) tourniquet test
-Mouth ulcers -rash
-Cough
-Pus from eyes
-Runny nose
-Clouding of cornea
-Red eyes
CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A
MALARIA RISK AREA

SIGNS CLASSIFY IDENTIFY TREATMENT

AS
•Any general danger •Give first dose of an appropriate
sign antibiotic.
•Stiff neck •Treat the child to prevent low blood
VERY SEVERE sugar.
FEBRILE •Give one dose of paracetamol in
DISEASE clinic for high fever (38.5° C or above).
•Refer URGENTLY to hospital.

•NO general danger •Give one dose of paracetamol in

sign clinic for high fever (38.5° C or above).
AND FEVER— •Advise mother when to return
•NO Stiff neck. MALARIA immediately.
UNLIKELY •Follow-up in 2 days if fever persists.
•If fever is present every day for more
than 7 days, REFER for assessment.
 CLASSIFICATION TABLE FOR MEASLES
(IF MEASLES NOW OR WITHIN THE LAST 3 MONTHS)

SIGNS CLASSIFY IDENTIFY TREATMENT

•Any general danger •Give vitamin A.
sign or SEVERE •Give first dose of an appropriate
•Clouding of cornea or COMPLICATED antibiotic.
•Deep or extensive MEASLES*** •If clouding of the cornea or pus
mouth ulcers. draining from the eye, apply
tetracycline eye ointment.
•Refer URGENTLY to hospital.
•Pus draining from the •Give vitamin A.
eye or MEASLES WITH •If pus draining from the eye, treat eye
•Mouth ulcers EYE OR MOUTH infection with tetracycline eye
COMPLICATIONS** ointment.
* •If mouth ulcers, treat with gentian violet.
•Follow-up in 2 days.

•Measles now or within •Give vitamin A.

the last 3 months. MEASLES

*** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are
classified in other tables.
FEVER WITH RASHES
 Ear Problem
For ALL sick children ask the mother about the ask about cough or difficult breathing,
diarrhoea, fever and then
ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

If NO If YES

IF YES ASK: LOOK AND FEEL:

•Is there ear pain? •Look for pus draining from the
•Is ther ear discharge? ear.
If yes, for how long? •Feel for tender swelling
behind the ear.

CLASSIFY the child’s illness using the colour-coded-classification table for ear
problem.

Then CHECK for malnutrition and anaemia, immunization status and for other problems.
 CLASSIFICATION TABLE FOR EAR PROBLEM

SIGNS CLASSIFY IDENTIFY TREATMENT

•Give first dose of an appropriate
•Tender swelling antibiotic.
behind the ear. MASTOIDITIS •Give first dose of paracetamol for pain.
•Refer URGENTLY to hospital.

•Pus is seen draining •Give an oral antibiotic for 5 days.

from the ear and •Give paracetamol for pain.
discharge is reported ACUTE EAR •Dry the ear by wicking.
for less than 14 days, INFECTION •Follow-up in 5 days.
or
•Ear pain.
•Pus is seen draining •Dry the ear by wicking.
from the ear and CHRONIC EAR •Follow-up in 5 days.
discharge is reported INFECTION
for 14 days or more.

•No ear pain and No No additional treatment

pus seen draining from NO EAR
the ear. INFECTION
 Malnutrition and Anemia
For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea,
fever, ear problem and then
CHECK FOR MALNUTRITION AND ANAEMIA.

LOOK AND FEEL:

•Look for visible severe wasting.
•Look for palmar pallor.
Is it: Severe palmar pallor? Some palmar pallor?
•Look for edema of both feet.
•Determine weight for age.

CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition
and anemia

Then CHECK immunization status and for other problems.

CHILD WITH ANEMIA AND MALNUTRITION
 CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA
SIGNS
•Visible severe wasting or
•Severe palmar pallor or
•Oedema of both feet.
•Some palmar pallor or
•Very low weight for age.
•Not very low weight for age
and no other signs or
malnutrition.
CLASSIFY IDENTIFY TREATMENT
•Give Vitamin A.
SEVERE MALNUTRITION •Refer URGENTLY to hospital.
OR SEVERE ANAEMIA
•Assess the
feeding according to the FOOD box on the COUNSEL
THE MOTHER chart.
ANAEMIA OR VERY — If feeding problem, follow-up in 5 days.
LOW WEIGHT •If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk.
— Give mebendazole if child is 2 years or older and
has not had a dose in the previous 6 months.
•Advise mother when to return immediately.
•If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
•If child is less than 2 years old, assess the
NO ANAEMIA AND NOT feeding and counsel the mother on feeding
VERY LOW WEIGHT according to the FOOD box on the COUNSEL THE
MOTHER chart.
— If feeding problem, follow-up in 5 days.
•Advise mother when to return immediately.
 Immunization Status
For ALL sick children ask the mother about the child’s about cough or difficult
breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia
and
CHECK IMMUNIZATION STATUS.

AGE VACCINE
Birth BCG OPV-0
6 weeks DPT-1 OPV-1
IMMUNIZATION 10 weeks DPT-2 OPV-2
SCHEDULE: 14 weeks DPT-3 OPV-3
9 months Measles

DECIDE if the child needs an immunization today, or if the mother should be

told to come back with the child at a later date for an immunization.
Note: Remember there are no contraindications to immunization of a sick child
if the child is well enough to go home.

Then CHECK for other problems.

 HOW TO CHECK THE IMMUNIZATION STATUS

• Check the immunization status just as you would for an older infant
or young child. At 1 week of age BCG and Hepatitis 1 have been
given. At 6 weeks of age, DPT 1 and OPV 1 should be given. In
the Expanded Program of Immunization in the country BCG and
Hepatitis B 1 should be given at birth because of the high
prevalence of tuberculosis and hepatitis B.
• Giving an infant immunizations when he is
too young does not guarantee that his body
will be able to fight the disease very well.
Also if the infant does not receive an immunization
as soon as he is old enough, his risk of
getting the disease increases.
 HOW TO CHECK THE IMMUNIZATION STATUS
• Sometimes health workers would consider a minor illness as a contraindication
to immunization. They would send mothers away telling them to bring them
back when the infant is well. This is a bad practice because it delays
immunization. This leads to poor compliance on the part of the mother and the
infant may run the risk of getting the infections.
• There are only three situations at present that are
contraindicated to immunization:
1. Do not give BCG to a child known to have AIDS.
2. Do not give DPT to a child with recurrent convulsions
or another active neurological disease of the CNS.
3. 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.
THE SICK YOUNG
INFANT AGE 1 WEEK UP
TO 2 MONTHS:
ASSESS AND CLASSIFY
 SUMMARY OF ASSESS AND CLASSIFY
Ask the mother or caretaker about the young

Check for POSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker about If diarrhoea is present:

DIARRHOEA: •assess the infant further for signs related to
diarrhoea, and
•classify the illness according to the signs
which are present or absent.

Check for FEEDING PROBLEM OR LOW WEIGHT and classify the

Check the infant’s immunization status and decide if the infant needs any
immunization today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Infant (PART V),
and Counsel the Mother (PART VI)
How to check a young infant for possible bacterial infection
For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION

CHECK FOR POSSIBLE BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL:
•Has the infant had •Count the breaths in one minute.
Repeat the count if elevated. YOUNG
convulsions? •Look for severe chest indrawing. INFANT
•Look for nasal flaring MUST BE
•Look and listen for grunting. CALM
•Look and feel for bulging fontanelle.
•Look for pus draining from the ear.
•Look at the umbilicus. Is it red or draining pus?
Does the redness extend to the skin?

•Measure temperature (or feel for fever or low body temperature)

•Look for skin pustules. Are there many or severe pustules?
•See if the young infant is lethargic or unconscious.
•Look at the young infants’s movements. Are they less than normal?

CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL
INFECTION.

Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other
problems.
 CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
SIGNS CLASSIFY IDENTIFY TREATMENT
•Convulsions or •Give first dose of intramuscular
•Fast breathing (60 breaths
per minute or more) or antibiotics.
•Severe chest indrawing or •Treat to prevent low blood sugar.
•Nasal flaring or •Advise mother how to keep the infant
•Grunting or
•Bulging fontanelle or warm on the way to hospital.
•Pus draining from ear or POSSIBLE •Refer URGENTLY to hospital
•Umbilical redness extending SERIOUS
to the skin or
•Fever (37.5 C* or above or BACTERIAL
feels hot) or low body INFECTION
temperature (less than 35.5
C* or feels cold) or
•Many or severe skin pustules
or
•Lethargic or unconscious or
•Less than normal movement.

•Red umbilicus or •Give an appropriate oral antibiotic.

draining pus or LOCAL •Teach the mother to treat local infections at
•Skin pustules. BACTERIAL home.
INFECTION •Advise mother to give home care for the
young infant.
•Follow-up in 2 days

*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.
How to assess and classify a young infant for diarrhea?

For ALL sick young infants check for signs of possible bacterial
infection and then
ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSESS AND CLASSIFY the young infant’s diarrhoea

using the DIARRHOEA box in the YOUNG INFANT chart. The
process is very similar to the one used for the sick child.

Then CHECK for feeding problem or low weight, immunization

status and other problems.
 For ALL sick young infants check for signs of possible bacterial infection, ask about
diarrhoea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.

ASK: LOOK, LISTEN, FEEL:

œ
 Is there any difficulty feeding? œ Determine weight for age.

œ
 Is the infant breastfed? If yes,how many times in 24 hours?
œ
 Does the infant usually receive any other foods or drinks?
If yes, how often?
œ
 What do you use to feed the infant?

IF AN INFANT: Has any difficulty feeding,

Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age,
AND
Has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
œ
 Has the infant If the infant has not fed in the previous hour, ask the mother to put her
breastfed in the infant to the breast. Observe the breastfeed for 4 minutes.
previous hour?
(If the infant was fed during the last hour, ask the mother if she can wait
and tell you when the infant is willing to feed again.)

 Is the infant able to attach?

œ
no attachment at all not well attached good attachment
 For ALL sick young infants check for signs of possible bacterial infection, ask about
diarrhoea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.

TO CHECK ATTACHMENT, LOOK FOR:

— Chin touching breast
— Mouth wide open
— Lower lip turned outward
— More areola visible above then below the mouth
(All these signs should be present if the attachment is good.)

• Is the infant suckling effectively (that is, slow deep sucks, sometimes
pausing)?

no suckling at all not suckling effectively suckling effectively

• Clear a blocked nose if it interferes with breastfeeding.

• Look for ulcers or white patches in the mouth (thrush).
 CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT
SIGNS
•Not able to feed or
• No attachment at all or
•Not suckling at all.
•Not well attached to breast or
•Not suckling effectively or
•Less than 8 breastfeeds in 24 hours or
•Receives other foods or drinks or
•Low weight for age or
•Thrush (ulcers or white patches in
mouth).
•Not low weight for age and no other
signs of inadequate feeding.
CLASSIFY IDENTIFY TREATMENT
NOT ABLE TO FEED POSSIBLE •Give first dose of intramuscular antibiotics.
SERIOUS BACTERIAL •Treat to prevent low blood sugar.
INFECTION •Advise the mother how to keep the young infant warm on the way to
hospital.
•Refer URGENTLY to hospital.
• Advise the mother to breastfeed as often and for as long as the infant
wants, day and night.
-If not well attached or not suckling effectively, teach correct
positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise to increase
FEEDING PROBLEM OR LOW frequency of feeding.
WEIGHT • If receiving other foods or drinks, counsel mother about breastfeeding
more, reducing other foods or drinks, and using a cup.
•If not breastfeeding at all:
— Refer for breastfeeding counselling and possible
relactation.
— Advise about correctly prepared breastmilk substitutes
and using a cup.
• If thrush, teach the mother to treat thrush at home.
• Advise mother to give home care for the young infant.
•Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for
age in 14 days.
•Advise mother to give home care for the young infant.
NO FEEDING •Praise the mother for feeding the infant well.
PROBLEM
COMMUNICATE AND COUNSEL
GOOD CHECKING QUESTIONS POOR QUESTIONS

How will you prepare the ORS solution? Do you remember how to mix the
ORS?

How often should you breastfeed your child? Should you breastfeed your child?

On what part of the eye do you apply Have you used ointment on your child
the ointment? before?

How much extra fluid will you give after each Do you know how to give extra
loose stool? fluids?

Why is it important for you to wash your hands? Will you remember to wash your
hands?
GIVE FOLLOW-UP CARE
FOLLOW-UP CARE FOR THE SICK
YOUNG INFANT
• When to return immediately
• Signs of any of the following:

• Breastfeeding or drinking poorly

• Becomes sicker
• Develops a fever
• Fast breathing
• Difficult breathing
• Blood in the stool
 FOLLOW-UP CARE FOR THE SICK
YOUNG INFANT
• Follow-up in 2 days – on antibiotics for local
bacterial infection or dysentery
• Follow-up in 2 days - with a feeding problem or oral thrush
• Follow-up in 14 days – with low weight for age
 FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

If the child has: Return for follow-up in:

PNEUMONIA 2 days
DYSENTERY
MALARIA, if fever persists
FEVER—MALARIA UNLIKELY, if fever
persists
MEASLES WITH EYE OR MOUTH
COMPLICATIONS

PERSISTENT DIARRHOEA ACUTE EAR 5 days

INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving

PALOR VERY 14 days

LOW WEIGHT FOR AGE 30 days

God Bless You!