Sick Child Age 2 Months to 5 Years

CLINICAL FEATURE

CLASSIFY AS

MANAGEMENT

Any general danger sign

Very Severe Disease

• Give diazepam if convulsing (rectal diazepam 0.5 mg/kg)
• Quickly complete the assessment
• Give any pre referral treatment immediately
• Treat to prevent low blood sugar (breastfeed or give expressed breast milk breastmilk substitute or sugar water by cup or NGT)
• Keep the child warm
• REFER URGENTLY

Ask

• If child has cough and/or difficulty in breathing

If yes, ask

• For how long child has had this?

Look Listen and feel

Ensure the child is calm, then

• Count the number of breaths/minute
• Look for chest indrawing
• Look/listen for stridor (stridor is an abnormal harsh, high-pitched sound caused by obstructed airflow, usually more audible while inhaling)
• Look and listen for wheezing
• If pulse oximeter is available, determine oxygen saturation. Refer if < 90%

If wheezing with either fast breathing or chest indrawing:

• Give a trial of rapid acting inhaled bronchodilator (with spacer) for up to 3 times 15-20 min apart. Count the breaths and look for chest indrawing again, and then classify

Fast breathing:

• Child 2–12 months: ≥50 breaths per minute
• Child 1–5 years: ≥40 breaths per minute

CLINICAL

FEATURES

CLASSIFY AS

MANAGEMENT

• Any general danger sign
• Or stridor in calm child
• SpO2 < 90%

Severe Pneumonia or Very Severe Disease

• Give 1st dose of appropriate antibiotic : ampicillin 50 mg/ Kg IM and gentamicin 7.5 mg/Kg IM
  • Or Benzylpenicillin 50,000 IU/Kg IM if at HC2
  • Or Amoxicillin DT 40 mg/kg if parenteral antibiotics not available
  • Refer URGENTLY to HC4/HOSPITAL

If referral not possible

• Continue ampicillin 6 hourly and gentamicin once daily for 5 days
• If strong suspicion of meningitis, dose of ampicillin can be increased 4 times

• Chest in drawing
• Fast breathing
• Child 12 months: ≥ 50 breaths/minute
• Children 1-5 years: ≥40 breaths/minute

Pneumonia

• Give amoxicillin DT 40 mg/kg for 5 days as first line treatment
• If wheezing give an inhaled bronchodilator for 5 days (salbutamol inhaler every 3-4 hours as necessary)
• If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma assessment
• If chest in drawing in HIV exposed/infected child, give first dose of amoxicillin DT 40 mg/kg and refer
• Soothe throat/relieve cough with safe remedy
• If coughing for more than 14 days or recurrent wheeze refer for possible TB or asthma assessment .
• Advise mother when to return immediately (danger signs)
• FOLLOW UP in 3 days and reassess
  • If better (slower breathing, no indrawing, less fever, eating better), praise the mother and advise to complete treatment
  • If not better or worse, refer urgently to hospital

Cough or Cold

(No pneumonia)

Most likely viral so no antibiotics needed

• If wheezing give an inhaled bronchodilator (salbutamol inhaler every 3-4 hours as necessary) for 5 days
• Soothe throat/relieve cough with safe remedy
• If coughing for more than 14 days or recurrent wheezing, refer for possible TB or asthma assessment
• Advise mother when to return immediately (danger signs)
• If not improving, FOLLOW UP in 5 days

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

Any 2 of these signs:

• Lethargic or unconscious
• Sunken eyes
• Unable to drink or drinks poorly
• Skin pinch returns very slowly (>2 seconds)

Severe Dehydration

• If child has no other severe classification, give dehydration Plan C
• If child also has another severe classification:
  • Give pre-referral treatment and refer urgently with mother giving frequent sips of ORS on the way
• Advise mother to continue breastfeeding
• If child is 2 years or older and there is cholera in your area:
• Give 1st dose of erythromycin 125 mg (if child < 2 years) or 250 mg (child 2-5 years) every 6 hours for 3 days
• Educate mother on hygiene and sanitation

Any 2 of these signs:

• Restless, irritable
• Sunken eyes Thirsty, drinks eagerly
• Skin pinch returns slowly

Some Dehydration

• Give fluid, zinc supplements, and food if possible See Dehydration Plan 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
• Advise mother when to return immediately 
• FOLLOW UP in 5 days
• If better (diarrhoea stopped, less than 3 loose stools per day, praise mother and advise her on feeding)
• If not better (> 3 loose stools per day), reassess, treat dehydration and refer
• Educate mother on hygiene and sanitation

• Not enough signs to classify as some or severe dehydration

No Dehydration

• Give fluid, zinc supplements, and food to treat diarrhoea at home (Plan A)
• Advise mother when to return immediately
• FOLLOW UP in 5 days
  • If better (diarrhoea stopped, less than 3 loose stools per day, praise mother and advise her on feeding)
  • If not better (> 3 loose stools per day), reasses, treat dehydration and refer
• Continue with breast feeding
• Educate mother on hygiene and sanitation

• Blood in stool

Dysentery

• Give ciprofloxacin 15 mg/kg for 3 days for Shigella
• FOLLOW UP in 3 days
  • If better (fewer stools, less blood in stool, less fever, less abdominal pain, better feeding) praise the mother, complete the ciprofloxacin and advise on feeding
  • If not better, refer

If diarrhoea for 14 days or more:

Dehydration present

Severe Persistent Diarrhoea

• Give vitamin A
• Treat dehydration before referral (unless child has another severe classification)
• Refer to hospital

No dehydration

Persistent Diarrhoea

• Advise mother on feeding child with PERSISTENT DIARRHOEA
• Give vitamin A; multivitamins and minerals (including zinc) for 14 days
• FOLLOW UP in 5 days
  • If better (diarrhoea stopped, less than 3 loose stools per day, praise mother and advise her on feeding)
  • If not better (> 3 loose stools per day), reassess, treat dehydration and refer
  • If symptoms are the same or worse, start treating dehydration if present and refer to hospital

Note:

• The current recommendation for treatment of diarrhoea is oral rehydration salts (ORS) and zinc salts (Zn sulphate, Zn gluconate or Zn acetate).
  • Give zinc for 10 days: Child < 6 months: 10 mg per day; Child > 6 months: 20 mg per day

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

• Any general danger sign
• Stiff neck

Very Severe Febrile Disease

• Give 1st dose of rectal artesunate (10 mg/kg) or IM/IV artesunate (3 mg/kg if < 20 kg, 2.4 mg/kg if > 20 kg) (see Malaria)
• Give 1st dose of appropriate antibiotic for serious bacterial infection: ampicillin 50 mg/Kg IM and gentamicin 7.5 mg/Kg IM or
  • Benzylpenicillin 50,000 IU/Kg IM if at HC2
• Treat child to prevent low blood sugar (breastfeed or give expressed breast milk or breastmilk substitute or sugar water by cup or NGT)
• Give one dose of paracetamol 10 mg/kg for high fever (38.5°C)
• Refer urgently

• Malaria test positive

Malaria

• Give 1st line malaria treatment 
• Give one dose of paracetamol 10 mg/kg for high fever (38.5°C)
• If a bacterial infection is also identified, give appropriate antibiotic treatment
• Advise mother when to return immediately, counsel on use of insecticide treated mosquito nets and educate on environmental sanitation
• FOLLOW UP in 3 days if fever persists:
  • Do a full reassessment and look for other causes of fever
  • Check that the child has completed the full course of antimalarials (without vomiting any dose)
  • Do not repeat RDT if it was positive on the initial visit
  • If no danger sign, no other apparent cause of fever and antimalarial treatment was given correctly, refer for microscopy and/or second line antimalarial
• If fever every day for >7days, refer for assessment

• Malaria test Negative

Fever

No Malaria

• Give one dose of paracetamol 10 mg/Kg in child with high fever (38.5°C)
• If a bacterial infection is identified, give appropriate antibiotic treatment
• If no bacterial infection identified, reassure, give paracetamol, advise to come back in 3 days or in case of any problem
• Advise mother when to return immediately and counsel on use of insecticide treated mosquito net and educate on environmental sanitation.
• FOLLOW UP in 3 days if fever persists
• Reassess the child for danger signs and other possible causes of fever
  • Repeat the malaria test and treat if positive
  • If no apparent cause of fever, refer
  • If fever every day for >7days, refer for assessment

If measles now or in last 3 months, classify as:

• Any general danger sign
• Clouding of cornea
• Deep or extensive mouth ulcers

Severe Complicated Measles

• Give vitamin A
• Give 1st dose of appropriate antibiotic for severe bacterial infection: ampicillin 50 mg/Kg IM and gentamicin 7.5 mg/Kg IM or
  • Benzylpenicillin 50,000 IU/Kg IM if at HC2
• If clouding of cornea or pus draining from eye: apply tetracycline eye ointment
• REFER URGENTLY to hospital

• Stridor
• Difficulty in breathing
• Diarrhoea
• Acute malnutrition
• Ear problem

Complicated Measles

• Refer to the relevant IMCI sections

• Pus draining from eye
• Mouth ulcers

Measles + Eye Or Mouth Complications

• Give vitamin A
• If pus draining from eye: Apply tetracycline eye ointment
• If mouth ulcers, apply gentian violet paint
• FOLLOW UP in 3 days
• If eyes still discharging pus and treatment has been given correctly, refer. If eyes only red or better, complete treatment
• If mouth ulcers/thrush are the same or better, continue treatment. If worse and/or child has problem swallowing, refer

• Measles now or in the last three months

Measles

• Give Vitamin A

Note:

• Body temperatures are based on axillary measurement. Rectal readings are approximately 0.5°C higher
• For doses of Vitamin A, Gentian violet and Tetracycline ointment see section on Medicines for Home Use below. 

Ask

Look and feel

• Does the child have an ear problem?
• If yes,
• Does the child have ear pain?
• Is there discharge:
• If yes, ask for how long

Look for pus draining from the ear

Feel for tender swelling behind the ear

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

• Tender swelling behind the ear

Mastoiditis

• Give 1st dose of appropriate antibiotic ampicillin 50 mg/ Kg IM and gentamicin 7.5 mg/Kg IM or
  • Benzylpenicillin 50,000 IU/Kg IM
  • Amoxicillin DT 40 mg/kg if parenteral not available
• Give 1st dose of paracetamol 10 mg/kg for pain
• REFER URGENTLY

• Ear pain
  • Pus seen draining from ear, and discharge for
    <14 days

Acute Ear Infection

• Give amoxicillin DT 40 mg/kg every 12 hours for 5 days
• Give paracetamol 10 mg/kg for pain
• Dry ear by wicking
• FOLLOW UP in 5 days
  • If high fever and/or swelling behind the ear: refer urgently
  • If pain or discharge persists: continue antibiotics for 5 more days and reassess
  • If no pain and discharge, praise the mother, complete the 5-day treatment

• No ear pain or discharge

No ear infection

• No additional treatment needed

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

• Oedema of both feet OR
• WFH/L less than -3 z scores OR
• MUAC less than 115 mm or
• Visible severe wasting AND
• Any one of the following:
  • Medical complication present OR
  • not able to finish RUTF OR
  • Breastfeeding problem

Complicated Severe Acute Malnutrition

• Give first dose appropriate antibiotic (ampicillin 50 mg/Kg IM and gentamicin 7.5 mg/Kg IM or
  • Benzylpenicillin 50,000 IU/Kg IM
• Treat the child to prevent low blood
• sugar (breastfeed or give expressed breast milk or sugar water by cup or NGT)
• Keep the child warm
• Refer URGENTLY to hospital

• WFH/L less than -3 z scores OR MUAC less than 115 mm
• Or very low weight for age AND
• Able to finish RUTF

Uncomplicated Severe Acute Malnutrition (SAM)

• Give oral antibiotics amoxicillin DT for 5 days (40 mg/kg twice a day)
• Give ready-to-use therapeutic food (RUTF) for a child aged 6 months or more
• Counsel the mother on how to feed the child
• Assess for possible TB infection
• Advise mother when to return immediately
• FOLLOW UP in 7 days
  • Reassess child and If no new problem, review again in 7 days.
• FOLLOW UP in 14 days
  • Reassess and reclassify and continue feeding. Keep checking every 14 days

• WFH/L between -3 and -2 z-scores

• OR MUAC 115 up to 125mm
• Or low weight for age

Moderate Acute Malnutrition (MAM)

• Assess the child’s feeding and counsel the mother on the feeding recommendations
• If feeding problem, counsel and FOLLOW UP in 7 days
• Assess for possible TB infection.
• Advise mother when to return immediately
• FOLLOW UP in 30 days
  • Reassess and reclassify.
  • If better, praise the mother and counsel on nutrition.
  • If still moderate malnutrition, counsel and - FOLLOW UP in one month
  • If worse, loosing weight, feeding problem: refer

• WFH/L - 2 z-scores or more
• OR MUAC 125 mm or more

No acute Malnutrition

If child is < 2 years old, assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations

f If feeding problem, FOLLOW UP in 7 days

Reassess and counsel

Note:

• WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts
• MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children ≥ 6 months
• RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malnutrition.
• RUTF already contains all the necessary vitamins and minerals (folic acid, iron etc) so there is no need of additional supplements

Ask

In appropriate local language, ask if presence of sickle cell anaemia in the family

Look

Look for palmar pallor. Is it

• Severe palmar pallor?
• Some palmar pallor?

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

• Severe palmar pallor

Severe Anaemia

• Refer URGENTLY to hospital

• Some palmar pallor

Anaemia

• Give ferrous sulphate ½ tab/day if 1-5 years, 1 ml of syrup/day if 2-12 months
• If child has severe acute malnutrition and is receiving
• RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF)
• Give folic acid 2.5 mg/daily in child with sickle cell anaemia
• Give mebendazole if child is 1 year or older and has not had a dose in the previous 6 months
• Advise mother when to return immediately
• FOLLOW UP in 14 days:
  • Review and give iron tablets every 2 weeks
  • If child still has palmar pallor after 2 months, refer
  • If better, continue iron treatment for 3 months after Hb has normalized

• No palmar pallor

No Anaemia

• If child is less than 2 years old, assess the child’s feeding and counsel the mother according to the feeding recommendation
• If feeding problem, FOLLOW UP in 5 days

Ask

• Is the child already enrolled in HIV care?

If not, ask

• Has the mother or child had an HIV test?

If yes: decide HIV status

• Mother: POSITIVE or NEGATIVE
• Child:
  • Virological test POSITIVE or NEGATIVE
  • Serological test POSITIVE or NEGATIVE

If no, then test

• Mother and child status unknown: TEST mother.
• Mother HIV positive and child status unknown: TEST child
  • If below 18 months: do virological testing
  • If above 18 months, do serological testing

If mother is HIV positive and child is negative or unknown, ASK:

• Was the child breastfeeding at the time or 6 weeks before the test?
• Is the child breastfeeding now?
• If breastfeeding ASK: Is the mother and child on ARV prophylaxis?

Note

For HIV testing algorithm and result interpretation in children, see HIV section

CLINICAL FEATURES

CLASSIFY AS

MANAGEMENT

• Positive virological test in child OR
• Positive serological test in a child 18 months or older

Confirmed HIV Infection

(See Section)

• Initiate ART treatment and HIV care
• Give cotrimoxazole prophylaxis
• Assess the child’s feeding and provide appropriate counselling to the mother.
• Advise the mother on home care
• Assess or refer for TB assessment and Isoniazid (INH) preventive therapy (see section 5.2.11.3)
• FOLLOW UP regularly as per national guidelines

• Mother HIV- positive AND negative virological test in a breastfeeding child or only stopped less than 6 weeks ago OR
• Mother HIV- positive, child not yet tested OR
• Positive serological test in a child less than 18 months

HIV Exposed

(See Section)

• Give cotrimoxazole prophylaxis till infection can be excluded by HIV testing after cessation of breastfeeding for at least 6 weeks
• Start or continue ARV prophylaxis as recommended
• Do virological test to confirm HIV status: if negative, repeat 6 weeks after cessation of breastfeeding
• Assess the child’s feeding and provide appropriate counselling to the mother
  Advise the mother on home care
  FOLLOW UP regularly as per national guidelines

• Negative HIV test in mother or child

HIV Infection Unlikely

• Treat, counsel and FOLLOW UP on existing infections

• Immunization not up to date according to national schedule (see Immunizations)

Child Not Immunized as Per Schedule

• Give all missed doses on this visit
• (Include sick child unless being referred)
• Give vitamin A if not given in the last 6 months
• Give mebendazole or albendazole (if age >1 year) if not given in the last 6 months

• Immunization up to date as per national schedule

Child Immunized as Per Schedule

• Praise the mother
• Advise the caretaker when to return for the next dose

DRUG

DOSE

INDICATION

DRUG

DOSE

INDICATION

Pneumonia 

Acute ear infection

Up to 6 months: 50,000IU

6–12 months: 100,000IU

12 months –5 years: 200,000 IU

1 ml 4 times daily for 7 days

5 mm of ointment inside lower lid, 4 times daily till pus discharge resolves

1-2 drops 3
times daily

INFECTION

TREATMENT

• Clean both eyes 4 times daily:
  • Wash hands
  • Ask child to close eyes
  • Use clean cloth with clean water to gently remove pus
  • Use a different part of the cloth for each eye
  • Clean each eye from nose-side to ear-side to avoid passing the infection from one eye to the other
• Apply tetracycline eye ointment 1% to each eye 4 times daily after cleaning the eyes
  • Ask the child to look up
  • Squirt a small amount (5 mm length) on the inside of the lower eyelid
  • Wash hands again
• Continue application until the redness has disappeared

Do not put anything else into the eye

• Dry the ear at least 3 times daily
  • Roll clean absorbent cloth or soft gauze into
  • a wick
  • Place this in the ear and remove when wet
  • Replace wick with a clean one
  • Repeat this process until the ear is dry

In chronic ear infection:

• Instill ciprofloxacin ear drops 3 times daily for 3 weeks

Do not put anything else into the ear

• Treat these twice daily
• Wash hands
• Wash child’s mouth with clean soft cloth moistened with salt water and wrapped around the finger
• Paint the mouth with gentian violet aqueous paint 0.5% (if necessary, dilute 1% with an equal volume of water and provide this for the mother to use at home)
• Wash hands again
• Continue giving gentian violet for 48 hours after ulcers are cured
• Give paracetamol for pain relief

• Treat for thrush four times daily for 7 days
• Wash hands
• Wash a clean soft cloth with water and use to wash the child’s mouth
• Instill nystatin 1 ml every six hours
• Avoid feeding for 20 minutes after medication
• If breastfed, check mother’s breasts for thrush and if present treat with nystatin
• Advice mother to wash breast after feeds
• If baby unable to breastfeed advise mother to feed baby with a cup and spoon.
• Give paracetamol of needed for pain

• Use a safe remedy to soothe the throat and
  relieve cough:
  • Breastmilk (for exclusively breastfed infant)
  • Warm (lemon) tea with honey

Do not use remedies containing codeine or antihistamines (e.g. chlorphenamine,
promethazine)